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Admission Date: [**2100-11-4**] Discharge Date: [**2100-11-23**]
Date of Birth: [**2034-7-13**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Confusion, rash and fever.
Major Surgical or Invasive Procedure:
Lumbar puncture, twice.
History of Present Illness:
This is a 66 year old woman with recent diagnosis of HIV/AIDS
on HAART, last CD4 count 253 and, depression and mild dementia,
who presented from home with a vesicular rash, confusion and
fevers on the [**4-4**]. She was admitted to medicine.
Mrs. [**Known lastname 100760**] was in her usual state of health approximately one
week before admission. Her husband has noticed for the past [**3-17**]
days she has seemed more confused than normal. At the same time
she has developed a right sided vesicular rash, located over her
right breast. The rash was painful and mildly pruritic. She had
had mild fevers at home to as high as 100.1 without chills. She
had not had headache, photophobia or neck stiffness. Nor had she
chest pain or difficulty breathing. No nausea, vomiting,
adominal pain, diarrhea, constipation, dysuria, hematuria, leg
pain or swelling. She did have decreased PO intake for the past
week. She did have one episode of urinary incontinence which is
unusual for her and no episodes of bowel incontinence. She was
seen by her VNA on the day of presentation who noted her to be
mildly confused with a temperature of 100.1. Her primary care
physician was [**Name (NI) 653**] who recommended transfer to the
emergency room.
In the ED, initial vs were: T: 102 BP: 136/75 P: 85 R: 16 O2:
100% on RA. She had a CXR which showed a possible small left
lower lobe opacity. She had a head CT without acute changes. EKG
showed normal sinus rhythm, normal axis, normal intervals, small
q waves in III, avF, poor baseline tracing but no acute ST
segment changes, no change from prior dated [**2100-6-24**]. She had a
lumbar puncture which showed 18 WBC in tube 4 with 16 RBC, 61%
neutrophils. Protein was 62, glucose 66. She received
ceftriaxone 2 grams IV x 1 and azithromycin 500 mg PO x 1. She
weas admitted to the floor for further workup.
Past Medical History:
1. Diabetes mellitus - diet controlled.
2. History of cutaneous T-cell lymphoma - quiescent after UV
light treatment.
3. Hospitalized at [**Location (un) 511**] [**Hospital **] Hospital in [**2087**] for
psychotic depression.
4. Hospitalized at [**Hospital 1263**] Hospital in [**2098**] for depression (with
psychotic features) - in remission and controlled with
mirtazipine, aripiprazole.
5. Question of mild cognitive impairment prior to HIV diagnosis.
6. HIV - diagnosed after presenting with pneumocystic pneumonia
in [**2100-6-14**]. Last negative test [**2087**]. Possible occupational
exposure (unclear). CD4 count at diagnosis 60, started on HAART
with good response (see below).
Social History:
From [**State 9512**], college in [**State 33977**]. Separated from husband
[**Doctor Last Name **] [**Telephone/Fax (1) 100761**] cell). Has a daughter who lives in
[**State 9512**]. Worked in [**Hospital1 18**] micro lab as medical technician since
[**2066**]. Reports occupational exposures. No h/o smoking,
excessive alcohol drinking or illicit drug use.
Family History:
Adult onset DM in both parents. Father with possible depression.
Colon CA in brother who died of it at 67; heart disease in one
brother. [**Name (NI) **] breast cancer.
Physical Exam:
Initial examination on arrival on the [**Hospital1 **]
Vitals: T: 99.5 BP: 154/85 P: 86 R: 18 O2: 100% on RA
General: Cachectic, somolent but arrousable, oriented x 3, no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.
Exam on re-admission to floor (from ICU)
Vitals: T: 99.6 BP: 134/86 P: 79 R: 18 O2: 100% on RA
General: Cachectic, slightly withdrawn with little spontaneous
behavior, oriented x 3, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: Supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic blowing
murmur loudest at upper left sternal edge, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.
Neurological: Mentation is slow and there is a poverty of speech
and movement. Affect is flat. Oriented to person, place and
time. Decreased 4/5 strength on left side in UMN pattern: paucy
of finger movement which is slow and clumsy; RUE WNL. Tone
decreased in lower extremities and surprisingly depressed
reflexes in the lower extremities. Tone lower in legs. Unable
to walk at present and needs walker at baseline.
Exam on discharge:
VS: T 98.8 BP 126/73 HR 91 RR 18 O2 Sat 98% RA
Gen: cachectic-appearing, in NAD. MMM. No thrush.
Neck: supple, trachea midline, no LAD, no JVD
Lungs: CTAB, no evidence of accessory muscle use
COR: RRR, no n/g/r
Abd: soft, non-tender. No h/s/m.
BACK: no CVAT.
SKIN: faint erythematous macular rashes of various shape and
sizes on cheeks, trunk, and limbs. No vesicle or ulcer.
Musculoskeletal: Decreased range of motion in lower extremities.
Neuro: Mental status: alert, oriented to person and place.
Intermittently oriented to year. Knows president is [**Last Name (un) 2753**]. Says
that her colleague came to see her today (on the day of
discharge). "[**Doctor First Name **] had swine flu!" Took 3 trials to learn
objects. Recalled [**1-16**] objects without hint. Recalled 2nd object
with a hint. Did not recall 3rd object with hint. Could not
complete days of week backwards, though she occasionally is able
to. Able to name pen and pen-cap. Able to repeat "no ifs, ands,
or buts." Followed 2-step command. Answered questions
appropriately, with some delay, improved. CN: PERRL, EOM
intact, visual fields intact, facial sensation intact, tongue
protrudes midline. I, VIII, visual acuity not evaluated
specifically. Sensation: intact to touch and temperature in both
upper and lower extremities. Strength: Increased tone in upper
and lower extremities. Hip flexion [**4-18**], hip extension not
evaluated. Right leg extension [**3-18**]. Left leg extension [**4-18**]. Leg
flexion [**3-18**]. Plantar flexion [**4-18**]. Dorsiflexion [**3-18**]. Upper
extremity strength 4/5. Patient able to sit up from supine to 40
degrees without assistance. Able to prop herself up on her arms.
Able to sit up in chair without props. Finger-to-nose intact.
DTR exam deferred. Unable to walk at present.
Pertinent Results:
Laboratory data at admission
Blood studies:
[**2100-11-4**] 02:00PM BLOOD WBC-4.0 RBC-3.47* Hgb-9.3* Hct-27.9*
MCV-80* MCH-26.8* MCHC-33.3 RDW-15.0 Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD Neuts-65.7 Lymphs-25.9 Monos-7.1 Eos-0.4
Baso-0.9
[**2100-11-4**] 02:00PM BLOOD Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD PT-12.5 PTT-26.6 INR(PT)-1.1
[**2100-11-4**] 02:00PM BLOOD Glucose-131* UreaN-14 Creat-1.1 Na-133
K-4.2 Cl-99 HCO3-25 AnGap-13
[**2100-11-5**] 08:05AM BLOOD ALT-22 AST-31 AlkPhos-76
[**2100-11-5**] 08:05AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.7 Mg-1.9
[**2100-11-5**] 08:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2100-11-4**] 02:10PM BLOOD Lactate-1.5
Crytococcal antigen - Negative
HIV-1 Viral Load/Ultrasensitive (Final [**2100-11-12**]): 177 copies/ml.
Urine studies:
[**2100-11-4**] 03:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2100-11-4**] 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
CSF studies:
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) WBC-18 RBC-16*
Polys-61 Lymphs-28 Monos-0 Eos-1 Atyps-1 Macroph-9
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) TotProt-62*
Glucose-66
CYTOMEGALOVIRUS - Negative
PCR HERPES SIMPLEX VIRUS - Negative
PCR [**Male First Name (un) 2326**] VIRUS (JCV) - Negative
TOXOPLASMA GONDII BY PCR - Negative
VARICELLA DNA (PCR) VDRL - Positive
VDRL - Negative
Laboratory data at discharge:
[**2100-11-23**] 06:36AM BLOOD WBC-5.1 RBC-2.81* Hgb-7.6* Hct-22.4*
MCV-80* MCH-26.9* MCHC-33.7 RDW-16.1* Plt Ct-447*
[**2100-11-20**] 06:50AM BLOOD Neuts-78.9* Lymphs-14.0* Monos-2.3
Eos-4.7* Baso-0.2
[**2100-11-23**] 06:36AM BLOOD Plt Ct-447*
[**2100-11-23**] 06:36AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2100-11-23**] 06:36AM BLOOD Glucose-112* UreaN-6 Creat-0.8 Na-141
K-4.1 Cl-103 HCO3-30 AnGap-12
[**2100-11-23**] 06:36AM BLOOD ALT-36 AST-39 LD(LDH)-342* AlkPhos-100
TotBili-1.3
[**2100-11-22**] 05:01AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
Other studies (pertinent only):
MRI head (with and without contrast):
Mild brain atrophy and mild medial temporal atrophy and mild
changes of small vessel disease. These findings are unchanged
from previous MRI of [**2100-6-20**]. No enhancing brain lesions are
seen.
MRI spine (with and without contrast):
No abnormal signal is seen within the spinal cord or extrinsic
compression identified, nor there is evidence of abnormal
enhancement. No significant change is seen since [**2100-11-11**].
Degenerative changes.
EMG ([**2100-11-12**]):
Limited study. There is no electrophysiologic evidence for a
generalized polyneuropathy affecting large-diameter nerve
fibers. There is no evidence of ongoing denervation suggestive
of a neurogenic process. Poor muscle activation, likely
secondary to a central nervous system process, prevents accurate
diagnosis or exclusion of a myopathy or radiculopathy.
Portable chest x-ray ([**2100-11-17**]):
Left PICC line shows a normal course and terminates in the right
atrium, withdraw the catheter to 3 cm for standard positioning.
No complications related to the procedure.
EKG ([**2100-11-4**]):
Artifact is present. Sinus rhythm. There is a late transition
with Q waves in the anterior leads consistent with probable
prior anterior myocardial infarction. Low voltage in the
precordial leads. Compared to the previous tracing low voltage
is new.
Brief Hospital Course:
Summary
Ms. [**Known lastname 100760**] presents with single dermatomal herpes zoster with
concurrent CNS herpes zoster infection, manifesting as a
meningoencephalitis (confirmed by pleocytosis and elevated
protein level in CSF, VZV PCR positive in CSF, and positive VZV
DFA from scrapings of vesicular rashes in the right T3
dermatome), in the context of HIV/AIDS. Tests for other causes
including seizure, TB, fungi, HSV, HTLV, CMV, JCV, T. pallidum
were negative. Varicella zoster virus infection was treated
with intravenous acyclovir resulting in the resolution of mental
status changes and a return to baseline over cognitive function
over the two weeks following admission. She will now need some
intensive physical therapy to restore the function of her legs.
Acyclovir therapy will continue until she follows up with
Neurology, Dr. [**Last Name (STitle) 2340**], on the [**7-1**]. Dr. [**Last Name (STitle) 2340**]
will perform lumbar puncture at that time to repeat CSF VZV PCR.
Chronology
Ms. [**Known lastname 100760**] was initially admitted to the floor, where she was
initially somnolent but alert and oriented, but became less
responsive over the course of the day. Repeat CSF on the floor
showed 133 with 69% PMNs, protein 114 and glucose 54, concerning
for evolving meningoencephalitis. Brain MR w/wo contrast was
obtained, per Neurology recommendations, and showed no
abnormalities. The patient was transferred to the [**Hospital Unit Name 153**] for
further care.
In the [**Hospital Unit Name 153**], antibiotic treatment continued that included
empiric treatment for bacterial or viral meningitis with
acyclovir, ceftriaxone, amoxicillin, and vancomycin. She was
noted to have hyperreflexia and spasticity on exam. Her mental
status improved over the course of her ICU stay. She was alert,
responsive to voice commands, able to answer simple questions.
Upon becoming more stable she was returned to the floor.
Brief Hospital Course by Problem
Meningoencephalitis and Mental Status Changes
Given fever, confusion and lumbar puncture findings, viral and
other non-bacterial meningoencephalitides were considered most
likely early in the stay. Numerous other processes were
excluded as summarized above and these phenomena were attributed
to CNS VZV infection. This was also considered most likely
given concomitant Shingles. As can sometimes occur in the
context of HIV, Ms. [**Known lastname 100760**] suffered from a diffuse and
generalized encephalitis as a result of this infection. This
has been successfully treated with high-dose intravenous
acyclovir. Mental status appears to have returned to
pre-admission character with some residual lower extremity
weakness (as discussed below).
Given her gradual deterioration prior to admission, we also
consider it likely that AIDS dementia complex may have been
present, that has possibly partially responded to HAART.
Herpes Zoster rash
The patient had a vesicular rash over her right breast, classic
in appearance for zoster; her direct antigen test was positive
for VZV and negative for HSV. Acyclovir was given throughout
the admission. The rash resolved over about ten days. Analgesia
was given cautiously given her mental status and our concern for
masking fever. Low doses of opioids were used.
HIV/AIDS
Ms. [**Known lastname 100760**] was recently diagnosed with HIV/AIDS in [**6-/2100**] when
she presented with PCP pneumonia, most recent CD4 count 253.
She was continued on her antiretroviral therapy consisting of
Norvir, Reyataz and Truvada. She was continued on Bactrim for
and azithromycin prophylaxis.
Depression with psychotic features
Given the resolution of her mental status changes, we can now
see that it is unlikely that depression contributed to these
changes. Nonetheless, psychiatry was consulted while she was an
inpatient. Abilify was reduced from 20 to 10 mg at night
because of concern that this may have contributed to mental
status changes.
Elevated PTT - excessive response to heparin
The patient was initially placed on subcutaneous heparin for
DVT prophylaxis. After a couple of days on the subcutaneous
heparin, her PTT was noted to be elevated at 150, and her PT and
INR were also elevated. Recheck of her coags showed that they
were down-trending, and they had returned to [**Location 213**] levels by
the evening.
The patient was placed on pneumoboots for DVT prophylaxis. It
appears that she does not have an allergy to heparin, but
responded in excess of expectation. We advise caution with
further use (lower dose and monitor PTT).
Rash
She developed an erythematous rash with confluent plaques on
the arms, legs, chest, and back, sparing the mucous membranes,
consistent with a drug reaction. This appeared two weeks after
admission. Dermatology were consulted and thought the reaction
most consistent with cephalosporins rather than acyclovir.
Given this impression and the importance of acyclovir in
treatment, acyclovir was continued and the rash treated with
fexofenadine, famotidine, and triamcinolone ointment. The rash
resolved while acyclovir was continued supporting the above
impression.
Lower Extremity Weakness
Despite improvements in mental status, the patient continued
to have lower extremity weakness of unknown etiology. An MRI
and EMG were performed to evaluate for cord compression, other
intrathecal process, radiculopathy or polyneuropathy without
identifying a cause. Her lower extremity weakness is improving
with her mental status, suggesting that this was a result of
encephalitis. She has developed some degree of contracture in
the lower extremities and intermittently complains of joint
aches. Physical therapy has worked with her to help improve her
range of motion.
Nutrition
Feeding has also recovered with the recovery of baseline
mental status. Feeding had been an issue with poor PO intake.
The patient and her husband have declined replacement of a
Dobbhoff feeding tube, and she required 1:1 assistance with
meals of ground solids. PO intake continues to improve, and
patient has started to feed herself.
Anemia
Likely contributions include reduced nutritive intake for part
of the admission, the present illness and HIV. No source of
blood loss, no evidence of hemolysis.
Joint Pain
Likely due to osteoarthritis and immobility.
Diabetes Mellitus
Stable with small doses (two units) of Humalog by sliding
scale on occasion.
Medications on Admission:
Abilify 20 mg, 1 tablet, PO daily
Mirtazapine 15 mg, 1 tablet PO HS
Multivitamin, one capsule PO daily
Norvir 100 mg, one capsule PO daily
Reyataz 150 mg, 2 capsules PO daily
Trimethoprim-Sulfamethoxazole 400 mg- 80 mg, 1 tablet PO daily
Truvada 200 mg- 300 mg, 1 tablet PO daily
Zithromax, 2 tablets PO weekly
Discharge Medications:
1. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours).
2. Insulin sliding scale
Humalog 2 units has sometimes been required before lunch or
dinner.
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day.
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Reyataz 300 mg Capsule Sig: One (1) Capsule PO once a day.
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(FR).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Skin rash: Please continue
while rash is present. Likely to only be required for another
few days after discharge. .
11. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**]
Discharge Diagnosis:
Primary diagnoses
Varicella zoster virus rash (shingles)
Varicella zoster virus meningoencephalitis.
Secondary diagnoses:
Dementia
Hypertension
HIV
Depression
Diabetes, type II
Drug reaction - rash
Osteoarthritis
Anemia
Drug rash
Discharge Condition:
mental status now at baseline; lower extremity weakness,
improving
Stable, mental status at baseline. Lower extremity weakness
improving.
Discharge Instructions:
You were seen at [**Hospital1 18**] for varicella zoster virus
meningoencephalitis (viral infection with inflammation of the
brain and membranes surrounding it) and shingles (varicella
zoster virus rash). We have been treating you with acyclovir, to
treat this infection, greatly impoving your mental status, lower
body weakness, and rash.
Please continue to take all of your prescribed medications, as
directed. Your medications have changed. Please note new
medications and/or old medications with NEW doses.
ACYCLOVIR- 500 mg IV every 8 hours
LISINOPRIL- 5 mg by mouth at bedtime
ABILIFY- NEW dose- 10 mg by mouth daily
We did not change your HIV medications. Please continue to take
NORVIR 100 mg by mouth daily, REYATAZ 2 capsules by mouth daily,
TRUVADA 200mg-300mg by mouth daily.
Please keep all of your follow-up appointments.
If you get a fever of 100.4, chills, nausea, vomiting, your
symptoms do not improve or if they worsen, please return to the
hospital for evaluation.
Followup Instructions:
Please follow-up with:
Provider: [**Name10 (NameIs) 2341**] [**Name11 (NameIs) **], Neurologist and HIV specialist. Your
appointment is on [**2100-12-1**] at 2:00 PM. MD Phone: ([**Telephone/Fax (1) 100762**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:([**Telephone/Fax (1) 6732**]
Date/Time:[**2100-12-3**] 11:30
Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 26**] [**Name8 (MD) 30125**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2100-12-14**] 2:20
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
|
[
"2761",
"4019",
"25000",
"2859"
] |
Admission Date: [**2118-7-23**] Discharge Date: [**2118-7-25**]
Date of Birth: [**2065-4-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p [**First Name3 (LF) **] to LAD
History of Present Illness:
53M with HIV (Dx [**2105**], CD4 520, VL ND, on Atripla), HCV (14.M
VL, [**3-25**]), +40 pack year smoking hx, no known CAD that presents
with 3 hrs of chest pain. The pt reports that he awoke this
morning with emesis at followed by chest pain. Initially was
intermittent, then constant for >1hr, radiating to his back. The
pt denies prior episodes of chest pain and is able to walk up
two flights of stairs without difficulty. as well. Associated
with vomiting, diaphoresis, no shortness of breath. Has not had
these symptoms before. CP x 3 and +SOB. no parasthesias. BP
153/119 on left.
.
On arrival to the ED 95.1 80 NSR 153/119 (LUE) 168/140 (RUE) 16
100% RA. ECG with STEs V1-V4. WBC of 18K. He received ASA,
Plavix 600mg, Metoprolol 5mg IV, Heparin gtt. He was
subsequently transferred to the cath lab.
.
While in the cath lab, the pt noted to have mid LAD total
occulusion. The pt underwent balloon angioplasty followed by
[**Month/Year (2) **]. He had AIVR following reperfusion. He received two boluses
of Eptifibatide and then continued on Eptifibatide gtt. Pt
subsequently transferred to the CCU.
.
On arrival to the CCU the pt denies chest pain, SOB, nausea,
vomitting or leg pain.
.
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, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# HIV CD4 520, VL ND, on Atripla
# HCV 14.M VL, [**3-25**]
# GERD
# s/p Tonsillectomy
Social History:
MSM. Lives with partner. Computer Analyst. Vice President.
-Tobacco history: +
-ETOH: Not significant
-Illicit drugs: None
Family History:
Mom died at age 53 from CVA, Dad died at 74 CAD.
Physical Exam:
ON admission:
VS: Afebrile 80NSR 132/83 16 100% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Clear anteriorly. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: R groin with small non-tender hematoma 1cm. No
appreciable bruit. No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
On discharge:
Tm 99.6 BP 107-115/69-86 77-87 16 100% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Clear anteriorly. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: R groin with large, stable hematoma. No appreciable
bruit. No c/c/e. No femoral bruits. R pedal pulses 2+
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ON admission:
.
[**2118-7-23**] 11:00AM BLOOD WBC-18.9*# RBC-4.86 Hgb-15.5 Hct-45.9
MCV-94 MCH-32.0 MCHC-33.9 RDW-14.6 Plt Ct-366
[**2118-7-23**] 11:00AM BLOOD Neuts-82.1* Lymphs-14.8* Monos-1.9*
Eos-0.4 Baso-0.8
[**2118-7-23**] 11:00AM BLOOD PT-11.9 PTT-22.6 INR(PT)-1.0
[**2118-7-23**] 11:00AM BLOOD Glucose-158* UreaN-12 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-21* AnGap-20
[**2118-7-23**] 11:00AM BLOOD cTropnT-<0.01
.
On discharge:
[**2118-7-25**] 06:35AM BLOOD Hct-39.6*
[**2118-7-25**] 06:35AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-143
K-4.2 Cl-107 HCO3-28 AnGap-12
[**2118-7-25**] 06:35AM BLOOD cTropnT-1.20*
[**2118-7-25**] 06:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1 Cholest-137
[**2118-7-25**] 06:35AM BLOOD Triglyc-163* HDL-36 CHOL/HD-3.8
LDLcalc-68
.
[**2118-7-23**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel disease. The LMCA was normal. The
LAD had a
mid vessel occlusion, but was otherwise normal. The LCx and RCA
were
normal.
2. Limited resting hemodynamics demonstrated mild systemic
hypertension
with central aortic pressure 146/89 with a mean of 102 mmHg.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild systemic hypertension.
.
[**7-25**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 35%) with mild
global hypokinesis and akinesis of the mid to distal
septum/anterior wall and apex. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion
Brief Hospital Course:
ASSESSMENT AND PLAN:
53M with HIV, HCV p/w with chest pain, found to have mid-LAD
occulusion now s/p [**Month/Year (2) **].
# Mid-LAD STEMI: Patient with no known cardiac history but w/
risk factors - 40 pack-year tobacco, HIV on HAART and family hx.
Presented with 10/10 chest pressure and EKG concern for anterior
STE. Cath revealed LAD occlusion and [**Month/Year (2) **] was placed. ASA 325 mg,
plavix (loaded w/ 600 mg) 75 mg qday, atorvastatin 80 mg qday
were started. Beta-blocker was given in the ED but was not
started immediately out of concern for groin hematoma.
Eptifibatide gtt was started and continued for 18 hours
post-cath. He was subsequently started on Toprol XL 50 mg qday.
He remained symptom free during the rest of his hospital stay.
.
# Apical akinesis: [**7-25**] TTE demonstrated mild global hypokinesis
and akinesis of the mid to distal septum/anterior wall and apex,
so patient was started on Warfarin 5mg daily with Lovenox (80mg
[**Hospital1 **]) bridge. He will follow-up at [**Hospital1 778**] on [**7-27**] for an INR and
further management of his warfarin will be done by his PCP. [**Name10 (NameIs) **]
should follow up in one month for repeat ECHO to assess for
resolution or improvement of akinesis.
# Right Groin Hematoma: Enlarged acutely after cath while on
integrillin gtt. Pressure was held with stabilization of
hematoma. Good distal pulses. No appreciable bruit. Hematocrit
remained stable.
# PUMP: No known CMP. Pt appears clinically euvolemic. Received
B-Blocker while in ED and was started on Toprol XL 50mg daily.
TTE showed Overall left ventricular systolic function is
moderately depressed (LVEF= 35%) with mild global hypokinesis
and akinesis of the mid to distal septum/anterior wall and apex.
Management as above.
# RHYTHM: Pt currently in NSR. AVIR following reperfusion.
Monitored on tele thereafter.
# HIV: Last CD4 520, VL ND. Continued Atripla
(Emtricitabine/Tenofovir/Efavirenz)
# HCV: (14.M VL, [**3-25**]). Followed by hepatology as outpatient.
Last bx with focal mild portal and minimal lobular mononuclear
inflammation (grade 1). Patient was encouraged to follow-up with
his outpatient hepatologist.
FOLLOW UP
1. AKINETIC LV - on coumadin and lovenox. Instructions given to
patient and [**Hospital1 778**] to check INR on Wednesday [**7-27**]. Patient
instructed to have follow up TTE in one month; follow up with
cardiology planned.
2. STEMI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] - [**Last Name (Prefixes) **] instructed to never stop aspirin.
Medications on Admission:
Atripla 1 tab daily
Omeprazole 20mg Daily
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:*11*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*11*
5. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO qday ().
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Syringe
Subcutaneous twice a day.
Disp:*10 Syringe* Refills:*0*
8. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please check INR on Wednesday [**2118-7-27**].
.
Please fax results to Dr. [**Last Name (STitle) 7991**] at [**Telephone/Fax (1) 34420**].
.
Goal INR [**3-17**]
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
STEMI s/p [**Month/Day (3) **] to LAD
.
Secondary:
HIV on HAART
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for chest pain and you were
found to have had a heart attack. You had a blockage in one of
your main coronary arterties - the left anterior descending
artery. A drug-eluting stent was placed. We started many new
medications that are important to help prevent further heart
attacks and to keep the stent patent. Please stop smoking as it
will greatly improve your heart health.
.
We made the following changes to your medications:
We STARTED Aspirin 325 mg per day
WE STARTED Atorvastatin 80 mg per day
We STARTED Clopidogrel (Plavix) 75 mg per day to keep your stent
open
We STARTED Lisinopril 2.5 mg per day
We STARTED Toprol XL 50 mg per day
.
You have also been started on a medication called Warfarin (or
coumadin) which is a blood thinner. You should get your blood
checked on Wednesday [**7-27**] at [**Hospital1 778**] to assess if your coumadin
level (INR) is therapeutic. Until your INR is therapeutic you
should take the medication Lovenox. This can be discontinued
once your INR is >2.
.
You should follow-up with your cardiologist and arrange a repeat
ECHO in 1mo to assess if you need to continue on warfarin at
that time.
.
You should never stop taking Aspirin.
.
Your follow-up information is listed below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 8002**]
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Location (un) 34421**], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: Tuesday, [**8-2**], 10AM
Department: CARDIAC SERVICES
When: THURSDAY [**2118-8-4**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: THURSDAY [**2118-10-6**] at 8:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2118-7-25**]
|
[
"41401",
"3051",
"53081",
"4019"
] |
Admission Date: [**2156-9-28**] Discharge Date: [**2156-10-8**]
Date of Birth: [**2117-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Flex Sigmoidoscopy
Upper endoscopy
History of Present Illness:
This is a 39 year old male with a history of UC s/p subtotal
colectomy with ileo-anal pull-through, who presents with BRBPR
x10 episodes starting this am. Notes stool is purple and bright
red. This has been associated with fatigue, lightheadedness,
orthostasis, tinnitus, and dyspnea/palpitations on exertion. He
also confirms mild crampy lower abdominal discomfort, but denies
nausea, emesis, epigastric pain, or melena. The patient had a
prior episode of BRBPR in [**3-18**], and flex sig showed mild
pouchitis and chronic inactive colitis, which was treated with
ciprofloxacin and canasa suppositories. An EGD also in [**3-18**] was
notable for Schatzki ring, eosinophilic esophagitis, and a small
duodenal erosion. He had similar self-limited episodes of rectal
bleeding in [**5-9**], and [**7-18**], for which he took canasa. He
notes that his current presentation is more severe than prior
episodes.
.
On arrival to the ED, vital signs were: 98.8 115 108/70 16 99%.
He remained tachycardic to the 120s and his hematocrit was found
to be 32, down from 42 last month. He had a frankly bloody BM in
the ED.
18g and 16g peripheral IVs were placed and he was given 2 units
pRBCs and 1L IV fluids. His BP remained stable. GI was consulted
and plan for a flex sig in the am. Prior to transfer, vitals
were: 98.5 98 113/65 16 98RA.
.
In the ICU, he is currently feeling better after fluid/blood
tranfusion. Review of systems is negative for f/c/n, undercooked
or unusual foods, recent dehydration, or travel. He is unaware
of sick contacts, but works in an elementary school.
Past Medical History:
Ulcerative colitis, diagnosed late [**2126**].
- S/p subtotal colectomy [**2143**] for toxic megacolon (some retained
rectal mucosa).
- S/p ileoanal pull-through with J-pouch [**2144**].
- Pouchitis [**3-18**] flex sig and [**9-17**]
Eosinophilic esophagitis
Schatzki ring s/p dilation [**3-18**]
Depression and anxiety
Multiple epiphyseal dysplasia s/p L knee arthroscopy
Allergic rhinitis
Septoplasty at age 19
Social History:
Lives with his wife, no kids. Works as an elementary school
teacher. He does not smoke or use drugs. He has ~3 drinks of
alcohol per week.
Family History:
Paternal grandfather with [**Name2 (NI) 499**] CA in his 30s. No other GI
diseases.
Physical Exam:
VS: HR 110s BP 120s/70s
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MM dry. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
.
.
On discharge
Vitals: 96.6 110/81 100-107 18 94%RA
Pain: denies today
Access: RUE midline
Gen: nad
HEENT: anicteric, mmm
CV: regular, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nondistended today, +BS, improved
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: LUE with palpable cord antecubital, improved erythema
psych: appropriate
.
Pertinent Results:
*had normal WBC around [**5-19**], then developed acute leukopenia
since [**0-**] (wbc 2.5-3 with up to 19% bands), has resolved
since [**10-4**], with wbc 6s on discharge
.
HCT 31-->35-36 for 3days before discharge (baseline hct 40, down
to 29, s/p 3U prbc last [**9-28**], then stable at HCT 30s, now
increasing to 35)
chem panel: BUN/creat 9/0.9
Mag 2.1
LFTs [**10-3**] wnl
coags wnl
.
Stool Cx [**9-28**]: negative
UA [**10-2**] negative
blood cx X2 [**10-2**] NTD
C-diff [**10-3**] negative
.
.
Imaging/results:
CT scan [**10-4**] (reviewed with GI and Surgery):
1. Partial small- bowel obstruction with two transition points
in the left lower quadrant, the appearance is most conistent
with two adhesions as the transition points are farther apart.
Internal hernia remains in the differential diagnosis with
volvulus being least likely. There are no signs of ischemia.
2. Cholelithiasis without evidence of cholecystitis.
3. Trace left pleural effusion and associated bibasilar
atelectasis.
.
[**10-1**] SBFT: IMPRESSION: Findings may represent ileus or early
partial small bowel obstruction. Recommend follwup KUB to
document movement of contrast through the bowel
.
KUB #1 and #2 from [**10-1**] and [**10-2**] am--personally reviewed
imaging and discussed findings with radiologist: proximally
dilated bowel loops, likely jejunal, +air fluid levels, no
transition point, contrast throughout bowel, concern for partial
SBO vs ileus
.
KUB #3 [**10-2**]: The current study was obtained in the supine and
upright AP projection. The bowel loops, in particular of
jejunum, continue to be dilated up to 5.3 cm in the left lower
quadrant. Contrast is seen through the rectum. The findings are
nonspecific and differentiation between partial obstruction
versus ileus cannot be determined based on the radiograph of the
abdomen
.
KUB #4 [**10-3**]-reviewed personally and with radiology: dilated
bowel and contrast but improved since last study. no free air.
.
KUB #5 [**10-4**]: Persistent intestinal distention. No significant
contrast migration since one day prior
.
.
Flex Sig [**9-28**]; Stool in the pouch. Very shallow ulcerations and
erythema in the pouch compatible with pouchitis. Both limbs of
anastomosis was examined. No blood or activate bleeding was
noted. Otherwise normal sigmoidoscopy to splenic flexure
.
EGD [**9-28**]: Multiple mucosal rings in the whole Esophagus
compatible with eosinophilic esophagitis
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
.
Bleeding scan [**9-28**]:
IMPRESSION: Normal study without evidence of gastrointestinal
system bleed.
Brief Hospital Course:
39year old male with h/o UC s/p colectomy, eosophillic
esophagitis, schatzki's ring s/p dilation [**3-18**], anxiety, h/o GIB
of unclear etiology was admitted again with bloody stools and
acute blood loss anemia. He was initially admitted to ICU.
Recieved total of 3U blood with nadir HCT 29 (baseline 40). He
underwent upper and lower endoscopy [**9-28**] w/o a source. Given
dropping HCT, he also underwent bleeding scan [**9-28**] which did
not reveal as source either. He was stabilized by HD#3 w/o
further bleeding and stable HCT. Was seen by GI who reccommended
he have oupt capsule study to further eval. Given his h/o
Schatzki's ring, they wanted an UGI/SBFT to make sure capsule
would pass. He had previously been tolerating PO okay. However,
the SBFT on [**10-1**] suggested there was delayed transit of the
barium either due to ileus or SBO (air fluid levels w/o clear
transition point). Pt also felt distended and was passing very
little. He did not have any nausea/vomiting so NGT was defered.
He also developed acute leukopenia and bandemia on [**10-1**] (wbc
10->2.5 with 19% bands) which was very concerning. Serial KUBs
showed the ileus vs pSBO but no free air to suggest obstruction.
CT scan was held off because radiology felt it would have too
much artifact due to dense barium used for SBFT. He was
monitored with serial KUBs, exams, npo/IVFs, and Surgery
consult. He was started on empiric cipro/flagyl on [**10-2**] given
persistant leukopenia-neutropenia/bandemia and low grade fevers.
His CXR, UA, c-diff was negative. He completed a 7day course
with now normalized wbc count and no fevers. On [**10-4**], the
barium had diluted enough so that we were able to get CT a/p to
further eval whether this was SBO vs ileus. He did show 2
transition points in LLQ which Dr. [**First Name (STitle) 2819**] (surgery) and Dr.
[**Last Name (STitle) 3315**] (GI) were made aware off. However, by this time, pt was
clincially doing better, passing more barium, less distended
etc. Given a sugery for LOA would be high risk, we opted to
continue medical management. Since he was stable, he was started
on clears on [**10-6**] which he tolerated. He was advanced to low
residue diet on [**10-7**] and he tolerated this as well. He is asked
to continue low residue diet until his BMs are more formed as
previous. By time of discharge, his HCT was already rising and
was 35. He still needs a capsule study at some point after a
couple weeks and GI fellow, Dr [**Last Name (STitle) 1256**] will schedule this. His HR
remained 100s but this is due to anxiety per patient. As for the
pouchitis seen on lower endoscopy and findings of eosinophiilc
esophagitis seen on EGD, he needs to f/u with dr. [**Last Name (STitle) 6880**]
for further management.
.
.
See progress note below from day of discharge for detailed plan
according to problem list:
.
39year old male with h/o UC s/p colectomy, eosophillic
esophagitis, schatzki's ring s/p dilation [**3-18**], anxiety, h/o GIB
of unclear etiology admitted [**9-28**] with brbpr X10, acute blood
loss anemia s/p blood transfusion, unclear etiology of bleed.
Hospital course now complicated by abdominal distention, partial
SBO, and leukopenia/low fevers, all of which are improving
.
Abdominal distention, partial SBO: No nausea/vomiting,
clinically is doing better. Occuring since about [**9-30**].
-CT scan with possible adhesions as cause. Would be high risk
surgery
-improved with conservative management. has tolerated low
residue diet.
-continue cipro/flagyl, change to PO, day [**6-15**], bandemia/fevers
resolved
-replete lytes aggressively
-no narcotics
.
Leukopenia: unclear etiology. Developed abruptly on [**10-1**] with
significant bandemia which was very concerning. no pulm
symptoms, UA negative. Has superficial phlebitis from IVs but no
evidence of cellulitis and would not expect such bandemia. Other
concern is focal perforation or abcess in abdomen, esp given
ileus/pSBO. pt also at risk for c-diff but this was
negative.Wouldnt expect myelosuppression from meds to cause
bandemia. No longer leukopenic/bandemic improved with Abx.
-cont empiric cipro/flagyl to cover GI pathogens, day [**6-15**].
-NTD blood cx and CIS
.
Acute GI bleeding/blood loss anemia: s/p 3U total (last [**9-28**]),
HCT 30 since [**10-1**]. no further bloody BMs. EGD/Flex sig/bleeding
scan unrevealing for source. Plan was for SBFT to ensure no
obstruction, then outpt capsule, but SBFT showed above.
-stable for GI bleeding standpoint. still plan for capsule in a
few weeks
-PPI PO qd
-follow HCT, has been rising so good BM response
.
Pouchitis: defer further mesalamine enema to Dr. [**Last Name (STitle) 6880**].
hold imodium on discharge.
.
Eosinophilic esophagitis: unclear how symptomatic pt is. not on
any treatment currenlty. seen on [**3-18**] and [**9-17**]. Note,
eosinophilia is related to this. pt was supposed to start PPI,
which was started here.
.
Depression/anxiety: resume elavil 200mg qhs
.
Superficial thrombophlebitis: LUE>RUE. no cellulitis.
-warm packs. no NSAIDs given GIB
.
Sinus tachy: continue hydration. also anxiety component. follow,
stable around 100.
Medications on Admission:
Amitriptyline 200mg qhs
Loperamide 2mg daily
Omeprazole 20mg daily (hasn't yet started)
MVI daily
Naproxen 1 tab daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
3. Multi-Day Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestinal Bleed of unclear source
acute blood loss anemia s/p 3U prbc
partial small bowel obstruction [**1-12**] adhesions
.
Secondary:
Anxiety
Ulcerative Colitis s/p colectomy with pouchitis
Eosinophilic esophagitis
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted to the Intensive Care Unit at [**Hospital1 771**] because you were having bright red
blood per rectum, and there was concern that the bleeding could
increase and become dangerous. Your bleeding stopped. However,
we did not find the source of bleeding despite upper and lower
endoscopy or bleeding scan. You have not had any further
bleeding for 10days. You need to have capsule study done as
outpt and Dr. [**Last Name (STitle) 1256**] will schedule this. Please return to the
hospital if you develop recurrent bleeding, lightheadedness,
dizziness, or any concerning symptoms.
.
Also while you were here, you developed a small bowel
obstruction around [**10-1**]. This was managed conservatively with
bowel rest, fluids, serial xrays and exams. Luckily you improved
with this and did not require surgery. Please follow low residue
diet until you start to have formed bowel movements. I would not
take loperamide until you follow up with Dr. [**Last Name (STitle) 6880**].
Finally your upper endoscopy showed eosinophillic esophagitis
and your lower scope showed pouchitis. please discuss further
management with Dr. [**Last Name (STitle) 6880**]. You are started on omeprazole
while here. try to avoid naproxen and take tylenol for pain.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 78127**], please make an appointment in
2weeks to review your hospital stay
Please f/u wtih Dr. [**Last Name (STitle) 6880**] in 2weeks.
You will be contact[**Name (NI) **] regarding your capsule study
|
[
"2851",
"42789"
] |
Admission Date: [**2161-8-24**] Discharge Date: [**2161-9-23**]
Date of Birth: [**2107-5-21**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 88109**]
Major Surgical or Invasive Procedure:
[**2161-8-24**] CEREBRAL ANGIOGRAM WITH COILING OF THE L ICA ANEURYSM
[**2161-8-24**] RIGHT FRONTAL EXTERNAL VENTRICULAR DRAIN
[**2161-8-25**] LEFT HEMICRANIECTOMY
[**2161-8-25**] DIAGNOSTIC CEREBRAL ANGIOGRAM
[**2161-9-3**] ANGIOPLASTY RIGHT MCA/LEFT MCA/RIGHT ICA
[**2161-9-4**] ANGIOPLASTY OF BASILAR ARTERY
[**2161-9-18**] VP SHUNT LAP ASSISTED
History of Present Illness:
HPI:This is a 54 year old female with history of migranes who at
3 am experienced headache and speech difficulties. The headache
had been gradual onset and had originally started at 3 pm in the
afternoon. At approx 3am, the patient's husband called 911 and
the patient was brought to [**Hospital3 **] where a Head CT
revealed extensive SAH and left sided hemorhage. The patient
was
given Dilantin 1000mg and Decadron 10 mg IV. The patient was
intubated and trasnferred here for further care. The husband
states that she took one Aspirin 325 mg po last night. He states
that the patient does not take any other blood thinning
medications such as coumadin, heparin, plavix or lovenox. She
does not take Aspirin on a daily bassis.
Past Medical History:
PMHx:migraines, chronic pain
Social History:
Social Hx:lives with husband
Family History:
Family Hx:unknown
Physical Exam:
ROS:patient in intubated.
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]:grade 4 [**Doctor Last Name **]:grade 4 GCS E:1 V:5 Motor:1T
O BP: 124/ 93 HR:113 R: 20 O2Sats100% assit
control 100% FIO2 x 18 peep 5
Gen: intubated
HEENT: Pupils: 4-3mm EOMs- unable to test
Neck:
Extrem: Warm and well-perfused.
Neuro:
Mental status/orientation: GCS 7 T/intubated
Recall: unable to assess
Language: intubated/non verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields unable to test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength and sensationunable to test
VIII: Hearing -unable to test
IX, X: Palatal elevatin - unale to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius- unable to test
XII: Tongue - unable to test
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength- . Pronator drift-unable to test
Sensation: unable to test
Toes bilaterally UP going
Coordination: unable to test
Handedness Right
Exam on discharge:
Patient is Trached and tolerating Trach mask.
At times opens eyes spontaneously, other times opens to nox.
stim.
PERRL at 4mm to 2mm bilaterally.
Moves upper extremities to stim and spontaneously flexing, not
purposeful.
Minimally withdraws bilateral lower extremities.
Pertinent Results:
CXR [**2161-8-24**]
IMPRESSION:
1. ETT in proximal trachea, please advance 3 cm.
2. NGT in distal esophagus, please advance 10 cm.
CTA BRAIN [**2161-8-24**]
CONCLUSION: Extensive left frontal intraparenchymal hemorrhage,
as well as
subarachnoid and intraventricular hemorrhage. Demonstration of
left
supraclinoid internal carotid artery aneurysm. Intervention
neuroradiology
consultation advised, if not already obtained.
CT BRAIN [**2161-8-24**]
There is interval development of a small amount of
hyperdense material overlying the longus [**Last Name (un) **] muscles in the
nasopharynx. The finding could represent a small amount of
blood, secondary to the intubated status of the patient.
CT Head [**2161-8-25**]
IMPRESSION:
1. Increase in the size of the large left frontal lobe
hemorrhage.
2. Worsening mass effect and shift of normally midline
structures.
3. Evolving left MCA and PCA infarcts.
CT head [**2161-8-25**] post-op
1. Patient is status post left hemicraniectomy with mild relief
of the mass effect. Shift of the midline structures is still
significant at 1 cm to the right.
2. Unchanged extensive subarachnoid hemorrhage and large left
frontal lobe
hematoma.
ECHO [**2161-8-26**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is dilated. There is moderate to severe regional left
ventricular systolic dysfunction with severe hypokinesis of the
distal two-thirds of the left ventricle. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. A mass is present on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction suggestive of
stress cardiomyopathy. No significant valvular abnormality seen.
Mild to moderate pulmonary artery hypertension.
CXR [**2161-8-26**]
ET tube, left subclavian line and nasogastric tube are in
standard placements respectively. No consolidation. Heart size
normal. No pleural effusion. Lungs essentially clear.
CXR [**2161-8-26**]
Comparison is made with prior study performed on same day
earlier in the
morning. There are low lung volumes. Cardiac size is top normal.
Mediastinal widening is unchanged. Lines and tubes remain in
place and unchanged in standard position. There is no
pneumothorax. There are small bilateral pleural effusions. There
is new mild-to-moderate vascular congestion.
BLE Dopplers [**2161-8-27**]
IMPRESSION: No evidence of deep vein thrombosis in either leg.
ECHO [**2161-8-28**]
Moderate to severe regional left ventricular systolic
dysfunction, c/w CAD. Differential diagnosis includes stress
cardiomyopathy or neurogenic regional LV systolic dysfunction
CXR [**8-28**]
Lines and tubes are in unchanged standard position. Cardiac size
is top
normal. There has been interval improvement in now mild
pulmonary edema.
Left lower lobe retrocardiac atelectasis has improved.
Persistent opacities in the right upper lobe could be due to the
pulmonary edema, but attention in this area is recommended in
followup studies to exclude a focus of infection
CTA head [**8-28**]
1. Limited study due to venous contamination. However, there
appears to be
narrowing of the mid to distal basilar artery and narrowing of
the bilateral M1 MCA segments suggesting vasospasm.
2. Increased midline shift and mass effect from the large
intraparenchymal
hemorrhage.
3. Stable intraparenchymal, subarachnoid, intraventricular
hemorrhage.
CT HEAD: [**2161-8-29**]
FINDINGS: There is overall little change in the extensive
intraparenchymal, bilateral subarachnoid and intraventricular
hemorrhage. Right frontal approach ventriculostomy catheter
terminates in the third ventricle. Ventricular size is
unchanged. There has also been no change in approximately 15 mm
rightward shift of normally midline structures. The patient is
status post left frontal craniectomy. Marked sulcal effacement
bilaterally, greater on the left is again seen. Metallic
artifact from coil was seen in the region of the supraclinoid
ICA.
There is partial opacification of the left mastoid air cells, as
on the
previous study with the remainder of the paranasal sinuses well
aerated.
IMPRESSION: Grossly stable widespread subarachnoid,
intraparenchymal and
intraventricular hemorrhage with unchanged 15 mm rightward
subfalcine
herniation. Hypodensity in left cerebral hemisphere extending to
occipital
cortex is also unchanged.
[**2161-8-30**] CT PERFUSION
IMPRESSION:
1. Head CT shows no significant change since the CT of
[**2161-8-29**] with
left-sided craniectomy and blood products in the left frontal
lobe with
surrounding edema and hypodensity in the left occipital lobe.
2. CT perfusion shows perfusion abnormality in the region of
hemorrhage, but no other perfusion abnormalities are seen.
Diffuse perfusion abnormalities could not be excluded in absence
of quantitative assessment.
3. CT angiography demonstrates diffuse vasospasm involving the
arteries of
anterior and posterior circulation.
BILAT LOWER EXT VEINS [**2161-9-1**]
No evidence of deep vein thrombosis in either leg
CT HEAD W/O CONTRAST [**2161-9-1**]
Grossly stable widespread subarachnoid, intraparenchymal, and
intraventricular hemorrhage with unchanged 15-mm rightward
subfalcine
herniation.
CTA HEAD W&W/O C & RECONS [**2161-9-4**]
1. No significant change in widespread subarachnoid,
intraparenchymal and
intraventricular hemorrhages with shift of midline structures to
the right and rightward subfalcine herniation.
2. Unchanged left hemispheric edema which likely is due to
ischemia/infarction.
3. Improved caliber of bilateral middle cerebral arteries.
4. Unchanged narrowing of the basilar artery, bilateral
posterior and
anterior cerebral arteries.
5. Assessment of patency of coiled aneurysm is limited due to
the streak
artifact.
[**2161-9-6**] CT Chest/Abdomen/Pelvis:
IMPRESSION:
1. No CT findings to explain patient's fever.
2. Right lower lobe aspiration.
3. Volume overload with small pleural effusions, ascites, and
body wall
edema.
4. Left ovarian cystic lesion. Recommend correlation with
patient's
menstrual status, as well as outpatient pelvic ultrasound in 6 -
12 weeks
CTA HEAD W&W/O C & RECONS [**2161-9-7**]
1. Evolution of the known infarcts in the left cerebral
hemisphere.
2. Grossly stable widespread subarachnoid, intraparenchymal, and
intraventricular hemorrhage with stable rightward subfalcine
herniation.
3. Diffuse vasospasm of the anterior and posterior circulation
with the M1
segment of the left MCA containing a stent.
[**2161-9-8**]: In comparison with the study of [**9-6**], the monitoring
and support devices remain in place. There is a new dense streak
of opacification at the right base consistent with atelectasis.
Otherwise, little change with no evidence of vascular congestion
or acute pneumonia.
[**2161-9-8**]: Lower extremity doppler ultrasound: negative for DVT
bilaterally
[**2161-9-9**]: stable right lower lobe infiltrate/aspirate
[**2161-9-9**]: MRI Brain noncontrast IMPRESSION:
1. Extensive multifocal acute infarcts involving, as detailed
above,
involving the frontal cortex, centra semiovale, cingulate gyri,
bilaterally, as well as the left posterior parietal cortex,
basal ganglia and occipital pole. There is no specific evidence
of hemorrhagic transformation of these infarcts.
2. Extensive multifocal hemorrhage including diffuse
subarachnoid hemorrhage, layering intraventricular blood and
left frontotemporal parenchymal hematoma, as on recent studies.
3. Status post extensive left frontotemporoparietal craniectomy
with
herniation of edematous brain through the craniectomy defect, as
before.
4. Status post right transfrontal ventriculostomy catheter
placement,
unchanged in position, with no further ventricular dilatation to
suggest
ventriculostomy malfunction or obstructive hydrocephalus.
[**2161-9-14**] Portable Chest Xray
FINDINGS: There is a newly placed left PIC catheter with the tip
positioned in the upper SVC. A right-sided subclavian catheter
tip is positioned within the mid SVC. The tip of a Dobbhoff
feeding tube is within the stomach. The patient has been
extubated and a tracheostomy catheter has been placed and the
tip of the tracheostomy catheter is 4.2 cm from the carina. Lung
volumes are low with bibasilar atelectasis. Small bilateral
effusions may be present.
[**2161-9-16**]: CT head: IMPRESSION:
1. Massive ventriculomegaly, new from prior study, suggesting
that the
ventriculostomy catheter may not be functioning properly.
2. No new foci of hemorrhage identified.
3. Parenchymal and subarachnoid hemorrhage has largely resolved.
[**2161-9-18**]: CT Head: IMPRESSION:
1. Status post right frontal approach VP shunt placement with
tip terminating near the septum pellucidum and expected
postoperative changes.
2. Overall stable appearance of the brain with edematous and
protuberant left hemisphere with similar distribution of
hypodensity, released by a left-sided craniotomy.
3. Stable degree of hydrocephalus.
4. Stable trace intraventricular hemorrhage layering along the
occipital
horns.
5. No new hemorrhage or major vascular territorial infarct.
EEG [**9-20**] to [**9-22**]:
Final read pending. Preliminary reports indicate some spikes but
no active seizure activity.
Brief Hospital Course:
Ms. [**Known lastname 17204**] was admitted to the ICU under the care of Dr.
[**First Name (STitle) **], Neurosurgery, after being transferred intubated from
[**Hospital3 7571**]Hospital. She underwent cerebral angiogram and
the Left ICA aneurysm was coiled. an EVD was placed. A clot was
noted proximal to the aneurysm and integrilin was given. She was
kept on a Heparin drip through the night and her R femoral
sheath remained in place.
She was brought to the angio suite to re-evaluate this thrombus
the following am on [**2161-8-25**]. When on the angio table it was
noted that her left pupil was dilated and fixed. 10 mL of csf
was removed from the proximal EVD and her pupils were then equal
and reactive. She was brought emergently to the CT scanner.
Her image revealed that she had increased cerebral edema
surrounding the left IPH.
She then was brought emergently to the OR for a left
hemicraniectomy on [**8-25**]. She tolerated this procedure well. A
subgaleal drain was placed. She was brought back to the ICU to
recover. Her postoperative exam was stable and her pupils were
briskly reactive [**2-14**]. Her postoperative images were as expected.
She then returned to the angio suite that same day for
diagnostic cerebral angiogram and the thrombus was not
visualized. The dome of the aneurysm does not have flow but the
base still has some blood flow within it. Her EVD was
functioning well and kept at 15 cm of H20.
On [**8-26**] Cardiac enzymes trended down, Her subgaleal drain was
discontined. CT head done after removal showed mild relief of
the mass effect. Echo showed regional LV systolic dysfunction
suggestive of stress cardiomyopathy with an EF of 30%. No
significant valvular abnormality seen. Mild to moderate
pulmonary artery hypertension or AV mass. TCD were without signs
of vasospasm. Her corrected dilantin level was 10.7 and no blus
was given. She needed fentanyl and a paralytic blous around 6pm
as she was overbreathing the ventilator and had respiratolry
alkalosis. Her low POC2 was putting her as risk for
vasoconstriction and vasospasm, her PEEP was brought up to 8. A
Levophed drip was started for hypotension. All paralytics and
fentanyl were held for a neuro assessment at 7pm. At this time
she had bilateral corneal reflexes and mild pupillary reaction.
There was flexion in her UE to noxious stimuli, right greater
than left. She withdrew her LE to noxious. EEG monitoring was in
place. Her EVD was functioning well. She required a distal flush
due to blood in the line and her output slowed down in the
evening as her ICP was not exceeding 15 often and her EVD level
was 15 cm H2O.
Her status remained Critical on [**8-27**]. Events of the day
included weaning of the Levophed, maintained on Neo, sedation
was changed to fentanyl and Midazolam to control her neurogenic
respiratory rate and respiratory alkolosis. TCDs were within
normal limits. The cerebral angiogram was discontinued given
her cardiopulmonary instability. Broad spectrum antibiotics were
started for GNR in her BAL. Lower extremity dopplers were
obtained to rule out DVTs- which was negative.
A CTA was performed on [**8-28**] which showed increasing cerebral
edema surrounding the left temporal hematoma and diffuse SAH.
She also was febrile. We intiated agressive cooling to 34
degrees Celcius for cerebral protection. She required sedation
and neruo checks were limited to pupillary exams. The EVD was
functioning well. EEG showed diffuse encephalopathy. She
required multiple agents for hypotension.
An attempt was made at removing the arctic sun pads but the pts
temperature began to climb. It was re-initiated after ICP's
began to rise as well. She recieved a single dose of 24.3% NS.
On [**9-1**] a mini BAL was done which resulted in 2+ staph and
patient was started on ceftriaxone. On [**9-2**], patient was
started on a pentobarb coma for increase in ICP. Diamox was
given x4 and artic sun reinitiated. On [**9-3**], CTA revealed
vasospasm, pentobarb was weaned to 1.0, rewarm to 36 degrees,
and SBP greater than 160. Patient was taken to angiogram where
angioplasty of the R MCA and ACA as well as L MCA was done, she
recieved verapamil in each of the arteries and the size of
aneurysm was seen to be larger in size. Patient was transported
to ICU with sheath in place. On [**9-4**], repeat head CTA showed
basilar artery vasospasm and CT showed new L ACA infarct. She
was taken for angiogram where the basilar artery was angioplasty
and the L ICA aneurysm was stented and coiled. L ACA was seen to
be in vasospasm as well, but was unable to administer verapamil.
She was taken back to the ICU where she was placed on plavix.
Cooling and pentobarb were discontinued. Blood pressure goal was
to be around liberalized 120-160. EVD was stable at 10. Sheath
was taken out post angio.
On [**9-7**] she remained stable except for persistant fevers,
persumably from VAP and she remained on a cooling blanket to
maintain normothermia. Bedside TCDs revealed moderate spasm of
bilateral vertebrals and basilar. A CTA was performed that
showed diffuse vasospasm of the anterior and posterior
circulation with the M1 segment of the L MCA. A bronch was done
for a fever of 102.
On [**9-8**], patient had EO to noxious, RUE attempts to localize,
LUE flexion to nox, BLE w/d to noxious stimuli. PERRL. Lower
extremity dopplers were obtained for survailance with no
evidence of DVTs. MRI head with DWI was done on [**9-9**] for
prognostic evaluation. EVD was raised to 20cm H2O. She was no
longer being cooled.
The MRI showed extensive left sided infarcts and bifrontal
infarcts. A family meeting was held with Dr [**First Name (STitle) **] and the
Stroke team to discuss prognosis and determine goals of care.
The patient's husband was told that there would be extensive
deficit but maybe with extensive rehab she may regain some
function that allows some ability for self care. He was also
told that she would not go to rehab from this hospitalization
given her cognitive status- as she is unable to participate in
rehab so a [**Hospital1 1501**] would be needed. The husband wanted to consult
with other family members before making any decision. On [**9-9**]
overnight, she became febrile and her ICPs elevated to the 20's.
She was placed on the cooling blanket to cool her to
normothermia and her EVD was dropped to 15cm.
On [**9-10**], the husband consented to go ahead with further care
and consented to a trach/peg placement. Her trach was placed on
[**9-10**]. The plan as of [**9-10**] is to stop plavix on [**9-11**], place
peg on [**9-16**], and VPS on [**9-18**]. She remained on the cooling
blanket and her EVD remained at 15cm. There was no further ICP
issues through the day and her exam remained unchanged.
On [**9-11**], patient continues to spike temperatures. CSF was sent
for culture and cooling was discontinued. ID was also consulted
for increase in WBC and fevers. Trach was placed on [**9-10**]. ICP
are stable and EVD was replaced overnight for leaking around
drain site and remained at 15cmH20. Patient had EO to voice and
stimuli, weak flexion in BUE, triple flexion in RLE and weak w/d
in LLE. She continues to be on two pressors to maintain her SBP
140-160.
on [**9-12**] patient was placed on Trach collar and able to tolerate
that for a brief period of time. Pressors were stopped and
patient was able to maintain a blood pressure above 100. On
[**9-14**] patient was tolerating Trach mask and stable from a
pulmonary status, had low grade temps but no fever spikes,and
completed a 21 day course of Nimodipine. A low hematacrit was
noted on am CBC at 22, a repeat was performed that confirmed the
initial finding, but no blood transfusion was performed since
the patient remained hemodynamically stable. Two C.diff
cultures came back negative.
from [**9-12**] to [**9-18**] patient remained afebrile off antibiotics.
She was started on a course of oral Diflucan for vaginal
candidiasis. She underwent a ventricular perotineal shunt
placement on [**9-18**] with the help of general surgery for the
laproscopic aproach to the abdomen.
On [**9-19**] the patient's craniectomy site was noted to be more
sunken compared to the prior day. Her shunt setting was changed
to 1.5 (from 1.0). She was also noted to have increased tone,
especially in her lower extremties so she was started on
baclofen. Neurologically she was stable and tolerating a trach
mask.
On [**9-20**] her craniectomy site appeared full and her shunt was
dialed down to 1.5.
She was started on EEG to r/o seizure activity as she was noted
to have increased tone. On [**9-21**] she remained stable, EEG reports
indicated some spikes but no active seizure activity. We
increased keppra to 1000 [**Hospital1 **] on [**9-22**].
Medications on Admission:
Relpax for migraines, tramodol for pain, Savella
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks: PLEASE DISCONTINUE ON [**2161-10-4**].
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
PLEASE DISCONTINUE AFTER [**2161-10-6**] DOSING.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
8. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for Fevers.
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. potassium chloride 20 mEq Packet Sig: One (1) Packet PO PRN
(as needed).
12. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain/agitation.
14. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Ondansetron 4 mg IV Q8H:PRN N/V
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. Metoprolol Tartrate 5 mg IV Q6H:PRN HR>110
19. potassium phosphate dibasic 3 millimole/mL Parenteral
Solution Sig: One (1) Intravenous PRN (as needed).
20. magnesium sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed).
21. potassium chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed).
22. calcium gluconate in D5W 2 gram/100 mL Solution Sig: One (1)
Intravenous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care
Discharge Diagnosis:
LEFT ICA ANEURYSM
LEFT INTRAPARENCHYMAL HEMORRHAGE
INTRAVENTRICULAR HEMORRHAGE
CEREBRAL EDEMA
HYDROCEPHALUS
POST-OPERATIVE ANEMIA REQUIRING TRANSFUSION
FEVER
TACHYCARDIA
INTERNAL CAROTID ARTERY THROMBUS
HYPOTENSION
Respiratory alkalosis
Stress Cardiomyopathy with EF 30%
Coma
Protien/Calorie malnutrition
Electrolyte imbalance
Pneumonia
Pulmonary Edema
4 x 3.6 cm L adnexal cystic lesion
AORTIC MASS
DYSPHAGIA
RESPIRATORY FAILURE
SPASTICITY
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:
General Instructions:
*** YOU ARE GOING TO BE SCHEDULED FOR REPLACEMENT OF YOUR BONE
FLAP for Wednesday, [**10-14**]. A Head CT is scheduled for
8am and surgery at 1pm. Please find detailed surgical
instructions with your d/c paperwork.
**** YOU WILL NEED TO STOP YOUR ASPIRIN 1 WEEK PRIOR TO SURGERY
(Last dose to be on [**2161-10-6**]).
**** PLEASE DISCONTINUE PLAVIX ON [**2161-10-4**].
**** YOU DO NOT NEED AN OFFICE VISIT BEFORE YOUR SURGERY
**** Please draw pre-op labs while in rehab and fax to our
office at [**Telephone/Fax (1) 87**]. A lab requistion has been sent along.
***** You have a programmable VP shunt, it is set at 1.5. You
will need to have this reprogrammed after any MRI. ******
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
If your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Followup Instructions:
- Please return on Wed [**10-14**] for your cranioplasty and
pre-op CT Head. The surgical letter has been sent along with
your d/c paperwork. Please call [**Telephone/Fax (1) 4296**] with any questions
or concerns.
- During your hospital stay it was noted that you have L adnexal
cystic lesion- postmenopausal -> recommend outpt pelvic US.
Please call your primary care physician for this / this should
be done wihtin 6-12 weeks
Completed by:[**2161-9-22**]
|
[
"51881",
"2851"
] |
Admission Date: [**2123-3-15**] Discharge Date: [**2123-3-17**]
Date of Birth: [**2084-5-13**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
39 y/o M with PMH of type 1 DM, depression, and bipolar who is
brought in by EMS with altered MS. [**Name13 (STitle) **] is unable to give
history. Per ED history the patient was feeling poorly for the
last few days. His family reports that he felt like he had the
flu on sat. night, however they are unable to give further
history. Per the ED the patient has had diarrhea and vomiting as
well as cough over last few days, however the family is unable
to verify this information. His family was unable to get a hold
of him this afternoon and a friend went over to check on him. He
was found to be confused and brought to the ED for further
evaluation.
On arrival to the ED VS were T 102, HR 120, BP 166/86 RR 22 100%
on unknown amount of oxygen. He was found to be confused and
agitated and was intubated for airway protection. He was given
fentanyl 100mcg, Etomidate 20mg, succ 120mg IV and vecuronium
100mg IV. He was noted to have L gaze deviation and R beating
nystagmus. LP was performed that showed 9500 WBC (91% polys),
250 RBC, 1140 prot and glu 6. He was given dexamethasone 10mg
IV, acyclovir 700mg IV, ampicillin 2gm IV, vancomycin 1gm IV and
ceftriaxone 2gm IV. He also received 4L IVF, versed 2mg IV x 3,
tylenol 1gm, propofol gtt and insulin gtt. Neuro was consulted
given his neuro findings. Head CT showed no acute bleed and
prominant ventricles. CTA head was normal. Labs were notable for
WBC 21.8 with 8% bands and INR 1.8. Glu was elevated to 522. He
was admitted to the ICU for further management.
On arrival to the ICU the patient is intubated and sedated. ROS
is unable to be obtained. Noted to be tachycardic to 160s and
hypertensive to 227/111. T was 101.9. He was given 5mg IV
labetolol , tylenol and continued on IVF.
Past Medical History:
IDDM since age 3
Depression, h/o suicide attempt 2 years ago by hanging
CRI, unknown baseline
Bipolar
recent back injury
Social History:
Married, separated from wife. Have 10 year old child. Lives
alone in [**Location (un) 745**]. Previously worked as mechanic, out of work due
to back injury. Current smoker, 1ppd x 20+ years. H/o oxycodone
and EtOH abuse, has been sober for over 2 years. No h/o IVDU.
Family History:
mother - bipolar
[**Name (NI) 9876**] - DM
Physical Exam:
On admission
VITAL SIGNS: T 101.9 BP 227/111 HR 126 RR 19 O2 100% on vent
GENERAL: Intubated, sedated
HEENT: superficial abrasions on forehead, pupils non-reactive,
R>L. No conjunctival pallor. No scleral icterus. ETT and OG tube
in place.
CARDIAC: Tachy, irregular, No murmurs, rubs or [**Last Name (un) 549**] audible.
LUNGS: CTA anteriorly
ABDOMEN: NABS. Soft, ND. No HSM
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses, R elbow with surrounding erythema and possible effusion
SKIN: No rashes, multiple tattoos, no rash
NEURO: Sedated, babinski unequivocal, pupils unreactive,
withdraws to painful stimuli.
Pertinent Results:
[**2123-3-17**] 07:42AM BLOOD WBC-22.0* RBC-3.72* Hgb-10.9* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.3 RDW-14.3 Plt Ct-236
[**2123-3-15**] 09:41PM BLOOD Neuts-53 Bands-43* Lymphs-2* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2123-3-16**] 04:03PM BLOOD PT-15.5* PTT-26.8 INR(PT)-1.4*
[**2123-3-16**] 03:23AM BLOOD Fibrino-638*
[**2123-3-15**] 09:41PM BLOOD FDP-40-80*
[**2123-3-17**] 07:42AM BLOOD Glucose-246* UreaN-23* Creat-1.2 Na-162*
K-3.8 Cl-132* HCO3-25 AnGap-9
[**2123-3-16**] 03:23AM BLOOD ALT-18 AST-26 LD(LDH)-190 CK(CPK)-220*
AlkPhos-45 TotBili-0.4
[**2123-3-16**] 03:23AM BLOOD CK-MB-7 cTropnT-0.14*
[**2123-3-17**] 07:42AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.3
[**2123-3-15**] 09:41PM BLOOD Hapto-267*
[**2123-3-17**] 07:42AM BLOOD Osmolal-340*
[**2123-3-15**] 02:15PM BLOOD Ammonia-64*
[**2123-3-15**] 02:15PM BLOOD Acetone-TRACE
[**2123-3-15**] 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-3-15**] 02:30PM BLOOD Glucose-498* Lactate-7.4*
[**2123-3-15**] 06:35PM BLOOD freeCa-1.11*
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) WBC-9500 RBC-250*
Polys-91 Lymphs-2 Monos-7
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) TotProt-1140*
Glucose-6
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS -
PCR-Test
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
[**2123-3-15**] 02:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.031
[**2123-3-15**] 02:15PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2123-3-15**] 02:15PM URINE RBC-[**2-25**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
39 y/o M with PMH of type 1 DM, depression, and bipolar who is
brought in by EMS with altered MS, found to have pneumococcal
meningitis.
#. Meningitis: Pt's initial presentation was that of DKA and
altered mental status. He had focal neurologic changes on exam
as well as increased ICP on LP. Lumbar puncture and preliminary
blood cultures confirmed pneumococcal meningitis. Etiology of
this was unknown, as pt and family denied any drug use and had
negative tox screen, but pt was likely predisposed to severe
infection due to longstanding diabetes type 1. He was
intubated, treated with pressors, dexamethasone, vancomycin,
ampicillin, ceftriaxone and acyclovir and was followed by ID and
neuro. Head CT showed severe intracranial edema and EEG showed
no signs of seizure. Given pt's severe meningitis and
displacement of grey-white junction, central DI (sodium to
160s), hypothermia, lack of reflexes, pt was though to have
minimal likelihood of recovery. He was evaluated by the organ
bank, who ruled him out as a donor given his high risk
bacteremia. Family was informed and after parents arriving, pt
was made CMO and extubated. He passed away from pulmonary arrest
at 3:10pm on [**3-17**]. Autopsy was offered but refused.
Medications on Admission:
Insulin, unknown
Zestril, unknown dose
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumococcal Meningitis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2123-3-17**]
|
[
"5849",
"40390",
"5859",
"2724",
"32723"
] |
Admission Date: [**2195-7-29**] Discharge Date: [**2195-8-17**]
Date of Birth: [**2139-1-6**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Metformin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CVL placement
Midline access placement
Intubation
Thrombolysis of submassive PE
EGD and Colonoscopy
IVC filter placement
History of Present Illness:
56 yo [**Male First Name (un) 4746**] male with Crohn's disease, diverticulosis s/p
hemicolectomy times 2, type 2 diabetes, and obesity who
initially presented to OSH for shortness of breath of one week
duration and found to have bilateraly submassive PEs and
intubated for respiratory failure.
.
Transferred to [**Hospital1 18**] on [**2195-7-29**]. Echo showed RB strain. Received
TPA for thrombolysis and heparin gtt was started. Vital signs
were stable and was extubated on [**2195-7-30**]. After the heparin gtt
was initiated, pt developed maroon stools mixed with BRBPR,
thought likely secondary to underlying crohn's disease. Hcts
were measured closely and fell from 40 on admission to 30
following heparin initiation. GI was consulted and pt underwent
upper endoscopy which showed no active source of bleeding.
Steroids were increased from 20mg daily to 40mg daily and pt was
continued on pentasa.
.
Called out to the floor on [**2195-8-2**] with stable vital signs, but
hct dropped from 30->26 requiring transfusion of 2 units prbcs.
With bowel prep for colonoscopy planned for the next day, it was
decided to readmit patient to ICU for better monitoring of Hcts
and vital signs. Patient was never hemodynamically unstable. In
total, he has needed 4 units of PRBCs.
.
In the ICU, patient underwent colonoscopy, showing diffuse
crohn's disease consistent with a flare but no intervention was
warranted. IVC filter was placed on [**2195-8-4**], should the patient
require emergent cessation of anticoagulation secondary to large
GI bleed. Hcts and vitals signs stable during this admission.
Bridge to coumadin has been initiated.
.
Upon reaching the floor, patient reports that he is feeling
good. Denies lightheadedness, weakness, shortness of breath,
chest pain, acute change in abdominal pain.
Past Medical History:
Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis
Social History:
Patient is not married but lives with significant other (female)
and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. He only drinks alcohol 2x year
currently, but reports heavy alcohol use that stopped
approximately 20 years ago. He denies tobacco use. He reports
using cocaine with cessation approximately 25 years ago. He is a
former mechanic.
Family History:
No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.
Physical Exam:
Physical exam: ([**2195-8-5**])
VS: T: 97.3 (97.5-98.6), HR 61 (61-76) BP 139/80
(133-139/80-90), 97% RA, RR: 18
Gen: NAD, comfortable.
HEENT: PERRLA, EOMI, MMM, oropharynx clear
CV: distant heart sounds, RRR with nl S1, S2. No m/r/g.
Pulm: CTA B with no w/r/r.
Abd: obese, midline scar and lateral scars on left and right
with herniations visible. Nontender, positive bowel sounds in
all 4 quadrants. Right femoral site has dressing from IVC
placement - c/d/i.
Ext: ecchymosis noted on the arms bilaterally, no pedal edema,
no calf tenderness, no palpable cord.
Neuro: A+OX3, 5/5 strength in all 4 extremities
Pertinent Results:
Selected Labs:
[**2195-7-29**] 02:15PM BLOOD WBC-16.7* RBC-4.72 Hgb-13.2* Hct-40.8
MCV-86 MCH-27.9 MCHC-32.3 RDW-15.1 Plt Ct-338
[**2195-7-30**] 03:04AM BLOOD WBC-17.1* RBC-4.31* Hgb-11.7* Hct-37.3*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.3 Plt Ct-267
[**2195-7-31**] 03:14AM BLOOD WBC-10.8 RBC-3.67* Hgb-10.2* Hct-30.5*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.1 Plt Ct-240
[**2195-8-1**] 03:02AM BLOOD WBC-8.2 RBC-3.29* Hgb-9.1* Hct-27.6*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-261
[**2195-8-2**] 08:09AM BLOOD WBC-7.2 RBC-3.21* Hgb-9.0* Hct-26.6*
MCV-83 MCH-28.0 MCHC-33.7 RDW-14.9 Plt Ct-273
[**2195-8-3**] 04:05AM BLOOD WBC-9.5 RBC-3.68* Hgb-10.0* Hct-30.3*
MCV-82 MCH-27.1 MCHC-32.9 RDW-15.0 Plt Ct-309
[**2195-8-4**] 04:52AM BLOOD WBC-9.0 RBC-3.62* Hgb-10.2* Hct-30.1*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.6 Plt Ct-317
[**2195-8-5**] 06:04AM BLOOD WBC-10.5 RBC-3.70* Hgb-10.1* Hct-30.9*
MCV-84 MCH-27.3 MCHC-32.7 RDW-14.6 Plt Ct-362
[**2195-8-13**] 07:10AM BLOOD WBC-14.1* RBC-4.27* Hgb-11.4* Hct-36.0*
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.3 Plt Ct-441*
[**2195-8-14**] 07:00AM BLOOD WBC-14.1* RBC-4.17* Hgb-11.3* Hct-35.0*
MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4 Plt Ct-411
[**2195-8-15**] 07:22AM BLOOD WBC-13.9* RBC-4.34* Hgb-11.5* Hct-37.1*
MCV-86 MCH-26.6* MCHC-31.1 RDW-14.5 Plt Ct-416
[**2195-8-16**] 06:47AM BLOOD WBC-13.6* RBC-4.29* Hgb-11.5* Hct-36.0*
MCV-84
.
[**2195-7-29**] 02:15PM BLOOD Glucose-265* UreaN-22* Creat-1.4* Na-139
K-5.6* Cl-106 HCO3-23 AnGap-16
[**2195-8-16**] 06:47AM BLOOD Glucose-145* UreaN-23* Creat-1.2 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
.
[**2195-7-29**] 02:15PM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1
[**2195-8-7**] 06:39AM BLOOD PT-13.6* PTT-82.7* INR(PT)-1.2*
[**2195-8-8**] 05:27AM BLOOD PT-15.9* PTT-66.9* INR(PT)-1.4*
[**2195-8-9**] 05:22AM BLOOD PT-17.2* PTT-62.5* INR(PT)-1.5*
[**2195-8-10**] 05:55AM BLOOD PT-17.3* PTT-78.4* INR(PT)-1.6*
[**2195-8-10**] 05:09PM BLOOD PT-16.7* PTT-45.0* INR(PT)-1.5*
[**2195-8-11**] 02:51AM BLOOD PT-17.3* PTT-101.6* INR(PT)-1.6*
[**2195-8-11**] 09:10AM BLOOD PT-18.3* PTT-66.3* INR(PT)-1.7*
[**2195-8-11**] 04:32PM BLOOD PT-17.6* PTT-49.1* INR(PT)-1.6*
[**2195-8-12**] 06:38AM BLOOD PT-17.0* PTT-58.4* INR(PT)-1.5*
[**2195-8-12**] 10:00AM BLOOD PT-16.7* PTT-52.5* INR(PT)-1.5*
[**2195-8-15**] 01:25AM BLOOD PT-24.4* PTT-58.3* INR(PT)-2.3*
[**2195-8-14**] 04:25PM BLOOD PT-23.9* PTT-43.7* INR(PT)-2.3*
[**2195-8-14**] 07:00AM BLOOD Plt Ct-411
[**2195-8-14**] 07:00AM BLOOD PT-23.4* PTT-83.9* INR(PT)-2.2*
[**2195-8-13**] 07:10AM BLOOD PT-20.0* PTT-77.1* INR(PT)-1.8*
[**2195-8-13**] 01:40AM BLOOD PT-18.4* PTT-71.9* INR(PT)-1.7*
[**2195-8-14**] 07:00AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-13**] 07:10AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.1
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-16**] 06:47AM BLOOD PT-30.5* PTT-87.6* INR(PT)-3.0*
[**2195-8-15**] 04:55PM BLOOD PT-27.4* PTT-61.2* INR(PT)-2.7*
.
[**2195-7-29**] 02:15PM BLOOD Calcium-8.6 Phos-6.1* Mg-2.0
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
.
Upon reaching the floor on [**2195-8-5**] until discharge, patient's
hematocrit remained between 30.4 and 37.3.
.
ECG ([**2195-7-29**]): Tracing 1. Sinus tachycardia. Non-specific
intraventricular conduction delay. Non-specific ST-T wave
changes. No previous tracing available for comparison.
.
TTE ([**2195-7-29**]): IMPRESSION: RV strain c/w acute pulmonary
embolism.
.
CTA Chest, Abdomen, Pelvis ([**2195-7-29**]): IMPRESSION: 1. Extensive
bilateral pulmonary emboli involving the bilateral main
pulmonary arteries with extension through to the lobar,
segmental, lower lobe subsegmental branches bilaterally, as
above. Associated findings of right heart strain. 2. No evidence
of acute aortic injury. 3. Bilateral dependent
atelectasis/aspiration. 4. Small left-sided ventral abdominal
hernia containing non-obstructed loop of small bowel. Suggestion
of right-sided spigelian hernia, incompletely assessed as right
lateral aspect of the abdomen fully included.
.
ECG ([**2195-7-30**]): Tracing 2. Sinus tachycardia. Non-specific T wave
changes. Low QRS voltage in the limb leads. Compared to the
previous tracing of [**2195-7-29**] the QRS voltage has decreased in the
limb leads. ST segment depression is less pronounced and the
ventricular rate is slower.
.
ECG ([**2195-7-31**]): Tracing 3. Sinus rhythm. T wave inversions in
leads V1-V3. Cannot exclude ischemia. Low QRS voltage in the
limb leads. Compared to the previous tracing of [**2195-7-31**] artifact
is present. T wave inversions are less pronounced in lead V3 and
the T waves are more upright and normal appearing in leads
V4-V5.
.
CXR ([**2195-7-30**]): The ET tube tip is 4.5 cm above the carina. The
right internal jugular line tip is at the level of mid low SVC.
There is no change in the cardiomediastinal contour with the
mediastinal widening being due to extensive mediastinal
lipomatosis. Bibasilar atelectasis have developed in the
interim, new, but note is made that the lung bases cannot be
entirely evaluated since they were not entirely included in the
field of view. No evidence of pulmonary edema. No pneumothorax.
.
Bilateral Lower Extremity Vein Ultrasound ([**2195-7-31**]): IMPRESSION:
1. Non-occlusive thrombosis of the right popliteal (deep) vein.
Non- visualization of right posterior tibial veins, can not
exclude thrombosis
within these veins. 2. No evidence of deep venous thrombosis in
the left lower extremity.
.
ECG ([**2195-8-5**]): Sinus tachycardia. Possible left atrial
abnormality. There is one ventricular premature contraction.
Non-specific inferior ST-T wave changes. Compared to the
previous tracing of [**2195-8-5**] there is no significant change.
Brief Hospital Course:
56 yo [**Male First Name (un) 4746**] with DMII, HTN, crohn's disease on steroids,
diverticulosis s/p colectomy X 2, who was admitted to the MICU
on [**7-29**] for respiratory failure requiring intubation secondary to
submassive PE.
.
# Pulmonary Embolism. Patient presented to [**Hospital1 18**] and found to
have submassive clot burden on CTA with significant hypoxia
(PAO2 only 130 in spite of 100% oxygen). He required intubation
for respiratory failure and also had evidence of right heart
strain from bedside echo. He was lysed with TPA and extubated
afteward. He was begun on heparin gtt. Shortly after the
initiation of heparin, pt developed maroon stools with BRBPR and
required transfusion of 4 u PRBC. Hematocrits were measured
closely and fell from 40 on admission to 30 following heparin
initiation. GI was consulted and pt underwent upper endoscopy
which showed no active source of bleeding. Steroids were
increased from 20mg daily to 40mg daily and pt was continued on
pentasa. Patient was called out to the floor on [**2195-8-2**], but
given persistence of maroon stools with BRBPR, patient returned
to the MICU the following morning for bowel prep for anticipated
colonoscopy with close monitoring of vitals and hematocrit. He
underwent colonoscopy and was found to have evidence of active
Crohns disease, though no active bleeding was identified. His
hematocrit stabilized but because he had a clot in his lower
extremities in combination with concerns regarding his ability
to tolerate anticoauglation in the short term, an IVC filter was
placed on [**2195-8-4**]. Patient was called out to floor on [**2195-8-5**]
with a stable hematocrit greater than 30. Vital signs remained
stable without any requirement for supplemental oxygen.
.
On the floor, heparin gtt was continued with bridge to
therapeutic INR with Coumadin. Hematocrits were monitored
closely and remained stable. The option to be discharged home
on lovenox therapy was presented to the patient on several
occasions but given the gravity of his presentation and his
underlying anxiety, pt preferred to remain hospitalized until
his INR was therapeutic. Patient never developed hypoxia and
never complained of shortness of breath on the floor. Patient's
INR slowly elevated over the course of this admission, reaching
therapeutic INR (2.2) on [**2195-8-14**]. In order to reach this INR,
coumadin doses were increased as tolerated, with daily doses
between 5-15 mg daily depending on the INR. On [**2195-8-10**], patient
reported that central line was accidentally removed during
showering, and occlusive dressing was placed. Patient was given
midline access and was without anticoagulation for approximately
3-4 hours. Patient was bridged for 48 hours upon reaching
therapeutic INR. The duration of his anticoagulation therapy
remains unclear, but patient has been instructed to follow up
with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for further guidance.
He will likely need anticoagulation for at least 3 months, with
repeat LENIs to determine if clot burden is still present. If
clots are present, he will need to continue anticoagulation. If
clots are absent, stopping of anticoagulation may be considered.
However, if his underlying crohn's disease is the etiology of
his increased susceptibility to hypercoagulability, patient may
require life-long anticoagulation with coordinated care between
his PCP and gastroenterologist. In regards to patient's IVC
filter, it was not removed during this admission due to
persistent clot burden and the necessity to continue heparin
gtt. He will follow up with interventional radiology at [**Hospital1 18**]
and will have it removed within the next year, as per IR.
.
# acute blood blood loss anemia: Likely secondary to underlying
crohn's disease with flare in the setting of anticoagulation.
Patient developed maroon stools with BRBPR in response to
initiation of heparin gtt, with concurrent drop in hematocrit
from 40 on admission to 26 on [**2195-8-2**]. Patient was transfused
with 4 units PRBC in the MICU. EGD showed no acute bleeding but
colonoscopy showed diffuse crohn's disease. Hematocrit was
measured frequently, stabilized around 30 on [**2195-8-3**] and
remained at or above this level throughout this admission. On
[**2195-8-15**], Hct was noted to be 37.2. Active type and screen was
maintained. Patient continued to have BRBPR/maroon stools until
[**2195-8-9**], which may have been due to the passing of clots. All
other vital signs remained stable and patient did not experience
any signs of hypotension or anemia.
.
# Crohns. Diagnosed in [**5-2**] but patient reported chronic
symptoms for many years. Prior to admission, patient was on
20mg PO prednisone taper for prior crohn's flare. As above,
following administration of tpa lysis and heparin gtt for PE,
patient developed BRBPR and maroon stools. In the MICU, an EGD
showed no upper GI bleeding and a colonoscopy showed an active
crohn's flare with no intervenable bleeding areas. GI followed
patient during this admission and increased PO steroid dose to
40mg PO in the MICU. He was continued on mesalamine 500mg PO
BID. On [**2195-8-9**], patient reported that his stools were brown,
formed, without blood. On [**2195-8-10**], GI was re-consulted and his
prednisone was tapered down. He will be discharged on 30mg PO
daily with a goal taper of 5mg per week. Remained
hemodynamically stable and asx. Patient will follow up with his
gastroenterologist, Dr. [**Last Name (STitle) **], for further management as an
outpatient.
.
# Type 2 Diabetes: With the administration of increased
steroids, it was suspected that blood sugars would run higher.
It was difficult to control dinner and evening sugars, which
spiked in the 300's. During this admission, patient was
continued on HISS with long acting glargine. The scale was
continually uptitrated with goals of containing sugars under
300. Patient will be discharged on his home insulin regimen,
which he reports was effective in controlling his sugars. The
tapering of steroids will help with better sugar control.
.
# HTN. Patient's outpatient medication for hypertension included
lisinopril. In the MICU and in the setting of his lower GI
bleeding, this medication was held. After several days of
continued stabilized of the hematocrits and vital signs,
lisinopril was restarted. Blood pressures remained stable
following re-initiation of this medication.
.
# Acute Renal failure. Patient was noted to have a creatinine
of 1.4 on presentation. Likely secondary to decreased volume
status in the setting of lower GI bleeding. Creatinine improved
in response to fluids and remained stable over the course of
this admission.
.
# Disposition: There were several obstacles to the discharge of
this patient. Patient is from [**Hospital3 4298**] and
transportation was an initial problem. [**Name (NI) **] was originally
agreeable to discharge on lovenox therapy, provided that his
significant other could pick him up from the hospital. Primary
team and social work contact[**Name (NI) **] pt's significant other, who
reported that she was not ready to have patient back home. She
initially reported that the weekend traffic at [**Hospital3 4298**]
was too overwhelming for her to travel. Upon further
conversation, she revealed that in the last year, patient had
become increasingly angry and had become more threatening
(though not physically). Patient believed that he was not
medically stable, was anxious, and demanded to stay on heparin
gtt until he was therapeutic. Denied several offers to leave on
lovenox therapy.
.
Patient if FULL code. HCP is long-time girlfriend, [**Name (NI) **]
[**Name (NI) **] ([**Telephone/Fax (1) 82747**].
Medications on Admission:
Medications at Home: (as per initial note)
Lisinopril 10 mg daily
Humalog ISS
Lantus 30 qhs
NPH 30 qam
Tramadol 50 mg PO daily
Pentasa 500 mg [**Hospital1 **]
.
Medications on Transfer:
Pantoprazole 40 mg PO Q24H
Warfarin 5 mg PO DAILY
Hydrocortisone Acetate Ointment 1% 1 Appl PR DAILY
Heparin IV Sliding Scale
Insulin SC (per Insulin Flowsheet)
Mesalamine 500 mg PO BID
PredniSONE 40 mg PO DAILY
Cepacol (Menthol) 1 LOZ PO PRN
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime: please continue to take your humalog
sliding scale as prior to hospitalization.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for pain.
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Please follow up with your PCP as scheduled to check your
INR, with goal INR of [**1-27**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Submassive Pulmonary Embolus
Acute Blood loss anemia from lower GI bleed
Crohns Disease
Type 2 Diabetes
Hypertension
Arthritis
Discharge Condition:
Stable, hematocrit 30-33, stools brown and formed.
Discharge Instructions:
You initially went to an outside hospital with difficulty
breathing. After getting transferred to [**Hospital1 18**], we found that you
had a large blood clot in your lung. We treated your with
medication to dissolve your clot and this caused you to have
lower GI bleeding. We then put a filter in your IVC, put you on
blood thinners, and your bleeding has improved. Your vital
signs and hematocrit continue to remain stable. You were given
coumadin to thin your blood and now your INR levels are
therapeutic. Your stools are no longer bloody or maroon in
color.
.
We made the following changes to your medications:
-ADDED Coumadin 7.5mg by mouth daily. Your dose of this
medication may vary. Your primary care doctor, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **]
tell you whether to increase or decrease this medication to keep
your INR between 2 and 3
-ADDED Prednisone 30mg by mouth daily. You should continue to
take this medication until you follow up with your GI doctor.
-ADDED Pantoprozole 40mg by mouth daily. You can speak with
your GI doctor about when to stop this medication.
.
Please follow up with your GI doctor and your PCP as below. You
will need to have your blood levels monitored closely over the
next few weeks.
.
If you have any abdominal pain, fevers, chills, increase in your
bloody bowel movements, please contact your primary care
physician or visit the emergency room.
Followup Instructions:
GI doctor: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. Thursday [**8-20**] at 4pm.
[**Telephone/Fax (1) 82746**]. Please talk to your doctor about starting Bactrim
for prophylaxis if you will require long term steroids. Please
follow up with him regarding the tapering of your steroid doses.
.
Primary Care Doctor: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], check INR Wednesday [**8-19**] at 12:00pm. [**Telephone/Fax (1) 29822**]. Please go to the clinic on
Wednesday morning to have your labs drawn. The clinic will call
you in the afternoon and tell you if you need to adjust your
coumadin dose. Your primary care physician will order you a
repeat ultrasound at 3 months after discharge to see if you
still have a blood clot in your leg. If this ultrasound is
negative, you may consider stopping anticoagulation and schedule
to remove your IVC filter. You can call the interventional
radiology department at [**Hospital1 18**] to remove your IVC filter within 1
year. Phone: [**Telephone/Fax (1) 8243**]
.
You may ask your primary care physician to set you up with a
hematologist to determine if you are at risk for any future
clots.
|
[
"51881",
"5849",
"2851",
"25000",
"40390",
"2767"
] |
Admission Date: [**2141-3-10**] Discharge Date: [**2141-3-14**]
Date of Birth: [**2086-12-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypoxia/resp failure
Major Surgical or Invasive Procedure:
ICU monitoring, endotracheal intubation, flexible bronchoscopy,
arterial catheter, IJ CVC, donor nephrectomy in OR
History of Present Illness:
This is a 54 yo M with a history of IPF, currently undergoing
lung transplant evaluation who was sent in to the ED with
hypoxia and worsening dyspnea.
.
The patient has been at [**Hospital **] rehab with baseline sats there
on 6L of high 80s to low 90s. Over the last 24 hours, he was
found to be having increasing work of breathing and decreased
sats to low 80s. Per his family, he was having difficulty even
completing sentences due to dyspnea. Additionally he spiked a
temperature to around 103. He was subsequently sent to an OSH
for evaluation. Per report, he was in respiratory distress and
was intubated. CXR there showed pulmonary fibrosis, unclear if
there was superimposed infiltrate. He was not given any
medications (?ertapenem) but rec'd 2 L of NS. As his care is
primarily here (he is followed by [**Doctor Last Name **]), he was sent here.
.
Patient was recently admitted from [**Date range (1) 80477**] with progressive DOE
without any new source. It was thought to be secondary to
worsening IPF. He intermittently required increased oxygen up
to 6L NC but did not require BiPAP or intubation. His work up
for lung transplant was continued during that time.
.
In the ED, initial VS 103.2 120 73/49 39 100% on vent, unclear
settings. Once propofol was weaned, BPs increase to 120s.
However, patient became agitated and was given versed which also
made him hypotensive. He was given 1 gram of tylenol,
Vanc/Levoflox for presumed pna and 3 additional L of IVF. Also
had dirty appearing urine. UA contaminated. He was sent to the
floor for further management.
.
On arrival to the floor, patient was satting in the low 80s on
PEEP of 5 which was increased to 10. O2 sats increased to the
mid-90s. He required versed for sedation as he became
dyssynchronous with the vent when agitated and more awake.
.
Review of sytems: Unable to obtain secondary to
intubation/sedation
Past Medical History:
Born w/ pectus excavatum
IPF undergoing transplant evaluation
HTN
AVNRT s/p ablation in [**1-30**]
Social History:
Currently works as a painter, but previously has worked with
sandblasting for 4 yrs during the [**2111**] (wore respirator but
beard prevented tight seal). Occasionally travels overseas to
[**Country 2045**] and [**Country 14635**] but states not a/w Sx. No known asbestos
exposure. Smoked for 19 yrs but quit 19yrs ago.
Family History:
Brother died of rare, agressive form of pulmonary fibrosis at
VA in CT. Brother did work with him briefly as a painter.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2141-3-10**] 06:10AM BLOOD WBC-22.1*# RBC-4.41* Hgb-12.3* Hct-37.9*
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.2 Plt Ct-375
[**2141-3-10**] 06:10AM BLOOD Neuts-89* Bands-1 Lymphs-3* Monos-6 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2141-3-10**] 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2141-3-10**] 06:10AM BLOOD PT-17.1* PTT-25.0 INR(PT)-1.5*
[**2141-3-10**] 06:10AM BLOOD Glucose-108* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-100 HCO3-29 AnGap-12
[**2141-3-10**] 06:10AM BLOOD ALT-34 AST-42* CK(CPK)-142 AlkPhos-152*
TotBili-0.5
[**2141-3-10**] 06:10AM BLOOD Lipase-21
[**2141-3-10**] 06:10AM BLOOD CK-MB-7
[**2141-3-10**] 06:10AM BLOOD Albumin-2.6* Calcium-8.3* Phos-4.1 Mg-2.0
[**2141-3-10**] 01:45PM BLOOD Cortsol-12.1
[**2141-3-10**] 09:45AM BLOOD Type-ART pO2-175* pCO2-76* pH-7.20*
calTCO2-31* Base XS-0
[**2141-3-10**] 06:30AM BLOOD Glucose-109* Lactate-1.1 Na-136 K-3.9
Cl-98* calHCO3-29
[**2141-3-10**] 07:26PM BLOOD O2 Sat-98
[**2141-3-10**] 07:26PM BLOOD freeCa-1.16
[**2141-3-14**] 03:21AM BLOOD WBC-15.8* RBC-2.85* Hgb-8.2* Hct-25.1*
MCV-88 MCH-28.6 MCHC-32.5 RDW-13.7 Plt Ct-369
[**2141-3-14**] 03:21AM BLOOD PT-18.0* PTT-30.1 INR(PT)-1.6*
[**2141-3-14**] 03:21AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-136
K-3.9 Cl-97 HCO3-35* AnGap-8
[**2141-3-10**] 06:10AM BLOOD cTropnT-0.16*
[**2141-3-10**] 01:44PM BLOOD CK-MB-15* MB Indx-6.3* cTropnT-0.14*
[**2141-3-10**] 10:10PM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-0.11*
[**2141-3-11**] 02:10AM BLOOD CK-MB-9 cTropnT-0.11*
[**2141-3-12**] 02:17AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2141-3-14**] 03:21AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2141-3-14**] 03:21AM BLOOD Vanco-13.1
[**2141-3-14**] 01:20PM BLOOD Type-ART Temp-36.4 Rates-35/0 Tidal V-448
PEEP-8 FiO2-70 pO2-130* pCO2-67* pH-7.36 calTCO2-39* Base XS-9
-ASSIST/CON Intubat-INTUBATED
[**2141-3-14**] 01:20PM BLOOD Lactate-1.3
[**2141-3-13**] 04:50PM BLOOD O2 Sat-78
.
Radiology
.
[**3-10**] TTE: 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. The left ventricular cavity size
is normal for the patient's body size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. An eccentric,
posteriorly directed jet of Mild (1+) mitral 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 [**2140-12-26**], the RV
appears (more) dilated with evidence of pressure overload. The
estimated PA pressure has increased.
.
[**3-10**] CXR: Findings: There has been interval worsening of
opacification of the upper lung fields. A linear lucent line is
noted within the medial border of the left lung which most
likely represents pneumothorax. The endotracheal tube projects
approximately 6.7 cm above the carina. The NG tube distal tip
projects in the pylorus. IMPRESSION: 1. Interval increase in
opacification of upper lung zones. 2. New left pneumothorax.
.
[**3-13**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular free wall
is hypertrophied. The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
IMPRESSION: Severely dilated and moderately hypokinetic right
ventricle with at least moderate pulmonary artery systolic
hypertension. Moderate tricuspid regurgitation. Normal left
ventricular regional and global function. Small pericardial
effusion without evidence of tamponade.
Compared with the prior study (images reviewed) of [**2141-3-10**],
the findings are similar. The prior report mentions that the
right ventricle is mildly hypokinetic and moderately dilated
however on review, it was severely dilated and moderately
hypokinetic then.
.
[**3-14**] CXR: FINDINGS: In comparison with the study of [**3-13**], there
is little interval change. Support and monitoring devices remain
in place. Widespread bilateral pulmonary opacifications persist.
Enlargement of the trachea is again noted, unchanged from the
previous study.
.
Brief Hospital Course:
Respiratory failure: The patient's acute decompensation was
likely due to superimposed pneumonia on a patient with no
pulmonary reserve due to severe idiopathic pulmonary fibrosis.
According to prior OMR discharge summaries, he has been
experiencing worsening dyspnea with increased O2 requirement for
the last several weeks. He was treated with N-acetylcysteine,
vancomycin, meropenem, and ciprofloxacine during this admission.
Dr. [**Last Name (STitle) **] was in contact with [**Hospital6 1708**]
regarding the patient's transplant status. A repeat
Echocardiogram was obtained on [**3-13**], which showed severely
dilated and hypokinetic RV. This unfortunately meant that the
patient was no longer a candidate for transplant. A family
meeting was held on [**3-14**], and the patient was made CMO. The
patient was made eligible for kidney and spleen donation and
NEOB coordinated transfer of patient to the OR for nephrectomies
and splenectomy post-mortem.
Medications on Admission:
Acetylcysteine 20% 20 mg PO BID
Zolpidem Tartrate 5 mg PO HS:PRN
Sodium Chloride Nasal [**12-23**] SPRY NU [**Hospital1 **]:PRN
Lactulose 30 mL PO BID:PRN
Guaifenesin-CODEINE Phosphate [**4-30**] mL PO Q6H:PRN
Cosamin DS *NF* 500-400 mg Oral [**Hospital1 **]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Acetaminophen 325-650 mg PO Q6H:PRN
Vitamin D 400 UNIT PO DAILY
Senna 1 TAB PO BID:PRN
Omeprazole 20 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Docusate Sodium 100 mg PO BID
Calcium Carbonate 500 mg PO QID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
Benzonatate 100 mg PO QID
Aspirin 325 mg PO DAILY
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute exascerbation of IPF in setting of PNA
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2141-3-14**]
|
[
"51881",
"486",
"4280",
"4019",
"2859"
] |
Admission Date: [**2120-1-10**] Discharge Date: [**2120-1-11**]
Date of Birth: [**2068-7-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
CC:[**Hospital1 76627**]
Major Surgical or Invasive Procedure:
1. Successful PTCA and stenting of the mid RCA with a Taxus drug
eluting stent.
2. Successful direct stenting of the 2nd OM with a Cypher drug
eluting
stent.
History of Present Illness:
51 yoF w/ a h/o HTN, HL, DM, 36 pk year smoking history, and Fam
Hx of [**Hospital **] transferred to [**Hospital1 **] for an elective cath for unstable
angina. She had an IMI in [**2117**] which was treated with RCA bare
mental stent (prox and distal) at [**Hospital1 **]. In [**6-29**] she again
had an NSTEMI tx w/ Lcx bare metal stenting and 1 month later
presented with ACS- underwent a cath and had a instent
restenosis of the RCA stents placed 2 years earlier, taxus stent
was placed. LCx was patent at that time. Few weeks prior to
admission she had a recurrence of her anginal symptoms which are
her typical symptoms of tightness in her mid-sternal region and
chest pain radiating to her axilla bilaterally. No
N/V/diaphoresis. Associated with dyspnea. These symptoms are
non-exertional. She underwent a cardiac catheterization which
revealed a 90% stenosis of the RCA in between the two previously
placed stents and an OM2 stent with a 60% instent restenosis. EF
60%. She was transferred from [**Hospital1 **] following her diagnostic
cath for intervention. Here at the [**Hospital1 **] her RCA was stented with a
3.0 taxus DES and LCx was stented with a 2.5 Cypher DES.
.
Initially upon groin insertion she had a vagal episode and
required 1 of atropine. Subsequently immediately post sheath
pull her SBP dropped 100 to 70 systolic and her HR dropped to
the 40s. She responded to 2 of atropine, again she responded to
this. She had at that time also complained of lower abdominal
pain and back pain, her foley was draining well and her physical
exam performed by the NP at that time revealed a benign
abdominal exam. 2 hours post sheath pull her husband and her
noticed bleeding externally at her femoral insertion site, she
called the nurse who applied pressure, the patient's blood
pressure dropped initially to systolic of 90 and subsequently to
a nadir of 70 and was nauseas and vomiting,She was given 2 of
atropine without response and the code team noticed she became
somnolent with an altered mental status. She was started on
fluids and 10mcg/kg of dopamine with a response in her BP to the
systolics in the 170s and HR in the 170s. Her EKG at the time
was sinus tach rate of 135 with 2mm STE in the inferior leads
and ST depressions in I and aVL. Dopamine was d/c'd and her HR
came down, repeat EKGs at a HR of 100 revealed a resolution of
her EKG changes.
.
Past Medical History:
PAST MEDICAL HISTORY:
CAD s/p multiple stents, MI in [**2117**] RCA stent, MI in [**6-29**] s/p
LCx stent, [**7-29**] ACS and taxus stent to RCA
HTN
Hyperlipidemia
DM 2
PVD known subclavian stenosis, plan for iliac intervention in
[**1-29**]
Rheumatoid arthritis
.
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: no h/o CABG, no PPM
.
[**7-29**] [**Hospital1 **] cath
LMCA normal
LAD normal
LCx stent in mid portion w/ 20% stenosis distal aspect
RCA 60% proximal stenosis (near ostia), diffuse 30% in stent
stenosis in proximal stent, new 90% stenosis in Mid RCA, 70%
instent stenosis in distal RCA stent. 60-70 % stenosis of native
RCA distal to stents.
*Taxus in distal RCA stent, and another overlaping taxus in
distal stent, another taxus in mid RCA stenosis and a proximal
taxus stent.
.
[**2120-1-9**] Cath [**Hospital1 **]:
LMCA normal
LAD normal
Lcx OM2 stent in OM2 has 60% diffuse instent restenosis
RCA ostial stent patent, prox RCA diffuse 20% instent
restenosis, mid RCA stents widely patent, in gap b/w mid and
distal RCA 90% stenosis, distal RCA normal.
Social History:
SOCIAL and FAMILY HISTORY:
36 pack years history of smoking- quit [**7-29**]. Works full time as
warranty administrator at a car dealership. Denies ETOH use,
lives w/ her husband and has 3 children.
Family History:
father had an MI at 46, mother alive. Two sisters no CAD,
Brother w/ DM.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.4 , BP 134/89 , HR 96 , RR 16 , O2 99 % on 5L NC
Gen: NAD, AOx3, somnolent obese female
HEENT: NCAT. JVP 8 but difficult to assess given body habitus.
PERRL 6mm down to 2mm bilaterally. EOMI, Sclera anicteric.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
slight petechial hemorrhages of hard palate.
CV: nl S1 and S2 w/ physiologic splitting of S2, [**1-28**] cresc
decresc murmur best heard @ USB w/o radiation.
Chest: anteriorly clear bilaterally
Abd: Obese, soft, slightly distended.
Ext: No c/c/e. distal pulses intact. Groin sites no bruits or
hematomas, dressing w/ slight blood ooze, no active bleeding.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2120-1-11**] 03:05PM BLOOD WBC-9.3 RBC-3.65* Hgb-12.1 Hct-35.8*
MCV-98 MCH-33.1* MCHC-33.8 RDW-13.0 Plt Ct-377
[**2120-1-11**] 05:17AM BLOOD Glucose-120* UreaN-7 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-28 AnGap-11
.
[**2120-1-10**] 05:17PM BLOOD CK(CPK)-49
[**2120-1-11**] 01:40AM BLOOD CK(CPK)-147*
[**2120-1-11**] 05:17AM BLOOD CK(CPK)-163*
[**2120-1-10**] 05:17PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2120-1-11**] 01:40AM BLOOD CK-MB-6 cTropnT-0.01
[**2120-1-11**] 05:17AM BLOOD CK-MB-7 cTropnT-0.01
.
[**2120-1-10**] 07:21PM BLOOD %HbA1c-7.7*
[**2120-1-11**] 05:17AM BLOOD Triglyc-82 HDL-38 CHOL/HD-3.1 LDLcalc-65
[**2120-1-10**] 05:14PM BLOOD Glucose-146* Lactate-2.2* Na-137 K-4.8
Cl-102
.
[**2120-1-10**] 09:39PM BLOOD Type-ART pO2-137* pCO2-51* pH-7.40
calTCO2-33* Base XS-5
[**2120-1-10**] 05:14PM BLOOD Type-[**Last Name (un) **] pO2-134* pCO2-42 pH-7.38
calTCO2-26 Base XS-0
.
Cardiac cath [**1-10**]
BRIEF HISTORY: 51 year old female with a history of coronary
artery
disease s/p PCI to the RCA in [**2119-6-23**] with four Taxus drug
eluting
stents (3x12mm; 3x20mm; 2.5x12mm; 2.5x8mm Prox to distal) along
with PCI
to the LCX with a bare metal stent in [**2119-7-23**]. Pt complained
of
increasing pain with exertion. Diagnostic catheterization at
outside
hospital demonstrated a 90% lesion between the proximal and mid
RCA
lesion along with 70% in-stent restenosis of the first obtuse
marginal
bare metal stent. Pt transferred for planned intervention.
.
INDICATIONS FOR CATHETERIZATION:
1. Two vessel coronary artery disease
2. Planned intervention to the RCA and OM
.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
left femoral artery, using a 6 French right [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French XB and a 6 French JR4 catheter, with manual contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Percutaneous coronary revascularization of an additional vessel
was
performed using placement of drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED 40
2) MID RCA DIFFUSELY DISEASED 90
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DIFFUSELY DISEASED 30
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
12) PROXIMAL CX NORMAL
13) MID CX DIFFUSELY DISEASED
13A) DISTAL CX DIFFUSELY DISEASED
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 70
.
PTCA COMMENTS:
.
Initial angiography demonstrated a diffusely diseased
right coronary artery with a 90% de [**Last Name (un) 11083**] lesion between the
proximal and
mid RCA Taxus drug eluting stents. We decided to treat this
lesion with
PTCA and stenting. Aspirin, Clopidogrel and Bivalrudin were
started
prophylactically. Multiple guide catheters were used to engage
the RCA
including the JR 4, [**Doctor Last Name **] 0.75 and Hockey stick. The hockey
stick engaged the artery. A prowater guide wire crossed the
lesion with
minimal difficulty. The lesion was predilated with a Maverick
(2.5x9mm)
balloon inflated to 8 atm. We were unable to pass a Taxus stent
into
the ostium of the RCA due to poor guide support. The Hockey
Stick guide
was exchanged for a [**Doctor Last Name **] 1 guide which provided adequate support
throughout the case. The [**Doctor Last Name **] 1 guide provided enough support to
to
deliver a Taxus (3x20mm) drug eluting stent which was deployed
at 16
atm. The stent was then postdilated with a Quantum Maverick
(3x15mm)
balloon inflated to 18 atm. We next dilated up the two proximal
stents
from her previous intervention with the the Quantum Maverick (18
atm
three times). Final angiography demonstrated no
angiographically
apparent dissection, no residual stenosis and TIMI III flow
throughout
the vessel.
.
We next turned our attention to the 70% in-stent restenosis of
the
2nd obtuse marginal. A 6F XB provided excellent support
throughout the
procedure. A prowater guidewire crossed the lesion with minimal
difficulty. We treated the lesion with an IC bolus of
Nitroglycerine
(200 mcg). The lesion was then predilated with a Cypher
(2.5x18mm) drug
eluting stent. Final angiography demonstrated no
angiographically
apparent dissection, no residual stenosis and TIMI III flow
throughout
the vessel. The patient left the cath lab in stable condition
and free
of angina.
.
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two (2) vessel coronary artery disease. The right
coronary
artery demonstrated diffuse disease throughout the vessel
including a
90% de [**Last Name (un) 11083**] lesion between the proximal and mid RCA stents. All
four
stents were patent with some in-stent restenosis in the
proximal/ostial
and mid RCA. The left main was a small vessel with mild luminal
irregularities. The left anterior descending artery was not
well
engaged/visualized (See diagnostic catheter). The left
circumflex was a
small caliber vessel with mild diffuse throughout including a
70%
in-stent stenosis in the OM 2 bare metal stent.
2. LV ventriculography was deferred.
3. Successful PTCA and stenting of the RCA with a Taxus
(3x20mm) drug
eluting stent which overlapped the two previous which was
postdilated
with a Quantum Maverick 3.0 mm balloon. Final angiography
demonstrated
no angiograpahically apparent dissection, no residual stenosis
and TIMI
III flow throughout the vessel (See PTCA comments).
4. Successful direct stenting of the 2nd Obtuse Marginal with a
Cypher
(2.5x18mm) drug eluting stent. Final angiography demonstrateed
no
angiographically apparent dissetion, no residual stenosis and
TIII flow
(See PTCA comments).
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PTCA and stenting of the mid RCA with a Taxus drug
eluting
stent.
3. Successful direct stenting of the 2nd OM with a Cypher drug
eluting
stent.
.
[**1-10**]: CXR
.
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Pulmonary vasculature is normal. Lungs are clear and there is no
pleural effusion or pneumothorax. Cardiac silhouette is
borderline enlarged and the azygos vein is distended consistent
with elevated central venous pressure or volume.
EKG [**2120-1-10**] pre cath NSR, rate 53, nl axis and intervals and q
and inverted T in III. Post cath EKG unchanged.
EKG during period of tachycardia, post dopamine for hypotension:
sinus w/ rate 150 and 2-3mm STE in inverior leads as well as ST
depressions in I and aVL.
Brief Hospital Course:
51 yoF w/ a PMHx significant for CAD, s/p 2 MIs and multiple
stent placement, who was transferred to [**Hospital1 18**] for therapeutic
cardiac cath for unstable angina. Pt has stent placement in RCA
and OM2. During the removal of the cath in the lab pt developed
hypotension and bradycardia in response to administering groin
pressure. Pt was given atropine x 3, w/ resolution of symptoms.
Two hours after angiosheath removal pt developed oozing. Pt
again developed hypotension with groin pressure. Pt was noted to
have mental status changes at this time. An ABG was done which
showed an elevated level of CO2. A code was called and pt was
intubated briefly. With in minutes she self extubated and was
breathing with out distress, able to protect her airway. She
was started on dopamine and transferred to CCU for further
management. She was weaned off of dopamine with in hours. She
had no more episodes of hypotension or bradycardia during her
hospital stay. She was afebrile, blood cultures and urine
cultures were drawn and both negative for bacterial growth. Her
hematocrit was stable during her hospital stay. No significant
hematoma was noted on exam. Pt was felt to be low probability
for an RP bleed based on exam and stable hct.
.
It was felt that her symptoms of hypotension and bradycardia
were secondary to a vasovagal response caused by groin pressure.
The mental status changes and hypercapnea the patient
experienced were transient and associated with atropine
administration. Pt remained stable for 24 hours before
discharge. The only medication changed at discharge was norvasc
10mg. This medication was held at discharge.
.
PROBLEMS:
.
#.Coronary Artery Disease: 4 stents in RCA and 1 in LCx prior
to cath on [**1-10**]- on this date rec'd two additional stents. She
has a LMCA w/ mild luminal irregularites and of small caliber,
Lcx 70% instent restenosis in the BMS placed in a large OM2
branch and RCA w/ 90% stenosis between two stents. Two DES
placed in these two lesions. Pt with unstable angina w/
multiple prior stents w/ a Taxus (3x20mm) drug eluting stent
which overlapped the two previous which stents in the right
coronary artery. A Cypher (2.5x18mm) drug eluting stent was
placed in the 2nd obtuse marginal artery. Continue plavix 75mg
daily, continue ASA 325mg daily
.
#Hypotension / bradycardia- 3 episodes of hypotension /
bradycardia all in the setting of groin manipulation. The first
two responded to atropine and the third responded to dopamine.
All three episodes were thought to be [**2-24**] to vasovagal response
occurring w/ groin pressure. No signs of bleed or infection.
..
# mental status - initially s/p code sluggish in response, but
follows commands, moving extremities spontaneously, pupils equal
reactive to light 5->2mm, delta MS felt [**2-24**] atropine. Pt had an
elevated WBC count that normalized after 1 day. ABG revealed
slightly elevated co2, but mental status continued to improve.
Resolved by discharge. Urine culture, blood culture and chest
xray were all negative.
.
# DM: on Lantus and glyburide at home. Pt was continued on
lantus during her hospital stay. Pt discharged on home lantus
and glyburide dose. Patients renal function had a Cr of 0.8, but
received dye load of 330ml of cardiac cath on [**1-10**]. HgBA1C 7.7%
.
# PVD f/u w/ Dr. [**First Name (STitle) **] [**First Name (STitle) **] in early [**Month (only) 404**] for PVD and
intervention.
.
# HTN: Patient discharged on lisinopril 10mg daily and lopressor
25mg po bid. Patients blood pressure was a systolic of 110 at
discharge. Home Norvasc dose of 10mg was held at discharge.
.
# PVD f/u w/ Dr. [**First Name (STitle) **] [**First Name (STitle) **] in early [**Month (only) 404**] for PVD and
intervention.
.
Follow up:
Please follow up with Dr. [**Last Name (STitle) **] in the first week of [**Month (only) 404**].
Please follow up in clinic with Dr. [**Last Name (STitle) 1295**]. You are scheduled
for an apointment for [**2-9**] at 1130am at [**Location (un) 76628**], Ma. Please call if you have to reschedule
[**Telephone/Fax (1) 6256**].
Please follow up on Thursday [**1-18**] at 11:15pm with Dr.
[**Last Name (STitle) 37063**] [**Street Address(2) 76629**] in [**Location (un) 29789**]. If you can not keep this
appointment please call to reschedule at [**Telephone/Fax (1) 37064**].
Medications on Admission:
Aspirin 325mg daily
plavix 75 mg daily
protonix 40mg daily
colace 100mg daily
metoprolol 25mg [**Hospital1 **]
glyburide 5 mg daily
lantus 40 units daily
simvastatin 40mg daily
norvasc 10mg daily
lisinopril 10m daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
CAD
Hypotension
secondary diagnosis:
HTN
Hyperlipidemia
DM
PVD
Discharge Condition:
Stable, normal blood pressure and heart rate. Chest pain free.
Discharge Instructions:
Mrs. [**Known lastname **] you were admitted to the hospital for elective
cardiac cath. You had two stents placed during your cardiac
cath. A Taxus (3x20mm) drug eluting stent which overlapped the
two previous which stents in your right coronary artery and a
was postdilated
with a Quantum Maverick 3.0 mm balloon was placed. A Cypher
(2.5x18mm) drug eluting stent was placed in your 2nd obtuse
marginal artery.
During your cath procedure you developed some hypotension "low
blood pressure" and bradycardia "low heart rate." It was felt
that the drop in your blood pressure was due to a "vasovagal
response", where pressure applied to major blood vessels can
cause a reflex drop in blood pressure and heart rate. You
received some medications that helped raise your heart rate and
blood pressure.
.
You then were then sent to the hospital floor. Later after the
removal of your angiocath from your groin, you developed groin
bleeding. Pressure was placed on your groin to stop the bleeding
and you again dropped your blood pressure and developed a
confused mental status. We again think that the blood pressure
drop was secondary to the pressure placed on your groin, another
"vasovagal episode" You were confused during this time period
and it was noted that the carbon dioxide levels in your blood
had elevated. We believe this confusion and elevated carbon
dioxide levels was caused by the atropine you received earlier
to raise your heart rate. You were briefly intubated to support
your airway. Then extubated. You had no more similar episodes of
hypotension during your hospital stay.
Your RBC counts stayed relatively stable during your
hospitalization making us think that it was not a bleed that
caused your low BP. Your blood and urine cultures did not show
any bacterial growth, making an infection a less likely cause
for your blood pressure drop.
We restarted your home medications.
Aspirin 325mg daily
plavix 75 mg daily
protonix 40mg daily
colace 100mg daily
metoprolol 25mg [**Hospital1 **]
glyburide 5 mg daily
lantus 40 units daily
simvastatin 40mg daily
lisinopril 10m daily.
The only medication we stopped temporarily was your Norvasc. We
wanted to you to have a couple of days of normal blood pressure
before restarting your novasc 10mg.
You discharged w/ no more episodes of low blood pressure or low
heart rate.
Take ASA and Plavix daily uninterrupted, for prevention of stent
thrombosis. Stopping these medications may result in a heart
attack
.
Please follow up with your primary care physician with in the
next 1-2 weeks.
.
If you develop dizziness, chest pain, SOB, arm pain, worsened
swelling in your groin or any overall worsening in your
condition please go to the emergency room immediately.
.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the first week of [**Month (only) 404**].
Please follow up in clinic with Dr. [**Last Name (STitle) 1295**]. You are scheduled
for an apointment for [**2-9**] at 1130am at [**Location 76628**], Ma. Please call if you have to reschedule
[**Telephone/Fax (1) 6256**].
Please follow up on Thursday [**1-18**] at 11:15pm with Dr.
[**Last Name (STitle) 37063**] [**Street Address(2) 76629**] in [**Location (un) 29789**]. If you can not keep this
appointment please call to reschedule at [**Telephone/Fax (1) 37064**].
|
[
"41401",
"42789",
"4019",
"2724",
"25000",
"V5867"
] |
Admission Date: [**2112-6-1**] Discharge Date: [**2112-6-8**]
Service: Cardiothoracic
CHIEF COMPLAINT: Mr. [**Known lastname **] is an 84-year-old man referred
by Dr. [**Last Name (STitle) 120**] for outpatient cardiac catheterization because
of a positive ETT.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is preoped for a
right iliac artery aneurysms repair. At the time of
preoperative workup, the patient stated he was having left
sided chest pain and shortness of breath for the past 3-6
months. These episodes occur at rest as well as with
activity. The discomfort and shortness of breath resolve
within 5-10 minutes and occur 2-3x/week. Persantine MIBI was
done on [**5-25**]. The patient had dyspnea during the
infusion, no electrocardiogram changes, imaging was limiting
due to patient's motion, and revealed the possible reversible
moderate inferior wall defect and a possible reversible
defect involving the anterior aspect.
An echocardiogram done on the [**6-6**], showed moderately
decreased ejection fraction of 57% with posterior akinesis
consistent with electrocardiogram evidence of an old
posterior myocardial infarction. There was mild aortic
regurgitation and mild mitral regurgitation. The patient was
referred to [**Hospital1 69**] for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Peripheral neuropathy.
4. Supraventricular tachycardia.
5. Hernia repair.
6. Cataract surgery.
ALLERGIES: He has no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Corgard 20 mg q day.
2. Verapamil 40 mg tid.
3. Glyburide 5 mg q day.
Patient's electrocardiogram prior to catheterization showed
inferior ST elevations and anterolateral ST depressions,
sinus bradycardia with an old IMI.
LABORATORIES: White count 7.2, hematocrit 39.9, platelets
200. Sodium 145, potassium 3.9, chloride 102, CO2 33, BUN
20, creatinine 0.9, glucose 153, INR 1.1. CK 75, and normal
LFTs.
Chest x-ray showed no congestive heart failure or effusions.
PHYSICAL EXAMINATION: Five foot 7 inches, 73 kg, heart rate
64, blood pressure 140/59, respiratory rate 20. Neurologic:
cranial nerves II through XII are grossly intact, nonfocal
examination. Excellent strength in all four extremities.
Respiratory is clear to auscultation bilaterally. Heart
sounds regular, rate, and rhythm, S1, S2. Abdomen is soft,
nontender, nondistended, positive bowel sounds, no
hepatosplenomegaly. Extremities are warm and well perfused
with no clubbing, cyanosis, or edema. No varicosities. Neck
with no jugular venous distention and no bruits.
Patient was brought to the cardiac catheterization
laboratory. Please see the catheterization report for full
details. In summary, the catheterization showed left main
with mild disease, left anterior descending artery with a
total occluding at the left main origin. Circumflex with a
95% occlusion, right coronary artery with 90% occlusion and
global hypokinesis.
Following cardiac catheterization, the patient was referred
to CT Surgery for evaluation for coronary artery bypass
graft. He was seen by CT Surgery, and accepted for coronary
artery bypass grafting. On [**6-3**], the patient was brought
to the operating room. Please see operating room report for
full details. In summary, the patient had coronary artery
bypass graft x3 with a LIMA to the left anterior descending
artery, saphenous vein graft to the OM, and saphenous vein
graft to the PDA. He tolerated the procedure well, and was
transferred from the operating room to the Cardiothoracic
Intensive Care Unit.
At the time of transfer, the patient had Neo-Synephrine at
0.2 mcg/kg/min, propofol at 30 mcg/kg/min, and aprotinin at
25 cc/hour. He was A-paced at 80 beats per minute with a
mean arterial pressure of 70 and a CVP of 13.
The patient did well in the immediate postoperative period.
He was weaned from all cardioactive IV medications. His
anesthesia was reversed and sedation was discontinued. He
was weaned from the ventilator and successfully extubated.
Postoperative day one, the patient remained hemodynamically
stable. He was kept in the Intensive Care Unit because of an
episode of rapid atrial fibrillation, a period of hypotension
associated with rapid atrial fibrillation. At that point, he
was started on amiodarone and converted back to a sinus
rhythm.
Postoperative day two, patient remained hemodynamically
stable. His chest tubes were removed. Central line was
discontinued, and he was transferred from the floor for
continuing postoperative care and cardiac rehabilitation.
Over the next several days with the assistance of the nursing
staff and Physical Therapy staff. Patient's activity level
was increased until on postoperative day #5, it was decided
that the patient was stable and ready to be transferred to a
rehabilitation center for continuing postoperative care and
rehabilitation.
At the time of transfer, the patient's physical examination
is as follows: Vital signs: Temperature of 97.3, heart rate
60 sinus rhythm, blood pressure 117/80, respiratory rate 18,
and O2 saturation is 94% on room air. Weight preoperatively
71.5 kg. At discharge, 72.4 kg. Laboratory data: White
count 9.6, hematocrit 30.9, platelets 137, sodium 135,
potassium 3.6, chloride 99, CO2 27, BUN 16, creatinine 0.9,
glucose 124.
Physical examination: Alert and oriented times three, moves
all extremities, follows commands. Respiratory: Breath
sounds are clear to auscultation bilaterally, although
slightly diminished in the left base. Cardiac: Regular,
rate, and rhythm, S1, S2 with a slight systolic ejection
murmur. Sternum is stable, incision with Steri-Strips, open
to air clean and dry. Abdomen is soft, nontender, and
nondistended, normoactive bowel sounds. Extremities are warm
and well perfused with no edema. Left saphenous vein graft
sites with Steri-Strips open to air, clean, and dry. Large
ecchymotic area of the left upper thigh.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg q day x7 days.
2. Potassium chloride 20 mEq q day x7 days.
3. Colace 100 mg [**Hospital1 **].
4. Amiodarone 400 mg q day x1 week, then 200 mg q day x1
month.
5. Nadolol 20 mg q day.
6. Ranitidine 150 mg [**Hospital1 **].
7. Enteric coated aspirin 325 q day.
8. Glyburide 5 mg q day.
9. Regular insulin-sliding scale.
10. Percocet 5/325 1-2 tablets q4h prn.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x3 with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the
posterior descending artery, and saphenous vein graft to the
obtuse marginal.
2. Diabetes mellitus.
3. Hypertension.
4. Supraventricular tachycardia.
5. Neuropathy.
6. Congestive heart failure.
7. Hernia repair.
8. Cataract surgery.
9. Right iliac aneurysm to be addressed by Vascular Surgery
following recovery from coronary artery bypass grafting.
DISCHARGE INSTRUCTIONS: The patient is discharged to
rehabilitation. He is to have followup with his primary care
provider three weeks following his discharge from
rehabilitation, and follow up with Dr. [**Last Name (STitle) 70**] in six weeks
from discharge from [**Hospital1 69**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2112-6-8**] 11:56
T: [**2112-6-8**] 12:24
JOB#: [**Job Number **]
|
[
"4019",
"41401",
"9971",
"42731",
"4280"
] |
Admission Date: [**2149-6-4**] Discharge Date: [**2149-6-18**]
Service: NEUROLOGY
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Change in Mental Status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
ADMISSION NOTE TO TSICU SERVICE:
86yo M on coumadin for AFib who recently [**First Name3 (LF) 1834**] excision
of a 4cm R inguinal cyst by Dr. [**First Name (STitle) 2819**] on [**2149-5-20**], c/b wound
infection s/p bedside I&D on [**2149-5-28**]. On that return he was
noted to have altered mental status, improved with drainage,
antibiotics, and rate control of his AFib, permitting discharge
by the medical service on [**2149-5-31**]. He was placed on a lovenox
bridge to coumadin at that time. According to the records from
rehab, he had another episode of unresponsiveness on [**2149-6-1**],
which resolved spontaneously. On [**6-3**] had another episode of
unresponsiveness, reportedly hemodynamically stable, and
transferred to [**Hospital1 18**] for further evaluation. On arrival here
described by [**Name8 (MD) **] RN as awake and interactive. After placement of
nasal cannula, developed epistaxis, which has been only
partially
relieved with afrin and packing by the ED staff. Has already
undergone neurosurgical evaluation for small SDH, who feel
likely
artifact / chronic and not causative for his current mental
status changes. Surgical consult called due to large R flank
hematoma and anemia (prior baseline 40). There is no
documentation or knowledge of a flank hematoma noticed prior to
today. No history of trauma is known.
.
INITIAL NEUROLOGY CONSULT NOTE (in setting of acute obtundation)
prior to transfer to Neurology Service:
HISTORY OF PRESENT ILLNESS:
Mr. [**Known lastname **] is an 86 year-old right-handed man with a past
medical history including myasthenia [**Last Name (un) 2902**], hypertension,
atrial
fibrillation (coumadin/lovenox dc'd [**6-4**]), COPD, recent
pseudomonal wound infection, and recurrent episodes of decreased
responsiveness who developed an acute change of mental status in
the setting of anemia.
.
Records show that Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a right inguinal cyst
removal [**2149-5-20**] at the [**Hospital1 **] [**Location (un) 620**]. He subsequently presented to
the [**Hospital1 18**] with confusion on [**2149-5-28**] and was ultimately found to
have a right inguinal pseudomonal infection with wound
dehiscence. Following an incision and drainage, empiric
treatment with cefazolin was transitioned to a seven day course
of ciprofloxacin and flagyl. The discharge summary notes that,
despite the myasthenia [**Last Name (un) 2902**], the patient has tolerated these
agents well in the past. He was discharged to rehab on [**2149-5-31**].
.
The primary team indicates that the patient had at least two
episodes of unresponsiveness while at rehabilitation. One event
lasted 5-10 minutes; as it occurred on the commode, the syndrome
was attributed to vasovagal syncope. The details of the next
event remain unclear. However, he then presented to the [**Hospital1 18**]
with a change in mental status on [**6-3**]. A neurosurgery consult
was requested as an initial non-contrast CT of the head was
thought to show a 10 x 8 x 5 mm hyperdense area adjacent to the
right frontal lobe concerning for hemorrhage. INR was 2.1. The
neurosurgical evaluation suggests he would make nonsensical
vocalizations, had equal round and reactive pupils with facial
symmetry, and withdrawal of extremities to noxious. The
features
of the imaging was considered atypical for a subdural and
aubarachnoid hemorrhages.
.
While in the ED, the hematocrit was noted to be 23.6 (relative
to
40.6 on [**2149-5-31**]) in the context of epistaxis and a large right
flank hematoma. After a surgical evaluation, he was intubated
for airway protection and admitted to the TSICU. He received
three units of packed red blood cells and two units of FFP. The
hematocrit remained stable thereafter. Cipro and flagyl were
continued. A non-contrast CT of the head was repeated on [**6-4**]
and failed to reveal the previously noted abnormality. The
patient was successfully extubated on [**6-4**] without complication.
Since that time, he has moved to the medical service on the
wards.
.
The patient apparently did well until [**2149-6-6**]. Per report, at
about 5:30 pm, he became unresponsive. There was no apparent
trigger. Blood glucose was reported to be 170. An ABG showed
a
pH of 7.47, pCo2 36, pO2 92, TCO2 27. It does not appear that
any new medications were started recently.
NEUROLOGICAL REVIEW OF SYSTEMS
- unkown
.
GENERAL REVIEW OF SYSTEMS:
- unknown
Past Medical History:
- Afib - coumadin and lovanox dc'ed [**6-4**] secondary to hematoma
-Chronic systolic CHF (LVEF 40-45% on [**2148-4-3**] TTE)
-2+ Mitral regurgitation
-DMII
-Hypertension
-COPD
-Hypothyroidism
-Neurological deficits (word finding difficulty) - ED visit in
[**2149-1-17**], deficits resolved
-Essential tremor
-? Normal pressure hydrocephalis (Discharge summary [**2148-10-8**])
-Myasthenia [**Last Name (un) 2902**] - stable per note [**6-3**]; followed by Dr.
[**Last Name (STitle) 557**]
[**Name (STitle) 92931**] episodes of delirium
-Depression/Anxiety
-Scarlet fever c/b hearing loss
.
PAST SURGICAL HISTORY:
-appy
-ccy
-umbilical hernia repair
Social History:
- retired pharmacist
- widowed and lives alone in an [**Hospital3 **] facility ([**First Name4 (NamePattern1) 951**]
[**Last Name (NamePattern1) **] building in [**Location (un) 5110**])
- He receives 5 dinners per week, has a VNA one per week to fill
his med box, and a visitor for 3 hours/day 5x per week.
- walks without a walker/cane and can bath himself.
.
HABITS:
- Tobacco Use: remote (40 pack year hx)
- Alcohol Use: negative per notes
Family History:
- positive for DM, CAD (mother)
Physical Exam:
On initial ADMISSION to TICU:
96 113/57 28 98 on 2L NC
non-interactive, unresponsive
PERRL
active bleeding of bright red blood, partially tamponaded with R
nare packing
CTAB with decr BS R-side
irreg irreg
soft, NT, ND
R flank with large and tense ecchymosis extending to mid-thigh,
tender.
R groin wound shallow, with purulent/fibrinous exudate. no
surrounding erythema or induration.
BL LE WWP, with brawny skin changes BL shins
PIV x2, Foley
.
AT TIME OF CONSULT for OBTUNDATION [**2149-6-6**]:
Vitals: T: 98.1 P: 82 R: 18 BP: 110/70 SaO2: 99 RA
General: Does not arouse to loud voice or sternal rub. Does
eventually open eyes with foreced opening of eyelids and
supraorbiatl pressure.
HEENT: ? New hematoma on right forehead. No scleral icterus
noted. Forced mouth closure.
Neck: Supple.
Cardiac: Regular rate, irregularly irregular rhythm.
Pulmonary: Expiratory wheezes bilaterally anteriorly.
Abdomen: Obese. Normoactive bowel sounds. Soft. Non-tender,
non-distended. Expansive right flank hematoma.
Extremities: Right thigh hematoma, tense.
Skin: changes consistent with veous stasis in lower extremities
bilaterally.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Arouses with repetitive noxious
stimulation (forced opneing of eyelids, periorbital pressure).
.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: Anisicoria with left pupil 1mm > right pupil; both round
and reactive to light (previously documented finding). * III,
IV, VI: Gaze conjugate
* V, VII: corneals intact bilaterally.
* VII: No facial droop, facial musculature symmetric..
* IX, X: Gag/cough present but palate appears relatively low and
soft
.
Motor:
* Bulk: No evidence of atrophy.
* Tone: Normal in UE. Increased in lower extremities
bilaterally
* Drift: No pronator drift bilaterally.
* Adventitious Movements: No tremor or asterixis noted.
Strength:
* Left Upper Extremity: does not withdraw to nailbed pressure;
will intermittently hold arm in air when placed at 90 degrees
* Right Upper Extremity: does not withdraw to nailbed pressure;
will intermittently hold arm in air when placed at 90 degrees
* Left Lower Extremity: does not withdraw to nailbed pressure
* Right Lower Extremity: does not withdraw to nailbed pressure
Reflexes:
* Left: 2+ throughout Biceps, Triceps, Bracheoradialis, Patella
* Right: 2+ thoughout Biceps, Triceps, Bracheoradialis, Patella
* Babinski: flexor bilaterally
Sensation:
* Responds by opening eyes to supraprbital pressure
Pertinent Results:
Admission Labs:
WBC-8.5 RBC-2.62* HGB-7.9* HCT-23.6* MCV-90 MCH-30.3 MCHC-33.5
RDW-14.7
GLUCOSE-183* LACTATE-1.4 NA+-134* K+-3.8 CL--101 TCO2-26
UREA N-34* CREAT-1.5*
PT-22.5* PTT-49.0* INR(PT)-2.1*
HGB-6.3* calcHCT-19
.
Pertinent Labs (at time of acute mental status change [**2149-6-6**]):
BLOOD Hct-26.6*
BLOOD Type-ART pO2-92 pCO2-36 pH-7.47* calTCO2-27 Base XS-2
.
Daily Labs on [**2149-6-6**]:
wbc 5.6, hct 26.6 (mcv 91), plt 134
na 135, k 3.5, cl 103, bicarb 25, bun 12,m crea 1
ca 7.3, mg 1.8, phos 2.8
.
[**2149-6-12**] 12:12PM BLOOD Type-ART pO2-83* pCO2-33* pH-7.50*
calTCO2-27 Base XS-2 Intubat-NOT INTUBA
.
Discharge Labs ([**2149-6-13**]):
WBC-9.0 RBC-3.74* Hgb-11.4* Hct-35.5* MCV-95 MCH-30.5 Plt Ct-397
Glucose-216* UreaN-20 Creat-1.1 Na-136 K-3.8 Cl-101 HCO3-23
AnGap-16
Calcium-8.3* Phos-2.3* Mg-1.7
.
IMAGING
.
CT Chest, Abdomen, Pelvis with Contrast ([**2149-6-3**]):
IMPRESSION:
1. Large right proximal thigh hematoma lateral to the greater
trochanter with at least two areas of active extravasation.
2. No retroperitoneal hematoma.
3. Right hypoattenuating renal lesion is slightly irregular in
shape with internal density values slightly higher than expected
for a simple cyst. If clinically indicated, further evaluation
with ultrasound is recommended.
.
Non-Contrast CT Head ([**2149-6-3**]):
IMPRESSION:
10 x 8 x 5 mm hyperdense area adjacent to the right frontal lobe
may be artifactual but a focus of extra-axial hemorrhage cannot
be completely excluded. Repeat CT should be considered for
monitoring if clinically indicated.
Non-Contrast CT Head ([**2149-6-4**]):
IMPRESSION: Previously seen hyperdense focus at the right
superior frontal gyrus is no longer seen and was likely
artifactual in nature. No evidence of acute intracranial
hemorrhage.
.
EEG ([**2149-6-10**]):
IMPRESSION: This telemetry captured two pushbutton activations.
They
did not show electrographic or clinical evidence of seizure.
Routine
sampling showed a mildly disorganized background throughout in
wakefulness. It was mildly slow for much of the time but reached
an 8.5
Hz frequency posteriorly at times. There were no epileptiform
features
or electrographic seizures.
.
CXR ([**2149-6-5**]):
FINDINGS: On the current image, no endotracheal tube is visible.
Right-sided PICC line in unchanged position. Borderline size of
the cardiac silhouette. Moderate atelectasis of the
retrocardiac
lung areas. No other changes.
Healed left-sided rib fractures. No interval recurrence of focal
parenchymal opacities suggesting pneumonia.
.
CXR ([**2149-6-11**]):
IMPRESSION:
1. No acute cardiopulmonary process with no evidence of
congestive heart
failure.
2. Findings compatible with COPD.
3. Segmental area of tracheal narrowing seen at the
cervicothoracic junction and it is unclear whether this
represents intrinsic narrowing of the trachea or an extrinsic
compression.
.
Thyroid Ultrasound ([**2149-6-12**]):
IMPRESSION: Heterogeneous right lobe nodule which is decreased
in size from the prior ultrasound, although this is a very
limited thyroid ultrasound due to the retrosternal placement of
the gland and the patient's body habitus.
.
Microbiology
.
[**2149-6-7**]:
c. difficile: negative
blood culture: negative
.
[**2149-6-6**]
blood culture: negative
.
[**2149-6-4**]
sputum culture: resp commensals
blood cultures x 2: negative
Brief Hospital Course:
Mr. [**Known lastname **] is an 86 year-old right-handed man with a past
medical history including myasthenia [**Last Name (un) 2902**], atrial fibrillation
(previously on coumadin), COPD, DMII, and s/p [**5-20**] inguinal cyst
removal complicated by pseudomonas wound infection who was
transferred from rehabilitation to the [**Hospital1 18**] with a change in
mental status and was found to have anemia in the setting of a
right flank hematoma. Following intubation, he was initially
admitted to the Trauma ICU. Following an easy extubation the
following day, he was transferred to the medical wards team. He
was ultimately transferred to the Neurology Service to address
recurrent episodes of decreased arousal. He was on the General
Neurology Service until the time of his discharge on [**2149-6-13**].
.
HEMATOLOGY:
At the time of arrival in the [**Hospital1 18**] ED, Mr. [**Known lastname **] was found to
have anemia in the setting of right flank and thigh hematomas.
The injuries were thought to be secondary to a recent fall at
[**Hospital1 **] ([**5-31**]). While a CT scan revealed no evidence of a
retroperitoneal hematoma, there was evidence of a large right
proximal thigh hematoma lateral to the greater trochanter with
at least two areas of active extravasation. At the time of
initial evaluation, the hematocrit was found to be 23.6 with an
INR of 2.1. In the context of subsequent epistaxis (after
placement of nasal cannula) his hematocrit dropped to 19.
Following admission to the trauma ICU service. Anticoagulation
was discontinued and the patient received three units of packed
red blood cells RBCs. At the recommendation of the surgery team,
he was also given Factor IX, vitamin K, and two units of fresh
frozen plasma. The hematocrit [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 92932**] and then
remained stable. By the day of discharge it was 35. The wound
care service helped monitor the hematomas. By the day of
discharge, the affected areas were much smaller. The right
thigh was much less tense.
.
NEUROSURGERY:
While being evaluated in the ED, a neurosurgery consult was
requested as an initial non-contrast CT of the head was thought
to show a 10 x 8 x 5 mm hyperdense area adjacent to the right
frontal lobe concerning for hemorrhage. The features
of the imaging was considered atypical for a subdural and
subarachnoid hemorrhages.
A non-contrast CT of the head was repeated on [**6-4**] and failed to
reveal the previously noted abnormality.
.
NEUROLOGY/PULMONOLOGY:
On the night of [**6-6**], the neurology service was consulted to
evaluate Mr. [**Known lastname **] in the setting of an acute change in mental
status. Blood glucose was in normal range. An ABG was
unrevealing. Recommended neuroimaging failed to reveal acute
contributory changes. Despite the recent use of potentially
exacerbating antibiotics, the ease with which the patient was
extubated, and the recent stability of the condition, argued
against the role of Myasthenia [**Last Name (un) **] in the syndrome. He
reportedly returned to his baseline mental status within about
six hours in the absence of direct intervention. However he
developed a change in mental status two days later ([**2149-6-8**]),
prompting transfer to the Neurology Service for further
evaluation.
.
At the time of transfer to the Neurology Service,
electroencephalogram leads were placed for long-term monitoring.
Although he did not have any further episodes of change in
mental status while being monitored, the telemetry failed to
demonstrate evidence of seizure activity.
.
Of note, the patient's SSRI was discontinued at the time of his
transfer to the Neurology Service. As he had no additional
discrete episodes of obtundation, it is possible that the
medication was playing a contributing role. Accordingly, it is
recommended that celexa and similar agents be avoided in the
future. Modafanil was started to help with mental activation.
(This can be discontinued if it adversely affects heart rate.)
.
An ABG performed at the time of one episode of obtundation
([**2149-6-6**]) was generally unrevealing. Regardless, there was some
concern that hypoxia, particularly in the setting of anemia,
could be contributing to the periods of unresponsiveness.
Continuous oxygen saturation monitoring demonstrated drops to
levels as low as 60. Of note, the readings were ultimately
thought to be due to artifact. After an evaluation, the
pulmonary team indicated that the periods of unresponsiveness
were unlikely to have a pulmonary component. Therefore,
continuous supplemental oxygen therapy and CPAP was considered
to be of little benefit. Mr. [**Known lastname **] is scheduled to
participate in an outpatient sleep study to further evaluate
pulmonary and sleep physiology.
.
Physical examinations periodically revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6055**]-[**Doctor Last Name **]
pattern of respiration. A chest x-ray was performed to evaluate
for evidence of CHF, which can be associated with [**Last Name (un) 6055**]-[**Doctor Last Name **]
patterns of breathing. The imaging showed no evidence of CHF.
There was evidence of extrinsic compression of the trachea of
unclear significance; according to the radiology team, the
lesion did not appear to change with respiration (as it would
with tracheomalacia for example). A thyroid ultrasound did not
show convincing evidence of compression by the thyroid gland.
.
The etiology of the events remains unclear. Likely, the cause
is multifactorial. As the episodes have not recurrend since the
hematocrit has risen, anemia could have played a role.
Similary, the absence of events since the discontinuation of the
SSRI argues for the potential role of medication. Transient
hypoxia could also be an important precipitant. There does not
seem to be evidence of seizure or clear toxic, metabolic,
endocrinological, infectious, or structural explanations.
.
CARDIOLOGY
In setting of significant bleeding, warfarin was discontinued
[**6-3**]. Aspirin 81 mg po daily was started on the day of
discharge. Diltiazem was continued and metoprolol was started
for rate control and cardioprotection. Anticoagulation should
be discussed at the patient's next cardiology visit. We are
also contacting the patient's cardiologist.
.
INFECTIOUS DISEASE
The patient completed the planned course of metronidazole and
ciprofloxacin for a previously diagnosed pseudomonal wound
infection on [**2149-6-6**]. He remained afebrile.
.
ENDOCRINOLOGY:
The patinet's oral hypoglycemics were held in favor of an
insulin sliding scale.
.
REHABILITATION:
Members of the physical therapy team participated in the
patient's care and recommended inpatient rehabilitation as one
important element of an optimal discharge plan.
.
CODE:
At the time of the patient's discharge, his code status was
DNR/DNI.
Medications on Admission:
HOME MEDICATIONS: (Discharge Medications [**5-31**])
Glyburide 2.5 mg PO DAILY
Levothyroxine 88 mcg DAILY
Omeprazole 20 mg DAILY
Primidone 50 mg DAILY
Pyridostigmine Bromide 60 mg PO BID
Warfarin 5 mg Daily
Cholestyramine-Sucrose 4 gram Packet PRN
Citalopram 20 mg DAILY
Ergocalciferol (Vitamin D2) 50,000 unit
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Aspirin 81 mg DAILY
Diltiazem HCl 300 mg DAILY
Ciprofloxacin 500 mg Tablet for 6 days ([**6-6**])
Metronidazole 500 mg Tablet PO Q8H for 6 days (5/210
Enoxaparin 80 mg/0.8 mL twice a day.
Discharge Medications:
1. Glyburide 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
2. Levothyroxine 88 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Primidone 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
5. Pyridostigmine Bromide 60 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO
BID (2 times a day).
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Month/Year (2) **]: One (1)
Capsule PO once a month.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Year (2) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Aspirin 81 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
9. Diltiazem HCl 300 mg Capsule, Sustained Release [**Hospital1 **]: One (1)
Capsule, Sustained Release PO once a day.
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3
times a day).
11. Modafinil 100 mg Tablet [**Hospital1 **]: 0.25 Tablet PO QAM (once a day
(in the morning)).
12. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Cholestyramine-Sucrose 4 gram Packet [**Hospital1 **]: One (1) packet PO
twice a day as needed for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
- Anemia in the setting of a right flank hematoma and
therapeutic INR.
- Obtundation, likely multifactorial (pharmacological,
hematological, respiratory contributions) in etiology
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
The neurological examination is notable for disorientation to
date (although he tried to use ambient cues), location,
situation, poor memory, dysnomia, anisicoria with left > right.
His gait was evaluated by physical therapy.
Discharge Instructions:
You presented to the [**Hospital1 18**] after a change in mental status.
Physical examination revealed a large bruise in the area of the
right flank and thigh. Your hematocrit was also found to be low
enough to require transfusions. Fortunately, there was no
evidence of continued bleeding after the transfusiuons. Please
note that the coumadin and lovenox were stopped in the setting
of the bleeding. On the day of discharge aspirin 81 mg po daily
was restarted.
.
In the course of the hospitalization, you had several episodes
where you did not respond to verbal, tactile or noxious
stimulation (for as long as six hours). Of note, these
episodes did not recur after your blood count came up and the
citalopram was discontinued. We think that anemia, hypoxia, and
medication effects were contributing to the episodes. There was
no clear evidence of seizure, infection, or structural change to
explain the syndrome.
.
It will be important to continue to monitor vital signs,
hematocrit, and the appearance of the hematoma.
.
* Please take all medications as prescribed.
* Please attend all follow-up appointments.
* Please seek medical attention for symptoms you consider
concerning.
Followup Instructions:
* Please attend appointments with the following providers:
- Neurologist [**Name6 (MD) 4739**] [**Last Name (NamePattern4) 4740**], M.D. (Phone:[**Telephone/Fax (1) 558**]) on
[**2149-7-9**] at 3:00 pm.
.
Department: SURGICAL SPECIALTIES
When: [**Date Range **] [**2149-6-23**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: [**Location (un) **] [**2149-6-30**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: CARDIAC SERVICES
When: [**Location (un) **] [**2149-10-20**] at 9:20 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2149-6-23**] 11:30
|
[
"5849",
"2851",
"4280",
"42731",
"4019",
"496",
"25000",
"2449"
] |
Admission Date: [**2196-8-16**] Discharge Date: [**2196-8-18**]
Date of Birth: [**2160-7-23**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Vioxx / Penicillins / Cellcept / Ceftriaxone /
Ferrlecit
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
peritoneal dialysis
History of Present Illness:
Ms. [**Known lastname **] is a 36 year old female with a history of SLE, lupus
nephritis, ESRD on PD who presented to the ER with two days of
chest pain and worsening shortness of breath. At home she had
been having pain. She had been having pain during her PD
sessions at home, and was having difficulty tolerating the PD
sessions, so she stopped doing her home PD sessions Sunday
evening. Over the next few days, she started having more
shortness of breath, was experiencing chest heaviness, orthopnea
and PND. Her shortness of breath worsened over, and she
presented to the ER today for further evaluation. She denies any
cough, nasal congestion, fever/chills, night sweats, n/v/d. Does
have her baseline abdominal pain and has felt worsening
"abdominal heaviness" since missing her PD sessions.
.
In the ED, initial vs were: T-98.2 P-124 BP-133/92 R-24 O2
sat-98%. On arrival she was tachypneic to the 20's, complaining
of chest heaviness and also tachycardic. She had a CXR that
showed bilateral pleural effusions, pulmonary vascular
congestion, an EKG that showed sinus tachycardia with TWI in I,
AVL. An echocardiogram was done that was mostly unchanged from
prior, showing an LVEF of 40% with severe 3+ MR. [**First Name (Titles) 6**] [**Last Name (Titles) **] showed
7.47/34/179, troponin of 0.09, CK of 135, MB of 3, BNP>[**Numeric Identifier **], K+
was 5.3, serum tox was positive for tricyclics, otherwise
negative. She was given 60mg IV lasix as she still makes urine,
SL nitro x 2, and levofloxacin to cover for CAP.
.
On the floor, her initial VS were: T-96.5, HR-133, BP-128/97,
RR-38, 100% on NRB. She continues to complain of shortness of
breath, despite stable oxygen saturations. She also continues to
complain of abdominal pain/heaviness, and generally feels
overwhelmed with her illness and doing the PD at home, has also
not been having as regular of bowel movements at home recently.
Also of note, she was recently on a prednisone taper for a lupus
flare, where she experiences vague symptoms, including SOB,
arthritis, abdominal heaviness.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough. Denies
palpitations. Denies nausea, vomiting, diarrhea. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
# Lupus rash
# Herpes Simplex I - [**12-1**], white lesions on the tongue and
buccal mucosa
# Axillary Adenopathy - [**10-1**], biopsied -> reactive lymph node
# Osteopenia - [**7-1**], L spine Tscore -2.40, Fem neck -1.91, Tot
Hip -1.41
# Hypercholesterolemia - [**7-31**]
# Lung abscess - [**7-31**]
# Pulmonary emboli (PE) - [**5-31**]
# Angioedema vs Anasarca - [**5-31**], associated with 2 grand mal
seizures, required intubation for massive facial/laryngeal
swelling
# Pleural Effusions - s/p pleurodesis in [**6-10**] nephrotic
syndrome
# Lupus nephritis / Nephrotic syndrome - [**4-30**], renal bx showed
focal proliferative class III
# GERD / Gastric ulcer - [**2-1**], seen on barium swallow
# Recurrent pneumonia - [**2185**], possibly from aspirations, most
recent [**2191-10-1**]
# Antiphospholipid antibody syndrome (APS) - [**2184**], requiring
anticoagulation to INR of 2 to 3
# Breast Masses - [**8-/2182**], bilateral, largest right upper outer
quadrant 4/3 cm
# Thrombotic thrombocytopenic purpura (TTP) - [**10/2182**], s/p
plasmapheresis
# Inflammatory eye mass - [**11/2180**], s/p excision of mass, [**2-2**] lupus
# Gonorrhea - [**7-/2180**], disseminated gonococcus
# Abnormal pap smear - [**2180**], subsequent paps x 2 normal
# Systemic lupus erythematosus (SLE) - [**2179**], followed by Dr.
[**Last Name (STitle) **]
# Raynaud's syndrome
# Stroke - hemiparalysis
# Asthma - no problems for several years
Social History:
Married with three children, born in [**2184**], [**2185**], and [**2188**]. Lives
in [**Hospital1 8**]. Went to [**University/College 3036**]. Worked as an accountant
until health declined in early [**2187**]. No tobacco, ethanol or drug
use.
Family History:
No collagen vascular disorders. Maternal grandmother died of
pancreatic cancer last year. No other cancers in the family. No
FH heart disease. Her parents are alive and she has 3 healthy
children.
Physical Exam:
VS: Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 121 (118 - 133) bpm
BP: 136/94(104) {128/94(103) - 165/106(120)} mmHg
RR: 18 (17 - 38) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
General Appearance: Thin, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, dry MM
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
Tachycardic
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Crackles : , Bronchial: right base , Diminished: bases )
Abdominal: Soft, Distended, Tender: diffusely
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Musculoskeletal: No(t) Unable to stand
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
[**2196-8-16**] 02:15PM WBC-7.2# RBC-2.53* HGB-7.8* HCT-22.4* MCV-89
MCH-30.9 MCHC-34.9 RDW-15.0
[**2196-8-16**] 02:15PM NEUTS-73.1* LYMPHS-19.2 MONOS-3.7 EOS-3.7
BASOS-0.3
[**2196-8-16**] 02:15PM PLT COUNT-248
[**2196-8-16**] 02:15PM PT-42.8* PTT-26.2 INR(PT)-4.5*
[**2196-8-16**] 02:15PM RET AUT-1.2
[**2196-8-16**] 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2196-8-16**] 02:15PM HAPTOGLOB-191
[**2196-8-16**] 02:15PM TOT PROT-5.1*
[**2196-8-16**] 02:15PM CK-MB-3 proBNP-GREATER TH
[**2196-8-16**] 02:15PM cTropnT-0.09*
[**2196-8-16**] 02:15PM ALT(SGPT)-5 AST(SGOT)-8 LD(LDH)-337*
CK(CPK)-135 ALK PHOS-50 TOT BILI-0.1
[**2196-8-16**] 02:15PM GLUCOSE-99 UREA N-55* CREAT-14.2*# SODIUM-136
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
[**2196-8-16**] 02:34PM LACTATE-0.9 K+-5.3
[**2196-8-16**] 02:34PM TYPE-ART PO2-179* PCO2-34* PH-7.47* TOTAL
CO2-25 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2196-8-16**] 09:05PM FIBRINOGE-632*#
----------------
[**2196-8-16**] TTE: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2196-7-29**],
the heart rate is now higher and LVEF is slightly lower.
.
[**2196-8-17**] CXR (PA and Lat): FINDINGS: In comparison with the study
of [**8-16**], there are bilateral pleural effusions with compressive
atelectasis and engorgement of pulmonary vessels, consistent
with the clinical impression of volume overload. The possibility
of supervening pneumonia cannot be definitely excluded and would
have to be made on clinical grounds.
Brief Hospital Course:
#) Volume Overload/Shortness of Breath: in the setting of
missing PD sessions, likely due to volume overload, especially
in the context of the findings on CXR, and echo. Also possible
is PNA. We consulted the renal team and continued Ms. [**Known lastname **] on
PD while in the ICU on an aggressive schedule to remove extra
fluid. She was started on empiric treatment for CAP with
levofloxacin. While she was afebrile on the floor and had a
normal WBC, she had a fever in the ED and it was decided to
continue empiric treatment of possible CAP as an outpatient for
a total of 5 days (last dose to be [**2196-8-20**]) of 750 mg
levofloxacin daily.
.
#) High INR: Pt has h/o PEs and has anti-phospholipid Ab
syndrome with no evidence of bleed. It peaked at 6.0 and rather
than give Vitamin K, we decided to let it drift back down by
holding coumadin. The INR was 3.6 on the day of discharge, and
she is followed by the coumadin clinic at [**Company 191**]. We have
contact[**Name (NI) **] the [**Name (NI) 191**] clinic for her f/u. As their recs, she should
take 3.75 mg tonight, and 5 mg starting tomorrow ([**8-19**]) until
she hears back from the [**Hospital3 **]. She will need
to F/U by getting an INR check on [**Hospital3 766**], [**8-22**], which will need
to be faxed to [**Company 191**] coumadin clinic.
.
#) ESRD on PD: As per renal, we continued her PD in house, and
she will be returning to her regular home regimen as an
outpatient.
We have continued her senna and colace as an outpatient to help
with constipation, and have tried miralax while in house. She
also came in with a positive amitryptiline when she arrived to
[**Hospital1 18**] and her dose was held. We rechecked a level and it is
still pending. We told pt not to take any more of this
medication until this result came back and she followed up with
her PCP.
.
#) Tachycardia: Pt has been in sinus tach since arriving on the
floor. TSH nl. Has baseline tachy, possibly [**2-2**] anemia. Pt
would decline blood products. Given her low EF on echo, it was
decided to start labetalol 100 mg POBID for her which has helped
bring both her BP and heart rate down.
.
#) Anemia: patient with recent HCT of around 25, however in the
end of [**Month (only) 116**] HCT was around 30, drop thought to be due to
hemolysis. Hemolysis labs were rechecked which were negative.
Her Hct was stable for us around 25. We kept an active T/S, and
the plan is to continue her darbepoetin Q2 weeks.
.
#) Hypertension: we continued her home medications, and given
her EF of 40% with 3+ MR, and her persistent hypertension, we
continued her home dose of lisinopril, amlodipine, and added
labetalol 100 mg POBID.
.
#) Depressed EF (40%) on TTE, with 3+ MR.
- Continue labetalol.
- Arrange for cardiology f/u with Dr. [**Last Name (STitle) 171**] next week.
.
#) SLE: Continued her home plaquenil
Medications on Admission:
1. Amlodipine 5 mg DAILY
2. Calcitriol 0.25 mcg DAILY
3. Cyclobenzaprine 10 mg HS as needed for pain.
4. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Syringe q 2
weeks.
5. Hydroxychloroquine 200 mg: Two (2) Tablet PO EVERY OTHER DAY
6. Hydroxychloroquine 200 mg: One (1) Tablet PO EVERY OTHER DAY
7. Lisinopril 40mg DAILY
8. Ranitidine HCl 150 mg twice a day.
9. Prednisone 20 mg Tablet Sig: see below Tablet PO DAILY
(Daily): [**Date range (1) 3045**]: 3 tabs daily, [**Date range (1) 3046**]: 2 tabs daily,
[**Date range (1) 3047**]: 1 tab daily, [**Date range (1) 3048**]: [**1-2**] tab daily.
Disp:*25 Tablet(s)* Refills:*0*
10. Sevelamer Carbonate 800 mg TID W/MEALS
11. Coumadin 10 mg M, W, F, Sun.
12. Coumadin 7.5 mg T, Th, Sat.
Discharge Medications:
1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cyclobenzaprine 10 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed for pain, muscle spasm.
9. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
11. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
EVERY OTHER DAY (Every Other Day).
12. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO
EVERY OTHER DAY (Every Other Day).
13. Coumadin 2.5 mg Tablet Sig: 1.5-2 Tablets PO once a day:
Please take one and a half pills (3.75 mg) on [**8-18**], and two
pills starting [**8-19**] until you hear back from the [**Hospital 3052**].
Disp:*30 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please have INR checked and fax to [**Hospital 191**] [**Hospital3 **]:
([**Telephone/Fax (1) 3053**]
Discharge Disposition:
Home
Discharge Diagnosis:
Volume overload/shortness of breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because you were short of breath from having too much fluid on
after suboptimal peritoneal dialysis sessions for a few days.
While you were here, we were able to aggressively use peritoneal
dialysis to take off fluid to make you more comfortable. Your
blood pressure and heart rate were also high, and we have
started a new medication for you to help with this problem.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS:
1) Please START taking labetalol 100 mg by mouth two times a day
2) Today ([**8-18**]), please take 3.75 mg of coumadin.
3) For the next two days (Friday, [**8-19**] and Saturday, [**8-20**]),
please take 5 mg of coumadin.
4) Go back to your regular dose of coumadin on [**8-21**] (Sunday).
5) Do not take your amitriptyline. We have drawn a level and if
it comes back normal you can continue taking it. Your PCP can
let you know when this level comes back or you can call to find
out if you can start taking this medication again.
PLEASE CONTINUE THE FOLLOWING FOR YOUR PERITONEAL DIALYSIS
1) 5 cycles of 1500 milliliter fill, 1.5% dextrose alternating
with 2.5% dextrose; 1 day dwell of 1.5% dextrose with 1500
milliliter fill.
2) PLEASE CALL [**Doctor First Name 3040**] at [**Location (un) **] peritoneal dialysis
center.
Followup Instructions:
INR CHECK
Please go for a blood draw to check your INR on [**Location (un) 766**], [**8-22**],
and have the results faxed to the [**Hospital 18**] [**Hospital3 **]
[**Hospital 197**] Clinic ([**Telephone/Fax (1) 3053**].
CARDIOLOGY
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-8-24**] 2:40
RHEUMATOLOGY
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2196-9-22**]
1:00
[**First Name8 (NamePattern2) 3049**] [**Last Name (NamePattern1) 3050**], MD Phone:[**Telephone/Fax (1) 3051**] Date/Time:[**2196-10-5**]
11:15
Completed by:[**2196-9-13**]
|
[
"486",
"4240",
"V5861",
"4168"
] |
Admission Date: [**2175-10-4**] Discharge Date: [**2175-10-10**]
Date of Birth: [**2106-4-25**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This 69 year-old male with a
history of hypertension, but no known cardiac disease had
sudden onset of substernal chest pain on the [**8-31**].
The patient saw his primary care physician [**Last Name (NamePattern4) **] [**10-3**] and was
found to have electrocardiogram changes in the anterior and
lateral leads. He was admitted to [**Hospital 1474**] Hospital and
placed on intravenous nitroglycerin, heparin and Aggrastat.
The patient was referred to [**Hospital1 188**] for cardiac catheterization. Cardiac catheterization
showed a left ventricular ejection fraction of 40% with
severe anterolateral and inferoapical hypokinesis and apical
diakinesis, 90% left anterior descending coronary artery
lesion, 80% LCX lesion, diffuse right coronary artery
disease. The patient was referred to Dr. [**Last Name (STitle) **] for cardiac
surgery.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Asthma. 3.
Benign prostatic hypertrophy. 4. Osteoarthritis.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: 1. Aspirin 325 mg po q day. 2.
Lopressor 12.5 mg po t.i.d. 3. Lovastatin 20 mg po q day.
4. Serevent MDI two puffs po b.i.d. 5. Albuterol MDI two
puffs q 4 hours prn. 6. Proscar 5 mg po q day.
INITIAL PHYSICAL EXAMINATION: Pulse 72 sinus rhythm. Blood
pressure 126/74. Neck is supple without JVD. Carotids are
2+ bilaterally without bruits. Chest is clear to
auscultation without wheeze. Heart regular rate and rhythm.
Normal S1 and S2 without murmur, rub or gallop. Abdomen
positive bowel sounds, nontender. Peripheral vascular 2+
femoral pulses bilaterally without bruits. No lower
extremity edema. He moves all extremities. Strength 5 out
of 5. Neurological is nonfocal.
LABORATORY: White blood cell count 9.3, hematocrit 40.6,
platelet count 270. Chem 7 138, potassium 4.2, chloride 104,
bicarb 26, BUN 12, creatinine 1.0, glucose 80, CKMB 28.6.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2175-10-5**] with Dr. [**Last Name (STitle) **] for a coronary artery bypass
graft times three, left internal mammary coronary artery to
distal left anterior descending coronary artery, saphenous
vein graft to proximal left anterior descending coronary
artery, saphenous vein graft to ramus. The patient was
transferred to the Intensive Care Unit in stable condition on
5 micrograms per kilogram per minute of Dopamine. The
patient was weaned and extubated from mechanical ventilation
on his first postoperative night. Dobutamine was weaned off
with adequate cardiac index. The patient was transferred
from the Intensive Care Unit to the floor on postoperative
day one. The patient's chest tubes were removed on
postoperative day number two.
The patient had an episode of atrial fibrillation on
postoperative day two and started on oral Amiodarone load.
On the evening of postoperative day number three the patient
experienced episode of hypoxia, agitation, anxiety and
respiratory distress, which subsided with oxygen with no
evident cause. Chest x-ray was without pneumothorax or
pleural effusion. The patient again experienced another
episode on postoperative day number three similar, awoke from
sleep complaining of shortness of breath. Pulse oximeter
showed him to be low oxygen saturation in the 80s, which
subsided with a nonrebreather, which was quickly weaned to
nasal cannula. The patient was also found to be febrile to
101. The patient was pan cultured. Chest x-ray showed
bilateral atelectasis. Pulmonary and psychiatry consults
were obtained. The patient felt that the episodes were due
to anxiety. No history of similar episodes at home.
Psychiatry felt that the episodes were perhaps pulmonary in
nature. Pulmonary consult felt that the patient perhaps had
a history of previously undiagnosed sleep apnea exacerbated
by atelectasis on chest x-ray and sedating medications in the
hospital. Pulmonary recommended outpatient sleep study and
continuous pulse oximetry monitoring.
The patient had continuous pulse oximetry monitoring on the
night of [**2175-10-9**]. The patient did not experience any
similar episodes of hypoxia or anxiety. The patient's lowest
pulse oximeter [**Location (un) 1131**] was 91% on room air. The patient's
urinalysis from [**10-9**] showed greater then 100,000 gram
negative rods, positive for nitrites. The patient was
started on Ciprofloxacin. On postoperative day number five
the patient was felt to be dramatically improved and stable
for discharge to a rehabilitation facility.
CONDITION ON DISCHARGE: Temperature max 101.8 on [**10-9**].
Temperature current 97. The patient has been afebrile since
before midnight. Pulse 81 and in sinus rhythm. Blood
pressure 98/57. Room air oxygen saturation 97%.
Neurologically, the patient is awake, alert and intact
reporting a restful night sleep. No episode of anxiety or
night terrors. Cardiovascular the patient is regular rate
and rhythm. Distant heart sounds. No murmurs, rubs or
gallops. Respiratory, breath sounds are decreased bilateral
posteriorly. No wheezes or rhonchi are present.
Gastrointestinal, abdomen is large and soft. Positive bowel
sounds. Nontender. The patient reports positive flatus.
Sternal incision staples are intact. No erythema or drainage
noted. Sternum is stable. Right lower extremity
Steri-Strips are intact. The saphenectomy site, there is no
erythema or drainage.
CBC from [**2175-10-10**] white blood cell count 8.1, hematocrit
23.1, which is stable. Platelet count 342. Chem 7 sodium
135, potassium 4.5, chloride 101, bicarb 28, BUN 21,
creatinine 1.2, glucose 109. Sputum culture from [**10-9**] shows
oropharyngeal flora. Cultures are pending. Blood culture
times two from [**10-9**] are pending. Urine culture from [**10-9**]
gram stain shows greater then 100,000 gram negative rods.
Culture is pending. Urinalysis from [**10-9**] was positive for
nitrites. Chest x-ray from [**10-9**] shows patchy opacities at
bilateral lung basis consistent with atelectasis. The
patient was placed on Ciprofloxacin for ten days for presumed
urinary tract infection with gram negative rods.
DISCHARGE STATUS: The patient is to be discharged to a
rehabilitation facility in stable condition.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Postoperative atrial fibrillation.
3. Postoperative urinary tract infection.
4. Episodes of nocturnal dyspnea, hypoxia, questionable
obstructive sleep apnea.
5. Hypertension.
6. Asthma.
7. Benign prostatic hypertrophy.
8. Osteoarthritis.
DISCHARGE MEDICATIONS: 1. Lopressor 75 mg po b.i.d. 2.
Lasix 20 mg po b.i.d. times one week. 3. K-Ciel 20
milliequivalents po b.i.d. times one week. 4. Lovastatin 20
mg po q.h.s. 5. Ciprofloxacin 500 mg po b.i.d. times ten
days. 6. Aspirin 81 mg po q day. 7. Colace 100 mg po
b.i.d. 8. Serevent MDI two puffs b.i.d. 9. Albuterol MDI
two puffs q 4 hours prn. 10. Ibuprofen 400 to 600 mg po q 6
hours prn. 11. Amiodarone 400 mg po t.i.d. times five days
and then 400 mg po b.i.d. times seven days and then 400 mg po
q day. 11. Oxazepam 15 mg po q.h.s.
The patient is to follow up with Dr. [**Last Name (STitle) **] upon discharge
from rehab. The patient is to follow up with his
cardiologist and primary care physician in three to four
weeks. The patient is to have follow up sleep study as an
outpatient to rule out obstructive sleep apnea.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2175-10-10**] 11:46
T: [**2175-10-10**] 12:25
JOB#: [**Job Number 31114**]
|
[
"41401",
"9971",
"42731",
"5990",
"4019",
"2720"
] |
Admission Date: [**2106-10-8**] Discharge Date: [**2106-10-20**]
Date of Birth: [**2042-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
Shortness of breath, cough, right-sided chest pain
Major Surgical or Invasive Procedure:
Thoracentesis
Placement of thorocostomy drain
VATS with placement of chest tube
History of Present Illness:
HPI: 64M PMH EtOH/PBC cirrhosis and new diagnosis HCC s/p RFA
admitted with DOE and a 5 pound weight gain (268lb from recent
discharge 263lb [**2106-10-6**]; patient had been admitted for fluid
overload). He noted progressive shortness of breath, right
sided chest pain, and cough after discharge on [**2106-10-6**]. He was
originially admitted last earlier in the month with weight gain
and edema after RFA in late [**Month (only) 216**]. A pleural effusion was
noted during his last admission, but as it was improving
radiologically upon discharge, it was not tapped. He denied
hemoptysis, worsening abdominal pain.
Past Medical History:
-Cirrhosis secondary to PBC and alcoholism. Portal Hypertension,
Grade 1 varices. Not yet evaluated/listed fro transplant.
-Hepatocellular carcinoma--diagnosed on [**2106-9-29**] biopsy
-Prostate cancer s/p prostatectomy
-Hemorrhoids
-Hypertension--diet controlled
Physical Exam:
General: NAD
HEENT: nc/at, EOMI grossly, OP clear, MMM, no LAD
CV: RRR, no murmur
Resp: [**Month (only) **] BS right [**2-2**] of lung, [**Month (only) **] left base
Abd: soft, obese, mild distention, mild ttp RUQ, liver edge palp
with
insp, + splenomegaly, NABS
Ext: 1+ edema to mid shin bilaterally
Neuro: AOx4, CN II-XII intact grossly, no asterixis
Pertinent Results:
Admission Labs:
[**2106-10-8**] 01:30PM BLOOD WBC-14.5* RBC-3.72* Hgb-14.8 Hct-40.7
MCV-110* MCH-39.9* MCHC-36.5* RDW-16.7* Plt Ct-183#
[**2106-10-8**] 01:30PM BLOOD Neuts-72.9* Lymphs-12.1* Monos-12.3*
Eos-2.3 Baso-0.4
[**2106-10-8**] 01:30PM BLOOD PT-21.6* INR(PT)-2.1*
[**2106-10-8**] 01:30PM BLOOD UreaN-31* Creat-1.2 Na-126* K-4.5 Cl-90*
HCO3-27 AnGap-14
[**2106-10-8**] 01:30PM BLOOD ALT-40 AST-65* AlkPhos-135* TotBili-4.7*
[**2106-10-9**] 06:25AM BLOOD TotProt-5.4* Albumin-2.5* Globuln-2.9
Calcium-8.1* Phos-2.6* Mg-2.3
.
Discharge Labs:
[**2106-10-20**] 06:15AM BLOOD WBC-3.8* RBC-2.72* Hgb-10.1* Hct-29.5*
MCV-108* MCH-36.9* MCHC-34.1 RDW-16.5* Plt Ct-65*
[**2106-10-20**] 06:15AM BLOOD PT-20.0* PTT-40.5* INR(PT)-1.9*
[**2106-10-20**] 06:15AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-136
K-3.8 Cl-106 HCO3-24 AnGap-10
[**2106-10-20**] 06:15AM BLOOD ALT-13 AST-33 AlkPhos-89 TotBili-2.7*
[**2106-10-20**] 06:15AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.8
.
Studies:
CXR [**2106-10-8**]:
A large right pleural effusion has increased in size with
adjacent atelectasis in the middle and lower lobes. There is no
substantial left pleural effusion. Cardiomediastinal contours
are stable in appearance allowing for increased obscuration of
the right heart border.
IMPRESSION: Enlarging right pleural effusion.
.
RUQ U/S [**2106-10-9**]:
IMPRESSION:
1. Cirrhotic liver. Limited doppler interrogation demsontrates
patent portal veins with possible slow flow within main portal
vein.
2. Complex right pleural fluid consistent with provided history
of
hemothorax.
.
CT chest with contrast [**2106-10-10**]:
IMPRESSION:
1. Moderate, partially loculated right pleural effusion with
increased
density compared to simple peritoneal fluid, likely reflecting
recent
hemorrhage, although no evidence od active bleeding is present.
Small amount of pleural air, most likely related to recent
thoracentesis.
2. Atlectatic right middle lobe and right lower lobes adjacent
to effusion.
3. Multifocal patchy lung parenchymal opacities, new since
[**2106-10-5**], and mostly in the left lung. Differential
diagnosis includes aspiration, infection, and hemorrhage.
4. Small mediastinal and 1 cm right and midline paracardiac
lymph nodes.
5. Tiny left pleural effusion.
6. Coronary calcifications, extensive.
7. Significant gynecomastia, related to known liver cirrhosis.
Subcutaneous fat stranding might be atributed to
hypoalbuminemia.
8. Intra-abdominal findings consistent with liver cirrhosis.
For evaluation of the intra-abdominal pathology, please refer to
dedicated abdomen CT from [**2106-10-2**].
Brief Hospital Course:
A/P: 64 yo with cirrhosis and new diagnosis HCC s/p RFA with
resulting right hemothorax and left pneumonia.
.
# Right sided pleural effusion: The pleural effusion was tapped
with over 2L of bloody pleural fluid removed from his right
chest. This resulted in very little improvement radiologically.
The effusion was noted to be loculated by CT and CXR. A
pigtail catheter was then placed to drain and flushed, resulting
in little extra drainage. He was then taken to thoracic surgery
for VATS to remove the loculated hemothorax. He was in the MICU
for one day following the VATS because of difficulty weening
from the ventilator after the surgery. He was stabilized,
extubated, and returned to the floor where the chest tube was
removed a couple days later. Of note, he also had a left upper
lobe infiltration which was treated with vanc and zosyn for nine
days and finished before he went home. Upon D/C, he was
symptomatically and radiologically improved. He was set up with
VNA to help him with any continued draining through the chest
tube site.
.
# Weight gain: received albumin and was fluid restricted. His
edema improved through his stay and his weight was decreased
upon discharge. He was discharged on low dose diuretics, lasix
20mg and spironolactone 50mg daily.
.
# anemia: He was anemic throughout his stay and required 2U
pRBCs while in the MICU. He required no further blood
transfusions on the floor. He likely has a new baseline due to
decreased epo production from liver.
.
# Cirrhosis/HCC: s/p RFA, in transplant workup. He had a slight
LFT elevation upon admission, likely related to the recent
procedure. It trended toward baseline during his stay. He was
continued on [**Last Name (un) **] Forte, and given lactulose. Recent slight LFT
elevation from baseline, likely related to recent procedure, now
normalized.
Medications on Admission:
1. Ursodiol 250 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: Take in between the 5-10mg (at 2 hours) doses
if needed.
Disp:*15 Tablet(s)* Refills:*0*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**2-2**] Adhesive Patch, Medicateds Topical APPLY FOR 12HRS/DAY ():
Do not leave on for more than 12 hours per day.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*2*
Discharge Medications:
1. Ursodiol 250 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Do not
leave patch on for more than 12 hours per day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please draw CBC, Chem7, LFTs, INR, PTT, PT. Please fax results
to [**Telephone/Fax (1) 697**], attn. [**Doctor Last Name 1022**].
Please fax results also to [**Telephone/Fax (1) 42485**], attn. [**Doctor First Name 6480**].
Discharge Disposition:
Home With Service
Facility:
SE VNA
Discharge Diagnosis:
Primary:
Right sided hemothorax
.
Secondary:
PBC and alcoholic liver cirrhosis
Hepatocellular carcinoma
Hypertension
Hypercholesterolemia
prostate cancer s/p prostatectomy
Discharge Condition:
good, improved SOB and cough, ambulating
Discharge Instructions:
You were seen at [**Hospital1 18**] for a right hemothorax (blood in your
chest cavity). You had a thoracentesis, followed by surgery to
remove the fluid and break up any loculations. The chest tube
was removed on [**2108-10-20**]. You will be provided with home nursing
care to help you manage your chest tube wound site.
.
You will need to have your labs checked in one week on [**10-27**]. You
can do this at [**Hospital3 **]. The labs should be faxed to Dr. [**Name (NI) 8390**] office at [**Telephone/Fax (1) 697**].
.
We made the following changes to your medication regimen:
- Your lasix is now 20mg daily
- Your aldactone is now 50mg daily
- We added lactulose 30ml twice daily
- We sent you out with a limited supply of oral dilaudid for
pain
.
You have follow-up as below.
.
You should return to the ED or call your primary care provider
if you experience worsening shortness of breath, abdominal pain,
coughing blood, increase in chest tube site drainage or blood in
the drainage, fever greater than 101.4 degrees F, blood in your
stool, increasing swelling in your legs, or any other symptoms
that concern you.
.
You should maintain a low sodium sodium diet with less than 2
grams of sodium a day. You should also restrict your fluid
intake to less than 2 or 2.5 liters.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-10-27**] 11:45
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2106-10-27**] 1:00
.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2106-10-28**] 10:30. This is the thoracic surgery follow
up. You will need your sutures removed at this time.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2106-11-3**] 10:30. Address: [**Last Name (NamePattern1) **]. [**Location (un) **]
[**Hospital Ward Name **] Bld. [**Location (un) 86**], [**Numeric Identifier 718**].
.
Provider: [**Last Name (NamePattern4) 42486**], MD Phone:[**Telephone/Fax (1) 35930**]
Date/Time:[**2106-11-5**] 2:00
.
Please call if you need to reschedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
|
[
"5849",
"4019",
"2720"
] |
Unit No: [**Numeric Identifier 32397**]
Admission Date: [**2161-3-9**]
Discharge Date: [**2161-3-13**]
Date of Birth: [**2101-8-24**]
Sex: M
Service: CSU
CHIEF COMPLAINT: Known bicuspid aortic valve with aortic
stenosis and aortic regurgitation.
HISTORY OF PRESENT ILLNESS: A 59-year-old man with a history
bicuspid aortic valve and AS scheduled for aortic valve
replacement due to severe AS on echocardiogram. The patient
was admitted to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] in [**2161-1-27**]
for cardiac catheterization and then referred for aortic
valve replacement with subsequent repair of his ascending
aorta.
PAST MEDICAL HISTORY:
1. Aortic stenosis with aortic insufficiency.
2. Lactose intolerance.
3. Psoriasis.
4. Colonic polyps.
5. Fractured ankle requiring surgical repair.
ALLERGIES: The patient states an allergy to CODEINE.
MEDICATIONS PRIOR TO ADMISSION: Include Procardia 60 mg
daily and aspirin 81 mg daily.
FAMILY HISTORY: Significant for CAD. His father had an MI at
the age of 69.
SOCIAL HISTORY: Married. Lives with his wife. [**Name (NI) **] is the vice-
president of a paint company. Denies tobacco use. Occasional
alcohol use.
LABORATORY DATA PRIOR TO ADMISSION: White count of 5,
hematocrit of 45.3, platelets of 142, INR of 1.2. Sodium of
143, potassium of 3.9, chloride of 105, CO2 of 32, BUN of 18,
creatinine of 1.1, glucose of 195.
RADIOLOGIC STUDIES: Catheterization done on [**2161-2-5**]
showed a right-dominant system with no angiographically
apparent coronary artery disease. Cardiac index was 3.4.
Moderate aortic stenosis with a peak gradient of 35 and a
mean gradient of 28. Calculated aortic valve area of 1.3. EF
was 54%. Supraventricular aortography revealed moderate-to-
severe aortic insufficiency with a mildly dilated ascending
aorta.
An echocardiogram done in [**2160-9-29**] showed a bicuspid
aortic valve with moderate aortic stenosis, with a mean
gradient of 33 and a peak gradient of 56, with moderate-to-
severe aortic insufficiency, and mild mitral regurgitation,
with a mildly dilated aortic root, and ascending aorta of 3.8
cm, and an EF of 55%.
PHYSICAL EXAMINATION: In general, in no acute distress.
HEENT reveals anicteric, not injected. No JVD. The neck is
supple. The chest is clear to auscultation bilaterally.
Cardiac reveals a regular rate and rhythm with a 4/6 systolic
ejection murmur and a [**12-4**] diastolic murmur that radiates
bilaterally to the carotids. The abdomen is soft, nontender,
and nondistended. Extremities are warm and well perfused with
no clubbing, cyanosis, or edema. Pulses are 2 to 3+
throughout. Height is 5 feet 8 inches. Weight is 200 pounds.
HOSPITAL COURSE: The patient was admitted directly to the
operating room on [**2161-3-9**] where he underwent aortic
valve replacement with a #27 CE Perimount Magna pericardial
aortic valve and ascending aortic hemiarch replacement with a
#24-mm Gelweave graft. Please see the OR report for full
details. In summary, the patient tolerated the operation
well. His bypass time was 157 minutes with a cross-clamp time
of 130 minutes. He was transferred from the operating room to
the cardiothoracic intensive care unit. At the time of
transfer the patient was in an sinus rhythm at 90 beats per
minute with a mean arterial pressure of 95. He had
epinephrine at 0.02 mcg/kg/min, and Neo-Synephrine at 0.75
mcg/kg/min, and propofol at 30 mcg/kg/min.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. He remained
hemodynamically stable throughout the operative day. On
postoperative day #1, the patient's epinephrine was slowly
weaned. He was maintained on nitroglycerin to have adequate
blood pressure control, and he remained in the intensive care
unit while he was on vasoactive IV medications. On
postoperative day #2, the patient continued to do well. He
was weaned from his epinephrine drip over the course of
postoperative day #1, however he required continued
nitroglycerin infusion to maintain adequate blood pressure
control on postoperative day #2. At that time, he was begun
on oral beta blockade as well as diuretics. His chest tubes
were discontinued. His Foley catheter was removed, and he was
sent to [**Hospital Ward Name 121**] Two for continuing postoperative care and
cardiac rehabilitation.
Over the next 2 days, the patient had an uneventful
postoperative course. His activity level was increased with
the assistance of the nursing staff as well as physical
therapy. His medications were adjusted as tolerated by blood
pressure. On postoperative day #4, it was decided that the
patient was steady and ready to be discharged to home with
visiting nurses.
At the time of this dictation, the patient's physical exam is
as follows. Temperature of 98.4, heart rate of 81 (sinus
rhythm), blood pressure of 119/84, respiratory rate of 22,
and O2 saturation of 95% on room air. Weight preoperatively
was 92 kg and at discharge 96.8 kg. Physical exam reveals
neurologically alert and oriented x 3, moves all extremities,
follows commands, a nonfocal exam. Pulmonary reveals clear to
auscultation bilaterally. Cardiac reveals a regular rate and
rhythm. S1 and S2 with no murmurs. The sternum is stable.
Incision with Steri-Strips with no drainage or erythema. The
abdomen is soft, nontender, and nondistended with normal
active bowel sounds. The extremities are warm and well
perfused with no edema.
CONDITION ON DISCHARGE: Good.
DI[**Last Name (STitle) 408**]E FOLLOWUP: He is to have followup in the [**Hospital 409**]
Clinic in 2 weeks, followup with Dr. [**Last Name (STitle) 7047**] in 3 to 4 weeks,
and followup with Dr. [**Last Name (Prefixes) **] in 4 weeks.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with a #27 [**Last Name (un) 3843**]-
[**Doctor Last Name **] Magna pericardial valve as well as ascending aorta
hemiarch replacement with a #24 Gelweave graft.
2. Colonic polyps.
3. Psoriasis.
4. Lactose intolerant.
5. Status post ankle fracture with open reduction and
internal fixation.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg b.i.d.
2. Colace 100 mg b.i.d.
3. Aspirin 81 mg daily.
4. Percocet 5/325 1 to 2 tablets q.4-6h. as needed (for
pain).
5. Potassium chloride 20 mEq daily (x 2 weeks).
6. Lasix 20 mg daily (x 2 weeks).
DISCHARGE DISPOSITION: The patient is to be discharged to
home with visiting nurses.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2161-3-13**] 12:25:28
T: [**2161-3-13**] 13:35:12
Job#: [**Job Number 32398**]
|
[
"4241"
] |
Admission Date: [**2185-6-15**] Discharge Date: [**2185-7-11**]
Date of Birth: [**2125-8-3**] Sex: M
Service: MEDICINE
Allergies:
Byetta
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Syncope at MRI
Major Surgical or Invasive Procedure:
Cervical spine surgery....
History of Present Illness:
59M w/ HIV (last CD4 count was in the 400s with a viral load of
41,000), DM, pulm art htn, R sided CHF who is s/p syncope at
MRI, mild CP, resolved, in setting of CHF, pulm hypertension,
persistent hypoxia, likely baseline.
.
Patient was scheduled for outpatient MRI of L spine for ongoing
neurological workup. Feeling dizzy before MRI, has had this
sensation before, then was in machine, then felt like body was
hot, "burning", and was having back pain, so started to cry. Had
them stop MRI and then sat up and then passed out. At some
point, while in the MRI machine, reports feeling like he could
not breath. Denies nausea, sweating prior to event. Has had
panic attacks in the past. FSBG at the time was 73.
.
In the ED, initial VS 99.9, 89, 119/54, 15, 94% 3L (88% on RA).
CXR showed mild fluid congestion. EKG: SR 83, NA/, Q 3, avF.
Given 1L NS. Admitted to medicine for further workup of syncope,
hypoxia.
.
On arrival to the floor, he is asymptomatic and resting
comfortably in bed.
.
ROS: Denies fever, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
.
Past Medical History:
- HIV (last CD4 count 588 on [**2184-1-17**])
- Hepatitis C with stage IV cirrhosis, s/p antiviral tx
- Chronic kidney disease requiring several hospitalizations and
short-term dialysis
- Hypercholesterolemia
- Obstructive sleep apnea
- Depression
- CHF - last echo [**10-17**]: Moderate pulmonary hypertension.
Dilated right ventricle with depressed systolic function.
Moderate symmetric left ventricular hypertrophy with preserved
systolic function. Normal valvular function.
- GERD
- Obesity
- h/o C diff colitis ([**3-14**])
- Pancreatitis
- s/p Cholecystectomy
- s/p Appendectomy
Social History:
Patient lives with a female companion on [**Location (un) **]. He lost most
of his possessions, including property, when his bank when under
and recalled his loans which he could not pay and foreclosed his
home and other properties. This precipitated his psychiatric
admission for depression in [**Month (only) 116**]. Denies tobacco, alcohol or
current IV drug use. Has h/o IVDU
Family History:
Depression and anxiety. Father with DM, CAD; Mother with CAD.
Brother was MI at age 46.
Physical Exam:
Admission PHYSICAL EXAM:
VS: 99.2 138/P 86 22 96% 4l (75% RA sleeping) FSBG over 24h 159,
221, 174, 212
GENERAL: obese man in NAD, uncomfortable due to arm pain,
appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: faint crackles at bases but otherwise clear, ?decreased
inspiratory effort given pain
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, obese but does not appear fluid overloaded in
LE, SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, pt has pain in
arms from neuropathy, great difficult raising arms, also looks
like some muscle wasting in arms [currently being worked up
outpt]
.
Discharge:
VS: 97.5 138/78 p84 r20 91% on RA
GENERAL: obese man in NAD, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: faint bibasilar crackles, otherwise clear, breathing
comfortably on RA.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, obese but does not appear fluid overloaded in
LE, R wrist with mild edema compared to L wrist.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength ?~1-2/5
in upper and extremities bilaterally, difficult to assess
limitations [**2-9**] weakness versus discomfort
Pertinent Results:
Admission Labs:
[**2185-6-14**] 10:00PM BLOOD WBC-5.9 RBC-3.87* Hgb-10.5* Hct-31.4*
MCV-81* MCH-27.0 MCHC-33.3 RDW-16.3* Plt Ct-373#
[**2185-6-15**] 07:10AM BLOOD WBC-5.2 RBC-3.79* Hgb-10.3* Hct-31.3*
MCV-82 MCH-27.1 MCHC-32.9 RDW-16.2* Plt Ct-329
[**2185-6-14**] 10:00PM BLOOD Neuts-69.1 Lymphs-22.6 Monos-5.4 Eos-0.9
Baso-2.0
[**2185-6-14**] 10:00PM BLOOD Plt Ct-373#
[**2185-6-15**] 07:10AM BLOOD Plt Ct-329
[**2185-6-14**] 07:40PM BLOOD Creat-1.9*
[**2185-6-14**] 10:00PM BLOOD Glucose-74 UreaN-75* Creat-2.0* Na-137
K-3.8 Cl-90* HCO3-32 AnGap-19
[**2185-6-15**] 07:10AM BLOOD Glucose-232* UreaN-65* Creat-1.8* Na-137
K-3.7 Cl-94* HCO3-32 AnGap-15
[**2185-6-15**] 07:10AM BLOOD CK(CPK)-65
[**2185-6-14**] 10:00PM BLOOD proBNP-162
[**2185-6-14**] 10:00PM BLOOD cTropnT-0.01
[**2185-6-15**] 07:10AM BLOOD CK-MB-2
[**2185-6-15**] 07:10AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.1
.
Diabetes monitoring:
[**2185-6-20**] 07:20AM BLOOD %HbA1c-8.3* eAG-192*
.
LFTs:
[**2185-7-2**] 07:40AM BLOOD ALT-16 AST-22 LD(LDH)-201 AlkPhos-92
TotBili-0.6
Discharge labs:
[**2185-7-10**] 08:58AM BLOOD WBC-4.7 RBC-3.65* Hgb-9.5* Hct-29.5*
MCV-81* MCH-26.1* MCHC-32.3 RDW-15.7* Plt Ct-411
[**2185-7-10**] 08:58AM BLOOD Glucose-125* UreaN-42* Creat-0.8 Na-134
K-3.9 Cl-94* HCO3-32 AnGap-12
[**2185-7-10**] 08:58AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
.
.
Micro:
[**2185-7-7**] 9:35 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],7/02/11,9:52AM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2185-7-9**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2185-7-8**] 8:00 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
.,
C. diff: negative x2
.
Urine culture: negative
.
Blood cultures ([**6-21**]. [**6-12**], [**6-23**], [**7-2**], [**7-3**], [**7-5**]) negative
.
EKG admission:
Sinus rhythm. Prolonged Q-T interval. Intraventricular
conduction delay. Old inferior myocardial infarction. Poor R
wave progression. Compared to the previous tracing of [**2184-12-3**]
no significant change
.
Imaging:
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Study Date of [**2185-6-14**] 6:54
IMPRESSION:
1. Disc herniations from C5-C6 through C7-T1. Severe spinal
canal stenosis
with spinal cord compression at C5-6, and moderate spinal canal
stenosis with spinal cord deformation at C6-7. Evaluation for
spinal cord edema or
myelomalacia is limited by motion artifacts.
2. Globally narrow spinal canal from L3 through L5 due to short
pedicles.
This is further exacerbated by degenerative disease at L4-5
where there is
moderate to severe spinal canal stenosis with crowding of the
cauda equina. An osteophyte arising from the right L4-5 facet
joint impinges the traversing right L5 nerve root in the
subarticular recess.
3. Moderate bilateral L4-5 neural foraminal narrowing and severe
bilateral
L5-S1 neural foraminal narrowing, with impingement of the
exiting L4 and L5 nerve roots, respectively.
CHEST (PA & LAT) Study Date of [**2185-6-14**] 11:41 PM
FINDINGS:
There is mild cardiomegaly and mild vascular congestion. There
is no pleural effusion and no pneumothorax. An external
line/tube is projecting over the thoracic spine.
IMPRESSION: Mild cardiomegaly and vascular congestion. No
pneumonia.
UNILAT LOWER EXT VEINS Study Date of [**2185-6-15**] 2:52 PM
FINDINGS: [**Doctor Last Name **]-scale and color son[**Name (NI) 1417**] of bilateral common
femoral and
left-sided superficial femoral, popliteal, and calf veins were
evaluated. The calf veins demonstrated normal compressibility.
Remaining vessels
demonstrated normal flow, compressibility and augmentation.
IMPRESSION: No DVT in the left lower extremity.
CARDIAC PERFUSION PERSAN 2-DAY Study Date of [**2185-6-18**]
INTERPRETATION:
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium other than some mild
attenuation at the apex.
The LV cavity is enlarged.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 58%.
The end-diastolic volume is 130 ml.
No prior study is available for comparison.
IMPRESSION: No evidence of pharmacologically induced ischemia.
Moderate LV
dilation.
Cardiology Report Stress Study Date of [**2185-6-19**]
INTERPRETATION: This 59 year old type 2 IDDM man with a Hx of
obestiy, pulmonary HTN and shortness of breath was referred to
the lab
prior to non-cardiac surgery. The patient was infused with 0.142
mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or
chest
discomfort was reported by the patient throughout the study.
There were
no significant ST segement changes during the infusion or in
recovery.
The rhythm was sinus with rare isolated vpbs. Appropriate
hemodynamic
response to the infusion and recovery. The dipyridamole was
reversed
with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
FOOT AP,LAT & OBL BILAT [**2185-7-7**]
LEFT FOOT: There are no erosions identified. There are mild
degenerative
changes of the first MTP joint with minimal soft tissue
prominence along the
medial aspect of the first MTP joint. Mineralization is grossly
preserved.
RIGHT FOOT: There is a periarticular erosion involving the first
metatarsal
head with adjacent soft tissue calcifications. This finding is
compatible
with patient's known gouty arthritis. The joint spaces are
preserved. Rest
of bony structures are intact.
Brief Hospital Course:
Primary Reason for Hospitalization:
59M w/ HIV (last CD4 count was in the 400s with a viral load of
41,000), DM, pulm art htn, R sided CHF who initially presented
due to syncopal episode in MRI scanner and was subsequently
admitted for C5-T2 laminectomy fusion for severe cervical
stenosis. He was transferred to the SICU immediately post-op
for delayed extubation, and on POD#1 he was transferred to the
medical service for management of his post-operative pain and
multiple medical issues.
.
Active issues:
.
# Syncope: Likely panic attack in MRI scanner. Given flushing,
could also be related vasovagal episode. Given h/o pHTN,
appearance of mild fluid overload on CXR, hypoxia, there was
concern for cardiogenic cause. However, pt didn't eat or drink
for several hours before MRI, and is on high doses of diuretics,
he could be hypovolemic. Pt was given fluids in ED and improved.
Also got home dose of lorazepam w/good effect. No cardiac
arrythmias detected on tele and pt was asymptomatic.
.
# Neuropathy, arm pain, DDD: Pt MRI shows severe degenerative
changes in cervical region w/multiple disc herniations and
stenosis. Pain is debilitating. Pt at one point voiced that he
could not live this way and was thinking about suicide. Although
he was a very high surgical risk he wished to persue surgery in
the hopes of some improvement in symptoms. Surgery was consulted
and eventually plan was for surgery on [**2185-6-28**].
.
# S/p C5-T2 laminectomy/fusion: Pain was controlled with topical
agents (lidoderm patch, bengay), tylenol, gabapentin (increased
from his home dose of 800mg q8hr to 1200mg q8hr), and oxycodone
PO liquid (10mL q4-6hrs prn). The spine service followed him
and recommended outpatient follow-up 4-6 weeks after surgery.
Physical therapy evaluated him and felt that he would benefit
from a stay in a rehab facility for additional therapy due to
his limited mobility.
.
# Chronic diastolic heart failure: Due to pulmonary hypertension
and cor pulmonale. [**Name (NI) **], pt initially required
continuous O2 via NC due to hypervolemia. He was continued on
his home dose of torsemide and metolazone, and his oxygenation
improved as he became euvolemic. His torsemide and metolazone
were later held due to evidence of pre-renal acute renal failure
and a gout flare (see below). On discharge he was breathing
comfortably and maintaining O2sats >94% on RA. It was
recommended that he resume his home dose torsemide but refrain
from using metolazone as it could increase risk of recurrent
gout flares.
.
# Renal Insufficiency: Pt has h/o chronic renal insufficiency
(baseline appears to be around 1.5), showed evidence of
pre-renal acute renal failure during hospitalization based on
urine lytes. Diuretics were held and creatinine improved to
normal range.
.
# Gout: Pt had no known h/o gout prior to admission, but
post-operatively developed pain/swelling of his R wrist,
shoulder, and knee as well as low grade fevers (to 100.6F). DVT
of the RUE was ruled out by RUE U/S. There was initial concern
for possible infection, and an infectious work-up was pursued
with blood/urine/stool cultures and CT C-spine to evaluate for
possible post-operative abscess. After work-up was negative for
infection, he was evaluated by rheumatology who performed a
joint aspiration of the wrist and requested Xrays of the R
shoulder, wrist, knee, and foot. His uric acid was notably
elevated at 14.3. He was diagnosed with an acute gout flare
based on clinical suspicion and radiographic evidence (erosion
of the 1st R metatarsal on foot Xray). He started treated with
prednisone 20mg PO daily and transitioned to colchicine 0.6mg
daily prior to discharge. It was recommended that he
discontinue his metolazone as it could increase risk of
recurrent gout flare.
OUTPATIENT ISSUES;
-- Continue Colchine 0.6mg tablets. Take one tablet daily for
6mths
-- Follow-up with Rheumatology (Dr. [**Last Name (STitle) 34211**] in 3-4weeks
.
# Diabetes type II: Continued lantus sc daily, SSI, diabetic
diet. Reviewed [**Last Name (un) 387**] records and touched base w/PCP regarding
[**Name9 (PRE) **] dose, per pcp pt was on 180U qhs but pt working on diet
control and decreasing lantus at home to 140-150U. Initially
started on 40U lantus [**Hospital1 **] due to poor PO intake and eventually
uptitrated to home lantus 180U lantus qhs with insulin sliding
scale prior to discharge. He will need to follow up with his
PCP to evaluate his insulin regimen after leaving the hospital
and resuming his normal diet.
OUTPATIENT ISSUES;
-- Continue close monitoring of fingers with adjustment of
insulin and ISS as needed
.
# Diarrhea: Chronic, per patient. C diff antigen lab negative
x3. Improved with immodium prn.
.
# Depression: Continued home citalopram. In setting of acute
pain crisis and anxiety pt had voiced suicidal ideation but this
resolved and mood improved post-operatively as pain better
controlled.
.
# + Blood culture. Patient with 1 blood culture + Coag negative
Staph Aureus on [**7-7**]. Thought likely a contaminant. Previous
blood cultures ([**6-21**], [**6-22**], [**6-23**], [**7-2**], [**7-3**], [**7-5**]) negative;
[**7-8**] blood culture pending. At time of discharge patient afebrile
with normal WBC.
OUTPATIENT ISSUES:
-- Continue to follow-up pending culture date
.
# DISPO: rehab for continued PT to optimize strength and
mobility
.
# CODE: DNI/DNR
.
Inactive issues:
.
# HIV: Continued home HAART medications. Discrepancy between med
reconcilation on admission and standard HAART dosing. Discharged
patient on Kaletra 200-50 [**Hospital1 **] and Epzicom 600-300 QD.
.
# Pulmonary hypertension/CHF: Continued sildenafil, torsemide.
Metolazone discontinued due to pre-renal failure and gout, as
above.
.
# Hyperlipidemia: Continued home tricor, pravastain, ASA
.
# OSA: Continued CPAP
.
Transition:
Mr. [**Known lastname **] will need an appointment to follow up with his PCP,
[**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**], within 1 week of leaving the hospital. He has
appointments scheduled to follow up with his neurologist, Dr.
[**First Name (STitle) **], and his spine surgeon, Dr. [**Last Name (STitle) **], after discharge. In
addition, he will need appointments scheduled to follow up with
the following providers within 2-4 weeks of hospital discharge:
NAME: [**Last Name (LF) 20863**], [**First Name3 (LF) 20862**]
DIVISION: Rheumatology
OFFICE LOCATION: CLS-936
OFFICE PHONE: ([**Telephone/Fax (1) 34212**]
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**]
Note: Dr. [**Last Name (STitle) **] is currently booked through [**Month (only) 216**], but can
call the clinic and receptionists will fit him into the
schedule). He should follow up with his ID specialist, Dr.
[**Last Name (STitle) 724**], within 3-4 weeks regarding his current CD4 count and viral
load.
Name: [**Last Name (LF) 724**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: THE TRANSPLANT CENTER
Address: [**Doctor First Name **], [**Apartment Address(1) 34213**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 457**]
NAME: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
DEPARTMENT: Cardiology
LOCATION: [**Location (un) **]., W/[**Hospital1 **] 319
PHONE: [**Telephone/Fax (1) 13133**]
Medications on Admission:
ABACAVIR-LAMIVUDINE [EPZICOM] - (Prescribed by Other Provider) -
600 mg-300 mg Tablet - 1 Tablet(s) by mouth daily
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
[**1-9**]
puffs(s) by mouth every four (4) to six (6) hours as needed for
cough/wheezing
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth twice a day
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1
Tablet(s) by mouth 1
GABAPENTIN - 600 mg Tablet - 2 Tablet(s) by mouth three times a
day
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - for
glucose control four times a day per sliding scale (4 packs per
month; uses about 60 units QID)
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 180 units at
bedtime
LOPINAVIR-RITONAVIR [KALETRA] - (Prescribed by Other Provider) -
100 mg-25 mg Tablet - 2 Tablet(s) by mouth 2 times per day
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for anxiety
METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day take
together with torsemide
OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth daily
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 2 Tablet(s) by
mouth three times a day as needed for pain
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
SILDENAFIL [REVATIO] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth three a day
TORSEMIDE - 100 mg Tablet - one Tablet(s) by mouth once a day
(take together with metolazone)
TRAMADOL - 50 mg Tablet - 1-2 Tablets(s) by mouth every four (4)
- six (6) hours as needed for pain
.
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth take one daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use to
test your blood sugar up to six times a day or as directed.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. insulin glargine 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous every twelve (12) hours.
8. insulin aspart 100 unit/mL Insulin Pen Sig: 0-65 units
Subcutaneous four times a day as needed for elevated blood
glucose: glucose control four times a day per sliding scale -
see attached.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1)
Tablet PO every six (6) hours as needed for pain: Do not exceed
2g/24 hours.
11. methyl salicylate-menthol Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for pain.
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to affected area for 12 hours, remove for 12 hours before
applying new patch.
13. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
twice a day.
14. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day.
15. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for costipation.
18. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
19. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-9**] Sprays Nasal
QID (4 times a day) as needed for dry nose, congestion.
20. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
21. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
23. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID:prn as
needed for anxiety.
24. insulin glargine 100 unit/mL Solution Sig: One Hundred
Twenty (120) units Subcutaneous at bedtime.
25. Humalog 100 unit/mL Solution Sig: Per insulin sliding scale
Subcutaneous four times a day: For glucose control, see attached
sliding scale.
26. Insulin Pen Needle 29 x [**1-9**] Needle Sig: One (1)
Miscellaneous As directed by insulin sliding scale.
27. One Touch Ultra Test Strip Sig: One (1) strip
Miscellaneous Up to six times a day or per insulin sliding
scale.
28. oxycodone 10 mg Tablet Sig: [**1-9**] to 1 Tablet PO every [**4-13**]
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Primary:
1. syncope
2. cervical stenosis
3. cervical myelopathy
4. gout
Secondary:
pulmonary hypertension
chronic diastolic heart failure
HIV
HCV
HLD
OSA
Depression
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 came to the hospital because you experienced an episode of
fainting while undergoing and MRI. Tests were performed to
ensure that this was not heart related; these were negative. We
believe that you episode of fainting was likely caused by a
combination of factors including slightly low blood sugar for
you, having to not eat or drink prior to the MRI, pain and
emotional stress. You symptoms improved with IV fluids, food and
receiving your home dose of lorazepam.
.
While in the hospital, the limited MRI that came back showed
severe degenerative changes of the cervical spine (neck) with
herniation of the discs and stenosis (narrowing). It was
believed that this was causing your severe, debilitating arm
pain and inability to move your arms. You were given steriods
and medications to better manage your pain. The spine [**Hospital 24379**]
evaluated you and felt that you would benefit from surgery given
the severity of the pain and the significant impact that the
pain and functional limitations it imposed. The risks and
benefits were discussed with you. Given your cardiac history, a
stress test was performed in preparation for surgery; this was
negative. Pulmonary evaluation was performed as you are a high
risk surgical candidate given your pulmonary hypertension and
obstructive sleep apnea. They recommended working on breathing
exercises (deep breathing) and incentive spirometer in
preparation for your surgery.
.
On [**6-28**] you had surgery on your spine (laminectomy fusion) to
try and improve your pain. You were transferred to the surgical
intensive care unit because you still required a breathing tube.
On [**6-30**] your breathing tube was removed and you were
transferred to the medical service. Your diuretic medications
were temporarily increased to remove fluid, and your pain
medications were increased for pain control. You developed
increased pain in your right hand, shoulder, and knee. You were
evaluated by the Rheumatology service, who felt that this was
due to gout (likely a result of taking diuretics). You were
started on prednisone and colchicine for treatment of gout, and
your metalazone was stopped. You were evaluated by Physical
Therapy, who felt that you would benefit from additional therapy
at a rehabilitation facility.
.
The following changes were made to your medications:
- START colchicine 0.6mg daily
- START lidoderm patch for 12 hours/day as needed for shoulder
pain
- START bengay ointment three times a day as needed for shoulder
pain
- START acetaminophen 500mg PO every 6 hours for pain (do not
exceed 2g in 24 hours)
- START oxycodone PO 5-10mg every 4-6 hours ONLY AS NEEDED FOR
PAIN NOT CONTROLLED BY tylenol, bengay and/or lidoderm [**Month/Year (2) 18539**].
If your pain is well controlled with either tylenol, bengay
and/or lidoderm [**Last Name (LF) 18539**], [**First Name3 (LF) **] not take this medication.
- INCREASE your gabapentin dose FROM 800mg TO 1200mg every 8
hours
- DECREASE your insulin glargine (Lantus) dose FROM 180 units TO
120 units every day at bedtime
- STOP oxycontin
- STOP tramadol
- STOP metolazone
.
We made no other changes to your medications. Please continue
to take the rest of your home medications as prescribed by your
physician.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if your weight goes up
more than 3 lbs in a single day.
.
Please be sure to keep all follow-up appointments with your
primary care provider, [**Name10 (NameIs) 24379**] and other health care providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please have your rehab facility schedule an appointment with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**], within 1-2 weeks of
leaving the hospital.
.
You have the following appointments scheduled at [**Hospital1 18**]:
.
Department: NEUROLOGY
When: FRIDAY [**2185-7-15**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: MONDAY [**2185-7-18**] at 8:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: SPINE CENTER
When: MONDAY [**2185-7-18**] at 8:40 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
.
In addition, you should ask your rehab facility to schedule
appointments for you to follow up with the following specialists
within 2-4 weeks of leaving the hospital:
.
NAME: [**Last Name (LF) 20863**], [**First Name3 (LF) 20862**]
DIVISION: Rheumatology
OFFICE LOCATION: CLS-936
OFFICE PHONE: ([**Telephone/Fax (1) 34212**]
.
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**]
*The Pulmonary staff are working on an appointment for you to
see Dr. [**Last Name (STitle) **] within a few weeks. Please call the department
directly after you leave the hospital to schedule an appointment
time.
.
Name:[**Last Name (LF) 724**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location:THE TRANSPLANT CENTER
Address:[**Doctor First Name **], [**Apartment Address(1) 34213**], [**Location (un) **],[**Numeric Identifier 718**]
Phone:[**Telephone/Fax (1) 457**]
.
NAME: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
DEPARTMENT: Cardiology
LOCATION: [**Location (un) **]., W/[**Hospital1 **] 319
PHONE: [**Telephone/Fax (1) 13133**]
|
[
"5849",
"2761",
"4280",
"32723",
"2720",
"311"
] |
Admission Date: [**2139-2-10**] Discharge Date: [**2139-2-23**]
Date of Birth: [**2070-7-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Blood transfusions
Intravenous immunoglobulin infusion
Platelet transfusion
History of Present Illness:
Ms. [**Known lastname **] is a 68yo F w/ PMH of severe AS, MR, CHF, ITP,
type 2 DM, and cryptogenic cirrhosis who was recently admitted
from [**Date range (1) 37495**]/07 for variceal banding and a resultant pneumonia
(s/p 7 day course of levo/flagyl) who presented initially on
[**2139-2-10**] s/p an episode of shortness of breath and hypotension
following an infusion of Winrho for ITP. Approximately 45
minutes after the infusion, she developed rigors and became
hypotensive to 70/50. She also became increasingly hypoxic to
87% on 3L (compared to 91-94%). She had a blood gas of
7.47/44/54/33. She was given Solumedrol, Benadryl, tylenol, and
20 IV lasix and was sent to the ED. In the ED, her VS were
notable for BP 110/70, HR 140s with ST depressions in V4-V6, RR
30s. Her CXR was felt to be consistent with CHF so she was given
an additional 40 mg IV lasix with 530 cc UO. She remained
tachypneic so she was placed on Bipap for 35 minutes with
improvement in her oxygenation and shortness of breath. She was
then noted to have a temp to 102.2 so blood cultures were sent.
She was given a dose of vancomycin and was transferred to the
ICU for further management and supportive care.
.
On arrival to the ICU, the patient noted mild shortness of
breath but denied lightheadedness, palpitations, or chest pain.
She denied current fevers, sweats. She reports an 8lb weight
gain over the prior week with increasing abdominal girth and
lower extremity edema. She reports sleeping on one pillow at
night which is stable. She denies PND. She denies cough.
Past Medical History:
#. Probable rheumatic heart disease with mod-severe AS, mild AR,
moderate MS, mod-severe MR, mild-moderate TR
#. Congestive heart failure - EF 70% per MR, 80% per TTE ([**9-26**])
-
- Followed by Dr. [**Last Name (STitle) 171**]
#. Secondary Pulmonary HTN - as above - On 2L Home O2
- Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37496**] and Dr. [**Last Name (STitle) **]
#. ITP - [**10-27**] - antiplatelet ab positive - no significant
response to IVIG, platelet transfusion, low-dose prednisone, and
most recently prednisone 60 mg daily x 7 days (now tapered off x
1 week.
- Followed by Dr. [**Last Name (STitle) 6944**]. S/P bm bx today. S/P Winrho today
(works by production of anti-[**Doctor Last Name **] (D)-(anti-D) coated RBC
complexes resulting in Fc receptor blockade, thus sparing
antibody- coated platelets).
#. Anemia - s/p 1 U PRBC on [**2139-2-6**], Iron studies nl in [**11-26**]
#. Cirrhosis c/b portal hypertension s/p banding of esophagael
varices on [**2139-1-22**] -negative hepatitis B and C serologies, normal
ceruloplasmin, normal ferritin, normal AFP, negative [**Doctor First Name **], but
positive antismooth muscle antibody, suggesting possible
autoimmune cirrhosis
#. Type 2 DM - On Insulin
#. Osteoporosis
Social History:
She lives alone. Her daughter lives in [**Name (NI) 8**], and is
involved with her care. She is independent with ADLs. She
reports a 20-25 pack year smoking history, quit ~25 yrs ago. She
denies alcohol intake. She has VNA services once a week, but has
a blood pressure cuff and scale that are connected via modem to
her VNA association.
Family History:
M - died of CAD/MI at 75
No h/o autoimmune disorders or cancers
Physical Exam:
.
VS: T- 98.3 BP: 84/55 HR: 94 RR: 20 O2: 98% on 4L NC
.
General: Patient is a very pleasant white middle aged female,
standing at bedside, in NAD
HEENT: NCAT, EOMI. OP: MM mildly dry appearing
Neck: JVP 9-10cm vertical. +carotid bruit, likely transmitted
from precordium. carotids 2+ bilaterally
Chest: + rales [**12-23**] way up lung fields posterior bilaterally.
Cor: RRR. + harsh III/VI systolc crescendo-decrescendo murmur,
mid peaking with preservation of S2. + radiation to carotids. No
R/G
Abdomen: morbidly obese, few eccymoses. Non-tender
Back: large ecchymosis over right buttock [**1-23**] recent BM Bx
Extremity: warm, [**1-24**]+ pitting edema to knees bilaterally. DP 1+
[**1-23**] overlying edema
Pertinent Results:
LABS on admission:
WBC 3.5, Hct 30.5, MCV 81, Plt 43*
diff: Neuts-74.1* Lymphs-16.7* Monos-7.4 Eos-1.5 Baso-0.3
PT 13.7, PTT 29.3, INR 1.2*
Retic 4.7*
Na 129, K 4.6, Cl 90, HCO3 30, BUN 24, Cr 0.8
LD(LDH) 352, TotBili 2.0, DirBili 0.5, IndBili 1.5
Albumin 3.0, Calcium 7.9, Phos 3.4, Mg 1.8
Hapto 40
IgG 1417 IgA-382 IgM-156
ABG: pO2-54* pCO2-44 pH-7.47* calTCO2-33* Base XS-7
Lactate 2.4*
.
LABS post hemolysis [**2139-2-11**]:
WBC 10.5, Hct 23.4, MCV 78, Plt 44
fibrinogen 136, FDP 40-80, Hapto <20*
Na 129, K 3.6, Cl 91, HCO3 29, BUN 44, Cr 0.8, Glu 220
Cortisol 72.2*
TSH 1.5
ALT 275, AST 387, LDH 707, AlkPhos 104, TBili 13.9, DBili 7.2,
IndBili 6.7
Cardiac enzymes:
[**2139-2-10**] 07:00PM BLOOD CK(CPK) 112, CK-MB 5, cTropnT-0.17*
[**2139-2-11**] 09:50PM BLOOD CK(CPK)-83, CK-MB 4 cTropnT 0.13*
.
On discharge [**2139-2-22**]
WBC 6.8, Hct 22.0, MCV 92, Plt 83*
PT 14.4, PTT 30.7, INR 1.3*
Na 132, K 4.2, Cl 94, HCO3 29, BUN 66, Cr 1.9
ALT 39, AST 39, LDH 444, AlkPhos 112, TBili 3.0, DBili 1.2,
IndBili 1.8
.
URINE studies:
[**2139-2-11**] 01:36AM URINE Color-[**Location (un) **] Appear-Hazy Sp [**Last Name (un) **]-1.015
Blood-LGE Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR
Bilirub-SM Urobiln-1 pH-5.0 Leuks-TR RBC-0 WBC-0 Bacteri-NONE
Yeast-NONE Epi-0
.
[**2139-2-15**] 11:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR RBC-5* WBC-5
Bacteri-NONE Yeast-NONE Epi-<1
.
[**2139-2-15**] 11:15PM URINE Hours-RANDOM UreaN-714 Creat-64 Na-LESS
THAN
[**2139-2-15**] 11:15PM URINE Osmolal-368
.
MICRO:
[**2139-2-10**]: Bone marrow bx
1. Hypercellular bone marrow for age with erythroid hyperplasia,
see note. Although rare dyspoietic erythroid precursors are
seen, overall morphologic findings are not diagnostic of a
primary myelodysplastic syndrome. Please correlate with clinical
and cytogenetic findings. Abundant megakaryocytes are seen,
which are in keeping with peripheral destruction/sequestration
as a cause of patient's thrombocytopenia.
2. Decreased storage iron.
.
[**2139-2-10**]: blood cx x2 no growth
[**2139-2-10**]: urine cx no growth
[**2139-2-11**]: urine cx no growth
.
RADIOLOGY:
[**2139-2-11**] ABD U/S:
1. The liver shows coarsened echotexture with nodular
architecture consistent with chronic liver disease. No focal
mass is seen within the liver.
2. There is a contracted gallbladder containing multiple
stones. There is no gallbladder wall edema or evidence of
cholecystitis.
3. Moderate amount of ascites. The right lower quadrant was
marked for paracentesis by clinical team.
4. Splenomegaly.
5. Doppler evaluation of the hepatic vessels show normal
hepatopetal flow within the portal vein. The hepatic vein and
arteries demonstrate normal waveforms.
.
[**2139-2-12**] CT CHEST:
1. Smoothly thickened septal lines and ground glass opacities
are most consistent with hydrostatic pulmonary edema, especially
in the setting of a right pleural effusion and known cardiac
disease. However, this process could potentially obscure
underlying chronic interstitial disease, and if clinically
indicated, repeat scanning following diuresis could be
performed.
2. Several scattered noncalcified sub 5-mm nodular opacities
within the right lung, possibly representing noncalcified
granulomas given the presence of other calcified granulomas.
However, followup CT in three months is recommended to document
stability and to exclude a neoplastic etiology.
3. Pulmonary arterial hypertension.
4. Cirrhotic-appearing liver, with moderate amount of ascites
and
splenomegaly.
5. Cholelithiasis.
6. 1.4-cm mediastinal lymph node, which is nonspecific but may
related to CHF.
7. Coronary artery calcifications.
.
[**2139-2-17**] ECHO:
The left atrium is markedly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated, with mild global free wall
hypokinesis. There are three thickened/deformed aortic valve
leaflets. There is at least moderate aortic stenosis, but
accurate quantification of its severity was technically limited.
Trace aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. There is severe mitral annular
calcification and moderate thickening of the mitral valve
chordae. There is mild mitral stenosis (area 1.5-2.0cm2).
Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. The main pulmonary
artery is dilated. There is no pericardial effusion.
IMPRESSION: No patent foramen ovale seen. Left ventricular
hypertrophy with preserved global and regional systolic
function. Dilated right ventricle with mild systolic
dysfunction. At least moderate aortic stenosis. Mild mitral
stenosis. Moderate to severe mitral regurgitation. Moderate
pulmonary hypertension.
.
[**2139-2-17**] CAROTID U/S: Less than 40% stenosis of the proximal
internal carotid arteries bilaterally.
Brief Hospital Course:
# MICU course:
In the MICU, the patient was stablized with IVF, however her
laboratory values showed a severe hemolytic reaction with an
rise in her total bilirubin to 21, a drop in her hematocrit to
23, acute renal failure with a creatinine of 2, and LDH >800 and
haptoglobin <20. She received 1u pRBC and her Hct stabilized at
23. Cardiology and renal were consulted to help guide further
management, given that she was in need of diuresis in the
setting of severe aortic stenosis and acute renal failure. She
become hypotensive when diuresis was attempted with IV lasix.
She was switched to a lasix gtt with improvement in her diuresis
and less change in her blood pressure. She was transferred to
[**Hospital Ward Name 121**] 6 for continued diuresis and CT surgery evaluation for
valve replacement.
.
# CV:
1) CHF - Her recent ECHO and cardiac MRI reveal moderate to
severe aortic stenosis, with [**Location (un) 109**] 0.8cm2, likely causing her CHF
in the setting of volume overload. She also has 3+ MR, 1+ TR,
and pulmonary artery hypertension. She was started on a lasix
gtt for diuresis given that she was in renal failure and was not
making large volumes of diuresis. She then began a post-ATN
diuresis and 2kg were able to be diuresed using a lasix gtt and
IV diuril. CT surgery was consulted for evaluation of the
patient's candidacy for aortic and mitral valve replacement. At
their request, hepatology and pulmonary were consulted.
Hepatology felt that the patient was currently a Child's class C
which would put her at high operative risk. Discussions between
all of the consulting teams led to the decision to hold off on
surgery currently given the patient's tenuous medical status.
Thus, attempts were made to get her diuresing on a stable PO
regimen that could be reproduced at home or rehab. She was tried
on lasix 120mg PO TID, which was a dose equivalent to what she
as receiving on the lasix gtt. Her BP remained in the high 70s
and low 80s, which limited our ability to use spironolactone and
metolazone as additional diuretic agents. She was kept on fluid
restrictions, had daily weights, and strict I/O monitoring. Her
creatinine was monitored daily and remained at 1.9. Her
electrolytes were checked regularly given the aggressive
diuresis and were repleted as needed.
.
2) CAD - Ms. [**Known lastname **] had a clean cath in [**2137**]. However, she
also had troponin elevation from <.01 to .17 in the setting of
tachycardia, hypotension, hemolysis, and ARF. Her last troponin
was .13 on [**2139-2-11**]. She was not able to receive aspirin given
her thrombocytopenia and she could not take an ACE-I given her
hypotension and acute renal failure. She was started on nadolol
for b-blockade, cirrhosis and varices; however, her BP often
prohibited her from receiving this medication. Lipids were
checked in [**2137**] and showed an LDL 67. Given the low LDL, no
statin was started, especially since she would not likely be
able to tolerate the drug given her liver dysfunction.
.
3) Rhythm - She remained in normal sinus rhythm throughout most
of her hosptialization, with short beats of NSVT. She was
monitored on telemetry daily and her electrolytes were repleted
regularly.
.
#. Acute hemolytic transfusion reaction: She developed an acute
hemolytic transfusion reaction in the setting of her recent
Winrho infusion. DAT was positive, haptoglobin was <20, LDH
>800, and bilirubin of >21. She was essentially monitored and
given supportive care until her labs began to improve.
.
# Thrombocytopenia - Her platelets were 38 after the Winrho
infusion, but then came up to 83 by the time of discharge. She
was given another trial of IV Ig followed by 2 bags of
platelets, in order to see if the patient could tolerate this
during surgery in case the need arised. Her platelets remained
stable after infusion. There was concern about the etiology of
her thrombocytopenia, given her minimal response to ITP
therapies in the past. Hepatology was concerned that her
thrombocytopenia may also be a result of her liver disease. The
possibility of using rituxan as an outpatient was considered by
her hematologist and will be discussed as a potential therapy at
her next hematology appointment.
.
#. Hypoxia - The etiology of her hypoxia is most likely
multifactorial, with elements of volume overload, CHF, and
valvular disease contributing. She also has evidence of
pulmonary artery hypertension on ECHO. Even prior to this event,
she has a baseline O2 requirement of unclear etiology. Her CT
chest from [**2-12**] was consistent with CHF, as was her clinical
exam. She has a questionable diagnosis of ILD in the past, with
PFTs c/w a restrictive pattern. By time of discharge, she was
back to her baseline O2 requirement of 2L by nasal canula.
.
#. Acute renal failure: She likely developed ATN from
hypotension and hemoglobinuria. Her Cr stabilized at 1.9. She
was discharged on a diuretic regimen of lasix, spirinolactone
and metolazone. Renal followed the patient to help manage her
renal failure.
.
# Cirrhosis: Hepatology was consulted for risk stratification
during CT surgery. Hepatology feels that the patient is Child's
class B at baseline, but now is a class C given the recent
events, which makes her operative mortality high. Ms. [**Known lastname **]
wanted to continue with surgery but the decision was made to
hold off for now until her liver function improves in order to
improve her chances of survival.
She will follow up with her outpatient hepatologist, Dr.
[**Last Name (STitle) **], in several weeks.
.
#. Type 2 DM - Her FS remained elevated throughout her
hospitalization, requiring uptitration of her lantus dose. The
etiology of her hyperglycemia was not clear. She was discharged
on a standing dose of lantus as well as a humalog sliding scale.
.
#. Anemia - Her hematocrit dropped to 23 post-Winrho infusion,
and then trended down to 21. She was given 1u pRBC to see if
that would improve her dyspnea and renal perfusion and her Hct
bumped to 25.7. However, it slowly drifted back down to 22 by
time of discharge. No further transfusions were given as we were
trying to limit her fluid intake. It seemed that the patient had
ongoing hemolysis, given that her haptoglobin remained <20 and
her DAT remained positive. She also had one guaiaic positive
stool on [**2-18**], but had no further episodes. Excessive phlebotomy
might also be contributing to her anemia as she was having labs
checked [**Hospital1 **] to replete her electrolytes. She was kept on folate
supplementation upon discharge.
.
#. Hyponatremia - She developed a hyposmolar, hypervolemic
hyponatremia likely secondary to heart failure. Her sodium
eventually normalized despite diuresis. Her Na was 135 on
discharge.
.
#. FEN - She was given a diabetic, low sodium diet. She was
fluid restricted, to take <1500cc/day. She was given no
additional IVF once on the floor. Her electrolytes were checked
regularly and were repleted to keep K >4, Mg >2.
.
#. PPX - She was ordered for pneumoboots for DVT prophylaxis,
but the patient did not wear them due to her low plts. She tried
to ambulate for short distances daily. She was treated with a
PPI and sucralfate daily, but the sucralfate was discontinued
after consulting with hepatology. She was also given a bowel
regimen prn.
.
#. Code - FULL; her daughter was designated her HCP during this
hospitalization.
.
#. Access - Perpiheral IVs
.
#. Dispo - To rehab.
.
Medications on Admission:
Medications prior to transfer:
Carafate 1 g [**Hospital1 **]
Furosemide 80 mg daily
Valsartan 40 mg daily
Spironolactone 25 mg daily
Trazodone 50 mg HS
Insulin Glargine 40-50 Y
Pantoprazole 40 mg [**Hospital1 **]
Prednisone stopped [**12-23**] wks ago
Humalog SS
Fosamax q Sunday
.
Medications on transfer
Furosemide 2-15 mg/hr IV DRIP INFUSION
Pantoprazole 40 mg PO Q24H
Alendronate Sodium 70 mg PO QSUN
Ropinirole HCl 0.5 mg PO QPM
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO BID
FoLIC Acid 1 mg PO DAILY
Sucralfate 1 gm PO QID
Insulin SC Sliding Scale & Fixed Dose
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: 0.5 - 1 Tablet PO HS (at bedtime)
as needed.
4. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*810 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Seventy Six (76)
units Subcutaneous at bedtime: Please continue to monitor your
fingersticks. You may need to adjust your dose accordingly. .
7. Humalog 100 unit/mL Solution Sig: Variable units Subcutaneous
four times a day: As per sliding scale.
8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 3 days.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
10. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary diagnoses:
Acute hemolytic transfusion reaction
Acute renal failure
Anemia
.
Secondary diagnoses:
ITP
Aortic stenosis
Mitral stenosis
Mitral regurgitation
Cryptogenic cirrhosis
Discharge Condition:
Stable. BP 90's/50's, HR 70's. Able to ambulate without
lightheadedness.
Discharge Instructions:
You were admitted to the hospital because you had a reaction to
the medication Winrho that you were given for your ITP. You were
in the intensive care unit for several days to support you
immediately after the reaction. You were then transferred to the
cardiac floor for careful monitoring of your volume status. You
were seen by multiple specialists, including hepatology,
cardiothoracic surgery, pulmonary, cardiology, and renal, who
helped guide your care. Discussions were held about the
possibility of surgery to repair your heart valves, but the
decision was made to wait until your body recovers further from
the Winrho reaction. You will continue to follow-up with your
physicians to help determine the next course of action.
.
Please keep all your follow-up appointments.
.
Please take all your medications as prescribed. Your LASIX dose
has been increased to 120mg three times a day. METOLAZONE was
added to help with the diuresis. Your fingersticks have been
harder to conrol in the hospital, so your LANTUS dose has been
increased as well. PROTONIX was added to prevent bleeding from
the varices.
.
You no longer need to take the VALSARTAN or the CARAFATE as you
had been previously. For now we are holding the NADOLOL as well
as the SPIRONOLACTONE because your blood pressure has been low.
Please discuss with your doctors when these should be restarted
(when you are euvolemic).
.
if weight > 3 lbs. Please adhere to 2 gm sodium diet. Please
also continue the fluid restriction of 1500mL per day as you
were doing in the hospital.
.
Please call your doctor or go to the nearest ER if you develop
any of the following symptoms: fever, chills, shortness of
breath, difficulty breathing, lightheadedness, dizziness,
worsening abdominal bloating, pain in your legs, chest pain,
fainting, or any other worrisome symptoms.
Followup Instructions:
Please keep all of your follow-up appointments:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (hematology) on [**2139-2-25**] at 2:40pm; phone
#[**Telephone/Fax (1) 22**]. Your labs will need to be checked at this visit,
in particular, the hematocrit, potassium, and platelet counts.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (cardiology) on [**2139-3-4**] at 3:40pm; phone
#[**Telephone/Fax (1) 1989**]
[**Name6 (MD) **] [**Name8 (MD) **], MD (hepatology) on [**2139-3-11**] at 1:10pm; phone
#[**Telephone/Fax (1) 2422**]
|
[
"5845",
"2761",
"2762"
] |
Admission Date: [**2177-11-14**] Discharge Date: [**2177-11-21**]
Date of Birth: [**2139-5-19**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
male transferred from [**Hospital 1562**] Hospital early on the morning
of [**2177-11-14**], with acute renal failure, hyperkalemia,
abdominal pain and nausea. The patient reports that two
friends brought a bottle of "Midori" to the house last
Thursday. He states that they were attempting to poison him.
He notes feeling suspicious of them because the bottle was
already open. They did not drink any of it. He became
violently sick the next day and he noted that the Midori
tested like a sweet liquid. Despite his suspicions, he drank
three large glasses of it. There is some question that he
was drinking vodka earlier in the evening. Although he
states these friends did this to him, he cannot describe any
possible motive they might have and refuses to reveal their
names. He denies feeling concerned or afraid at this time
and does not plan to report the incident to the police. The
patient admits to drinking alcohol on a daily basis. He
states he checked himself into detoxification facility on
Tuesday after having several days of severe nausea, vomiting
and abdominal pain. It is unclear what he did from Thursday
to Tuesday. The patient denies that it was any kind of
suicide attempt. He reports feeling in good spirits and not
wishing to ever do himself any harm. He states that he has
his family to live for but has not seen his sister for three
months. Three years ago when his mother died, she ask him to
keep the family together which he states is impossible. He
was checked into a detoxification facility [**2177-11-9**]. He
reports feeling poorly, continuing to have nausea and
vomiting and abdominal pain. On [**2177-11-13**], he says that he
had not urinated since entering the program. At [**Hospital 1562**]
Hospital, his blood urea nitrogen was 183 and creatinine was
60 with a bicarbonate of 14 and anion gap of 18. On arrival
to the [**Hospital1 69**] Emergency
Department, he seized and was treated with Ativan. He was
then admitted to the MICU and was treated with emergent
hemodialysis for a bicarbonate of 7 and potassium of 6.0.
His creatinine at that time was down to 22.
PHYSICAL EXAMINATION: Temperature was afebrile, heart rate
95, blood pressure 153/93, respiratory rate 22. The patient
was 98% on 100% nonrebreather. In general, he is a 38 year
old male in no acute distress. Head, eyes, ears, nose and
throat examination is normocephalic and atraumatic. The
pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Anicteric
sclera. Neck is supple. Lungs revealed diffuse bilateral
wheezing. Cardiovascular is tachycardic, normal S1 and S2,
no murmurs, rubs or gallops. Abdomen is soft, nontender,
nondistended, with decreased bowel sounds. Extremities
revealed no cyanosis, clubbing or edema. Neurologically,
alert and oriented times zero, moving all four extremities
spontaneously.
LABORATORY DATA: White blood cell count 15.2, hematocrit
42.0, platelet count 216,000, 81% neutrophils, 10%
lymphocytes, Sodium 130, potassium 5.7, chloride 85,
bicarbonate 8, blood urea nitrogen 178, creatinine 22.2,
glucose 132, anion gap 33. Calcium 9.5, magnesium 3.1,
phosphate 16.3, troponin 0.08.
Chest x-ray shows mild congestive heart failure. Head CT
negative for bleed, but small hypodensities bilaterally
towards the vertex in the frontoparietal region.
Electrocardiogram showed normal sinus rhythm at 84 beats per
minute. Normal intervals. Questionable nonspecific changes
in the T waves in V1 through V6. No acute ST-T wave changes.
HOSPITAL COURSE:
1. Acute renal failure - Initially, the patient was treated
in the MICU with emergent hemodialysis for a bicarbonate of 7
and potassium of 6.0. It was felt likely acute tubular
necrosis secondary to ingestion most suspicious for ethylene
glycol although difficult to diagnose as the patient
presented seven to eight days after possible ingestion. He
was also anuric times two weeks. Renal ultrasound showed
enlarged kidneys bilaterally with left measuring 14
centimeters and right measuring 13 centimeters. No stones
and no hydronephrosis. No oxalate crystals were seen in his
urine. Now after two weeks, his urine output is beginning to
increase to 200cc per 24 hours. His initial laboratories on
[**2177-11-14**], were negative for ethylene glycol, acetone methanol
and isopropanol with a serum anion gap of 33 and plasma
osmolar gap of 15 but acute renal failure may cause both
elevation in the serum anion gap and osmolar gap, making
these uninterpretable. The patient will likely not require
biopsy if his urine output continues to increase and he will
likely be discharged to a rehabilitation facility and
follow-up for outpatient dialysis treatments as necessary and
follow-up with renal in clinic.
2. Serum anion gap and plasma osmolar gap - Suspected
polyethylene glycol ingestion although complicated by the
fact that acute renal failure can cause both to be elevated.
Both gaps are improved now. No calcium oxalate crystals are
seen in the urine. Urine output continuing to increase.
3. Decreased mental status - Concern for intracranial
hemorrhage initially but head CT negative for bleed. Small
hypodensities found in the vertex near frontoparietal region
likely secondary to toxic metabolic damage secondary to
ingestion. The patient had seizures on arrival to the
Emergency Department [**2177-11-14**], and was treated with Ativan.
These were felt to be likely withdrawal seizures from
alcohol.
4. Hypertension - Poorly controlled hypertension while in
the hospital with evidence of some fluid overload and
possible element of diastolic dysfunction secondary to
ingestion. He will be continued on Metoprolol 150 mg p.o.
Three times a day, Hydralazine 25 mg p.o. four times a day,
Clonidine patch and Norvasc 10 mg p.o. once daily.
5. Increasing white blood cell count - White blood cell
count initially was 15.2 and has now increased up to 23.0.
He has unclear source of infection and this may possibly be a
leukemoid reaction to his ingestion. Urinary analysis was
negative. KUB examination is negative. Blood cultures are
no growth to date. We will check a repeat chest x-ray
although he has had no infiltrates on past chest x-rays.
6. Pulmonary - The patient with intermittent desaturation
into the high 80s with increased blood pressure and crackles
on examination. Likely secondary to fluid overload and
improved saturation with tighter blood pressure control and
more frequent dialysis. Will check a chest x-ray today to
rule out any pneumonia.
7. Code Status - Full.
8. Disposition - The patient will likely be discharged to
rehabilitation facility with outpatient dialysis treatment
when white blood cell count is improved and his hypertension
is controlled.
MEDICATIONS ON DISCHARGE:
1. Metoprolol XL 450 mg p.o. once daily.
2. Hydralazine 30 mg p.o. four times a day.
3. Sevelamer 800 mg p.o. three times a day a.c.
4. Amlodipine 10 mg p.o. once daily.
5. Calcium Acetate two grams p.o. three times a day with
meals.
6. Thiamine 100 mg p.o. once daily.
7. Multivitamin one tablet p.o. once daily.
8. Diazepam 5 mg p.o. q6hours p.r.n.
9. Pantoprazole 40 mg p.o. once daily.
10. Folate 1 mg p.o. once daily.
11. Clonidine patch one patch transdermal q.Friday.
12. Albuterol p.r.n.
FOLLOW-UP PLANS: The patient is to follow-up with his
primary care physician in one to two weeks. He is also to
follow-up for dialysis at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Plaza starting
Tuesday, [**2177-11-25**], and be dialyzed Tuesday, Thursday,
Saturday at 7:00 a.m. He can call [**Telephone/Fax (1) 16209**] to reach
them. He is also to follow-up with [**Hospital 10701**] Clinic in two
to four weeks.
DISCHARGE STATUS: Stable. Discharged to rehabilitation
facility.
DISCHARGE DISPOSITION: Full code.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2177-11-21**] 17:47
T: [**2177-11-21**] 20:29
JOB#: [**Job Number 16210**]
|
[
"5845",
"5070",
"4280"
] |
Admission Date: [**2199-6-14**] Discharge Date: [**2199-6-19**]
Date of Birth: [**2143-6-21**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Betadine / Iodine / Demerol / Lisinopril
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Stridor, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 55 year-old woman with past medical history
significant for h/o TBM, paradoxical vocal fold movements
(PVFM), GERD, HTN, and OSA on home CPAP. Patient states she was
at work in [**Hospital3 4298**] this morning and felt suddenly
anxious, very short of breath and with a coughing fit. She tried
used her nebulizer but without relief. Her boss became very
concerned and called '911' and she was transfered to the ED in
[**Hospital3 4298**]. She describes associated sharp sternal pain
and back pain and pain on inspiration. Pt also had 3 'coughing
attacks' the day prior to admission which resolved with
nebulizers. She denies any associated chest pains, dizziness,
palpitations. No fainting episodes.
On additional history she explains that she has had "breathing
troubles" since [**2198-4-13**] after she had developed acute
angioedema and anaphylaxis that was attributed to lisinopril. Pt
reports that these coughing episodes are not associated with a
known trigger, a particular location or time of day. Further
workup by IP demonstrated tracheo-bronchomalacia and she had a
silicone Y stent placed with subsequent removal after recent
flexible bronchoscopy on [**5-10**] which demonstrated severe
granulation tissue at the right distal end of the Y-stent.
To date, she has had multiple hospital and ICU admissions (one
intubation) during this past year, with prior bronchoscopy also
demonstrating paradoxical vocal fold movements.
At OSH emergency room the patient was given 125mg IV solumedrol,
racemic epinephrine, combivent nebs and a total of 9mg ativan
over several hours. She was placed on 6L nasal cannula at OSH
with improvement on her dyspnea and stridor. En route to [**Hospital1 18**]
ED patient was given additional 75mg fentanyl and 4mg Zofran
with med-flight team.
In the [**Hospital1 18**] ED, initial vs were: T afebrile, HR 103, BP
138/112, RR 24 and O2 sats 94% on 6L nasal canula. She was given
some additional racemic epinephrine nebs and duonebs in ED.
Given Levaquin 750mg IV x1 for question of LLL infiltrate on
portable CXR. She has no recent
fevers or leukocytosis on labs.
On arrival to ICU, initial vitals were: T 96.9F, HR 105, BP
150/88, RR 18 and O2 sat 94% on 5L NC. She appeared very anxious
but able to speak full sentences without minimal shortness of
breath.
Past Medical History:
1. Tracheobronchomalacia s/p 2 stents, most recent placed [**2-20**]
2. Paradoxical vocal fold movements (PVFM)
3. Asthma
4. Hypertension
5. Hyperlipidemia
6. S/p cholecystectomy
7. S/p appendectomy
8. S/p Tonsillectomy
9. Back surgery (unclear procedure)
10. OSA, on home BIPAP
11. Obesity
12. Numerous right hand surgeries s/p R hand trauma
Social History:
Lives with mother, father, and brother in [**Location (un) 15984**]. Works
as patient coordinator at [**Hospital **] hospital and has strong support
network at work.
- Tobacco: Denies any history.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Mother and father with HTN, Mother with [**Name (NI) 10322**]. [**Name2 (NI) **] h/o lung
diseases
Physical Exam:
Vitals: T 96.9F, HR 105, BP 150/88, RR 18 and O2 sat 94% on 5L
NC
General: Fully alert and oriented, no acute distress, easily
winded while speaking
HEENT: PERRL, EOMI. Sclera anicteric, MMM, oropharynx clear.
Nares clear and NC in place.
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Diffuse bilateral wheezes. Mild crackles at LLL, no
rhonchi.
CV: Rapid but 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:
[**2199-6-15**] CXR: IMPRESSION: Probable cardiomegaly. Improvement in
left retrocardiac opacity suggesting improving atelectasis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 55yo F with TBM, OSA on home CPAP, HTN, and
questionable paradoxical vocal cord dysfunction who was admitted
to ICU as OSH transfer for acute dyspnea and stridor.
# PVFM, paradoxical vocal fold movement: ENT assessment again
shows PVFM. Mainstay of treatment is outpatient Speech/Voice
therapy. The patient saw, Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] at [**Hospital1 2025**] for a second
opinion and was also recommended to have speech therapy.
This patient has had frequent admissions for this same issue.
IP, Psychiatry, ENT, and Speech Therapy were all consulted to
help with developing a longterm plan and also to try to
formulate a more successful outpatient plan.
Here are some interventions and recommendations:
1. Metoprolol was discontinued for concern of bronchospasm as a
side effect.
2. Psychiatry provided relaxation techniques and recommended
outpatient Cognitive Behavioral Therapy (see Dr.[**Name (NI) 60808**]
note). Also increase dose of SSRI and for patient to use fast
acting anxiolytics.
3. IP recommends maximizing Asthma and GERD treatments to
minimize coughing. Coughing is one of her major stimuli for
going into an acute dyspneic episode.
4. ENT recommends further speech/voice therapy
5. Speech Therapy recommends more aggressive outpatient speech
therapy (3-4 sessions weekly)
A consensus letter will be prepared by this author and Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] to outline a proposed treatment plan for the [**Location (un) 7453**] providers to try to reduce unnecessary helicopter
transfers. The patient is nearly 100% successful in having her
episodes resolved in the hospital with relaxation techniques,
neb treatments, and use of anxiolytics.
If outpatient management fails, then future disposition to
[**Hospital 3058**] rehab should be considered.
Medications on Admission:
Ipratropium Bromide 0.02 % Solution nebs q6hrs PRN
-Benzonatate 100 mg Capsule PO TID
-Fluticasone-Salmeterol 500-50 mcg INH [**Hospital1 **]
-Fexofenadine 60 mg PO BID
-Omeprazole 20 mg PO BID
-Simvastatin 10 mg Tablet PO DAILY
-Ranitidine HCl 150 mg PO HS
-Sertraline 50 mg Daily
-Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q6H (every 6 hours).
-Lorazepam 1 mg PO Q4H (every 4 hours) as needed
-Guaifenesin 600 mg SR PO twice a day.
-Metoprolol Succinate 100 mg PO once a day
Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 month supply* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit dose Inhalation every four (4)
hours as needed for shortness of breath or wheezing.
Disp:*30 unit doses* Refills:*2*
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for Anxiety: [**Month (only) 116**] use under tongue (sublingual).
Disp:*30 Tablet(s)* Refills:*0*
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Paradoxical vocal fold movements (PVFM)
SECONDARY DIAGNOSES:
- Tracheobronchomalacia
- Chronic asthma
- Obstructive sleep apnea, on home BIPAP
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation and management of your
shortness of breath. Re-evaluation by ENT again revealed that
you have a condition called PVFM, or paradoxical vocal fold
motion. This diagnosis is consistent with the assessment made
by the other ENT doctor you saw from [**Hospital1 2025**], Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]. The
mainstay of treatment for this condition is Speech/Voice
Therapy. It has been offered to you to come up to the [**Hospital1 18**] to
have Speech Therapy by our specialists and this will be
available to you when you are able and ready to utilize their
services. You were also assessed by our Psychiatry service and
they were able to provide you with relaxation techniques that
can assist you in any future episodes that you may experience.
Since you have receieved assessment from two separate ENT groups
and have received the same diagnosis, it is not necessary to
continue to follow up with ENT. You may want to continue seeing
a Psychiatrist to work on relaxation techniques. Your condition
is exacerbated by anxiety and learning how to cope with the
anxiety associated with your condition will help you
successfully live with your condition without having to go to
the hospital.
If you do have to go to the hospital again at [**Hospital3 4298**],
the first line of treatment should be similar to how we manage
you on the medicine floor here at the [**Hospital1 18**]. Relaxation
techniques, use of anxiety medication such as Ativan or
Alprazolam (Xanax), and possibly medications used for asthma
flare ups such as nebulized albuterol or steroids. These
resolve your symptoms almost every episode.
Maximizing treatment for GERD (gastroesophageal reflux disease)
and asthma will also help you with your chronic cough. Try to
sleep with the head of your bed elevated and do not eat large
meals close to bedtime.
Dr. [**Last Name (STitle) **] and other providers will be putting together a
consensus plan for your care providers at the [**Hospital3 **] for future severe episodes. This will be sent to you
when the final draft is completed. Contingency plans for
possible short-term stay in rehabilitation facility was
discussed with you during the multidisciplinary team meeting
with you during this hospitalization. This will be considered
if outpatient management is not as successful as we would hope
during the next 2 months.
MEDICATION RECOMMENDATIONS:
1. Omeprazole 40mg twice daily (INCREASED) for GERD
2. Ranitidine 150mg before bedtime for GERD
3. Singulair 10mg daily for Asthma (NEW)
4. Advair 500mg-50mg inhaled twice daily for Asthma
5. Albuterol nebulizer as needed every 4 hours for Asthma
6. Amlodipine 5mg daily (NEW) for Hyertension
7. STOP Metoprolol because of concern that it may cause
bronchospasm
8. Sertraline 75mg daily (INCREASED) for anxiety
9. Alprazolam 0.5mg as needed for anxiety up to 3 times daily
(NEW), may use under tongue for quicker effect.
Followup Instructions:
Please make an appointment to see your primary care physician
for your regular follow up and for medication refills. Please
also ask your primary care physician for [**Name Initial (PRE) **] referral for physical
therapy.
Our psychiatry service will be in touch regarding follow up with
them or a provider at the [**Name9 (PRE) **].
Please contact Dr.[**Name (NI) 5070**] staff to arrange for follow up
appointment in Pulmonary Clinic.
|
[
"2875",
"32723",
"53081",
"4019",
"2724"
] |
Admission Date: [**2201-6-12**] Discharge Date: [**2201-6-16**]
Date of Birth: [**2154-12-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 40 year old with unknown past medical history who was
found down by EMS. Unfortunately, there is no EMS report in
chart, but per ED report, he was found down with no
identification. Reportedly there was no drug paraphenalia at
seen. And per ED report, EMS did not report signs of recent
trauma. He was found lethargic and unable to answer questions
and reportedly had a normal FSG in the field. On arrival to the
ER, he was noted to be lethargic. EDVS T 97 HR 82 RR 13 96%
RA. Due to concern for airway protection and need for head CT ,
he was intubated after a few attempts (reportedly with a very
"anterior" and difficult airway). He was started on propofol
and was admitted to the medical ICU. Of note, ED labs were
notable for serum ETOH of 641 and CT head with a "subtle focus
of increased attenuation in the left basal ganlgia that may
represent asymmetric mineralization."
.
On the floor, he is intubated and sedated.
.
Review of systems:
(+) Unable to obtain
Past Medical History:
ETOH abuse
Social History:
Living at a shelter currently.
Family History:
Unknown
Physical Exam:
From ICU admission:
Vitals: T: 96 BP: 124/84 P: 100 500/16 FiO2 50 PEEP 8
General: Intubated, sedated, unresponsive to commands
HEENT: Pupils constricted but reactive, poor dentition, mucous
membranes dry
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2201-6-12**] 10:04PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2201-6-12**] 10:04PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2201-6-12**] 10:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2201-6-12**] 09:55PM PH-7.33* COMMENTS-GREEN TOP
[**2201-6-12**] 09:55PM GLUCOSE-136* LACTATE-2.5* NA+-150* K+-3.4*
CL--102 TCO2-25
[**2201-6-12**] 09:55PM HGB-15.4 calcHCT-46
[**2201-6-12**] 09:55PM freeCa-1.19
[**2201-6-12**] 09:48PM UREA N-11 CREAT-0.6
[**2201-6-12**] 09:48PM estGFR-Using this
[**2201-6-12**] 09:48PM ALT(SGPT)-50* AST(SGOT)-77* ALK PHOS-51 TOT
BILI-0.4
[**2201-6-12**] 09:48PM LIPASE-245*
[**2201-6-12**] 09:48PM ASA-NEG ETHANOL-641* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2201-6-12**] 09:48PM WBC-9.1 RBC-4.40* HGB-14.4 HCT-42.8 MCV-97
MCH-32.7* MCHC-33.6 RDW-13.6
[**2201-6-12**] 09:48PM PLT COUNT-244
[**2201-6-12**] 09:48PM PT-11.0 PTT-25.8 INR(PT)-0.9
[**2201-6-12**] 09:48PM FIBRINOGE-231
Brief Hospital Course:
Mr. [**Known lastname 1352**] is a 56 year old man found down by EMS and brought
to the [**Hospital1 18**]. He was initially intubated for airway protection
and imaging of his head. His blood alcohol level was > 600 on
admission and this was ultimately felt to be the cause of his
obtundation. He was initially admitted to the MICU where he
received supportive care. He was called out of the ICU on
[**Last Name (LF) 1017**], [**6-14**] to the General Medical floor for ongoing care.
He has been treated with a CIWA scale for alcohol withdrawal
symptoms as well as thiamine and folate. He did well with
conservative, supportive care. On the day of discharge, he was
no longer tremulous, had not required diazepam for quite some
time and professed to feeling ready to leave the hospital. He
was seen by SW (see their note) and offered additional
resources. He was reluctant to accept any help from SW or the
medical team re: arranging f/u care in [**Location (un) 3844**]. Dr.
[**Last Name (STitle) **]
personally advised him that it appeared that he had T2DM and
should seek a PCP upon his arrival to NH for this and his other
medical needs. He stated he understood and would do so.
Medications on Admission:
None
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
## alcoholism, continuous
## alcohol withdrawal
## Mild transaminitis/hepatitis, likely secondary to above
## Encephalopathy secondary to intoxication, resolved
## macrocytic anemia with normal folate level, low-normal B12
## Type 2 DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for alchool intoxication. You
were found down and you needed to be intubated (have a tube in
your throat that breaths for you). Your alchool levels were very
high at admission. You got fluids and medication for alchool
withdraw. You have been doing well for the last 2 days. You have
decided to go to NH. You did not want our social worker to help
you organize your move. You were given her phone number in case
you need help in arranging your trip or getting to AA meeting.
You also did not want to go to outpatient program here.
.
Your blood sugar was also elevated which means that you have
diabetes. It is extremely important that you find a primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] as soon as you arrive. You will likely need to
start on medications for your diabetes and you will need to have
close follow-up. You were also found to have anemia related to
your alcohol intake and you were B12 injection and you should
continue to take the medications listed below.
.
It is very important that you stop drinking. Alchool can have
serious effects in your health and can cause death. You strongly
recommend that you go to AA meetings in the area that you will
be moving to in NH and that you find a primary care doctor as
soon as you get to the town where you will be living.
.
We have added the following medications, since alcohol can cause
anemia and brain problems:
-Thiamine
-Multivitamin
-Folate
Followup Instructions:
Please call the local AA in [**Location (un) **], NH:
Meetings on Wed. night 8:00PM-9:15PM
[**Doctor Last Name **] [**Hospital1 107**] Building
[**Last Name (NamePattern1) 85626**], NH
NH AA HOTLINE: 1-[**Telephone/Fax (1) 85627**]
|
[
"51881",
"2760",
"25000"
] |
Admission Date: [**2183-12-16**] Discharge Date: [**2183-12-18**]
Date of Birth: [**2116-4-10**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 9223**]
Chief Complaint:
confusion, weakness
Major Surgical or Invasive Procedure:
Stenting of Left Internal Carotid Artery
History of Present Illness:
This is a 67 year old female who was previously admitted on
[**2183-12-5**] with an expressive aphasia and right arm and hand
weakness. She was treated with tPA with resolution of symptoms
at 2 hours. MRI showed minimal L hemispheric lesions. A left
carotid ultrasound showed > 90 percent stenosis with velocities
> 400 cm/second. Her TEE showed an aortic arch atheroma.
Sympotomatically she says she now feels back to normal, with no
confusion, speech impediment, or extremity weakness.
Past Medical History:
HTN
Hypercholesterolemia
Hypothyroidism
s/p Hysterectomy
s/p L eyelid surgery
Social History:
+ current smoker [**12-14**] ppd x many yrsRare EtOH, no drugsIs a
librarian. Lives with her son (30 yrs old)
Family History:
No hx of stroke
Father:CAD - MI in 50's
Physical Exam:
ON admission:
Afebrile, vital signs stable
Gen: oriented, normal language, attention, calculation
Neck: no carotid bruit appreciated
Lugs: CTAB
CV: 2/6 systolic murmur, regular rate and rhythm
Abdomen: soft, NT/ND, + bowel sounds
Extr: warm
Neuro: no neglect, no aphasia, full visiual fields, EOMI, PERRL,
face symmetric with no dysarthria, full strength bilaterall
upper and lower extremities, no pronator drift, normal range of
motion, normal muscular tone, normal sensation to touch
throughout, normal coordination and gait
Pertinent Results:
SEROLOGIES
[**2183-12-16**] 04:36PM BLOOD WBC-5.3 RBC-3.47* Hgb-11.0* Hct-32.8*
MCV-95 MCH-31.6 MCHC-33.4 RDW-13.1 Plt Ct-232
[**2183-12-17**] 01:11AM BLOOD WBC-10.7 RBC-3.26* Hgb-10.4* Hct-30.3*
MCV-93 MCH-31.9 MCHC-34.3 RDW-12.9 Plt Ct-243
[**2183-12-17**] 04:26AM BLOOD WBC-7.3 RBC-2.76* Hgb-8.6* Hct-26.2*
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.2 Plt Ct-178
[**2183-12-18**] 09:40AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.5* Hct-31.2*
MCV-95 MCH-31.9 MCHC-33.6 RDW-13.9 Plt Ct-202
[**2183-12-16**] 04:36PM BLOOD PT-18.1* PTT-150 IS HIG INR(PT)-2.1
[**2183-12-17**] 04:26AM BLOOD PT-13.8* PTT-92.6* INR(PT)-1.2
[**2183-12-18**] 09:40AM BLOOD PT-12.8 PTT-27.3 INR(PT)-1.0
[**2183-12-16**] 04:36PM BLOOD Glucose-100 UreaN-18 Creat-0.7 Na-140
K-4.0 Cl-115* HCO3-21* AnGap-8
[**2183-12-17**] 04:26AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-141
K-4.4 Cl-115* HCO3-22 AnGap-8
[**2183-12-18**] 09:40AM BLOOD Glucose-149* UreaN-11 Creat-0.9 Na-142
K-3.7 Cl-110* HCO3-22 AnGap-14
[**2183-12-16**] 04:36PM BLOOD Calcium-7.3* Phos-3.2 Mg-1.6
[**2183-12-17**] 04:26AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.9
[**2183-12-18**] 09:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7
RADIOLOGY
[**2183-12-17**] Cerebral angiogram: no residual stenosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]
stenting
Brief Hospital Course:
This is a 67 year old female who presented a week prior to this
admission with symptoms related to a left carotid artery
stenosis. She now was admitted for stenting procedure. She
underwent this procedure on [**2183-12-17**] without complication;
post-procedure cerebral angiogram revealed no residual stenosis.
Neurologically she remained at baseline pre and post-procedure,
with no signs of mental status changes or extremity weakness or
numbness/paresthesias; her cranial nerve exam was normal. She
was started on aspirin and Plavix which she will continue
indefinitely for her stent. She was seen by the Neurology Stroke
service for pre-procedure and post-procedure evaluation. On day
of discharge she was found to have a baseline neurologic exam,
good pain control, and able to ambulate. She was transfused one
unit of blood for a slow drop in hematocrit secondary to
dilution; her hematocrit rose appropriately. She will follow-up
with Dr. [**Last Name (STitle) 1132**] in 2 weeks. All questions were answered to her
satisfaction upon discharge
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*40 Capsule(s)* Refills:*0*
4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Internal Carotid Stenosis
Discharge Condition:
Good
Discharge Instructions:
Please contact the office or come to the emergency room with any
vision changes, worsening headaches, confusion, dizziness,
worsening pain in your groin, or worsening bleeding from your
incision site. You may shower in 24 hours.You may remove your
dressing in one week. Do not drive while on narcotic pain
medications.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in 2 weeks (call [**Telephone/Fax (1) 1669**]) to
setup a time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 9225**]
Completed by:[**2183-12-18**]
|
[
"2851",
"4019",
"2720",
"2449"
] |
Admission Date: [**2106-3-23**] Discharge Date: [**2106-3-29**]
Date of Birth: [**2057-7-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p self inflicted stab wounds
Major Surgical or Invasive Procedure:
neck exploration and closure
b/l arm wound closures
intubation and mechanical ventilation
History of Present Illness:
48yoM s/p self inflicted stab wounds to transverse neck and b/l
volar forearms. Brought to OSH, found to be HD stable but
agitated. Intubated for airway protection and [**Location (un) **]
transport. HD stable on arrival to [**Hospital1 18**].
Past Medical History:
depression
Social History:
wife, children
Family History:
nc
Physical Exam:
Multiple Linear full thickness lacerations from the flexure of
the wrist to the anticubital fossa bilaterally. An ~6 cm long
linear full thickness laceration extends transversly across zone
2 of the neck with minimal oozing of the site. Alert and
oriented x3.
Pertinent Results:
[**2106-3-23**] 07:09PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0 TRANS EPI-0-2
[**2106-3-23**] 07:09PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2106-3-23**] 07:09PM PT-13.1 PTT-23.6 INR(PT)-1.1
[**2106-3-23**] 07:09PM WBC-34.7* RBC-4.53* HGB-13.6* HCT-39.3*
MCV-87 MCH-29.9 MCHC-34.5 RDW-12.6
[**2106-3-23**] 07:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2106-3-23**] 07:09PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-3-23**] 07:13PM HGB-13.8* calcHCT-41
[**2106-3-23**] 08:13PM WBC-20.7* RBC-3.01*# HGB-8.9*# HCT-26.6*#
MCV-88 MCH-29.4 MCHC-33.4 RDW-12.5
[**2106-3-23**] 08:13PM GLUCOSE-107* UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-25 ANION GAP-8
[**2106-3-23**] 09:05PM HGB-9.2* calcHCT-28
[**2106-3-23**] 10:34PM TYPE-ART TEMP-34.2 PO2-152* PCO2-44 PH-7.31*
TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED
[**2106-3-25**] 02:28PM BLOOD Hct-27.4*
[**2106-3-28**] 05:50AM BLOOD WBC-10.4 RBC-3.34* Hgb-9.8* Hct-28.8*
MCV-86 MCH-29.5 MCHC-34.1 RDW-12.8 Plt Ct-296
CTA head and neck [**3-23**] IMPRESSION:
1) Focus of extravasion of the left jugular vein adjacent to the
throid concerning for laceration.
2) Remaining vessels appear intact.
3) NG tube curled within upper esophagus.
4) Bilateral emphsematous changes and apical scarring fo the
lungs.
CXR/PXR [**3-23**] IMPRESSION: No evidence of traumatic injury.
Brief Hospital Course:
Trauma evaluation in ED demonstrated multiple large vertical
incisions on bilateral volar forearms with exposed muscle and
vessels, no active arterial bleeding, capillary refill intact.
Also demonstrated large transverse incision of Zone 2 neck with
obvious muscle and vessel exposure but no active bleeding. CTA
neck and head with ?internal jugular vein extravasation. Pt
went to OR with trauma surgery, plastic surgery, and thoracic
surgery for neck exploration and closure, EGD and Bronchoscopy
(both negative), and wound closure. Tolerated all procedures
well, no significant vascular injury noted. Extubated after
swelling of neck decreased sufficiently on HD 4 without
complication. HD4-7 pt progressed well, tolerating POs,
ambulating, denying current suicidal ideation, wounds healing as
expected. Stable and transferred to psychiatric inpatient
service on HD 7. Sutures of neck and bilateral forearms to be
removed 14days s/p injury.
Medications on Admission:
none
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
3. Citalopram Hydrobromide 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).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
bilateral forearm stab wounds
neck stab wound
Discharge Condition:
Good
Discharge Instructions:
-return the the ED or call your doctor with any increasing
redness, pus, or drainaged from neck or arm wounds.
Followup Instructions:
-Followup with the trauma service for suture removal 14days
after injury- if in hospital, page on call trauma resident
monday [**4-5**]- if discharged home, call for a trauma clinic
appointment for tuesday [**4-6**] afternoon at [**Telephone/Fax (1) 12786**]
Completed by:[**2106-3-29**]
|
[
"311"
] |
Admission Date: [**2138-3-9**] Discharge Date: [**2138-3-15**]
Date of Birth: [**2056-6-15**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
lethargy, decreased right sided movement
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81yo woman with PMH significant for recent R MCA and
bilateral ACA strokes, atrial fibrillation, and other vascular
risk factors, presents from rehab with one week of lethargy,
absence of speech, and right hemiparesis. She is known to the
neurology service, where she was admitted [**Date range (1) 16572**] with these
infarcts. She initially presented with left hemiparesis and was
found to have R MCA infarct, which was treated with IV tPA. She
did well initially with improvement in her left sided movement,
and was noted in angio to have had revascularization of the MCA
without IA tPA or MERCI retrieval. The next day she was noted to
be moving the left side better than the right, specifically in
the leg. Repeat scan showedd bilateral ACA infarcts, with both
ACAs deriving from the right circulation. She was abulic,
nonverval, with RLE plegia and decreased spontaneous movement
throughout. She was discharged to [**Hospital 38**] Rehab on [**2-25**].
At rehab, she was seen by neurology and was started on coumadin
on [**2-26**]. Per her daughter, her examination began to improve, to
the point on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**] that she was able to answer questions
about her family (where her sister-in-law lived, for example)
and
make a family joke. That night she became very tired, and
lethargy continued into Monday. She no longer spoke and stopped
moving the right side. This continued throughout the course of
the week, attributed to waxing/[**Doctor Last Name 688**] post-infarct, until she
appeared dehydrated and was brought in to [**Hospital1 18**] for further
evaluation.
Of note, INRs were 8.6 on [**3-6**].5 on [**3-7**], and 2.3 on [**3-9**].
Past Medical History:
-Afib dx 1 month ago-declined coumadin because of frequent blood
draws
-HTN (not well controlled per daughter)
-CABG stent x5 (20 y ago)
-CAD
patient had 3 stents placed. One stent was placed in [**2132**] and
another stent was placed in [**2135**]
-breast mass diagnosed in [**2137-7-10**]
[**2137-8-10**]- breast cancer was resected (lumpectomy) with
negative, clear margins
No chemo or radiation
-Bilateral CEA
Social History:
Married, has 2 daughters, one of whom died in her 50s of an
aneurysm bleed
daughter Ms. [**Last Name (Titles) 56256**], [**Telephone/Fax (1) 56257**](C), [**Telephone/Fax (1) 56258**](H),
[**Telephone/Fax (1) 56259**](W)
Family History:
Had daughter who died of brain aneurysm
Physical Exam:
PE: VS: T 98, BP 164/48 on arrival, to 84/48 at time of exam on
propofol, HR 67, RR 14, SaO2 100%/vent
Genl: intubated, sedated, taken off just briefly before
examination
HEENT: NCAT, MMM, ETT in place
CV: unable to appreciate over vented BS
Chest: vented BS, sound clear to auscultation
Abd: soft, NTND, PEG in place
Ext: warm and dry
Neurologic examination:
MS: moves to noxious, no eye opening, does not follow commands
CN: pupils small and irregular, asymmetric, but reactive b/l,
unable to appreciate OCR, corneals R>L, no response to nasal
tickle, +cough
Motor: extends BUE to noxious, triple flexes BLE to noxious,
tone
decreased throughout
Sensory: responds to noxious throughout
DTRs: 2+ in RUE, 2 in LUE, unable to elicit in BLE, toes upgoing
bilaterally
Pertinent Results:
128 93 23
-----------< 114
5.0 25 0.8
estGFR: 69 / >75 (click for details)
CK: 101 MB: 5 Trop-T: 0.03
Ca: 9.5 Mg: 2.1 P: 3.6
9.6 > 35.4 < 503
N:74.0 L:17.3 M:6.6 E:1.8 Bas:0.2
PT: 24.1 PTT: 24.3 INR: 2.3
Imaging: HCT: "Large intraparenchymal hemorrhage consistent with
hemorrhagic transformation in the known area of left anterior
cerebral artery infarct with intraventricular extension, and
surrounding edema causing rightward subfalcine herniation." ICH
appears to be 6cm x 6cm x 3cm, with 9mm MLS
Brief Hospital Course:
81yo woman with PMH significant for recent R MCA and bilateral
ACA strokes (both her ACAs oriinate from R ICA), in the context
of recent dx of atrial fibrillation not on Coumadin, and other
vascular risk factors, presents from rehab with one week of
lethargy. She was found to have large hemorrhagic transformation
into her L frontal infarct, likely in the setting of
supratherapeutic INR. Her ICH scale is at least 3, likely 4, for
volume, age, and poor GCS score.
She was initially admitted to the Neuro ICU, intubated, and
given prophylene to reverse her INR, as well as started on
Mannitol. After discussion with the family and in light of her
extremely poor prognosis, they decided to make her CMO status.
She was started on a Scopolamine patch, Morphine gtt and PRN
Ativan. She had a very irregular breathing pattern with
occasional apneic episodes during the ensuing few days while on
the [**Hospital1 **] but seemed comfortable. She died around noontime on
[**2138-3-15**].
Medications on Admission:
Meds:
amantadine 50mg daily
ASA 81mg daily
cholestyramine
famotidine 20mg daily
MgOxide 400mg daily
metoprolol 50mg q8hrs
miconazole topical [**Hospital1 **]
MVI 5ml daily
simvastatin 80mg daily
coumadin 3mg qhs
prns:
tylenol 650mg q6h
bisacodyl 10mg daily
colace 100mg [**Hospital1 **]
sorbitol 30ml daily
All: PCN, sulfa
Discharge Medications:
patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
hemorrhagic conversion of L frontal infarct
Discharge Condition:
patient was made CMO and died on [**3-15**]/8
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2138-3-24**]
|
[
"51881",
"42731",
"41401",
"V4582",
"V4581"
] |
Admission Date: [**2116-12-14**] Discharge Date: [**2117-1-16**]
Date of Birth: [**2042-4-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Bleeding small bowel mass, presents for elective surgical
resection
Major Surgical or Invasive Procedure:
[**12-14**] Small bowel enteroscopy, small bowel resection, lysis of
adhesions
History of Present Illness:
Mr. [**Known lastname 69005**] is a 74 year old male who who had a probable
transient ischemic attack earlier in the year and underwent
extensive cardiovascular work-up and was placed on aspirin and
Plavix. He became persistently anemic despite iron therapy and
GI evaluation was undertaken. Upper GI and colonoscopy were both
negative. The small bowel was evaluated with capsule endoscopy,
which identified a lesion in the small bowel that was ulcerated
and bleeding. Push
enteroscopy was not successful. Preoperative CT scan was done
which showed no evidence of intraabdominal neoplasia. No small
bowel lesion was seen. The preoperative CEA level was normal.
Resection was recommended as no other source of bleeding had
been found. After preoperative clearance, the patient was taken
to the operating room for scheduled surgery on [**12-14**].
Past Medical History:
Past Medical History;
Lower gastrointestinal bleeding
Hypertension
?TIA
Osteoarthritis
Grade 2 esophagitis
Past Surgical History;
Removal of bullet in Korean war
Social History:
Married, former smoker x 20 yrs, 1 pack per day, quit 25 yrs
ago; Occasional alcohol use
Family History:
Non-contributory
Physical Exam:
T 99 P 78 BP 147/52 R 20 SaO2 95%
Gen - no acute distress
Heent - no scleral icterus, no cervical lymphadenopathy
Lungs - clear
heart - regular rate and rhythm
Abd - soft, nontender, nondistended, bowel sounds audible
Extrem - warm, well perfused, no lower extremity edema
Pertinent Results:
Post-operative:
[**2116-12-14**] 09:55PM BLOOD Hct-30.9*
[**2116-12-15**] 04:12AM BLOOD Plt Ct-330
[**2116-12-14**] 09:55PM BLOOD Glucose-190* UreaN-11 Creat-1.0 Na-141
K-3.4 Cl-104 HCO3-21* AnGap-19
[**2116-12-14**] 09:55PM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
Discharge:
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Small bowel lesion identified by
capsule endoscopy, source of anemia.
POSTOPERATIVE DIAGNOSIS: Small bowel and pelvic adhesions
with acute angulation.
PROCEDURE PERFORMED: Exploratory laparotomy, lysis of
adhesions, intraoperative enteroscopy of the entire small
bowel through jejunal enterotomy and small bowel resection
x1.
Pathology Examination
SPECIMEN SUBMITTED: JEJUNUM.
DIAGNOSIS:
Segment of jejunum:
1. Peritoneal fibrous adhesions with focal foreign body
reaction.
2. Inflammatory polyp with marked granulation tissue.
3. There is a transmural tear without hemorrhage or
inflammation which is probably post-surgical.
4. The rest of the mucosa is within normal limits.
Clinical: Small bowel ulcerated lesion, source of anemia.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2116-12-15**] 1:07 AM
CHEST (PORTABLE AP)
Reason: please eval placement of NGT.
COMPARISON: No prior studies are available for comparison. CT of
the abdomen and pelvis [**2116-11-19**] was reviewed.
IMPRESSION: Nasogastric tube tip overlying the stomach. No acute
cardiopulmonary process identified.
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2116-12-16**] 5:50 PM
Reason: evL FOR PE PT IS S/P sb RESECTION W/ HYPOXIA AND MENTAL
STAT
CTA OF THE CHEST.
COMPARISON: None.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Small right-sided pleural effusion, and minor atelectatic
changes bilaterally.
CHEST (PORTABLE AP) [**2116-12-16**] 2:00 PM
IMPRESSION: Possible left lower lobe infiltrate.
Cardiology Report ECG Study Date of [**2116-12-16**] 2:10:24 PM
Normal sinus rhythm. Non-specific ST-T wave abnormalities. No
change compared
to the previous tracing of [**2116-12-8**].
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 134 100 390/424.42 9 -9 86
Operative Report [**12-26**]:
PREOPERATIVE DIAGNOSIS: Bile drainage from abdominal wound.
POSTOPERATIVE DIAGNOSIS: Enterocutaneous fistula with wound
abscess due to suture erosion.
PROCEDURE PERFORMED: Exploratory laparotomy, repair of
enterotomy, abdominal wash-out and wound closure.
CT scan [**1-1**]
IMPRESSION:
1. New enterocutaneous fistula, most likely arising from the
small bowel anastomosis. Extraluminal contrast within small
amount of intraperitoneal fluid.
2. Bibasilar pulmonary opacities probably representing a
combination of atelectasis, aspiration, and pneumonia, grossly
unchanged since [**2116-12-23**].
3. New small bilateral pleural effusions.
Microbiology:
[**2116-12-26**] 10:58 am SWAB Source: wound.
**FINAL REPORT [**2116-12-30**]**
GRAM STAIN (Final [**2116-12-26**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2116-12-28**]):
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).
RARE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT WITH
SKIN FLORA.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2116-12-30**]): NO ANAEROBES ISOLATED.
[**2117-1-4**] 10:00 am SWAB Source: Rectal swab.
**FINAL REPORT [**2117-1-6**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2117-1-6**]):
No VRE isolated.
[**2117-1-4**] 10:00 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2117-1-6**]**
MRSA SCREEN (Final [**2117-1-6**]): No MRSA isolated.
[**2117-1-3**] 2:01 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2117-1-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2117-1-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
Mr. [**Known lastname 69005**] had no intra-operative complications,
post-operatively he was NPO with a Dilaudid PCA, a subcutaneous
pain pump, intravenous hydration, telemetry monitoring, foley
catheter, and nasogastric tube. He experienced confusion and
agitation post-operatively which was treated with restraints and
Haldol, an EKG was negative for ischemia, he was afebrile, and
hemodynamically stable with a hematocrit of 29.8, the confusion
had resolved by POD 1. On POD 2 he had hypovolemia with
decreased urine output which responded well to intravenous
bolussing. On POD 2 he had intermittent confusion with
desaturation which improved on nasal cannula; chest x-ray and
chest CT scan were negative for an embolus, he had a small right
pleural effusion without evidence of aspiration. A geriatrics
consult was placed and the narcotics were discontinued. On POD 4
he had +flatus and a bowel movement, his diet was advanced which
he tolerated well, he had improvement in his mental status with
orientation to person, time, and place.
On POD 8, he had an episode of emesis with desaturation, was
transferred to the ICU for furher management of aspiration
pneumonia confirmed by CT and X-ray, broad spectrum antibiotics
were started, he was maintained on oxygen therapy, a nasogastric
tube was placed, and he was NPO with initiation of TPN. On POD
11, he required mechanical ventilation with intubation, was
febrile with leukocytosis of 20k, received a transfusion for a
hematocrit of 23; all microbiology cultures had been negative to
date. His incision was noted to have bilious drainage, he was
taken back to the operating room for an exploratory laparotomy,
repair of enterotomy, abdominal wash-out and wound closure, with
findings of an enterocutaneous fistula with wound abscess due to
suture erosion. The skin was not closed, and the wound was
packed with gauze. Post-operatively he required additional
transfusions for a hematocrit of 24, with a good response.
On POD 16/4, he was sucessfully extubated. The following day,
he became hypertensive with SBP up to 200, ekg showed inverted T
waves, and cardiac enzymes were cycled which were negative for
myocardial infarction. He had a swallow evaluation which showed
aspiration of thin liquids. We continued the TPN and advanced
his PO diet slowly. Tube feeds were started via a Dobhoff tube,
but was stopped because the patient had increased drainage from
his wound. On [**2117-1-1**], a CT scan was obtained for leukocytosis
and abnormal drainage from the abdominal wound, which revealed
an enterocutaneous fistula, most likely arising from the small
bowel anastomosis. There was also extraluminal contrast with a
small amount of intraperitoneal fluid. A VAC dressing was
placed over the wound for drainage purposes.
The patient developed hypernatremia and a Renal consult was
obtained. It was determined that the patient likely was having
post-acute tubular necrosis diuresis with an element of
nephrogenic diabetes insipidus. TPN without sodium as well as
D5W were infused to keep his sodium level less than 147. Sodium
levels were followed closely throughout the day and it remained
stable at 143 at discharge with the D5W infusions.
On [**2117-1-6**], the patient was transferred to the floor.
Throughout the [**Hospital 228**] hospital course, he had been delirious,
confused, and agitated at times requiring haldol for sedation.
We encouraged the patient to use the incentive spirometer, use
of neuroleptics were held, and we continued to reorient the
patient. One to one sitter was obtained to monitor the patient.
His agitation improved, but he continued to remain confused.
Physical therapy was consulted to assist the patient with
mobility and rehab was recommended for him. We expect his
mental status to improve in rehab.
When the patient's bowel function returned, he was started on a
diet of nectar thickened liquids, pureed solids with PO meds
crushed in puree. Supervision with meals by nursing staff were
done to maintain aspiration precautions. The patient continued
to have poor PO intake. His TPN was discontinued in order to
see if this would increase his appetite and we continued to
encourage PO intake. Before discharge, the patient had another
swallow evaluation and demonstrated signs of aspiration of thin
liquids by straw sips and his diet was changed to a thin liquid,
soft solid diet without the use of a straw. The patient
continued to have poor PO intake despite the new diet. A PICC
line was placed should the patient require TPN.
On the day of discharge, the patient had cloudy urine in his
foley bag and was having liquidy stools. A cdiff test was
pending. A UA was positive for UTI and the patient was started
on a 7 day course of Cipro. The patient was discharged in
stable condition.
Medications on Admission:
Plavix
ASA
Prilosec
Iron
MVI
Glucosamine
Triamterene
Tylenol
Ibuprofen
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebule
Inhalation Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebule
Inhalation Q6H (every 6 hours) as needed.
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Bleeding from small bowel polyp
Enterocutaneous fistula
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor if you experience fever, chills,
lightheadedness, dizziness, chest pain, shortness of breath,
palpitations, severe abdominal pain, or nausea/vomiting.
No driving while taking pain medications.
Activity as tolerated.
No tub baths.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17489**] Follow-up appointment
should be in 2 weeks
|
[
"5070",
"51881",
"2760",
"5845",
"5990",
"4019"
] |
Admission Date: [**2107-5-18**] Discharge Date: [**2107-5-24**]
Date of Birth: [**2034-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Spiriva / Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
unstable angina with tight left main disease
Major Surgical or Invasive Procedure:
[**2107-5-18**]:
emergent coronary artery bypass grafts x
3(LIMA-LAD,SVG-OM,SVG-RCA)
History of Present Illness:
This 71 year old white male with known coronary artery disease
developed chest pain, shortness of breath and hemoptysis over
the previous 2 days. A stress test was abnormal.Cardiac
catheterization revealed 99% left main coronary artery stenosis.
He was transferred for urgent revascularization.
Past Medical History:
hypertension
hyperlipidemia
myocardial infarction [**2088**]
emphysema
h/o dysphagia with Schatzki ring
right upper lobe wedge resection (necrotic granuloma) [**2105**]
s/p appendectomy
Social History:
Race: caucasian
Lives with: wife
Occupation: retired military
Tobacco: quit [**2088**]
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: 65 Resp: 16 O2 sat:
B/P Right: Left: 142/78
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2107-5-24**] 07:15AM BLOOD WBC-10.4 RBC-3.44* Hgb-11.0* Hct-32.7*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.5 Plt Ct-326
[**2107-5-23**] 06:30AM BLOOD WBC-17.7* RBC-3.99* Hgb-12.9* Hct-37.3*
MCV-93 MCH-32.2* MCHC-34.5 RDW-13.9 Plt Ct-303
[**2107-5-22**] 06:25AM BLOOD WBC-16.6* RBC-4.00* Hgb-12.8* Hct-37.9*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.5 Plt Ct-256#
[**2107-5-20**] 06:15AM BLOOD WBC-13.5* RBC-3.90* Hgb-12.6* Hct-37.5*
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.1 Plt Ct-170
[**2107-5-18**] 02:06PM BLOOD WBC-8.7 RBC-5.06 Hgb-16.1 Hct-48.1 MCV-95
MCH-31.8 MCHC-33.4 RDW-14.0 Plt Ct-278
[**2107-5-23**] 06:30AM BLOOD Glucose-148* UreaN-19 Creat-0.8 Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2107-5-20**] 06:15AM BLOOD Glucose-116* UreaN-19 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
[**2107-5-18**] 02:06PM BLOOD Glucose-113* UreaN-15 Creat-0.7 Na-137
K-4.7 Cl-105 HCO3-25 AnGap-12
[**2107-5-18**] 02:06PM BLOOD ALT-21 AST-24 LD(LDH)-145 CK(CPK)-52
AlkPhos-60 TotBili-0.8
[**2107-5-18**] 09:57PM BLOOD Type-ART pO2-74* pCO2-36 pH-7.36
calTCO2-21 Base XS--4
Brief Hospital Course:
This is a 73 year old male who presented after a markedly
positive stress test. Cardiac cath demonstrated severe 99%
distal left main stenosis with a subtotally occluded LAD filling
via collaterals from a dominant right system which had a 60-70%
mid lesion. The patient was transferred emergently from [**Hospital 40796**] to the [**Hospital1 **] Hospital for
emergent coronary artery bypass grafting. Upon arrival the
patient was hemodynamically stable and chest painfree on
intravenous nitroglycerin only.
He was taken to the Operating Room on [**5-18**] and underwent
emergent coronary bypass grafting x3. See operative note for
full details. He tolerated the procedure well,weaning from
bypass on Neo Synephrine and Propofol infusions.
Post-operatively he was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward his preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes were left in for a persistent air leak with chest x-ray
showing a right basilar pneumothorax. The air leak resolved and
the right chest tube was removed with a persisitent small
basilar pneumothorax. This was stable at dischage and the
patient was assymptomatic. Pacing wires were discontinued
without complication.
The patient was evaluated by the Physical Therapy service for
assistance with strength and mobility. He had a leukocytosis to
17,700 with no obvious source or fever after POD 1. Blood
culture were sent on two days, urine culture was nagative and
his CXR was clear. The WBC fell to 10,000 on [**5-24**] and he was
discharged home.By the time of discharge on POD 6 the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged
home with visiting nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
simvastatin 80 daily, atenolol 50 daily, valsartan 320 daily,
finasteride 5 daily, asa 325 daily, asmanex 220mcg [**Hospital1 **], foradil
12mcg [**Hospital1 **], fish oil capsules 1000mg [**Hospital1 **], calcium 600mg daily,
multivitamin daily, proventil prn
Allergies: spiriva, niacin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*1 * Refills:*0*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Coronary Artery Disease with tight left main disease
s/p coronary artery bypass grafts
chronic obstructive pulmonary disease
Schatski Ring w/ dysphagia
hyperlipidemia
hypertension
s/p wedge resection Right upper lobe for granulomatous disease
s/p appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Perocoet
Incisions: sternum/left leg-clean, dry and intact
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2107-6-21**] at 1:30pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) **] in [**1-22**] 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:[**2107-5-24**]
|
[
"41401",
"496",
"25000",
"412",
"4019"
] |
Admission Date: [**2149-3-14**] Discharge Date: [**2149-3-29**]
Date of Birth: [**2086-8-27**] Sex: F
Service: [**Location (un) 259**]
CHIEF COMPLAINT/REASON FOR ADMISSION: Hyperkalemia and acute
renal failure.
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 21806**] is a
62-year-old female with a past medical history significant
for alcoholic pancreatitis and cirrhosis, type 3 diabetes
mellitus, and depression. The patient presented to the [**Hospital1 1444**] Emergency Room complaining of
nausea, anorexia, and weakness. These symptoms have worsened
over the past week. She denies any nausea, vomiting,
diarrhea. She has not noted any decrease in urine output.
In the emergency department, she was found to have a
creatinine of 11, potassium of 8.4, pH of 7.20. The EKG
revealed evidence of increased QRS interval widening and
peaked T waves. The patient was given Kayexalate, insulin
and D50 immediately and then had a left Quinton subclavian
line placed emergently for emergency hemodialysis. She was
then transferred to the medical Intensive Care Unit for
further observation.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis.
2. Type diabetes mellitus, diet controlled, status post
partial gastrectomy with a Billroth II in [**2128**].
3. History of multiple falls.
4. Gastroesophageal reflux disease.
5. Depression, status post appendectomy, status post total
abdominal hysterectomy, bilateral salpingo-oophorectomy,
status post laminectomy.
6. Degenerative joint disease, status post right shoulder
surgery.
7. History of chronic pancreatitis, pancreatic
insufficiency, history of recurrent lower extremity
cellulitis.
MEDICATIONS ON ADMISSION:
1. Aldactone 25 mg p.o.q.d.
2. Carafate 1 mg p.o.t.i.d.
3. Inderal 60 mg p.o.q.d.
4. K-Dur 10 meq p.o.q.d.
5. Lasix 40 mg p.o.q.d.
6. Pancrease 2 tabs t.i.d.
7. Prilosec 20 mg p.o.q.d.
8. Rhinocort.
9. Trazodone 50 mg q.h.s.
10. Ultram 15 mg p.r.n.
11. Verapamil 40 mg p.o.b.i.d.
12. Vioxx 25 mg p.o.q.d.
13. Zyprexa 10 mg q.h.s.
ALLERGIES: The patient is allergic to VANCOMYCIN, WHICH
LEADS TO A SEVERE RASH; DEMEROL.
SOCIAL HISTORY: The patient lives alone in [**Location 21807**].
She is close with her son. She quit alcohol use in the
[**2126**]. She is homebound.
FAMILY HISTORY: The patient's father died of a myocardial
infarction at the age of 49.
PHYSICAL EXAMINATION: GENERAL: The patient was in bed in no
apparent distress with occasional twitches. HEENT: Pupils
equal, round, and reactive to light. Extraocular muscles are
intact. Oropharynx dry. NECK: No JVD, no lymphadenopathy.
LUNGS: Lungs were clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs,
or gallops. ABDOMEN: Midline scar, soft, nontender,
nondistended, good bowel sounds, no hepatosplenomegaly.
EXTREMITIES: The patient had an area of erythema, warmth,
over the dorsum of her right foot along with an area of
erythema over her inferior/anterior tibia consistent with
cellulitis.
LABORATORY DATA: Laboratory data revealed the following:
White count 5.5, hematocrit 28.3, platelet count 297, sodium
124, potassium 8.4, chloride 105, bicarbonate 7, BUN 144,
creatinine 11.9, glucose 87. Urinalysis revealed the pH of
5.0 with one white blood cell and two white blood cells. ALT
12, AST 11. Alkaline phosphatase 225, amylase 40, total
bilirubin 0.3, CK 127, less than 0.3, lipase 9, albumin 3.5,
calcium 6.9, phosphatase 12.2, hematocrit 1.6, pH 7.20, pCO2
24, PAO2 116 on room air.
Chest x-ray revealed no acute cardiopulmonary disease.
Renal ultrasound was performed showing bilaterally small
echogenic kidneys consistent with medical renal disease.
There was no evidence of hydronephrosis or stones.
HOSPITAL COURSE:
PROBLEM LIST:
RENAL FAILURE: The patient required hemodialysis three times
a week while she was in the hospital, being stable on
hemodialysis. Surgery Department was consulted and attempted
to place an A-V graft in her right arm, but they were
ultimately unsuccessful. She will need followup with the
Department of Surgery at a later date for them to attempt a
graft of fistula at another site. While in the operating
room, she had a right IJ Perm-A-Cath placed for hemodialysis.
The left subclavian Quinton line, which was inserted on
admission, was discontinued before discharge. The exact
cause of her renal failure was unclear. Acute and chronic
renal failure may have been precipitated by her NSAID use.
MENTAL STATUS CHANGES: The patient became nonverbal after
her first course of hemodialysis. She remained nonverbal for
four days and eventually returned to her baseline mental
status. She became talkative and returned to her baseline
mental status five days afterwards. During this time, head
CT was done, which revealed no evidence of intracranial
pathology. EEG was done, which showed a result consistent
with widespread encephalopathy likely secondary to her renal
failure. Mental status remained stable throughout the rest
of her hospital stay.
LOWER EXTREMITY CELLULITIS: The patient was started on
Levofloxacin, Flagyl, and Oxacillin for treatment of her
cellulitis. On day #10, she was switched to dicloxacillin
with continued improvement of the affected area. She will
need to complete a total of a 14-day course of Levofloxacin,
Flagyl, and Dicloxacillin.
LINE TIP INFECTION: Because the femoral and hip culture grew
Methicillin resistant Staphylococcus aureus and
coagulase-negative staph, the patient was treated with a
five-day course of Linezolid for possible line infection.
She was treated with Linezolid rather than Vancomycin due to
her confirmed allergy to Vancomycin. Repeat blood cultures
were no growth. The patient remained afebrile, except for
minor temperature spike of 99.5 four days prior to admission.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was started
on tubes feeds for nutrition upon admission. She required
frequent electrolyte repletion on the first several days of
admission, but became stable after several courses of
hemodialysis. The patient was also started on Vitamin B12
injections after discovering that her vitamin B12s were low.
After the mental status had improved, two swallowing studies
were done, which revealed that she was aspirating only thin
liquids. She was kept on a ground-solid renal diet with
nectar-thickened liquids. She was given
...................at breakfast, lunch, and dinner and
thiamine and Nephrocaps to for vitamin supplementation. She
was continued on her outpatient dose of pancrease for her
pancreatic insufficiency.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o.q.d.
2. Thiamine 100 mg p.o.q.d.
3. Tramadol 25 mg p.o.q.4h to 6h.p.r.n.
4. Vitamin B12 100 mcg IM q. month.
5. Calcium carbonate 500 mg p.o.t.i.d. hold if the phosphate
is less than 4.5.
6. Miconazole powder 2% applied to the feet b.i.d.
7. Nephrocaps one p.o.q.d.
8. Pancrease two caps p.o. t.i.d. with meals.
9. Heparin 5000 units subcutaneously b.i.d.
10. Metoprolol 12.5 mg p.o.b.i.d.
11. EPO alpha 4000 units subcutaneously IV q Monday,
Wednesday, and Friday at hemodialysis.
12. Trazodone 50 mg p.o.q.h.s.p.r.n.
13. Tylenol 650 mg q.4h to 6h.p.r.n. pain.
14. Levofloxacin 250 mg q.4h.to 8h.times two days.
15. Dicloxacillin 250 mg q.6h.p.o. for two more days.
16. Flagyl 500 mg p.o.b.i.d. times two more days.
FOLLOW-UP CARE: The patient is to followup with her PCP, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21808**] in one week.
PROBLEM LIST:
1. End-stage renal disease on hemodialysis.
2. Bilateral lower extremity cellulitis
3. Type 2 diabetes mellitus.
4. Alcoholic cirrhosis, status post partial gastrectomy with
Billroth II.
5. History of multiple falls.
6. Gastroesophageal reflux disease.
7. Depression.
8. Status post appendectomy.
9. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy, status post laminectomy.
10. Osteoarthritis/degenerative joint disease.
11. Status post right shoulder injury.
12. Chronic pancreatic insufficiency secondary to chronic
pancreatitis.
DR.[**Last Name (STitle) 21809**],[**First Name3 (LF) **] 12-658
Dictated By: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2149-3-28**] 15:12
T: [**2149-3-28**] 16:07
JOB#: [**Job Number 21810**]
|
[
"5849",
"2767",
"40391",
"2762",
"25000"
] |
Admission Date: [**2197-6-25**] Discharge Date: [**2197-7-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Vancomycin weakness
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
84 yo male with h/o HTN, CADs/p CABG was in his USOH until 48
hours ago when he started feeling weak and having dizziness.
Was seen at [**Hospital1 **] [**Location (un) **] and found to have HR in the 30s with a
junctional rhythm on EKG. Was given atropine, and his HR
improved to 40. Found to have new onset renal failure cr 3.6 and
hyperkalemia (5.7) and was given Ca, dextrose, bicarb, insulin,
kayexalate and transferred to [**Hospital1 18**].
.
In the ED here, his HR was in the 40s and he felt better. No CP,
no SOB, no lightheadedness. SBP 140s. HR in upper 40s and lower
50s, Was given glucagon w/ GI upset but w/o improvement in HR.
EKG here w/ ? slow atrial fibrillation. Patient usually receives
lopressor 12.5 9 a.m. and cardizem 240mg XR 9 a.m.
.
The patient denies a change in urination, itchiness, but has had
trouble sleeping recently. Also complains of sinus congestion
and HA for the last few weeks and a week of a nonproductive
cough.
.
PAST MEDICAL HISTORY:
1. CAD s/p CABG ([**2177**])
2. Hypertension
3. Hyperlipidemia
4. Anemia - for the last year, had a transfuion in [**9-26**],
baseline in the low 30's
5. Diverticulitis s/p partial colectomy
6. Mass on the kindey and lung - found last [**Month (only) 321**]; no
current workup, as workup would be too invasive
7. Chronic diarrhea
8. Emphysema
9. History of bowel obstructions
10. s/p Cholecystecomy
11. s/p two hernia repairs
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2177**] anatomy as follows: 3 vessel
disease
.
OUTPATIENT MEDICATIONS:
1. Cardizm XR 240 mg daily
2. Zestril 40 mg daily
3. Metoprolol succinate 12.5 mg daily
4. Norvasc XR 10 mg daily
5. ASA 81 mg daily
6. Zocor 20 mg daily
7. Omeprazole 20 mg daily
8. Trental ZR 400 mg tid
9. Ativan 0.5 mg prn
10. Temazepam 30 - 45 mg qhs
11. Zyrtec 1 tab daily
12. Nasonex 2 sprays q nostril daily
13. Eye drops for runny eyes
14. Miralax once daily
15. B12 shot once monthly
.
ALLERGIES: NKDA
.
SOCIAL and FAMILY HISTORY:
Social history is significant for the a 125 pack year history;
quit 8-10 years ago. There is no history of alcohol abuse. There
is no family history of premature coronary artery disease or
sudden death, however several family members have had [**Name (NI) 5290**].
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope. He sleeps
with one pillow.
.
PHYSICAL EXAMINATION:
VS - T 97.6 BP 162/52 P 54 R 20 sat 98% on 3 L
Gen: thin, elderly male lying in bed in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear.
Neck: Supple with JVP of 8 cm.
CV: Midline well-healed scar present; regular and bradycardic,
normal S1, S2. No m/r/g. 2 + radial pulses.
Chest: Wheezing present Left > Rt; crackles present bilaterally
at the bases. Audible wheezing at baseline. Respirations
unlabored, no retractions.
Abd: + BS, distended with gas. No hepatosplenomegaly present.
Ext: No c/c/e.
Skin: Thin skin throughout
.
MEDICAL DECISION MAKING
EKG [**6-25**] - HR 50, irregular,
TELEMETRY demonstrated: bradycardia
2D-ECHOCARDIOGRAM performed on [**10-27**] demonstrated: EF 40-45%,
mild to moderate regional left ventricular systolic dysfunction
with inferior/inferolateral/inferior akinesis.
.
LABORATORY DATA:
Na 14 K 4.9 Cl 109 Bicarb 24 BUN 69 Cr 3.6 Glu 155
WBC 8.7 Hct 30.0 Plt 201 (83.8% N, 11.6% L)
Pt 12.9 Ptt 25.8 INR 1.1
Troponin 0.02
[**1-27**] CT abdomen:
- Cystic renal cell carcinoma left kidney, likely high-grade
papillary type. This has grown since [**2192**].
- Multiple left lower lobe nodules (in the lungs) are new since
[**2197-1-13**]. Though the largest has an appearance concerning for
metastasis, this would be unlikely to have grown to 1 cm in this
short interval and this may represent a small airways infection
or
aspiration as is evident in the right middle lobe.
.
[**6-25**] CXR mild interstital fluid overload without evidence of PNA
or pleural effusion.
.
ASSESSMENT AND PLAN:
84 yo male with pmh of CAD s/p CABG, htn, and renal and
pulmonary masses who presents with ARF and a juntional
bradycardia.
.
#. CAD - patient is s/p CABG, currently without chest pain.
- Continue ASA, statin.
- Are holding B-blocker due to bradycardia.
.
#. Pump - patient has some signs of volume overload - crackles
halfway up his chest and interstial fluid on CXR. Will monitor
and watch his I/Os as he is in renal failure and may become
volume overloaded.
- We will continue BP control with norvasc, but are holding
metoprolol and diltiazem as he is bradycardic. Can consider
starting hydralazine if further BP control is needed.
.
#. Rhythm - patient is currently in a juntional escape rhythm
likely due to his ARF as diltiazem is renally cleared and may be
accumulating causing AV block.
- Continue to monitor on telemetry
- Hold his B-blocker and diltiazem
.
#. Acute renal failure - Differential includes prerenal vs
intrarenal vs postrenal. Unlikey to be prerenal as there is no
history to suggest volume depletion. As for postrenal, he has a
history of RCC which could have metastasized or he may have BPH
which could have caused obstruction. Intrarenal causes included
extension of his RCC, intrinsic golmerular disease, or
interstitial disease.
- Renal US to rule out obstruction
- F/U urinary electrolytes and [**Hospital1 **] electrolytes
- F/U UA amd UCx
- Consider CT abd/ pelvis to evaluate renal mass
.
# Kidney/ lung masses - last CT abd was in [**1-27**]
- Consider CT abd/ pelvis to evaluate renal mass
.
# Wheezing - patient has crackles and interstial fluid on CXR
- albuterol nebs prn
- Will monitor respiratory status
.
# Hx of diarrhea and bowel obstruction - continue home PPI,
ranitidine and miralax.
- As the patient is very gassy, will give simethicone prn
.
# Sinus problems - continue zyrtec and nasonex
.
#. FEN: Follow and replete electrolytes. Cardiac diet. No IVF at
present.
.
#. Access: PIV
.
#. PPx: SQH, bowel regimen.
.
#. Code: full
.
#. Dispo: pending resolution of his junctional rhythm and
diagnosis of the cause of his ARF
.
Past Medical History:
CAD s/p MI and CABG
hx recurrent partial small bowel obstructions
htn
diverticulitis
s/p ccy
s/p sigmoid colectomy
Dengue fever and malaria in WWII
small bowel obstruction in [**2196-1-21**]
colonoscopy [**10-16**] with one polyp removed
EGD [**2196-10-15**] with gastritis
Social History:
Wife died within the 2 months prior to admission. Notes
decreased appetite and endorses depression symptoms. One
daughter lives nearby and is very involved but is also recently
married and has failing in-laws, so is spread thin. Currently
lives alone but daughter frequently in the home. H/o smoking,
but has quit. No EtOH.
Family History:
NC
Physical Exam:
VS - 100.4 95 123/60 16 100% on AC 0.7 500 16 5
Gen: Thin, elderly male. Intubated. Opens eyes and responds to
commands correctly.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear.
Neck: JVP 8cm. Supple. No thyroid enlargement.
CV: Well-healed midline scar; regular and bradycardic, normal
S1, S2. No m/r/g.
Chest: Faint crackles at bases but essentially clear anteriorly.
Abd: OG tube in place. + BS, soft, NT, ND.
Ext: No c/c/e.
Hand grip intact b/l. Tracks and makes eye contact.
Pertinent Results:
[**2197-6-25**] 03:30AM PT-12.9 PTT-25.8 INR(PT)-1.1
[**2197-6-25**] 03:30AM NEUTS-83.8* LYMPHS-11.6* MONOS-3.4 EOS-1.0
BASOS-0.2
[**2197-6-25**] 03:30AM WBC-8.7# RBC-3.23* HGB-9.6* HCT-30.0* MCV-93
MCH-29.7 MCHC-32.0 RDW-14.6
.
RENAL U.S. Study Date of [**2197-6-25**] 12:52 PM
1. Bilateral hypoechoic renal lesions, not meeting son[**Name (NI) 493**]
criteria for simple cyst. In setting of the suspicious left
renal mass previously
described on CT, further characterization of these lesions with
MR is
recommended.
2. The left renal superior pole mass highly suspicious for
pappillary RCC,
seen on CT, [**2197-1-20**] was not demonstrated today. In discussion
with referring physician [**Last Name (NamePattern4) **].[**Last Name (STitle) **] no interim intervention was
undertaken due to decision to pursue non-invasive management
approach. In view of which, this mass could have been obscured
by the rib shadows in that region and MR evaluation is
recommended.
.
Cardiology Report ECG Study Date of [**2197-7-6**] 6:19:00 AM
Sinus rhythm with ventricular premature beats including a slow
triplet.
Consider left atrial abnormality. Left ventricular hypertrophy.
ST-T wave
abnormalities. Since the previous tracing of [**2197-7-2**] the rate
has slowed.
Also, the rate of the ventricular ectopy has slowed. Consider
left atrial
abnormality.
.
CHEST (PORTABLE AP) Study Date of [**2197-7-4**] 3:06 AM
Moderate right pleural effusion layers posteriorly, obscuring
detail in the
right lung but interstitial edema is still present.
Consolidation is
unchanged at the left base since [**6-29**], either atelectasis or
pneumonia.
Heart size is top normal. There is no pneumothorax.
.
Brief Hospital Course:
SUMMARY: Patient is an 84M with a hx of HTN and CAD s/p CABG who
p/w weakness and dizziness. He was found to have renal and
pulmonary masses of unknown significance and also found to have
bradycardia and renal failture. He ultimately underwent
intubation for hypoxic respoiratory failure due to a combination
of NSTEMI and aspiration pneumonia. He was successfully
extubated and improved, thus he was transferred to the floor on
[**2197-7-1**]. He was briefly CMO in the MICU, but was made DNI/DNR
prior to transfer to the floor. He was on 40-50% facemask upon
transfer. He improved to NC 4L on the floor and was stable with
improving pulmonary exam until on [**2197-7-2**], he developed
hypercarbic respiratory failure likely due to mucous plugging
and/or aspiration with blood pH 7.08 and CO2 74. He was sent
back to the MICU to receive CPAP, which he did not tolerate.
However, he improved without CPAP and has been transitioned back
to 4L NC with last ABG on [**7-3**] showing pH 7.26. He was initially
started on vanc/cefepime/flagyl, then the flagyl was
discontinued. He currently feels well with no SOB, CP, abdominal
pain or any other complaints. His current code status remains
DNR/DNI with comfort centered care: cont antibiotics, bp
control, but no escalation of care. As his respiratory function
was improving, he was discharged to home with nursing services
and hospice care. He completed his course of antibiotics, which
was abridged from a 10 day course to a 9 day course (last dose
on day of d/c).
.
# Hypercapneic respiratory failure: This was thought to be
secondary to witnessed aspiration and either pneumonitis or PNA.
He was started on aspiration and hospital acquired PNA
antibiotics. His sputum GS and culture were contaminated
however. Swallow also recommended soft diet with surveillance
while eating. His respiratory function improved and he was
satting 93% on 2L at time of d/c.
.
# NSTEMI: Patient had many PVCs on telemetry but no evidence of
a second infarction. We continued aspirin, beta blocker, and
statin but held the ACE-I b/c of his ARF. We initially held
amlodipine because the patient was bradycardic but restarted it
for better BP control.
.
# Bradycardia: Cause of original admission. HR was initially in
30s due to junctional rhythm and B-blocker, CCB. His
bradycardia resolved and his HR remained in the 60s. Amlodipine
was restarted but diltiazem was held.
.
# Acute renal failure: Cre 2.9 on admission, down to 1.5 at time
of discharge, with a baseline of 1.0 - 1.2. His ARF is likely
[**1-21**] hypoperfusion, probably from bradycardia and/or hypotension
after NSTEMI. His renal function improved with IVF.
A renal U/S showed no hydronephrosis/post-renal obstruction from
mass, but did identify a lesion suspcious for RCC. The family
has chosen not to pursue further w/u.
.
# Hypertension: Patient was hypertensive upon transfer to floor
but improved control with metoprolol. We restarted amlodipine
at the time of d/c.
.
# Hypernatremia: Patient was hypernatremic to 147 but improved
with free water intake and D5W fluid infusion. Sodium was
corrected slowly.
.
# Kidney and lung masses: Had CT abd in [**1-27**] (showed Cystic
renal cell carcinoma left kidney, left lower lobe nodules
largest measures 1 cm). The patient and family do not want
further w/u, however.
.
# Anemia: Patient's baseline hematocrit is low 30s, and he
likely has anemia of chronic disease. We are not working this
up further at this time.
.
# Acute decompensated systolic heart failure: with EF 25-30%.
Previous EF 40%. Patient currently appears euvolemic. Tolerated
IVFs for treatment of ARF which largely resolved. An ACE-I may
be restarted in the future as the patient's renal fxn improves.
.
# Sleep/agitation: Patient was given olanzapine qhs for sleep
and prn haldol 0.25 for agitation. Family members helped with
frequent orientation. Patient tolerated olanzapine and was
weaned off of his home Temazepam. He also was given trazadone
at night to sleep. However, at time of d/c, he requested a
script for his Temazepam, which was restarted.
.
#. FEN: cardiac diet, crushed meds, soft solids w/ thin liquids,
and one-to-one supervision w/ meds. We repleted lytes prn and
d/c'd his foley.
.
#. Access: A PICC was placed during his hospital stay and
removed at time of d/c.
.
#. Code: DNR/I, not CMO, but no escalation in care. Note that
patient did not tolerate CPAP when we transferred him to the
MICU for resp distress. The family spoke with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(palliative care) and the decision was made to discharge the
patient home with hospice care.
.
# Communication: During the hospital stay, we contact[**Name (NI) **] the
patient's sister [**First Name8 (NamePattern2) **] [**Name (NI) **]) at [**Telephone/Fax (1) 67896**] to inform her
of respiratory arrest and intubation; she is the patient's HCP.
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Zyrtec Oral
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Temazepam Oral
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
9. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal once a day.
10. Vitamin B-12 Injection
11. Ativan 0.5 mg Tablet Oral
Discharge Medications:
1. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
2. Zyrtec Oral
3. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
4. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal once a day.
5. Vitamin B-12 Injection
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
Disp:*3000 mg* Refills:*2*
9. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H
(every 6 hours) as needed for fever/pain.
Disp:*300 mL* Refills:*0*
10. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane
ASDIR (AS DIRECTED).
Disp:*30 appl* Refills:*2*
11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*240 Puff* Refills:*2*
14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
Disp:*360 puffs* Refills:*2*
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
sleep.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
17. Home supplemental Oxygen at 3 to 4 liters
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
Disp:*30 Tablet(s)* Refills:*2*
19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
20. Home Physical Therapy
Please assist in developing strength and endurance
21. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q2h
as needed for pain or shortness of breath.
Disp:*30 ml* Refills:*0*
22. Temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
23. 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*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary
1. Non-ST elevation myocardial infarction
2. Acute renal failure
3. Junctional bradycardia secondary to medication acculmulation
in the setting of acute renal failure
.
Secondary
1. CAD s/p CABG ([**2177**])
2. Hypertension
3. Hyperlipidemia
4. Anemia - for the last year, had a transfuion in [**9-26**],
baseline in the low 30's
5. Diverticulitis s/p partial colectomy
6. Mass on the kindey and lung - found last [**Month (only) 321**]; no current
workup, as workup would be too invasive
7. Chronic diarrhea
8. Emphysema
9. History of bowel obstructions
10. s/p Cholecystecomy
11. s/p two hernia repairs
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to a slow heart rate
accompanied by acute renal failure. You slow heart rate was
found to be due to accumulation of the diltiazem secondary to
your renal failure. You were also found to have suffered a
heart attack and you developed pneumonia. We treated you with
antibiotics and other drugs.
.
We changed several of your medications. Please see the
medications sheet for specific medications and doses.
.
Please contact your primary care physician if you have chest
pain, shortness of breath, fevers, chills, or any other
concerns.
Followup Instructions:
Please schedule an appointment with your primary care doctor in
the next one to two weeks:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]
.
No follow-up with [**Hospital1 18**] Oncology Department for incidental lung
and kidney findings per family's request.
Completed by:[**2197-7-10**]
|
[
"5849",
"41071",
"51881",
"5070",
"4280",
"42789",
"2767",
"V4581",
"4019",
"2724",
"412",
"2859"
] |
Admission Date: [**2167-3-19**] Discharge Date: [**2167-3-27**]
Date of Birth: [**2101-7-23**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old male,
who presented with new onset of exertional symptoms x3 weeks.
Patient reports dyspnea on exertion with left chest
discomfort that radiates to the left arm. Symptoms resolved
with rest. Patient denies orthopnea, paroxysmal nocturnal
dyspnea, lightheadedness, edema, or claudication.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Right shoulder arthritis.
PAST SURGICAL HISTORY:
1. Right shoulder arthroscopy.
2. Back surgery.
3. Right rotator cuff surgery.
4. Right great toe surgery for osteomyelitis.
5. Exploratory abdominal surgery.
MEDICATIONS ON ADMISSION:
1. Motrin 800 mg prn.
2. Aleve prn.
3. Aspirin 81 mg p.o. q.d.
4. Toprol 25 mg p.o. q.d.
PHYSICAL EXAM: On physical exam, the patient was afebrile
and vital signs stable, saturating 97% on room air. General:
In no apparent distress. Head was normocephalic, atraumatic.
No scleral icterus noted. Neck was soft and supple, no JVD
noted, and no carotid bruits. Heart was regular rate and
rhythm, S1, S2. Chest was clear to auscultation bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremity examination was unremarkable. Neurologic
examination with no focal deficits.
SOCIAL HISTORY: Significant for a 50-pack year history.
Patient also had 6-7 beers history per day history of
drinking.
FAMILY HISTORY: Significant for brother who died of a stroke
at 67.
SUMMARY OF HOSPITAL COURSE: Patient is a 65-year-old male
with a history of hypertension and positive family history,
who presents with drinking and tobacco history, who presents
with exertional dyspnea x3 weeks. Patient was admitted to
the Medicine service and taken for cardiac catheterization on
[**2167-3-19**], which revealed severe left main diffuse
three-vessel disease, moderate-to-severe reduction of the
left ventricular ejection fraction of 25%, severe right iliac
disease, severe bilateral renal artery disease. Resultant
from this data, patient was scheduled for angioplasty and
stenting of iliac and renal artery disease, and Cardiac
Surgery was consulted for revascularization via CABG.
Cardiac Surgery was consulted on [**2167-3-20**]. Patient was
planned for the OR. Preoperative testing was significant for
a transthoracic echocardiogram which showed depressed left
ventricular function and moderate MR. Cardiac
catheterization results as stated before as well as a carotid
duplex, which revealed left internal carotid artery occlusion
and right internal carotid artery stenosis with 60-70%.
On [**2167-3-20**], the patient was taken to the cardiac
catheterization laboratory for angioplasty and stent
placement. Stents were placed in the common iliac arteries
bilaterally as well as the left renal artery. Patient was
placed on Plavix.
Patient was taken to the OR on [**2167-3-23**] for CABG x2: LIMA to
LAD and SVG to OM. For more detailed account, please see
operative report. Postoperatively, patient went to the CSRU
and was extubated on postoperative day #0. Patient was
placed on a CIWA scale immediately for alcohol withdrawal,
which was treated with beer prn. Swan and chest tubes were
D/C'd on postoperative day #2, and the patient was discharged
to the floor later on that day.
On postoperative day #2, patient had an episode of confusion,
hallucinations, which was alleviated with Haldol prn as well
as beer prn. On postoperative day #2, wires were D/C'd and
patient was started on metoprolol 25 mg p.o. b.i.d.
The remainder of [**Hospital 228**] hospital course was unremarkable.
Patient worked with Physical Therapy and achieved level five
on postoperative day #4. Patient had no additional episodes
of alcohol withdrawal, confusion, or hallucinations.
DISCHARGE STATUS: Home with VNA.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post Coronary artery bypass graft x2.
3. Hypertension.
4. History of alcohol abuse.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Protonix 40 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Thiamine 100 mg p.o. q.d.
6. Folic acid 1 mg p.o. q.d.
7. Metoprolol 75 mg p.o. b.i.d.
8. Vicodin 1-2 tablets p.o. q.4-6h. prn for pain.
FOLLOW-UP INSTRUCTIONS: Patient is to followup with the
[**Hospital 409**] Clinic in two weeks, Dr. [**Last Name (STitle) **] the primary care
physician [**Last Name (NamePattern4) **] [**3-26**] weeks and Dr. [**Last Name (STitle) 70**] in six weeks.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2167-3-27**] 12:01
T: [**2167-3-27**] 12:12
JOB#: [**Job Number 53177**]
(cclist)
|
[
"41401",
"4240",
"4019"
] |
Admission Date: [**2134-10-29**] Discharge Date: [**2134-11-3**]
Date of Birth: [**2095-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic ascending aortic aneurysm
Major Surgical or Invasive Procedure:
Aortic Valve Replacement
Ascending Aorta Replacement
History of Present Illness:
39 year old asymptomatic caucasian male who was found to have a
bicuspid aortic valve with a dilated ascending aorta. The
patient was referred for surgery due to the 6cm ascending aortic
aneurysm.
Past Medical History:
bicuspid aortic valve
ascending aortic aneurysm
asthma
gastroesophageal reflux disease
obstructive sleep apnea
Social History:
tobacco: quit [**2120**]
EtOH: <1 drink per week
recreational marijuana use
works as a flower delivery man
lives with parents
Family History:
non-contributory
Physical Exam:
Gen: NAD, overweight white male, appears stated age
HEENT: NCAT, EOMI, PERRL
Skin: unremarkable
Lungs: CTAB
Heart: RRR, no murmur or rub
Abd: obese, NABS, soft, non-tender
Incision: c/d/i, no erythema or drainage, sternum stable
Ext: trace edema
Pertinent Results:
[**2134-11-1**] 05:45AM BLOOD WBC-10.6 RBC-4.14* Hgb-13.0* Hct-36.9*
MCV-89 MCH-31.5 MCHC-35.3* RDW-13.5 Plt Ct-134*
[**2134-11-3**] 05:33AM BLOOD PT-32.3* INR(PT)-3.3*
[**2134-11-1**] 05:45AM BLOOD Glucose-149* UreaN-12 Creat-0.7 Na-133
K-3.8 Cl-94* HCO3-34* AnGap-9
[**Known lastname **],[**Known firstname 488**] [**Medical Record Number 107703**] M 39 [**2095-1-25**]
Radiology Report CHEST (PA & LAT) Study Date of [**2134-11-3**] 10:06
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2134-11-3**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 107704**]
Reason: f/u effusions, ptx
Preliminary Report !! PFI !!
No pneumothorax. Interval improvement of aeration of the lung
bases but with
still present atelectasis and small bilateral pleural effusion.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
PFI entered: WED [**2134-11-3**] 12:11 PM
Brief Hospital Course:
Thirty-nine year old white male with a history of bicuspid
aortic valve and ascending aortic aneurysm. The patient was
admitted to the hospital and brought to the operating room on
[**2134-10-29**] where he underwent aortic valve replacement with a
mechanical valve as well as ascending aorta replacement (please
see operative note for full details). Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for invasive
monitoring.
By post operative day 1 the patient was extubated, alert and
oriented and breathing comfortably. He was weaned from
vasopressor support. Chest tubes and pacing wires were
discontinued in the usual fashion, without complication and the
patient was transferred to the step down unit.
Coumadin was started for a goal INR 2.5-3. The patient made
good progress on the floor with physical therapy, showing good
strength and balance before discharge. He was gently diuresed
toward his preoperative weight. He was discharged to home in
stable condition on POD#5. His INR will be drawn on Fri. [**11-5**]
and will be called to Dr. [**First Name (STitle) **].
Medications on Admission:
albuterol
prilosec
paxil
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. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed by Dr. [**First Name (STitle) **] for an INR goal of 2.5-3.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Bicuspid aortic valve
aortic stenosis
aortic regurgitation
ascending aortic aneurysm
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr.[**First Name (STitle) 9529**],HARVEEN [**Telephone/Fax (1) 82564**] in 1 week, please call for
appointment
Dr. [**Last Name (STitle) 59945**] please call for an appointment for 2-3 weeks.
Completed by:[**2134-11-3**]
|
[
"4241",
"32723",
"49390",
"4019",
"53081"
] |
Admission Date: [**2183-7-4**] Discharge Date: [**2183-7-6**]
Date of Birth: [**2117-11-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
diaphoresis, nausea and lightheadedness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 22771**] is a 65 year old male with hx of T2DM, CAD,
ischemic cardiomyopathy with LVEF 30-35% who presented to the ED
after a near-fainting episode not associated with nausea,
vomiting, chest pain or shortness of breath. He had a pint of
beer this morning and subsequently walked for two hours to visit
his wife. At the end of two hours, he felt faint and began to
black out. His nephew caught him and put him into a car. He did
not hit his head. He immediately woke up. He had not had any
water all day. He has been feeling somewhat ill for about a
week and has had episodes in which he has felt faint. He had not
passed out until today. He complains of a mild cough.
.
In the ED, initial vs were: 100.3, 96, 80, 72/42, 16, 100/RA.
Awake, alert. SBP came up after 2L IVF with SBP 153. FS 350,
rectal temp 100.3 at triage. EKG showed new TWIs in V4-V6. Trop
0.02, MB 17 MBI 4.8. His next trop was .01.
Trauma u/s neg except IVC w/ minimal resp variation. Initial
thought was CVL for monitoring but has been hemodynamically
stable.
.
The pt had a UA with >182 WBC< few bact, lrg leuk. Lactate of
5.9 down to 3.1 after 2L IVF. Creatinine was also elevated to
1.7 from 1.1 two days prior. ALT 127, AST 100, TB 1.8. Lipase
62.
.
Blood and urine cultures were sent. And the pt was given
dextrose, Zosyn, and Vancomycin 1g.
.
Abd U/s showed diffuse hepatic fat deposition. Contracted
gallbladder with equivocal wall thickening but no evidence of
cholecystitis. Pancreas not well visualized. CXR without acute
CPP.
.
VS on transfer 72 153/85 18 100% 2L. On the MICU floor, he had
no complaints. He felt well. He was hemodynamically stable.
.
Review of systems:
(+) Per HPI
(-) 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, 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:
-Type 2 diabetes mellitus
-Atrial fibrillation (diagnosed [**12/2181**])
-Hyperlipidemia
-Asthma
-Arthritis in bilateral hands/shoulders
-Anemia
-Hypertension
-Ischemic cardiomyopathy (LVEF 30-35%)
-Coronary artery disease inf/post (Cath in [**1-2**] w/ 70% stenosis
of OM2 of LAD - no intervention; MI in [**2166**])
-Stabbed in his abdomen s/p surgery at [**Location (un) 8599**]Hospital
([**2180**])
-h/o periodontitis
Social History:
Drugs: none
Tobacco: 1 pack/week
Alcohol: 1 drink per week
Family History:
Father and paternal uncle both had heart problems, s/p ?CABG.
Paternal uncle's course complicated by diabetic infection. Older
brother died after a stroke. [**Name (NI) **] brother with gastric
cancer. All brothers ([**Name (NI) 22772**]) have diabetes. Cancer and diabetes in
brothers and sisters
Physical Exam:
ADMISSION EXAM:
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : CTAB)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
LABORATORY DATA
-Admission Labs
[**2183-7-4**] 02:30PM BLOOD WBC-10.4# RBC-5.20 Hgb-16.2 Hct-50.4
MCV-97 MCH-31.1 MCHC-32.1 RDW-15.0 Plt Ct-250
[**2183-7-4**] 02:30PM BLOOD Neuts-69.5 Lymphs-23.6 Monos-4.8 Eos-1.0
Baso-1.2
[**2183-7-4**] 02:30PM BLOOD Glucose-369* UreaN-17 Creat-1.7* Na-136
K-3.8 Cl-96 HCO3-20* AnGap-24*
[**2183-7-4**] 02:30PM BLOOD ALT-127* AST-100* CK(CPK)-351*
AlkPhos-121 TotBili-1.8*
[**2183-7-4**] 02:30PM BLOOD Lipase-62*
[**2183-7-4**] 02:44PM BLOOD Lactate-5.9*
-Cardiac Biomarkers
[**2183-7-4**] 02:30PM BLOOD CK-MB-17* MB Indx-4.8
[**2183-7-4**] 02:30PM BLOOD cTropnT-0.02*
[**2183-7-4**] 07:35PM BLOOD cTropnT-<0.01
[**2183-7-5**] 04:27AM BLOOD cTropnT-0.01
-Discharge Labs
[**2183-7-6**] 05:25AM BLOOD WBC-6.2 RBC-4.77 Hgb-14.8 Hct-45.2 MCV-95
MCH-31.1 MCHC-32.9 RDW-15.0 Plt Ct-162
[**2183-7-6**] 05:25AM BLOOD Glucose-111* UreaN-16 Creat-1.0 Na-139
K-4.1 Cl-99 HCO3-29 AnGap-15
[**2183-7-6**] 05:25AM BLOOD ALT-115* AST-85* AlkPhos-92 TotBili-1.6*
[**2183-7-6**] 05:25AM BLOOD Calcium-9.0 Phos-4.5 Mg-1.6
[**2183-7-5**] 05:17AM BLOOD Lactate-1.1
MICROBIOLOGY:
[**7-4**] URINE CULTURE (Final [**2183-7-5**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**7-4**] URINE CULTURE (Final [**2183-7-5**]): <10,000 organisms/ml.
[**7-4**] Blood Culture, Routine (Final [**2183-7-10**]): NO GROWTH.
[**7-4**] MRSA SCREEN (Final [**2183-7-7**]): No MRSA isolated.
[**7-5**] Hepatitis Serologies
Hepatitis B Surface Antigen: NEGATIVE
Hepatitis B Surface Antibody: NEGATIVE
Hepatitis B Core Antibody, IgM: NEGATIVE
Hepatitis A Virus IgM Antibody: NEGATIVE
Hepatitis C Virus Antibody: NEGATIVE
IMAGING:
[**7-4**] RUQ Ultrasound
IMPRESSION: 1. Diffusely echogenic liver is most consistent with
fatty deposition although more advanced liver disease such as
cirrhosis and/or fibrosis cannot be excluded. 2. No evidence of
acute cholecystitis.
Brief Hospital Course:
65 year old male with hx of DM2, CAD, ischemic cardiomyopathy
with LVEF 30-35% p/w diaphoresis, acute onset of nausea and
lightheadedness and was found to have UTI, [**Last Name (un) **], and hypotension
which responded to fluids in the MICU. Patient has been
hemodynamically stable since.
# UTI: Will complete a 7-day course of ciprofloxacin 500mg Q12H
for complicated UTI (male). Dysuria improved.
# [**Last Name (un) **]: Resolved with IVF. Etiology prerenal azotemia, in the
context of exertion and glucosuria. Creatinine trended back to
baseline by time of discharge.
# Transaminitis: Fatty liver on RUQ ultrasound, however
cirrhosis or fibrosis cannot be ruled out. Hepatitis serologies
negative. Recommended outpatient liver followup.
# CAD w/Ischemic Cardiomyopathy: LVEF 30-35%. Troponin negative
x 2. No chest pain. Continued aspirin, metoprolol, lisinopril,
atorvastatin and isosorbide mononitrate SR. Held HCTZ, can
discuss restarting with PCP.
# IDDM: Continued home lantus 25 units qAM in addition to
supplemental HISS once patient started eating. Metformin held
while in-house.
# History of Afib: Metoprolol switched from home metoprolol
succinate to metoprolol tartrate for closer BP control while
in-house; switched back to metoprolol succinate on discharge.
Coumadin was held in the context of supratherapeutic INR (3.6).
# Supratherapeutic INR: Possibly secondary to liver injury.
Coumadin was held & INR monitored closely.
# Asthma: Continued Flovent as needed.
# DVT Prophylaxis: Systemic anticoagulation (INR 3.6).
# Code status: Full code.
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous qAM (every morning).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual q5min: Max: 3 doses within 15 min.
7. nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
8. warfarin 5 mg Tablet Sig: 1-2 Tablets PO once a day: CALL DR. [**Location 22773**] OFFICE TO FIND OUT HOW MUCH YOU SHOULD TAKE.
9. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
12. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# Urinary tract infection
# Acute kidney injury
# Hypotension
# Hyperglycemia
Secondary diagnoses:
# Fatty liver with transaminitis
# Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
# You were admitted to the hospital after almost fainting and
found to have kidney injury, low blood pressure, elevated blood
sugar and a urinary tract infection. Your blood pressure and
kidney injury improved with fluids. You were started on a 7-day
course of antibiotics (ciprofloxacin) to treat your urinary
tract infection ([**Date range (1) **]).
# Your liver enzymes were elevated and an ultrasound of your
liver showed fatty deposits, both of which are signs of injury
to your liver. You should talk to your PCP about this & likely
follow up in the Liver Clinic.
# Your INR was very elevated when you came to the hospital, so
held your coumadin.
**IT IS VERY IMPORTANT THAT YOU CALL YOUR PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD [**Telephone/Fax (1) 608**]) TOMORROW ([**Last Name (LF) **], [**7-7**]) TO FIND OUT HOW MUCH
COUMADIN YOU SHOULD TAKE**
# We made the following changes to your medications:
- STOPPED hydrochlorothiazide for now (**discuss restarting this
with Dr. [**First Name (STitle) **] when you see him this Thursday, [**7-10**]**)
- STARTED ciprofloxacin 500mg by mouth twice a day for the next
4 days to complete a total 7-day course.
- You should restart Imdur (isosorbide mononitrate) on [**Month/Year (2) 766**],
[**7-7**].
# It is important that you take all of your medications as
prescribed and keep all of your follow up appointments.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: THURSDAY [**2183-7-10**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS Best Parking:
Completed by:[**2183-8-8**]
|
[
"5990",
"5849",
"2762",
"25000",
"4280",
"V4581",
"49390"
] |
Admission Date: [**2104-3-28**] Discharge Date: [**2104-4-3**]
Service: MEDICINE
Allergies:
Megace / Ativan / Latex / Reglan
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Palpitations and light-headedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 yo female with h/o afib, presents from assissted living with
palpitations, lightheadedness, presyncope and labored breathing
for 3 days. Per patient has had atrial fibrillation since [**2100**].
At that time she was walking home from the grocery store and had
severe shortness of breath and palpitations. She was worked up
in [**State 2748**] and placed on toprol 25mg in am. She had some
light-headedness with the full dose of Toprol in the morning and
so was switched at some point to [**1-18**] tab (12.5mg) in the am and
[**1-18**] in the pm. She has had palpitations with this off and on
since then. This is the first time that she has felt
light-headed with this. Over the last few days she has felt
light-headed and felt that her heart was racing/vibrating. This
morning she says that everything went "cloudy" and she felt like
she was going to faint. She told the people at her assissted
living and they sent her to the ED.
.
VS in ED were T:97.5 HR80 BP: 93/60 RR 20 O2 99%RA. EKG in ED
showed 3:1 block versus complete AV dissociation (narrow complex
QRS at rate of 60, sinus rate of ~180). ep was paged and in ER
immediately - 3:1 block, no active EP issues. labs in ED showed
Tn 0.02, MB 2, EP recommended trending to ROMI and will continue
to follow on floor for ? of possible pacemaker placement.
.
On presentation to floor patient denied light-headedness even
with standing. Denied any history of chest pain. Felt that pulse
was better and she felt better. She denied ever feeling short of
breath. The patient denies any chest pain or pressure, new
exertional dyspnea, orthopnea, PND or leg edema,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits. No change in weight, bowel habit
or urinary symptoms. No cough, fever, night sweats, arthralgias,
myalgias, headache or rash. All other review of systems
negative.
Past Medical History:
open appendectomy complciated with colocutaneous fistula,
incisional hernia, and c diff
sepsis with [**Female First Name (un) **] when on TPN
right hip fracture with prosthesis
mitral valve prolapse
Per patient extensive cardiac history all worked up in CT
- CHF (although patient denies this)
- Atrial fibrillation on coumadin
- Cath in [**2101**] that per patient showed no cad but showed a
"scar on heart"
Recent stool cards [**2-22**] positive for blood
.
Cardiac Risk Factors: Diabetes(-), Dyslipidemia(-),
Hypertension(-)
Social History:
Social History: Originally from [**Location (un) 42751**]. Now lives at [**Hospital1 **]
crossing ALF. denies tobacco/alcohol/illicit drugs.
Family History:
brother X 2 died of MI. Sister with MVP.
Physical Exam:
VS - T97.3 HR95-117 BP140/94 RR18 O2100RA
Orthostatics:
standing: 115/74 84 Sitting: 120/70 and 76 Laying: 120/70 80bpm
Gen: Thin elderly female in NAD . Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
Neck: Supple with no JVD
CV: PMI located in 5th intercostal space, midclavicular line.
Irregular irregular rhythm. No m/r/g.
Chest: =CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Incisional hernia nt.
pin-point fistula with no expressable discharge.
Ext: No c/c/e.
Neuro: A+OX3
Pertinent Results:
[**2104-3-28**] 06:59PM CK(CPK)-134
[**2104-3-28**] 06:59PM CK-MB-5 cTropnT-0.01
[**2104-3-28**] 11:25AM GLUCOSE-92 UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2104-3-28**] 11:25AM CK(CPK)-143*
[**2104-3-28**] 11:25AM cTropnT-0.02*
[**2104-3-28**] 11:25AM CK-MB-7
[**2104-3-28**] 11:25AM WBC-8.6 RBC-4.03* HGB-11.9* HCT-34.6* MCV-86
MCH-29.4 MCHC-34.4 RDW-15.2
[**2104-3-28**] 11:25AM NEUTS-71.8* LYMPHS-21.8 MONOS-5.0 EOS-0.8
BASOS-0.5
[**2104-3-28**] 11:25AM PLT COUNT-369
[**2104-3-28**] 11:25AM PT-22.9* PTT-27.4 INR(PT)-2.2*
Brief Hospital Course:
EKG demonstrated [**2104-3-28**] with atrial flutter with 3:1 block and
occasional PVCs. Compared to prior now in atrial flutter as
opposed to atrial premature beats.
TELEMETRY demonstrated: rates 80s-90s
#. CAD: Had cardiac cath in [**2101**] with no intervention done per
patient although does have vague history of "scar" on heart.
Patient had three sets of cardiac enzymes that were negative.
She had no complaints of chest pain and her EKGs showed no ST/TW
changes so she was essentially ruled out for MI.
#. Pump: Nl TTE in [**2103-6-17**]. Euvolemic on exam.
#. Rhythm: Admitted with some what looked like atrial flutter
with 3:1 block. CHADS2 score 1. EP was consulted and felt that
she should be rhythm controlled so that she could come off of
coumadin given the recent guaiac positive stools. She was
started on propafenone for rhythm control and continued on her
coumadin. She had some episodes of tachycardia (180 BPM)
overnight and thus her toprol was re-started (12.5mg [**Hospital1 **]). She
had some bradycardia and then long pauses on telemetry requiring
atropine. For this she was transferred to the CCU for further
management of her arrhythmias and potentially a PPM placement.
***CCU stay: Initially while monitored on telemetry, she was
still having pauses on tele, this was thought secondary to beta
blockade. As her beta blocker wore off, he HR picked up and she
stopped having pauses. She was anxious prior to procedure but
went ahead. She had her pre-procedure dose of Vancomycin and
after completion had some flushing of forehead and scalp. She
underwent the procedure without complications.
*****FLOOR stay: She was transferred to the floor after the PPM
placement. She had no further complications. She remained paced
at a rate of around 70 on the telemetry. She had no
palpitations, sob, chest pain. Her pacemaker site was without
hematoma or sign of infection. She had a followup chest x-ray
that showed ppm leads in place. She will follow up with device
[**Hospital1 **] in 1 week and will follow up with Dr. [**Last Name (STitle) 22973**] in 3
months.
#. Entero-cutaneous fistula: Throughout admission the wound
looked clean and there was no significant discharge from it. She
continued her normal wound care regimen while she was
hospitalized.
#. Urinary frequency: patient noted that she has no dysuria and
that frequency is a common symptom for her for several years.
However, she was nervous about having an infection and wanted us
to check it so a UA C+S were sent and were pending at time of
transfer.
#. Communication:
[**First Name8 (NamePattern2) **] [**Known lastname **]: [**Telephone/Fax (1) 78758**]
[**First Name8 (NamePattern2) **] [**Known lastname **]: [**Telephone/Fax (1) 78759**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78760**]: [**Telephone/Fax (1) 78761**]
#. Code: full
Medications on Admission:
Warfarin 1.5mg daily
Metoprolol 12.5mg [**Hospital1 **]
Citracal +D (315/200) 2 tabs twice daily
MVI
Discharge Medications:
1. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*30 Tablet(s)* Refills:*2*
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start after 6 days of twice daily amiodarone.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check INR 1 week after discharge and have results called
into the [**Hospital 191**] [**Hospital 2786**] [**Hospital **] at [**Telephone/Fax (1) 250**].
Discharge Disposition:
Home With Service
Facility:
Care Solutions, Inc
Discharge Diagnosis:
Tachy-brady syndrome
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with palpitations and
dizziness. This was from an abnormal rhythm of your heart. We
have started a medication to keep your heart in the normal
rhythm (amiodarone). You should keep taking your coumadin and
have your INR's checked in one week as sometimes the coumadin
interacts with your new medication (amiodarone).
While you were here you had very slow heart beats. You had a
pacemaker placed to keep your heart beating regularly. You
should have your pacemaker function checked in 1 week and follow
up with the cardiologist, Dr. [**Last Name (STitle) 22973**], in 3 months.
Medication Changes:
START: amiodarone 200mg twice daily for 6 more days, then 200mg
by mouth once daily
Please come back to the hospital or call your pcp if you have
fainting, dizziness, light-headedness, chest pain, shortness of
breath, nausea, vomiting, palpitations, leg swelling, abdominal
pain, pain with urination, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2104-4-3**] 3:45
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2104-6-4**] 12:00
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
on [**2104-4-15**] at 10:00am.
Please follow up in the pacemaker DEVICE [**Date Range **]
Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2104-4-11**] at 2:30pm.
Please follow up with Dr. [**Last Name (STitle) 22973**] at the cardiology [**Last Name (STitle) **] on
[**2104-7-3**] 9:00am. His office is on the [**Location (un) 436**] of the [**Hospital Ward Name **]
building on the [**Hospital Ward Name 516**] of [**Hospital1 **].
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2104-4-3**] 3:45
Completed by:[**2104-4-3**]
|
[
"42731",
"V5861",
"4240",
"4280"
] |
Admission Date: [**2162-1-17**] Discharge Date: [**2162-1-23**]
Date of Birth: [**2097-1-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
weakness, hypotension
Major Surgical or Invasive Procedure:
IR percutaneous nephrostomy tube placement [**2162-1-18**]
History of Present Illness:
Ms [**Name13 (STitle) 43791**] is a 64-year-old female with metastatic breast
cancer, history of DVT, s/p recent ureteral stent placement
([**2162-1-12**])for left sided hydroureteronephrosis, who was
transferred to the [**Hospital1 18**] with weakness, hypotension. The patient
was initially brought to [**Hospital3 417**] hospital after being
found on her bathroom floor, without loss of consciousness,
apparently following a fall in which she injured her right knee.
.
Upon arrival to the ED, the patient was found to be hypotensive
with a BP of 94/37. She received 2.5 L of NS with minimal
improvement in her BP, and was started on Levophed for her
hypotension. CT scan of the abdomen and pelvis revealed possible
mild diverticulitis, and her U/A was suggestive of UTI. She
subsequently was transferred to the [**Hospital Unit Name 153**] for presumed urosepsis.
.
In the [**Hospital Unit Name 153**], she was initially treated with cipro/flagyl. She
was persistently hypotensive requiring IVF and levophed.
Ceftriaxone was added to regimen. Vancomycin was also added
given persistent hypotension. She underwent a percutaneous
nephrostomy tube placement on [**2162-1-18**]. She has been off
vasopressors since pm [**1-18**]. She was transfused 1 unit PRBCs on
[**1-19**] for Hct 24->22. She has had no evidence of active bleeding.
She has been maintained on dilaudid PCA for back pain and plan
was to wean off 12 hrs after placement of fentanyl patch (she
was found to have 2 patches on by nursing, both of which were
removed and new patch placed at 8 pm [**1-19**]. She has only minimal
PCA requirements at this time.
.
Currently, patient is feeling well. Niece is at bedside to
interpret. Patient currently notes back pain, which has been
improving. She also notes R knee pain with movement. She denies
fevers, chills, chest pain, SOB, abdominal pain, nausea,
vomiting.
Past Medical History:
# metastatic breast cancer s/p chemo, XRT, 5 years tamoxifen,
arimidex, Cyberknife, Xeloda, Zometa
# Left-sided hydroureteronephrosis with a question of mass at
the left ureter s/p ureteral stent placement [**2162-1-12**]
# DVT treated with lovenox [**2161-2-19**]
# Right total knee replacement
# HTN
# s/p Thyroidectomy
# s/p Cholecystectomy
.
Onc History:
She was diagnosed with left-sided breast cancer with lumpectomy
and axillary lymph node dissection 12 years ago. She had stage
II disease and was treated with adjuvant radiation therapy and
chemotherapy and five years of tamoxifen. She later had a
mastectomy, which had no evidence of residual disease. In
[**8-/2159**], she presented with bone metastases and diffuse
lymphadenopathy. A lymph node biopsy of a left supraclavicular
node confirmed metastatic disease on [**2159-10-1**]. The tumor was
ER/PR positive and HER-2/neu negative. Currently on Arimidex
and Zometa beginning in 11/[**2158**]. Received 10 treatments XRT for
lesion growing on C2 bone, completed [**2160-9-17**].
Social History:
Patient lives at home with her husband. [**Name (NI) **] [**Name2 (NI) **], etoh, drugs.
Family History:
NC
Physical Exam:
T: 96.1 BP: 102/57 HR: 80 RR: 20 O2 97% RA
Gen: Pleasant, well appearing female in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, JVP low.
CV: RRR. nl S1, S2. II/VI sys murmur. L portocath CDI.
LUNGS: Bibasilar crackles.
ABD: Obese. NABS. Soft, NT, ND. No HSM. L sided nephrostomy tube
dressed, CDI.
EXT: WWP, NO CCE. 2+ DP pulses BL
MSK: + R knee effusion with pain on active and passive ROM
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities.
Pertinent Results:
On Admission:
[**2162-1-17**] 03:15PM BLOOD WBC-9.8 RBC-2.79* Hgb-10.3* Hct-30.3*
MCV-109* MCH-37.1* MCHC-34.1 RDW-16.4* Plt Ct-234
[**2162-1-17**] 03:15PM BLOOD Neuts-84.0* Lymphs-12.4* Monos-2.5
Eos-0.8 Baso-0.2
[**2162-1-17**] 03:15PM BLOOD PT-14.5* PTT-33.4 INR(PT)-1.3*
[**2162-1-17**] 03:15PM BLOOD Glucose-161* UreaN-28* Creat-1.7* Na-142
K-4.5 Cl-113* HCO3-21* AnGap-13
[**2162-1-18**] 03:59AM BLOOD ALT-14 AST-17 LD(LDH)-219 AlkPhos-47
TotBili-0.3
[**2162-1-18**] 03:59AM BLOOD Albumin-3.4 Calcium-8.2* Phos-1.3* Mg-1.9
.
Imaging:
CT Abdomen/Pelvis:
1. Colonic diverticulosis with minimal perisigmoid inflammatory
fat strand to
suggest uncomplicated diverticulitis.
2. Persistent left hydroureteronephrosis with indwelling
internal nephrostomy
stent. There is high attenuation layering in the dilated left
collecting
system, this may represent debris, infection or hemorrhage.
3. No significant change in appearance of known osseous
metastases.
Brief Hospital Course:
[**Hospital Unit Name 13533**]:
Patient was admitted to the [**Hospital Unit Name 153**] with hypotension. It was felt
to be urosepsis from pyelonephritis. A CT scan demonstrated
stranding and possible infection in the collecting system of her
recently stented kidney. She was given fluids and levophed. She
did not improve during the first 24 hours of her admission, and
was unable to wean from levophed. Thus, she was taken for a
percutaneous nephrostomy tube. During the next 12 hours, she was
able to wean from levophed. She was continued on vancomycin,
ceftriaxone and cipro, double coverage for possible gram
negatives and pseudomonas. She was called out to Oncology
service for continued management of metastatic breast cancer
with bony mets.
.
Oncology Course: According to problems.
.
# Urosepsis ?: Felt to be etiology of hypotension, however
unclear. [**Name2 (NI) **] positive cultures. However, CT does demonstrate high
attenuation focus which could be infection - consequently
continued Cipro for 10 day course.
.
# L hydronephrosis: CT Abdomen [**10-17**] new L hydronephrosis with
transition point mid ureter -> concerning for metastasis left
ureter. Stent placed [**2162-1-12**]. CT abdomen [**1-18**] persistent L
hydroureteronephrosis indwelling internal nephrostimy stent.
High attenuation dilated L collecting - diff includes debris,
infection, hemorrhage.
- Patient to follow-up with urology (Dr. [**Last Name (STitle) 770**] as outpatient
in [**1-13**] weeks
- To be discharged with draining PTC drain - will need to follow
up with Interventional Radiology
.
# Anemia: Most likely secondary to hematuria, serosangiunous
draining from PTC. Patient to follow-up with urology as
outpatient.
.
# Knee Pain: Chronic plus recent trauma. Resolved with lidocaine
patch. Continue outpatient pain medications.
.
# Breast Cancer: s/p multiple rounds of chemo, hormonal therapy,
XRT, and Cyberknife.
- Per primary oncologist
.
# h/o DVT: Diagnosed [**2161-2-19**]. Had been on lovenox. Was initially
transitioned to heparin gtt, stopped [**1-18**] prior to percutaneous
nephrostomy tube placement.
- Prior to discharge re-started patient on prophylactic Lovenox
dose
.
# HTN: Valsartan was discontinued. Patient's BP < 120. [**Month (only) 116**] be
re-started as outpatient is blood pressure increases.
.
# Hyperlididemia: Continued statin
Medications on Admission:
CAPECITABINE [XELODA] - 1500 mg in am, 1000mg in pm
ENOXAPARIN [LOVENOX] - 120 mg/0.8 mL Syringe qd
FENTANYL [DURAGESIC] - 75 mcg/hour Patch 72 hr - 1 patch TD q 72
hours
LOVASTATIN - (Prescribed by Other Provider) - 40 mg qhs
NYSTATIN - 100,000 unit/mL Suspension - 5 mL Suspension(s) by
mouth four times a day Swish
OMEPRAZOLE [PRILOSEC] - 20 mg [**Hospital1 **]
OXYCODONE - 5 mg q 3-4 hours prn pain
PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg q8hrs prn nausea
VALSARTAN [DIOVAN] - 160 mg qd
ZOLEDRONIC ACID [ZOMETA] - (infusion in clinic) - 4 mg/5 mL
Solution - monthly
ACETAMINOPHEN [TYLENOL] - 325 mg by mouth daily
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER]
SENNOSIDES-DOCUSATE SODIUM [PERI-COLACE] - 8.6 mg-50 mg [**Hospital1 **]
.
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD (): 12 hours on, 12
hours off. Apply to knee. .
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: For 10 day total. .
Discharge Disposition:
Extended Care
Facility:
Bay [**Hospital **] Rehab
Discharge Diagnosis:
Breast Cancer
L hydronephrosis
Anemia, hematuria
Possible urosepsis
Discharge Condition:
Good, ambulating, stable BP.
Discharge Instructions:
You were admitted for low blood pressure and weakness. You were
monitored in the ICU, started on antibiotics and a tube was
placed to drain your kidney.
.
Attend all your follow-up appointments.
.
Follow your discharge medication list closely.
.
Return to the ER if you experience fever, chills, abdominal
pain, difficulty breathing, passing out or other concerning
symptoms.
Followup Instructions:
You need to follow-up with urology, Dr. [**Last Name (STitle) 770**], in [**1-13**] weeks.
We were unable to schedule you the appointment, please call
([**Telephone/Fax (1) 7707**] to make an appointment. It is very important you
follow-up with Urology regarding your stent.
.
Schedule an appointment with your primary care doctor,
[**Doctor Last Name 43792**],TALIN [**Telephone/Fax (1) 3183**], in [**12-11**] weeks.
Completed by:[**2162-1-24**]
|
[
"5990",
"2724",
"4019"
] |
Admission Date: [**2179-2-26**] Discharge Date: [**2179-3-5**]
Date of Birth: [**2127-7-26**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
right flank pain/large vascular lesion arising from segment VI
Major Surgical or Invasive Procedure:
segment V-VI resection, ccy, wedge liver biopsy [**2179-2-26**]
History of Present Illness:
51 y.o. female who developed right flank pain after falling on
the ice bruising her righ hip and right side. Pain worsened. She
was seen by PCP and [**Name Initial (PRE) **] CT of the abd was done revealing a large
mass measuring 12.5x8.2x6.7 cm arising from the right lobe of
the liver. There was heterogeneous enhancement throughout most
of the mass and its inferior aspect. There was also a 3.2x2.2 cm
area of lower density, probably representing a cystic
degeneration. Another low density fluid consistent with
subcapsular hemorrhage measured 5.5x6cm. There was concern for
ruptured and bleeding HCC. She initially saw Dr. [**Last Name (STitle) **] then was
referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. A triphasic CT was done to better
define these areas. Dr. [**Last Name (STitle) **] discussed indication fo rsegment
VI resection and /or right hepatic lobectomy.
Past Medical History:
cervical ca in [**2151**]
benign breast tumor s/p resection
partial hysterectomy [**2151**], ovaries still in place
Hypothyroidism
Depression
Social History:
Married. Has high school education. Works as housecleaner. She
has three adult children
Family History:
Maternal grandfather died of stomach CA
[**Name (NI) 6961**] alive with HTN
Physical Exam:
Well appearing, 66 in, 55kg
Neck FROM
RRR, I/VI sys Murmur
Lungs clear B
Ext-no edema
Pertinent Results:
[**2179-2-26**] 05:11PM freeCa-1.10*
[**2179-2-26**] 05:11PM HGB-11.1* calcHCT-33
[**2179-2-26**] 05:11PM GLUCOSE-132* LACTATE-4.5* NA+-133* K+-4.2
CL--106
[**2179-2-26**] 06:08PM PT-13.9* PTT-26.6 INR(PT)-1.2*
[**2179-2-26**] 06:08PM PLT COUNT-262
[**2179-2-26**] 06:08PM WBC-11.3*# RBC-3.56* HGB-10.8* HCT-31.9*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.5
[**2179-2-26**] 06:08PM ALT(SGPT)-202* AST(SGOT)-207* ALK PHOS-58 TOT
BILI-0.6
[**2179-2-26**] 06:08PM GLUCOSE-171* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12
Brief Hospital Course:
She underwent Segment V-VI resection, CCY, IOUS, wedge bx of
liver nodule, wedge bx to research on [**2179-2-26**] by Dr. [**First Name (STitle) **] W.
[**Doctor Last Name **]. EBL was 350cc. OR findings were as follows "the patient
had a large hard mass arising from segment 5, segment 6 of
the liver. There were multiple small satellite nodules adjacent
to the mass as well as multiple other nodules in the right lobe
and medial segment. There were no palpable nodules in the left
lateral segment. Intraoperative ultrasound confirmed these
findings. The patient also did have a small 1 cm cavernous
hemangioma in the dome of the right lobe of the liver. The mass
was densely adherent to the transverse colon near the hepatic
flexure as well as to the omentum." Please see OR report for
further details.
Postop, hct was 31.9. The JP was draining serosang drainage. She
experienced a good deal of pain despite epidural. A bolus of
lidocaine was given as well as iv morphine and ativan with
decreased pain. Morphine was changed to dilaudid for breakthru.
She continued to experience incisional pain and toradol was
started for 2 days. On [**3-1**], the epidural was removed and iv
dilaudid pca was started with good relief of pain. Diet was
slowly advanced and tolerated. The foley was removed on pod 2.
LFTs trended down. The incision remained c/d/i and her abd was
mildly distended, soft with +bowel sounds. The JP continued to
drain ~ 95 to 78cc/day.
On pod 5, the pca was d/c'd after starting oxycodone. On [**3-3**] a
24 hour urine was started to check 5-HIAA and a serum serotonin
and chromogran were sent given neuroendocrine features seen on
liver bx. Final pathologic diagnosis was confirmatory of
hepatocellular carcinoma with ? vascular invasion.
Vital signs were stable and she was ambulatory. She was
discharged home on [**3-5**] in stable condition.
Medications on Admission:
Levoxyl 75', Celexa 10', Wellbutrin 300', Calcium, Magnesium
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
multifocal hepatocellular carcinoma in liver
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, incision redness/drainage or increased abdominal pain,
jaundice (yellowing of skin/eyes) or any questions.
[**Month (only) 116**] shower
No driving while taking pain medications.
Take stools softeners while taking pain medications
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-3-9**] 11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2179-3-5**]
|
[
"4019",
"2449"
] |
Admission Date: [**2150-11-2**] Discharge Date: [**2150-11-10**]
Date of Birth: [**2070-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o M with questionable seizure disorder, Parkinson's on
sinemet, recently diagnosed UTI on ciprofloxacin transferred
from OSH following witnessed tonic clonic seizures x 2.
.
Per medical records, patient c/o progressive right lower
extremity weakness with painful leg spasms x 2- 3mths. Due to
impaired mobility, he was unable to take care of himself at home
and had several subsequent falls. Also according to notes, he
was displaying increasingly aggitated behavior/ unstable mood.
He initially presented to an OSH on [**10-21**] and was evaluated with
negative CT head and MRI spine. His symptoms were attributed to
parkinson's dx and his dose of sinemet was increased. He was
discharged to a nursing home.
.
At his nursing home, 2 days prior, he was noted to have cloudy/
foul smeeling urine and was dx with pansensitive citrobacter
UTI, and started on ciprofloxacin. This afternoon, he had
witnessed tonic clonic seizures x 2 lasting less than 2 min each
at NH. He was initially brought to an OSH and sent to [**Hospital1 **] for
neurologic evaluation.
.
VS at [**Hospital1 18**]: were T 97.4 HR 107 BP 118/73 RR 18 SpO2 100% 2L.
His exam was notable for poor attention and confusion with
initial labs revealing leukocytosis to 24.9 with grossly
positive U/A. Due to recent seizure activity, he was placed in a
c- collar and cleared with a CT c-spine with clinical exam.
Neurology evaluated patient in ED and felt that most of his
symptoms were due to his underlying infection.
Past Medical History:
Parkinsonism
Anxiety
HTN
Seizure Disorder
Social History:
Recently moved to nursing home. His [**Age over 90 **] y/o mother is his
healthcare proxy and former primary caregiver. [**First Name (Titles) **] [**Last Name (Titles) **], smoking
or IVDA.
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
VS: Temp: 97.4 HR: 107 BP: 118/73 RR: 18 SaO2: 100% 2L
GEN: elderly, chronically ill appearing male
HEENT: Masked facies, b/l erythematous conjunctiva with purulent
discharge around R eye, PERRL, EOMI, anicteric. Dry oral mucosa
with dentures in place and moderate amt dried mucus secretions
plastered to upper palate
NECK: trachea midline, JVP at base of neck
RESP: CTA b/l with good air movement throughout
CV: tachycardic S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e +2 DP pulse
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx2 (not to place- thought [**Hospital3 **]). R sided
facial droop. Strength 4/5 right upper and lower extremity.
Grosly intact to light touch. +3 DTR throughout right with
upgoing toes. Dysmetria on FNF
.
Discharge Exam:
VS: Tm 97.8, Tc 97.0, BP 140-160/70-74, HR 81-82, RR 20, SO2 96%
GEN: elderly male in NAD
HEENT: conjunctivae clear with no erythema
NECK: trachea midline, JVP at base of neck
RESP: unlabored breathing, CTAB
CV: RRR, normal S1, S2
ABD: S/NT/ND, BS+
EXT: warm, 2+ peripheral pulses
NEURO: masked facies, AAOx3, CN II-XII intact, strength 5/5 on
the left and [**4-13**] on the right, cogwheel rigidity present,
sensation intact, with dysmetria on FNF
Pertinent Results:
Initial Results:
.
[**2150-11-2**] 06:20PM WBC-24.9* RBC-3.95* HGB-12.7* HCT-36.9*
MCV-93 MCH-32.2* MCHC-34.5 RDW-12.8
[**2150-11-2**] 06:20PM NEUTS-95.0* LYMPHS-2.6* MONOS-2.1 EOS-0.1
BASOS-0.2
[**2150-11-2**] 06:20PM PLT COUNT-187
[**2150-11-2**] 06:20PM PT-13.7* PTT-26.3 INR(PT)-1.2*
[**2150-11-2**] 06:20PM GLUCOSE-110* UREA N-30* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
[**2150-11-2**] 07:20PM URINE MUCOUS-MOD
[**2150-11-2**] 07:20PM URINE RBC-21-50* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2150-11-2**] 07:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2150-11-2**] 07:20PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012
[**2150-11-2**] 08:52PM LACTATE-1.7
.
Microbiology:
.
Urine Culture ([**10-31**], OSH): Citrobacter UTI (pansensitive)
.
EKG ([**11-2**]): Sinus tachycardia. Left axis deviation. T wave
abnormalities. No previous tracing available for comparison.
.
Imaging:
.
CT C-Spine ([**11-2**]):
1. No acute fracture.
2. Minimal retrolisthesis of C3 on C4 may be degenerative but is
age-indeterminate and clinical correlation is advised.
3. Tracheal secretions may predispose to aspiration.
.
CT Head Without Contrast ([**11-2**]) (REPORT FROM OUTSIDE HOSPITAL):
Chronic-appearing bilateral lacunar infarcts with no
intraparrenchymal hemorrhage or extra-axial fluid collections.
No mass effect or midline shift.
.
Interval Results:
.
[**2150-11-4**] 05:40AM BLOOD calTIBC-142* Ferritn-894* TRF-109*
[**2150-11-4**] 05:40AM BLOOD %HbA1c-5.1 eAG-100
[**2150-11-4**] 05:40AM BLOOD Triglyc-89 HDL-37 CHOL/HD-2.4 LDLcalc-35
[**2150-11-5**] 06:22AM BLOOD CRP-39.0*
.
Lower Extremity U/S ([**11-3**]):
Acute DVT involving right posterior tibial veins.
.
EEG ([**11-4**]):
This is an abnormal routine EEG in the waking and drowsy
states due to the slow 8 Hz posterior predominant rhythm which
may be
seen in generalized encephalopathy such as due to medications,
ischemia,
or toxic/metabolic etiologies, as well as medication effect.
There were
no focal, lateralized, or epileptiform features noted.
.
MRA Brain Without Contrast/MR [**Name13 (STitle) 430**] With and Without
Contrast([**11-4**]):
1. Two heterogeneously enhancing lesions in the left parietal
lobe
subcortical white matter, the larger one measuring 3.2 x 2.8 x
3.9 cm with
mild-to-moderate surrounding edema without significant mass
effect.
Differential diagnosis includes primary glial neoplasm vs
metastasis/
lymphoma. Other etiologies such as inflammatory or subacute
infarction are
less likely given the thick rind of tissue in the periphery. To
correlate
clinically and consider neurosurgical consult.
2. Patent major intracranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm more than 2 mm
within the resolution of MR angiogram. Mild atherosclerotic
disease involving the Basilar, internal carotid, and the MCA
branches without flow-limiting stenosis.
.
CXR ([**11-8**]): Patchy opacity left base. This finding is similar,
but slighlty more prominent, than on an outside film dated
[**2150-11-2**] that has been scanned into PACS.
.
Lower Extremity U/S ([**11-9**]): Thrombus now visualized in the
right popliteal vein as well as the posterior tibial and
peroneal veins on the right.
.
Discharge Labs:
.
[**2150-11-10**] 06:19AM BLOOD WBC-8.8 RBC-3.27* Hgb-10.3* Hct-30.9*
MCV-94 MCH-31.5 MCHC-33.4 RDW-13.2 Plt Ct-373
[**2150-11-10**] 06:19AM BLOOD Glucose-94 UreaN-18 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-30 AnGap-9
[**2150-11-10**] 06:19AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
Brief Hospital Course:
80 year-old male with Parkinson's disease, a questionable
history of a seizure disorder and a recently diagnosed UTI being
treated with Ciprofloxacin who was transferred from an OSH
following two witnessed tonic clonic seizures.
.
1. Tonic-Clonic Seizures: On admission there was report of a
history of seizure disorder with recent witnessed epileptic
activity in setting of likely infection and medication known to
lower seizure threshold. The patient was confused on arrival to
the ED which was attributed to a post-ictal state with CT scan
at OSH showing no evidence of stroke and no significant
metabolic derangement on laboratory testing. The patient was
admitted to the ICU and started on Keppra for seizure
prophylaxis by neurology recommendations and his antibiotic was
changed to Ceftriaxone. His mental status was significantly
improved the morning after admission. The patient was
subsequently transferred from the ICU to the medicine service.
As part of the patient's seizure workup, an MRI was ordered
which revealed two heterogeneously enhancing lesions in the left
parietal lobe, with suspicion for a malignant glioma. An EEG
revealed diffuse slowing consistent with encephalopathy but no
epileptiform activity was noted. The information was presented
to the patient and given the progressive nature of his
Parkinson's disease and debilitated state he chose not to
undergo any further evaluation of the brain lesions. The patient
clearly expressed the risks of not pursuing any further
evaluation or treatment and was willing to accept the
consequences. The patient was discharged on Keppra 500 mg twice
a day for seizure prophylaxis which was the dose started on
admissionto [**Hospital1 18**].
.
2. Right Lower Extremity DVT: Several days into his admission,
the patient developed right lower extremity erythema and
swelling. A lower extremity ultrasound was performed and
revealed a right posterior tibial vein thrombosis. Vascular
surgery was consulted and recommended repeat ultrasound in 48
hours. Repeat ultrasound revealed presence of the thrombosis in
the right peroneal and right popliteal veins in addition to the
original location. Vascular surgery was again contact[**Name (NI) **] and an
IVC filter was placed without complication. Post-procedure
evaluation did not reveal any hematoma or venous hum at the
site. Vascular surgery reported that this patient would not be a
candidate for IVC filter removal and that no follow-up was
necessary.
.
3. Urinary Tract Infection: The patient was admitted two days
into a course of Ciprofloxacin for a urinary tract infection
that was culture positive for Citrobacter, which was
pan-sensitive. Given the neurological complications associated
with Ciprofloxacin in the elderly, the patient was switched to
Ceftriaxone. The patient completed a total of 10 days of
antibiotics (from the start of the Ciprofloxacin) as an
inpatient. Of note, the patient was transferred to the medicine
service with a foley in place but was discontinued. The patient
subsequently failed to void, was started on Tamsulosin for
presumed BPH and the foley was replaced. Two days later the
patient failed to void once again and was found to have 700 cc
of urine on bladder scan. The foley was again replaced and was
present at discharge. Given the patient's urinary retention
observed as an inpatient, it is likely that this contributed to
the development of his urinary tract infection. ** The foley may
be possible to discontinue as an outpatient and another trial is
likely warranted. **
.
4. Aspiration Risk: The patient was evaluated by speech and
swallow in the ICU and was started on a dysphagia diet and
nectar-thickened liquids due to high aspiration risk. The
patient repeatedly expressed interest in eating a regular diet.
The patient again failed a bedside evaluation. It was decided
that while inpatient that he should remain on the recommended
diet. The patient clearly understood the risks of eating a
regular diet and drinking normal liquids, particuarly that
aspiration was high likely. He stated that given his underlying
illness he would assume the risk. ** The patient again expressed
interest in eating a regular diet at discharge, understood the
risks and demonstrated clear capacity to make his own decisions.
This should be re-addressed as an outpatient but the patient
should likely be allowed to eat the diet he wishes. **
.
5. Right-sided Weakness: The patient reported chronic
right-sided weakness on presentation that most likely
represented an old neurologic deficit from his prior CVA that
was exacerbated by worsening malnutrition and acute illness. The
patient's listed PCP was called to discuss the patient's
baseline, however the PCP had only known the patient for the
several days that he was at the nursing home, and could not
provide much background information. The patient was continued
on Sinemet although it seemed unlikely that Parkinson's disease
was a major contributor to this particular problem.
.
6. Parkinson's Disease: The patient was admitted on Sinemet for
his Parkinson's disease of unknown duration. The patient had
masked-facies and bradykinesia with some cogwheel rigidity of
the upper extremities on examination. The patient was continued
on his Sinement during this hospitalization without problem.
.
7. Leukocytosis: The patient had a normal white count on
transfer to the. Several days into his stay on the medicine
floor, the patient's white count was elevated to 13. The patient
reported a new cough that was concerning for a possible
aspiration event. A chest x-ray revealed a patchy left lower
lobe opacity that was possibly increased over an outside film
scanned into the [**Hospital1 18**] system and likely represented atelectasis
vs possible early infectious infiltrate. The patient had a known
UTI as per above. Given the location of the infiltrate on chest
x-ray, there was low suspicion for an aspiration event but one
could not be ruled out definitely. Given that the patient was
already on a third generation cephalosporin and clinical
suspicion was low for another infectious process, no additional
antibiotic coverage was added. The following day the patient's
white count was down to 11.3 and was 8.8 the following day, the
morning of discharge.
.
8. Anemia: The patient's hematocrit was 37 on admission. The
patient received vigorous hydration in the ICU prior to transfer
to the medicine floor and his hematocrit declined to 32.8 at
time of transfer to the medicine service. Given his poor oral
intake, the patient was continued on intermittent fluids on the
floor. His hematocrit stabilized at approximately 30 and
remained so for the next eight days until the time of discharge.
The patient was guaiac negative. Iron studies were ordered and
were consistent with anemia of chronic disease (calTIBC 142,
Ferritin 894, TRF 109) which was consistent with the patient's
underlying disease process.
Medications on Admission:
1. Carbidopa-Levodopa - 25-100 1 Tablet(s) Four times daily
2. Cyanocobalamin (vitamin B-12) - 100 mcg 1 Syringe(s) monthly
3. Tylenol
4. Mylanta prn
5. Biscodyl
6. Ciprofloxacin: started yesterday 250 mg [**Hospital1 **] for a UTI
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. cyanocobalamin (vitamin B-12) Injection
3. Tylenol Oral
4. bisacodyl 5 mg Tablet Oral
5. Mylanta Oral
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. Levetiracetam 500 mg tablet, Sig: One (1) tablet by mouth
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**]
Discharge Diagnosis:
Primary Diagnosis:
Seizures
Brain tumor (likely malignant glioma but there is no tissue
diagnosis)
.
Secondary Diagnoses:
Parkinsonism
Hypertension
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **]:
.
You were admitted to [**Hospital1 18**] after experiencing several seizures.
An imaging study of your brain was performed that revealed
several tumors. After lengthy discussions with you, it was
decided that you did not want to pursue further treatment.
Although you do not want to have treatment of your tumors, you
have been given medication to help prevent the seizures that the
tumors are likely causing. Also, on admission to the hospital
you were being treated for a urinary tract infection with an
antibiotic called Ciprofloxacin. As this medication can be
associated with neurological side-effects in elderly
individuals, you were changed to another antibiotic called
Ceftriaxone. You completed your course of this antibiotic in the
hospital and will not need any further antibiotics.
.
The following changes have been made to your medications:
.
1. Start Keppra 500 mg by mouth twice a day, in the morning and
in the evening. This medication will help prevent seizures.
2. Start Vitamin D 400 unit tablet. Take one tablet twice a day.
3. Start Calcium carbonate 500 mg tablet. Take one tablet by
mouth three times a day.
4. Start Tamsulosin 0.4 mg tablet by mouth. Take one tablet by
mouth at night. This medication will help prevent urinary
retention.
5. Stop Ciprofloxacin. You completed your course of antibiotics
in the hospital for your urinary tract infection.
.
No other changes were made to your medications. You should
continue taking all other medications as previously prescribed.
Followup Instructions:
Please follow-up with your outpatient physicians as you feel
appropriate.
Completed by:[**2150-11-11**]
|
[
"5990",
"4019"
] |
Admission Date: [**2107-2-27**] Discharge Date: [**2107-3-19**]
Date of Birth: [**2034-3-20**] Sex: F
Service: Surgery
HISTORY OF PRESENT ILLNESS: The patient presented on [**2-27**] with a 4-week history of progressive malaise, anorexia,
nausea, diarrhea, and food intolerance. Finally, on the day
of admission, she experienced postprandial emesis. She had
been treating the diarrhea with Imodium and noted fevers and
a 20-pound weight loss over the past weeks. She denied any
abdominal distention.
On the day of admission, she developed the acute onset of
right-sided abdominal pain which brought her to the Emergency
Department.
PAST MEDICAL HISTORY:
1. Fibromyalgia.
2. Hypothyroidism.
3. Recurrent diverticulitis.
4. Parotid cancer with radiation therapy.
5. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: (Her past surgical history included)
1. Excision of a right parotid tumor.
2. Total hip replacement on the right.
3. Low anterior resection of sigmoid colon and partial
rectum for recurrent diverticulitis.
4. Inguinal hernia repair.
5. Repair of a uterine prolapse in the past.
MEDICATIONS ON ADMISSION: Medications on admission included
Prevacid, Synthroid, trazodone, Imodium as needed.
ALLERGIES: She had an allergy to X-RAY DYE (which caused
itching) and was sensitive to SOME SOAPS and DETERGENTS.
SOCIAL HISTORY: She had a significant smoking history, which
she had quit, and rare alcohol intake.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
presentation were 100.4 F., heart rate of 112, blood pressure
was 106/65, breaths 20 and oxygen saturation was 97% on room
air. Her physical examination at that time was notable for a
soft abdomen which was obese, a midline surgical incision,
and bilateral lower quadrant tenderness. Her rectal
examination was guaiac negative.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her
laboratories at the time of admission revealed complete blood
count with a white blood cell count of 5, hematocrit was
35.7, and platelets were 431. The differential on the white
count with 69% neutrophils, 24 bands, and 2% lymphocytes.
Chemistry revealed sodium was 135, potassium was 3.8, blood
urea nitrogen was 25, creatinine was 0.8, and bicarbonate was
29. Liver function tests were drawn and were within normal
limits.
She had an abdominal x-ray which did not demonstrate free
air. She had no dilated loops.
Her urinalysis was positive for nitrites, 3 to 5 white blood
cells, and 6 to 10 red blood cells. The albumin was noted to
2.3.
PERTINENT RADIOLOGY/IMAGING: She had an abdominal plain
x-ray which did not demonstrate free air. She had no dilated
loops.
HOSPITAL COURSE: At that time, it was decided to proceed
with an abdominal computed tomography scan which was notable
for free air and a thickened pylorus. At that point, the
patient was started on resuscitative fluids.
The patient had a nasogastric tube and was started broad
spectrum antibiotics and was emergently taken to the
operating room.
The patient was taken to the operating room on [**2-27**] and
had an exploratory laparotomy, a small-bowel resection times
two, lysis of adhesions, placement of a feeding jejunostomy
tube, and repair of a ventral hernia primarily.
Intraoperative findings were that of diffuse peritonitis with
purulent succus entericus and ascites, multiple intra
abdominal thick adhesions, a ventral hernia, and perforated
jejunum at the site of jejunal diverticula with ischemia
around it.
The patient had intraoperative cultures which ended up
growing multiple flora including alpha streptococcus,
Klebsiella, enterococcus, Morganella, Escherichia coli, some
yeast in her sputum, as well as yeast in her operating room
swab. She was maintained on broad spectrum antibiotics and
antifungals.
She required pressors around the time of her surgery. Her
postoperative course was also notable for large-volume
resuscitate, prolonged mechanical ventilation, and
malnutrition. Her antibiotic regimen was ampicillin,
gentamicin, Flagyl, and fluconazole; this was based on the
findings on Gram stain in the operating room and culture
data. She was supported nutritionally with total parenteral
nutrition and with initiation of tube feeds on postoperative
day four.
It was noted on postoperative day five, the lower portion of
the wound was opened for purulent drainage. On postoperative
day six, she became febrile with an elevated white blood cell
count. A computed tomography was obtained at that time which
showed a lot of postsurgical changes, but no drainable
collection.
On postoperative day 11, she was extubated after a
substantial amount of diuresis, and two days later she was
found to have a partial thrombosis of the right internal
jugular secondary to a central line. The line was removed,
and systemic heparinization was begun.
On postoperative day 14, tube feed like material appeared to
drain from the lower portion of the wound. A wound drainage
sump was placed, and the output from this (thought to be
fistula) was quite low. Another computed tomography of the
abdomen was obtained and resulted in the drainage of an
intra-abdominal abscess.
Three days later, on postoperative day 17, she was found
unresponsive in her chair requiring emergent intubation. Her
heparin was stopped. Her partial thromboplastin time was
never greater than 63.5.
An emergent computed tomography scan of the head was
performed which was significant for a large posterior fossa
bleed. A Neurosurgery consultation was obtained almost
simultaneously with the results of the computed tomography
scan. A ventriculostomy drain was placed without any
improvement in her neurologic function. She was
unresponsive.
As a result of this course of events, and multiple family
meetings, and with knowledge of the patient's wishes, it was
decided that the patient would be made comfort measures only.
She was extubated and shortly thereafter passed away. The
patient's body was sent for autopsy.
The date of the patient's death was [**2107-3-19**].
DISCHARGE/DEATH DIAGNOSES:
1. Perforated jejunum.
2. Jejunal diverticula.
3. Sepsis.
4. Pneumonia.
5. Intra-abdominal abscess.
6. Hemodynamic instability.
7. Ventilator-dependent pneumonia.
8. Ventilator-dependent respiratory distress.
9. Large posterior fossa intracranial hemorrhage with
subsequent cerebrovascular accident, subsequent herniation,
and death.
SECONDARY DIAGNOSES:
1. Enterocutaneous fistula.
2. Anemia (treated with blood transfusions); likely due to
chronic disease as well as volume loss.
3. Fibromyalgia.
4. Hypothyroidism.
5. Diverticulitis.
6. Parotid cancer.
7. Gastroesophageal reflux disease.
8. Ventral hernia.
9. History of low anterior resection.
10. History of incisional hernia repair.
11. History of hip replacement.
12. History of excision of parotid tumor.
CONDITION AT DISCHARGE: Death.
DISPOSITION: The patient underwent an autopsy.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2107-5-9**] 09:52
T: [**2107-5-9**] 10:18
JOB#: [**Job Number 9247**]
|
[
"2449"
] |
Admission Date: [**2107-2-21**] Discharge Date: [**2107-3-2**]
Date of Birth: [**2035-9-9**] Sex: F
Service: SURGERY
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / IV Dye, Iodine
Containing
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Cool, pulseless Right foot - R common femoral artery occlusion
found on CTA at [**Hospital3 **]
Major Surgical or Invasive Procedure:
[**2107-2-22**] Right iliofemoral popliteal embolectomy and thrombectomy.
[**2107-2-28**] PCI of the SVG-LAD with DES
History of Present Illness:
71 F with a complex pmh who presented to [**Hospital3 19345**] on [**2107-2-22**] c/o R leg pain. On exam she was found to
have cool, pulsless right foot and a CTA revealed a right CFA
occlusion. She was transfered to [**Hospital1 18**] for further evaluation
and intervention.
Of note the pt has a h/o PAD with a left fem-[**Doctor Last Name **] bypass and
subsequent angioplasty to the graft about a year ago. She was
admitted to [**Hospital3 **] in [**2106-12-21**] and had bilateral lower
extremity angiography for persistent bilateral LE claudication
symtptoms. Per the report, she had angioplasty of the fem-[**Doctor Last Name **]
bypass graft. Records also state that the angio showed
hemodynamically moderate Right common iliac artery stenosis and
moderate distal right superficial femoral artery and popliteal
artery.
Past Medical History:
DMII
Dyslipidemia
HTN
CAD
CHF
PVD
MI
Cirrhosis
GERD
Depression
Breast CA lump/XRT
H.pylori
Duodenal Ulcer
COPD
PFO
Anaphylactic rxn to iodinated contrast
Social History:
[**Doctor Last Name **] speaking - unable to read; lives with [**Doctor Last Name **] speaking
daughter, who does not read
Only english speaking/[**Location (un) 1131**] family member is daughter in law -
[**Name (NI) 2127**] ([**Telephone/Fax (1) 86176**]
Family History:
non contributory
Physical Exam:
VSS:
A&Ox3
WDWN in NAD at time of d/c
card: RRR
lungs: cta bilat
abd: obese with large panus, soft +bs, no m/t/o
skin: skin under panus moist with small excoriations
extremities: R groin wound clean and intact - small amount of
serosanginous drainage. LLE - warm and pink, no edema, fem/dp/pt
pulses palp RLE - warm and pink, DP/PT pulses palp.
Pertinent Results:
[**2107-2-28**] 04:12AM BLOOD WBC-10.3 RBC-2.93* Hgb-9.2* Hct-27.3*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.0 Plt Ct-336
[**2107-3-2**] 05:29AM BLOOD PT-22.8* PTT-35.2* INR(PT)-2.1*
[**2107-3-2**] 05:29AM BLOOD Glucose-62* UreaN-38* Creat-1.4* Na-140
K-3.7 Cl-104 HCO3-26 AnGap-14
SHOULDER (AP, NEUTRAL & AXILLARY) xray
Degenerative changes seen in the acromioclavicular joint.
[**2107-2-22**] TTE
The left atrium is mildly dilated. A small secundum atrial
septal defect is present. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Small secundum ASD. Normal global and regional
biventricular systolic function. Mild pulmonary hypertension.
[**2107-2-28**] Cardiac Cath
1. Native three vessel coronary artery disease.
2. Patent SVG-Diag-OM and SVG-RCA grafts.
3. Origin stenosis of the SVG-LAD graft.
4. Successful PCI of the SVG-LAD with DES.
5. Extensive left SFA disease.
Brief Hospital Course:
Ms. [**Known lastname 43357**] was transferred from an OSH on [**2107-2-21**] with acute
ischemia of her right
lower extremity and a CT angiogram which showed thrombus
involving the distal external iliac, common femoral and proximal
superficial femoral and deep femoral arteries. Upon transfer the
patient was in florid pulmonary edema (as a result of contrast
dye allergy), had EKG changes suggestive of an evolving MI and
was intubated. As a result, we decided to try to temporize with
IV heparin to see if she
would stabilize to the point where surgery could be avoided.
However, by the morning of [**2107-2-22**], it was clear that her foot
was not really improving, it was dusky, somewhat mottled in
appearance although the muscles were very soft and we
decided in spite of the high risk situation to proceed with
embolectomy. She was taken to the OR and underwent Right
iliofemoral popliteal embolectomy and
thrombectomy. She tolerated the procedure well and was
transferred back to the CVICU on a heparin gtt in stable
condition. Coumadin was initiated and she remained on heparin
until a therapeutic INR was reached. An echo was obtained on [**2-22**]
and was normal with an EF >55% without sign of thrombus. Ms.
[**Known lastname 43357**] was monitored closely and was not felt stable for
extubation until [**2107-2-24**]. She was transferred to the VICU and
began taking po's on [**2-24**] as well.
The pt had atrial fibrillation on [**2-24**] which initially resolved
with iv lopressor. She did have several other episodes of afib
and was eventually rate controlled with beta blocker. Given the
initial ekg changes, rising troponins and afib, and strong
cardiac hx, a cardiology consult was obtained. They advised
continued heparin gtt, aggressive beta blockade, addition of an
ace inhibitor, serial ekgs and troponins. On [**2107-2-28**] her INR was
reversed with FFP and she was taken for a cardiac cath. She was
found to have stenosis of the SVG-LAD graft and underwent
successful PCI of the SVG-LAD with DES. She tolerated the
procedure well. Although initially anticoagulated for her
iliofemoral thrombus, it is also indicated given her atrial
fibrillation. She was restarted on coumadin with a goal INR of
2.0-3.0
On [**2-25**] the bedside nurse noted the pt had difficulty swallowing
and a speech/swallow consult was obtained. It was recommended
that the pt be NPO until further evaluation. However, on [**2-26**] the
pt did take some po's with nursing supervision and tolerated
without difficulty. A speech re-evaluation later confirmed that
the pt was taking po's without difficulty.
Also on [**2-25**] Ms. [**Known lastname 43357**] complained of Right shoulder pain and
reported that she fell and "broke" it several weeks prior. A
should xray and orthopedics consult were obtained. Found to have
a remote rt humeral head fracture which is non operable at this
time. They recommended active and passive ROM as tolerated and
sling as needed for comfort. Pt felt she did not need the sling
at this time. She should f/u in [**Hospital 3782**] clinic in [**4-26**] weeks.
Ms. [**Known lastname 43357**] continued to improve through out the remainder of
her stay. She remained hemodynamically stable and chest pain
free after her stent. She worked with physical therapy and was
able to ambulate with assistance. She was tolerating a regular
diet and voiding without difficulty. On [**2107-3-2**] she was deemed
stable for discharge to home with family.
She is discharged with a VNA and eval for home PT. I have spoken
to her daughter in law who is the only family member that can
read. I have reviewed the instructions with her, and will also
review with the pt and son via a [**Name (NI) 8003**] interpreter prior to
discharge. I have spoken to the nurse at her primary care and
cardiologists office. The PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16968**] will follow her PT/INR
and see her in clinic next week. Her cardiologist, Dr.
[**Last Name (STitle) 86177**] will see her in 2 weeks.
Medications on Admission:
lipitor 80 qd
plavix 75 qd
lisinopril 10 qd
asa 325 qd
amlodipine 10 qd
furosemide 80 qd
prilosec 20 qd
humalog 75/25 70am, 60pm
zoloft 100 qd
calcitriol 0.25 m/w/f
ultram 50 tid
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 12 months: you will take this for 1 year.
Disp:*30 Tablet(s)* Refills:*11*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for life.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): home med.
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
home med.
5. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
home med.
6. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day: use
this in place of prilosec.
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: you must have your blood monitored.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
home med.
9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 70
units in the morning, 60 units at night with meals Subcutaneous
twice per day with meals: resume your home dose of this
medication.
10. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
mon weds fri.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain: this is over the counter
tylenol.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs 1 mo supply* Refills:*2*
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: over the counter.
16. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary: Acute ischemia of right lower extremity
Secondary:
- Anticoagulation
- New Onset Afib ([**2106-2-21**])
-CAD with stenosis of the SVG-LAD graft
-Remote Rt humeral head fracture found on this admission
-DMII
-Dyslipidemia
-HTN
-PVD
-Cirrhosis
-GERD
-Depression
-Breast CA lump/XRT
-H.pylori
-DU
-COPD
-PFO
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a blood clot in one of the major arteries (blood
vessels) in your right leg. You had a surgery to remove the
clot. You will need to be on a medicine to thin your blood for
the rest of your life. This medication is called COUMADIN or
WARFRIN. Please see the information sheet which has been
printed for you. It is very important that you have a special
blood test called PT/INR while on this medication. Your primary
care physician
You also were found to have significant narrowing in one of the
coronary bypass grafts in your heart. You had a drug eluding
cardiac stent placed in this artery to keep it opened. You will
need to take Plavix x 1 year, and aspirin forever for this.
Division of Vascular and Endovascular Surgery
Discharge Instructions
Please call our office if you have any questions
Phone:[**Telephone/Fax (1) 1237**]
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
?????? 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 [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk
?????? 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
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower-let the soapy water run over incision, rinse
and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
for the rest of your life
Take Plavix 75mg daily for 1 year
?????? Keep your follow up appointments with your surgeon,
cardiologist and primary care physician
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
Followup Instructions:
Primary Care:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16968**]
[**Name (STitle) **] [**3-8**] 2:45pm
[**Hospital **] Medical Assocs Riverwalk
[**Hospital1 86178**], [**Numeric Identifier 59250**]
Phone Number:([**Telephone/Fax (1) 86179**]
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD
[**Hospital1 **] - [**Location (un) 86**]
[**Hospital Unit Name 86180**]
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2107-3-10**] 1:00
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86177**]
1 Parkway [**Location (un) **], MA
[**Telephone/Fax (1) 86181**]
Weds [**3-16**] 145pm
Orthopedics:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 86182**]
[**Hospital3 **] [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Building
[**Telephone/Fax (1) 79748**]
[**4-14**] 1045am
PT/INR: Followed by Dr. [**Last Name (STitle) 16968**] office.
The blood will be drawn by the VNA and the results sent to Dr.
[**Last Name (STitle) 16968**] office. His staff will call you and tell you how to
adjust the coumadin dose.
Completed by:[**2107-3-2**]
|
[
"41401",
"25000",
"496",
"4280",
"4019",
"53081",
"42731"
] |
Admission Date: [**2132-2-17**] Discharge Date: [**2132-2-20**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is an
82-year-old female with a past medical history significant
for coronary artery disease, status post cardiac
catheterization at [**Hospital1 69**] in
[**2125**] showing 70% LAD, status post PTCA, diabetes mellitus
with neuropathy and nephropathy, hypertension, presenting to
[**Hospital3 3583**] on [**2132-2-14**] with nausea, vomiting,
and chest pain for several days.
On presentation to [**Hospital3 3583**], blood pressure was
181/93, respiratory rate 13, temperature 101.2, fingerstick
283.
Initial EKG showed the rate of 115, atrial fibrillation, left
axis deviation consistent with left anterior hemiblock, ST
depression 1 to 2-mm anterolaterally and T wave inversion
inferiorly.
Per the admission history and physical at [**Hospital3 3583**],
the patient's ST segment changes were about the same as in
[**2131-12-13**]. The patient was started on Heparin, IV
Nitroglycerin, Levaquin for faint bilateral infiltrates on
chest x-ray. Also, in the emergency department at [**Hospital3 6265**], the patient was given charcoal for possible
medication ingestion because the patient was slightly
confused. Head CT was negative and serum toxicology screen
was negative.
At [**Hospital3 3583**] initial cardiac enzymes were as follows:
CK #1: 250, CK #2: 246. CK #3: 136. Troponin was 1.34
(normal less than 0.4) MB fraction 5.7 to 6. Followup EKG
during the hospitalization showed questionable prolonged QT
interval and, therefore, Zoloft and Levaquin were
discontinued.
On the morning of [**2132-2-17**], the patient developed
more chest pain, unrelieved with Nitroglycerin. The patient
was given IV Morphine and Aggrastat IV. The EKG showed
normal sinus rhythm with rate of 62, normal axis, T-wave
inversions anterolaterally and inferiorly.
The patient was transferred to [**Hospital1 188**]. On transfer to [**Hospital1 69**],
the patient was chest-pain free.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post cardiac
catheterization at [**Hospital1 69**] in
[**2125**], showing 70% LAD lesion, with PTCA of the lesion and 20%
residual stenosis.
2. Type 2 diabetes mellitus complicated by nephropathy and
neuropathy. The patient requires a walker at home.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. History of urinary tract infection.
6. Depression.
7. Stress urinary incontinence.
The last echocardiogram was done on [**2132-1-2**]
showing a normal ejection fraction with mild inferior
hypokinesis.
ALLERGIES: The patient is allergic to TEGRETOL.
MEDICATIONS ON TRANSFER:
1. Aspirin 325 mg p.o. q.d.
2. Lopressor 50 mg p.o.b.i.d.
3. Neurontin 300 mg p.o.q.d.
4. Lasix 80 mg p.o.q.d.
5. Lisinopril 20 mg p.o. b.i.d.
6. Protonix 40 mg p.o.q.d.
7. Ditropan XL 10 mg p.o.q.d.
8. Humulin 70/30, 14 units subcutaneously q.a.m.
9. Multivitamin one p.o.q.d.
10. Potassium chloride 20 mEq p.o.b.i.d.
11. Valsartan 80 mg p.o.b.i.d.
12. Percocet.
FAMILY HISTORY: The patient denied a family history of
coronary artery disease.
SOCIAL HISTORY: The patient denied social or alcohol use.
The patient has three children.
PHYSICAL EXAMINATION: Examination on admission revealed the
vital signs of a temperature 98.6, heart rate 53, respiratory
rate 15, blood pressure 115/50, mean arterial pressure of 72,
96% room air, oxygen saturation. GENERAL: The patient is an
elderly female, who is in no acute distress and comfortable.
HEAD AND NECK: Pupils equal, round, and reactive to light.
Oropharynx clear. No jugular venous distention. Brisk
carotid upstroke. CARDIOVASCULAR: Regular rhythm,
bradycardia, normal S1 and S2. No S3 or S4. No murmurs.
LUNGS: Crackles bilaterally ?????? of the way up; good aeration.
ABDOMEN: Good bowel sounds in all four quadrants. Minimal
tenderness to deep palpation of the lower quadrant. GROIN:
No bruits. EXTREMITIES: 1+ edema bilaterally up to the
knees, 1+ dorsalis pedis pulses bilaterally, 0-1 PT pulse
bilaterally.
LABORATORY DATA: Laboratory data revealed the following:
Admission labs at [**Hospital3 3583**] were as follows: White
blood cell count 15.9, hematocrit 40.6, platelet count
230,000, 76 neutrophils, 12 basophils, 6 lymphocytes. PT and
PTT, INR were 11.5, 24, 1.0. Urinalysis showed no leukocyte
Estrace, no nitrates, 0 to 1 white blood cell count. Chem 7
showed the sodium of 139, potassium 3.5, chloride 101,
bicarbonate 28, BUN 19, creatinine 1, glucose 159.
FOLLOW-UP LABS: Follow up labs at [**Hospital3 3583**] revealed
the following: A drop in the hematocrit from 40.6 on
admission to 33.4 on [**2132-2-17**].
Admission labs at [**Hospital1 69**] were
as follows: WBC 7.6, hematocrit 33.8, platelet count
234,000, 62% neutrophils, sodium 132, potassium 4.1, chloride
97, bicarbonate 27, BUN 20, creatinine 1.4, glucose 124, PT
12.6, PTT 63.6, INR 1.1. The EKG at [**Hospital1 190**] showed T-inversions anteriorly in V1 through
V3 and inferiorly; normal sinus rhythm; normal axis.
HOSPITAL COURSE: The impression was that this was an
80-year-old female with a history of coronary artery disease
status post PTCA to LAD in [**2125**], type I diabetes mellitus,
hypertension, transferred from an outside hospital,
presenting with angina, elevated troponin. The patient was
admitted from an outside hospital with non-ST segment
elevation MI. The patient was transferred for a cardiac
catheterization.
#1. CARDIOVASCULAR: Ischemia. The patient was chest-pain
free when admitted to the hospital. The patient was
continued on Heparin, IV Nitroglycerin, and Aggrastat IV.
The patient was continued on antihypertensive regimen on
transfer with the exception of the Valsartan, as the patient
was already on an ACE inhibitor. Cardiac enzymes were cycled
and noted to have trended down from an outside hospital.
Cardiac catheterization was done on [**2-18**], showing
mildly elevated left ventricular and diastolic pressure (20)
no mitral regurgitation, normal left ventricular ejection
fraction, focal posterobasal hypokinesis. The patient had
multivessel PTCA. The LAD showed proximal diffuse disease to
maximum 80% stenosis and extending to ostial V2. The RCA had
proximal calcified 80% stenosis, mid 80% stenosis. The
patient had two stents placed in the proximal and distal LAD,
with no residual stenosis. The patient also had two stents
placed in the proximal RCA with 10 to 20% residual stenosis.
After cardiac catheterization, the patient was started on
Plavix and Aggrastat drip was continued until the morning
after cardiac catheterization. Post cardiac catheterization
hospital course was complicated by mucous membrane bleeding
for a short period (from nose, mouth), followed by abrupt
cessation. The patient was continued on Aggrastat without
further bleeding.
The patient's cardiac enzymes were cycled post cardiac
catheterization and were all negative.
The patient's antihypertensive regimen was modified as
follows during the hospital course: The patient was
continued on Lisinopril 40 mg p.o.q.d.; Lopressor 50 mg
t.i.d.; and Amlodipine 2.5 mg p.o.q.d. added for optimal
blood pressure control. The patient's systolic blood
pressures were noted to be mildly elevated (150s to 160s).
#2: CONGESTIVE HEART FAILURE: The patient was noted to have
crackles ?????? of the way up on admission. However, chest x-ray
showed no evidence of CHF, and clinically, the patient did
not have S3 or elevated jugular venous pressure. The patient
was continued on her standing dose of Lasix 80 mg p.o. q.d.
Oxygen saturations were followed and were within normal
limits throughout the hospital course with the patient not
requiring more oxygen above her baseline. As the admission
chest x-ray did not show any infiltrates and the patient did
not have the signs and symptoms of pneumonia, antibiotics,
which were started at the outside hospital were followed.
#3. RENAL: The patient's creatinine was noted to be 1.2 on
admission. With the patient's history of diabetic
nephropathy, Mucomyst was administered prior to cardiac
catheterization and the patient was given pre-catheterization
and post-catheterization hydration.
The patient's creatinine remained stable throughout the
hospital course.
The patient's sodium was noted to have fallen to 129 on the
morning after the cardiac catheterization presumably
secondary to IV fluid hydration pre-cardiac catheterization
and post-cardiac catheterization.
The patient was given one liter of IV normal saline with
return of sodium to baseline.
#4. INFECTIOUS DISEASE: The patient was started on
antibiotics at an outside hospital for presumed pneumonic
infiltrate on chest x-ray. However, on admission to [**Hospital1 1444**], the patient was not febrile
and had no clinical signs or symptoms of pneumonia.
Therefore, antibiotics were not continued.
The patient remained afebrile throughout the hospital course.
Urine culture was done and it was negative.
#5. GASTROINTESTINAL: The patient was continued on
Protonix.
#6: ENDOCRINE: The patient was continued on her diabetic
regimen of NPH 14 units subcutaneously q.a.m. regular insulin
sliding scale. The patient was given one half normal NPH
dose on the morning of cardiac catheterization as the patient
was NPO since the night prior.
#7: FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
given a cardiac diet during the hospital stay. Magnesium was
repleted during the initial part of the hospital stay.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is going for [**Hospital 3058**]
rehabilitation pending the nursing home placement. The
patient was diagnosed as status post non-ST elevation MI,
status post PTCA with four stents placed.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o.q.d.
2. Ditropan XL 10 mg p.o.q.d.
3. Humulin insulin 70/30 14 units subcutaneously q.a.m.
4. Multivitamin, one tablet p.o. q.d.
5. Regular insulin sliding scale.
6. Percocet one tablet p.o.q.4 to 6h.p.r.n. pain.
7. Aspirin 325 mg p.o.q.d.
8. Atenolol 50 mg p.o.q.d.
9. Neurontin 300 p.o.q.d.
10. Lasix 80 mg p.o.q.d.
11. Plavix 75 mg p.o.q.d.
12. Amlodipine 5 mg p.o.q.d.
13. Lipitor 10 mg p.o.q.d.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 12984**]
MEDQUIST36
D: [**2132-2-20**] 11:10
T: [**2132-2-20**] 11:14
JOB#: [**Job Number 40977**]
|
[
"41071",
"41401",
"4280",
"4019",
"53081"
] |
Admission Date: [**2172-2-16**] Discharge Date: [**2172-2-26**]
Date of Birth: [**2121-4-23**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
male with a history of diabetes mellitus status post
laparoscopic cholecystectomy on [**2-14**], who was
transferred from [**Hospital1 **] with hypotension, oliguria,
increased BUN and creatinine. He underwent cardiac
catheterization on [**2-11**], which was negative and then
underwent laparoscopic cholecystectomy on [**2-14**]. On
postoperative day #1, the patient was noted to have decreased
urine output and tachycardia with hypotension. On [**2172-2-15**], the patient underwent a computerized tomography
scan which showed no ductal dilatation and was negative for
free air. HIDA scan showed no excretion from the liver to
small bowel. There was a questionable common bile duct
obstruction. The patient was started on Levofloxacin and
Flagyl and transferred to [**Hospital6 2018**] for further workup.
PAST MEDICAL HISTORY: Diabetes mellitus, hypertension,
asthma, status post cardiac catheterization [**2-11**].
PAST SURGICAL HISTORY: Laparoscopic cholecystectomy [**2-14**], tonsillectomy.
MEDICATIONS ON ADMISSION: Insulin, Metformin, Klonopin,
Lisinopril, Ursodiol.
ALLERGIES: Prednisone.
SOCIAL HISTORY: No tobacco, no alcohol.
FAMILY HISTORY: Non-contributory. No pancreatitis.
PHYSICAL EXAMINATION: Vital signs 99.5, 108, 142/72, 18, 92%
on 4 liters of nasal cannula. The patient was alert and
oriented times three. Oropharynx was clear. Sclera was
anicteric. Regular rate and rhythm. No murmurs, rubs or
gallops. Clear to auscultation bilaterally. Abdomen was
distended, tender, in the epigastric. Wounds were clean, dry
and intact. Lower extremities were warm without edema.
SUMMARY: In summary the patient is a 50 year old male with a
history of diabetes mellitus who was transferred to [**Hospital6 1760**] for workup of questionable
common bile duct obstruction, status post laparoscopic
cholecystectomy.
HOSPITAL COURSE: The patient was directly admitted to the
Intensive Care Unit where he had monitored hemodynamics, via
PA catheter to maximize optimal perfusion and was continued
on Ampicillin, Levofloxacin, and Flagyl antibiotics. On
hospital day #2, the patient had a creatinine of 8.6 and had
an endoscopic retrograde cholangiopancreatography done and
was given on Lasix 100 mg times one and the Renal Team was
consulted at that time and recommended decreasing all
antibiotics to renal dosing. At this time, the patient's
creatinine was 9.5. Lopressor was increased on hospital day
#3 for an increased blood pressure and the patient had
continued to have minimal urine output and a creatinine of
10.8. The patient's urinary output picked up increased urine
output at 500 cc and hemodialysis was delayed.
Endoscopic retrograde cholangiopancreatography showed normal
biliary anatomy but, due to the severity of his condition at
that time, a 10 French by
7 cm cotton [**Doctor Last Name **] biliary stent was placed successfully in the
common
bile duct. At this point the patient's creatinine began to
rise to 12.2.
On hospital day #5, the patient remained in the Intensive
Care Unit with increase in creatinine, however, was having
good urine output. The patient's creatinine began coming
down to 11.7 and with nonoliguric renal failure, the patient
was stable and was off of oxygen at this point. He was
transferred to the floor, and taken off of fluid restriction.
He was given free access to water and Lasix was held.
Physical therapy began seeing the patient at this time no
acute distress continued to see the patient throughout his
hospital course. On hospital day #7, the patient was
encouraged to ambulate and made 2 liters of urine output with
creatinine of 10.2. The patient continued to do well on
hospital day #8 and antibiotics were discontinued. The
patient was placed on p.o. medications and dialysis was
delivered for decrease in creatinine. Other than
hyponatremia the patient had a benign examination and Foley
catheter was discontinued on hospital day #9. Creatinine
continued to decrease to now 7, and was 6.1 on [**2-24**],
and on hospital day #10, the patient continued to be
encouraged to drink to thirst and physical therapy evaluated
the patient and had follow up with [**Hospital6 407**]
for home physical therapy.
The patient was discharged on hospital day #11 with a
creatinine of 3, was placed on diabetic diet and was
instructed to only take half of NPH and no regular insulin
until follow up with primary care physician for decreased
sugars in the daytime and was encouraged to drink as much as
he desired p.o. to keep himself well hydrated. He was
encouraged to follow up with Dr. [**Last Name (STitle) **] at next available
visit and encouraged to follow up with primary care physician
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] also as soon as possible.
DISCHARGE MEDICATIONS:
Percocet 5/325 mg tablet, one to two tablets p.o. q. 4-6
hours prn pain.
Lopressor 50 mg tablet, p.o., .5 tablet p.o. b.i.d.
Protonix 40 mg tablet, one tablet p.o. q. day
TUMS 500 mg tablet, one tablet p.o. q.i.d.
Colace 100 mg tablet, one tablet p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Status post laparoscopic cholecystectomy.
2. Acute nonoliguric renal failure.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Last Name (NamePattern4) 7013**]
MEDQUIST36
D: [**2172-2-26**] 21:28
T: [**2172-2-26**] 22:27
JOB#: [**Job Number 53275**]
|
[
"5849",
"2760",
"25000",
"4019",
"49390"
] |
Admission Date: [**2120-4-5**] Discharge Date: [**2120-4-13**]
Date of Birth: [**2063-9-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Recurrent GIST
Major Surgical or Invasive Procedure:
[**2120-4-5**] Exploratory laparotomy, resection of recurrent GIST, w/
hand sown G-J and stapled J-J
History of Present Illness:
56F with history of perforated GIST in [**2117**] s/p subtotal
gastrectomy and
Roux-en-Y gastro-Jejunostomy presents with a recurrence of the
GIST.
Past Medical History:
PMH: GIST, HTN
PSH: lap cholecystectomy, subtotal gastrectomy/roux-en Y
gastro-jejunostomy [**10/2117**]
Social History:
She moved here from [**Country 4194**] approximately three years ago. She is
a widow. She has five healthy children. She denies tobacco,
alcohol or drug use. She lives on [**Hospital3 4298**] and
previously worked as a housecleaner. Independent of ADLS.
Family History:
Significant for father who died of a stomach tumor and a mother
and sibling who died of cardiac disease.
Physical Exam:
On Discharge:
Afebrile, Vital signs stable
No distress, alert and oriented x 3
PERLA, EOMI, anicteric
RRR, lungs clear
Abdomen soft, nontender, nondistended
Incision clean, dry, with minimal serosanguinous drainage, no
erythema
Ext without edema
Pertinent Results:
[**2120-4-5**] 03:00PM BLOOD Hgb-9.5* Hct-27.4*
[**2120-4-5**] 07:43PM BLOOD WBC-7.7# RBC-2.42*# Hgb-7.8* Hct-23.0*
MCV-95 MCH-32.2* MCHC-33.8 RDW-13.0 Plt Ct-106*
[**2120-4-5**] 10:00PM BLOOD Hct-26.4*
[**2120-4-6**] 03:49AM BLOOD WBC-5.7 RBC-3.73*# Hgb-11.6*# Hct-33.4*
MCV-90 MCH-31.2 MCHC-34.9 RDW-14.7 Plt Ct-80*
[**2120-4-6**] 03:28PM BLOOD WBC-7.0 RBC-3.64* Hgb-11.6* Hct-33.2*
MCV-91 MCH-31.9 MCHC-34.9 RDW-15.4 Plt Ct-86*
[**2120-4-7**] 07:51AM BLOOD Hct-26.0*
[**2120-4-7**] 04:17PM BLOOD WBC-6.2 RBC-2.72* Hgb-8.5* Hct-24.5*
MCV-90 MCH-31.4 MCHC-34.7 RDW-15.9* Plt Ct-73*
[**2120-4-8**] 01:49AM BLOOD Hct-27.3*
[**2120-4-8**] 10:57PM BLOOD Hct-29.4*
[**2120-4-11**] 07:55AM BLOOD Hct-30.6*
Brief Hospital Course:
Ms. [**Known lastname 74914**] [**Last Name (Titles) 1834**] a successful exploratory laparotomy with
resection of recurrent GIST with a hand sewn gastrojejunostomy
and stapled jejunojejunostomy on [**2120-4-5**]. Her immediate
post-operative course was complicated by bleeding. Her
hematocrit was 19 at it lowest value. Her intravascular
depletion caused her to be hypotensive requiring vasopressors.
She was admitted to the [**Hospital Unit Name 153**] for management. She did receive
transfusions of 4 units of PRBCs in the immediate post-operative
period. The vasopressors were able to be weaned off and she was
extubated successfully. She did begin to have melena, which was
attributed to bleeding from her anastomoses. Her hematocrits
remained relatively stable. Ultimately she did received
transfusions of 3 more units of PRBCS over the next 2 days. Her
melena resolved and her hematocrit remained stable after a total
of 7units of PRBCs. She remained normotensive and was able to
be transfered out of the ICU and to the surgical floor. A PPI
was started in the form of protonix. Her diet was advanced
slowly starting with sips and then culminating in a regular
house diet. She had the return of bowel function with nonbloody
bowel movement and was tolerating a regular diet. Pain control
was excellent with oral medications. She was able to void and
ambulate without difficulty. A physical therapy consult was
obtained to help with ambulation and she was cleared for
discharge to home without services. Her abdominal incision
remained clean with minimal serosanguinous drainage; there was
no erythema. She was discharged home on POD8 in good condition
with discharge instructions on danger signs to look out for.
Medications on Admission:
Ferrous sulfate
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent GIST
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call your physician if you experience:
- fever > 101
- chills
- persistent nausea or vomiting
- inability to eat or drink
- increasing abdominal pain not relieved by your medication
- continued bloody bowel movements
- abdominal distension or no bowel movements or gas
- increasing redness around or drainage from your incisions
.
Medications:
- continue taking all of your home medications
- you will be given a prescription for pain medication, do not
drive while taking this pain medication
- take a stool softener to prevent constipation while on pain
medication
- continue to take protonix daily
Incision:
- you may place dry gauze over your incion as needed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2120-4-24**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"2851",
"2875",
"4019"
] |
Admission Date: [**2177-7-30**] Discharge Date: [**2177-8-5**]
Date of Birth: [**2095-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2087-7-29**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to PDA)
History of Present Illness:
82 y/o male c/o chest pain over past six months with increase in
episodes with activity. First underwent ETT which was positive.
Then had a cardiac cath which revealed left main/three vessel
disease.
Past Medical History:
Hypertension, CVA, Benign Prostatic Hypertrophy, Gout, s/p
Appendectomy, s/p Tonsillectomy
Social History:
Denies tobaccco and ETOH use.
Family History:
Both parents died from heart failure in 70's.
Physical Exam:
VS: 51 16 [**11/2148**]
GEN: NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM -JVD, -carotid bruit
Chest: CTAB
Heart: RRR -murmur
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -JVD
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**7-29**] Chest CT: 1. Atherosclerosis involving the aorta and
coronary arteries as described with ascending aorta free of
bulky calcifications up to 6 cm above the aortic valve. 2.
Ground-glass nodular opacity and solid pulmonary nodules as
described, followup in six months is recommended with a chest
CT. 3. Degenerative changes of the thoracic spine as described
with some diffuse osteopenia.
[**7-30**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the
left atrial appendage. Left ventricular wall thicknesses and
cavity size are normal. The left ventricle contracts normally.
The RV is normal in size and systolic fxn. The ascending aorta
is mildly dilated. There are simple atheroma in the ascending
aorta. An epi-aortic scan showed posterior atheroma, and helped
place the cannula and cross-clamp. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are mildly thickened.
No aortic regurgitation is seen. The mitral valve leaflets are
myxomatous. Trivial mitral regurgitation is seen. There is no
pericardial effusion. Post-CPB: Patient is in NSR, on low dose
phenylephrine infusion. Good biventricular systolic fxn. No AI.
Aorta intact. Trace MR.
[**2177-7-29**] 01:45PM BLOOD WBC-3.9* RBC-3.98* Hgb-12.6* Hct-37.5*
MCV-94 MCH-31.6 MCHC-33.5 RDW-13.2 Plt Ct-147*#
[**2177-8-1**] 07:55AM BLOOD WBC-7.3 RBC-2.95*# Hgb-9.3* Hct-26.3*
MCV-89 MCH-31.5 MCHC-35.3* RDW-15.2 Plt Ct-106*
[**2177-7-30**] 12:44PM BLOOD PT-16.3* PTT-42.8* INR(PT)-1.5*
[**2177-7-31**] 02:29AM BLOOD PT-14.4* PTT-33.1 INR(PT)-1.3*
[**2177-7-30**] 02:23PM BLOOD UreaN-17 Creat-0.9 Cl-109* HCO3-28
[**2177-8-1**] 07:55AM BLOOD Glucose-113* UreaN-22* Creat-1.1 Na-135
K-4.4 Cl-101 HCO3-30 AnGap-8
[**2177-8-4**] 06:15AM BLOOD WBC-4.9 RBC-3.09* Hgb-9.5* Hct-28.0*
MCV-91 MCH-30.6 MCHC-33.8 RDW-14.9 Plt Ct-152
[**2177-8-4**] 06:15AM BLOOD Plt Ct-152
[**2177-8-5**] 12:20PM BLOOD Glucose-136* UreaN-20 Creat-1.2 Na-138
K-4.6 Cl-97 HCO3-34* AnGap-12
[**Known lastname 79442**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79443**]Portable
TTE (Complete) Done [**2177-8-4**] at 3:51:07 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2095-2-6**]
Age (years): 82 M Hgt (in): 65
BP (mm Hg): 109/62 Wgt (lb): 155
HR (bpm): 70 BSA (m2): 1.78 m2
Indication: Pericardial effusion.
ICD-9 Codes: 424.0, 424.2
Test Information
Date/Time: [**2177-8-4**] at 15:51 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 11320**] E.
[**Location (un) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W057-0:20 Machine: Vivid [**7-20**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.52 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Stroke Volume: 103 ml/beat
Left Ventricle - Cardiac Output: 7.18 L/min
Left Ventricle - Cardiac Index: 4.04 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 27
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms
TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). False LV tendon
(normal variant). Estimated cardiac index is normal
(>=2.5L/min/m2). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Suboptimal image quality - poor suprasternal views.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). 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
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No
pericardial effusion.
CLINICAL IMPLICATIONS:
Based on [**2176**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2177-8-4**] 17:20
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit on [**2177-7-30**] after undergoing
pre-operative work-up as an outpatient. He was taken directly to
the operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Initially
post-op he had some increased bleeding and required blood
transfusions with resolution of his bleeding. Within 24 hours,
he was weaned from sedation, awoke neurologically intact and was
extubated. By post-op day two, his pressors were weaned off and
he was started on beta-blockade, aspirin and a statin. He was
then transferred to the step down unit for further recovery. Mr.
[**Known lastname **] was gently diuresed towards his preoperative weight.
The physical therapy service was consulted for assistance with
his postopertive strength and mobility. The remainder of his
postoperative course was uneventful and he was ready for
discharge home on postoperative day six.
Medications on Admission:
Atenolol 25mg qd, Flomax 0.4mg qd, Allopurinol 100mg qd, Zestril
10mg qd, Aspirin 81mg qd, Niacin 1500mg qAM, 1000mg qPM, Plavix
75 mg qd (last dose 7/11), Omeprazole 20mg qd, Finasteride 5mg
qd, NTG
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
7. Niacin 500 mg Tablet Sig: see below Tablet PO twice a day:
please take 1500mg in the am and 1000mg in the pm.
Disp:*150 Tablet(s)* Refills:*0*
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO twice a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, CVA, Benign Prostatic Hypertrophy, Gout, s/p
Appendectomy, s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 5686**] in [**2-16**] weeks [**Telephone/Fax (1) 11554**]
Dr. [**Last Name (STitle) **] in [**1-15**] weeks [**Telephone/Fax (1) 10508**]
CT scan in 6 months for evaluation of nodular opacity and solid
pulmonary nodules
Completed by:[**2177-8-5**]
|
[
"41401",
"4019"
] |
Unit No: [**Numeric Identifier 65935**]
Admission Date: [**2183-2-9**]
Discharge Date: [**2183-3-29**]
Date of Birth: [**2183-2-9**]
Sex: M
Service: NB
INTERIM SUMMARY:
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **], [**Name2 (NI) 37336**] A, is
the 1460 gram product of a 30 week IVF [**Name2 (NI) 37336**] gestation, born
to a 32 year-old, Gravida II, Para 0 to [**Name (NI) 1105**] mother. Prenatal
screens: Maternal blood type A positive, antibody negative,
hepatitis B surface antigen negative. RPR nonreactive.
Rubella immune. GBS unknown. Pregnancy complicated by IUGR
and oligo for [**Name (NI) 37336**] B, requiring delivery today. Maternal
medications include Zantac, iron and Terbutaline. The
triplets were delivered by Cesarean section. [**Name (NI) **] A
emerged breech, vigorous, with good cry. Brought to warmer,
dried, stimulated and suctioned. Pinked with blow-by oxygen.
Apgars 8 at 1 minute, 8 at 5 minutes, admitted to the NICU
for management.
PHYSICAL EXAMINATION: On admission, patient's birth weight
was 1460 grams, 75th percentile. Length 41 cm, 50th to 75th
percentile. Head circumference 29.5, 75th percentile.
HOSPITAL COURSE: Respiratory: Patient was intubated on day
of life 0, received Surfactant x3. Extubated to C-Pap on day
of life 5. Transitioned to nasal cannula day and
has remained in room air since day of life 13.He has had
occasional episodes of Apnea/Bradycardia.
Cardiovascular: Patient was hemodynamically stable at birth,
developed a murmur on day of life 2. Echo revealed a PDA,
treated with one course of Indomethacin. No further echo, no
further murmur.
Fluids, electrolytes and nutrition: Patient initially n.p.o.
with 80 ml/kg per day parenteral nutrition, started feedings
day of life 5, n.p.o. on day of life 19, due to guaiac
positive stools and dilated loops on a KUB; n.p.o. for 7
days; feedings resumed on day of life 7; reached full feeds
on day of life 33, of Nutramigen 24 calorie at 150 ml/kg per
day p.o./p.g. He then again developed quiac positive stools,
which on [**3-18**] became markedly guiac positive, stools never
became grossly positive. For this reason on [**3-19**] he was
switched to Neocate and increased to Neocate 24 the following
day. He takes 150-180 cc/kg/Day. Most recent weight:
He had immature suck/swallow coordination, which improved
before we discharged him home.His weight at discharge was
2.835 kg.
Gastrointestinal: Patient treated for hyperbilirubinemia,
received phototherapy on day of life 11 until day of life 13.
Peak bilirubin 9.6 over 0.3.
Hematology: Patient received packed red blood cells
transfusions on day of life 24 for hematocrit of 25. His most
recent Hct/Retic on [**3-24**] was 30.9/1.8.
Infectious disease: Patient 7 days n.p.o., day of life 19 to
day of life 26. Received bowel rest secondary to guaiac
positive stools and 2 siblings with concerns for necrotizing
enterocolitis. CBC was unremarkable. Blood cultures negative
to date. 7 days of Zosyn, last dose on day of life 26.
On [**3-18**] he developed R eye drainage for which he was placed on
5 days of erythromycin opthalmic ointment.
Neurology: Head ultrasound on [**2-17**] showed a small right
germinal matrix hemorrhage. Repeat head ultrasound on [**2-24**]
showed a resolving hemorrhage, F/U on [**3-12**] was normal.
Sensory: Eye exam: Eyes immature. Eyes examined most
recently on [**3-10**] revealing immaturity of the retinal vessels
to zone 2 but no ROP as of yet. Follow-up exam on [**3-24**] was
mature z 3 ou. Hearing screen passed on [**3-25**]
Psychosocial: The [**Hospital1 69**]
social worker is involved with the family. Contact social
worker's name is [**Name (NI) **]. She can be reached at [**Telephone/Fax (1) **].
SKIN:Has a capillary hemangioma on central lower back.
Circumcision:Done on [**3-24**].
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Location (un) 8985**], [**Telephone/Fax (1) 65936**].
CARE RECOMMENDATIONS: Feeds: Feeds are currently at full
feeds of Neocate 24 calories.
Medications: Ferrous Sulfate 0.2 ccs PO,QDay
Car seat screening test has not been performed to date.
State newborn screen status: State screens were sent on [**2-12**]
[**2183-2-24**] and [**3-24**].
Immunizations received: Hepatitis B [**3-14**].
Follow-up appointments: Dr. [**Last Name (STitle) **], [**Location (un) 2274**]/[**Location (un) 8985**] [**3-31**]
VNA day post discharge, EI referral done.
DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Hyperbilirubinemia.
4. Medical NEC/rule out sepsis.
5. S/P Apnea/bradycardia.
6. Immature suck/swallow coordination.
7. Hemangioma on central lower back.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2183-3-18**] 15:02:15
T: [**2183-3-18**] 16:00:53
Job#: [**Job Number 65937**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2150-8-2**] Discharge Date: [**2150-8-13**]
Date of Birth: [**2118-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Dyspnea, Syncope, L calf pain
Major Surgical or Invasive Procedure:
PICC line.
History of Present Illness:
Ms. [**Known lastname 26438**] [**Last Name (Titles) 813**] is a 31 y.o. woman on OCPs who presents
with dyspnea, syncope and L calf pain. Her symptoms began 1.5
weeks ago with pain in the back of the L knee, which was
exacerbated with stair-climbing and alleviated with Tylenol. She
had started running and thought she had tendonitis. About 1 week
ago, she noticed that she was short of breath when she would
climb stairs or talk quickly or excitedly. The joint pain
stopped, and she began to a feel throbbing lower calf pain that
at times extended to the ankle. On the day of admission, she had
[**3-10**] consecutive syncopal episodes, falling to the ground each
time, before calling her mother, who called EMS.
.
In the ED, initial VS: BP 89/74 HR 106 RR 24 95% on NRB. Per
ED resident, A&O x 3. Labs were drawn, which were significant
for leukocytosis of 15.3 and ARF of 1.2. ED performed bedside
U/S that showed right sided hypokinesis. EKG with R heart
strain. CT head and CTA performed. CTA showed bilateral
pulmonary embolism. Guiaic negative in ED. Given persistent
hypotension, patient started on alteplase in ED.
Post-thrombolysis VS improved wth BP 110-142/70-82.
.
Currently, she denies light-headness, chest pain, palpitations,
shortness of breath, or ankle edema.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, congestion,
cough, nausea, vomiting, diarrhea, abd pain, dysuria.
.
Past Medical History:
1. Abnormal Pap smear with colposcopy in [**2148**]; cervical biopsy
with squamous metaplasia in [**2143**]
2. History of STDs, including genital warts and + HPV, gonorrhea
and chlamydia ([**2145**]).
3. Single pregnancy, elective termination in [**2137**]
Social History:
She grew up in [**Location (un) 538**]. Graduated from [**University/College **]in
[**2148**], currently works as a social worker at a program for people
with mental illness, schizophrenia, she does do home visits and
enjoys her job. Has worked there for two years, lives by
herself. Although her mother lives downstairs, they live in a
three-family house. Drinks alcohol, twice a month 2 drinks each
time without blackouts. Sexually active with one partner right
now, does not use condoms and was planning to stop OCP and try
to get pregnant. She smoke intermittently, with last smoking 1
month ago 10 cigarettes over 1 week, but has smoked up to 1
pack.
Family History:
Mother has hyperlipidemia. Paternal grandmother has breast
cancer. Other grandmother has pacemaker and increased blood
pressure. No diabetes, no cancers, no early heart disease.
Distant history of DVT in great aunt and a distant cousins in 50
or 60s, but no bleeding disorders or clotting disorders in
immediate family. No family history of miscarriages.
Physical Exam:
PHYSICAL EXAM
VITAL SIGNS: T 99.2 HR 90 BP 138/85 RR 17 98% RA
GEN: pleasant, alert young woman in NAD
HEENT: EOMI, anicteric, OP - moist mucosal membranes, no
erythema, no cervical LAD, R cheek hematoma under eye.
CHEST: Chest clear to auscultation bilaterally; no wheezes or
rhonchi
CV: regular rate and rhythm, 1/6 systolic ejection murmur at USB
ABD: soft, non-tender and non-distended
EXT: R elbow hematoma with ecchymoses from mid-arm to forearm, R
knee hematoma largely resolved, L calf non-tender, 2+ DP and
radial pulses bilaterally
NEURO: CN II-XII grossly intact, facial strength and sensation
intact, 5/5 strength and sensation intact and symmetric in
bilateral upper and lower extremities, 2+DTR in [**Name2 (NI) **]
SKIN: As described above.
Pertinent Results:
LABS ON ADMISSION
WBC 15.3 Hgb 13.3 Hct 38.7 Plt 342 MCV 90
N 65.1 L 30.7 M 1.8 E 1.9 Bas 0.4
PT 13.6 PTT 26.3 INR 1.2
Na 139 Cl 105 BUN 14
K 3.5 Bicarb 22 Cr 1.2 AG 12
CK 116 MB 3 Trop <0.01
LABS ON DISCHARGE
[**8-10**] INR 2.0 PTT 90.5
[**8-11**] INR 1.9 PTT 88.7
[**8-12**] INR 1.9 PTT 99.2
[**8-13**] INR 2.2 PTT 36.7 (Heparin gtt stopped, pt on Lovenox)
PERTINENT STUDIES:
EKG [**2150-8-2**]: sinus tachycardia ~110s, nl axis, Q wave in [**Last Name (LF) 1105**], [**First Name3 (LF) **]
elevations in AVR and V1, ST depressions V4-V6
.
CT HEAD W/O CONTRAST [**2150-8-2**] (FINAL):
FINDINGS: There is no acute intracranial hemorrhage. There is no
mass, mass effect, edema, or infarction. Ventricles and sulci
are normal in size and configuration. There is no acute
fracture. There is moderate opacification of the maxillary
sinuses bilaterally, with some aerosolized secretions. Paranasal
sinuses and mastoid air cells are otherwise normally aerated.
Surrounding soft tissues are unremarkable.
IMPRESSION: No acute intracranial hemorrhage.
Sinus opacification as detailed above.
.
CTA [**2150-8-2**] (FINAL):
There is extensive bilateral pulmonary embolism. On the right,
the right main pulmonary artery is largely free of clot, but
there is extensive thrombus in nearly all the lobar arteries,
extending into the segmental and subsegmental branches. On the
left, the left main pulmonary artery is clear. There is thrombus
in the left lower lobar pulmonary artery which is partially
occlusive, and more extensive thrombus in segmental pulmonary
arterial branches to the left lower lobe, lingula, and left
upper lobe.
There are signs of right heart strain, with enlargement of the
right
ventricle, flattening of the interventricular septum, and slight
bowing of the interventricular septum towards the left
ventricle.
.
TTE ECHOCARDIOGRAPHY [**2150-8-3**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
BILATERAL EXTREMITY ULTRASOUND [**2150-8-4**]
Grayscale and Doppler ultrasound was performed of the bilateral
common femoral, superficial femoral, popliteal, peroneal, and
posterior tibial veins. There is a nonocclusive thrombus in the
left popliteal vein. The remainder of the veins show normal
compressibility, flow, and augmentation where applicable.
.
Brief Hospital Course:
31 y.o. F with history of abnormal pap smear with colpo in [**2148**],
on OCPs and an intermittent smoker, who presents with
hypotension, syncope x 3, found to have bilateral pulmonary
embolism.
# Pulmonary Emboli: Seen on CTA with signs of right heart
strain. Likely originated from L calf DVT and seconday to OCP
and intermittent smoking use. Per mother and patient, no 1st or
2nd generation family members with history of clotting or
bleeding disorders or frequent miscarriages. Patient s/p
thrombolytic therapy with normalization of vital signs and
hemodynamically stable with significant improvement in heart
rate and oxygen requirement. The patient was continued on
heparin IV per weight based protocol bridging to coumadin.
Patient was therapeutic for 3 days and discharged on Warfarin
8mg PO Daily. She was to f/u at coumadin clinic on Monday, [**8-17**].
# Multiple hematomas: Pt had falls prior to admit with trauma to
R elbow, knee and cheek. Patient has a large R elbow hematoma
with smaller hematomas on R cheek and R knee which were
exacerbated by alteplase. Hand surgery followed and recommended
pressure dressings, ice and elevation. Patient's R arm hematoma
grew once but was otherwise stable throughout the admission with
no signs of compartment syndrome. Patient's R arm pain improved
and disappeared by discharge.
# Acute Renal Failure: Patient presented with Cr of 1.2
(baseline of 0.8). Cr quickly returned back to baseline of 0.7
after fluid challenge.
# Leukocytosis: Likely secondary to stress response to PE,
resolved on day after presentation. Quickly resolved after
admission.
Medications on Admission:
Apri 0.15 mg-0.03 mg Tablet - 1 tablet po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation: Please take twice a day while
using morphine. .
Disp:*60 Capsule(s)* Refills:*1*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation: Please use twice a day while using morphine. .
Disp:*60 Tablet(s)* Refills:*0*
3. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
Disp:*14 * Refills:*1*
4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
Daily PRN: Please take for constipation.
Disp:*10 * Refills:*0*
6. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bilateral PE with RV Strain
DVT
Secondary:
R elbow hematoma
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted for evaluation of difficulty breathing, calf
pain, and fainting. Imaging studies showed multiple blood clots
in both lungs, known as pulmonary embolism. You were treated
with clot destroying medication and later blood thinning
medications called heparin. You are now being treated with
coumadin and will continue with supplemental lovenox until your
INR (blood thinning level) is at the correct level.
Because of the clot destroying medicines, you developed a
hematoma in your right arm. Your hematoma was treated with
pressure wrapping, elevation and ice. The hematoma grew slightly
at one point and was evaluted by our hand surgery team who
deemed it to be stable.
You will be able to start work on Thursday, [**2150-8-20**]. You
will be able to resume normal activities without restrictions
except no contact sports while on coumadin. You will need your
INR checked twice a week for the first 1-2 weeks. After your INR
levels stabilize you will then need to check your INR once a
week thereafter. Over the next month you will have probably 2
appointments a week (including getting INR checked).
We have made some changes to your medications:
STOP taking your Avri birth control
START taking Coumadin 8mg by mouth daily
START taking Morphine by mouth every 6 hours as needed for pain
START taking Senna 8.6 mg Tablets by mouth twice a day as
needed for constipation. Please take while using morphine for
pain.
START taking Docusate 100mg by mouth twice a day as needed for
constipation. Please take while using morphine for pain.
You will be given scripts for Lovenox to take just in case your
INR levels are low on Monday. You do NOT need to take Lovenox
unless intstructed by the [**Hospital 197**] Clinic.
It is critically important to your health to stop smoking, as
this is a significant risk factor for pulmonary embolism
particularly while using birth control. You must also avoid
using any hormonal birth control, as they can increase your risk
of pulmonary embolism.
If you experience sudden chest pain, shortness of breath, high
fevers, or any other concerning symptoms please come to the
emergency department as soon as possible.
Followup Instructions:
You will need to go to the [**Hospital 197**] Clinic this Monday, [**8-17**] between the hours of 8:30am and 5:30pm.
Thereafter, you will need to visit the [**Hospital 18**] [**Hospital 197**] Clinic to
check your INRs on a weekly basis for the first month. You can
go to the [**Hospital 197**] clinic anytime between the hours of 8:30am
and 5:30pm Mondays, Tuesdays, Thursdays, Fridays, NOT
Wednesdays.
You have an appointment with the hematology specialist [**First Name11 (Name Pattern1) 1730**]
[**Last Name (NamePattern4) 5056**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2150-9-4**] 12:00pm.
Please call his office if you need any changes.
You have an x-ray at ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2150-8-18**] 9:10am
You have an appointment at the HAND CLINIC Phone:[**Telephone/Fax (1) 3009**]
Date/Time:[**2150-8-18**] 9:30am
You have an appointment with your PCP, [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-8-21**] 9:40am
Completed by:[**2150-8-14**]
|
[
"5849",
"2859"
] |
Admission Date: [**2167-7-27**] Discharge Date: [**2167-8-17**]
Date of Birth: [**2112-4-9**] Sex: M
Service:
DISPOSITION: The patient is transferred to the general
medical floor at this time.
HISTORY OF PRESENT ILLNESS: This is a 55 year-old male with
a history of atrial fibrillation, depression, alcohol abuse,
hypertension and hyperlipidemia who was transferred from an
outside hospital with increasing hepatic failure, renal
failure, tremors, change in mental status and possible sepsis
in the setting of an elevated white count with bandemia and
mild respiratory distress. The patient had presented to
[**Hospital 1558**] Medical Center on [**2167-6-17**] after
injuring his knee from a fall at work. He was found to have
a right patellar fracture and was transferred to [**Hospital6 **], closer to his home, where his hospital course there
was significant for atrial flutter that developed on the day
of his admission. The patient was then monitored on
telemetry. During his hospital stay he had increasing
respiratory distress and was eventually intubated on [**2167-6-20**].
The patient was suspected to be in delirium tremens and was
also diagnosis with a Staphylococcus aureus pneumonia. On
[**2167-6-27**] he was diagnosed with an Alpha Strep bacteremia by
positive blood culture. A lumbar puncture done on [**2167-6-28**]
ruled out meningitis. Bronchial washings done on [**2167-7-5**]
were significant for growth of [**Female First Name (un) 564**] Albicans and also the
catheter tip culture grew coagulation negative Staph, two
bottles, from a blood culture also on [**2167-7-5**].
During his hospital course his hematocrit dropped from 38 to
25. His liver function also worsened, AST changing from 105
to 133, ALT from 77 to 113 and total bilirubin from 1.9 to
17.5. Renal failure also worsened throughout his hospital
stay. BUN changed from 17 to 57 and creatinine from 0.8 to
2.9. In addition, a stage two decubitus ulcer developed in
his perianal area.
PAST MEDICAL HISTORY: Atrial fibrillation treated with
Propanthenone for approximately five years. History of
hyperlipidemia, depression, hypertension, history of alcohol
abuse, gout.
MEDICATIONS: Medication on transfer from outside hospital
were Propanthenone 150 mg p.o. t.i.d., Thiamine 100 mg p.o. q
day, Folate one tablet p.o. q day, Multivitamin p.o. q day,
Flovan 110 mcg inhaled two puffs b.i.d., Protonix 40 mg p.o.
q day and Flagyl 500 mg p.o. b.i.d., Morphine 2 mg
intravenously p.r.n., lactulose 15 ml p.o. b.i.d., Actigall
300 mg p.o. b.i.d., Prednisone 60 mg p.o. q times five days,
antifungal cream.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married but separated from his wife. Denies
recent smoking. The patient has a long history of alcohol
abuse. The patient works as a construction supervisor.
FAMILY HISTORY: Family history is significant for both
parents with a history of cirrhosis without A-B hepatitis
diagnosis.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs temperature 97.4, heart rate 130, blood
pressure 112/82, respiratory rate 24, pulse oximetry 95
percent on two liters. General jaundiced tremulous
diaphoretic, moderately obese male. Head, eyes, ears, nose
and throat examination revealed positive marked icterus,
extraocular movements intact, pupils equally reactive to
light and accommodation. Next, no jugulovenous distension,
no bruits, no lymphadenopathy. Lungs, diffuse crackles,
increased bibasilar. Heart, normal S1, S2, no rubs, murmurs
or gallops, irregularly irregular. Abdomen, positive bowel
sounds, distended, no masses, positive fluid wave with
shifting dullness. Extremities, marked peripheral and
truncal edema. Neurological examination notable for tremors
in all extremities, most marked in the arms. The patient was
alert and oriented to name only. Moving all extremities.
LABORATORY DATA: White count of 22, 81 percent neutrophils,
8 percent bands, 8 percent lymphocytes, 2 percent monocytes.
Hematocrit 31.1. Platelet count 295. MCV 95. Electrolytes,
sodium 142, potassium 4.2, chloride 113, bicarbonate 50, BUN
76, creatinine 3.3, calcium 9.1, magnesium 2.0, phosphate
5.3, glucose 127, ionized calcium 1.27, lactate 3.5. Arterial
blood gases 7.27, PCO2 37, PO2 77, INR 1.5, PT 15, PTT 34.
AST 133, ALT 113, alkaline phosphatase 357, total bilirubin
16.7, LDH 303, CK 26, albumin 2.5, uric acid 13.8.
Abdominal ultrasound on admission negative for significant
ascites. Hepatobiliary ducts are patent. Positive
gallbladder edema. No evidence of stones of sludge. At the
outside hospital Hepatitis B and C antibodies are negative.
Cerebrospinal fluid studies were negative on [**2167-6-28**]. Urine
eosinophil is positive on [**2167-7-22**]. Bronchial washings
[**2167-7-6**] negative for malignant cells. CT of the head on
[**2167-7-1**] was negative.
ASSESSMENT AND PLAN: A 55 year-old male with history of
alcohol abuse, hypertension, atrial fibrillation who presents
with multi-organ failure, namely hepatic failure, renal
failure and respiratory distress following a prolonged course
at an outside hospital.
HOSPITAL COURSE: Problem #1: Renal. The patient has renal
failure of an etiology that is multifactorial by history.
The patient had likely acute tubular necrosis from a
hypotensive episode at the outside hospital. Also, the
patient had positive eosinophils at the outside hospital and
was diagnosed with acute interstitial nephritis and was
finishing a course of prednisone for this diagnosis during
the time of transfer to this hospital. Here he was found to
have a positive antistreptolysin O antibody and therefore was
diagnosed with a post Streptococcal glomerular nephritis,
treatment for which was conservative. Intravenous fluids
were continued for prerenal azotemia and ongoing
intravascular depletion. The patient's creatinine improved
throughout his hospital stay, decreasing from 3.3 to 0.9 on
the time of transfer. The patient had marked anasarca and
was continually diuresed throughout his hospital stay,
however, the patient also had ongoing hypernatremia which was
addressed with intravenous fluids D5W and free water boluses
four times each day while also receiving free water with his
tube feeds. His sodium level did return to within normal
limits on this regimen and much of his edema had resolved by
the time of transfer.
Problem #2: Cardiovascular. The patient presented with
atrial fibrillation, a chronic issue. His Propanthenone was
discontinued as it had not been effective for several years.
The patient was continued on Metoprolol t.i.d. for control of
his heart rate. His anticoagulation was continued for the
majority of his stay, initial Coumadin and then later changed
to heparin which was held on occasions for concerns about
decreasing hematocrit on several occasions. When the patient
was extubated, he developed marked elevation of his blood
pressure and his heart rate and did require a Diltiazem drip
which was changed to a Labetalol drip for better control of
these abnormalities. He was quickly weaned back to a regimen
of Metoprolol and Diltiazem. An echocardiogram done during
his hospital stay showed ejection fraction of 50 to 55
percent, marked left atrial and right atrial dilation
secondary to an atrial septal defect, 4+ tricuspid
regurgitation and 2+ mitral regurgitation.
Problem #3: Respiratory. The patient was initially treated
for respiratory acidosis with intermittent BIPAP to bring his
pH from below 7.2 to above 7.3, however, due to ongoing
issues with poor control of his respiratory acidosis he was
intubated on [**2167-8-4**] after a prolonged weaning on pressor
support and back to assist control. The patient was
eventually extubated on [**2167-8-14**] and his respiratory status
improved to a point where he was adequate saturations on two
liters of nasal cannula. The etiology of his respiratory
failure included pneumonia and pulmonary edema with marked
effusion.
Problem #4: Gastrointestinal. The patient presented in
marked liver failure with hepatic encephalopathy. His
transaminases and total bilirubin were markedly elevated on
admission. The etiology of his liver failure was suspected
to be alcoholic hepatitis. Viral and autoimmune causes were
ruled out and drug reaction was also considered a
contributing factor. Serial ultrasounds ruled out
significant ascites that would necessitate paracentesis. The
patient was continued on a course of Versadile and Lactulose
in addition to tube feeds for nutrition to address his
ongoing liver failure and resulting encephalopathy. His AST
improved from 113 to 46, ALT from 133 to 50, alkaline
phosphatase from 357 to 229 and his total bilirubin from 16.7
to 5.3 during his Medical Intensive Care Unit stay. His
hepatic encephalopathy largely resolved during this time.
Problem #5: Neurology/mental status. The patient's mental
status was altered secondary to hepatic encephalopathy and
uremic encephalopathy, however, even with resolution of both
of these abnormalities his mental status was persistently
altered and other factors such as hypernatremia, hypoxia and
acidosis were suspected to be contributing to his altered
state. An electroencephalogram done was consistent with a
metabolic encephalopathy. A CT of the head was negative for
hemorrhage or mass. An Magnetic resonance scan showed a
right frontal lobe lesion that did not account for mental
status change. A lumbar puncture was also done to rule out
infectious causes of mental status change. On the day of
transfer, the patient had marked improvement of his
alertness, awareness and orientation.
Problem #6. Infectious disease. The patient was diagnosed
with a pneumonia shortly after admission. He was initially
treated with Zosyn and Vancomycin for a suspected nosocomial
pneumonia. The patient developed a rash with this antibiotic
course and this treatment was discontinued. The patient
later developed urinary tract infection with pseudomonas and
E coli growth and also spiked fevers from the suspected line
sepsis in which blood cultures had grown coagulation negative
Staphylococcus. The patient was started on a course of
ciprofloxacin and vancomycin. He again developed a rash that
was attributed to vancomycin and a course of Linasoid was
started. A lumbar puncture during the hospital course ruled
out meningitis.
Problem #7: Hematology. During the hospital course the
patient received five units of packed red blood cells for
ongoing issues of decreased hematocrit. No evidence of
bleeding or hemolysis was discovered during the [**Hospital 228**]
hospital stay. A retroperitoneal bleed was ruled out by a
CAT scan as well. The etiology of his anemia is likely
multifactorial.
Problem #8: Orthopedics. The patient presented with a
fractured right patella. Per orthopedic's recommendations,
the right leg was kept immobilization and surgical
intervention was deferred until his medical issues had
resolved.
Problem #9: Fluid electrolytes and nutrition. The patient
was markedly acidotic on admission and throughout much of the
early part of his hospital stay. The acidosis was
multifactorial including an andiron gap acidosis initially
from a lactic and uremic source. These abnormalities
resolved with improved liver and renal function. Non-andiron
gap acidosis was more persistent due to ongoing diarrhea
induced by lactulose treatment.
For nutrition, tube feeds were continued throughout the
[**Hospital 228**] hospital stay. Folic acid and thiamin
supplementation was also continued.
Problem #10. Endocrinology. The patient was continued on a
regular insulin sliding scale for intermittently high blood
sugars.
Problem #11. Dermatology. The patient had cutaneous
candidiasis most marked on his left axilla which was treated
with Miconazole powder.
Problem #12: Prophylaxis. The patient was continued on
anticoagulation, Coumadin and later heparin and also
Metoprolol.
Problem #13: Access. The right internal jugular vein
central line and a left arterial line were discontinued
during the final week of the [**Hospital 228**] Medical Intensive Care
Unit stay. The right arm PICC line was placed on [**2167-8-11**].
Please see subsequent discharge summary addendums for the
remaining hospital course and discharge plans.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2167-8-18**] 23:08
T: [**2167-8-19**] 05:00
JOB#: [**Job Number **]
|
[
"5849",
"5990",
"42731",
"5070"
] |
Admission Date: [**2107-2-14**] Discharge Date: [**2107-3-3**]
Date of Birth: [**2107-2-14**] Sex: M
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **]-[**Known lastname 49876**] is
the 1865 gm product of a 34 [**2-18**] week twin gestation born to a
32 year old gravida 3, para 1, now 3 woman with a past
obstetric history notable for spontaneous vaginal delivery at
negative, RPR nonreactive, Rubella immune, hepatitis surface
antigen negative, Group B Streptotoccus unknown
(previous pregnancy Group B Streptotoccus positive).
Pregnancy, significant for monochorionic diamniotic twin
gestation with discordant fetal growth attributed to
twin/twin transfusion syndrome. Therapeutic amniocentesis
performed at 19 weeks. Growth discordancy of 1000 gm noted
32 weeks, presented for induction of labor and later
decreased interval growth. Proceeded to spontaneous vaginal
delivery under epidural anesthesia. Rupture of membranes, 30
minutes prior to delivery, yielding clear amniotic fluid.
Interpartum antibiotics administered five hours prior to
delivery.
Neonatal course - Infant vigorous at delivery, orally and
nasally bulb suctioned. Dried, subsequently pink in no
respiratory distress. Apgars of 9 and 8 at 1 and 5 minutes.
Transferred to the Newborn Intensive Care Unit for further
management of prematurity.
PHYSICAL EXAMINATION: Birthweight 1865 gm, 25th to 50th
percentile, head circumference 33 cm, 75th to 90th
percentile, length 47 cm, 75th percentile. Anterior
fontanelle, soft and flat, nondysmorphic, palate intact.
Neck and mouth normal. No nasal flaring. Chest with minimal
retractions, good breathsounds bilaterally, no crackles.
Cardiovascular, well perfused, regular rate and rhythm,
femoral pulses normal. S1 and S2 normal, no murmurs.
Abdomen soft, nondistended, no organomegaly, no masses.
Bowel sounds active. Anus patent. Three vessel umbilical
cord. Genitourinary, normal male genitalia, testes descended
bilaterally. Infant, active, alert, appropriate for
gestational age.
HOSPITAL COURSE:
Respiratory - [**Known lastname **] remained stable in room
air throughout the hospital course. He had brief periods
of self-resolving desaturation with the most recent being on
[**2107-2-25**]. He has had no further episodes and
has been respiratory stable.
Cardiovascular - No issues.
Fluids, electrolytes and nutrition - Initially started on 60
cc/kg/day of D10/W for initial dextrose stick of 28, required
a D10 bolus and an enteral feed. Subsequently he had another
low dextrose stick and that issue had resolved. The infant
is currently feeding ad lib amounts of Enfamil 24 calorie,
taking in adequate amounts of approximately 160 to 180
cc/kg/day. His discharge weight is 2160.
Gastrointestinal - Peak bilirubin was on day of life #3 of
10.2/0.3. He received phototherapy for a total of four days
and the issue has resolved.
Hematology - Hematocrit on admission was 51.1. He has not
required any blood transfusions during this hospital course.
Infectious disease - A complete blood count and blood culture
obtained on admission, complete blood count was benign,
antibiotics were held. Blood culture remained negative at 48
hours and infant has had no further issues with sepsis.
Sensory - Audiology: Hearing screen unsuccessful in the right ear
which was referred times two. Parents
have been given information to schedule for outpatient follow
up at [**Hospital6 1129**].
Psychosocial - A social worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 38487**], phone [**Telephone/Fax (1) 38488**].
CARE RECOMMENDATIONS:
1. Feeds - Continue ad lib feedings Enfamil 24 calorie.
2. Medications - Not applicable.
3. Carseat position screen - Infant passed, 90 minutes of
monitored supervision in carseat.
4. State newborn screens - Sent per protocol.
5. Immunizations - The infant received hepatitis B vaccine
on [**2107-3-2**].
FOLLOW UP APPOINTMENTS: Recommend follow up with audiology
secondary to deferred hearing screen.
DISCHARGE DIAGNOSIS:
1. Premature twin #1 born at 34 3/7 weeks gestation,
2. Status post hyperbilirubinemia
3. Status post rule out sepsis.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2107-3-3**] 18:48
T: [**2107-3-3**] 17:00
JOB#: [**Job Number 49877**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2193-5-22**] Discharge Date: [**2193-6-1**]
Date of Birth: [**2126-7-31**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
female who presents with a history of angina and
hypertension. She underwent an angioplasty in the past and
stent placed recently. An angiogram after the stent showed
an aortic valve disease. Six months ago she was hospitalized
with congestive heart failure and treated with Lasix.
Currently she is unable to lie flat in bed or at least since
that episode.
PAST MEDICAL HISTORY: Type 2 diabetes time five years
treated with oral medicines, hypertension, high cholesterol,
coronary artery disease. In [**2162**]'s she had empyema, in [**2164**]
she had a Cesarean section. Cardiac catheterization showed
severe aortic disease with less than .57 cm sq valve area and
coronary arteries without significant lesions and severe
diastolic ventricular dysfunction. Her echo showed an EF of
25%, mild LVH, moderate LVH, aortic valve leaflets thickened
with stenosis, no regurg, 3+ mitral regurgitation with a
thickened valve.
MEDICATIONS: Preoperative meds are Aspirin, Atenolol, Lasix,
Zestril, Premarin and Provera, Glyburide, Glucophage,
Lipitor, Paxil, Multivitamin and Motrin. She has a rash
allergy to Sulfa drugs.
HOSPITAL COURSE: So on [**2193-5-22**] the patient was taken to the
operating room where she had an aortic valve replacement
surgery with Porcine valve. The indications for surgery were
an aortic stenosis with valve area less than .5 and CHF and
symptomatic severe aortic stenosis with shortness of breath
at rest, edema and occasionally cough. She tolerated the
procedure well. The day after surgery, when she awoke, she
was initially alert and oriented times three. However, by
mid morning she was confused and agitated with some paranoid
features. Her vital signs were stable with a heart rate of
between 80's and 90's and sinus rhythm with occasional APC's
and she had an episode of supraventricular tachycardia to
the 130's which resolved. She also had a thick yellow sputum
cough and she was started on Captopril on postoperative day
#1, 25 mg [**Hospital1 **] for her ejection fraction. Her postoperative
cardiac index was around 2.5, hematocrit 29 and she was alert
with some confusion but hemodynamically she was stable and
she was transferred to the floor. On the floor she had an
episode of being found with sudden onset of unresponsiveness
with eyes deviated to the left side. She had no verbal
output and was not moving her right arm and leg. She was
transferred to the CTIC and was intubated. She then
underwent a stat head CT which was negative for an acute
bleed. She was awakened the next morning and she had gradual
resolution of the symptoms on the right side of her body.
Aspirin was given to her as well and she was kept with
systolic blood pressure around 140/80.
Anesthesia was called for the emergent intubation.
Dr. [**Last Name (STitle) **] was made aware of this event. The following day
she was extubated and continued to have improvement in her
exam. She was not aware what had happened to her the day
prior. She was found to have a right pleural effusion and
she had a chest tube placed which drained about 400 cc of
serosanguineous fluid. She had gradual increase in her WBC
count from 13 to 24 and she was started on Ciprofloxacin.
She was being treated for E. coli in her UTI and sputum H flu
and found to have enterococcus and we added Ampicillin to her
antibiotic regimen. The patient on the floor was kept on
Ampicillin and Ciprofloxacin and she had slow progression.
She was seen by physical therapy. Her mental status changes
gradually improved and on postoperative day #9 she was
thought to be pretty much back to her baseline. She was
afebrile. Her WBC count was coming down and she will be
followed up at the skilled nursing facility, similar to where
she came from.
DISCHARGE MEDICATIONS: Lopressor 50 mg [**Hospital1 **], Multivitamin,
Darvocet N 100 mg prn, prn Albuterol nebs, Premarin,
Glucophage, Glyburide, Provera, Paxil, Captopril 25 mg [**Hospital1 **],
Lipitor 20 mg q d, Triamcinolone cream, Tylenol prn, Motrin
prn and Aspirin 81 mg po q d.
DISCHARGE INSTRUCTIONS: Include following up with neuro
clinic [**Telephone/Fax (1) **] in approximately two weeks, to continue to
check her WBC count. She should get a repeat urinalysis and
she should continue Cipro for 9 additional days. She should
continue Ampicillin for 6 more days for a total course of 10.
DISCHARGE DIAGNOSIS:
1. Status post AVR with hancok porcine valve.
2. Urinary tract infection.
3. Congestive heart failure.
DISCHARGE CONDITION: Stable. She will be followed up by Dr.
[**Last Name (STitle) **] in his office three weeks from date of surgery,
approximately 10 days from her discharge date and she should
get her staples removed in approximately 5 days from
discharge, postoperative day #14.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2193-6-1**] 06:20
T: [**2193-6-1**] 07:28
JOB#: [**Job Number 8345**]
|
[
"4280",
"41401",
"5119",
"5990",
"25000",
"4019"
] |
Admission Date: [**2124-10-19**] Discharge Date: [**2124-10-23**]
Date of Birth: [**2061-9-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
right handed gentleman who was diagnosed with non small cell
and small cell adenocarcinoma of the lung in 11/00 by biopsy.
It was felt to be inoperable and at the time patient was
treated with chemotherapy and radiation. He did well until
[**2124-3-16**] when he developed post radiation esophagitis
requiring tube feeding. He noted bilateral peripheral
neuropathy by hands and fingers and toes and this remained
stable and unchanged. She had otherwise been well and
reportedly had abdomen and chest CT done last week which were
stable. He had an MRI yesterday as part of a routine
postoperative follow-up and unfortunately was found to have a
large left sided cerebellar lesion with significant
surrounding edema. The patient reported one episode of
recent vomiting three days ago and denied headache, fever,
chills, nausea, blurred vision, double vision, photophobia or
noticeable changes in his mentation. He was told by his
primary care doctor to come to the Emergency Room for
evaluation.
PAST MEDICAL HISTORY: Includes appendectomy and mild
arthritis of the left hip.
MEDICATIONS: Include Buspar, Amitriptyline and Prilosec.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.9, heart rate 114,
blood pressure 143/86, respiratory rate 16, sats 98% on room
air. HEENT: Pupils are equal, round, and reactive to light,
extraocular movements full with no nystagmus, anicteric.
Neck supple, no nodes, no thyromegaly. Lungs clear to
auscultation without rales, rhonchi or wheezes. Cardiac,
tachycardic in the 110-114 range, in normal sinus rhythm.
Abdomen soft, nontender, non distended, positive bowel
sounds. Extremities with increased tone, normal bulk without
obvious atrophy, no clubbing, cyanosis or edema.
Neurologically his finger to nose was slightly off on the
left side. He had no clonus. His cranial nerves II through
XII were intact, there was full range of motion in all
extremities and he had mild 4/5 weakness of the proximal leg
on the left side greater than the right. Sensation was
intact to light touch. Deep tendon reflexes were increased.
His toes were downgoing bilaterally.
HOSPITAL COURSE: The patient was admitted to the heme/onc
service. On [**2124-10-20**] he was transferred to the [**Hospital Ward Name 517**]
and underwent a suboccipital craniotomy for resection of
tumor by Dr. [**First Name (STitle) **]. There were no intraoperative complications.
Postoperative he was monitored in the surgical Intensive Care
Unit. His vital signs were stable. He was afebrile. He was
awake and alert, moving all extremities with good strength
and following commands. He was transferred to the regular
floor on [**2124-10-21**]. He was awake, alert, oriented times three
with smiles symmetric, tongue midline with no drift. His
finger to nose was at its baseline with left dysmetria. The
patient was seen by physical therapy and occupational therapy
and found to be safe for discharge to home. He was
discharged to home in stable condition with follow-up with
Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**] Clinic in two weeks and staple
removal in 10 days.
DISCHARGE MEDICATIONS: Zantac 150 mg po bid, Decadron to be
weaned off over 10-14 days, Lopressor 25 mg po bid, Prilosec
20 mg po q day, Buspar 15 mg po bid, Amitriptyline 50 mg po q
h.s.
CONDITION ON DISCHARGE: Stable. He will follow-up in the
Brain [**Hospital 341**] Clinic in [**10-29**] days for staple removal.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2125-1-3**] 12:45
T: [**2125-1-4**] 19:40
JOB#: [**Job Number 7310**]
|
[
"4019",
"25000"
] |
Admission Date: [**2165-2-27**] Discharge Date: [**2165-2-28**]
Date of Birth: [**2103-1-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP and sphincterotomy
History of Present Illness:
62 yo male with hx of CAD s/p CABG, ischemic CMPY, and gallstone
and pancreatic stone pancreatitis who presented to OSH with
abdominal pain transferred to [**Hospital1 18**] for ERCP now s/p
sphincteromy but aborted pancreatic duct stone removal. Prior to
recent presentation pt was treated with ERCP in [**7-17**] for
pancreatic stones which they were hesitant to attempt to remove
given his cardiomyopathy so he was manage expectantly. He
represented to OSH on [**2165-2-14**] with increasing adominal pain in
his epigastrum radiating to his chest. He had negative CE, but
amylase and lipase were elevated to 319 and 3209, respectively.
CT scan showed no acute abnormalities with coarse calcifications
in the pancreatic head with calcified gallstones. He slowly
improved with central line placement, TPN and NPO with
advancement to clears, and he was transferred to [**Hospital1 18**] for ERCP
vs laproscopic surgical therapy for definitive treatment. He was
initially reluctant to have a procedure due to his cardiac risk
but was seen by cardiology who felt his risk was not
unreasonable and the patient was agreeable. Of note during his
OSH stay he developed a cough with LLL infiltrate on CXR so was
started on CTX and azithromycin changed to vancomycin. Pt
tolerated his ERCP well on [**2164-2-28**] during which he received 3.1L
of crystaloid. The procedure was difficult and pancreatic stones
were unable to be removed although extensive sphincterotomy was
performed. He had severe nausea and abdominal pain post
procedure so given risk of ERCP induced pancreatitis in pt with
poor LV function he was tranferred to the ICU for close
post-procedure monitoring.
Past Medical History:
Pancreatitis
CAD s/p CABG [**2143**]
left orchiectomy for orchitis
CHF EF 25-35% s/p AICD
COPD
HTN
TIA/CVA [**2158**]
remote EtOH
recurrent pancreatitis
cholelithiasis
BPH
Social History:
Drank heavily until first pancreatitis flare in [**7-17**]. Cont to
smoke 1 ppd since age 12, no use of other illicit substances.
Lives with his wife.
Family History:
Brother died of unknown type of CA, father died at 37 of
rheumatic heart disease, no other hx of CAD, CVA, CA or
pancreatic disease
Physical Exam:
T 99.0 HR 90 BP 110/75 RR 16 O2Sat 99% on 6L
Gen-mild pain
HEENT-PERRL, JVP to 7cm, MM dry
Hrt-RRR, nS1 S2, [**3-19**] SM at RUSB, no R or G
Lungs-crackles 2/3 up bilat
Abd-distended and tympanitic, no fluid wave, mild diffuse
tenderness
Extrem-2+ radial and dp pulses
Neuro-CNII-XII intact, [**6-15**] UE strength, distal sensation intact
Pertinent Results:
WBC 9.2 Hct 30.7 Plt 332
.
Chem 7
138 104 12 140
3.7 25 0.7
.
AP 54 AST 42 ALT 53 amylase 183
.
Ca 8.0 Mg 1.7 Phos 2.9
.
[**2165-2-18**] ETT-EF 36%, WMA septal, anterior and lateral worse toward
the apex with coincident fixed perfusion defects
.
ECG- a sensed and V paced with intermittent AV sequestial
pacing, cannot assess for ischemia with pacing.
.
CXR-bibasilar atelectasis
.
[**2165-2-27**] ERCP:
1. Localized continuous congestion of the mucosa was noted in
the first part of the duodenum
2. Cannulation of the bile duct was performed with a
sphincterotome using a free-hand technique.
3. The common bile duct was normal.
4. There were gallstones seen in the gallbladder
5. A biliary sphincterotomy was performed in the 12 o'clock
position using a sphincterotome.
6. Cannulation of the pancreatic duct was performed with a 5-4-3
tapered catheter.
7. Large impacted stones could be seen in a highly irregular
pancreatic duct in the head of the pancreas.
8. We were unable to traverse the stones with a guidewire.
9. A pancreatic sphincterotomy was performed using a
sphincterotome.
10. Pancreatic fluid mixed with stone fragments were seen
following the pancreatic sphincterotomy.
Brief Hospital Course:
62 yo male with hx of CAD s/p CABG, ischemic CMPY, and gallstone
and pancreatic stone pancreatitis who presented to OSH for
abdominal pain transferred for ERCP now s/p sphincterotomy but
aborted pancreatic duct stone removal.
.
## Abdominal pain: Patient received uneventful sphincterotomy
after presenting to OSH with symptoms consistent with acute
pancreatitis. The procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **].
Given instrumentation and dye injection into the pancreatic duct
during ERCP, the pt was at increased risk of ERCP-induced
pancreatitis. He was therefore transferred to the ICU for
further monitoring. The morning following the procedure, the
patient was completely asymptomatic without any complaints of
abdominal pain, nausea, or vomiting. It was therefore requested
that he be transferred back to his initial hospital for further
watchful waiting. It was also discussed, given his improved
cardiac function on a recent study, whether surgery would be an
option for treating this disease. However, this decision will
be deferred to his primary physicians.
.
## Cardiomyopathy: Recent imaging study suggested improving pump
function. He diuresed well on his own following the procedure
without need for any diuretics. His ace inhibitor and beta
blocker were restarted the morning following his procedure.
.
## Coronary artery disease: No evidence of ischemia over the
course of admission. Not on aspirin apparently since starting
warfarin at time of TIA in [**2158**]. Warfarin was held with the
possibility of further procedures in the near future.
.
## COPD: No documented PFTs in our system, although does have
significant smoking hx. Sounded more bronchospastic on exam
during admission. He was continued on albuterol, ipratropium as
needed.
.
## Pneumonia: Recently completed 10-day course of Zosyn. No
clinical evidence of pneumonia currently. He was not treated
with antibiotics following his procedure.
.
## TIA: On warfarin as an outpatient, although reason is not
entirely clear as there is no evidence that patient has atrial
fibrillation. Likely fewer bleeding events with aspirin with
similar secondary prevention benefit. He was not restarted on
aspirin or warfarin as described above, however, this should be
addressed with cardiolist/PCP at later time.
Medications on Admission:
Outpt meds:
Folate 1mg qd
Toprol XL 25mg qd
Lasix 40mg qd
Lipitor 20mg qd
Coumadin 2mg qd with 3mg on Wed
Imdur 60mg qd
Lisinopril 10mg qd
Prozac 20mg qd
Omeprazole 20mg qd
Creon
.
Meds on transfer:
Tylenol
Lipitor 20mg qd
Zosyn
Clonopin 0.5mg tid prn
Fluoxetine 20mg qam
Folate 1mg qd
Imdur 60mg qam
Lactulose 30ml qd
Lisinopril 10mg qam
Magaldrate 10mg qid prn
Reglan 10mg qachs
Toprol XL 25mg qd
MOM prn
Morphine 4mg q3h prn
ondansetron 4mg q8h prn
Protonix 40mg [**Hospital1 **]
Zolpidem 5mg qhs
Ipratropium and albuterol nebs
Discharge Medications:
1. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO ONCE (Once) as needed for nausea for 1 doses.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety, agitation.
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for indigestion.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheeze.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheeze.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
15. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed for nausea.
16. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: pancreatic stones, pancreatitis s/p ERCP
Secondary: CAD, CHF, COPD, HTN, BPH
Discharge Condition:
stable, pain-free, breathing comfortably on RA
Discharge Instructions:
You are being transferred back to [**Hospital3 3583**] for further
monitoring of your abdominal pain and pancreatic stones.
Followup Instructions:
Follow up with your PCP and gastroenterologist 1-2 weeks after
you are discharged from the hospital.
|
[
"4280",
"496",
"4019",
"V4581"
] |
Admission Date: [**2132-5-11**] Discharge Date: [**2132-5-16**]
Date of Birth: [**2082-8-23**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Tegretol / Hytrin / Zoloft / Prozac / Procardia Xl /
Wellbutrin / Doxepin Hcl
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
abd pain, n/v
Major Surgical or Invasive Procedure:
1. upper endoscopy
History of Present Illness:
49y/o F w/ DM type 1 for 29 yrs w/ triopathy, autonomic
dysfunction, HTN, Hypercholesterolemia, p/w 3 day h/o nausea,
emesis(clear, bilious then coffee grounds on day of presentation
to ED), followed by abd pain (epigastric location, non
radiating). Patient noticed blood sugars >500 [**Location (un) 1131**] on her
insulin pump. She thought that the pump was malfunctioning and
stopped it, decided to give herself insulin injections. Had
loose stool in am today. She had decreasd appetite, fatigue,
called 911 who transported pt to [**Hospital1 18**] ED.
In ED was given 5L NS, started on insulin gtt, Gap was 34 then
26 after several hours. Pt noted to have coffee ground emesis in
ED, placed NGT then NGL with one liter, cleared. Admitted to
MICU.
.
Her anion gap closed with insulin gtt, but with poor po intake,
she
remained on the insulin gtt. She remained NPO on [**5-13**] for EGD to
investigate the etiology of her upper GI bleeding.
Ultimately, she tolerated po intake, and was started on Lantus
10U HS.
The upper endoscopy demonstrated esophageal candidiasis, mild
gastritis, and severe esophagitis in the lower third of the
esophagus. H. pylori serology was sent, protonix was continued,
and
she was started on diflucan.
.
On review of systems, she denies any fever, chills, sweats,
nausea/vomiting/hematemesis/coffee ground emesis, chest pain,
shortness of breath, ankle swelling.
She does report some mild epigastric pain with swallowing over
the past few days.
Past Medical History:
1) Type I diabetes mellitus (DM1) Multiple admissions of DKA. In
particular, 2 years ago, the patient suffered from
pneumonia, sepsis, gastroenteritis, and was in a coma for 1
week. DM1 complicated by autonomic neuropathy, proliferative
retinopathy, peripheral neuropathy, and proteinuric nephropathy.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] manages at [**Last Name (un) **]. Managed with Neurontin for
peripheral neuropathy. Managed with Proamatine and Florinef for
orthostatic hypotension from autonomic neuropathy. Followed by
neurologist. Glucose control managed with Lantus and Humalog
Pump.
2) Major depressive disorder (over fifteen years) has required
admission in the past
3) Dialectal behavioral therapy (DBT) her participation with
reported benefit may suggest borderline personality disorder.
4) Breast cancer: Status post left lumpectomy and external
radiation therapy (XRT) ([**10-2**])
5) Left supraspinatus tendonitis
6) Hypertension
7) Hypercholesterolemia
.
Past surgical history:
1) Vitrectomy x4
2) Bilateral tubal ligation
3) Left lumpectomy ([**2130-9-30**])
Social History:
Occ Etoh, none recently. Not a smoker. Not currently working due
to MMP. Patient lives alone in [**Location (un) **], MA. She does not have
any children and has never been married. Prior to going on
disability, she was a manager of day care center for
approximately twenty years. She is educated to be a special
education teacher.
Family History:
No history of diabetes mellitus. No history of cancer.
Father - Died of myocardial infarction at the age of sixty-two.
[**Name (NI) 12237**] Hypertension
Brother - Hypertension
Physical Exam:
:
vitals: 98.6, 97.0, 98, 22, 154/64, 99% RA
GEN: a/o, no acute distress
HEENT: moist mucous membranes; no visible oropharyngeal
candidiasis
neck; supple, full range of motion
lungs; CTA bilaterally
heart: regular rate, rhythm. no m/r/g
abd: soft, hypoactive bowel sounds, non-tender, non-distended
ext: no c/c/e
neuro: grossly non-focal
Pertinent Results:
[**2132-5-11**] 11:11PM GLUCOSE-122* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-20
[**2132-5-11**] 11:11PM CK(CPK)-70
[**2132-5-11**] 11:11PM CK-MB-NotDone cTropnT-0.01
[**2132-5-11**] 11:11PM CALCIUM-8.2* PHOSPHATE-3.0# MAGNESIUM-2.4
[**2132-5-11**] 11:11PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2132-5-11**] 11:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2132-5-11**] 11:11PM URINE RBC-[**5-9**]* WBC-0 BACTERIA-RARE YEAST-NONE
EPI-1
[**2132-5-11**] 11:11PM URINE GRANULAR-0-2
[**2132-5-11**] 05:33PM GLUCOSE-125* UREA N-21* CREAT-1.2* SODIUM-143
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2132-5-11**] 05:33PM HCT-29.7*#
[**2132-5-11**] 01:00PM GLUCOSE-375* UREA N-32* CREAT-1.5* SODIUM-143
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-15* ANION GAP-30*
[**2132-5-11**] 10:23AM GLUCOSE-517*
[**2132-5-11**] 10:10AM GLUCOSE-553* UREA N-37* CREAT-1.9*#
SODIUM-139 POTASSIUM-5.7* CHLORIDE-91* TOTAL CO2-14* ANION
GAP-40*
[**2132-5-11**] 10:10AM ALT(SGPT)-26 AST(SGOT)-32 CK(CPK)-70 ALK
PHOS-109 AMYLASE-39 TOT BILI-0.3
[**2132-5-11**] 10:10AM LIPASE-17
[**2132-5-11**] 10:10AM CK-MB-NotDone cTropnT-0.02*
[**2132-5-11**] 10:10AM ALBUMIN-4.9* CALCIUM-11.2* PHOSPHATE-2.3*
MAGNESIUM-2.2
[**2132-5-11**] 10:10AM NEUTS-94.0* BANDS-0 LYMPHS-4.4* MONOS-1.4*
EOS-0.1 BASOS-0
[**2132-5-11**] 10:10AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2132-5-11**] 10:10AM PLT COUNT-405#
Brief Hospital Course:
Impression/Plan:
49yo type I DM X 29 years, w/ triopathy, autonomic dysfunction,
HTN, hypercholesterolemia, p/w DKA secondary to presumed insulin
pump dysfunction and coffee ground emesis.
.
1. Diabetic ketoacidosis
Etiology of her DKA was felt to be insulin pump dysfunction.
There was no evidence of infarction or infectious source - other
than esophageal candidiasis. She underwent aggressive volume
resuscitation, her anion gap closed, and was successfully was
changed over to lantus sc with sliding scale coverage.
Lantus dosing at discharge was 9units HS with humalog sliding
scale.
She was seen by [**Last Name (un) **] while in house, and will f/u with both
her pcp and [**Name9 (PRE) 387**].
.
2. Upper GI bleeding/ esophageal candidiasis
She presented with coffee ground emesis in the context of
nausea/vomiting. This was suspected to be [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]-[**Doctor Last Name **] tear,
but EGD demonstrated severe esophagitis, mild gastitis, and
esophageal candidiasis. Continued PPI and diflucan for
esophageal
candidiasis. She will complete a 14day course of fluconazole,
and will continue her PPI [**Hospital1 **]. Though her candidal infection was
likely in the setting of uncontrolled hyperglycemia, HIV RF were
addressed and the patient was offered testing. She was negative
for HIV ab.
.
.
Medications on Admission:
MEDS: lisinopril 10', lipitor 20', venlafaxine sr 150', asa
325', iron, fludrocortisone .1 M/W/F, calcium carbonate 500'',
gabapentin 1200', midodrine 5'', pantoprazole 40', insulin pump
(regular insulin with daily requirements near 8units per day of
regular), epo 1000u qwk, flonase 2p', lantus 3u qhs, humalog
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
2. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
3X/WEEK (MO,WE,FR).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
Disp:*300 units* Refills:*2*
11. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. DM 1, DKA
2. autonomic neuropathy, nephropathy, retinopathy
3. upper GI bleed; severe esophagitis and esophageal candidiasis
4. htn
5. hypercholesterolemia
6. depression, personality d/o
7. breast ca
Discharge Condition:
good
Discharge Instructions:
Continue to take your insulin by injection. Continue
to monitor your sugars at home and call your doctor if
your sugars are persistently in the 200's range. Call your
doctor for any abdominal pain, nausea, or vomiting. Continue
to drink plenty of fluids.
Followup Instructions:
* Call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for a follow up appointment
and also remember to follow up with [**Hospital **] Clinic
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"4019",
"2720"
] |
Admission Date: [**2126-5-7**] Discharge Date: [**2126-5-15**]
Date of Birth: [**2073-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine / Penicillins / Metformin / Heparin Agents /
Ativan
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
PICC line placement ([**5-8**]).
History of Present Illness:
This is a 53 yo man with history of severe COPD s/p tracheostomy
on continuous home 02 who presents with 2-3 days of worsened
dyspnea and thicker respiratory secretions. He has a
complicated pulmonary history with tracheomalacia s/p tracheal
stent placement and subsequent removal, history of MRSA and
resistant pseudomonas pneumonia, chronically elevated right
hemidiaphragm, chronic copious secretions and right and left
base atelectasis. PMHx also notable for steroid induced DM and
osteoporosis with subsequent vertebral fracture, kyphosis and
chronic back pain. He had been doing well from a respiratory
standpoint until recently. He had seen his pulmonologist Dr.
[**Last Name (STitle) 4507**] in clinic on [**4-24**], was steadily improving and tapering
his oxygen, requiring as little as 1L with rest at 3L with
exertion. At that time his steroids were decreased from 20mg
daily to 10mg alternating with 20mg. He does not endorse sick
contacts, but states " I live in a nursing home, everybody's
sick." Otherwise no change in medications. Symptoms of
increased dyspnea associated with low 02 sats, he checked on his
own, noted some levels to as low as the high 70s. He always has
lots of secretions, but noted lately they were thicker and
harder to cough up. Unsure if he has had fevers or chills, but
has had night sweats for the past several weeks. He has been
using his nebulizers more frequently. Also reports chest
tightness with episodes of respiratory distress, resolves with
nebulizers. Complaining of exacerbation of chronic low back
pain, occasional abd pain, improving with eating, and increased
lower extremity edema with R>L lower extremity erythema.
.
Reported VS at NH: VS 98.1 RR32 88/65 98% NRB with BS 177.
Received some IVF prior to transfer. In ED was 99.2 120 118/80
28 97% NRB, improved to 92% on 4L HR 110 100/70 RR 26 at time of
transfer to ICU. Labs were notable only for a left shifted WBC.
CXR showed old LLL collapse with partial new RLL collapse. He
received 1 dose of vancomycin in the ED, received 300 cc IVF
with 850 cc UOP. ECG showed sinus tach. He had a trop of 0.02
with MBI 9.1, CK 219 MB 20. Cardiology was called and
recommended trending enzymes, giving aspirin, no heparin. There
was concern for a PE in the ED due to patient's tachycardia, but
as he was unable to lay flat due to respiratory distress the
decision regarding treatment and work up was left to the
accepting team.
.
He was admitted to the [**Hospital Unit Name 153**] for further monitoring in the
setting of respiratory distress with tachycardia and need for
frequent suctioning.
.
In the [**Hospital Unit Name 153**] the patient complained mainly of [**8-19**] back pain as
well as shortness of breath as described above. He denied HA,
no change in appetite/PO intake. Endorses occasional heart burn
and RUQ pain, improved with meals. Constipation. No melena or
hematochezia. Otherwise ROS negative.
Past Medical History:
1) Severe O2-dependent COPD, recently on [**1-12**] L continuous O2 at
home
2) Tracheal stenosis s/p stent, stent removal, dilatation, and
tracheostomy insertion [**Month (only) 205**]-[**2124-8-9**]
3) Diabetes mellitus.
4) Osteoporosis.
5) Hepatitis B.
6) Vertebral compression fractures (details unknown).
7) Left 3rd finger amputation for osteomyelitis
8) History of intravenous drug use.
9) multi-drug resistant pseudomonas infection, + MRSA sputum
10) PUD hx of ulcers
11) Chronic right hemidiaphragm elevation/paralysis
Social History:
Mr. [**Name13 (STitle) 14302**] lives in the [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home. He quit
using heroin about eight years ago, but has an approximately 20
year history. He quit drinking more than seven years ago. He
quit smoking approximately one to two ears ago and has a 60 pack
year history. He smoked two packs per day for many years. He
tested HIV negative in the past. He used to work as a dog
groomer. He did work in construction in the past, but does not
know of any asbestos exposure. He denies TB exposure.
Family History:
Non-contributory.
Physical Exam:
Physical Exam at discharge:
Vitals: afebrile, normotensive, SaO2: 93% 40% Trach mask and 3L
General: unkempt, diaphoretic, jocular, mild tachypnea.
HEENT: No scleral icterus. Cushingoid facies. MMM.
Neck: Trach collar in place. JVD to 7cm at 90 degrees. Supple.
Pulmonary: Markedly kyphotic, persistant but overall inproved
wheezes with mildly prolonged expiratory phase. No crackles, no
appreciable egophany.
Cardiac: Tachycardic, regular
Abdomen: Protuberant. + BS. No rebound or guarding. Mild
distention. Bowel sounds present.
Extremities: R>L pitting edema to knee, RLE with pretibial
erythema, not warm, non-blanching, improves with elevation.
Skin: Cherry angiomata on chest.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout.
Pertinent Results:
Labs at Admission:
[**2126-5-7**] 01:00PM BLOOD WBC-6.4 RBC-4.83 Hgb-12.4* Hct-41.7#
MCV-86# MCH-25.7* MCHC-29.8* RDW-15.7* Plt Ct-294
[**2126-5-7**] 01:00PM BLOOD Neuts-86.0* Lymphs-7.9* Monos-4.4 Eos-1.3
Baso-0.5
[**2126-5-8**] 03:02AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0
[**2126-5-7**] 01:00PM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-142
K-4.0 Cl-101 HCO3-32 AnGap-13
[**2126-5-8**] 03:02AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
[**2126-5-7**] 01:10PM BLOOD Lactate-1.8
Cardiac Enzymes:
[**2126-5-7**] 01:00PM BLOOD CK-MB-20* MB Indx-9.1* proBNP-36
[**2126-5-7**] 01:00PM BLOOD cTropnT-0.02*
[**2126-5-7**] 08:13PM BLOOD CK-MB-16* MB Indx-5.6 cTropnT-<0.01
[**2126-5-8**] 03:02AM BLOOD CK-MB-20* MB Indx-7.1* cTropnT-0.01
Imaging Studies:
Chest x-ray PA and lateral ([**5-7**]):
1. Worsening right lung atelectasis with collapse of right
middle and right lower lobes.
2. Improving atelectasis left lower lobe.
Transthoracic Echocardiogram ([**5-8**]):
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 global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. with normal free wall contractility. There is
abnormal septal motion/position. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2124-6-9**], there is now moderate pulmonary hypertension detected.
Pertinant labs from admission:
[**2126-5-7**] 01:00PM BLOOD WBC-6.4 RBC-4.83 Hgb-12.4* Hct-41.7#
MCV-86# MCH-25.7* MCHC-29.8* RDW-15.7* Plt Ct-294
[**2126-5-15**] 04:41AM BLOOD WBC-11.3* RBC-4.55* Hgb-11.6* Hct-38.3*
MCV-84 MCH-25.4* MCHC-30.2* RDW-15.1 Plt Ct-329
[**2126-5-7**] 01:00PM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-142
K-4.0 Cl-101 HCO3-32 AnGap-13
[**2126-5-15**] 04:41AM BLOOD Glucose-146* UreaN-13 Creat-0.5 Na-142
K-4.6 Cl-94* HCO3-43* AnGap-10
[**2126-5-7**] 01:00PM BLOOD CK(CPK)-219*
[**2126-5-7**] 08:13PM BLOOD CK(CPK)-287*
[**2126-5-8**] 03:02AM BLOOD CK(CPK)-283*
[**2126-5-7**] 01:00PM BLOOD cTropnT-0.02*
[**2126-5-7**] 08:13PM BLOOD CK-MB-16* MB Indx-5.6 cTropnT-<0.01
[**2126-5-8**] 03:02AM BLOOD CK-MB-20* MB Indx-7.1* cTropnT-0.01
[**2126-5-8**] 03:02AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
[**2126-5-15**] 04:41AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
[**2126-5-7**] 06:53PM BLOOD Type-ART pO2-76* pCO2-86* pH-7.26*
calTCO2-40* Base XS-8
[**2126-5-13**] 02:02PM BLOOD Type-ART pO2-77* pCO2-74* pH-7.42
calTCO2-50* Base XS-18
[**2126-5-13**] 02:02PM BLOOD Lactate-1.8
CXR:
The tracheostomy is at the midline with its tip approximately 5
cm above the carina. The left PICC line tip is at the level of
cavoatrial junction/low SVC. There is no interval change in
bilateral pleural effusions, moderate in bibasal atelectasis.
The heart size is difficult to assess due to obscuration by
bilateral pleural effusions.
Brief Hospital Course:
In summary a 53 yo man with complicated pulmonary history
including COPD, tracheomalacia, diaphragmatic paralysis and
chronic right lower lobe collapse now presenting with three days
of worsening respiratory distress.
# Respiratory distress
The differential diagnosis for his respiratory distress included
COPD flare, pneumonia, lung collapse, CHF, pulmonic effusion,
PE, ACS. His respiratory symptoms were likely multifactorial. He
has had worsening thickened secretions and a CXR with evidence
of bilateral collapse and a possible LLL infiltrate. His BNP was
normal arguing against CHF. His ECG was unchanged, and the
slight increase in cardiac enzymes was likely due to demand in
the setting of tachycardia rather than true ACS. In terms of PE,
he had other more compelling diagnoses so this was not pursued
aggressively at admission. ABG in the ICU showed acute on
chronic respiratory acidosis.
He was started on meropenem and vancomycin given his history of
MRSA and MDR pseudomonas in sputum. Sputum and blood cultures
taken during this admission were negative. He was also started
on high dose corticosteroids with standing nebulizers with q1h
suctioning. Overnight he was placed on pressure support. With
these interventions, his respiratory status improved. He will
complete an eight day course of Vancomycin and Merpenum on
[**2126-5-15**]. A PICC-line has been placed for IV antibiotics. He was
given high dose steroids for COPD flare. He was attempted to
wean down to oral prednisone but the patient felt he was not
ready and so he remained on solumedrol. He was discharged on
solumedrol 20mg tid and will require a slow taper.
His trach was replaced with a trach that had a cuff to
mechanically ventilate him. This should be left in place until
he is at his baseline. He was having a lot of mucous secretions
and an insuflator/exeflator was utalized to mobalize secretions.
# Lower extremity erythema and edema
This appeared to be chronic, and per patient had worsened with
the need to sit up to sleep with legs dangling. On exam the
erythema was not warm, tender or blanching and thus a low
suspicion for cellulitis. He was encouraged to elevate his legs
at night. In addition, a TTE was done to work-up lower extremity
swelling. The TTE showed preserved left ventricular ejection
fraction with moderate pulmonary artery systolic hypertension.
There were no valvular abnormalities. On the second hospital
day, he was restarted on home Lasix. The lower extremity
erythema and edema remained stable.
# Chronic back pain
He has chronic mid-back pain, likely associated with known
mid-thoracic vertebral compression fractures from osteoporosis.
His pain was managed with prn Percocet and morphine IR.
Narcotic-related constipation was treated with docusate, senna,
and lactulose. During his course his morphine was increased as
he continually requested pain medication. He eventually started
to retain CO2 and his Trach was replaced with a cuffed trach so
he could be mechanically ventilated. He was somnolent for about
a day and his morphine was held. He recovered well and was
started on percocet 325/5 and oxycodone 5 to approximate his
home regemin.
# Elevated cardiac enzymes
These were felt to be due to demand ischemia as mentioned above.
Serial troponins were negative. He was continued on aspirin.
# Diabetes mellitus
He was kept on a regular diet with humalog insulin sliding
scale.
# Osteoporosis
We continued his home calcium and vitamin D. We spoke to him
about the importance of alendronate, which he adamently refused
to take due to stomach upset.
# Restless legs and insomnia
We increased the dose of Mirapex.
# FEN/electrolytes
He was kept on a cardiac, diabetic diet.
# Prophylaxis
No heparin for reported allergy, pneumoboots. Home proton-pump
inhibitor.
# Code status
His code status is full code as confirmed with patient.
Medications on Admission:
Albuterol sulfate nebs - 2.5 mg/3 mL (0.083 %) solution q4h prn
Alendronate 70 mg qweek
Citalopram 20 mg qday
Advair HFA 230 mcg-21 mcg inh - 2 puffs [**Hospital1 **]
Lasix 20 mg [**Hospital1 **]
Dilaudid 2 mg q6h prn
Insulin lispro sliding scale
Ipratropium 0.2 mg/mL (0.02 %) solution - 1 neb q4h
Lactulose 10 gram/15 mL - 30 mL [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Percocet 7.5 mg-325 mg q6h
Oxygen [**2-13**] lpm at rest, 4 lpm with sleep/exertion
Prednisone 10 mg qday alternatin with 20 mg qday
Bactrim DS 800 mg-160 mg qM-W-F
Acetaminophen 650 mg q4h prn
Bisacodyl 10 mg PR prn
Calcium 500 mg tid
Vitamin D3 800 U [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Milk of magnesia
Senna 8.6 mg 2 tablets qhs
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO twice a day.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
11. Pramipexole 0.125 mg Tablet Sig: Two (2) Tablet PO QHS (once
a day (at bedtime)).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath.
18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
19. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain.
20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
21. MethylPREDNISolone Sodium Succ 20 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses
Tracheobronchitis
COPD exacerbation
Secondary Diagnoses
Severe O2-dependent COPD
Tracheal stenosis s/p tracheostomy
Steroid-related diabetes mellitus
Steroid-related osteoporosis
Hepatitis B
Chronic back pain, likely related to known vertebral compression
fx
History of intravenous drug use
Narcotic dependence
Discharge Condition:
Vital signs stable
Discharge Instructions:
You were admitted to the hospital for respiratory distress. Your
symptoms improved with antibiotics and high-dose steroids. We
have increased the dose of the steroids, and started two new
antibiotics to be taken for two-weeks total. In addition, we
increased the dose of the Mirapex to help treat restless legs
syndrome and insomnia. There have been no other changes to your
medicines.
Please call your doctor or return to the ED for:
-worsening difficulty breathing, fevers
-any other symptoms concerning to you
Followup Instructions:
Previously-scheduled appointments
DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2126-9-24**] 8:30
|
[
"5180",
"2760"
] |
Admission Date: [**2149-7-7**] Discharge Date: [**2149-9-12**]
Date of Birth: [**2149-7-7**] Sex: F
Service: NEONATOLOGY
History: Baby Girl [**Known lastname 6870**] [**Known lastname 44451**] is the 865 gram product of a
26-4/7 weeks' gestation, born to a 31-year-old G3, P0, now 2,
mom. Prenatal screens: 0+, antibody negative, hepatitis
remarkable for spontaneous mono/di twinning. Noted a week
later found to be in preterm labor; admitted to the [**Hospital6 1760**] and treated with magnesium
sulfate and received betamethasone (complete on [**2149-7-5**]).
Twin-to-twin transfusion syndrome suspected by ultrasound
because of growth asymmetry. Mother also was
anemic with a hematocrit of 21. Advancing cervical
spontaneous vaginal delivery with Apgars of 8 and 8 for this
twin.
Physical Exam: Birth weight 865 grams (25th percentile),
length 35 cm (50th percentile), head circumference 24.5 cm
(25th to 50th percentile). Preterm infant with mild
respiratory distress, soft anterior fontanel, normal facies,
intact palate, moderate retractions, fair air entry, no
murmur, present femoral pulses, flat, soft, nontender abdomen
without hepatosplenomegaly. Normal perfusion, normal
external genitalia. Hips stable. Normal tone and activity
for chronological and gestational age.
History and Hospital Course by System:
Respiratory: [**Known lastname 6870**] was initially on the ventilator, maximal
settings 22/5. She received a total of two doses of
surfactant and by day of life 3 was extubated to CPAP. She
remained stable on CPAP until day of life #23, at which time
she was transitioned to nasal cannula O2. She remained on
nasal cannula O2 for a week, and was transitioned to room
air. She has remained stable on room air throughout the
remainder of her hospital course. She was empirically
started on caffeine citrate prior to extubation for management
of apnea and bradycardia of prematurity. Her caffeine citrate
was discontinued on [**2149-8-31**]. Her last documented episode
of apnea and bradycardia was on [**2149-9-4**].
Cardiovascular: [**Known lastname 6870**] initially required two normal saline
boluses and dopamine infusion for management of blood
pressure instability. She received one course of indomethacin
for presumed patent ductus arteriosus. She weaned off her
dopamine by day of life #2. Intermittent soft murmur has been
heard occasionally prior to discharge and attributed to anemia-
related flow murmur.
Fluid and Electrolytes: Her birth weight was 865 grams. Her
discharge weight is 2470 grams. She was initially started on
100 cc/kg per day of IV D5W. She started enteral feedings on
day of life #7, advanced to full enteral feedings by day of
life #27 with a brief period of NPO secondary to
infection. Her feeding course has been benign. Her maximum
enteral intake was 150 cc/kg per day of premature 30 calorie
formula with added protein via ProMod. She is currently
ad lib feeding, on NeoSure 24 calories per ounce as of [**2149-9-11**].
GI: Her peak bilirubin was 6.4 on day of life #1. She
was treated with phototherapy for a total of 10 days. Her
bilirubin rebound was within normal limits.
Hematology: Hematocrit on admission was 44.2. She received
two aliquots of packed red blood cells during her hospital
course. Her most recent hematocrit on [**2149-9-4**] was 25 with
a reticulocyte count of 9.8%. She is currently received
ferrous sulfate supplementation of 2 mg/kg per day, in
addition to her enteral feedings.
Infectious Disease: She was initially started on ampicillin
and gentamicin for rule out sepsis. Blood cultures remained
negative at 48 hours and antibiotics were discontinued. She
has received oxacillin times three doses for line
adjustments. On day of life #16 she presented with increased
work of breathing and concerns for sepsis were raised. CBC and
blood culture were obtained; blood culture was positive for E.
coli. The patient was treated for a total of 14 days with
gentamicin and ceftazidime and repeated blood cultures
remained negative. She has had no further issues with sepsis
during this hospital course.
Neurologic: Head ultrasounds on day of life #3, day of life
#7, and day of life #30, all have been within normal limits.
Sensory hearing screen was performed with automated auditory
brainstem responses and the infant passed both ears.
Ophthalmology: She has been followed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6955**] of
the CH ophthalmology department for mild retinopathy of
prematurity. Most recent exam on [**2149-9-12**] revealed mature
retinal vessels in both eyes. Followup with Dr. [**Last Name (STitle) 6955**] is
recommended in 8 months. His telephone number is [**Telephone/Fax (1) 43283**].
Psychosocial: A social worker has been following this
family. [**Doctor Last Name **], [**Known lastname 44452**] twin sister, passed away on
[**2149-8-13**]. The parents have been actively involved with their
social worker, [**Name (NI) 36130**] [**Name (NI) 6861**]. She can be reached at
[**Telephone/Fax (1) 8717**].
Condition at Discharge: Stable.
Discharge Disposition: Home.
Name of Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] from [**Hospital1 6687**],
[**State 350**], telephone number [**Telephone/Fax (1) 38070**].
Care Recommendations:
1) Feeds: Monitor growth closely; continue NeoSure until 6 to 9
months corrected gestational age to support nutritional needs and
growth.
2) Medications: Continue ferrous sulfate supplementation of
2 mg/kg per day to support her reticulocytosis.
3) Car seat position screening was performed for an hour and
a half; the infant passed the screening. State newborn
screens have been sent per protocol and have been within
normal limits.
Immunizations Received: She received her hepatitis B vaccine
on [**2149-9-6**]. She received her HIB, IPV and Pneumococcal
7-Valent on [**2149-9-6**]. She received her DTaP on [**2149-9-10**]
and she received her Synagis on [**2149-9-11**].
Immunizations Recommended: Synagis RSV prophylaxis should
be considered [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any
of the following three criteria: 1) Born at less than 32
weeks. 2) Born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the household or
with preschool sibs. 3) Chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease, once they
reach the responsive age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
Followup Appointments Recommended: Ophthalmology with
Dr. [**Last Name (STitle) 6955**] at [**Hospital3 1810**]. Telephone number is
[**Telephone/Fax (1) 44453**]. Referral has also been made to the Infant Follow-
Up Program at [**Hospital3 1810**], telephone nubmer 617-355-
DISCHARGE DIAGNOSES:
1) Premature twin #1, born at 26-4/7 weeks' gestation.
2) Status post respiratory distress syndrome.
3) Status post rule out sepsis,
4. Status post E. coli sepsis.
5) Anemia of prematurity.
6) Status post apnea of prematurity.
7) Status post hyperbilirubinemia
8) Status post retinopathy of prematurity.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2149-9-11**] 21:00
T: [**2149-9-11**] 21:26
JOB#: [**Job Number 44454**]
|
[
"7742"
] |
Admission Date: [**2101-10-15**] Discharge Date: [**2101-11-4**]
Date of Birth: [**2049-10-8**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worst headache of life
Major Surgical or Invasive Procedure:
[**2101-10-15**] EVD placement
[**2101-10-15**] Cerebral angiogram w/coiling
[**2101-10-25**] peg placement
[**2101-11-2**] VPS placement
History of Present Illness:
Patient is a 52 year old female who was in the bathroom when
she developed the worst headache of her life and syncopized.
She
awoke briefly but then quickly decompensated. 911 was called
and
she was taken to an OSH where she was intubated for worsening
neurologic exam and a CT of the head was obtained. the CT
showed
diffuse SAH consistent with a ruptured intracranial aneurysm.
She was transferred to [**Hospital1 18**] for further care. She arrives
intubated and sedated, BP prior to transport was reported at
220/120 and was lowered to 126/89 by the time [**Location (un) **] broguht
the patient to our ER. Per the [**Location (un) **] crew she was trying to
lift her head off the bed and shrug her shoulders when off
sedation in the helicopter. She is unable to participate in a
ROS secondary to intubation
Past Medical History:
Unknown
Social History:
Unknown
Family History:
Unknown
Physical Exam:
On Admission:
PHYSICAL EXAM:
Gen: Obese, intubated woman in distress. She is sedated
HEENT: Pupils: fixed at 1mm bilaterally
Neuro:
Mental status: intubated and sedated
Cranial Nerves:
I: Not tested
II: Pupils 1mm and nonreactive to light
III-XII unable to assess
Motor: extensor posture with BUE, TFR [**Location (un) **]
Toes upgoing bilaterally
ON DISCHARGE:
Lethargic, EO to voice, PERRL, oriented to self, month, and
"hospital" (although through hospital stay she has been only
oriented to self majority of the time). BUE is antigravity, but
patient is very deconditioned and complains of baseline
arthritic pain. [**Name (NI) **] - pt can lift antigravity although it is
difficult for her to do so, wiggles toes. Head Incision is C/D/I
with staples, patient is very diaphoretic and requires daily dsg
changes.
Pertinent Results:
CTA Head [**2101-10-15**]:
FINDINGS:
CT head demonstrates hemorrhage in the basal cisterns
predominantly in the
posterior fossa and suprasellar cistern. Blood is also seen in
the fourth
ventricle as well as in the lateral and the third ventricles.
There is
moderate hydrocephalus seen. There is exuberant calcification of
the distal vertebral arteries.
CT angiography of the head is limited due to insufficient and
mistiming of the bolus. Faint visualization of the posterior
circulation as well as the
anterior circulation arteries is seen. This appears to be a
focus of contrast in the suprasellar region adjacent to the
basilar tip suspicious for an aneurysm but this could not be
confirmed.
IMPRESSION: 1. Basal cistern and intraventricular hemorrhage.
Moderate
hydrocephalus. 2. CT angiography limited due to delayed contrast
bolus and
poor opacification of the intracranial vascular structures.
Subtle focus of hyperdensity in the suprasellar region adjacent
to the basilar artery
suspicious for an aneurysm.
CT Head [**2101-10-15**]:
IMPRESSION:
1. Status post basilar aneurysm clipping and new right frontal
approach
ventriculostomy catheter with tip in the atrium of right lateral
ventricle. Decreased caliber of right lateral ventricle,
persistent left lateral ventricular enlargement.
2. Mild redistribution of diffuse subarachnoid hemorrhage and
intraventricular hemorrhage as detailed.
CT HEad [**10-21**]:
1. Status post basilar aneurysm clipping with repositioning of
right frontal approach ventriculostomy catheter. Mild increase
of lateral ventricles is without evidence of hydrocephalus.
2. Interval redistribution of subarachnoid and intraventricular
hemorrhage
since [**2101-10-15**].
3. No new hemorrhage or acute vascular territory infarction is
noted.
CTA Head [**10-21**]:
IMPRESSION:
1. No siginificant change in the foci of SAH and IVH from recent
CT.
2. Patent major arteries, where well seen. Limited assessment
for the patency of the coiled Basilar tip aneurysm and adjacent
P1 segments
[**Month/Year (2) **] US/Doppler [**10-27**]:
IMPRESSION: No evidence of lower extremity DVT. Right-sided
[**Hospital Ward Name 4675**] cyst
MRI [**10-28**]:
1. No evidence of intracranial infection.
2. Subacute wedge-shaped left cerebellar infarct, as above.
3. Stable subarachnoid and intraventricular blood; stable
ventricular size.
CT Torso [**10-30**]:
IMPRESSION:
1. No cause for the patient's fever identified. No evidence of
pneumonia or abscess.
2. 13-mm splenic arterial aneurysm.
3. Fibroid uterus.
4. Prominent main pulmonary artery, suggestive of underlying
pulmonary
arterial hypertension
CT Head [**11-2**]:
IMPRESSION:
1. Interval placement of a ventriculoperitoneal shunt catheter
with tip in
the superior third ventricle.
2. Pneumocephalus, as above.
CT Head [**2101-11-4**]:
Stable appearance of ventricle size. VPS cath in place.
Brief Hospital Course:
52F who was admitted with a SAH after a basilar tip aneurysm
rupture. Upon admission an EVD was placed and she went
emergently to angio for coiling. She was admitted to the ICU for
close monitoring and Nimodipine was started. On [**10-16**] the angio
sheath was removed and an angio seal was placed. She remained in
the ICU and on [**10-19**] her EVD was clamped which patient only
tolerated for a few hours before her ICPs climbed > 20 and
sustained thus her EVD was re-opened. On [**10-20**] a clamping trial
was again attempted without success given the increase in her
ICPs and she has persistent fevers for which CSF fluid was sent
for analysis.
[**10-21**] patient was confused and not redirectable, concern for
vasospasm lead her to have a CTA which was negative for
vasospasm.
[**10-22**] persistant fevers, pan cultred. Another clamping trail was
attempted and was unsuccessful. CSF was sent for culture and
lopressor was started for tachycardia. PEG was discussed for
further nurtritional advancement.
On [**10-23**] patient's SBP was liberalized and her keppra was
discontinued. Exam remains the same with alert and oriented to
self, moving all extremities.
She has had multiple feeding trails with speech therapy and it
was recommended that she have a peg placed. She underwent this
procedure on [**10-27**].
On [**10-28**] we had to replace her EVD drain as it had fallen out and
we were no longer able to get an accurate pressure [**Location (un) 1131**] or
drain CSF.
Serial imaging from [**10-28**] remained stable. Clamping trials were
attempted time after time and failed. She underwent a VPS
placement on [**2101-11-2**]. Post-op she was stable but had decreased
urine output and received IV fluid boluses, she then became
hypertensive and had some wheezing and received Lasix x2, UOP
increased and patient remained stable. ID continued to follow
patient. She remained afebrile. ID recommended antibiotics for
14 days post VPS placement.
On [**2101-11-4**] she was discharged to rehab- [**Hospital3 **] in
[**Hospital1 3597**], NH
Medications on Admission:
Unknown
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Vancomycin 1000 mg IV Q 12H CSF infection
5. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
6. CefTAZidime 2 g IV Q8H
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
11. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days: started on [**11-4**].
12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP>160.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Basilar Tip Aneurysm
SAH
obstructive hydrocephalus
dysphagia
morbid obesity
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:
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 with Head CT
w/o contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Staple removal 10 days post-op. [**Month (only) 116**] be discontinued at Rehab.
Completed by:[**2101-11-4**]
|
[
"2859"
] |
Admission Date: [**2123-12-28**] Discharge Date: [**2124-1-4**]
Date of Birth: [**2050-11-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p MAZE,Coronary artery bypass grafts x 2( LIMA-LAD, RA-DG),
[**Last Name (un) 84256**] Mitral Valve Repair, ligation of left Atrial Appendage
[**12-30**]
History of Present Illness:
Ms. [**Known firstname 450**] [**Known lastname 92892**] is a 73 year old woman with a complex
past medical history including myocardial infarction in [**2104**] who
underwwent a cardiac catheterization after complaining of
dyspnea on exertion. This study revealed multi-vessel coronary
artery disease and she was referred for coronary artery bypass
surgery.
Past Medical History:
coronary artery disease s/p myocardial infarction [**2104**]
diabetes mellitis
paroxysmal atrial fibrillation
hypercholesterolemia
hypothyroidism
chronic obstructive pulmonary disease
carotid stenosis
kidney stones
gastroenteritis
mitral valve prolapse
WPW s/p ablation
hypertention
s/p tonsillectomy
s/p c-section
s/p vein stripping
Social History:
Ms. [**Known lastname 92892**] is an assistant manager in a retail store. She
quit smoking 15 years ago, but has a 35 pack year history. She
lives alone.
Family History:
Her family history is significant for a mother with a heart
murmur.
Physical Exam:
general: well appearing obese female in NAD.
VS: 98.6, 128/59, 59, 20, 99% on 2liters
HEENT: unremarkable
Chest: CTA bilat. Sternum stable.
COR: RRR S1, S2
ABD: obese, soft, round, NT,+BS
Extrem: Trace/ +1 edema of bilat LE. Left LE SVG intact and
healing well. Steri-strips in place.
neuro: intact. Affect flat.
Pertinent Results:
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2124-1-2**] 07:00AM 12.9* 3.45* 11.0* 31.3* 91 31.9 35.2*
14.5 176
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2123-12-28**] 11:00AM 63.5 29.0 4.2 2.1 1.3
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2124-1-4**] 05:20AM 24.9* 2.4*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2123-12-30**] 04:28PM 141*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2124-1-4**] 05:20AM 16 0.6 4.2
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2123-12-28**] 11:00AM Using this1
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2123-12-28**] 11:00AM 19 21 249 66 0.5
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2124-1-2**] 07:00AM 2.0
DIABETES MONITORING %HbA1c
[**2123-12-28**] 11:00AM 7.2*1
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 92893**]
(Complete) Done [**2123-12-30**] at 5:59:34 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2050-11-15**]
Age (years): 73 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Ischemic heart disease, Mitral regurg. Intraop
management
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2123-12-30**] at 17:59 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: *0.24 >= 0.29
Left Ventricle - Ejection Fraction: 65% >= 55%
Aorta - Annulus: 1.7 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Torn mitral chordae. No MS.
Moderate (2+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-24**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Houseofficer caring
for the patient was notified of the results by e-mail.
Conclusions
PREBYPASS
1. The left atrium is normal in size. Left atrial appendage PWD
velocities were > 20 cm/sec
2. No atrial septal defect or PFO is seen by 2D or color
Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF 65%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild (1+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened with a
significant thickening along the tip of the anterior leaflet
between A2 and A3. A small torn mitral chordae may be present in
the right atria. Predominantly moderate or at worst
Intermittently moderate to severe (3+) mitral regurgitation is
seen with a >=0.7cm withan eccentric, posteriorly directed jet.
Mitral valve area is 2.5 cm2, with a mitral annular diameter of
3.4 cm.
8. There is no pericardial effusion.
9. Dr. [**Last Name (STitle) 914**] told of all results during the surgery.
POSTBYPASS
1. Patient is on phenlyephrine and low dose epinephrine
2. The left ventricular function remains similar to prebypass
3. The mitral valve had [**First Name8 (NamePattern2) **] [**Last Name (un) 84256**] stitch placed. Post bypass
MVA measured 3.4 cm2 with a mitral annular diameter of 2.3 cm.
The vena contracta was 0.7 cm. The MR jet is directed along the
posterior wall.
4. The aortic wall is smooth after decannulation.
5. There is no left atrial appendage seen s/p ligation.
6. All findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2123-12-31**] 18:14
Brief Hospital Course:
Ms. [**Known lastname 92892**] was admitted pre-operatively for heparin given her
history of atrial fibrillation. On [**2123-12-30**] she underwent a
coronary artery bypass graft, mitral valve replacement, and MAZE
procedure with left atrial ligation. This procedure was
performed by Dr. [**Last Name (STitle) 914**]. The patient tolerated the procedure
well and was transferred in critical but stable condition to the
surgical intensive care unit. She was extubated and weaned from
her pressors by post-operative day two. By post-operative day
three she was able to be transferred to the surgical step down
floor. Her chest tubes and wires were removed. Coumadin was
started for her atrial fibrillation history her INR [**2124-1-4**] was
2.4 after rec'ing coumadin 2mg x3days. She was seen in
consultation by the physical therapy service. By post-operative
day 5 she was ready for discharge to rehab.
Medications on Admission:
glimiperide 0.5
pravastatin 40
coumadin 4 (M,W,F), 2 mg other days
levoxyl 100mcg
ASA 81
fosinopril 20
diltiazem 30 TID
lopressor 50 [**Hospital1 **]
albuterol
plavix 75
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): goal INR 2.0-2.5
Patient to take 1mg on [**1-4**] then as directed at rehabilitation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily ().
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
16. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 39721**]
Discharge Diagnosis:
paroxysmal atrial fibrillation
coronary artery disease
mitral regurgitation
s/p MAZE,Coronary artery bypass grafts x 2,Mitral Valve Repair,
ligation of left Atrial Appendage
Hypothyroidism
Noninsulin dependent diabetes mellitus
hypertension
hyperlipidemia
s/p Varicose vein ligation
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swiming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital 409**] clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**] in [**12-24**] weeks ([**Telephone/Fax (1) 24721**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks
please call for appointments
Completed by:[**2124-1-4**]
|
[
"41401",
"5119",
"496",
"42731",
"4240",
"4019",
"2449",
"2724",
"412",
"25000",
"V1582"
] |
Admission Date: [**2149-1-17**] Discharge Date: [**2149-2-5**]
Date of Birth: [**2080-7-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Progressive weakness
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy, C4-C5 and C5-C6.
2. Anterior cervical arthrodesis, C4-C5 and C5-C6.
3. Anterior instrumentation, C4 to C6.
4. Application, interbody device (VG2 graft), C4-C5 and C5-C6.
History of Present Illness:
Mr. [**Known lastname 98931**] is a 68-year-old man with a history of
cervical myelopathy and CIDP who presents with worsening
weakness.
He has a long-standing polyradiculoneuropathy, which began in
[**2135**] or [**2136**] with numbness over his right 4th finger. This has
been most recently treated with Prednisone. He has in the past
been treated with CellCept, but this was ineffective, and Imuran
caused a flu-like reaction. He has also recently been treated
with IVIg, but this has had to be held due to an acute worsening
of his chronic renal insufficiency - last treatment was [**2148-12-26**].
Plasmapheresis has been tried in the past, as well, but this was
also ineffective.
He had been doing well in [**Month (only) 1096**], and his prednisone dose was
decreased at that time from 15 mg daily to 10 mg daily. However,
at the beginning of [**Month (only) 404**], he developed tingling in his nose
and hands, and his prednisone was increased to 10 mg daily
alternating with 15 mg daily. This improved his symptoms.
He was due for an IVIg treatment on [**1-8**], but at that
appointment, it was noted that his Creatinine had risen up to
1.9, which had been a gradual increase over the prior 6 months.
The decision was made then to hold his IVIg until the etiology
could be determined.
He believes that he has been becoming progressively weak over
the
last 1-2 months, though it has been worse in the last week or
so,
with today being particularly bad. His proximal arm weakness was
noted to be worse at his visit on [**1-9**]. At the time,
this
was thought perhaps due to his cervical myelopathy. However, he
has progressed further since that time to the point of being
unable to get up the stairs to his apartment without assistance;
as recently as one month ago he was walking up 46 steps at the
[**Location (un) **] T station without help. As his neuromuscular fellow
points out, "All this has occured in the setting of prednisone
weaning, making steroid induced myopathy less likely."
He did have a C-spine MRI last week that showed a large disk
compressing the cord at C4/5. His orthopedic spine surgeon is
aware of his admission.
Mr. [**Known lastname 98931**] [**Last Name (Titles) 15797**] headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. [**Last Name (Titles) **] difficulties producing or
comprehending speech. [**Last Name (Titles) **] focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
[**Last Name (Titles) **] difficulty with gait.
On general review of systems, he reports some recent diarrhea,
consistent with his alternating constipation and diarrhea of
IBS.
He [**Last Name (Titles) 15797**] recent fever or chills. No night sweats or recent
weight loss or gain. [**Last Name (Titles) **] cough, shortness of breath. [**Last Name (Titles) **]
chest pain or tightness, palpitations. [**Last Name (Titles) **] nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. [**Last Name (Titles) **] arthralgias or
myalgias. [**Last Name (Titles) **] rash.
Past Medical History:
1. Chronic Inflammatory Demyelinating Polyradiculoneuropathy
(CIDP) as above.
2. Chronic renal insufficiency, baseline Cr 1.2-1.4, but with
elevation of his creatinine over the last month, now up to 2.0.
3. Possible myelodysplastic syndrome (persistently low blood
counts),
followed by Dr. [**Last Name (STitle) **]
4. Diabetes Mellitus
5. T8 compression fracture.
6. Squamous cell carcinoma
7. Cervical myelopathy
8. Irritable bowel syndrome, with chronic constipation
alternating with diarrhea
Social History:
He has a remote alcohol and smoking history, none now;
and no illicits. Formerly worked for the USPS.
Family History:
Father died age 57 of CAD, mother in 80s with
Alzheimers. No one with other neurologic disease.
Physical Exam:
Vitals: T: 98.5 P: 64 R: 18 BP: 139/87 SaO2: 99%RA FS 147
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. Bandages over forehead lesion. Slight edema around
eyes.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. Good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with 3 beats of bilateral end-gaze nystagmus.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Subtle pronator drift
bilaterally. No adventitious movements noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5- 4+ 4+ 4+ 4 4 4 5 5 5 5 4 4+
R 5 4 5 5 5 5 5 4- 5- 4+ 5- 5 4 4
-Sensory: Diminished sensation to pinprick over medial forearm
and medial fingers on right. Diminished cold sensation and
vibratory sense over bilateral feet to ankles. Proprioception
intact throughout. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 tr tr 0 0
R 1 tr tr 0 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Slightly wide-based with short stride.
Dorsiflexes toes while walking. Unable to walk in tandem.
Romberg
mildly positive.
.
MICU Txfer PE:
VS - Tm 102.7ax, Tc 100.4, BP 112/54 (112-164/54-70), HR 106
(58-106), RR 20, sats 100% on NRB. FS 140
I/O: incont today
I/O: [**1-29**]: 240 PO + 2275 IV/1485; [**1-30**]: 480PO + 1600/800 + BM x1;
[**1-31**]: 760 + 1800/1350
Gen: Obese, older male, in NAD. In c-collar and using NRB. Not
dyspneic or tachypneic. Talking in full sentences. Oriented x3.
HEENT: Sclera anicteric. PERRL. Slightly edematous L eyelid.
Skin flushed. MMM. Unable to assess for JVD due to collar.
CV: Tachy, regular, normal S1, S2. No murmurs appreciated but
difficult to hear due to rhonchorous breath sounds.
Lungs: Diffuse, rhonchorous breath sounds throughout the
anterior chest. No crackles appreciated at the bases.
Abd: Soft, NTND. + BS. No masses. No HSM appreciated.
Ext: No edema. Negative [**Last Name (un) 5813**] sign bilaterally. LE in
pneumoboots bilaterally. 2+ DP pulses. + erythema, warmth of L
knee.
Pertinent Results:
Radiologic Data:
MRI C-spine: Extensive degenerative changes of the cervical
spine
with severe canal stenosis at C4/5. Although the cord is
compressed at this level, there are no cord signal
abnormalities.
These findings are not significantly changed compared to
[**2147-5-22**].
.
Bone Marrow Biopsy: [**2149-1-21**]:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
1. Fragmented bone marrow biopsy with maturing trilineage
erythroid dominant hematopoiesis.
2. Absent iron stores
.
Renal US:
LIMITED LIVER ULTRASOUND: The liver shows no focal or textural
abnormalities. The gallbladder appears normal without evidence
of stones on this non-fasting study. There is no intra- or
extra-hepatic biliary dilatation; the CBD measures 4 mm in
diameter. Color Doppler demonstrates patent and anterograde
portal venous flow. Patency is also demonstrated in the right
and left portal veins, the hepatic veins, and the splenic vein.
There is no ascites.
IMPRESSION: Normal-appearing liver and gallbladder with patent
portal veins.
.
CTA Chest:
IMPRESSION:
1. No pulmonary embolism.
2. Bilateral lower lobe consolidation and small bilateral
pleural effusions. Patchy right upper lobe airspace opacity.
Differential diagnosis includes infectious etiology. Followup is
recommended.
3. Mid thoracic vertebral body compression deformity of unknown
chronicity.
.
CT NEck:
CLINICAL INFORMATION: Patient with acute hypoxia and tachypnea.
There is slight thickening of the right aryepiglottic fold
identified. The trachea and subglottic space is well maintained.
The nasopharynx is also well maintained. There are postoperative
changes in the lower cervical region with patient status post
anterior discectomy. There are degenerative changes visualized
in the cervical spine. No definite focal abscess identified.
Soft tissue changes are seen in the partially visualized right
sphenoid sinus and a retention cyst is seen in the left
maxillary sinus. At the right lung apex, linear opacities are
identified with opacities at the posterior lung base which could
be due to atelectasis. Correlation with chest CT recommended.
IMPRESSION: Status post anterior discectomy. Soft tissue changes
identified at the level of upper aspect of the postoperative
change with indentation on the posterior aspect of the
oropharyngeal airway, thickening of the right aryepiglottic
fold, and obliteration of the right piriform sinus could be
related to surgery but are slightly unusual in position and
direct inspection is recommended to exclude focal abnormality.
This finding is new since the previous cervical spine MRI of
[**2149-1-11**].
.
[**2-2**]: CXR:
Comparison is made with prior study performed a day earlier.
Left lower lobe retrocardiac opacity has improved, right lower
lobe atelectasis/consolidation is unchanged, ill-defined opacity
in the right upper lobe is also stable. Mild cardiomegaly is
unchanged. Small bilateral pleural effusions are stable.
.
[**2149-1-17**] 09:50AM BLOOD WBC-4.5 RBC-3.92* Hgb-10.7* Hct-33.0*
MCV-84 MCH-27.2 MCHC-32.3 RDW-17.6* Plt Ct-96*
[**2149-1-24**] 06:55AM BLOOD WBC-1.9* RBC-3.61* Hgb-9.7* Hct-30.1*
MCV-83 MCH-26.8* MCHC-32.2 RDW-17.2* Plt Ct-67*
[**2149-2-1**] 06:30AM BLOOD WBC-3.8* RBC-3.32* Hgb-9.0* Hct-27.6*
MCV-83 MCH-27.2 MCHC-32.7 RDW-19.3* Plt Ct-72*
[**2149-2-5**] 05:40AM BLOOD WBC-2.8* RBC-3.15* Hgb-9.4* Hct-26.5*
MCV-84 MCH-29.8 MCHC-35.4* RDW-20.0* Plt Ct-85*
[**2149-1-17**] 09:50AM BLOOD UreaN-40* Creat-2.0* Na-139 K-4.5 Cl-106
HCO3-24 AnGap-14
[**2149-1-31**] 05:50AM BLOOD Glucose-86 UreaN-21* Creat-1.4* Na-138
K-3.5 Cl-101 HCO3-29 AnGap-12
[**2149-2-5**] 05:40AM BLOOD Glucose-103 UreaN-16 Creat-1.3* Na-139
K-3.4 Cl-104 HCO3-28 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 98931**] is a 68-year-old man with a history of cervical
myelopathy and chronic inflammatory demyelinating
polyradiculoneuropathy (CIDP) who presents with
progressive weakness over the last month. His neurologic exam is
notable for diffuse weakness, worse distally than proximally
though with bilateral IP involvement. He also has sensory loss
distally. These findings are consistent with a neuropathy,
although the progressive weakness may be a result of his
myelopathy.
1. Cervical myelopathy:
The patient was admitted to the neurology service as his exam
suggested an upper motor neuron pattern of weakness (consistent
with spinal cord compromise more than his known CIDP), for
consideration of surgery. Orthopedics evaluated him (Dr.
[**Last Name (STitle) 1352**]) after an MRI showed cord compression in the upper
cervical cord. Surgery was recommended, but as his platelets
dropped during the admission, surgery was felt to be unsafe
until his platelets could be stablized. Eventually, after IVIG
infusions and transfusions of several packs of platelets
immediately afterwards, his platelets rose to >100,000 and he
was taken to the OR on [**2149-1-30**] for anterior discectomy and
fusion. Stress dose steroids were given perioperatively.
Surgery was uncomplicated and blood loss was only 50cc.
Dilaudid PCA was used postoperatively to control pain, then
transitioned to oral narcotics. Strength in the arms improved
during admission (residual C7 weakness bilaterally) and strength
in the legs also improved to 4+/5 at the right IP and [**4-28**] at the
left IP, 5-/5 at bilateral hamstrings. He was followed by the
Neuromuscular service while he remained in house. His platelets
remained stable for 48 hours after the procedure (80-100,000
range) but on post-op day three dropped to 72,000...
Physical therapy followed him both pre- and postoperatively and
recommended rehab.
2. CIDP
Prednisone was continued initially at his home dose. Lower
motor neuron signs of weakness consistent with the CIDP were
quite mild throughout the admission, and in fact, as his renal
function improved (initial reason IVIG was stopped), IVIG was
re-initiated, both for CIDP and for platelet dysfunction.
Stress dose steroids were given perioperatively, as above.
He gets 35g IVIG q day x 2 days every two weeks. He will be due
for his next dose of IVIG early next week. In the past he has
been receiving his IVIG infusinons at the infusion clinic at
[**Hospital1 18**]. The number for that clinic where he is known is : [**Telephone/Fax (1) 98932**]. If you are not able to get in contact with then,
please call Dr. [**Last Name (STitle) 7673**] at Pager: [**Telephone/Fax (1) 8717**], [**Numeric Identifier 58341**] (however,
the infusion clinic will be better able to assist with the
specifics of his infusions).
He is also maintained on prednisone for this, which at time of
discharge is being administered at doses of 10mg and 15mg on
alternative days (please restart this regimen on day #2 of
[**Hospital1 **] as he is to get 1 more day of 40mg prednisone for a
gout flare).
3. Acute on chronic renal insufficiency
FENa was checked and was 0.3, suggesting an element of pre-renal
failure, likely due to poor po intake and chronic diarrhea from
IBS. He was hydrated and electrolytes normalized, as renal
function overall improved. Renal consults followed him
initially and renal u/s was normal; they signed off once renal
function improved with hydration.On discharge, his Cr returned
to its baseline.
4. Respiratory illness
On post-op day 3 following the discectomy and fusion
(decompression of spinal cord), he was found to be febrile to
103.5 axillary, with low level of responsiveness and sats in the
low 80s (80-82%), tachypneic on exam with rhonchorous lung
sounds, and no improvement with high-flow nasal cannula. He was
placed on non-rebreather O2 and sats increased to high 90s; ABG
was: pH 7.40 pCO2 46 pO2 123 HCO3 30 BaseXS 2. He was started
on broad-spectrum antibiotics (vanco, levaquin and flagyl), and
maintained on nonrebreather as this was unable to be weaned
without substantial drop in oxygen saturations. CTPA and CT of
the neck were ordered which showed no post-surgical abscess and
no PE but confirmed a bilateral consolidation consistent with a
significant aspiration pneumonia. As he could not maintain his
SaO2 without the 100% Non-rebreather, a MICU consult was
initiated and transfer to that service was effected. He was
started on Vancomycin, Levofloxacin and Flagl to cover for
aspiration pneumonia and also to cover for MRSA given his long
hospital course. He did not require intubation; his O2
requirement was decreased after 2 days in the ICU and he was
able to breath on room air >48 hours prior to discharge. We plan
to continue him for 7 additional days with Vancomycin and
Flagyl. The Flagyl can be transitioned to PO.
5. Hematology/? Myelodysplastic syndrome:
Platelets dropped during the admission and after consult with
hematology, etiology was felt to be chronic ITP, likely kept at
bay with the IVIG infusions he had received as an outpatient for
the CIDP. Platelets were felt to be sequestered in the spleen,
and he was advised to ambulate with nursing three times daily to
limit this complication pre-op. Platelets rose to an acceptable
level for operation by [**1-30**] and he was taken to the OR after IVIG
and platelet infusion. Platelets dropped to 72,000 on [**2-1**]. In
addition to his thrombocytopenia, he was anemic, felt to be
severe iron deficiency-related. He was treated with IV Fe
Gluconate. he had a bone marrow biopsy on this admission - this
was not consistent with a myelodysplastic syndrome.
6. Diabetes
Team held metformin in preparation for possible surgery and
imaging studies, continued glyburide, while covering with ISS.
He was switched to glipizide at the recommendation of the Renal
team. Blood sugars were within goal range, in general.
7. HTN: the patient was changed from atenolol to metoprolol
given his renal insufficiency. He was still hypertensive to the
160s-170s - hence amlodipine 5mg daily was added onto his
regimen prior to discharge.
8. Gout Flare: Post op he developed gouty flares in his L knee,
L 1st MTP and L wrist. Rheumatology was consulted who
recommended:
- 2 days of prednisone 40mg
- colchicine 3x/week
- recheck his uric acid level in 1 month (it was 7.1 on [**2149-2-3**])
- by discharge, his knee and L 1st MTP were improved.
9. CODE: FULL
Medications on Admission:
ATENOLOL 50 mg--1 tablet(s) by mouth a.m.
Caltrate-600 Plus Vitamin D3 600 mg-400 unit--1 tablet(s) by
mouth twice a day
GLYBURIDE 2.5 mg--2 tablet(s) by mouth daily
LORAZEPAM 0.5 mg--Tablet(s) by mouth as needed for 3 times a day
prn
METFORMIN 500 mg--2 in am; 3 in pm twice a day
PREDNISONE 10 mg--1 tablet(s) by mouth 10mg alternating with
15mg daily
PROTONIX 40 mg--1 tablet(s) by mouth a.m.
TERAZOSIN 2 mg--twice a day one in the am and two at bedtime
VITAMIN B-12 1,000 mcg--once in am once in pm twice a day
XALATAN 0.005 %--1 drip instill each eye at night
Allergies: Penicillins
Discharge Medications:
1. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 7 days.
2. Vancomycin in Dextrose 1 gram/250 mL Solution Sig: One (1)
Intravenous twice a day for 7 days.
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 3x/week for 1
months: Please give every other day.
Hold for diarrhea.
.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
15. Terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-25**]
Puffs Inhalation Q6H (every 6 hours) as needed.
19. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal
QID (4 times a day) as needed.
20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
21. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 days.
22. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QOD: To
restart alternating between 15mg and 10mg daily. To start after
1 more dose of 40mg is given.
23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD: To
restart taking this. His typical prednisone dose is alternating
between 10mg and 15mg. (He has to get 1 more dose of 40mg before
enacting this regimen).
24. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
25. Heparin, Porcine (PF) 5,000 unit/0.5 mL Syringe Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Cervical stenosis with myelopathy.
2. Cervical spondylosis.
3. Chronic inflammatory demyelinating polyneuritis.
4. Thrombocytopenia with idiopathic thrombocytopenic
purpura.
Discharge Condition:
Stable to rehab
Discharge Instructions:
You were admitted for a fall and found to have compression of
your spinal cord. You underwent surgery for this. During your
hospitalization, you had an aspiration pneumonia.
.
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician.
Followup Instructions:
Please follow up the Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] at two weeks from the
date of your surgery. If you need to make this appointment,
please call [**Telephone/Fax (1) **].
.
You have the following premade appointments:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2149-2-27**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2149-3-28**]
1:00
Completed by:[**2149-2-5**]
|
[
"5849",
"5070",
"5180",
"40390",
"25000"
] |
Admission Date: [**2150-4-25**] Discharge Date: [**2150-5-15**]
Date of Birth: [**2085-10-25**] Sex: F
Service: MEDICINE
Allergies:
Hydrocodone / Imipenem/Cilastatin Sodium / Zosyn
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Transferred for management of cryptogenic organizing pneumonia
Major Surgical or Invasive Procedure:
VATS
History of Present Illness:
64 yo female w PMH of bilat pulm emboli in [**2147**] and in [**1-3**],
chronic bronchitis, transfer from [**Hospital1 **] [**Location (un) 620**] to [**Hospital1 18**] with
VATS confirmed cryptogentic organizing pneun on [**4-23**], with
increased FI02 requirments, increased PEEP and concern of
developing ARDS.
.
She initailly presented to OSH on [**4-11**] with c/o SOB/ DOE and
treated presumptively for pneumonia. She was started on
levofloxacin 500mg a day. Repeat x-rays showed increased
bilateral infiltrates. Despite antibiotics and inhalers, she
continued to have worsening shortness ofbreath. Sputum was sent
for culture that was negative. Influenza culturewas also
negative. The patient continued to do worse with saturations
dropping as low as 86% on two liters nasal cannula. By [**2150-4-13**],she was increasingly hypoxic and uncomfortable with
tachypnea. A repeatchest CT scan was done showing interval
development of interstitial consolidation and ground glass
bilaterally as well as bilateral effusions. There was no
evidence of new pulmonary emboli. The patient was transferred to
the intensive care unit for closer monitoring. Later that night,
she developed hypoxic respiratory failure and was intubated.
Repeat cultures were sent and the patient's antibiotic coverage
waschanged to Zosyn. Pulmonary and infectious disease were also
involved atthis point. Azithromycin was started for empiric
coverage of legionella which turned out to be negative. In
addition, human immunodeficiency virus and quantitative IgG were
checked to rule out immunocompromisedstated. Both were within
normal limits. The patient was started on empiric steroids which
did over some improvement. A bronchoscopy was done, cultures
from which remain negative including acid fast bacilli and
Pneumocystis carinii pneumonia. A few days later, steroids
wereabruptly discontinued because of concerns of intraabdominal
process. The patient self-extubated on [**2150-4-17**]. She
initially did well with 97%-98% on two to three liters nasal
cannula. However, over the course of several days, she continued
to have bilateral infiltrates and was not responding to
antibiotics. Ultimately, on [**2150-4-22**], the patient
underwent VATS: notable for an nflammatory process and negative
for an infectious process. Subsequent
to biopsy, the patient was restarted on high-dosed steroids. She
remains intubated with increasing hypoxic failure. Currently,
she is requiringincreasing amounts and PEEP and chest x-rays
show bilateral infiltrates onsistent with bronchiolitis
obliterans with organizing pneumonia,interstitial process, or
adult respiratory distress syndrome. Of note, antibiotics have
been changed from Zosyn to imipenem because of rash. Today, it
was noted that she developed a rash to Imipenum dose at 1:00am
and at 6:00am.
Past Medical History:
Pulmonary embolism [**1-3**]
chronic bronchitis
HTN
ulcerative colitis
chronic bronchitis
pneumonia
degenerative back
depression
Social History:
retired teacher, now runs a daycare center with her daughter;
+15 yr of tobacco hx quit 15 yrs ago
Family History:
breast cancer in aunt, sister,
stomach cancer and lung cancer in mom
Physical Exam:
GEN: lying in bed in NAD
HEENT: no JVD, MMM, ETT in place
CV: RR, no Murmur
Lung: CTAB; minimal crackles diffusely
Abd: soft, NT/ND, +bs
Ext: no C/C/E, +2DP pulses bilat
Pertinent Results:
[**2150-4-25**] 04:14PM WBC-20.2*# RBC-3.67* HGB-10.6* HCT-33.1*
MCV-90 MCH-28.7 MCHC-31.9 RDW-14.5
[**2150-4-25**] 04:14PM PLT COUNT-300
[**2150-4-25**] 04:14PM GLUCOSE-143* UREA N-25* CREAT-0.7 SODIUM-145
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-33* ANION GAP-7*
[**2150-4-25**] 04:14PM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-2.1
[**2150-4-25**] 04:14PM CK-MB-NotDone cTropnT-<0.01
[**2150-4-25**] 04:14PM PT-15.9* PTT-21.5* INR(PT)-1.6
[**2150-4-25**] 04:34PM freeCa-1.23
[**2150-4-25**] 04:34PM GLUCOSE-146* LACTATE-1.0
.
[**2150-4-30**] 11:20 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-4-30**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2150-5-2**]):
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
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
CHEST (PORTABLE AP) [**2150-4-26**] 11:16 PM
AP SUPINE VIEW OF THE CHEST: There is a right-sided IJ line
terminating in the distal SVC. There is a right-sided chest tube
terminating in the region overlying the right upper lung zone.
The ET tube is in satisfactory position within the thoracic
inlet. The NG tube terminates in the stomach. There are diffuse
bilateral patchy alveolar opacities. No evidence of
pneumothorax. There is no pleural effusion. Degenerative changes
with scoliotic curvature of the spine are noted.
IMPRESSION: Bilateral diffuse alveolar opacities with an
appearance consistent with ARDS.
.
PORTABLE ABDOMEN [**2150-5-2**] 3:41 PM
SINGLE SUPINE PORTABLE VIEW OF THE ABDOMEN: A feeding tube is
demonstrated overlying the distal second portion of duodenum. A
nonspecific bowel gas pattern is noted. There is a scoliotic
curvature of the spine with degenerative changes, convex to the
right.
.
Brief Hospital Course:
64 year old female with a history of pulmonary embolus, who was
transfered from an OSH after VATS confirmed cryptogenic
organizing pneumonia (COP). Initially, her respiratory failure
was thought to be related to cryptogenic organizing pneumonia
(COP). However, it was likely multifactorial due to a component
of pneumonia and CHF as well. She was continued on prednisone
for COP, and diuresed to a goal negative 1000cc per day. She
was eventually found to have a MRSA pneumonia and empyema for
which antibiotics and chest tube placed for treatment. She was
continued on assist control mechanical ventilation with
increased PEEP and FiO2 requirements. Eventually, it was clear
that she would not be able to wean from the ventilator due to
her deompensated respiratory status. It also became clear that
she could no longer be sustained on the ventilator. Given her
grim prognosis, her family members, including Health Care Proxy,
decided to withdraw care and remove the patient from the
ventilator. She was extubated, made comfortable with narcotics,
and passed away within an hour of ET tube removal.
Medications on Admission:
coumadin, lipitor, pentasa, prozac, cartia, albuterol, flovent,
HCTZ/triamterene, wellbutrin, protonix
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"99592",
"51881",
"78552",
"496",
"4019"
] |
Admission Date: [**2176-3-3**] Discharge Date: [**2176-3-8**]
Date of Birth: [**2115-8-17**] Sex: M
Service: UROLOGY
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Azithromycin /
Iodine / Shellfish / Ace Inhibitors / Ciprofloxacin
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
Chronic prostatitis
Major Surgical or Invasive Procedure:
TURP
History of Present Illness:
[**First Name4 (NamePattern1) **] [**Known lastname **] a 60-year-old man with a
long history of chronic prostatitis status post two
transurethral resection of the prostate procedures in [**2165**]
and [**2169**]. He also has a diagnosis of interstitial cystitis
and more significantly has a history of coronary artery
disease with a recent catheterization, supraventricular
tachycardia, and a progressive mitochondrial myopathy.
He has had symptoms of dribbling, stress
incontinence, hematuria, but has no dysuria. He was
preadmitted for cardiac clearance by Dr. [**Last Name (STitle) **], his
cardiologist.
Past Medical History:
1. Coronary artery disease (s/p stents to LAD and 3rd OM)
2. Supraventricular tachycardia (on a beta blocker).
3. Mitochondrial myopathy.
4. History of orthostasis with tilt table testing done in
the past.
5. Status post transurethral resection of prostate times
two (in [**2165**] and [**2169**]).
6. Interstitial cystitis.
7. Pericarditis.
8. Hypertension.
9. Hypercholesterolemia.
10. Gastrointestinal bleed
Social History:
denies any tobacco. Divorced, lives in [**State 108**]
Family History:
Father had MI at 42
Mother died of MI at 76
Physical Exam:
Gen: NAD
HEENT: MMM
CV: RRR, no m/r/g
Lungs: CTAB
Abd: soft, +distension with tympany, no HSM, hyperactive BS
Ext: no c/c/e
Neuro: A&Ox3.
ECG: NSR at 62, nl axis, nl intervals, Q waves in III, avR, V1.
TWI's in III, V1.
Pertinent Results:
[**2176-3-3**] 01:02PM GLUCOSE-94 UREA N-22* CREAT-1.4* SODIUM-142
POTASSIUM-5.9* CHLORIDE-108 TOTAL CO2-23 ANION GAP-17
[**2176-3-3**] 01:02PM CALCIUM-9.7 PHOSPHATE-3.9 MAGNESIUM-1.9
[**2176-3-3**] 01:02PM WBC-7.5 RBC-5.09 HGB-15.4 HCT-43.7 MCV-86
MCH-30.2 MCHC-35.2* RDW-13.6
[**2176-3-3**] 01:02PM PLT COUNT-257#
[**2176-3-3**] 01:02PM PT-12.2 PTT-23.8 INR(PT)-0.9
Brief Hospital Course:
On HD2, cardiac clearance was obtained by Dr. [**Last Name (STitle) **].
Patient tolerated procedure on [**2176-3-4**] and was transferred to
ICU for 24hr post-op cardiac monitoring. Stay was uneventful.
On POD1, patient was transferred out of [**Hospital Unit Name 153**] to 12R. Catheter
was removed. He was started on Pyridium.
On POD2, patient was deemed suitable and stable for discharge.
On POD4, patient was discharged.
Discharge Medications:
1. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for indigestion/gas
pain.
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
6. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
8. Phenazopyridine HCl 100 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) for 3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic prostatitis
Interstitial cystitis
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
Followup Instructions:
F/U with [**Doctor Last Name 365**]. Call for appointment
F/U with Dr. [**Last Name (STitle) **] in [**3-7**] weeks.
Completed by:[**2176-3-8**]
|
[
"41401",
"42789",
"4019",
"2720"
] |
Admission Date: [**2110-12-25**] Discharge Date: [**2111-1-7**]
Date of Birth: [**2077-12-29**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
HA, dizziness, progressive lethargy and ataxia
Major Surgical or Invasive Procedure:
[**2110-12-26**] diagnostic cerebral angiogram
[**2110-12-29**] cerebral angiogram with coil embolization of the left
middle meningeal artery.
[**2111-1-2**] cerebral angiogram with oynx embolization to the R
occipital dural fistulas
History of Present Illness:
Dr. [**Known lastname 91315**] is a 32 year old male who initially presented c/o
several days of progressive lethargy, nausea, and difficulty
ambulating. He also reports slurring of his words while
dictating medical notes. He reports of
intermittent headaches over several days which he says is
bitemporal and squeezing, and not associated with photophobia,
numbness, weakness or paresthesia.
At the OSH a head CT was done which showed diffuse multifocal
predominantly cortical abnormalities w/ numerous (too many to
count) hyperdensities. A few hyperdense lesions noted in the
posterior fossa as well. Midline shift of the falx 11.4 mm.
There was no
transcortical infarction.
MRI done here on [**2110-12-25**] demonstrated Vascular malformation
that
seems to be centered in the right occipital/temporal lobe and
cerebellum. Are of susceptibility with surr flair signal in
Right lower pons (7;60 with mild mass effect may represent small
hemorrhage. No evidence of ischemia or infection.
The neurology team here at [**Hospital1 18**] is requesting a consult for
cerebral angiography from the neurosurgical team.
Past Medical History:
GERD
Social History:
Works as a hospitalist at [**Hospital6 3105**]. He
graduated
from [**Hospital 15739**] Medical School and did a Med/Peds residency at
[**Location (un) 36413**], TX. He is married and his wife is a resident in
med/peds
at Brown. He does not smoke and drinks alcohol rarely. He lives
[**2-2**] the time in [**Hospital1 487**] and the other half in [**Doctor Last Name **].
Family History:
Mother - had a throat cancer (possibly squamous) treated
surgically and w/ radiation
Father - had a tachy-arrhythmia
Sister - healthy / 2 brothers - [**Name (NI) **] twins - both healthy
Physical Exam:
On Admission:
Vitals: 99.1 90 125/77 18 95%
General: Awake, cooperative, NAD. Slightly overweight
HEENT: NC/AT, non-icteric, mo oral lesions, no thrush
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
No thyromegaly, no palpable lymph nodes
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated, no splinter hemorrhages
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to spell WORLD backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects
from stroke card. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register "red, [**Location (un) **], honesty"
objects and recall all 3 at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Saccades to the right were
not smooth. With head thrust test to the left he had peristent
nystagmus.
V: Facial sensation intact to light touch.
VII: Left nasolabial fold flattening, facial musculature
symmetric.
VIII: Hearing intact to high-pitched tuning fork b/l
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense. Missed a few subtle movements of the left toe
on
proprioceptive testing. Ankle was normal
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No difficulty w/ [**Doctor First Name **] or
mirroring
-Gait: Romberg had a slight sway. Wide based stance with
short-stepping gait. Low confidence and required assistance in
order to walk.
On discharge:
Awake, alert, oriented x3, MAE with full motor, no nystagmus
noted.
Pertinent Results:
[**2110-12-25**] MRi brain
1. Extensive arteriovenous malformation/fistula predominantly
involving the right cerebral and the right cerebellar hemisphere
and the right side of the brainstem structures along with a few
prominent venous tributaries in the left temporal and occipital
lobes and the left cerebellar hemisphere. Assessment of the
vascular structures and venous sinuses is limited on the present
study. Correlate with angiogram- CTA/conventional angiogram, to
be performed subsequently.
2. Small-moderate focus of hemorrhage and surrounding in the
right side of
the pons, medulla/cerebellar hemisphere with mild mass effect on
the fourth ventricle and in the inferior midbrain. Minimal
displacement of the
cerebellar tonsils inferiorly. Attention on close followup. Mild
leftward
shift of midline structures is noted.
3. Mild paranasal sinus disease as described above
[**2110-12-25**] CXR
The cardiac, mediastinal and hilar contours
appear unremarkable. Low lung volumes are noted bilaterally with
crowding of bronchovascular markings. Opacification at the right
lung base may represent atelectasis versus aspiration;
infectious process cannot be completely excluded in the correct
clinical setting but is less likely. Opacification in the left
lung base likely represents atelectasis.
[**2110-12-26**] ECHO
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF 65%).
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
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
[**2110-12-29**]
CXR: FINDINGS: Supine portable AP view of the chest. There is
mild bibasilar linear opacities consistent with atelectasis. The
upper lungs are clear. The cardiac, mediastinal, and hilar
contours are unremarkable. Possible sclerosis of the T9 left rib
posteriorly and lateral portion of the left scapula. No pleural
effusions. No pneumothorax.
IMPRESSION:
1. Mild bibasilar atelectasis.
2. Possible sclerosis of the left posterior T9 rib and left
scapula, which
may be artifactual. Can further assess with conventional PA and
lateral chest radiographs, and bone detail views, if clinically
indicated.
CT HEAD W/O CONTRAST [**2110-12-30**]
1. No new intracranial hemorrhage identified. Assessment for
acute
parenchymal ischemic changes is limited on the present study.
2. Stable minimal mass effect on the fourth ventricle and in the
inferior mid brain/pons, with stable minimal displacement of the
cerebellar tonsils
inferiorly. Stable mild leftward shift of midline structures
LENIS [**2111-1-4**]
FINDINGS: There is normal compressibility, flow, and
augmentation of bilateral common femoral, superficial femoral,
left popliteal and the calf veins on both sides. Compression of
the right popliteal vein was limited since the caliber of the
vein is small. However, there is normal augmentation and flow.
IMPRESSION: No DVT.
Brief Hospital Course:
32 year-old right handed man who presnted to [**Hospital1 18**] from LGH
after a 3 day history of increasing lethargy, intermittent
vertigo, nausea and difficulty ambulating
who presented to LGH and was transferred after abnormal CT
findings.
He underwent MRI imaging which confirmed an extensive vascular
anomoly confimring AVM / Fistual. He was monitored in the ICU
and brought down for cerebral angiogram on the 25th. He
returned to angiography for coiling/embolization of the AVM.
This embolization was complex and was treated partially. He was
returned to the ICU. His headaches were fairly easy to manage.
His dizziness and nausea were not so easily controlled. We
consulted with the pharmacist to assist in this.
Patient had desaturations and required NC, question if this is a
result of narcotics. A CXR was done which showed atelectasis and
he was encouraged to use the IS. CT imaging was obtained due to
his emesis and dizziness to rule out continued hemorrhage. This
was negative. On [**12-30**], nausea and dizziness improved. Headaches
continued, but were managed with pain medication. He continued
to be intact on exam except for upward and lateral gaze
nystagmus.
On [**12-31**], patient continued to do well, he was transferred to
the SDU but remained in ICU until a bed was available. He was
encouraged to be OOB. On [**1-1**], PT was consulted and patient made
NPO after midnight for preparation of angiogram in AM.
He returned to angiography on Friday the 2nd for attempt at
completion of coiling of the AVM. He underwent this procedure
without event.
Over the weekend, patient was doing well, he was transferred to
the stepdown unit and lenis were ordered to rule out DVTs. He
was encouraged to ambulated and be OOB as much as possible.
On [**1-5**], patient remained intact, some mild headache and nausea,
but overall better. He has been ambulating with PT and advancing
his diet showly. His lenis were negative for DVTs and rad
oncology was consulted for radiosurgery of the AVM.
On [**1-6**], it was reported that while working with PT patient was
developing desats, and PA and lateral chest x-ray were ordered
to better evaluate the reported bibasilar atelectasis and left
lower lobe effusion. Medicine was consulted and felt this was
most likely deconditioning and encourage IS. He did better the
next day and was discharged home with services on [**1-7**].
Medications on Admission:
omeprazole 20mg daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
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:*2*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*100 Tablet(s)* Refills:*0*
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. dimenhydrinate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea/ dizziness.
Disp:*30 Tablet(s)* Refills:*0*
8. promethazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Multiple dural AV fistulas
Pons hemorrhage
Nausea
Headache
Dizziness
Hypoxia
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:
Angiogram with Embolization and/or Stent placement
Medications:
?????? 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).
?????? No driving until you are no longer taking pain medications
?????? Please refrain from heavy lifting > 10 lbs or heavy
activity until cleared by the Neurosurgeon.
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 Roo
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks for a follow-up
angiogram. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
After this angiogram, radiosurgery can be planned.
You have been referred to Dr [**Last Name (STitle) 1128**] at [**Hospital1 2025**] and Dr [**Last Name (STitle) 71863**] at
[**Hospital1 **]. Their offices will contact you to make these
appointments.
Completed by:[**2111-1-7**]
|
[
"5180",
"53081"
] |
Admission Date: [**2122-10-23**] Discharge Date: [**2122-10-26**]
Date of Birth: [**2066-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymtomatic
Major Surgical or Invasive Procedure:
MVRepair(#34 Annuloplasty ring/resection)Left side maze
w/ligation of Left atrial appendage. [**10-23**]
History of Present Illness:
56 yo M with known severe MR [**First Name (Titles) **] [**Last Name (Titles) **].
Past Medical History:
MVR/MVP, [**Last Name (Titles) **], Asthma
Social History:
lives with wife
no tobacco
[**1-13**] etoh per week
Family History:
NC
Physical Exam:
WDWN M in NAD, Actinic keratosis on forehead
Lungs CTAB
Heart RRR 3/6 late systolic murmur
Abdomen soft, NT, ND
Extrem wrm, no edema
No varitcosities
2+ pp
no carotid bruits
Pertinent Results:
[**2122-10-26**] 06:50AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.6* Hct-27.7*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.3 Plt Ct-122*
[**2122-10-25**] 12:51AM BLOOD WBC-7.6 RBC-2.96* Hgb-9.8* Hct-27.9*
MCV-94 MCH-33.0* MCHC-35.0 RDW-13.2 Plt Ct-104*
[**2122-10-26**] 06:50AM BLOOD Plt Ct-122*
[**2122-10-26**] 06:50AM BLOOD PT-12.8 PTT-26.7 INR(PT)-1.1
[**2122-10-26**] 06:50AM BLOOD Glucose-102 UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-106 HCO3-26 AnGap-11
CHEST (PORTABLE AP) [**2122-10-25**] 10:33 AM
Single portable radiograph of the chest demonstrates interval
removal of the support lines seen on [**2122-10-23**]. No
pneumothorax. Patient is again noted to be status post
prosthetic cardiac valve placement and median sternotomy.
Blunting of the left costophrenic angle persists as does
bibasilar atelectasis. Trachea is midline.
IMPRESSION:
Persistent bibasilar atelectasis and left-sided pleural
effusion. No pneumothorax.
Brief Hospital Course:
On [**10-23**] he was taken to the operating room where he underwent a
MVRepair, and full left sided maze with ligation of the left
atrial appendage. He was transferred to the ICU in critical but
stable condition.He was extubated later that day. He was
transferred to the floor on POD #1. He was restarted on
coumadin. He did well post operatively and was ready for
discharge on POD #3.
Medications on Admission:
bisoprolol 2.5', coumadin 7.5'
Discharge Medications:
1. 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*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO once a
day.
Disp:*15 Tablet(s)* Refills:*0*
7. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
MVR/MVP
[**Hospital3 **]
Asthma
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] (PCP) 2 weeks
Dr. [**Last Name (STitle) 914**] (Cardiac Surgeon) 4 weeks
Dr. [**Last Name (STitle) **] (Cardiologist) 2 weeks
Completed by:[**2122-10-26**]
|
[
"4240",
"5180",
"5119",
"42731",
"49390"
] |
Admission Date: [**2132-9-4**] Discharge Date: [**2132-9-11**]
Date of Birth: [**2063-8-24**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 69-year-old woman with
a history autoimmune hepatitis and cirrhosis and a chronic
abdominal abscess from diverticulitis who presented with some
increased abdominal pain and subjective fevers. This began
approximately 3 days prior to admission. She had noted a low-
grade fever of 100.3 degrees at home but denied any nausea,
vomiting, shortness of breath or diaphoresis. Her appetite
had been good at home.
She was originally seen at an outside hospital where her
liver function tests were significant for an ALT of 586 and
an AST of 370. Her amylase was normal. She was originally
accepted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] who follows her as an
outpatient for transfer to [**Hospital1 18**], with a presumed diagnosis
of autoimmune hepatitis exacerbation.
PAST MEDICAL HISTORY:
1. Autoimmune hepatitis x 5 years.
2. Cirrhosis; on the transplant list.
3. Chronic abdominal abscess controlled with a long course
of antibiotics which included daptomycin.
4. Celiac sprue.
5. Osteoporosis.
6. COPD.
7. Status post hysterectomy.
8. Status post laryngeal tumor removal which was benign.
MEDICATIONS AT HOME:
1. Prednisone 20 mg daily.
2. Calcium carbonate 500 mg t.i.d.
3. Cholecalciferol 400 mg daily.
4. Multivitamin.
ALLERGIES: The patient is allergic to AMOXICILLIN, SULFA
DRUGS, CODEINE and IODINE-CONTAINING CONTRAST.
SOCIAL HISTORY: The patient lives with her daughter who is
her healthcare proxy. She has a history of tobacco use but
quit 5 years ago. In addition, she also drank quite heavily
but quit 5 years.
FAMILY HISTORY: Her father died of cirrhosis. Her mother
also had hepatitis.
PHYSICAL EXAMINATION: Vital signs reveal temperature of
100.9, blood pressure of 95/55, heart rate of 95,
respirations of 20, SPO2 of 94% on room air. In general, she
was in no acute distress. Her neck was supple without JVD.
Her heart was regular with normal S1/S2 with no murmurs, rubs
or gallops. Her chest was clear to auscultation bilaterally.
Her abdominal exam showed a tense belly that was
hyperresonant to percussion and mildly distended. She was
mildly tender in the epigastrium. Her skin was not jaundiced,
although she did have a large bruise on her left shin. Her
extremities were clubbing, cyanosis or edema. Neurological
exam was grossly intact.
LABORATORY DATA ON ADMISSION: Her complete blood count was
significant for a white blood cell count of 7; and a
hematocrit of 31.6, platelets of 116,000. Coagulation panel:
PT of 16.3, PTT of 31.4, INR of 1.8 (elevated from her most
level of 1.5 on [**8-21**]). She had a urinalysis that was
negative. Electrolytes: Sodium of 132, potassium of 4.2,
chloride of 106, bicarbonate of 21, BUN of 18, creatinine of
0.8, glucose of 96. Her liver function tests were elevated at
ALT of 291, AST of 357, LDL of 254, alkaline phosphatase of
96, amylase of 101, and her total bilirubin was 1.9.
RADIOLOGICAL DATA: On admission the patient had a chest x-
ray which was significant for small pleural effusions, but
otherwise unremarkable.
She also had a CT scan of the abdomen and pelvis with recons
which demonstrated a small increase in size of her
diverticular abscess and a small amount of intra-abdominal
free air. Again seen were her extensive significant
diverticula.
BRIEF HOSPITAL COURSE: The patient was admitted at first to
the hepatology service for a presumed diagnosis of autoimmune
hepatitis exacerbation. However, upon further review of her
CT scan it was felt that she may have sustained an injury to
her bowel given that she had a small amount of free air on
her CT scan.
To investigate this she was taken to the operating room on
[**2132-9-5**] for exploratory laparotomy. During the
operation there was no frank stool and succus noted in
peritoneal cavity. However, a small 6-mm tear was found in
the duodenum. Please see the separately dictated operative
note for details. A gram patch was applied to fix this
lesion. She was stable in the post anesthesia care unit after
the procedure. Her vital signs were stable, and she was
extubated in the PACU. She was then admitted on postoperative
day zero to the ICU for close monitoring. Her vital signs
remained stable, and she did quite; requiring no pressor
support.
She was transferred to the floor on postoperative day 2 with
her vital signs remaining stable. She was restarted on her
home medications and treated with levofloxacin, Flagyl and
daptomycin for bacterial prophylaxis for her perforated
duodenal ulcer. She had an H. pylori serological study sent
which was negative. She also had a liver biopsy sent during
the operation, the final report of which came back as
consistent with autoimmune hepatitis. The patient was also
given stress-dose steroids during the perioperative period.
During her initial course in the ICU she was transfused 2
units of packed red cells for postoperative anemia and 4
units of fresh frozen plasma for postoperative coagulopathy.
She had a feeding tube placed during the operation which was
used beginning on postoperative day 2, starting at a basal
rate of tube feeds. These were advanced to her goal of 70 cc
an hour. Nutritional service was consulted, and her tube feed
regimen was optimized to include ProMod at 3/4 strength and
to be run at 75 cc an hour. This will be advanced to cycling
overnight.
On postoperative day 6, the patient had been afebrile for her
entire hospital course; and her vital signs were otherwise
stable. She was tolerating a p.o. diet with supplementation
by tube feeds. Her pain was under adequate control on p.o.
narcotics, and she was able to get out of bed on her own
strength. She was discharged home in stable condition.
MAJOR PROCEDURES:
1. Exploratory laparotomy with gram patch repair of
perforated duodenal ulcer on [**2132-9-5**].
2. Central venous line placements.
3. Arterial line placement.
4. Jejunal feeding tube placement.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to return to the emergency
department or call her physician if she noticed increased
redness or swelling or drainage from her incision or if
she has fevers greater than 101.4 degrees.
2. She was instructed to shower but not to soak in the tube
until her staples are removed at her follow-up
appointment.
3. She was instructed to take all medications as directed.
4. She was instructed to avoid all heavy lifting.
DISCHARGE DIET: The patient is to take a glutin-free, low-
protein and low-sodium heart healthy diet with tube feeds
supplementation which is to include ProMod with fiber at 3/4
strength at a goal rate of 70 cc per hour.
FOLLOWUP: The patient was instructed to follow up with Dr.
[**First Name (STitle) **] at her prearranged appointment.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Perforated duodenal ulcer, status post gram patch repair.
2. Autoimmune hepatitis and cirrhosis.
3. Diverticulitis.
4. Postoperative anemia.
5. Postoperative coagulopathy.
6. Celiac sprue.
7. Osteoporosis.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg daily.
2. Percocet 1 to 2 tablets p.o. q.4-6h. as needed for pain.
3. Protonix 40 mg daily.
4.
Prednisone 20 mg daily.
5. Feeding tube formula and supplies.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 30134**]
MEDQUIST36
D: [**2132-9-11**] 02:35:15
T: [**2132-9-11**] 04:00:40
Job#: [**Job Number 60600**]
|
[
"496"
] |
Admission Date: [**2185-11-7**] Discharge Date: [**2185-11-12**]
Date of Birth: [**2129-8-12**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 56 year old male with
a six year history of heart murmur. He had a negative stress
test and echo at the time of his initial diagnosis. He
recently had an abnormal EKG on an annual physical with an
echo showing a depressed ejection fraction of 30 percent with
critical aortic stenosis. Myoview had an ejection fraction of
31 percent. Cath done in prep for an aortic valve replacement
on [**9-29**] showed 50-60 percent LAD lesion, calcified aortic
valve, dilated aortic, aortic valve area of 0.5 cm2, mild MR,
probable bicuspid aortic valve, right dominant coronary
system with mild to moderate aortic insufficiency. He had a
cardiac echo on [**9-27**] showing an ejection fraction of 30
percent, left ventricular hypertrophy, mild to moderate
aortic insufficiency with an aortic valve area of 0.5
percent, peak gradient of 132, mean gradient of 100. His
aortic root measured 3.7 cm and his arch measuring 4.3 cm. At
this time, he was referred for an aortic valve replacement by
Dr. [**Last Name (Prefixes) **].
PHYSICAL EXAMINATION: Physical examination on initial
presentation showed a heart rate of 70 with an oxygen
saturation of 100 percent on room air. Blood pressure in his
right arm was 148/80 and in his left arm 151/92. Height was
6' 0" with a weight of 184 lb. General - he is a very fit,
athletic man. Skin - no obvious lesions. HEENT - pupils are
equal, round and reactive to light and accommodation.
Extraocular movements are intact, nonicteric, normal buccal
mucosa. Neck - no JVD and neck is supple. Chest - clear to
auscultation bilaterally. Heart - regular rate and rhythm, S1
and S2 with 3/6 systolic ejection murmur heard throughout
chest radiating to bilateral carotids. Abdomen is soft,
nontender and nondistended with positive bowel sounds. There
is no CVA tenderness. Extremities - warm, well-perfused,
ecchymotic right third toenail. Varicosities - none noted.
Neurologic - cranial nerves II through XII are grossly intact
with nonfocal exam. Strength is [**4-13**] in all four extremities.
PAST MEDICAL HISTORY: Past medical history is significant
for hyperlipidemia, benign prostatic hypertrophy, deviated
septum.
PAST SURGICAL HISTORY: Past surgical history of repair of
his left biceps tendon, left cataract surgery,
varicocelectomy and an orchiectomy.
MEDICATIONS ON ADMISSION: Anacin prn.
ALLERGIES: No known drug allergies.
CO[**Last Name (STitle) 14945**]HISTORY OF HOSPITAL COURSE: The patient was admitted
on [**2185-11-7**] and proceeded to the Operating Room where he
underwent a CABG times one with a LIMA to the LAD and aortic
valve replacements by Dr. [**Last Name (Prefixes) **]. He was transferred to
the Cardiac Surgery Recovery Room with a mean arterial
pressure of 70, a CVP of 8 and normal sinus rhythm with a
rate of 70. He was supported on phenylephrine drip,
amiodarone drip and a propofol drip. He was extubated on his
operative day without problem and continued in stable
condition that night. He was transferred to the Inpatient
Floor on postoperative day 1. He continued to do well on
postoperative day 2 when his chest tubes, Foley catheter and
cardiac pacing wires were removed. He was encouraged to
increase ambulation and was seen by Physical Therapy as well.
He began receiving warfarin on postoperative day 3, receiving
a dose of 5 mg on postoperative day 3 and postoperative day
4. On postoperative day 5 and 6, he had a dose of 7.5 mg each
with an INR of 1.9 on day of discharge and plan for recheck
of his INR on Monday, [**11-14**], to be followed by Dr. [**Known firstname 449**]
[**Last Name (NamePattern1) **]. He was in normal sinus rhythm throughout his hospital
stay without complications. He was followed by the Physical
Therapy team throughout his stay and was found to have no
further acute needs and to be safe for home on [**2185-11-11**] by
Physical Therapy. He was discharged home with plans to follow
with visiting nurse on [**2185-11-12**].
CONDITION ON DISCHARGE: Vital signs - temperature 98.0,
pulse 63 and sinus rhythm, blood pressure 128/80 with a
respiratory rate of 20. Weight is 91 kg, up from a
preoperative weight of 84 kg. Oxygen saturation is 98 percent
on room air. Labs on discharge include a hematocrit of 23.8,
sodium 137, potassium 4.1, chloride 101, bicarb 29, BUN 12,
creatinine 0.9, glucose 92, PTT 33.8 and INR 1.9. On physical
examination, he is alert and oriented and nonfocal. Pulmonary
- lungs are clear bilaterally. Cardiac - regular rate and
rhythm, sternal incision without drainage or erythema and
sternum stable. The incision is with Steri's, open to air,
clean, dry and intact. Abdomen - soft, nontender,
nondistended with positive bowel sounds.
DISCHARGE STATUS: The patient is discharged to home with
follow-up by Visiting Nurses Association.
DISCHARGE DIAGNOSES: Status post aortic valve replacement
and coronary artery bypass graft times one, hyperlipidemia,
benign prostatic hypertrophy.
DISCHARGE MEDICATIONS: Lopressor 25 mg po bid, Colace 100 mg
po bid, aspirin 81 mg po daily, Coumadin as directed daily
with a goal INR of 2.5-3, Percocet 5/325 mg one to two
tablets po q4-6h prn, Lasix 20 mg po daily for two weeks,
potassium chloride 20 mEq po daily for seven days, ferrous
sulfate 325 mg po daily, vitamin C 500 mg po bid with
instructions to take his warfarin 7.5 mg on [**11-12**] and [**11-13**]
and then as directed by Dr. [**Last Name (STitle) **].
FO[**Last Name (STitle) 996**]P PLANS: INR checked by VNA on [**11-13**] with results
called to [**Doctor First Name **] in the [**Hospital 197**] Clinic at Dr.[**Name (NI) 55526**] office,
[**Telephone/Fax (1) 60207**], [**Hospital 409**] Clinic in two weeks, Dr. [**Last Name (STitle) **] in two to
three weeks and Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2185-11-14**] 13:48:46
T: [**2185-11-14**] 14:44:28
Job#: [**Job Number 60208**]
|
[
"4241",
"41401",
"2724"
] |
Admission Date: [**2199-8-8**] Discharge Date: [**2199-8-17**]
Date of Birth: [**2139-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Shortness of breath, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 40503**] is a 60 year old male with a past medical history of
recently diagnosed Wegner's granulomatosis who presents with
worsening lower extremity edema and shortness of breath. Mr.
[**Known lastname 40503**] was recently admitted to this hospital from [**2199-7-7**] to
[**2199-7-30**]. He initially presented to an OSH with a three week
history of lower extremity edema, orthopnea, fatigue, and
shortness of breath. He was found to have bilateral pulmonary
infiltrates, acute renal failure with a creatinine of 9.6 and a
hematocrit of 14%. Initially bronchoscopy showed low grade
hemorrhage. He was started on solumedrol and cytoxan and
transferred to this hospital for plasmaphresis. He received 7
treatments of plasmaphresis and was continued on cytoxan and
steroids. He was ultimately found to be cANCA positive,
anti-GBM negative and anti-[**Doctor Last Name **] negative. Renal biopsy showed
pauci-immune crescentic glomerulonephritis felt to be consistent
with Wegner's granulomatosis. During his initial
hospitalization his renal failure improved as did his
oxygenation status after the initiation of immunosuppressive
therapy. His creatinine was 2.8 on the day of discharge and he
was breathing comfortably on 3 L NC.
.
The patient reports gradual decline in his health since
discharge from this hospital on [**2199-7-30**]. He says that he has
had worsening fatigue and shortness of breath. He denies
orthopnea or paroxysmal nocturnal dyspnea. He denies cough or
sputum production. He has had significant lower extremity edema
for the past two months but does not think that this has
worsened since the time of discharge. He denies any fevers or
chills at home. He has been trying hard to maintain a low
sodium/low potassium diet. He reports that he went and had his
blood drawn as scheduled two days prior to admission. He was
called and told to start taking medication for his potassium.
He subsequently presented to the emergency room.
.
In the emergency room his initial vitals were T: 98.2 HR: 57 BP:
109/72 RR: 18 O2: 97% on 3L NC. His initial laboratories were
notable for a BUN of 131, creatinine of 4.1, potassium of 7.3.
His initial EKG showed atrial flutter with a rate of 53, normal
axis, QTc of 449, TWI in II, V4-V6, no change from prior
tracings. CXR showed increasing bilateral pleural effusions.
He received 2 amps calcium gluconate, 2 amps of D50, 10 units IV
insulin, 30 mg PO kayexylate and 250 cc normal saline.
Potassium on recheck was 6.2. He is transferred to the [**Hospital Unit Name 153**] for
further management.
Past Medical History:
Wegner's Granulomatosis - diagnosed [**2199-6-28**], on 3 L oxygen
Aspergillus infection (positive in sputum, galactomannan 0.048)
- on voriconazole
Spiculated right apical lung lesion
Latent tuberculosis - 3 induced sputum for AFB negative in [**7-5**],
on INH/B6
Anemia - previous workup consistent with inflammatory anemia.
Hct on discharge was 27.8
Atrial Flutter
Steroid Induced Hyperglycemia
Social History:
Pt works full-time as a machine operator. Mostly stationary job.
Divorced, college-age son lives with wife. Lives alone.
Smoked 1-1/2 ppd until [**2194**] when he quit (possibly 50 pack year
hx prior). Drinks ~2 drinks/day, and on social occasions. Denies
other drug use.
.
Family History:
Mother passed from CVA in 80s. Father passed in 70s from unknown
cause. Twin brother passed from MI, another brother with hx
cardiac artery bypass graft. Denies family hx renal or pulmonary
disease.
Physical Exam:
Vitals: T: 97.1 HR: 63 BP: 101/65 RR: 23 O2: 95% on 3L
HEENT: Sclera anicteric, MMM, poor dentition, oropharynx clear
Neck: JVP at ear at 45 degrees, no LAD
Cardiovascular: RRR, s1 + s2, no murmurs, rubs, gallops
Chest: Harsh inspiratory and expiratory ronchi R > L, decreased
breath sounds at bases, no egophony or increased tactile
fremitus
GI: soft, non-tender, non-distended, +BS
GU: no foley
Ext: WWP, 2+ pulses, 3+ pitting edema to knees
Neurologic: Alert, oriented x 3, strength 5/5 in upper and lower
extremities, sensation intact to light touch bilaterally
Pertinent Results:
[**2199-8-8**] 11:30PM TYPE-ART PO2-64* PCO2-48* PH-7.39 TOTAL
CO2-30 BASE XS-2 INTUBATED-NOT INTUBA
[**2199-8-8**] 11:30PM GLUCOSE-60* LACTATE-1.3 NA+-141 K+-6.3*
CL--105
[**2199-8-8**] 11:30PM freeCa-1.15
[**2199-8-8**] 11:25PM CALCIUM-8.2* PHOSPHATE-5.4*# MAGNESIUM-2.1
[**2199-8-8**] 09:20PM K+-6.2*
[**2199-8-8**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-8-8**] 09:00PM URINE RBC-[**5-7**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
[**2199-8-8**] 09:00PM URINE GRANULAR-<1
[**2199-8-8**] 07:40PM K+-7.0*
[**2199-8-8**] 07:10PM GLUCOSE-86 UREA N-131* CREAT-4.1*# SODIUM-140
POTASSIUM-7.3* CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2199-8-8**] 07:10PM ALT(SGPT)-17 AST(SGOT)-22 LD(LDH)-267* ALK
PHOS-83
[**2199-8-8**] 07:10PM LIPASE-28
[**2199-8-8**] 07:10PM proBNP-[**Numeric Identifier 79234**]*
[**2199-8-8**] 07:10PM ALBUMIN-3.2*
[**2199-8-8**] 07:10PM WBC-7.4# RBC-3.19* HGB-9.5* HCT-30.7* MCV-96
MCH-29.7 MCHC-30.9* RDW-17.7*
[**2199-8-8**] 07:10PM NEUTS-96.2* LYMPHS-2.3* MONOS-1.5* EOS-0
BASOS-0
[**2199-8-8**] 07:10PM PLT COUNT-203
[**2199-8-8**] 07:10PM PT-13.1 PTT-26.3 INR(PT)-1.1
Radiology:
CXR: The consolidative changes of the mid zones of both lungs
are unchanged. There are increasing bilateral pleural effusions.
This most likely accounts for the increased haziness at both
lung bases. The cardiomediastinal silhouette and hilar contours
appear relatively unchanged. The fibrotic changes of both lung
apices are unchanged. No new focal infiltrate is visualized. The
osseous structures of the thorax appear unremarkable.
<br>
CT Chest without contrast [**8-11**]:
IMPRESSION:
1. Overall slight decrease in the degree of ground-glass opacity
and ill-
defined nodular opacities in a diffuse bilateral pattern,
consistent with
improvement of pulmonary involvement of Wegener's
granulomatosis.
2. No change in biapical spiculated opacities of unclear
significance, but
for which followup examination is recommended.
3. Mild decrease in the degree of mediastinal and hilar
lymphadenopathy.
4. No change in pattern of paraseptal and centrilobular
emphysema.
The study and the report were reviewed by the staff radiologist.
<br>
Echo, repeat study [**8-12**] compared to [**2199-7-8**] study:
The left atrial volume is markedly increased (>32ml/m2). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal regional and global left ventricular
function. Mildly dilated and hypokinetic right ventricle. Mild
aortic and mitral regurgitation. Biatrial enlargement. Dilated
aortic sinus and ascending aorta.
Compared with the prior study (images reviewed) of [**2199-7-8**],
septal hypokinesis is not seen on the current study. The degree
of pulmonary artery systolic hypertension has increased. The
other findings are similar.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2199-8-12**] 13:36
Brief Hospital Course:
60 yo M with recently dx Wegener's Granulomatosis with treatment
started last hospitalization (see prior d/c summary for
details), admitted again for acute on [**Year (4 digits) **] renal failure with
volume overloaded - tx with lasix diuresis - sx improving along
with slowly improved renal fx back to prior baseline of 2.8. Pt
cytoxan intially then decreased to 100mg qd, and day prior to
d/c was d/c [**12-29**] to drop in WBC, prednisone continued. Pt Ca
mgmt, a-flutter, hyperglyemia mgmt adjusted while monitored as
in-patient as detailed below. Pt's LFTs also increased - ID
consulted at that time - still continue vori and INH. Pt will
have close follow-up next week with rheum (mon), ID (tues), and
renal (thursday).
1. Acute on [**Month/Day (2) 8304**] Kidney Injury/Hyperkalemia/hypernatremia:
Patient's creatinine on discharge on [**2199-7-30**] was 2.8. He did
not require dialysis during his previous hospitalization. He
presented on admission with a creatinine of 4.1 with a potassium
level of 7.3. No EKG changes appreciated from hyperkalemia.
CXR notable for worsening pleural effusions initially, tx with
diuresis since admission to ICU. UA with 500 protein, [**5-7**] RBCs
and < 1 granular cast per high powered field. His acute on
[**Month/Year (2) **] renal failure is likely [**12-29**] Wegener's granulomatosis,
with improvement in creatinine to 2.5 on day of discharge. He
was noted to be hyperkalemic initially, with good response to
kayexelate/
He was diuresed with IV lasix initially, and then transitioned
to lasix 40 mg po bid. He was followed by the renal service
during his admission.
His hypernatremia remained relatively stable and asymptomatic.
He was noted to have an elevated PTH, and was started on
calcitriol 0.25 mcg/day and calcium carbonate 1.5 gm tid.
.
2. Wegner's Granulomatosis: Recent diagnosis made when patient
presented with renal failure, and pulmonary hemorrhage. Given
CRP/ESR levels mildly lower than before and his improvement in
his CT scan, it was thought that his disease process was
improving. His cytoxan dose was initially reduced, and then
discontinued given progressive drop in his WBC count. He was
continued on prednisone 50 mg daily. He will follow up in
rheumatology clinic on Monday. An echo was performed in-house
that did not show evidence of aortic regurgitation.
3. Shortness of Breath: Likely multifactorial related to his
Wegner's granulomatosis as well as worsening volume overload
from worsening renal function. CXR notable for increasing
bilateral pleural effusions on initial presentation. JVP
significantly elevated, but further improving and approaching
new baseline. BNP elev but no priors for comparison. Overall
significant improvement clinically; he was discharged on 40 mg
[**Hospital1 **] Lasix. He was continued on prednisone for his Wegener's. At
time of discharge, he was on 1.5L of oxygen. He will need to
continue his home inhalers. An outpatient pulmonary appointment
was made for him.
.
4. Aspergillus infection: Diagnosed by positive sputum culture
with negative galactomannan. Given immunosuppressed state
patient is being treated with voriconazole with plans for a
three month course. He was noted to have mildly elevated LFTs.
After consultation with infectious disease, decision was made to
continue the voriconazole, and to monitor the LFTs closely. His
transaminitis was stable during his admission.
5. Latent TB: Patient has a history of a TB exposure. He
recently
had three negative induced sputum samples for AFB. He was
started on INH therapy given need for prolonged immunosuppresive
medications. He was continued on INH and B6.
6. Anemia: Previous workup consistent with inflammatory
anemia. He was
transiently on Epogen, which was stopped.
7. Atrial Flutter: Well rate controlled on metoprolol and
diltiazem. Recent echocardiogram with elongated left atrium,
mildly dilated RV, 1+ MR, 1+ AR and mild pulmonary hypertension.
He was continued on metoprolol and diltiazem during his stay.
8. Steroid Induced Hyperglycemia - BS low in am with sx, oral
[**Doctor Last Name 360**] held since admission, will cont SSI in-house. He was
started on glipizide, with dose reduction to 2.5 mg daily
secondary to hypoglycemia.
9. [**Doctor Last Name 8304**] Immunsuppression: On steroids and cyclophosphamide
chronically since discharge, with discontinuation of the
cyclophosphamide [**12-29**] issues as noted above. He was continued on
calcium and calcitriol and alendronate.
Medications on Admission:
Pantoprazole 40 mg daily
Colace 100 mg [**Hospital1 **]
Nystatin 5 mL PO QID
Ambien 5 mg daily
Metoprolol 100 mg TID
Albuterol Nebulizer Q4H:PRN
Ferrous Sulfate 325 mg [**Hospital1 **]
Cholecalciferol 800 U daily
Voriconazole 300 mg [**Hospital1 **]
Calcium Carbonate 1000 mg TID
Bactrim 80-400 mg QMoWeFR
Senna
Glyburide 2.5 mg daily
Bisacodyl PRN
Ipratropium Inhaler Q6H:PRN
Spiriva 18 mcg daily
Cyclophosphamide 125 mg daily
Prednisone 50 mg PO daily
Diltiazem 180 mg daily
Isoniazid 300 mg daily
Vitamin B-6 25 mg PO daily
Alendronate 35 mg PO Qweek
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nystatin 100,000 unit/mL Suspension Sig: One (1) PO QID (4
times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*100 Tablet(s)* Refills:*2*
14. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO TID (3 times a day).
Disp:*270 Tablet, Chewable(s)* Refills:*2*
17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
18. Outpatient Lab Work
CBC with diff, am of [**2199-8-20**] for rheum clinic appointment before
8:30am
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary Diagnosis:
Wegener's Granulomatosis
Acute on [**Location (un) 8304**] Renal Failure/Hyperkalemia
Secondary Diagnosis:
Hypernatremia
Aspergillosis
Latent Tuberculosis
Anemia
Atrial Flutter
Steroid induced hyperglycemia
Neutropenia [**12-29**] Cytoxan
Discharge Condition:
Stable
Discharge Instructions:
Your diagnosis is as below.
<br>
Check daily weights in the morning soon after voiding, if you
gain more than 2 pounds take an extra 40mg lasix tablet that
morning, if you gain more than 4 pounds call your provider for
further instructions.
<br>
Adhere to a low sodium/low phosphoris/protein modified and [**Doctor First Name **]
diet as instructed to you this hospitalization
<br>
If your symptoms worsen as instructed to you in past - call your
provider [**Name Initial (PRE) **]/or return to emergency room.
<br>
Keep record of your blood sugars couple time a day with time and
bring to your PCP.
.
Your white cell count is low from the Cytoxan that you received
to treat your Wegener's Granulomatosis. This puts you at higher
risk for infection. If you develop fevers > 100.4, you should
call your PCP or go to the emergency room. You should be on
neutropenic precautions when you are at home. You should not eat
raw fruits and vegetables and you should wear a mask when you
leave the house to prevent exposure to infections.
.
On discharge, your oxygen requirement was 1.5 liters of oxygen.
This should be weaned down as tolerated. If you require oxygen
>3L, you should call your primary care doctor as it may indicate
that your lung disease is worsening or you have fluid in your
lungs.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2199-8-19**] 8:30 (Rheumatology appointment, important you
go and have blood drawn beforehand to check your white blood
count)
<br>
2. Provider: [**Name10 (NameIs) 11170**] [**Last Name (NamePattern4) 11171**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2199-8-19**] 1:30 (this is your primary care doctor in the
[**Hospital1 18**] system, given your close f/u, if you need to re-schedule
call monday early morning for the following week)
<br>
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2199-8-20**] 10:00. (Your infectious disese doctor for
your latent tuberculosis treatment)
<br>
4. Provider: [**Name10 (NameIs) **] FELLOW ([**Doctor Last Name 12049**]) Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2199-8-21**] 12:00
<br>
5. You will have a f/u appointment with Nephrology on [**2199-8-22**]
at 12:30. They should call to confirm this appointment on
Monday. The number for the [**Hospital 2793**] Clinic is [**Telephone/Fax (1) 60**].
<br>
6. Pulmonary (Lung doctor): Your appointment with the
pulmonary doctor is on Wed [**8-28**]. You have to check
in at 12:30pm for breathing test and vitals, then will see
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] at 1pm. The location is [**Hospital Ward Name 23**] 7.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
|
[
"5849",
"2760",
"2767",
"5859"
] |
Admission Date: [**2159-12-9**] Discharge Date: [**2160-1-2**]
Date of Birth: [**2084-11-24**] Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Nausea, diarrhea
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
History of Present Illness
75 F h/o AF, CHF, bioprosthetic aortic valve. Presents with 1
week h/o nausea & watery diarrhea. Also had one episode of
emesis. Otherwise, has been able to tolerate POs, denies f/c/s.
No sick contacts. [**Name (NI) **] BRBPR. Baseline dark stools, as she takes
Pepto Bismol. (+) lightheaded, but no syncope
.
ROS otherwise significant for chronic incisional chest pain,
described as a midsternal, radiating to back and neck, unchanged
in the last 6 years since her aortic valve replacement. No assoc
SOB, n/v, diaphoresis.
Past Medical History:
Past Medical History
s/p bio-prosthetic aortic valve replacement
Edema
Sciatica
h/o Breast Cancer, s/p L mastectomy
Back Pain
Hyperlipidemia
Hypertension
Osteoporosis
Congestive Heart Failure
Renal Insufficiency
Gout
Social History:
Social History
Lives with husband. Previous 1.5 PPD x 40 yr smoker, quit 20 yr
ago. Occas EtOH
Family History:
Family History
Noncontributory
Physical Exam:
Physical Examination
VS - T 97.3, BP 81/47, HR 104, RR 27, O2 sat 96% 2L NC
General - elderly female, pleasant, conversant, in no acute
distress
HEENT - PERRL, OP clr, no LAD, MM dry; JVP flat
CV - tachy, irreg
Chest - s/p L mastectomy; small pinpoint skin defect draining
serosanguinous, dressed; lungs CTAB
Abdomen - NABS, soft, NT/ND, no g/r, no CVAT
Neuro - A&O x 3
Pertinent Results:
LABS:
[**2159-12-8**] 11:03PM BLOOD WBC-16.1*# RBC-3.57* Hgb-12.1 Hct-35.9*
MCV-101* MCH-33.9* MCHC-33.7 RDW-16.1* Plt Ct-201
[**2159-12-31**] 03:53AM BLOOD WBC-12.5* RBC-2.96* Hgb-9.7* Hct-31.0*
MCV-105* MCH-32.6* MCHC-31.2 RDW-18.1* Plt Ct-716*
[**2159-12-9**] 04:09PM BLOOD Neuts-76* Bands-6* Lymphs-4* Monos-12*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-12-9**] 04:09PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Burr-2+
[**2159-12-9**] 03:45AM BLOOD PT-15.7* PTT-37.7* INR(PT)-1.4*
[**2159-12-30**] 03:09AM BLOOD PT-12.8 PTT-30.7 INR(PT)-1.1
[**2159-12-29**] 05:48PM BLOOD Ret Aut-3.4*
[**2159-12-10**] 03:01AM BLOOD Ret Man-1.2
[**2159-12-8**] 11:03PM BLOOD Glucose-70 UreaN-137* Creat-9.0*# Na-116*
K-7.5* Cl-82* HCO3-14* AnGap-28*
[**2159-12-31**] 03:53AM BLOOD Glucose-112* UreaN-37* Creat-1.9* Na-143
K-3.6 Cl-98 HCO3-33* AnGap-16
[**2159-12-8**] 11:03PM BLOOD CK(CPK)-247*
[**2159-12-9**] 03:45AM BLOOD ALT-52* AST-45* AlkPhos-178* Amylase-19
TotBili-0.6
[**2159-12-31**] 03:53AM BLOOD ALT-30 AST-31 AlkPhos-150* TotBili-1.1
[**2159-12-29**] 02:56AM BLOOD ALT-23 AST-22 LD(LDH)-200 AlkPhos-110
TotBili-1.4
[**2159-12-8**] 11:03PM BLOOD CK-MB-11* MB Indx-4.5
[**2159-12-8**] 11:03PM BLOOD cTropnT-0.02*
[**2159-12-9**] 03:45AM BLOOD CK-MB-8 cTropnT-<0.01
[**2159-12-9**] 12:05AM BLOOD Calcium-7.7* Phos-4.7* Mg-1.9
[**2159-12-31**] 03:53AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
[**2159-12-29**] 05:48PM BLOOD calTIBC-172* Ferritn-330* TRF-132*
[**2159-12-21**] 02:21AM BLOOD VitB12-1073* Folate-10.0
[**2159-12-20**] 02:40AM BLOOD Hapto-144
[**2159-12-10**] 03:01AM BLOOD Hapto-201*
[**2159-12-18**] 01:45AM BLOOD Triglyc-126
[**2159-12-9**] 03:45AM BLOOD Osmolal-304
[**2159-12-9**] 03:45AM BLOOD Cortsol-51.5*
[**2159-12-9**] 08:00AM BLOOD Type-ART pO2-102 pCO2-30* pH-7.26*
calTCO2-14* Base XS--12
[**2159-12-29**] 04:10AM BLOOD Type-ART Temp-36.2 pO2-142* pCO2-44
pH-7.45 calTCO2-32* Base XS-6
[**2159-12-9**] 12:40AM BLOOD K-5.7*
[**2159-12-9**] 03:09AM BLOOD Lactate-0.4*
[**2159-12-28**] 09:12AM BLOOD Lactate-0.6
.
MICRO:
Blood Cx ([**12-8**], [**12-9**]): MSSA
Urine Cx ([**12-9**]): E. coli, pansensitive
Chest Wall wound Cx ([**12-10**]): MSSA
Sternotomy Wire Cx ([**12-11**]): MSSA
.
RADIOLOGY:
CXR ([**12-8**]): IMPRESSION: Patchy retrocardiac opacity may
represent consolidation or atelectasis. There is also a small
left pleural effusion.
.
Chest U/S ([**12-9**]): IMPRESSION: Fluid/debris containing
collection within the subcutaneous tissues of the sternum in the
region of the patient's chest wall defect which may represent an
abscess or hematoma. Ultrasound-guided aspiration could be
performed, as clinically indicated, for therapeutic/diagnostic
purposes.
.
CT Torso ([**12-10**]): IMPRESSION:
1. New, multiple foci of gas seen within the sternal soft
tissues, with a small focus of gas seen in the left superior
mediastinum. Findings are concerning for underlying infection.
No drainable collection is identified.
2. Large bilateral pleural effusions with associated atelectasis
and infiltrate. Underlying pneumonia cannot be excluded.
3. Distended gallbladder, with evidence of sludge and stones
within. Clinical correlation recommended. Ultrasound would be
recommended for further evaluation if there is concern for
cholecystitis. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10752**] at 3:30
p.m. [**2159-12-11**].
4. Moderate amount of free fluid seen is within the abdomen and
pelvis. Soft tissue stranding suggesting anasarca.
5. Coronary calcifications, prosthetic aortic valve noted.
.
Renal U/S ([**12-10**]): IMPRESSION: No hydronephrosis. Normal-sized
kidneys. Mild amount of ascitic fluid.
.
TTE ([**12-10**]): 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%) The right ventricular cavity is mildly
dilated. Right ventricular systolic function is normal. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-7-17**], the
rhythm now appears to be atrial fibrillation, the right
ventricular cavity is now dilated, and the severity of pulmonary
artery systolic pressure is now lower. The bioprosthetic mitral
valve gradient and severity of aortic regurgitation are similar.
.
TEE ([**12-11**]): Overall left ventricular systolic function is
normal. There is symmetric LVH. Right ventricular function may
be depressed (not fully visualized). There are complex (>4mm)
non-mobile atheroma in the descending thoracic aorta. A
bioprosthetic aortic valve prosthesis is present and appears
well seated. The aortic valve prosthesis leaflets appear to move
normally. No masses or vegetations are seen on the aortic valve.
Trace aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. No mass or vegetation is seen on the
mitral valve. Mild to moderate ([**2-13**]+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
IMPRESSION: No vegetation or abscess identified
.
Abdomen Film ([**12-12**]): FINDINGS: Supine and upright abdominal
radiographs. Nonspecific bowel gas pattern with residual
contrast seen within the colon. Tip of NG tube is seen within
the stomach. There is no evidence of intra-abdominal free air.
There is right basilar atelectasis and pleural effusion. Median
sternotomy wires and Foley catheter are identified.
IMPRESSION: No evidence of obstruction.
.
Liver/GB U/S ([**12-15**]): IMPRESSION:
1. Distended gallbladder containing sludge with trace
pericholecystic fluid. Although there are no specific signs for
acute cholecystitis, a HIDA scan would be necessary to exclude
the possibility of acalculous cholecystitis.
2. Right pleural effusion and atelectasis.
.
CXR ([**1-1**]): FINDINGS: In comparison with the study of [**12-31**],
there has been a substantial increase in opacification
bilaterally, especially on the left, consistent with rapid
accumulation of pleural fluid. The status of the underlying lung
is difficult to evaluate in the absence of either a lateral view
or CT. There is further engorgement of the pulmonary vessels
consistent with increasing pulmonary venous pressure.
The nasogastric tube has been removed. The endotracheal tube is
difficult to see and may have been removed, though the patient's
head somewhat obscures the upper thorax. The fragmented wires in
this upper sternum are again appreciated.
Brief Hospital Course:
Patient is a 75 year old female with AF, CHF, bioprosthetic
aortic valve, admitted with ARF after 1 week of diarrhea, MSSA
bacteremia from sternal wound infection, intubated for
respiratory distress and acidosis, unfortunately failed
extubation and at this time not an ideal candidate for
trachestomy.
.
# Respiratory failure and Metabolic Acidosis: Initially
intubated for worsening acidosis and respiratory fatigue, also
appeared to have pulmonary edema on CXR. Failed attempted
extubation on [**12-20**], as she became tachycardic, tachypneic,
hypertensive, using accessory muscles and unable to clear
secretions or cough, and was subsequently re-intubated. It was
thought that she failed likely due to deconditioning/overall
weakness, likely component of restrictive lung disease, given
kyphosis, and overloaded fluid status. CXR continued to
demonstrate pulmonary edema and vascular congestion, along with
pleural effusions, however her CXR did seem improved when
compared to several days ago; we were continuing to monitor CXR
to help with assessment of fluid status. Overall appears less
fluid overloaded on exam, with much improvement in edema. She
was continued on a lasix gtt, having successfully removed 1
L/day, but lasix gtt was eventually held as she became
hypotensive. The initialy plan was that if the patient failed
extubation, Dr. [**Last Name (STitle) 2230**] had been contact[**Name (NI) **] and would start
arrangements for tracheostomy. Patient extubated [**12-31**],
initially did well then became increasingly uncomfortable, felt
short of breath. The patient wished not to be re-intubated and
did not want a tracheostomy.. After extensive discussions with
family and patient, decision was made for patient to be comfort
measures only, as patient did not want to be re-intubated or
placed on non-invasive ventilation. Family at bedside and in
agreement with plans for CMO. Morphine gtt was initiated, and
patient passed away on [**1-2**].
.
# MSSA infection/sepsis of sternal wound:
Her shock was secondary to staph aureus wound infection in her
sternum (from previous mitral valve surgery) and subsequent
bacteremia. Family declined any surgical intervention or
drainage/debridement of wound. Initially on neo, but then
weened to vasopressin, now off all pressors for several days.
Blood Cx ([**12-8**], [**12-9**]) MSSA, Wound Cx ([**12-10**]) MSSA, Sternotomy
Wire ([**12-11**]) MSSA, which was treated with nafcillin. LFTs were
monitored daily. Also Previous + urine culture for E. coli;
treated with 7 days of cipro. TEE did not demonstrate any
vegetations.
.
# Chronic back pain: Patient has related chronic back pain that
is likely exacerbated by prolonged stay in bed. Patient not on
any significant pain management medications at home. As
discussed earlier, osteomyelitis is less likely, and work up
would not change management. Pain control adequate at present,
likely improved with OOB to chair and working with PT. Fentanyl
patch of 25 mcg initiated, using boluses as fentanyl needed,
however not needed for quite some time. Tylenol ATC and
Lidoderm patch added.
.
# Anxiety: Patiend had severe anxiety regarding extubation.
Family relates that patient is a "worrier" at baseline, but
otherwise manages her anxiety on her own, and does not seek
medications. We had attempted to maximize medical management of
her anxiety to assist with success of weaning from vent. To
decreased anxiety, only the on-call team would see the patient
on daily rounds, and only the attending and respiratory
therapist were in the room for extubation. She was given
Klonopin 0.5 mg [**Hospital1 **] to help with significant anxiety, Ativan PRN
for additional anxiety.
Re-assuring, supportive care from family, staff.
.
# Elevated LFTs/Cholestasis: Resolved. Previous US showed mild
gallbladder distension. Will continue to monitor trend, LFTs
(except alk phos, trending down) and T. Bili within normal
limits.
.
# Abdominal discomfort: Resolved, was likely secondary to
irritation from heparin injections. Attempted to transition to
lovenox, so patient would only get one daily injection, however
pharmacy concerned given patient's low weight and low creatinine
clearance. D/ced heparin SC as patient promised to keep on
pneumoboots.
.
# AF w/RVR: Patient developed AF w/RVF, was on amiodarone drip,
and was successfully cardioverted back in to NSR, flips back
into AF occasionally. Restarted ASA for anticoagulation
(outpatient regimen, was not on Coumadin or any other [**Doctor Last Name 360**] as
outpatient). Continued on amiodarone PO 400 mg TID for 2 weeks,
then changed on [**1-1**] to 400 mg [**Hospital1 **] for 2 weeks (with plans to
then change to 400 mg daily. Metoprolol was d/c'ed, given low
bp, will favor diuresing in lieu of beta blocker, as patient has
not been able to tolerate both.
.
# Anemia: No clinical evidence of bleeding. Continued B12,
Folate supplementation. Received 1 U PRBCs on [**12-28**]. CT
abd/pelvis showed no rp bleed.
.
# Renal failure: Presented with cr 9.0, from baseline cr
2.5-2.6; presumed prerenal from diarrhea, also likely worsened
by hypotension. Improved with iv hydration. Renal U/S completed,
no evidence of hydronephrosis or obstruction. E coli UTI
treated with 7 days cipro. Urine lytes, sediment have been
unremarkable.
Creatinine improved to 1.8-1.9, lower than prior baseline.
Diuresed as tolerated by b.p. with lasix gtt.
.
# Right arm erythema, left arm edema: Patient with redness at
area of prior PICC in R arm, which was d/c'd as it was cracked.
Area was marked, and has not extended beyond mark. No warmth or
fluctuance. Suspect that as diuresis has occurred, patient's
left arm has more residual edema in light of prior masectomy and
lymphedema she has chronically had on that arm, and at this time
in light of her total body edema, she has proportionally more in
her left arm which is now more noticable as diuresis continues.
Will continue to monitor, no lines, pain, or palpable cords in
arm to suspect DVT.
.
# FEN: Started TFs. Monitored lytes [**Hospital1 **] with diuresis.
Hypernatremia resolved, d/c'ed free water flushes
Medications on Admission:
Medications
[**Doctor First Name **] 60 q12h prn
Allopurinol 100 qd
ASA 325 po qd
Calcitriol 0.25 po qod
Colchicine 0.6 qmwf
Compazine prn
Fosamax 70 qwk
Lasix 20 po qmwf
Maxzide (Triamterene-Hydrochlorothiazid) 75/50mg po qd
Toprol XL 100 po qd
.
Allergies
Keflex
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
None
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"99592",
"51881",
"78552",
"5990",
"2761",
"4280",
"42731"
] |
Admission Date: [**2138-5-11**] Discharge Date: [**2138-5-19**]
Date of Birth: [**2075-5-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2138-5-11**] Flexible bronchoscopy with BAL; left back
evacuation of hematoma with repair of diaphragmatic
laceration.
History of Present Illness:
62 yo MALE admitted s/p fall. He suffered a
fall while intoxicated this a.m. down some stairs. He was on the
ground for a few hours, then reportedly managed to crawl to a
recliner chair
prior to seeking emergency care. He was noted to have left
rib fractures from [**4-29**] with consequent pneumothorax s/p chest
tube placement and pulmonary contusions.
The patient was evaluated in the emergency dept and had shallow
breathing though he was able to speak in full sentences. He
reports severe pain from below the nipple to above the umbilicus
on the left, without radiation to the upper extremity. The pain
is exacerbated by breathing, coughing and movement. There is
some
improvement with narcotic pain medication. He denies any
numbness, tingling or motor weakness in any of his extremities.
There has been no loss of control of bowel or bladder. The
patient denies a history of chronic back pain or back surgery.
Past Medical History:
HTN, anxiety
PSH: Prostatectomy
Social History:
+EtOH
Family History:
Noncontirbutory
Physical Exam:
Upon presentation:
T 99.7 BP 123/67 P 87 R 18 SPO293% 6l o2 via nc PAIN [**9-28**]
HEENT: PERRL
NECK: Soft
CHEST: + chest tube LEFT, +large eccymoses LEFT flank, + ttp
LEFT
chest
ABD: soft
BACK: deferred
N:
CN 2-12 GI
Light touch intact bilat UE & LE
Str 4+ to [**4-23**] bilat UE & LE (some challenge with moving LUE [**1-21**]
pain)
Pertinent Results:
[**2138-5-11**] 10:49PM GLUCOSE-144* LACTATE-2.1* NA+-135 K+-4.8
CL--103
[**2138-5-11**] 10:35PM WBC-9.7 RBC-3.33* HGB-10.4* HCT-29.7* MCV-89
MCH-31.4 MCHC-35.1* RDW-15.2
[**2138-5-11**] 10:35PM PLT COUNT-128*
[**2138-5-11**] 10:35PM PT-13.6* PTT-29.8 INR(PT)-1.2*
[**2138-5-19**] 08:35AM BLOOD WBC-8.8# RBC-3.20* Hgb-10.0* Hct-30.0*
MCV-94 MCH-31.4 MCHC-33.4 RDW-15.9* Plt Ct-315
[**2138-5-17**] 12:00PM BLOOD WBC-18.8*# RBC-3.49* Hgb-11.2* Hct-32.5*
MCV-93 MCH-32.0 MCHC-34.4 RDW-15.9* Plt Ct-219
[**2138-5-16**] 07:35AM BLOOD WBC-8.8 RBC-3.27* Hgb-10.2* Hct-29.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-15.7* Plt Ct-238
[**2138-5-15**] 04:46AM BLOOD WBC-7.3 RBC-3.06* Hgb-9.3* Hct-27.4*
MCV-90 MCH-30.4 MCHC-34.0 RDW-15.6* Plt Ct-188#
[**2138-5-14**] 09:44AM BLOOD Hct-28.1*
[**2138-5-14**] 02:06AM BLOOD WBC-6.3 RBC-3.07* Hgb-9.7* Hct-26.9*
MCV-88 MCH-31.6 MCHC-36.0* RDW-16.0* Plt Ct-117*
[**2138-5-13**] 05:03PM BLOOD Hct-28.1*
[**2138-5-13**] 11:29AM BLOOD Hct-28.5*
IMAGING:
CT chest [**2138-5-11**]: Preliminary Report !! WET READ !!
1. Extensive left neck and chest wall subcutaneous emphysema,
accompanied by
pneumomediastinum.
2. Moderate-sized left pneumothorax.
3. Small focus of air anterior to the right lung is likely part
of
pneumoediastinum, however, close followup is recommended as this
may develop
into a pneumothorax.
4. left [**3-31**] posterior rib fx, with significant displacement of
7th-11th fxs.
5. Hypodense linearity within the spleen may represent a
laceration, however,
further assessment is limited due to motion artifact.
6. No retroperitoneal or intra-abdominal hematoma.
7. Great vessels appear intact.
8. Right scapula tip fx.
9. Nondisplaced fx of 8th and 9th left thoracic transverse
processes .
CTOH [**2138-5-11**]: Preliminary Report !! WET READ !! No acute
intracranial process.
CT C/S Preliminary Report !! WET READ !!
No acute fx or traumatic malalignment of the C spine.
Mild posterior disc bulge at C4/5 resulting in mild canal
narrowing. MRI can be considered if there are localizing
neurological symptoms.
Extensive L>R soft tissue emphysema, extending to the
prevertebral soft tissues. Pneumomediastinum.
CXR [**2138-5-11**]: IMPRESSION: Interval placement of left lower
thoracic chest tube.
CXR [**2138-5-11**]: IMPRESSION:
1. Multiple left lateral displaced rib fractures.
2. Moderate amount of subcutaneous emphysema at the left lateral
chest wall.
3. Pneumomediastinum.
4. Left anterior pneumothorax.
5. Patchy opacities at the left lung base may represent
atelectasis or contusion.
Brief Hospital Course:
He was admitted to the trauma service and transferred to the
Trauma ICU for further monitoring and analgesia. The Acute Pain
Service was consulted for paravertebral catheter placement. He
was given an intravenous banana bag; his chest tube output was
noted with high output >200cc/hr and he was transfused.
Arterial and central lines placed and he was taken to the OR for
flexible bronchoscopy with BAL; left back evacuation of hematoma
with repair of diaphragmatic laceration.
He remained in the ICU and was extubated on [**5-13**]; CT #1 was
removed on [**5-14**] and he was transferred to the regular nursing
unit. On [**5-15**] the remaining chest tubes were removed. He
continued to have pain control issues which were eventually
controlled with oral narcotics prior to his discharge.
Hepatology was consulted for hyperalbuminemia who recommended
following his LFT's which remained mildly elevated and that he
follow up with his primary care physician for his baseline mild
hyperalbuminemia after discharge.
He was evaluated by Physical therapy and recommended for home
PT. He was also followed closely by Social Work.
Medications on Admission:
Atenolol 50mg qd
Alprazolam 0.5 tid prn anxiety
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Taclonex Topical
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Tablet, Delayed Release (E.C.)(s)
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
s/p Fall
Left rib fractures [**4-29**]
Pneumothorax/hemothorax
Pneumomediastinum
Diaphragmatic laceration
Right scapula tip fracture
Nondisplaced fractures of T [**7-28**] left transverse process
Discharge Condition:
Ambulating
Tolerating regular diet
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
Your liver enzymes were elevated. We recommend not drinking
alcohol or taking tylenol. These will be checked at your follow
up appointment.
*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 with pain medication or is getting
worse. 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.
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 [**4-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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.
Followup Instructions:
Follow up with thoracic surgeon Dr. [**Last Name (STitle) **] in [**12-21**] weeks,
call [**Telephone/Fax (1) 66315**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **] in [**12-21**] weeks. Call [**Telephone/Fax (1) 1864**] for
an appointment.
Completed by:[**2138-7-31**]
|
[
"2851"
] |
Admission Date: [**2134-2-16**] Discharge Date: [**2134-2-16**]
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Transfer with SAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
: MS [**Known lastname 71553**] is a 85 y/o woman with a PMH of
hypertension,Bipolar disease, Glucoma and cataracts who was in
her usual state of health when at 8:45pm she was in her kitchen
with her son and yelled out in pain, he held her from not
falling
and she became unconscious with snoring respirations. She was
taken via ambulance to [**Hospital3 7571**]Hospital and a head CT
showed a SAH. She was intubated at that hospital and found to
have a "poor exam" and transferred here.
Past Medical History:
HTN
Bipolar Disease
Glucoma
Cataracts
Social History:
Widowed
Lives alone near son
[**Name (NI) **] alcohol no smoking
Family History:
Non contributory
Physical Exam:
Vitals: 233/96 HR 60 R 18 100% on vent
HEENT: Right pupil appears surgical 3mm non reactive; left pupil
2mm min reactive. No trauma to head
Neck: Collar in place
Lungs: Intubated clear
Heart: Bradycardic 60's
Abdomen: Soft non distended
Extremities: No edema
Neurological:
Intubated, last sedation 1.5 hours ago, Right pupil appears
surgical 3mm non reactive; left pupil 2mm min reactive.
+ Corneal on right, + Gag, + Cough
To deep pain stimuli internally rotates lower extremities
Slightly extends arms
Pertinent Results:
[**2134-2-16**] 12:57AM TYPE-ART RATES-/16 TIDAL VOL-500 PEEP-5
PO2-420* PCO2-30* PH-7.46* TOTAL CO2-22 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
[**2134-2-16**] 06:03AM PT-12.0 PTT-21.4* INR(PT)-1.0
[**2134-2-16**] 06:03AM PLT COUNT-213
[**2134-2-16**] 06:03AM WBC-16.0* RBC-3.56* HGB-10.9* HCT-33.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-13.3
[**2134-2-16**] 06:03AM CALCIUM-8.9 PHOSPHATE-2.1* MAGNESIUM-2.0
Brief Hospital Course:
Ms [**Known lastname 71553**] was transferred to [**Hospital1 18**] ER she was found to have a
poor neurologic exam as described in the exam section. She
underwent an immediate CTA which showed a
Extensive hemorrhage is noted involving the cerebral
sulci, bilaterally and diffusely, with relative sparing of the
parietal and
the occipital regions. There is also hemorrhage in the
interhemispheric
fissure and in the region of the tentorium cerebelli; extensive
intraventricular hemorrhage is noted in both lateral ventricles,
third and
fourth ventricles. Hematoma is also noted involving the rostrum
of the corpus
callosum. The osseous and the soft tissue structures are
unremarkable. The
visualized portions of the paranasal sinuses reveal fluid in the
sphenoid
sinus, which could be related to the intubated status of the
patient.
CT ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]:
There is a giant aneurysm, measuring 2.7 x 2 x 2.5 cm, arising
from the
anterior communicating artery with splaying of the A2 branches
on either side.
Bilateral internal carotid arteries and middle cerebral arteries
are patent
and normal in caliber. The A1 segment of the right anterior
cerebral artery
is hypoplastic. The A1 segment of the left anterior cerebral
artery is patent
and normal in caliber. Bilateral distal vertebral, basilar
artery, and
posterior cerebral arteries are patent and normal in caliber.
Given the results of the latest CT and her poor exam placing her
to be a grade 5 Hunt and [**Doctor Last Name 9381**] score we (Dr [**Last Name (STitle) **] and Chip
[**Name8 (MD) 3903**] NP) spent over two hours discussing the unfornate
diagnosis and that any type of recovery would not likely. The
family made the patient CMO and she was extubated in the morning
of the 23rd and passed away that evening.
Medications on Admission:
Altase 1.25 QD
HCTZ 25 QD
Xalatan 1 HS
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
SAH
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
N/A
Completed by:[**2134-2-17**]
|
[
"4019",
"42789"
] |
Admission Date: [**2184-4-7**] Discharge Date: [**2184-4-15**]
Date of Birth: [**2112-3-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Enlarging brain abcess
Major Surgical or Invasive Procedure:
[**4-9**] Left Craniotomy for evacuation of brain abscess
History of Present Illness:
Ms. [**Known lastname **] is a 72 y.o. RH female with PMH of HTN,
hyperlipidemia, ulcerative colitis and known left tempoparietal
brain abscess s/p stereotactic brain abscess drainage on [**2184-3-8**]
who presented to ED with multiple brain abscessed. She was
discharged on ceftriaxone, vancomycin and Flagyl. She was
followed by neurology and ID. She was recently found have
thrombocytopenia and ceftriaxone was changed to penicillin.
However, she was found to have Heparin-Induce Thrombocytopenia.
She was changed from Ceftriaxone to penicillin IV.
Now for the past several days, she has had increasing HAs,
agitation, nausea, vomiting and fevers. She had a head CT
yesterday which showed multiple ring enhancing lesion. Patient
presented to ED for further management. Neurosurgery consulted
for further management.
On review of systems patient reports chills and rigors. She has
no visual loss or paresthesia. No chest pain, abdominal pain or
SOB. All other systems are essentially non-contributory.
Past Medical History:
-HTN
-HLD
-Ulcerative colitis - per PCP/GI doc, trivial 15-30 cm of
colitis in distal sigmoid sparing rectum. Pathology showed mild
IBD. PCP/GI doc does not consider this UC.
-Femur fracture s/p rod + pins ([**9-/2183**])
-viral tongue lesion (dx 1 month ago) - s/p biopsy and ~4 wks
abx
-left cheeck skin cancer s/p topical/surgical removal - unclear
if basal cell vs melanoma. PCP [**Name Initial (PRE) 72520**]'t recall melanoma hx but
does not have in records. Derm: Dr. [**Last Name (STitle) 11487**] at [**Hospital1 **]
Screening tests (per PCP/GI Dr. [**Last Name (STitle) 110284**] - Pt often
refused.
- last colonoscopy [**2181**] - focal ischemia, no polyps
- mammogram [**2174**] - no abnl
- prev CXR [**2170**]
Social History:
She previously lived with her husband. She had been in rehab in
CT for her femur fx in [**9-/2183**] and subsequently living with
daughter in CT for further rehab; moved back with her husband
prior to her recent admission to [**Hospital1 18**] in [**2184-2-15**]. She is
now at Newbridge on the [**Hospital **] Rehab after that admission.
Family History:
Unable to obtain from patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 101.0 103 146/73 22 97%
Gen: WD/WN, comfortable, NAD, warm to touch, with rigors
HEENT: head: incision well-healed, disheveled, eye; clear, no
jaundice, ears: hearing intact, no drainage Nose: patent, no
drainage
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r.
Cardiac: RRR. S1/S2.
Abd: Soft, obese, NT, BS+
Extrem: Warm and well-perfused, no c/c/e
Neuro:
Mental status: Awake and alert, distressed and agitate.
Orientation: Oriented to person and hospital, thinks it is [**2194**].
Language: Speech fluent with good comprehension, following
commands, able to repeat
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally, fundoscopic - no papilledema, Visual fields are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-20**] throughout. No pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+----------
Left 2+----------
No clonus
Toes downgoing bilaterally
Bilateral rigors on coordination exam, but appropriate
Handedness Right
On Discharge:
Stable
Pertinent Results:
ADMISSION LABS:
[**2184-4-7**] 04:05PM BLOOD WBC-9.2# RBC-4.29 Hgb-12.4 Hct-38.4
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.2 Plt Ct-270#
[**2184-4-7**] 04:05PM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.1
Eos-0.4 Baso-0.3
[**2184-4-7**] 04:05PM BLOOD PT-12.9* PTT-27.4 INR(PT)-1.2*
[**2184-4-7**] 04:05PM BLOOD Glucose-126* UreaN-3* Creat-0.6 Na-130*
K-4.1 Cl-96 HCO3-19* AnGap-19
[**2184-4-7**] 04:05PM BLOOD CRP-1.5
[**2184-4-7**] 04:20PM BLOOD Lactate-1.7
REPORTS:
CT HEAD [**2184-4-6**]: IMPRESSION: Four rim-enhancing left parietal
fluid collections encompassing a larger area in comparison to a
previously-seen single abscess at this location. The findings
are concerning for recurrent or expanding infection. MR could
be considered for further evaluation.
Cardiovascular Report ECG Study Date of [**2184-4-7**] 3:45:24 PM
Sinus tachycardia. Possible prior septal myocardial infarction,
age
undetermined. Left ventricular hypertrophy with secondary
repolarization
changes. Compared to the previous tracing of [**2184-3-2**] lateral
ST-T wave changes are more prominent on the current tracing.
Other findings are similar.
[**4-7**] MR HEAD W & W/O CONTRAST
IMPRESSION:
1. Multiseptated, multiloculated peripherally enhancing lesion
in left
temporoparietal lobe is suggestive of an abscess with associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
3. Changes of chronic small vessel ischemic disease.
[**4-7**] CHEST (PORTABLE AP) FINDINGS: The patient has received a
right PICC line. The course of the line is unremarkable, the
line appears to terminate in the mid SVC. There is no evidence
of complications, notably no pneumothorax.
MR HEAD W/O CONTRAST Study Date of [**2184-4-8**] 11:51 AM
IMPRESSION:
1. Limited examination due to patient motion, functional MRI
sequences of the brain were cancelled due to lack of patient
cooperation.
2. DTI tractography images demonstrate significant deviation of
the
corticospinal fibers and association fibers; however, apparently
there is
evidence of cortical spinal tracts adjacent to this mass lesion.
3. In comparison with the prior examinations, no significant
changes are
visualized in the left occipital mass with persistent vasogenic
edema, slow diffusion and mass effect.
MR HEAD W/ CONTRAST Study Date of [**2184-4-9**] 4:44 AM
IMPRESSION:
1. Pre-operative planning study with stable multiseptated,
multiloculated
peripherally enhancing lesion in left temporoparietal lobe with
associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
[**4-9**] CT head postop: Status post craniotomy and drainage of left
parietal abscesses with small amount of post procedural
intraparenchymal and extra-axial hemorrhage and unchanged
vasogenic edema without evidence of significant mass effect.
[**4-10**] Chest Xray: There is an endotracheal tube whose distal tip
is 5 cm above the carina at the level of the aortic knob and
appropriately sited. Cardiac silhouette is upper limits of
normal. There is mild prominence of the pulmonary interstitial
markings without overt pulmonary edema. No large pleural
effusions or pneumothoraces are seen. There is a right-sided
PICC line whose distal tip is at the cavoatrial junction,
unchanged from prior.
[**4-10**] MR brain with & without Contrast:
IMPRESSION:
1. Post-surgical changes in the left parietal region, with
heterogeneous
enhancement in the left parietal lobe extend into the atrium of
the left
lateral ventricle with mild subependymal enhancement and
moderate surrounding edema. This is decreased since the
pre-operative study, with a few persistent blood products and
possible purulent material. Other details as above.
2. A faint focus of enhancement in the pons, likely represents
a capillary telangiectasia and is unchanged.
[**4-14**] Transthoracic Echocardiogram
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Brief Hospital Course:
This is a 72 year old female with known left tempoparietal brain
abscess who presented with increased headaches,nausea, vomiting,
and agitation who presented on [**2184-4-7**] with more enhancing
lesions (probable abcess) and cerebral edema. On [**2184-4-7**] the
patient was admitted to the neurosurgery service to the SICU
additional evaluation and treatment. The patient had a brain MRI
with and without contrast to assess the extent ofthe multiple
brain abscesses which was consistent with multiseptated,
multiloculated peripherally enhancing lesion in left
temporoparietal lobe is suggestive of an abscess with associated
significant
perilesional edema causing mass effect on the atrium and body of
left lateral
ventricle. Enhancement along the atrium of left lateral
ventricle which likely
represents subependymal spread of infection.Changes of chronic
small vessel ischemic disease. A functional MRI was performed as
this lesion is near her motor and speech centers of her brain
because she is right-handed and left hemisphere dominate which
was consistent with limited examination due to patient motion,
functional MRI sequences of the brain were cancelled due to lack
of patient cooperation. DTI tractography images demonstrate
significant deviation of the corticospinal fibers and
association fibers; however, apparently there is evidence of
cortical spinal tracts adjacent to this mass lesion. In
comparison with the prior examinations, no significant changes
are visualized in the left occipital mass with persistent
vasogenic edema, slow diffusion and mass effect. The patient
exhibited "red man's syndrome" and was given benadryl.
On [**4-8**],Infectious Disease was consulted and recommendations
were as follows:The failure to resolve her brain abscess after a
long course of metronidazole and ceftriaxone suggests that
either her infection was polymicrobial at the outset or she
developed a superinfection, perhaps via an organism introduced
at the time of
her prior surgery. Would cover gram positive organismsby adding
vancomycin to her regimen, and would monitor vancomycin levels
and renal function. For now would continue metronidazole and
ceftriaxione, since she initially seemed to
improve. Based on the results of new brain aspiration, would
adjust antibiotics accordingly, possibly to cover more resistant
gram negative rods or to cover yeast or other atypical
pathogens. On exam, the patient's mental status was improved.
On [**4-9**], A Wand MRI was performed for OR planning. The patient
went to the OR for a left craniotomy for evacuation and washout
of the brain abscess. The patient tolerated the procedure well
and she was transferred intubated to the ICU. Postoperative
head CT demonstrated no postoperative hemorrhage.
She remained intubated until after a postoperative MRI could be
obtained on [**4-10**]. Post extubation the patient remained
neurologically intact.
On [**4-11**] she was transferred to the regular floor. She was
repleted in the AM via IV for a Potassium of 2.8. Repeat
evening K was 3.4 for which she was repleted orally with a plan
to recheck in the AM. Vancomycin dosing was increased to 1250
IV BID per ID recommendations and a trough was scheduled for
prior to the 4th dose. On [**4-13**], she was screened for rehab and
ceftriaxone was changed to daily per ID. On [**4-14**], ID changed
flagyl to PO 500mg Q8H which patient could not tolerate due to
nausea so it was made IV once again. She continued to have
nausea around the administration of Flagyl and thus was managed
with oral and IV antiemetics. TTE was obtained on [**4-14**] which
demonstrated a normal EF of 55% with no evidence of vegetations.
She remained neurologically stable during her hospital stay and
at the time of discharge on [**4-15**] she was tolerating a regular
diet, ambulating with an assistive device, afebrile with stable
vital signs.
She is sheduled for follow up with ID in two weeks with a plan
to continue triple antibiotic therapy until then. Vancomycin
levels should be followed to maintain a goal trough level of
15-20.
Medications on Admission:
Penicillin 4 million units IV Q4h
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day This Rx has been called
into your mail order pharmacy
LEVETIRACETAM [KEPPRA] - (Prescribed by Other Provider) - 500
mg
Tablet - 2.5 Tablet(s) by mouth twice a day This Rx has been
called into your mail order pharmacy
LOPERAMIDE - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth four times a day as needed for diarrhea
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
METRONIDAZOLE [FLAGYL] - (Prescribed by Other Provider) - 500
mg
Tablet - 2 Tablet(s) by mouth two times a day and 1 tablet QHS
ONDANSETRON HCL - (Prescribed by Other Provider) - 4 mg Tablet
-
2 Tablet(s) by mouth every eight (8) hours as needed for nausea
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
heparin flushes - was discontinued prior to arrival
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. insulin regular human 100 unit/mL Solution Sig: per insulin
sliding scale Units Injection ASDIR (AS DIRECTED).
6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
8. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day).
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Vancomycin 1250 mg IV Q 12H
15. Ondansetron 4 mg IV Q8H
Please give prior to flagyl dosing
16. CeftriaXONE 2 gm IV Q24H
17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
18. Ondansetron 4 mg IV Q4H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Cerebral Abcess
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You have dissolvable sutures. You may wash your hair.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam) for seizure
prevention, you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain with and without
contrast.
- You are also scheduled to follow up with infectious disease in
2 weeks. You will see [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**] on
[**2184-4-26**] at 10:00am.
- You also have an appointment to follow up with Neurology:
Department: NEUROLOGY
When: MONDAY [**2184-6-28**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 43**] & [**Doctor Last Name 2336**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2184-4-15**]
|
[
"4019",
"2724"
] |
Admission Date: [**2160-2-22**] Discharge Date: [**2160-3-5**]
Date of Birth: [**2088-12-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Cold Left Lower Extremity
Major Surgical or Invasive Procedure:
Left iliac, femoral, superficial femoral artery, profunda
embolectomy, 4-compartment fasciotomy.
History of Present Illness:
73y/o female admitted to [**First Name9 (NamePattern2) 81456**] [**Doctor First Name **] [**2-16**] for 6 month history
of intermittent abdominal distention and flatus associated with
diminished appetite. Denies post pranial abdominal pain.
Admitting physical abdominal acities and distention. Patient was
to under go expl lab today but develope acute left
foot ischemia. The patient was evaluated by Dr. [**Last Name (STitle) 1391**] and
patient was transfered here for further evaluation. When she
arrived, her IV heparin was running at 850U/hr. Patient denies
any history of cardiac problems, asthma, stroke, arrythmia's,
PUD, bowel changes, melena or bloody stools.
Past Medical History:
no acute illness or surgical history
Social History:
Married, lives at home w/husband and daughter. [**Name (NI) 4906**]
recovering from recent hospitalization for perforated bowel. +
Tobacco use, 1ppd, though recently cut down 1 month ago. + ETOH,
approx 1 drink/day.
Family History:
not assessed
Physical Exam:
At admission:
VS: T 98.0 HR 124 B/P 117/81 RR 22 O2sat 95% @4L
Gen: no acute distress, anxious mild dyspena with speech
HEENT: no JVD, no carotid bruits, pulses 1+
Lungs: diffuse wheezing
Heart: irregular, irregular no mumur, gallop or rub.
ABD: mid distention with diminshed bowel sounds and mild RLQ
tenderness. No bruits
PV: left foot pale, cold, nonsensate, can not wiggle toes of
dorsiflex foot. temperature change extends to below left knee.
Rt. foot cool with good capillary rfill and motor/sensory
intact.
Pulse exam: 1+ femorals bilaterally with bruits, [**Doctor Last Name **] absent
bilaterally, rt. DP/PT dopperable monophasic .lt. pedal pulses
absent.
Neuro: oriented to time,place and person. non focal exam except
for left foot findings.
At discharge:
expired
Pertinent Results:
[**2160-2-22**] 05:53PM BLOOD WBC-21.6* RBC-4.26 Hgb-13.3 Hct-37.4
MCV-88 MCH-31.4 MCHC-35.6* RDW-13.1 Plt Ct-272
[**2160-2-23**] 04:50AM BLOOD WBC-18.5* RBC-3.75* Hgb-11.9* Hct-32.7*
MCV-87 MCH-31.8 MCHC-36.5* RDW-13.3 Plt Ct-256
[**2160-2-24**] 03:11AM BLOOD WBC-12.7* RBC-3.86* Hgb-11.9* Hct-34.2*
MCV-89 MCH-30.9 MCHC-34.9 RDW-13.3 Plt Ct-250
[**2160-3-3**] 12:51AM BLOOD WBC-7.1 RBC-2.45* Hgb-7.5* Hct-21.4*
MCV-87 MCH-30.7 MCHC-35.3* RDW-15.7* Plt Ct-364
[**2160-3-4**] 02:53AM BLOOD WBC-10.9# RBC-2.67* Hgb-8.2* Hct-23.2*
MCV-87 MCH-30.6 MCHC-35.1* RDW-15.4 Plt Ct-506*
[**2160-3-5**] 12:12AM BLOOD WBC-10.6 RBC-3.63*# Hgb-11.0*# Hct-31.3*#
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.0 Plt Ct-250#
[**2160-2-22**] 05:53PM BLOOD PT-15.5* PTT-53.8* INR(PT)-1.4*
[**2160-2-22**] 10:29PM BLOOD PT-17.1* PTT->150 INR(PT)-1.5*
[**2160-2-23**] 04:50AM BLOOD PT-15.0* PTT-71.0* INR(PT)-1.3*
[**2160-3-3**] 12:51AM BLOOD PT-15.8* PTT-101.1* INR(PT)-1.4*
[**2160-3-4**] 11:04PM BLOOD PT-15.6* PTT-62.8* INR(PT)-1.4*
[**2160-2-22**] 05:53PM BLOOD Glucose-80 UreaN-23* Creat-0.9 Na-131*
K-5.2* Cl-97 HCO3-23 AnGap-16
[**2160-2-22**] 10:29PM BLOOD Glucose-83 UreaN-22* Creat-0.8 Na-140
K-4.8 Cl-105 HCO3-27 AnGap-13
[**2160-2-23**] 04:50AM BLOOD Glucose-92 UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
[**2160-3-2**] 12:59AM BLOOD Glucose-84 UreaN-34* Creat-2.1* Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2160-3-3**] 12:51AM BLOOD Glucose-145* UreaN-41* Creat-2.2* Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
[**2160-3-4**] 02:53AM BLOOD Glucose-120* UreaN-53* Creat-2.1* Na-138
K-4.5 Cl-103 HCO3-26 AnGap-14
[**2160-2-22**] 05:53PM BLOOD ALT-133* AST-196* AlkPhos-134*
TotBili-0.5
[**2160-2-23**] 04:50AM BLOOD ALT-132* AST-297* CK(CPK)-[**Numeric Identifier 81457**]*
AlkPhos-108 TotBili-0.4
[**2160-2-25**] 01:30AM BLOOD ALT-129* AST-147* CK(CPK)-1632*
AlkPhos-119* TotBili-0.2
[**2160-3-3**] 12:51AM BLOOD ALT-32 AST-17 AlkPhos-127* TotBili-0.4
[**2160-2-25**] 03:00PM BLOOD CK-MB-26* MB Indx-2.1
[**2160-2-26**] 02:41AM BLOOD CK-MB-21* MB Indx-2.0
[**2160-2-27**] 11:29AM BLOOD CK-MB-16* MB Indx-2.8
[**2160-2-22**] 10:29PM BLOOD Calcium-5.6* Phos-4.1 Mg-1.3*
[**2160-2-23**] 04:50AM BLOOD Albumin-1.7* Calcium-6.6* Phos-3.5
Mg-1.3*
[**2160-3-3**] 12:51AM BLOOD Albumin-2.1* Phos-5.4* Mg-2.5
[**2160-3-4**] 02:53AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.4
[**2160-2-24**] 03:11AM BLOOD calTIBC-66* Ferritn-469* TRF-51*
[**2160-3-3**] 09:37AM BLOOD calTIBC-100* TRF-77*
[**2160-2-24**] 07:13PM BLOOD %HbA1c-5.9
[**2160-2-24**] 07:13PM BLOOD Triglyc-152* HDL-9 CHOL/HD-9.9 LDLcalc-50
[**2160-2-24**] 07:20PM BLOOD Ammonia-27
[**2160-2-24**] 07:13PM BLOOD TSH-2.6
[**2-22**] ECG: Sinus tachycardia (119). Diffuse ST-T wave abnormality.
Cannot rule out myocardial ischemia. Low QRS voltage in the limb
leads. No previous tracing available for comparison.
[**2-23**] TTE: The left atrium is normal in size. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is severe regional left ventricular systolic
dysfunction with basal to mid septal and anterior
hypokinesis/akinesis and mid inferior akinesis. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-30 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction consistent with multivessel coronary artery disease.
Mild (1+) mitral regurgitation. Moderate to severe [3+]
tricuspid regurgitation with moderate pulmonary artery systolic
hypertension.
[**2-23**] CT abd/pelvis: 1. Findings poorly evaluated without
intravenous contrast but potentially suspicious for peritoneal
carcinomatosis, including ascites and probable peritoneal and
serosal thickening. If there is an outside hospital CT with
intravenous contrast, then this can be scanned into the system
for comparison. 2. Partial small-bowel obstruction, with
transition point in the distal ileum. Contrast does pass into
the colon. 3. Moderate ascites. 4. Moderate bilateral pleural
effusions and adjacent atelectasis. 5. Small hiatal hernia. 6.
Tiny non-obstructing left nephrolithiasis. 7. Anasarca.
[**2-23**] CT Head: FINDINGS: There is a moderate-sized area of
hypodensity in the watershed territory between the right MCA and
PCA territory, consistent with reported history of subacute
infarction. There is no sign of hemorrhagic transformation
within this area. There is no other intracranial hemorrhage.
There is no mass, mass effect, or evidence of other area of
infarction.
There is moderate sulcal prominence in the bilateral frontal
lobes, most
consistent with atrophy, slightly out of proportion to
ventricular size. Basal cisterns are normal. There is mild
mucosal thickening in the ethmoid air cells, and nasal passages.
Paranasal sinuses and mastoid air cells are
otherwise normally aerated.
IMPRESSION: Evolving area of infarction in the watershed
territory between
the right MCA and PCA distributions. No sign of intracranial
hemorrhage, or hemorrhagic transformation of this infarct.
[**3-1**] cytology: Pleural fluid: ATYPICAL. Atypical epithelioid
cells present: Rare clusters of atypical epithelioid cells are
present, but degeneration precludes definitive classification.
[**3-5**] TTE: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality, however, [**Hospital1 **]-ventricular
systolic function appears to be preserved.
Brief Hospital Course:
The patient was admitted on [**2160-2-22**]. After initial evaluation,
she was taken to the OR emergently for LLE thrombectomy. She
underwent a left iliac, femoral, superficial femoral artery,
profunda embolectomy, 4-compartment fasciotomy.
Post-operatively, her pulses were pulses (DP and PT) were
monophasic. She was taken to the CVICU, intubated and sedated
and on pressors, and on a heparin drip. She remained on pressor
support, as her pressures could not tolerate her pain/sedation
drips.
She had new onset atrial fibrillation which was rate controlled.
She was aggressively treated for rhabdomyolysis and ARF with
hydration. She had a bedside ECHO which showed: severe regional
LV systolic dysfunction (EF 20-30%) consistent with multivessel
CAD. Mild (1+) MR. Moderate to severe [3+] TR with moderate PA
systolic hypertension. She had a head CT which showed right
parieto-occipital infarct. The patient remained intubated. She
could not be weaned off the ventilator - she would thrash about
in the bed, and was unresponsive to commands. She would move her
upper extremities, and right lower extremity; muscle twitches
were noted in her left lower extremity. Attempts to extubate
were not successful - she would hypertensive and very highly
aggitated when these attempts were made. She was switched to TPN
and made NPO when she vomitted tube feeds - this may have been
due to extensive carcinomatosis causing pSBO.
She was seen by gyn/onc for her ascites and distension, as well
as CT scan, which were concerning for ovarian cancer. She had a
CT scan of her abdomen and pelvis on [**2-23**]; this was concerning
for peritoneal carcinomatous, including ascites and probable;
pSBO; moderate bilateral pleural effusions and adjacent
atelectasis; small hiatal hernia; tiny non-obstructing left
nephrolithiasis; anasarca. Peritoneal ascites came back positive
for adenocarcinoma, suspicious for ovarian cancer. Pleural fluid
cytology, from a right thoracentesis on [**3-1**], came back positive
for malignant cells. She was not deemed to be a surgical
candidate, though may be a chemotherapy candidate; however,
discussing these options were deffered as the patient could not
be extubated to participate in these discussions.
The patient was made DNR/DNI [**2-26**]. On the morning of [**3-5**], the
patient became acutely hypotensive and was treated with blood
(for postoperative blood loss and intravascular depletion),
fluids and pressors. Her heparin drip was discontinued. A
femoral artery line was placed when the radial line stopped
working. The patient's lower extremity and abdomen became
mottled, her abdomen tense, and it became more difficult to
ventilate her; she became increasingly acidotic. Her family was
made aware. The decision was made to make her CMO. Time of death
was 0528 on [**2160-3-5**].
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2160-3-14**]
|
[
"5990",
"5849",
"51881",
"42731",
"496",
"4280"
] |
Admission Date: [**2125-5-23**] Discharge Date: [**2125-5-25**]
Date of Birth: [**2066-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Demerol / Adhesive Tape
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Direct admission for cardiac catheterization.
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher stent x 2.
History of Present Illness:
59-year-old female with a history of DMII complicated by
end-stage-renal disease, on peritoneal dialysis while undergoing
work-up for renal transplant, PVD, hyperlipidemia, glaucoma, and
anxiety transferred from the CMI service for hyperglycemia. She
had a planned admission to the CMI service for a cardiac cath
after having an abnormal adenosine stress on [**2125-3-1**] when she was
found to have an EF of 49% with mild inferior wall hypokinesis
and small perfusion defect in the basal inferolateral wall.
During the cath patient was discovered to have multiple lesions
in her LAD and received 2 cypher stents. After the cath the
patient was noted to have blood sugars in the 600's. She was
transferred to the MICU for close monitoring. Of note, she
received 10 units of humalog on the floor prior to transfer.
.
On interview patient says she feels a little nauseated and have
some intermittent right leg cramping. She is also having some
pain at the catheterization site.
Past Medical History:
1. Type 2 diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. End-stage renal disease, on peritoneal dialysis - failed
hemodialysis
5. Retinopathy, blind in right eye
6. Glaucoma of the left eye
7. Cataracts, status post left eye surgery
8. Peripheral neuropathy
9. Peripheral vascular diasease status post stent to left
anterior tibial artery
10. Anxiety
11. Chronic nausea
Social History:
She is married and lives at home with her husband. She does not
work. She does not smoke or drink.
Family History:
Her mother died of heart disease in her 60s.
Physical Exam:
VS: T: 96.3 P: 59 BP: 131/59 RR: 11 O2 sat: 99% on RA
GEN: lying in bed, eyes closed
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB to anterior exam, no w/r/r with good air movement
throughout
ABD: soft, tender near catheterization site, otherwise NT, ND, +
BS
EXT: warm, dry, +2 distal pulses on L, DP pulse dopplerable on
R, cath site with sheath in place
NEURO: alert & oriented, CN grossly intact, 5/5 strength
throughout. + decreased sensation in stocking and glove
distribution,
PSYCH: appropriate affect
Pertinent Results:
Labwork on admission:
[**2125-5-23**] 02:18PM GLUCOSE-531* UREA N-68* CREAT-5.1* SODIUM-141
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
[**2125-5-23**] 05:47PM CALCIUM-9.0 PHOSPHATE-5.4* MAGNESIUM-2.2
[**2125-5-23**] 02:18PM PLT COUNT-277
.
[**2125-5-23**] Cardiology C.CATH
Full report pending.
Cypher stent x 2 placed in LAD.
.
Labwork on discharge:
[**2125-5-25**] 03:06AM BLOOD WBC-11.2* RBC-3.31* Hgb-9.9* Hct-29.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-14.2 Plt Ct-293
[**2125-5-25**] 03:06AM BLOOD Glucose-172* UreaN-57* Creat-6.4* Na-141
K-4.4 Cl-104 HCO3-23 AnGap-18
[**2125-5-25**] 03:06AM BLOOD Calcium-8.9 Phos-5.7* Mg-1.9
Brief Hospital Course:
1. Hyperglycemia: The patient is a type 2 diabetic and was
instructed to hold her home insulin regimen the night prior to
catherization. She never had an anion gap. The patient's
glucose levels improved after resuming her home insulin regimen
and FSG was 131 prior to discharge. There were no localizing
signs or symptoms of infection and cardiac enzymes and EKG
remained stable. She was continued on reglan for diabetic
gastroparesis.
.
2. Relative hypotension: The patient's systolic blood pressure
dropped to the 80s after peritoneal dialysis with removal of 1.7
liters of fluid. The patient's blood pressure responded to
fluid resuscitation. The patient's hematocrit remained stable
and there was no concern for retroperitoneal hemorrhage. The
patient was kept an additional night for monitoring. Blood
pressure remained stable with systolics 110s prior to discharge.
.
3. Coronary artery disease: The patient underwent cardiac
catheterization for renal transplant evaluation. The patient
received two Cypher stents to the LAD. She was started on
Plavix to continue at least a three month course and Aspirin was
increased from 81 mg to 325 mg. The patient was continued on
Toprol XL and Simvastatin.
.
4. End-stage renal disease: The patient is on peritoneal
dialysis as an outpatient. The patient was continued on
nephrocaps, Calcitriol, and Sevelamer. The patient was followed
by the Renal service during admission and received PD per
schedule. Sevelamer was increased per Renal recommendations.
.
5. Glaucoma: No active issues. The patient was continued on
Prednisolone and Brimonidine eye drops.
.
6. Depression/Anxiety: No active issues. The patient was
continued on Bupropion, Venlafaxine, and Provigil.
Medications on Admission:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd ().
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Risperidone 0.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous twice a day: With humalog
sliding scale as per previous regimen.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd ().
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Risperidone 0.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous twice a day: With humalog
sliding scale as per previous regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Coronary artery disease status post Cypher stent x 2
.
Secondary:
1. Type 2 diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. End-stage renal disease, on peritoneal dialysis - failed
hemodialysis
5. Retinopathy, blind in right eye
6. Glaucoma of the left eye
7. Cataracts, status post left eye surgery
8. Peripheral neuropathy
9. Peripheral vascular diasease status post stent to left
anterior tibial artery
10. Anxiety
11. Chronic nausea
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted for a cardiac catheterization as part of your
kidney transplant evaluation. During the catheterization two
stents were placed. You need to take plavix for at least three
months; do not discontinue this medication unless instructed by
your cardiologist.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, worsening back pain, lower
extremity numbness or pain, or any other concerning symptoms.
Please take your medications as prescribed.
- You were started on plavix 75 mg daily.
- Your aspirin was increased from 81 mg to 325 mg daily.
- Your sevelemer was increased.
- No other changes were made to your medications.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-6-11**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-6-21**] 1:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2125-6-21**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"41401",
"40391",
"2720",
"2724"
] |
Admission Date: [**2122-4-7**] Discharge Date: [**2122-4-16**]
Date of Birth: [**2056-4-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Zolpidem / Tramadol / Ketorolac / Cyclobenzaprine
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Transfer for question of RCA "found down" at OSH on cardiac
catheterization
Major Surgical or Invasive Procedure:
[**4-7**] Cardiac catheterization with placement of BMS to the Left
Circumflex
Removal of Intraaortic balloon pump
History of Present Illness:
65 y.o. with prior cath [**10-11**] with 50% LCx and RCA totally
occluded treated with RCA cypher DES 2.5 x 8 mm, RCA PCI [**2119**],
recently admitted to [**Hospital 46**] Hosp with diastolic heart failure
about a month ago and sent to [**Location (un) 169**] rehab for long stay.
Finally returned home on [**3-30**]. She was home for two days and was
found down by VNA with blood sugar of 490. Per the pt she fell
becasue of feeling dizzy and was only down for a few minutes.
Negative Head CT. She went back to [**Hospital1 46**] and ruled in for small
NSTEMI with a Trop peak of 1.16 and cpk mb of 8.5. She declined
cath initally. Her mental status has been labile, paranoid at
times, and overall questionable. Her right to consent had been
revoked and her daughter [**Name (NI) 38129**] [**Name (NI) **] consented for cath. BS
today 120's. At cath they first engaged the left and found LCx
with 80% mid lestion. Noted STE in 2, 3 and AVF on EKG. Moved
over to the RCA but not actually engaged and found to be down.
She became bradycardic to the 40's. She did not receive
Atropine. She was started on IV nitro at 60mcg/mn and IV heparin
4000 unit bolus/1400 unit gtt. IABP was placed via 7 french
atrial sheath for ?chest pain. Also has 7 french venous sheath
all on the right. STE improved. 60cc contrast. Fentanyl and
Versed will be totalled when she leaves their labs. She was
awake and minimally agitated on transfer. Last Lovenox last
evening. BP now improved 140/70.
.
Labs at OSH notable for wbc 5.6, hgb 11.2, hct 32.2, plt 188, na
142, k 3.5 repleted earlier 40meq, cl 106, co2 26, bun 9, cr
0.93 (1.49 prior to hydration), iNR on [**4-2**] 1.02 ptt 23.1.
.
The patient came to [**Hospital1 18**] via Med Flight and went straight to
the cath lab. At this point, she was CP free and EKGs had
settled. Initial access was attempted from rt radial but pt had
spasm so they went in through the left radial initially with
diagnostic catheter which was later switched to PCI catheter.
RCA was found to be widely patent with previous stent in place.
Mid circ 80% lesion was intervened on with BMS. She was
transferred to the floor on heparin gtt and IABP with VSS of HR
60 BP 122/52 satting 99% on RA.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
- CARDIAC HISTORY: Diastolic Heart Failure, +Insulin dependent
Diabetes, +Dyslipidemia, +Hypertension, s/p cth [**10-11**] with 50%
LCx, 100% PDA and 90% RCA treated with ptca/cypher DES 2.5 x 8
mm stent, has a hx of inferior wall scar
.
- OTHER PAST MEDICAL HISTORY:
Anxiety Disorder
Morbid obesity
elevated left sided filling pressures
pancreatitis
peripheral neuropathy
s/p tonsillectomy/adeniodectomy
bilateral hip replacement
partial thyroidectomy
Social History:
pt lives at home w/ son. Uses a walker but can only go a few
feet before getting sob. uses three pillows at night.
- Tobacco history: no
- ETOH: no
- Illicit drugs: no
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 99.5 130/76 74 18 96%
General: AAOx2, cooperative
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: warm and dry
reflexes biceps, brachioradialis, patellar, ankle.
Pertinent Results:
[**2122-4-14**] 06:05AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-89 MCH-30.2 MCHC-34.2 RDW-16.2* Plt Ct-209
[**2122-4-14**] 06:05AM BLOOD Glucose-248* UreaN-15 Creat-0.6 Na-144
K-3.9 Cl-108 HCO3-26 AnGap-14
[**2122-4-10**] 12:56AM BLOOD calTIBC-250* Hapto-51 Ferritn-254*
TRF-192*
[**2122-4-9**] 10:10AM BLOOD TSH-5.6*
Cardiac enzymes:
[**2122-4-7**] 10:01PM BLOOD CK-MB-2
[**2122-4-7**] 10:01PM BLOOD CK(CPK)-27*
Other notable labs:
[**2122-4-9**] 10:10AM BLOOD VitB12-1125*
[**2122-4-10**] 12:56AM BLOOD calTIBC-250* Hapto-51 Ferritn-254*
TRF-192*
[**2122-4-9**] 10:10AM BLOOD TSH-5.6*
[**2122-4-9**] 10:10AM BLOOD Free T4-1.5
Coronary angiography: right dominant
LMCA: No angiographically-apparent CAD.
LAD: Mild luminal irregularities with 50% stenosis distally.
LCX: 80% diffuse into moderate sized OM1.
RCA: proximal 30%. Widely patent stent. Chronically occluded
PL unchanged from prior and fills distally from LCA
LCX:
2.5 x 18 mmIntegriti stent and postdilated to 2.5 mm with an NC
balloon
Echo [**2122-4-9**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with inferior and
inferolateral hypokinesis. The remaining segments contract
normally (LVEF = 40%). 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. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation
Brief Hospital Course:
65F w/ prior RCA stent, HTN, IDDM, anxiety disorder who was
flown in from [**Hospital3 **] after suspicion of acute occlusion
of RCA during elective cath for NSTEMI. Underwent cath here and
was found to have patent RCA, but got BMS to 80% LCX. Had
balloon pump removed which was placed at OSH presumably for for
chest pain.
.
#NSTEMI at OSH/CAD/patent at [**Hospital1 18**]: Patient transferred to the
[**Hospital1 18**] catheterization laboratory after the patient developed
chest pain, bradycardia and STE during diagnostic
catheterization at [**Hospital3 3583**]. During injections of the
LCA, the patient developed chest pain and inferior STE.
Nonselective angiography at that hospital demonstrated occlusion
of the RCA proximally. An IABP was inserted and she was
transferred to [**Hospital1 18**] for confirmatory angiography and possible
PCI of the RCA. The patient arrived without chest pain. Pt was
found to have patent RCA in [**Hospital1 18**] unlike report from OSH where
she was thought to have acute occlusion. Given report of
inferior STE changes, pt most likely had transient occlusion of
the RCA resulting from an air or other embolus. Pt did have 80%
lesion of LCX which was stented with BMS. Pt had balloon pump
weaned and removed without complication with no subsequent chest
pain or drop in pressure. Pt should be on Plavix (clopidogrel)
75 mg daily X 1 month uninterrupted and preferably 9 months
total, aspirin indefinitely,and Metoprolol XL 50 mg.
Atorvastatin was also started.
.
# Anxiety/Delirium: Long and significant hx of anxiety, panic
attacks etc. She was started on PRN benzos for severe agitation,
as well as haldol and olanzapine as needed. Psych was consulted,
and felt this was hospital induced delirium. Benzos were weaned
then stopped as were PRN anti-psychotics. She continued on
olanzapine 7.5 qHS with good effect. Her orientation improved to
oriented times three at the time of discharge. However, she
remains intermittently agitated, often worse later in the day,
although is redirectable.
.
# Acute on chronic systolic and diastolic CHF: Patient had
recent admission for DHF in [**Hospital1 46**]. Last EF 45%. Here she was
found to have inferior and inferolateral hypokinesis and LVEF of
40%. Pt had no signs of acute failure here. She will continue
with lisinopril, metoprolol. She was dry on exam here and thus
her home lasix 20 mg was held. Continued on discharge.
.
# DM2: pt reports blood sugars not well controlled. BS range
50-450 over last 1 month. She was on about 50 units of glargine,
which was reduced then held when patient was confused and not
eating. After starting eating, blood sugars were high. Restarted
lantus 25 units, with sliding scale. Discharged on this dose,
which can be increased as needed at rehab.
.
# Hyperlipidemia: [**2119-9-26**] chol 161, HDL 38, LDL 54, trig 433.
She was started on atorvastatin 80mg.
.
# Hypertension: stable. Continued metoprolol and lisinopril.
TRANSITIONAL ISSUES
- It is unclear what the patient's baseline mental status is now
after multiple admissions and multiple episodes of delirium.
While there are no obvious acute issues, she should undergo an
outpatient workup for dementia. TSH and folate wnl. No B12
deficiency.
- Rehab stay anticipated to be less than 30 days
Medications on Admission:
Plavix 75mg daily
ASA 325mg daily
MVI daily
Humalog SS AC/HS
Klonapin 0.5mg [**Hospital1 **]
Lantus 80 q12
Ativan 0.25 prn
Ferous sulfate 325
Lamictal 150mg daily
Neurotin 300mg daily
Paxil 30mg daily
Toprol 50mg daily
Zestril 20mg daily
Lasix 20mg qd
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. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO once a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. insulin glargine 100 unit/mL Cartridge Sig: Twenty Five (25)
units Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Breakfast/Lunch/Dinner
120-159 - 2 units (0 units qHS)
160-199 - 6 units (2 units qHS)
200-239 - 9 units (4 units qHS)
240-279 - 12 units (6 units qHS)
280-319 - 15 units (8 units qHS)
320-359 - 18 units (10 units qHS)
360-399 - 21 units (12 units qHS)
> 400 - 24 units (14 units qHS).
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 11792**] - [**Location (un) 7740**]
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 38130**],
You were admitted to the hospital for concern of a heart attack,
and underwent a cardiac catheterization with stenting of any
artery. You will be transferred to rehab care to help improve
your strength.
Medication changes:
Start atorvastatin 80mg daily
Start olanzapine 7.5mg at bedtime
Stop klonopin and ativan
Reduce insulin lantus to 25mg daily
Increase paxil to 40mg daily
Followup Instructions:
Please contact your primary care physician for [**Name9 (PRE) 702**] after
you have left rehab.
|
[
"41071",
"4280",
"41401",
"V4582",
"V5867",
"2724"
] |
Admission Date: [**2137-12-29**] Discharge Date: [**2138-1-1**]
Date of Birth: [**2055-9-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
GI distress, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo female with history of with stage IV NSCLCA (BAC) on
Alimta presents with GI distress. Her daughter called the on
call oncologist today who asked the patient to report to the ED.
Her daughter reported the patient was experiencing diarrhea
which started the evening after her last chemotherapy dose
([**2137-12-24**], cycle 30) with associated incontinence, which resolved
by Wednesday ([**2137-12-25**]). Since that time, she reports her
symptoms have progressed. She reports persistent nausea,
vomiting, diarrhea, fatigue, increased incontinence of bowel and
bladder. She reports for the last three days she has had dark to
black stool. Today, she reports worsening intermittent nausea,
with vomiting at 2 am and inability to tolerate oral
antiemetics. Of note, the patient has not allowed re-imaging of
her disease since [**8-1**]. She also has refused colonoscopies in
the past.
In the emergency department her initial vital signs were T 99.1
HR 78 BP 108/53 RR 20 O2 98% on RA. Her labs were significant
for Hct drop of 25 points in 5 days, from 41 to 16, baseline 40,
hypokalemia and elevated INR of 1.9 (on coumadin). 2 large bore
IVs were place. She was given 10mg of IV vitamin K. She was
transfused 2 units of PRBCs and 2 of FFP. GI was consulted in
the ED and felt she was stable for delayed scope. Oncology was
consulted and recommended transfer to the ICU. After signout was
given, it was noted that the patient has a history of right main
pulmonary artery invasion from the tumor, thus a CXR and CT
torso was done to rule out bleeding into chest.
On arrival to the [**Hospital Unit Name 153**], the patient reports continued fatigue
and weakness. She denies ongoing melena, diarrhea or nausea. She
denies pain currently. She reports she has not had any fevers or
chills. Her husband, four daughters and son accompanied her. Her
daughter who is a nurse reports she evaluated her yesterday. She
reports her blood pressure and HR were normal at that time and
she found her stool to be dark but did not believe it was
melena.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
- Bronchoalveolar Carcinoma initially diagnosed [**2112**], initially
treated with RML lobectomy. She had recurrence in [**2129-5-8**]
with a left lung nodule. LUL and LLL wedge resections were
completed in [**2129**]. She was treated with carboplatin and
Navelbine from [**2129-8-24**] through 01/[**2130**]. Because of
progression of disease by CT scan and rising CEA, she agreed to
a trial of Tarceva which she began on [**3-/2134**], however,
developed severe skin and mucosal reactions. In [**1-31**], she was
found to have right upper lobe collapse. She was started on
Alimta [**2136-2-23**] and is currently on her 30th cycle.
- Gastrointestinal Stromal Tumor with partial gastrectomy [**2121**]
w/o recurrence
- breast lumpectomy X2
- thyroid adenoma s/p resection
- Pulmonary Embolisms - in [**1-31**], on coumadin
Social History:
The patient has a remote history of tobacco abuse. Occassionally
uses alcohol. Denies illicit drug use.
Family History:
Not contributory
Physical Exam:
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. Significant conjunctival
pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-25**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EKG: sinus rhythm at 95bpm with AV conduction delay, no ST
changes.
CXR: Trachea deviation to the right, evidence of right sided
resection, missing right 3rd rib, collapse of right upper lobe,
fluid in the fissure on the right.
CT Torso:
1. No evidence of hemorrhage within the torso, or other
explanation for
hematocrit drop.
2. Grossly stable appearance of multiple pulmonary masses, and
post-surgical changes in the lungs, although limited in the
absence of IV contrast.
3. No acute abnormalities in the torso.
EGD [**2137-12-30**]:
Small hiatal hernia
We did not see sign of post-gastrostomy.
Polyps in the stomach body
Erythema in the antrum compatible with gastritis
There was dark blood clot in her stomach body, which was easily
dislodged by water flash. There was no ulcer or visible vessel
under the blood clot. However, the tissue around the blood clot
appears to be thickening and heaped up. The lesion is more
compatible with a dieulafoy lesion. Biopsy did not performed
because of the recent bleeding. (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Admission labs [**12-29**]:
WBC-7.3# RBC-1.66*# Hgb-5.4*# Hct-16.1*# MCV-97 MCH-32.3*
MCHC-33.3 RDW-16.1* Plt Ct-325
Neuts-87.7* Lymphs-10.5* Monos-0.3* Eos-1.2 Baso-0.2
PT-20.1* PTT-26.9 INR(PT)-1.9*
Glucose-121* UreaN-17 Creat-0.8 Na-137 K-3.5 Cl-102 HCO3-27
AnGap-12
ALT-14 AST-33 LD(LDH)-441* AlkPhos-52 TotBili-0.4
Calcium-8.4 Phos-3.4 Mg-1.9
Discharge labs [**1-1**]:
WBC-3.3* RBC-3.89* Hgb-11.7* Hct-35.1* MCV-90 MCH-30.2 MCHC-33.5
RDW-16.6* Plt Ct-191
Glucose-94 UreaN-10 Creat-0.8 Na-136 K-3.5 Cl-99 HCO3-28
AnGap-13
Calcium-8.6 Phos-4.0 Mg-1.8
Microbiology:
H. pylori negative
MRSA screen negative
Blood cultures pending (negative to date)
Brief Hospital Course:
82 yo female with stage IV bronchoalveolar carcinoma, history of
GIST, PEs on coumadin admitted for severe anemia likely
secondary to GI bleed.
#. GI Bleed: Patient admitted with large Hct drop and history
of melena. She underwent EGD that showed a gastic lesion
consistent with a likely dieulafoy lesion. Additionally, the
stomach mucosa was irregular, but no biopsy was performed at the
time of endoscopy because of recent bleeding. GI recommended
that the patient undergo repeat EGD and biopsy in 6 weeks. The
patient received a total of 4 units PRBCs and 2 units FFP, and
remained hemodynamically stable throughout. She was monitored
in the ICU and transferred to the medical oncology service after
36 hours. She had a couple guaiac positive stools but had a
stable hematocrit.
#. Bronchoalveolar Carcinoma: She is s/p LUL and LLL wedge
resections in [**2129**], prior RML lobectomy, with known RUL collapse
seconday to invasion, s/p multiple rounds of chemotherapy, most
recently 30th cycle of Alimta. The patient underwent CT torso
in the ED given her history of known right main pulmonary artery
invasion from the tumor. However, no gross hemorrhage was seen
in the chest cavity. Additionally, she was continued on folic
acid as an adjuct to her chemotherapy regimen. She is to
follow-up with her oncologist.
#. Pulmonary Embolisms: Last documented in [**1-31**], was on
coumadin on presentation. Given her significant GI bleed,
coumadin was stopped (and its effects reversed with FFP) and a
decision was made to stop anticoagulation henceforth. Per
primary oncology team, the patient's history of PE was related
to tumor compression of the pulmonary vasculature, and therefore
there is no clear indication for anticoagulation in the future.
#. Gastrointestinal Stromal Tumor: S/p resection in [**2121**]
without known recurrence, but suspicious lesion was seen on EGD.
The patient was advised to undergo repeat EGD in 6 weeks for
biopsy of gastric lesion. Also suggested outpatient
colonoscopy.
#. Hypothyroidism: S/p thyroid resection for adenoma.
Continued on home levothyroxine.
#. Hypokalemia: Likely secondary to severe diarrhea. Resolved
with fluid resuscitation.
#. Lower Extremity Edema: Likely secondary to chemotherapy vs.
venous stasis. Intially held home lasix due to risk of
hemodynamic compromise, but restarted after fluid resuscitation.
#. Leukopenia and Thrombocytopenia: Decreased platelets could be
consumptive process in setting of recent bleed but more likely
related to recent chemotherapy administration. Could also be
related to PPI administration.
CODE STATUS: DNR/DNI confirmed with patient
EMERGENCY CONTACT: HCP [**Name (NI) **] [**Name (NI) **] ([**2121**], Husband Mr.
[**Known lastname 74225**] [**Telephone/Fax (1) 106862**], Daughter [**First Name8 (NamePattern2) 4051**] [**Last Name (NamePattern1) 4580**] [**Telephone/Fax (1) 106863**]
Medications on Admission:
WARFARIN 5 mg QD
FUROSEMIDE 20mg QD
FOLIC ACID 1 mg QD
LEVOTHYROXINE 75 mcg QD
LORAZEPAM 0.5 mg [**1-25**] PRN
PROCHLORPERAZINE 10 mg PRN
ACETAMINOPHEN PRN
MULTIVITAMIN WITH IRON-MINERAL QD
VIT C-BIOFLAV-HESP-RUTIN-HB111 QD
VIT E- VIT C-MAGNESIUM-ZINC QD
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Upper gastrointestinal bleed
Secondary:
Non small cell lung cancer
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital because you were having
gastrointestinal bleeding. You were seen by gastroenterology who
performed who determined by a procedure called endoscopy that
the bleeding originated in your stomach. You received blood
transfusions and your blood counts have remained stable. Given
this bleeding episode your team of doctors [**Name5 (PTitle) **] decided to take
you off of coumadin.
You will
MEDICATION CHANGES:
STOP coumadin
START (NEW Med) omeprazole 40mg by mouth twice a day: for the
inflammation in your stomach
Followup Instructions:
WE SCHEDULED THE FOLLOWING:
UPPER ENDOSCOPY: [**2137-2-11**] Arrive at 8:30am at [**Hospital Ward Name 516**],
[**Hospital Ward Name 1950**] [**Location (un) 470**] for your upper endoscopy with Dr. [**Last Name (STitle) 349**].
[**Telephone/Fax (1) 463**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-9**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-1-9**]
10:00
----
THE FOLLOWING WERE ALREADY SCHEDULED
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-23**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-1-23**]
10:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2138-1-23**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-23**] 10:00
|
[
"2851",
"V5861",
"2875"
] |
Admission Date: [**2202-12-5**] Discharge Date: [**2202-12-8**]
Date of Birth: [**2159-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Bleeding from trach site
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 yo male with a history of anoxic brain injury living at a
rehab, who is trach and PEG dependent, with recent admission for
tongue laceration, who presents from his rehabilitation facility
with concerns for bleeding from trach. Staff from rehab report
about 400cc bright red blood from trach site over the last 12
hours.
Of note, patient had a recent admission from [**Date range (1) 105118**] for a
tongue laceration. During that hospital course he had total
teeth extraction. He also had a high grade MRSA bacteremia and
was started on 4 week course of Vancomycin (last day [**12-19**]). TEE
was negative. He also completed a 7 day course of Cefepime and
Cipro for VAP. LUE US developed thrombus, and patient was
discharged on lovenox [**Hospital1 **] (day 1 = [**11-30**]).
In the ED, initial vs were: T 97.5 P 86 BP 114/90 R 16 O2 sat
100. He recieved midazolam and fentanyl while IP did a bronch.
The bronch was clean without evidence of bleeding from the trach
or lower. The airways were reportedly free of lesions other than
mild, non-bleeding granulation tissue near the tracheostomy
tract. They thought that despite the inflated balloon he may be
aspirating blood from his bleeding gums. A CTA did not reveal a
PE but did show new nodular ground glass opacities in the right
lung and left apex compared to a CT from [**2202-9-2**] abdominal
CT. Because of this he was given Levofloxacin and Cefepime. He
was admitted for further work-up of new ground glass opacity,
and sent to the ICU given his trach. Prior to transfer vitals
were HR 75-85 BP 110s/80s RR 16 100% on vent.
On the floor, patient is alert, but not interactive.
Review of systems:
(+) Per HPI
(-) Unable to complete
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Systolic CHF: EF 20%
S/p STEMI [**6-/2193**], w/ large thrombus in the proximal LAD
complicated by cardiogenic shock w/ DES to prox LAD
[**11/2193**]: [**Month/Year (2) 3941**] placement for Low EF, runs of NSVT.
H/o alcohol and substance abuse
H/o deep vein thrombosis partially treated with Coumadin
Positive hepatitis B serologies in the past
S/p PEA arrest in [**9-/2202**] with resulting anoxic brain injury
during VT ablation in EP lab. At baseline, the pt is responsive
only to deep painful stim (such as deep suctioning), although he
does appear alert and open his eyes (no tracking). He is
completely dependent for all ADLs.
Social History:
He had been on disability for 10 years since his first heart
attack. Prior to that he was a manager at [**Company **]'s. He
reported smoking approximately one pack of cigarettes per week.
He also reported history of ETOH but denied any IVDA. Now
unresponsive to all but deep painful stim, and completely
dependent for all ADLs. Baseline GCS of 9.
Family History:
Non-contributory
Physical Exam:
Vitals: T: BP:114/70 P:88 R:[**10-23**] O2: 93-99% on trach collar
FiO2 40%
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, patient refuses to open mouth for
a prolonged period of time. Tongue appears intact and non
bloody. Lower gums appear to be oozing. Trach collar in place.
No bleeding around site.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2. 2/6 systolic murmur
loudest at apex.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. PEG tube in
place.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2202-12-5**] 04:40AM WBC-9.7 RBC-2.90* HGB-8.4* HCT-27.3* MCV-94
MCH-28.8 MCHC-30.6* RDW-17.5*
[**2202-12-5**] 04:40AM PLT COUNT-290
[**2202-12-5**] 04:40AM PT-17.0* PTT-38.8* INR(PT)-1.5*
[**2202-12-5**] 04:40AM GLUCOSE-128* UREA N-30* CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
Studies:
[**2202-12-5**] Chest Xray: Stable position of tracheostomy. Stable
cardiomegaly.
[**2202-12-5**] CTA Chest:
1. No evidence for pulmonary embolus or acute aortic syndrome,
although the evaluation of subsegmental pulmonary arteries is
technically limited.
2. Mild enlargement of the main pulmonary artery suggests
underlying
pulmonary hypertension.
3. There are diffuse nodular and ground-glass densities
throughout the right lung and at the left apex. These appear new
compared to [**2202-9-20**], when they were not seen on lung
bases on the CT of the abdomen and pelvis. There is associated
bronchial wall thickening and hilar adenopathy. Overall, this is
most conssitent with a infectious bronchopneumonia. Given the
clinical history, alvealar hemorrhage should also be considered.
Close imaging follow-up is recommended with radiography as well
as chest CT follow-up, particularly given lymphadenopathy,
within three months, if clinically indicated.
4. Trace pericardial effusion.
5. Small-to-moderate ascites.
[**2202-12-6**] Left upper extremity ultrasound:
No evidence of left upper extremity DVT. Mildly abnormal
subclavian venous waveform.
Brief Hospital Course:
43 year old male with anoxic brain injury, s/p PEG & trach,
after a PEA arrest in [**9-/2202**] (pt was undergoing VT ablation)
who was readmitted with bleeding from trach site.
#. Bleeding: This was his second admission for bleeding from his
trach site. The first admisison, it was felt that he was
gnawing at his tongue with his teeth and his teeth were
subsequently pulled. This time, it appeared his bleeding was
coming from his gums in the areas where his teeth had been
recently pulled. His Lovenox was stopped and he was started on
clonazepam 0.25mg po TID to prevent gnawing behaviors. His
hematocrit remained stable and he continued to have minimal
low-grade bleeding from his gums.
#. Aspiration pneumonitis: On admission he had ground glass
opacities seen on CT scan that were felt to represent likely
aspiration of blood. He had a bronchoscopy that was not notable
for thick secretions or alveolar hemorrhage. He was given a
dose of Levofloxacin and cefepime in the ED but antibiotics were
stopped on admission due to low clinical suspicion for pneumonia
(with the exception of Vancomycin for which he is completing a
course for prior bacteremia). He did not have any fevers,
cough, or new oxygen requirement.
#. MRSA Bacteremia: At his last hospitalization he had
high-grade MRSA bacteremia with 6/6 bottles positive on [**11-20**].
He continued a 4-week course of Vancomycin to end on [**2202-12-19**].
#. L UE Thrombus: He had a previous LUE thrombus of brachial
vein. Repeat ultrasound on this admission showed no evidence of
thrombus. Due to his bleeding, his Lovenox was discontinued.
His PICC line should be removed when he finishes his course of
Vancomycin on [**2202-12-19**].
#. S/p anoxic brain injury: He continues to be trach and PEG
dependent. He appearesd at his baseline mental status. His tube
feeds were restarted.
#. Diabetes: He was continued on an insulin sliding scale.
#. Hypertension: His antihypertensives were held due to low
blood pressure and bleeding on admission. These were restarted
at lower doses at discharge (lisinopril, carvedilol), and his
Lasix was restarted at full dose. His lisinopril can be
titrated up to 10mg daily and his carvedilol can be titrated up
to 25mg po bid if needed for hypertension.
#. Cardiovascular disease: His aspirin was initially held but
was restarted at discharge at a lower dose. He was continued on
atorvastatin.
#. Code Status: He was full code during this hospitalization.
Goals of care discussions were continued with the family during
this admission and should be continued after discharge.
Medications on Admission:
1. Bisacodyl 10 mg po daily PRN constipation
2. Senna 8.6 mg po bid PRN constipation
3. Aspirin 325 mg po daily
4. Atorvastatin 10 mg po daily
5. Acetaminophen 160 mg/5 mL Solution [**Date Range **]: Ten (10) mL PO Q6H
(every 6 hours) as needed for pain, discomfort.
6. Multivitamin 1 po daily
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Furosemide 20 mg po daily
9. Ciprofloxacin 750 mg po q12h: Last dose on [**2202-12-3**].
10. Insulin Sliding Scale
11. Carvedilol 25 mg po bid
12. Lorazepam 2 mg/mL Syringe [**Year (4 digits) **]: One (1) mg Injection Q8H
(every 8 hours) as needed for anxiety.
13. Pantoprazole 40 mg IV q24h
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Year (4 digits) **]: One (1)
Intravenous every twenty-four(24) hours: Last Dose 1/17.
16. Cefepime 2 gram IV q12h Last dose on [**12-3**].
17. Lovenox 80 mg sc bid day 1 = [**11-30**]
18. Lisinopril 10 mg po daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Aspirin 81 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
4. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: Ten (10) ml PO Q6H
(every 6 hours) as needed for pain, fever.
6. Multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Furosemide 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
9. Insulin Lispro 100 unit/mL Solution [**Month/Day (2) **]: One (1) Injection
Subcutaneous ASDIR (AS DIRECTED): Please use insulin sliding
scale as prior to admission.
10. Pantoprazole 40 mg Recon Soln [**Month/Day (2) **]: Forty (40) mg Intravenous
once a day.
11. Carvedilol 6.25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a
day.
12. Vancomycin 1,000 mg Recon Soln [**Month/Day (2) **]: 1000 (1000) mg
Intravenous Q 24H (Every 24 Hours): Last dose [**2202-12-19**].
13. Lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
14. Clonazepam 0.5 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO TID (3 times a
day).
15. Outpatient Lab Work
Needs vanc trough [**2202-12-10**] with goal 15-20. Needs hematocrit
daily x 2 days, then needs weekly Chem10 and CBC.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
Bleeding from mouth
Secondary Diagnosis:
Anoxic brain injury
Congestive heart failure
Diabetes Mellitus
Discharge Condition:
Mental Status: Nonverbal due to anoxic brain injury
Level of Consciousness: Responsive to pain/verbal stimuli by
opening eyes
Activity Status: Bedbound
Discharge Instructions:
You were admitted to the hospital with bleeding from your mouth.
Your blood count (hematocrit) remained stable and your bleeding
decreased. Your blood thinner (Lovenox) was stopped.
Changes to your medications:
STOPPED Lovenox
Continued vancomycin
Started Clonazepam 0.25mg by mouth three times daily
Changed aspirin from 325mg daily to 81mg by mouth daily
Decreased carvedilol to 6.25mg by mouth twice daily
Decreased lisinopril to 5mg by mouth daily
Since you also have a diagnosis of heart failure, you should be
weighed every morning, and notify your doctor if your weight
goes up more than 3 lbs.
You need to have a vancomycin trough level drawn the morning of
[**2202-12-10**] prior to your dose. Goal trough levels are 15-20.
Followup Instructions:
You have the following appointments scheduled:
Department: Cardiology
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**]
9:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**]
10:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-1-19**] 11:00
|
[
"5070",
"4280",
"25000",
"4019",
"2724",
"41401",
"V4582"
] |
Admission Date: [**2132-7-3**] Discharge Date: [**2132-7-5**]
Date of Birth: [**2071-6-8**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 99662**] presented to the ED the morning of admission at 10
AM, appearing disheveled and smelling of urine per triage note.
He told the nurses and doctors in the [**Name5 (PTitle) **] that he felt like he
was "going to have a seizure" and reported a history of alcohol
withdrawal seizures. He reports to us that he has recently been
drinking a large bottle of vodka each day, indicating with his
hands a bottle of a height suggestive of a liter's volume. He
did not remember this admission when he's had his last seizure
although he is sure that he has had them in the past; a past
note includes his statement that he last had one in [**2132-3-16**].
Of note he has been admitted to the [**Hospital1 18**] several times in the
past few months, including a recent admission on [**5-16**]/09 in
which he complained of hematemesis, and an EGD was unrevealing;
and an alcohol withdrawal admission in [**Month (only) 956**] of this year. He
left AMA for the latter admission. He has had periods of
sobriety and claimed in his prior admission that he had only
recently started drinking five days prior to that admission.
He endorses tremulousness and some anxiety and agitation. He
denies chest pain or shortness of breath. He denies recent GI
bleeding or hematemesis. He does report some pain in his right
groin which he evidently initially reported as right lower
quadrant abdominal pain.
In the emergency department his initial vitals were t 98.1, bp
137/95, hr 98, rr 18, O2 99% on room air. He received 3L NS; a
banana bag of thiamine, folate, MVI; valium 10, 20, 20, 10, with
a "may repeat" order for another 20, suggesting a total dosing
of 60. He was in the observation unit of the ED and there were
some gaps in him receiving timely valium doses. He got an
abdominal CT because of concern about his RLQ pain; this did not
show any acute process. A head CT showed stably large
ventricles.
Past Medical History:
* recent admission for hematemesis, thought likely to be
[**Doctor First Name **]-[**Doctor Last Name **] tear, endoscopy was unremarkable
* hypertension
* past chronic hepatitis C, genotype 2; (followed by Dr.
[**Last Name (STitle) **]; since [**2126**] has had undetectable viral loads after
successful treatment w interferon and ribavarin; last VL in
system from [**7-/2131**])
* ?hepatitis B exposure in the past
* alcoholism
* prior IDU with prior methadone maintenance
* depression/anxiety
* panic disorder with agoraphobia
* GERD s/p [**5-19**] Enteryx procedure
* s/p CCY
* chronic LBP, inactive
* tobacco use
* prior patellofemoral syndrome R knee
* s/p medial meniscectomy [**10-19**] R knee
* persistent nasal congestion
* s/p inguinal hernia repair [**2132-6-3**]
.
Social History:
Patient reports started drinking at age 13 with chronic use
since that time. He reported on a past admission that his
longest period of sobriety 4.5 years, although on this
admission, claimed 19 years. History of blackouts, numerous
prior detox programs. Remote cocaine, heroin, barbituates, +IVDU
last active illicit use in [**2113**]. Per last admission, started
drinking and smoking again 5 days prior to prior admission
(presumably ~[**2132-6-19**]). Lives in [**Location **] on [**Location **]. In contact with
mother ([**Age over 90 **] yo) and daughter ([**Name (NI) 12000**]).
Family History:
Father died at age 33 from malignant hypertension, mother with
depression but otherwise healthy at [**Age over 90 **] yo, Daughter died of
ovarian cancer, multiple other family members with etoh abuse on
both sides of family (cousin, sister, uncle, aunt, father).
Physical Exam:
On presentation to the MICU:
Flowsheet Data as of [**2132-7-4**] 02:19 AM
Vital Signs
Tmax: 36.4 ??????C (97.6 ??????F)
Tcurrent: 35.9 ??????C (96.6 ??????F)
HR: 90 (89 - 92) bpm
BP: 152/95(105) {133/77(90) - 152/95(108)} mmHg
RR: 14 (13 - 16) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 69 Inch
O2 Delivery Device: Nasal cannula
SpO2: 97%
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical
adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Wheezes : )
Abdominal: Soft, Bowel sounds present, Tender:
Extremities: Right: Trace, Left: Trace
Skin: Warm, No(t) Rash: no stigmata of liver disease, No(t)
Jaundice
Neurologic: Attentive, Follows simple commands, interactive w
conversation, somnolent when initially examined/interviewed;
Movement: purposeful; no focal deficits
.
Pertinent Results:
[**2132-7-3**] 10:00AM WBC-6.7 RBC-5.11 HGB-17.2 HCT-46.5 MCV-91
MCH-33.7* MCHC-37.0* RDW-14.8
[**2132-7-3**] 10:00AM NEUTS-47.6* LYMPHS-40.5 MONOS-5.9 EOS-4.5*
BASOS-1.5
[**2132-7-3**] 10:00AM PLT COUNT-205
.
[**2132-7-3**] 10:00AM GLUCOSE-82 UREA N-9 CREAT-0.9 SODIUM-144
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-27 ANION GAP-23*
.
[**2132-7-3**] 10:00AM ALT(SGPT)-42* AST(SGOT)-60* LD(LDH)-218 ALK
PHOS-96 TOT BILI-1.5
[**2132-7-3**] 10:00AM LIPASE-33
[**2132-7-3**] 10:00AM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-1.7
.
CT ABD/PELV: IMPRESSION:
1. No evidence of appendicitis.
2. Fatty infiltration of the liver.
3. Diverticulosis without evidence of diverticulitis.
4. Scattered simple renal cysts.
.
CT HEAD:
IMPRESSION: No acute intracranial process
Brief Hospital Course:
61yo M with EtOH abuse admitted for withdrawal.
#. Alcohol Withdrawal: Mr. [**Known lastname 99662**] on arrival showed signs of
intoxication but also signs of withdrawal including
tremulousness, tachycardia, and hypertension as well as
agitation. He states a history of prior seizures during
withdrawal. MCV of 91 and no appearance of malnourishment
supports possibility that relapse into serious alcohol abuse is
relatively recent, and he may have had even recent periods of
genuine sobriety. Pt does affirm a past devotion to 12 step
groups and has had 2 different sponsors in the past. He was
intially requiring Q1H IV valium due to CIWA of 20-27, but his
requirement has decreased and he was ordered for PO valium with
CIWA of 14 on morning after admission. Patient was trasnferred
to the floor and no longer required any additional Valium as per
his CIWA scale. Patient decided to leave AMA. Explained to
patient the risks of continued binge drinking as well as his
liver disease.
# HTN: Holding BP meds as he was normotesnive on presentation
and we were better able to assess withdrawal symptoms. Patient
instructed to resume his outpatient medications on discharge.
# Anxiety: C/O agoraphobia however not anxious when full medical
team in room. Patient states he is extremely nervous and anxious
and needs to leave the hospital. Social work was consulted and
note in the chart. Patient left AMA so was not able to furthur
address this issue.
# Hep C: Due for RUQ u/s as does not get followed as o/p for
this disease. Would rather set him up with liver service here
and then they can further evaluate him. Patient left AMA prior
to scheduling outpatient appointments. Patient advised that he
needs outpatient liver ultrasound and outpatient liver follow
up. Patient advised that needs to stop drinking.
Medications on Admission:
As of last admission [**2132-6-24**], but these were not discharge meds
given that he left AMA while still on a CIWA scale:
1. Thiamine HCl 100 mg PO DAILY
2. Folic Acid 1 mg PO DAILY
3. Omeprazole 20 mg daily
4. Lisinopril 10 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
NA
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: alcohol withdrawal
.
SEcondary:
* recent admission for hematemesis, thought likely to be
[**Doctor First Name **]-[**Doctor Last Name **] tear, endoscopy was unremarkable
* hypertension
* past chronic hepatitis C, genotype 2; (followed by Dr.
[**Last Name (STitle) **]; since [**2126**] has had undetectable viral loads after
successful treatment w interferon and ribavarin; last VL in
system from [**7-/2131**])
* ?hepatitis B exposure in the past
* alcoholism
* prior IDU with prior methadone maintenance
* depression/anxiety
* panic disorder with agoraphobia
* GERD s/p [**5-19**] Enteryx procedure
* s/p CCY
* chronic LBP, inactive
* tobacco use
* prior patellofemoral syndrome R knee
* s/p medial meniscectomy [**10-19**] R knee
* persistent nasal congestion
* s/p inguinal hernia repair [**2132-6-3**]
Discharge Condition:
afebrile, HR 74, BP 150/100, R 18 95% on RA
Discharge Instructions:
NA
Followup Instructions:
Patient left AMA
Completed by:[**2132-7-5**]
|
[
"3051",
"53081",
"4019"
] |
Admission Date: [**2153-2-14**] Discharge Date: [**2153-2-20**]
Date of Birth: [**2086-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain on exertion.
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->OM, RCA) [**2153-2-15**]
History of Present Illness:
Mr. [**Known lastname **] is a delightful 66 year old gentleman with a past
medical history which is significant for bladder cancer treated
15 years ago, obesity and hypertension. He presented to his
cardiologist at an outside hospital with the complaint of
exertional chest pain over the past several weeks. Work-up was
unremarkable and he was thus referred for a cardiac
catheterization which was performed today. This revealed severe
left main and three vessel disease. He was transported to the
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Hospital 9688**] Medical Center for surgical management.
Past Medical History:
Bladder Cancer
Hypertension
Obesity
Social History:
Widowed 6 months ago. 3 Children. Quit smoking 30 years ago.
Denies alcohol or recreational drug use. A retired mechanic.
Family History:
Mother, Brother and sister with hypertension. Mother died of
myocardial infarction at age 78.
Physical Exam:
GEN: Well developed male in no apparent distress
VITAL SIGNS: Temp-98.3 BP-135/81 HR-81 94% oxygen saturation
on room air
HEENT: Normocephalic, atraumatic, PERRL, EOMI, anicteric sclera,
oropharynx benign, dentition without obvious infection.
NECK: Supple, No JVD, no bruits
HEART: Regular rate and rhythm, no murmur, rub or gallop. Normal
S1-S2
LUNGS: Clear
ABDOMEN: Soft, Nontender, nondistended, No hernias, normoactive
bowel sounds.
RECTAL: Guaiac negative
EXTREMITIS: No clubbing, cyanosis or edema
PULSES: 2+ Fem, DP and PT bilaterally
Pertinent Results:
[**2153-2-14**] 09:00PM BLOOD WBC-5.7 RBC-4.76 Hgb-14.9 Hct-40.5 MCV-85
MCH-31.3 MCHC-36.8* RDW-13.3 Plt Ct-240
[**2153-2-19**] 06:00AM BLOOD WBC-7.5 RBC-3.49* Hgb-11.0* Hct-30.9*
MCV-89 MCH-31.6 MCHC-35.7* RDW-13.5 Plt Ct-251#
[**2153-2-19**] 11:25AM BLOOD UreaN-22* Creat-1.1 K-3.8
[**2153-2-14**] 09:00PM BLOOD Glucose-125* UreaN-17 Creat-1.3* Na-144
K-3.7 Cl-105 HCO3-30* AnGap-13
[**2153-2-14**] 09:00PM BLOOD ALT-32 AST-23 LD(LDH)-198 AlkPhos-48
TotBili-0.6
[**2153-2-19**] 06:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
ELECTROCARDIOGRAM PERFORMED ON: [**2153-2-14**]
Sinus rhythm 70
Inferior ST-T changes are nonspecific
No previous tracing
[**2153-2-15**] - Chest X-Ray
No evidence of acute cardiopulmonary disease.
[**2153-2-20**] - Chest X-Ray
Interval removal of multiple tubes and lines. Left lower lobe
partial atelectasis and questionable small left pleural
effusion. No evidence of pneumothorax.
[**2153-2-14**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Cardiac Catheterization performed [**2153-2-14**] at outside hospital
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Hospital 9688**] Medical
center on [**2153-2-14**] via transfer from an outside hospital for
further management of his coronary artery disease. He was
worked-up in the usual preoperative manner by the cardiac
surgical service and found to be suitable for surgery. On
[**2153-2-15**], Mr. [**Known lastname **] was taken to the operating room where he
underwent coronary artery bypass grafting to three vessels.
Postoperatively he was taken the the cardiac surgical intensive
care unit for monitoring. He was slowly weaned from pressors and
mechanical ventilation. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 26228**] neurologically intact and was extubated. He was gently
diuresed towards his preoperative weight. On postoperative day
three, he was transferred to the cardiac surgical step down unit
for further recovery. Beta blockade and aspirin therapy were
initiated. Chest tubes and wires were removed per protocol. The
physical theapy service was consulted for assistance with his
poa[**Name (NI) **] strength and mobility. Mr. [**Known lastname **] continued to make
steady progress and was discharged home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 27535**]e day five ([**2153-2-20**]). He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Toprol XL 50mg PO QD
Diovan 160mg PO QD
ECASA 81mg PO QD
Multivitamin PO QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health
Discharge Diagnosis:
CAD s/p CABGx3
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
may shower, no bathing for 1 month
no creams or lotions to any incisions
Followup Instructions:
with Dr. [**Last Name (STitle) 5017**] in [**2-15**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2153-3-7**]
|
[
"41401",
"4019"
] |
Admission Date: [**2125-1-24**] Discharge Date: [**2125-1-26**]
Date of Birth: [**2048-3-4**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Nsaids / Adhesive Tape
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer to CCU for hypotension status post elective peripheral
angiography
Major Surgical or Invasive Procedure:
Right lower extremity angiography
Percutaneous coronary angioplasty of right anterior tibial
artery
History of Present Illness:
Ms. [**Known lastname 9164**] is a 76 year-old female with a complicated PMHx
that includes CAD s/p Lcx stenting, DM type 2, s/p dual
pacemaker placement for bradycardia, atrial fibrillation on
chronic Coumadin therapy, with severe PVD s/p multiple stents,
angioplasties and atherectomies, with claudication symptoms. She
recently developed a RLE ulcer, and was referred for RLE
angiography and PTCA of her right tibial anterior tibial artery.
One hour after the procedure, Ms. [**Known lastname 9164**] became hypotensive
with SBP down to 30s when the sheath was pulled, HR paced at 60.
She also complained of severe right groin pain at the cath site.
She was given Atropine X 2, IVF bolus, and transfused 2 units of
PRBCs. Her HR subsequently increased to 120s, then she went into
atrial fibrillation with RVR in 160s. She spontaneously
converted back to NSR with HR 88. Her BP improved with the above
resuscitation measures, and she was trasnferred to the CCU for
further management and care.
An emergent CT scan was performed on arrival to CCU, which
revealed a right-sided RP bleed.
Past Medical History:
1. CAD s/p LCX stent in 2/[**2122**]. LM with 60% ostial stenosis,
total occlusion of RCA on last cardiac catheterization 05/[**2123**].
2. Congestive heart failure, mild LV systolic dysfunction with
EF 48% on last ventriculogram 05/[**2123**].
3. Peripheral [**Year (4 digits) 1106**] disease s/p left EIA and SFA stenting
[**3-/2123**], and s/p atherectomy/PTA of LSFA [**12/2123**] for instent
restenosis.
4. Bradycardia status post [**Company 1543**] dual chamber pacemaker
placement [**2123-12-29**].
5. Intermittent atrial fibrillation noted on PPM interrogation,
on chronic Coumadin therapy.
6. Hypercholesterolemia
7. Chronic ITP with [**Doctor First Name **]. BM bx normal in [**2113**].
8. Diabetes mellitus type 2, diet controlled
9. Peripheral neuropathy
10. Mild COPD
11. PUD
12. Gastritis, Barrett's esophagus
13. Multinodular goiter
Past surgical history:
1. Status post cholecystectomy
2. s/p TAH-BSO
3. s/p right THR
4. s/p L4, L5 discectomy
5. s/p appendectomy
Social History:
Widow. She lives with her son. She has 6 adult children.
Ex-smoker. She quit smoking 12 years ago; 120 pack-year smoking
history.
Family History:
Family history positive for CAD: brother died of MI at age 44,
another brother died at age 53 of MI.
Physical Exam:
Physical examination on admission to CCU:
VITALS: HR 65, V-paced, BP 120/46, RR 12, Sat 100% on 4L NC.
GEN: Alert, confused.
HEENT: PERRL.
NECK: JVP not elevated.
RESP: Limited to anterior chest. Clear to auscultation.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS normoactive. RLQ firm to palpation, tender. No clear
palpable hematoma.
EXT: Right groin with dressing in place. Tender to palpation.
Pedal pulses present via Doppler.
NEURO: Limited examination, patient non-cooperative. Moves all 4
extremities.
Pertinent Results:
Relevant laboratory data on admission to CCU:
CBC:
WBC-13.5*# RBC-3.39* HGB-11.4* HCT-32.8* MCV-97 MCH-33.6*
MCHC-34.6 RDW-16.3*
Chemistry:
GLUCOSE-153* UREA N-10 CREAT-0.8 SODIUM-140 POTASSIUM-3.4
CHLORIDE-107 TOTAL CO2-27 ANION GAP-9
CALCIUM-7.0* PHOSPHATE-4.5 MAGNESIUM-1.3*
Coagulation profile:
PT-13.8* PTT-23.5 INR(PT)-1.2
EKG: V-paced, rate 60 bpm, LBBB morphology.
[**2124-1-24**] RLE angiography: Initial angiography showed a severely
diseased AT. We planned to treat this vessel with PTA and
atherectomy. Heparin was given for anticoagulation. Access was
obtained in an antegrade fashion of the RCFA and a 7 French
Arrow sheath was advanced to the mid SFA. The AT was crossed
with great difficulties with numerous wires, including PT
[**Name (NI) 9165**], [**Name (NI) 9166**] and Shinobi. However, attempts to cross the
distal lesion with atherectomy or angioplasty devices failed.
Finally, a 2.0x20 mm Maverick crossed the lesion, which was
dilated at 12 Atm. Next, a 2.5x20 mm Quantum Maverick balloon
was used to dilate the entire AT at 12-22 Atm. Final angiography
showed no residual stenosis with flow to the foot through the PA
and AT. The patient left the lab in stable
condition.
[**2125-1-24**] CT OF THE ABDOMEN WITHOUT CONTRAST: Changes of
emphysema are seen at both lung bases. There is bibasilar
dependent atelectasis, without significant pleural effusion or
pneumothorax. Coronary artery calcifications and coronary
[**Month/Day/Year 1106**] calcifications are seen. Pacemaker wires are also
present.
There is residual contrast within the kidneys from recent
interventional procedure.
The liver, spleen, adrenal glands, kidneys, stomach, pancreas,
and small bowel are within normal limits. Marked [**Month/Day/Year 1106**]
calcifications are seen of the aorta, celiac axis, SMA, [**Female First Name (un) 899**], and
iliac/femoral arteries. The gallbladder is not identified, and
the patient may be status post cholecystectomy. There is a small
hiatal hernia present.
There is a large amount of retroperitoneal hemorrhage present,
tracking from the right groin to the right posterior pararenal
space. In the greatest axial dimensions, this measures
approximately 7.0 x 7.8 cm in size, and it extends a length of
approximately 20 cm in the SI dimension. There is no significant
abdominal lymph adenopathy present, and no ascites fluid is
present.
CT OF THE PELVIS WITHOUT CONTRAST: Diverticuli are seen, and the
large bowel is otherwise unremarkable in appearance. Hyperdense
free fluid is seen within the pelvis, possibly tracking from the
retroperitoneal hemorrhage. The bladder appears unremarkable,
with a Foley catheter in place.
A right-sided hip replacement is present. No significant osseous
abnormalities are seen aside from degenerative changes and
right-convex scoliosis centered at the thoracolumbar junction.
IMPRESSION:
1. Large right-sided retroperitoneal hemorrhage, extending from
the right groin to the right posterior pararenal space.
2. No significant hemorrhage is seen within the right groin or
extending into the right leg.
Brief Hospital Course:
76 year-old female with a complicated PMHX that includes CAD s/p
LCx stenting in [**2122**], DM type 2, s/p PPM placement for
bradycardia, atrial fibrillation on Coumadin, with severe PVD
s/p mutliple interventions, now s/p RLE angiography and right
anterior tibial artery PTCA with post-procedure hypotension and
RP bleed. Transferred to the CCU for further care.
1) Retroperitoneal bleed: Her hypotension was felt secondary to
her retroperitoneal bleed and likely vagal response at the time
of the sheath pull. As mentioned in the HPI, she was transfused
2 units of PRBCs in the cath lab, and was transfused an
additional unit in the CCU. She was also given IVF. She remained
hemodynamically stable throughout her stay in the CCU, without
need for pressors, and her HCT also remained stable following
the 3 units of PRBCs. Coumadin was held in the setting of her RP
bleed, to be restarted as an outpatient. Aspirin was resumed on
[**2125-1-25**] and well tolerated. Her hematocrit was 31.1 at
discharge.
2) s/p PTCA to right [**Doctor First Name **]: She was continued on aspirin while in
hospital. Pedal pulses were present via Doppler. She will
follow-up with Dr. [**First Name (STitle) **] in the week following discharge.
3) CAD: No acute issues in hospital. She was continued on
Lipitor. Aspirin, Atenolol, Diovan, and Lisinopril were
gradually resumed in hospital following the procedure.
4) Mental status change: On arrival to the CCU, Ms. [**Known lastname 9164**] was
noted to be confused, belligerent. Her acute mental status
change was felt most likely medication-related s/p
administration of Fentanyl in the cath lab, sedatives. No gross
electrolyte abnormalities, ABG unremarkable. She responded to
Haldol for acute agitation/confusion. She was alert and oriented
the following morning without recurrence of confusion.
5) Diabetes mellitus type 2: She was kept on a regular insulin
sliding scale in hospital. Her diabetes appears to be
diet-controlled as an out-patient.
Medications on Admission:
Atenolol 50 mg PO QD
Diovan 160 mg PO QD
Colace 200 mg PO QD
Ecotrin 81 mg PO QD
Effexor 150 mg PO QHS
HCTZ 12.5 mg PO QD
Lipitor 40 mg PO QD
Lisinopril 40 mg PO QD
MVI 1 tab PO QD
Prilosec 40 mg PO QD
Trazodone 200 mg PO QHS
Warfarin last dose on [**2125-1-20**]
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO DAILY (Daily).
6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
10. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Trazodone HCl 100 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
1. RLE Angiography and PTCA of right anterior tibial artery
2. Complicated by large retroperitoneal bleed
Discharge Condition:
Pt was in good condition, with a stable hematocrit, ambulating,
and good oxygen saturations on room air.
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] or return to the hospital if you
experience bleeding, weakness, dizziness, shortness of breath,
chest pain, groin, abdomen or back pain.
Dr.[**Name (NI) 3101**] office will call you Monday for an appointment next
week.
Stop taking your Coumadin until Dr. [**First Name (STitle) **] tells you to resume
it.
Followup Instructions:
See Dr. [**First Name (STitle) **] in one week. His office will call you Monday.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2125-2-21**] 2:00
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-5-15**] 11:00
Completed by:[**2125-1-27**]
|
[
"42731",
"4280",
"25000",
"412",
"V5861"
] |
Admission Date: [**2186-10-30**] Discharge Date: [**2186-11-16**]
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Zoster pain, constipation
Major Surgical or Invasive Procedure:
Endotracheal Intubation x2
Central venous catheter placement
History of Present Illness:
[**Age over 90 **] yo f w/ h/o herpes zoster, AF, COPD, and HTN admitted on
[**2186-10-30**] w/ ongoing pain surrounding a rash on her buttocks x 2
weeks as well as constipation. Patient was recently admitted one
week ago to Geriatrics for herpes zoster outbreak on her
buttocks that she noticed one week prior to admission. Treated c
acyclovir and PO steroids. Lesions improved and crusted over c
pt discharged four days ago on tylenol for pain control. Since
discharge pt c/o ongoing deep burning pain surrounding her L
buttock. Her daughters note the lesions have not changed since
discharge.
On day of transfer to ICU, nurse called for c/o abdominal pain
and mild wheezing. Of note, patient had been drinking golytely
to aid w/ bowel movement. On nurse's arrival, patient cyanotic,
gasping for air, and then became unresponsive. A code was
called. On arrival, patient awake, palpable pulse, but sats 88%
on 100% NRB. Anesthesia present and patient was intubated.
During intubation, patient had large amount of vomitus and was
aggressively suctioned. SBP still 112. Following bolus of
propofol for sedation, bp dropped to SBP 80. Groin line
attempted but unsuccessful. Patient transported to ICU. BP
improved to SBP 160 w/o major intervention. Approximately 1 L NS
had been infused. EKG post code was w/o evidence of ischemia.
Labs were remarkable for lactate 2.1, sodium 121, creatinine
1.7, wbc 17.6, and troponin 0.03.
Past Medical History:
1. Atrial fibrillation
2. [**Name (NI) 3672**] Pt uses 2.5L of oxygen at home.
3. Hyperlipidemia
4. Hypothyroidism
5. Hypertension
Social History:
Pt lives at home but has assistance every day. She has two
daughters who are very involved. Her health care proxy is her
daughter [**Name (NI) 553**] [**Name (NI) 5749**]. Her phone number is [**Telephone/Fax (1) 97970**]. Pt used to
smoke but quit many years ago. Denies ETOH and drug use.
Family History:
Non-contributory
Physical Exam:
Gen: Elderly woman resting on her right side with buttocks in
air.
HEENT- 2cm plaque superior to L temple c smaller plaques
surrounding, OP clear, dentures in place
Neck- No LAD, no JVD
L- CTAB
CV- RRR, nl S1S2, no M/R/G
Abd- sft, NT, hiatal hernia, TTP in LLQ
Exts- L buttock c multiple crusted over pustules on fading
erythematous base extending into anus, no evidence of
superinfection
Pertinent Results:
Admission Labs:
[**2186-10-30**] 05:00PM GLUCOSE-103 UREA N-26* CREAT-1.3* SODIUM-130*
POTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-25 ANION GAP-17
[**2186-10-30**] 05:00PM WBC-8.8 RBC-4.10* HGB-11.4* HCT-34.0* MCV-83
MCH-27.8 MCHC-33.6 RDW-19.1*
[**2186-10-30**] 05:00PM NEUTS-89.8* LYMPHS-7.5* MONOS-2.1 EOS-0.2
BASOS-0.3
[**2186-10-30**] 05:00PM PT-21.7* PTT-37.1* INR(PT)-3.4
Additional pertinent labs/Studies
Brief Hospital Course:
A/P: [**Age over 90 **]YO F c h/o AF, HTN, hypothyroidism admitted to hospital
for pain associated with zoster and constipation, now
transferred to MICU for respiratory failure likely secondary to
aspiration event. The patient was intubated on admission to the
MICU for probable aspiration pneumonia and started on cefepime
and Flagyl (Flagyl given additional concerns for C. Diff). The
patient was extubated on [**2186-11-5**] and appeared to be doing well
overnight. However, over the course of the next 24 hours the
patient was noted to become increasingly tachypnic, with diffuse
course wheezing and increasing hypoxia. The patient was treated
aggressively for her COPD by increasing nebulizer treatments to
standing nebs and she was started on high dose IV steroids.
During this episode, the patient was additionally found to be
hypertensive and increasingly tachycardic, with busrts of afib.
The patient's BP was agressively treated as well. Despite this,
the following day the patient was found to be still increasingly
tachypnic and hypoxic. Repeat chest film appeared to show new
lingular and bibasilar infiltrates with possible pulmonary
congestion. The patient was treated aggressively for CHF as well
by controlling the patient's afterload with increased dose of
losartan 100mg po qd, a nitroglycerin drip, and eventually a
diltiazem drip as well. Despite these efforts, the patient
developed increasing respiratory distress, requiring repeat
elective intubation with concern for impending respiratory
failure. Upon reintubation the patient was found to have
relatively rapid resolution of her tachyardia and hypertension.
Over the course of a couple days the patient was treated
aggressively for the underlying problems that likely
necessiatated reintubation. The patients afib with RVR was
controlled with rate control initially with a diltiazem drip
that was eventually converted to po dosing 90mg po qd. The
patient's hypertension was treated with losartan,increased to
100mg po qd, with serial addition of a nitroglycerin drip and
hydralazine 25 mg po q6hr. Underlying COPD was controlled
aggressively with steroids, cefepime for COPD and questionable
pneuomonia and nebulizer treatments. The patient was weaned to
minimal pressure support and was extubated after testing
revealed a RSBI of 45. The patient was extubated with the
addition of low dose haldol and ativan for associated anxiety
that likely contributed to tachpynea and respiratory distress on
previous extubation. The patient was extubated uneventfully and
subsequent blood gases revealed she was not markedly hypercarbic
although with still some hypoxia for which she continued to
receive supplemental oxygen by nasal cannula. Given her rising
creatinine, the patient's losartan was discontinued and her
blood pressure control was optimized with preload and afterload
reduction with isosorbide mononitrite and hydralazine
respectively. The patient's heart rate and BP were found to be
adequately controlled with this regimen and she was breathing
comfortably. Of note, despite this improvement, given the
patient's tenuous respiratory status and possibility for repeat
intubation indefiniteley, converation with patient's family
resulted in decision to make patient's code status DNR/DNI. Upon
transfer to the floor pt with ongoing respiratory distress. This
was unable to be controlled through aggressive diuresis. The
pt's Cr bumped in the setting of diuresis. She was placed on a
shovel mask, as she would not tolerate a face mask. Pt's WBC
rose again and she was found to have a UTI. She was started on
levofloxacin for this. The family and pt elected for comfort
care only. They did not want additional medications given. The
pt's respi status continued to worsen and on [**2186-11-16**] she
expired.
.
#. HTN: The patient has an outpatient regimen of isosorbide
mononitrate 10mg po bid, losartan 50mg po qd, amlodipine 10mg po
qd, Dyazide. The patient's pressures were noted to be poorly
controlled in the ICU. Initially, given concern for hypotension
with acute exacerbation the patient's losartan was cut in half
and dyazide held. The patient's full dose losartan was restarted
with the addition of 5mg po qd amlodipine, the losartan was then
titrated to 100mg po qd. As the patient remained hypertensive,
and in the setting of respiratory distress and afib, the patient
was serially placed on a nitroglycerin drip and then a diltiazem
drip as well for blood pressure control as well as rate control
of Afib with RVR. As above, the patient is currently receiving
adequate control with diltiazem, isosorbide mononitrite and
hydralazine and is additionally receiving low doses of lasix
with goal of gentle diuresis with attention towards her rising
creatinine. Her BP regimen was continued as above, while her
diuresis was limited [**2-15**] her rising creatinine.
.
#. PAF: On admission to the ICU the patient was in sinus
rhythym. With the advent of increasing resp distress and
uncontrolled hypertension, as described above, the patient was
eventually placed on a diltiazem drip for better rate control.
Also on admission, the patient was noted to have an elevated INR
for which additional coumadin dosing was held and Vitamin K
given once. The patient was given one dose of couamadin for an
INR of 1.3, but then the decision was made to maintain the
patient on Sub Q heparin only given concern for any possible
procedures, etc. The patient may be restarted on coumadin when
medically stabilized. Currently, as the patient is extubated
with better rate control and BP control, she received warfarin
.5mg po qhs and SQ Heparin has been discontinued, INR today 2.5.
.
.
#. Elevated troponin: Mildly elevated previously ([**11-3**])
- No evidence of ischemia on EKG on admission
- Likely demand. MI Ruled out by enzymes on admission.
#. Constipation - Constipation resolved with lactulose and
agressive bowel regimen. Pt continued on colace, senna and 30ml
lactulose qod to keep bowels regular to avoid further
constipation.
- C. Diff negative x3
.
#. Zoster: Patient had course of acyclovir and prednisone last
admission
- Continued topical lidocaine and neurontin for symptomatic
control. Topical lidocaine has been discontinued now that zoster
is resolving.
.
#. Urinary retention: - Patient currently has foley in place [**2-15**]
urin retention.
.
#. Hypothyroidism: TSH and Free T4 appropriate on [**2186-11-3**] (1.7,
1.6)
- continue levothyroxine 175mcg po q T/R/S/S
.
#. Anemia: Near baseline, patient s/p 1U PRBC [**2186-11-5**] with
appropriate bump, 23.5 -> 28.7, 29.5 today
- continue to follow qd
.
#. PPX: PPI, anticoagulated, tight glucose control w/ SSI
.
Medications on Admission:
Coumadin
Spiuvira
Norvasc
Advair
Protonix
Albuterol
Ambien
Amiodarone
Diazide
Lipitor
Cozaar
Isosorbide
Home O2
Discharge Disposition:
Home
Discharge Diagnosis:
Postherpetic neuralgia
Constipation
Aspiration Pneumonia
Heart Failure
Obstructive Pulmonary disease
Hypertension
Atrial Fibrillation
Discharge Condition:
Expired
Discharge Instructions:
Pt Expired
Followup Instructions:
Pt expired
|
[
"51881",
"5070",
"4280",
"5849",
"42731",
"2761",
"4019",
"2449"
] |
Admission Date: [**2102-5-6**] Discharge Date: [**2102-5-16**]
Date of Birth: [**2021-6-14**] Sex: M
Service: MEDICINE
Allergies:
Horse Blood Extract
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 yo M with PMH significant for ESRD on HD, CAD s/p
CABG x 3 COPD.Patient discharged 2 weeks ago from [**Hospital1 18**] after
he had a L subclavian stent placed. He presented to ED today
from [**Hospital3 **] where he c/o of cough , SOB weakness,
fatigue and low grade fever x 1 week. He was diagnosed with
influenza A 1 week ago.
.
In ED he was found to be very tachypneic RR 35 % and SpO2 100%
on a NRB mask. CxR with hyperinflated lung and interstitial
infiltrates. Patient had a CTA of chest to rule out PE after
which ,while he was back in the ED, he developed an episode
of SVT. Patient's BP remained stable. VBGs : 7.09/89/95/26 .He
was given 1 lt NS, Levaquin , Flagyl ,Lasix 80 mg , solumedrol
125 mg and bronchodilators. He was intubated and transferred to
MICU.
Renal was consulted for emergent hemodyalisis. They considered
there was no indication due to patient's abnormal heart rhythm.
Cardiology -was consulted , no indication for revascularization.
Recommended treating respiratory acidosis.
Past Medical History:
ESRD [**3-10**] HTN nephrosclerosis on HD
CAD s/p CABG X 3 in [**2082**]
PVD s/p mult revasculazations in [**12-10**] and [**2-10**].
CHF (EF 50%)
Hypercholesterolemia
Carotid Artery Stenosis s/p L CEA [**2087**]
COPD
h/o prostate CA on lupron (PSA undetectable)
Restless Leg Syndrome
Depression
Legally blind [**3-10**] macular degeneration
R inguinal hernia
Social History:
He is a former smoker one-half pack per day for
30 years quit 22 years ago. He has former alcohol abuse, quit
in
[**2070**]. He is a former elementary and [**Male First Name (un) 1573**] high school teacher.
Denies EtOH.Retired middle school teacher.functional status . He
uses a rolling walker at baseline.
Family History:
Mom DM
Father prostate ca
SIster breast ca
Physical Exam:
T 98.5 (102.5 ax in ED) BP 105/56 HR 72
AC TV 500 RR 20 PEEP 5 FiO2 0.6
ABGs 7.27/45/186/22
Gen - elderly, chronically ill, pale appearing male in NAD,
Skin - diffuse ecchymosis in abdomen and forearms
HEENT - tube @ 23 cm sclerae anicteric, slightly dry MM, OP
clear, LAD, neck ,supple
CV - RRR, +s1/s2, II/VI systolic murmur over LSB and apex
Lungs - limited by poor inspiratory effort, decreased BS b/l,
bilateral wheezing
Abd - Soft, NT, slightly distended, normoactive BS
Ext - no LE edema, DP pulses not appreciated but feet warm to
touch, has R forearm fistula
Neuro - not tested, sedated.
Pertinent Results:
EKGs :
-upon arrival : sinus rhythm, RBBB.
-During episode of SVT: left axis deviation, wide complex
tachycardia, small P waves in DII
-post SVT : RBBB
.
-CxR: hyperinflated lungs , bilateral interstitial infiltrates.
CTA chest:
.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. New nodular opacities in the right lower lobe and right
upper lobe with resolution of the left upper lobe opacity
previously seen. The rapidity of these changes are more
suggestive of an infectious or inflammatory process. However,
continued followup to ensure resolution is recommended.
3. Increased density and reticulated appearance to the
vertebral bodies, likely related to renal osteodystrophy.
4. Cardiomegaly and coronary artery disease and more diffuse
atherosclerosis
Brief Hospital Course:
#Respiratory Failure: most likely respiratory failure is
pneumonia in the setting of a patient with a very poor lung
function, as determined by previous PFTs and current CxR.
Additional V/Q mismatch is likely related to a PNA considering
he has fever, cough , secretions and a 2 opacities in RML and
RLL ,c/w multifocal PNA. Was extubated soon after intubation and
has been weaning off of O2.
-s/p course of azithro for possible legionella (legionella ag
negative) and continuing on zosyn for GN's and vanco for gm
positives (and enterococcus in urine).
.
#Respiratory Acidosis: Patient's ABGs c/w acute respiratory
acidosis, probably related to COPD with probably with
?hypoventilation?, muscular fatigue due to hypoxemia?
pHs improved after patient intubated and then remained fine
after extubation.
.
#PNA: Patient has fever, elevated WBC, infiltrate on CT.
Etiology unclear.
-sputum studies, Urine Legionella Ag negative. DFA for influenza
A and B negative.
-covering with Zosyn (to cover Pseudomonas considering patient
has bronchieactasis on CT and comes from rehab), Zithromax for
Legionella x 5 days (completed [**5-11**]). Vanco considering he has hx
of influenza infection, could have staph PNA.
-blood cultures neg
--remained afebrile through [**5-16**]. white count elevated but
otherwise no significant signs of infection, most likely due to
steroids. white count stabilized at discharge, minimal O2
requirement.
.
#COPD: Patient has histoty of severe COPD. Was initially given
solumedrol 80 tid which is being tapered. switched to prednisone
and tapered to zero at discharge.
-Continue nebs
-taper steroids quickly
.
#SVT: Patient had episode of SVT in ED. EKG in MICU has remained
within NSR. Per Cardiology, no signs of ischemia.
-Continue following EKG.
-added metoprolol
.
#CP pt c/o one episode of CP on am [**5-15**] with some rate related ST
changes, relieved with BB, Morphine and SLNTG, Enzymes negative
x 3. no recurrence.
.
#Borderline BP: Patients BP has remained systolic 105- 110s
unclear baseline. BP prior to intubation with systolic near
130-150s. Lactate elevated on admission. Most likely related to
hypoperfusion
-Initially held BP meds - now restarting with strict holding
parameters.
.
#CAD:
- Patient on ASA, Plavix, statin. BB added back and going back
up to home dose slowly.
- troponins were flat.
.
#ESRD: pt makes very little urine. HD scheduled for Mon, Wed,
Fri.
-Continue Phoslo and give Epo during dyalisis
-Follow Vanc levels in dialysis.
.
#Lung nodule: seems to have improved per new CT.
-Follow up after PNA has resolved.
.
#Coagulopathy: patient has elevated PTT and PT. D dimer elevated
but no evidence of DIC.
.
#Code status: Discussed with wife extensively who states pt is
definitely DNR/DNI now even though this had been reversed for
the intubation earlier on this admission. Wife is HCP and states
pt has been declining lately and they are prepared if he
declines further to make him CMO.
Medications on Admission:
Plavix 75 mg qd
ASA 325 mg qd
Metoprolol 37.5 mg tid
NTG 0.3 mg sl PRN
Lipitor 40 mg qd
Fluticasone 50 mcg qd
Albuterol nebulizer q 6 h
Combivent inhaler
Ipatropium inhaler
Citalopram 40 mg qd
Tamsulosin/Flomax 0.4 qd
Stool softeners
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
pneumonia
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. wigh yourself. you were treated in
the hospital for pneumonia which resolved. you are to return to
the rehab facility and resume all your other medications. follow
all instructions. return to the hospital for any chest pain or
shortness of breath.
Followup Instructions:
follow up with your doctor in the next two weeks.
|
[
"51881",
"486",
"2762",
"4280",
"496",
"40391",
"41401",
"2720",
"V4581"
] |
Admission Date: [**2121-5-12**] Discharge Date: [**2121-5-16**]
Date of Birth: [**2062-12-17**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Face swelling.
Major Surgical or Invasive Procedure:
Laryngoscopy.
History of Present Illness:
The patient is a 58 year old female with a history of lupus,
antiphospholipid syndrome w/ pulmonary and renal vein thromosis
on coumadin, stage V lupus nephritis who presents with 4 days of
progressive left facial swelling. Four days prior to
presentation, the patient began to develop a head ache. The
following morning she noticed swelling of her left lace and
neck. On the prior to presentation, the swelling became
markedly worse, and the patient developed subjective fevers and
chills. She felt as if her tougue could not fit within her
mouth, and noticed some dysphagia. She had no difficult
breathing, but pain with opening of her mouth. The pain
radiated to her left year, and has been upable to take much PO
intake. the patient reports no recent illness or sick contacks.
The patinet denies any history of salivary duct stones, neck
surgery, dental pain or recent procedures.
In the ED, initial vs were: T 100.5 P 120 BP 130/75 R 20 O2 sat
98% on RA. Patient had a CT scan that demonstrated a
submandibular gland obstructing stone with evidence of
infection. She was seen by ENT, underwent larygoscopy, was
given unasyn and vanc, 10mg IV decadron, and IV moprhine for
pain control. The patient was admitted to the MICU for airway
monitoring.
Past Medical History:
1. Systemic lupus erythematosus with antiphospholipid syndrome
on chronic anticoagulation-status post pulmonary embolism, renal
vein thrombosis
2. Stage V membranous glomerulonephritis Nephrotic syndrome,
now stage 3.
3. Depression
4. Obstructive sleep apnea
Social History:
The patient does not smoke any cigarettes, but she does drink
two to three alcoholic beverages per week. She is married and
works as a real estate [**Doctor Last Name 360**] and has one child who is healthy.
Family History:
Is notable for diabetes mellitus, and she does have one cousin
who did have lupus and was deceased of complications with
therapy.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
Vitals: T 97.9, BP 142/82, HR 63, RR 16, O2sat 100% on RA
Tm 98.6, 142-143/76-82, 63-72, 16, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear; face with very
mild assymtetric swelling of left side with slight neck
fullness; nontender; no appreciable exudate on oral exam
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2121-5-12**] 04:36PM LACTATE-1.8
[**2121-5-12**] 04:20PM GLUCOSE-118* UREA N-16 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2121-5-12**] 04:20PM CK(CPK)-104
[**2121-5-12**] 04:20PM cTropnT-<0.01
[**2121-5-12**] 04:20PM CK-MB-3
[**2121-5-12**] 04:20PM WBC-6.6# RBC-4.59 HGB-12.5 HCT-38.5 MCV-84
MCH-27.3 MCHC-32.5 RDW-14.9
[**2121-5-12**] 04:20PM NEUTS-86.8* LYMPHS-9.7* MONOS-1.9* EOS-1.2
BASOS-0.4
[**2121-5-12**] 04:20PM PLT COUNT-205
[**2121-5-12**] 04:20PM PT-25.7* PTT-26.9 INR(PT)-2.5*
On discharge:
[**2121-5-16**] 07:25AM BLOOD WBC-9.9 RBC-3.58* Hgb-9.8* Hct-30.2*
MCV-85 MCH-27.4 MCHC-32.5 RDW-15.0 Plt Ct-215
[**2121-5-16**] 07:25AM BLOOD PT-30.0* PTT-114.0* INR(PT)-3.1*
[**2121-5-16**] 07:25AM BLOOD Glucose-95 UreaN-23* Creat-1.0 Na-144
K-3.7 Cl-111* HCO3-24 AnGap-13
[**2121-5-15**] 02:46AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3
Wound Cultures showed mixed flora as well as [**Female First Name (un) **] ALBICANS.
STUDIES:
CT Neck with Contrast, [**2121-5-12**]:
Artifact from the dental amalgam degrades the images, within
these limitations there is a 20 x 15 mm enhancing inflammatory
mass below is angle of left mandible may be related to
infection/inflammation of the salivary gland or inferior
extension of the left parotid gland. Several enlarged neck lymph
nodes are seen.
Fiberoptic exam per ENT note:
Nasopharynx - right medial aspect of fossa of Rosenmuller with
approx 0.5cm clear watery cyst, posterior pharyngeal [**Name6 (MD) **] in NP
with 0.5cm mass with overlying granular muscosa in midline,
Larynx - valleculae clear, crisp epiglottis, patent piriforms
bil, crisp vocal folds with good mobility.
Brief Hospital Course:
# Left Facial Swelling: The patient presented with left
submandibular gland infection and large [**Location (un) 21511**] duct stone.
The patient was at risk for Ludwig's angina given rate of
progression of infection (over 1 day) and given that infection
already involves left submandibular space, and sublingual space.
Had been seen by ENT in ED, without evidence of airway
compromise. No evidence of laryngal swelling on scope. She
received antibiotics in ED and one time dose of dexamethasone.
She continued on vanc/unasyn while gland cultures were sent.
These returned with finding of mixed flora and [**Female First Name (un) **] albicans.
She was discharged on Augmentin and Fluconazole. ENT also
recommended [**Doctor Last Name 21512**] wedges QID and salivary massage QID to help
stimulate secretions. She was also discharged on Prednisone.
# Anti-phospholipid syndrome (APLS): The patient has a history
of PE and renal vein thromosis, managed on coumadin as
outpatient. Her INR remained therapeutic on this admission.
# Lupus: The patient has a history of Lupus managed by Dr.
[**Last Name (STitle) **]. No evidence of acute flare. No reason to suspect any
correlation with other autoimmune process like Sojourn's. She
continued hydrochlorquine but held cellcept in setting of
infection. She was discharged on Prednisone rather than Cellcept
until follow up with Dr. [**Last Name (STitle) 1667**].
# Glomerularnephritis: This had significantly improved on
cellcept. Grade 3 membranous glomerularnephritis with Cr at
baseline at 1.1. She was continued on hydrochloroquine and
lisinopril. Cellcept was held in setting of infection and was
discharged on Prednisone. She will likely resume Cellcept to be
decided at follow-up with Dr. [**Last Name (STitle) 1667**].
# Depression: She was continued on Prozac.
Medications on Admission:
Fluoxetine 40mg daily
Flovent
Hydrochloroquine 200mg [**Hospital1 **]
Lisinopril 40mg daily
Cellcept 500mg [**Hospital1 **]
Omeprazole 20mg daily
Mirapex 0.125mg qhs PRN
Coumadin
Vitamin D [**2111**] units daily
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,WE,FR,SA).
6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO DAYS (MO,TH).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
8. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
9. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Flovent HFA Inhalation
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Sialadenitis
Secondary:
-Systemic lupus erythematosus
-Membranous glomerulonephritis
-Antiphospholipid syndrome
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted for facial and neck swelling and found to have
sialdenitis (infection in salivary gland due to stone). The
stone is no longer obstructing your duct and the swelling has
improved. You should continue to take Augmentin as written
(875mg by mouth twice a day) for an additional 10 days. You
should also follow up with ENT in [**6-20**] days. Please continue to
use [**Doctor Last Name 5942**] slices to stimulate saliva and warm compresses as your
have been.
Dr. [**Last Name (STitle) 1667**] would like you to take 7.5mg of prednisone daily
instead of the Cellcept until you can follow up with her. You
have an appointment with her on [**2121-5-27**] at which time you can
further discuss your medication.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please have your INR checked on Monday [**5-19**] as your
antibiotics can interfere and your Coumadin dose may need to be
adjusted.
Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2121-5-27**]
10:30
ENT: Please see Dr. [**First Name (STitle) **] at [**Location (un) **]. on [**5-28**] at
2pm ([**Location (un) 55**]). The phone number there is [**Telephone/Fax (1) 2349**].
Please fill out the new patient forms and bring these with you
(If you need additional copies they can be found on the webiste
[**URL 21513**]/)
Provider: [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2121-6-23**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2121-6-27**] 11:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2121-5-26**]
|
[
"49390",
"32723",
"311",
"V5861"
] |
Admission Date: [**2127-4-29**] Discharge Date: [**2127-5-4**]
Date of Birth: [**2087-5-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Admited to [**Hospital Unit Name 153**] after cardiac arrest
Major Surgical or Invasive Procedure:
Intubation
Past Medical History:
h/o afib
TAH 2 week post partum
c-section [**2127-2-27**]
Social History:
Has 2 month old baby
Brief Hospital Course:
Ms. [**Known lastname **] is a 39 yo woman admitted to the Urology service
for management of urosepsis. She was doing well on IV
antibiotics. On the day before anticipated discharge, a midline
catheter was placed and one hour later she was found on the
ground, unresponsive and without a pulse. A code was called and
she was thought to be in PEA arrest. After chest compressions,
intubation, and three shocks, she regained a pulse in sinus
tachycardia. She was transferred to the [**Hospital Unit Name 153**]. Echo showed
severe LV akinesis. A CTA ruled out PE. Pt developed myoclonus
secondary to anoxic brain injury. A head CT three days later
showed cerebral edema and herniation. At this point, her family
decided to withdraw care. She died comfortably on [**2127-5-4**].
The cause of Ms. [**Known lastname 22033**] unexpected and untimely death is not
clear. An air emboli was considered, but the midline catheter
was placed about an hour before her unresponsiveness, the timing
of which is too long for air emboli. Also, there was no
thrombus or air on CTA. Our best formulation is that her
cardiac arrest may somehow be related to her prior cardiac
disease. She has had an ~18 year history of paroxysmal atrial
fibrilliation. She was started on Profathenone, Diltiazem, and
Toprol at [**Hospital1 756**] on [**3-18**], and was discharged with
prescriptions for these medications on [**3-20**]. However,
Ms. [**Known lastname **] was not taking these medications as an outpatient,
and did not inform her doctors [**First Name (Titles) **] [**Hospital3 **] that these
medications were recommended to her. As a result, these
medications were not restarted at [**Hospital3 **]. It was also
possible, as we discussed with the family, that Ms. [**Known lastname **] had
post-partum cardiomyopathy given her echocardiogram findings,
perhaps predisposing to a dysrhythmia. However, cardiomyopathy
was not noted on autopsy, but rather a massive LV infarct that
may have been secondary to a primary event that remains unclear.
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]
|
[
"42731",
"5070",
"2767",
"2762",
"4168",
"4240"
] |
Admission Date: [**2179-6-12**] Discharge Date: [**2179-6-18**]
Date of Birth: [**2107-7-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fall, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 71 year old female with had a mechanical fall. She was
walking with a walker at rehab and was hit by a swinging door in
the back and fell and hit her head on the doorknobb in the
process. She lost consciousness when she hit her head, not
prior. The fall was witnessed, she did have bladder incontinence
but no seizure like movements. She regained consciousness when
the She became short of breath when she was laid flat to have
the C- collar placed. She was taken to an outside hospital.
There she was found to have a head bleed and was thought to be
in pulmonary edema. She was given lasix (responded with a liter
of urine), duonebs and nitropaste. She was initially hypoxic to
the 60s but after the lasix her O2 sat improved. She was
transferred to [**Hospital1 **] for further managment.
.
In the ED, initial vs were: 97 106 182/98 18 99 NRB. Initially
on a NRB but was weaned down to NC. Patient was given zofran,
morphine IV, initially nitro gtt then changed to nitroprusside
gtt. She was given keppra per neurosurg. A CT Head was done
which confirmed the bleed. CT Neck was done which showed
degenerative spine disease and C-collar was cleared. Hip and
shoulder XR were read as normal. Vitals on transfer were 90,
152/86, 16, 100% 3L
.
On the floor, she was complaining of a headache and right
shoulder pain.
Past Medical History:
COPD
AFIB
DM
GI BLEED (2months ago treated at [**Hospital1 2025**])
ANEMIA
CHF
MI X2 (initial in [**Month (only) **] after her husband's death)
CRI
DVT
BREAST AND VULVULAR CA:treated with chemo and radiation.
Social History:
Widowed, lives with daughter. [**Name (NI) **] hx of Tobacco use. No EtOH
Family History:
NC
Physical Exam:
Discharge Physical Exam
Tc: 97.6 BP: 157/64 HR: 75 RR: 18 O2: 98%RA
Gen: NAD, A+Ox3, alert and cooperative, appropriate
HEENT: EOMI, MMM, OP clear, hematoma over R posterior occiput
CV: RRR, [**1-2**] cresceno-decrescendo murmur heard best at RUSB, no
radiation to carotids
Lungs: CTA bilaterally
Abd: soft, NT/ND, +bowel sounds. no HSM
Extrem: trace edema in bilateral LE
Pertinent Results:
Admission Labs:
[**2179-6-12**] 10:25AM BLOOD WBC-9.9 RBC-3.88* Hgb-11.4* Hct-35.0*
MCV-90 MCH-29.4 MCHC-32.5 RDW-14.8 Plt Ct-178
[**2179-6-12**] 10:25AM BLOOD Neuts-87.2* Lymphs-7.7* Monos-3.6 Eos-1.2
Baso-0.3
[**2179-6-12**] 10:25AM BLOOD PT-13.5* PTT-27.7 INR(PT)-1.2*
[**2179-6-12**] 10:25AM BLOOD Glucose-149* UreaN-40* Creat-1.4* Na-141
K-4.3 Cl-104 HCO3-26 AnGap-15
[**2179-6-12**] 10:25AM BLOOD proBNP-9919*
[**2179-6-12**] 10:25AM BLOOD cTropnT-0.03*
[**2179-6-12**] 08:00PM BLOOD CK-MB-5 cTropnT-0.04*
[**2179-6-13**] 02:27PM BLOOD calTIBC-212* Hapto-123 Ferritn-333*
TRF-163*
Discharge Labs:
[**2179-6-18**] 05:40AM BLOOD WBC-4.3 RBC-3.16* Hgb-9.4* Hct-27.8*
MCV-88 MCH-29.7 MCHC-33.7 RDW-14.8 Plt Ct-208
[**2179-6-18**] 05:40AM BLOOD PT-14.1* PTT-28.1 INR(PT)-1.2*
[**2179-6-18**] 05:40AM BLOOD Glucose-103* UreaN-45* Creat-1.2* Na-138
K-4.4 Cl-107 HCO3-24 AnGap-11
[**2179-6-18**] 05:40AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.7
.
[**2179-6-12**] CT Head:
18 x 40 mm right parietal epidural hematoma with associated
subgaleal
hemorrhage.
.
[**2179-6-12**] CT C-spine:
1. Multilevel degenerative disease with no acute fractures
noted. If
ligamentous injury is a clinical concern, then an MR is
recommended for
further evaluation.
2. Mild bilateral pulmonary edema.
.
[**2179-6-12**] CXR:
Findings mild pulmonary edema with possible superimposed
pneumonia. Aspiration cannot be excluded. Suggest follow-up to
resolution.
.
[**2179-6-13**] CT Head:
Stable epidural hematoma overlying the right parietal lobe.
Stable right-sided subgaleal hematoma.
.
[**2179-6-14**] CT Chest:
1. Right basal consolidation/atelectasis. Differential diagnosis
would
include aspiration. No clear evidence of neoplasm is
demonstrated.
2. Extensive vascular calcification as described in the body of
the report.
3. Status post right breast surgery with post-surgical changes
including
low-density collection which might represent seroma, please
correlate with
dedicated imaging.
4. Bilateral right slightly more than left pleural effusion that
appears to be low in density, nonhemorrhagic.
.
CT-Head [**2179-6-16**]: FINDINGS: A 28 x 16 mm epidural hematoma is
redemonstrated overlying the right parietal lobe near the vertex
(2:23). This is stable in size since the [**2179-6-13**] study and
decreased compared to [**2179-5-13**]. No new hemorrhage, edema, or
mass effect is seen. The ventricles and sulci are unchanged in
size and configuration. Relative hypodensity of the
periventricular white matter is compatible with chronic
microvascular ischemic disease.
There has been interval improvement of the right-sided subgaleal
hematoma with some decrease.
IMPRESSION:
1. Stable right parietal epidural hematoma since the [**2179-6-13**] study and decreased compared to [**2179-5-13**].
2. Decreased right subgaleal hematoma.
3. No evidence of new intracranial hemorrhage or mass effect.
ECG [**2179-6-16**]: Sinus rhythm. Left axis deviation like due to left
anterior fascicular block. Right bundle-branch block. Compared
to the previous tracing of [**2179-6-13**] lateral T wave changes are
not as apparent on the current tracing. The Q-T interval is
slightly shorter. Clinical correlation is suggested.
[**2179-6-17**]: Sinus rhythm. Right bundle-branch block. Left anterior
fascicular block. Compared to tracing #1 lateral ST-T wave
changes are not seen on the current tracing.
Brief Hospital Course:
This is a 71 year old female with multiple medical problems who
fell and hit her head and also became short of breath.
.
# Shortness of Breath: Patient's shortness of breath was related
to CHF. She improved dramatically from the lasix given in the
ED. Her CXR had what was likely a resolving pneumonia. She was
afebrile and without cough so was not treated with antibiotics.
She was treated symptomatically with lasix 40 mg IVx1. Her
respiratory status improved and O2 sats were 90s on room on air
on discharge from the ICU. She had Chest CT for evaluation of
possible lung malignancy. This was not done with contrast due
to her chronic kidney disease. Her CT did not show evidence of
malignancy. While on the floors she remained asymptomatic and
her oxygen saturations were normal on room air.
.
# Intracranial hemorrhage: Patient with both epidural and
sub-galeal bleed on head CT. Neurosurgery evaluated the patient
in the ED and opted for a non-operative course. Her neuro exam
remained unchanged and serial CT scans did not show expansion of
the hematoma. She was started on keppra for seizure
prophylaxis. She needs neurosurgical follow-up on discharge
with a repeat non-constrast Head CT. She should continue to
Keppra until her follow-up.
.
# Hypertension: Home hypertensive medications initially held and
patient was on a nitroprusside drip in the ICU to maintain SBP <
140 for head bleed. She was started on Carvedilol 25mg PO BID
(her home dose) and Nifedipine ER 60mg PO daily (changed from
her home Amlodipine). Her blood pressures were elevated one
night on the floor to the 200s/100s. She was given hydralazine
and a nitro patch which brought her under control. Her
nifedipine was increased to nifedipine SR 90 mg and she was
watched on this dose for 24 hours. Her pressures remained under
160 with this new regimen. Per neurosurgery, her goal SBP is
less than 160. We are discharging the patient on lisinopril 5 mg
by mouth daily as she does have comorbities that warrant ACE-I
use. We recommend that she takes this medicine at night as her
blood pressure trend showed higher pressures at night.
.
# DM: Home insulin regimen continued.
.
# CKD: The patient's creatinine trended down to 1.2 on the day
of discharge. It seems her kidney function has returned to
[**Location 213**].
.
# L Rotator Cuff Tear: OSH MRI was obtained from [**Hospital1 87076**] showing a L Rotator Cuff Tear. Ortho was called
and recommended outpatient evaluation with Dr. [**Last Name (STitle) **]. The
patient was told this and prefers to follow-up with Ortho at [**Hospital1 2025**]
after she is discharged.
.
# UTI: Patient had a positive UA on [**6-17**] and urine culture was
no growth to date at time of discharge. Was started on Cipro for
planned 3 day course.
.
# PENDING Labs at time of discharge: Urine culture no growth to
date on [**6-18**] after 2 days.
.
# Transition of care: Patient will require PCP/Gerontology
follow up after discahrge. Will also require neurosurgery
appointment in [**3-2**] weeks, and Orthopedic surgery follow up after
discharge.
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Colace100mg [**Hospital1 **]
Omeprazole 40mg [**Hospital1 **]
NPH 6units qpm before dinner
Ferrous Sulfate 325 QD
Nephrocaps 1 mg QD
Nystatin swish and swallow QID
Sevelamer 800 mg QD
Flomax 0.4mg SR QD
Nortriptyline 25mg qhs
Norvasc 10 mg daily
NPH 24u Qam
Sodium Bicarb 650mg 2 tabs tid
Claritin 10mg QD
Vicodin 5/500 prn
Cholecalciferol 400u [**Hospital1 **]
Discharge Medications:
1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Please take for 1 more day. Last day will be
[**6-19**].
10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous before dinner.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Hold if SBP < 100
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: epidural hematoma, subgaleal hematoma
Secondary: Diabetes mellitus, COPD, CHF - unknown systolic or
diastolic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 5385**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with and epidural hematoma
(bleeding around your brain). You initially were in the Medical
Intensive Care Unit where they closely monitored you. The
neurosurgeons were consulted and they said no acute intervention
was needed. You had serial CT scans of your head which showed
that the bleed was not enlarging. When you came to the general
floor, your blood pressure was elevated. We increased your
blood pressure medicine and got good control.
We increased 1 medication:
--> Increased carvedilol to 25 mg by mouth twice daily
We added 2 medications:
--> Nifedipine SR 90 mg by mouth daily
--> Lisinopril 5 mg by mouth daily - please take this medicine
at dinnertime
Please follow-up with your scheduled appointments with Dr. [**Last Name (STitle) 548**]
Followup Instructions:
Department: RADIOLOGY
When: FRIDAY [**2179-7-16**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: FRIDAY [**2179-7-16**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2179-6-21**]
|
[
"4280",
"5990",
"40390",
"42731",
"496",
"41401",
"412"
] |
Admission Date: [**2138-8-26**] Discharge Date: [**2138-9-9**]
Date of Birth: [**2056-2-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
loss of consiousness
Major Surgical or Invasive Procedure:
[**2138-8-26**] Right Frontal EVD
History of Present Illness:
This is a 82 year old female who developed a headache yesterday
and was
found down at home and unresponsive on the day of admission. The
patient was transferred to [**Hospital1 18**] for further care where CT head
showed a hemorrhage within
the right lateral ventricle with mild hydrocephalus but no
midline shift.
Past Medical History:
Basal cell carcinoma in forehead (s/p) resection and another
lesion on her upper lip.
Trigeminal neuralgia
Cholecystectomy
Ascending Aortic Aneurysm s/p replacement
Atrial fibrillation s/p MAZE and LAA ligation [**2137-05-25**]
Aortic, mitral, and tricuspid valve regurgitation
Dyslipidemia
Hypertension
Diverticulosis
Cataract Surgery
Bladder Suspension
cholecystitis
Social History:
Lives with: Son, independent of ADLs
Tobacco: Never
ETOH: Rare
Family History:
Extensive family history of cardiovascular disease and cancer
-Father died at 49 with unknown cancer ?prostate
-Mum died at 91 after multiple strokes
-5 brothers and 1 sister died of cancer (1 sister with bladder
cancer, brother with unknown cancer with brain mets, other
cancers unknown)
-6 sisters with heart disease all except 1 deceased.
Physical Exam:
On Admission:
BP: 177/99 HR: 88 R 17 O2Sats 96%
HEENT: Pupils: 2-1mm
Neuro:
Mental status: EO to voice, following commands in all
extremities, cooperative with exam but somewhat sleepy
Orientation: Oriented to person, place, and year but not month.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2 to 1
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.
[**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 [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2-----------
Left 2-----------
On the day of Discharge:
A&O to self, month, year,not to place ("arena") . PEERL, motor
intact, has 2 stables at EVD site.
Pertinent Results:
[**8-26**] Chest Xray: Cardiomediastinal silhouette is enlarged in
this patient who is status post median sternotomy. Opacities at
the left base are improved from the prior radiograph.
Parenchymal opacities
are better appreciated on the CT from the same day and given
change since
prior radiograph are consistent with mild interstitial edema.
No bony
irregularities are appreciated. Abdominal clips seen in right
upper quadrant.
[**8-26**] CT head 11:55am : Large intraventricular hemorrhage. No
definitive intraparenchymal component is seen. Enlargement of
the temporal horns bilaterally raising concern for
hydrocephalus.
[**8-26**] CT C-spine: There is no critical spinal canal stenosis or
prevertebral soft tissue swelling. Degenerative changes are
seen in the cervical spine; however, no evidence of acute
fracture. No major alignment abnormalities are noted. Imaged
portions of the lung apices show left upper lobe ground glass
opacities. There are bilateral extensive carotid bulb
calcifications.
[**8-26**] CT with and without contrast C/A/P: 1. No evidence of acute
intrathoracic or intra-abdominal injury. 2. Mild pulmonary
edema.
[**8-26**] Chest Xray: Interval placement of endotracheal tube with
tip approximately 6 cm from the carina. No other change.
[**8-26**] Chest Xray: The tip of the endotracheal tube projects 5.5
cm above the carina. Tip of the orogastric tube is in the
stomach. No complications. Otherwise, unchanged appearance of
the radiograph.
[**8-26**] CTA head: CTA HEAD: There is no aneurysm greater than 3
mm. No vascular malformation is noted.
Major intracranial vessels remain patent. There are scattered
foci of atherosclerotic plaques in the cavernous segments of the
internal carotid arteries, without flow-limiting stenosis.
There is moderate decreased caliber of the distal basilar
artery, with bilateral fetal origins of PCAs, likely represent
atherosclerotic disease superimposed on normal variants. There
is no distal occlusion.
The visualized paranasal sinuses and mastoid air cells are
clear. There is no acute skull base fracture.
NON-CONTRAST HEAD CT: There is slightly improved appearance of
the lateral ventriculomegaly. A new ventriculostomy tube is
seen via a right transfrontal approach, with the catheter
crossing midline and terminating in the left frontal [**Doctor Last Name 534**].
There is large amount of intraventricular hemorrhage in the
right lateral hemorrhage, possibly decreased from prior. There
is also a small amount of blood layering in the occipital [**Doctor Last Name 534**]
of the left lateral ventricle. There is no gross midline shift.
Small pockets of air and minimal subarachnoid hemorrhage track
along the catheter to the entry site, in keeping with the recent
procedure. The basal cisterns remain patent. Significant
periventricular white matter hypodensity, right worse than left,
likely represents transependymal CSF migration superimposed with
underlying chronic microvascular ischemic disease.
[**8-26**] CT head 10:30pm: 1. Re-positioned right frontal approach
ventriculostomy catheter, now terminating at the proximal third
ventricle.
2. Unchanged appearance of intraventricular hemorrhage, lateral
ventriculomegaly, and extensive neighboring edema. No
superimposed acute
hemorrhage or new mass effect seen since the 8:30 p.m. study.
[**2138-8-29**] NCHCT: In comparison to [**2138-8-26**] exam, there is interval
improvement of intraventricular hemorrhage involving
predominantly right lateral ventricle. Small amount of blood
products are seen in the occipital [**Doctor Last Name 534**] of the left ventricle.
No definite hemorrhage is seen in the third and fourth
ventricles on today's exam. Ventriculomegaly has improved since
prior, as demonstrated by decrease in size of the temporal
horns. No new intracranial hemorrhage.
CHEST (PORTABLE AP) Study Date of [**2138-9-1**] 8:45 AM
FINDINGS: As compared to the previous radiograph, all
monitoring and support devices, particularly the endotracheal
tube, have been removed. Sternal wires in correct alignment.
Surgical clips in unchanged position. The lung volumes are
normal. There is moderate cardiomegaly and tortuosity of the
thoracic aorta, but without evidence of pulmonary edema. No
pneumonia, no pleural effusions. No pneumothorax.
CT HEAD W/O CONTRAST [**2138-9-2**]
IMPRESSION:
1. Interval decrease in intraventricular hemorrhage. Decreased
size of the temporal and occipital horns of the right lateral
ventricle. Mildly increased size of the frontal [**Doctor Last Name 534**] of the
right lateral ventricle and of third ventricle; they are not
abnormally large for age.
2. New small isodense right frontal subdural collection with no
significant associated mass effect. Recommend continued
follow-up.
CT Head [**2138-9-3**]
IMPRESSION: Status post ventriculostomy catheter removal with
stable
intraventricular hemorrhage and stable blood products along the
catheter
tract.
[**2138-9-4**] BLE Lenis
No deep vein thrombosis in the bilateral lower extremities
Brief Hospital Course:
Ms. [**Known lastname 11193**] was evaluated in the ED and recieved FFP, and Vitamin
K for INR reversal. After she was examined she was intubated
for airway protection and transferred to the ICU. Right frontal
EVD was placed at the bedside for progressionof hydrocephalus.
CT head demonstrated malpositioned catheter tip and so the
catheter was withdrawn and replaced. Postprocedure CT
demonstrasted the catheter tip to be in good position. EVD hung
at 5cm above the tragus. CSF was blood tinged initially and
over time the drain became clotted and TPA was administered.
After the TPA CSF flowed freely.
CTA was performed that was negative for aneursysm or vascular
malformation.
The following morning on [**8-27**] the patient was extubated. She was
AOx1, oriented to self only, following commands. EVD remained
at 5cm above the tragus. Overnight the drain clotted again and
another dose of TPA was administered with good effect.
On [**8-28**] the patient remained AOx1 however mental status improved
and she followed commands more briskly.Her EVD functioned
without problem.
On [**8-29**] the patient was noted to have increasing ICP's. Upon
inspection and removal of the dressing, the catheter was noted
to be kinked. Once this was resolved the ICP's returned to
[**Location 213**]. A head CT was also performed and noted to be stable but
there was a collapsed right ventricle. Due to this the EVD was
raised to 10cm H20.
On [**8-30**] the patient and EVD remained stable.
On [**9-1**] the patient's EVD height was increased to 15cm. ICPs
remained stable overnight between [**2-2**] and the patient was better
oriented.
On [**9-2**], The patient's external ventricular drain was clamped at
0900 am. The intercranial pressure measured at 2-13 throughtout
the day. A non contrast Head CT was perormed which showed
"interval decrease in intraventricular hemorrhage, Decreased
size of the temporal and occipital horns of the right lateral
ventricle. Mildly increased size of the frontal [**Doctor Last Name 534**] of the
right lateral ventricle and of third ventricle as well as a new
small isodense right frontal subdural collection with no
significant associated mass effect. The patient's neurologic
exam remained stable.
on [**9-3**] the patient's ICP had remained stable overnight (less
than 10mmH2O) and she remained intact neurologically so the
decision was made to remove the EVD. This was done without
complication. A post removal CT was performed which revealed a
small hemorrhage along the previous catheter tract. Due to this
she was kept in the ICU overnight.
On [**9-4**] she was neurologically intact and hemodynamically stable.
She was cleared for transfer to the floor. PT and OT consults
were requested.
Physical therapy found the patient demonstrated good functional
improvement over the weekend but Occupational therapy found that
she was limited by poor memory and insight and would not be able
to return home without 24 hour supervision. On [**9-8**] her coumadin
was retarted at her home dose and patient agreed to go to rehab
for further evaluation and treatment. On [**9-9**], patient remained
stable and was discharged to rehab. She was started on levoquin
for a complicated UTI prior to her discharge.
Medications on Admission:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY constipation
3. CloniDINE 0.2 mg PO BID
hold for SBP < 90, HR <60
RX *clonidine 0.2 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 50 mg PO BID
6. Senna 1 TAB PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4hr Disp #*30 Tablet
Refills:*0
8. Levofloxacin 750 mg PO Q24H Duration: 5 Days
9. Warfarin 2 mg PO DAILY16
1.5mg alternating with 2mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Intraventricular Hemorrhage
hydrocephalus
Discharge Condition:
Mental Status: clear, coherent but intermettently not oriented
to place or date.
Level of Consciousness: Alert and interactive.
Activity Status: physically independent but limited due to poor
memory and insight.
Discharge Instructions:
Nonsurgical Brain Hemorrhage
?????? 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) **], 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.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
---Please return to the office by [**9-13**] for removal of your final
staples. This appointment can be made with the Nurse
Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please make this
appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a
distance from our office, please make arrangements for the same,
with your PCP.
Completed by:[**2138-9-9**]
|
[
"42731",
"V5861",
"4019",
"2724",
"53081"
] |
Admission Date: [**2119-9-13**] Discharge Date: [**2119-9-19**]
Date of Birth: [**2119-9-13**] Sex: M
Service: NB
TRANSFER DIAGNOSES: Premature male infant 32 6/7 weeks
gestation.
Status post hyperbilirubinemia.
Gross motor tremors.
HISTORY OF PRESENT ILLNESS: Raschaud is the former 1496 gm
male infant born at 32 6/7 weeks to a 28 year old O+
primigravida whose remaining prenatal screens were
noncontributory. Group B Strep status was unknown. Mother was
transferred from [**Name (NI) **] Hospital with a past medical history
notable for diabetes mellitus controlled with oral
medications. However, during pregnancy, she required insulin.
She also has chronic hypertension which was managed with
Aldomet and hypertension increased during pregnancy. In
addition, mother was noted to have oligohydramnios and the
fetus with enlarged bilateral echogenic kidneys. She was
transferred to [**Hospital3 **] Hospital for delivery. Delivery
was performed by cesarean for hypertension and
oligohydramnios. The infant emerged with apgars of 8 and 8.
No resuscitation was required.
The infant was admitted to the [**Hospital3 **] Special Care
Nursery. On admission, his length was 42 cm. Birth weight was
1495 gm and head circumference was 29.5 cm, all at the 10th
percentile.
PROBLEMS DURING HOSPITAL STAY: Respiratory: The infant
remained in room air throughout his hospital course. There
were no episodes of apnea of prematurity.
Cardiovascular: There were no cardiac issues. Blood
pressures were stable.
Feeding and Nutrition: The infant currently weighs 1435 gm,
is on 150 cc per kg per day of mother's milk 20 or Special
Care 20. He has been noted to have frequent spits and for
that reason, feeds were extended to one hour and ten minutes
via pump and this has improved the situation.
Infectious Disease: Since there were no maternal risk
factors and the infant did well on admission, no CBC was
obtained and he was not placed on antibiotics.
Neurologic: The infant was noted to have gross tremors since
birth. These were stopped by placing him on his abdomen or
holding the upper extremities. Urine was screened for
toxicology and was negative. Electrolytes were all normal
with a sodium of 143, potassium 4.2, chloride 108, CO2 23,
calcium 9.5 and normal dextrose sticks. The parents were
questioned about a drug history and they denied any taking of
drugs.
Hematologic: The mother is 0+. The baby had an initial
hematocrit of 55.7. Peak bilirubin on [**9-16**] was 9.2/0.3. The
patient was initially placed on phototherapy on [**9-15**]. It was
discontinued on [**9-19**] and a rebound bilirubin will be
obtained in 24 hours.
Genitourinary: Because of the initial fetal ultrasound report
of bilateral echogenic hydronephrotic kidneys, a repeat
ultrasound was done which was entirely normal.
CURRENT MEDICATIONS: None.
The parents have requested the infant be transferred to
[**Hospital **] Hospital to be closer to home. Upon discharge from
the Newborn Intensive Care Unit, he will be followed up at
[**Hospital1 **] [**Location (un) 1456**] Center by Dr. [**Last Name (STitle) 56727**].
RECOMMENDATIONS: The patient is to have follow-up bilirubin
at [**Hospital **] Hospital on [**9-20**]. Screening head ultrasound will
be done at [**Hospital **] Hospital.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-393
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2119-9-19**] 09:08:48
T: [**2119-9-19**] 09:54:15
Job#: [**Job Number **]
|
[
"7742"
] |
Admission Date: [**2119-4-14**] Discharge Date: [**2119-4-22**]
Date of Birth: [**2065-11-10**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53 year old male
with a diagnosis of muscle invasive Grade II to III/III
bladder carcinoma. In addition, his prostatic urethral
biopsies had been positive for carcinoma in situ. He is
status post transurethral resection of bladder tumor and BCG
therapy. His pathology sides have been reviewed here at the
[**Hospital1 69**] and have shown a
micro-papillary variant which tends to be very aggressive.
He had undergone MVAC chemotherapy with Dr. [**Last Name (STitle) **]. At this
time, he presents for discussion for his continent urinary
diversion. His cystoprostatectomy will be performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**].
He had a CT scan and bone scan in [**2118-10-13**], prior to
his chemotherapy that showed no evidence of metastatic
disease. He had a recent prostate biopsy because of a
prostatic nodule which showed no malignancy.
PAST MEDICAL HISTORY:
1. Diet controlled type 2 diabetes mellitus.
MEDICATIONS: He is on no medications except a multivitamin.
PAST SURGICAL HISTORY:
1. Transurethral resection of bladder tumor.
SOCIAL HISTORY: He quit smoking eight years ago. He does
have a 30 pack year smoking history previous to that. He is
a district service manager for the Steris Company. He drinks
two to three caffeinated drinks per day and one to two
alcoholic beverages per day.
FAMILY HISTORY: Significant for his father with a history of
lung cancer and a sister with diabetes mellitus.
ALLERGIES: Allergies are a questionable possible allergy to
Ampicillin.
REVIEW OF SYSTEMS: Review of systems on pre-surgical
evaluation showed mild urinary urgency after BCG treatment
and had decreased erectile function.
PHYSICAL EXAMINATION: Vital signs were 130/88; pulse 78 and
regular; respiratory rate was 16 and unlabored. Abdomen
soft, nontender, no palpable masses. No costovertebral angle
tenderness. No inguinal lymphadenopathy. Genitourinary:
Normal phallus, meatus and testes. No inguinal hernia.
Rectal: Normal tone; 40 gram prostate. Nodularity in the
left prostatic lobe. Extremities and Neurological: Moves
all four extremities without difficulty. Normal gait.
Neurologically and mentally intact.
LABORATORY: White blood cell count 6.7, hematocrit 35,
platelet count 267, BUN and creatinine are 20 and 1.0.
Urinalysis dipstick was three plus glucose; otherwise
unremarkable.
Given this preoperatively assessment, he was given a NuLYTELY
bowel prep and erythromycin and Neomycin based antibiotics
preoperatively. He had a preoperative CT scan repeated that
did not show any evidence of metastatic disease at that time.
HOSPITAL COURSE: On [**2119-4-14**], he came to the [**Hospital1 346**] and underwent a radical
cystoprostatectomy with bilateral pelvic lymph node
dissection and a continent cutaneous diversion. This was
performed by Dr. [**Last Name (STitle) 986**] and also Dr. [**Last Name (STitle) 4229**], with assistant
of Dr. [**First Name (STitle) **]. This was done under general endotracheal
anesthesia. Approximately ten liters of fluids were utilized
interoperatively and the patient had a 1500 cc. blood loss.
Urine output was not complete measured but was thought to be
"very good" per the Anesthesia Record. He did receive two
units of autologous blood interoperatively and received
Clindamycin and Gentamicin for antibiotics during the case.
Specimens from the case included bladder, prostate, bilateral
pelvic lymph nodes, ureteral cuff margins bilaterally.
Drains were the suprapubic tube, the diversion tube,
bilateral stents, [**Location (un) 1661**]-[**Location (un) 1662**] times two, a subclavian line
and an arterial line.
Findings overall were that of a normal anatomy.
He was discharged, intubated, to the Post Anesthesia Care
Unit and ultimately to the [**Hospital Ward Name 1826**] Intensive Care Unit. He
was extubated overnight. His pain was being controlled with
an epidural and he was otherwise feeling okay. He was noted
to have some mild hypotension immediately postoperatively in
the 70s. He was resuscitated with aggressive normal saline
boluses.
His postoperative hematocrit was 32. Sodium was 138,
potassium was 4.8, BUN and creatinine were 17 and 1.0. His
epidural was titrated back to help enhance his blood
pressure. His Propofol was weaned off to extubation. The
neobladder had flushes serially with normal saline and he was
maintained on Clindamycin and Gentamycin for 48 hours
postoperatively. X-rays showed no pneumothorax and he had a
left subclavian line that was in appropriate position.
Over the next 48 hours, the patient had some low grade
temperatures to 100.5 and 100.8 F., respectively. He was
requiring significant fluid boluses to keep his mean arterial
pressure in the 50s to 70s. Central venous pressures were
measured to be around 12. Ultimately, his urine output
through his suprapubic tube picked up. He was transferred to
the Floor on postoperative day number two. His hematocrit at
this time was 23.9. He was given an additional two units of
packed red cells. Creatinine was 0.8. His INR was 1.5.
His arterial line had been discontinued by this point. He
had a right internal jugular at this time; it was a new site
and stick that was placed. He had two ureteral stents, a
Foley catheter and a suprapubic tube. His epidural was still
being utilized, but it had been titrated back and he was now
on a total regimen of epidural and PCA for pain control. He
was hemodynamically stable. He had had a low-grade
temperature to 100.3 F., the night before, but was ultimately
deemed stable and appropriate for discharge, and sent to the
Floor.
On postoperative day number three, he was off antibiotics,
feeling well with no pain. His post transfusion hematocrit
was 27.3. His tachycardia had subsided. His BUN and
creatinine were 12.0 and 0.7 respectively. His examination
was otherwise benign. He was now walking and out of bed
without assistance. He was learning to care for his drains.
Over the next three to four days postoperatively, the patient
did well. He ultimately passed gas by postoperative day six.
At this time, his diet was advanced. His epidural was
discontinued. He was being controlled for pain with a PCA.
He was tolerating a clear liquid diet.
At this point of his postoperative course, the stents had
essentially all but fallen out on their own, so they were
discontinued. The [**Location (un) 1661**]-[**Location (un) 1662**] outputs had dropped off on
the left side, but the right [**Location (un) 1661**]-[**Location (un) 1662**] was noted to
increase immediately after the stent removal. The fear for a
possible urine leak status post stent removal was
investigated and creatinine values on the [**Location (un) 1661**]-[**Location (un) 1662**]
drains were drawn. They were showing to be 0.6 on the right
side and 0.4 on the left. This all but practically refutes a
possible urine leak.
The patient did very well over the next couple of days and
ultimately, by postoperative day number eight, he was
afebrile with a temperature of 98.6 F., pulse 80, blood
pressure 140/90; respiratory rate was 20 with 98% room air
saturation. He was tolerating a regular diet. His fluids
had been Hep-locked. He was making over a liter and a half
of urine through the suprapubic tube. His right
[**Location (un) 1661**]-[**Location (un) 1662**] outputs were averaging 100 to 150 q. shift, and
his left [**Location (un) 1661**]-[**Location (un) 1662**] out between 30 and 50 cc. q. shift.
Blood sugars were adequately controlled just on diet, ranging
106 to 112.
His examination was otherwise unremarkable. His wound is
well approximated with no drainage. Steri-Strips were in
place at this point postoperatively. He did have bowel
sounds and he was soft and flat otherwise. [**Location (un) 1661**]-[**Location (un) 1662**]
sites were secure times two. Suprapubic tube was
additionally in place draining yellow urine. The remainder
of his examination was unremarkable. At this point, he was
deemed appropriate and stable for discharge.
DISCHARGE MEDICATIONS:
1. Percocet 5/325, one to two tablets p.o. q. four to six
p.r.n.
2. Colace 100 mg p.o. twice a day.
3. Protonix 40 mg p.o. q. day.
4. Multivitamin one tablet p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. He will receive 30 to 40 cc. of normal saline flushes
with pull-back gently through the suprapubic tube three times
a day and p.r.n.
2. [**Location (un) 1661**]-[**Location (un) 1662**] care and output recordings.
3. He will receive a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] him with these
tasks.
4. Follow-up instructions will be to see Dr. [**Last Name (STitle) 4229**] in
approximately one to two weeks.
5. He will have a cystogram to test the patency of the
neobladder in approximately two weeks from time of discharge.
6. He will not be accessing his Foley catheter at that time
in his continent cutaneous diversion. This will be only
accessed in the presence of Dr. [**Last Name (STitle) 4229**] in the office.
7. The patient is going to be required to have follow-up
with Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 4229**], [**First Name3 (LF) **] that his plan of
care can be coordinated.
DISCHARGE DIAGNOSES:
1. Bladder carcinoma.
PATHOLOGY: Final pathology was pending, and please refer to
the interim pathology specimen report that is in the
computer.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Stable.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2119-4-21**] 17:49
T: [**2119-4-21**] 18:17
JOB#: [**Job Number 8149**]
|
[
"5180",
"2762",
"2875",
"25000"
] |
Admission Date: [**2166-11-11**] Discharge Date: [**2166-11-13**]
Date of Birth: [**2110-4-10**] Sex: M
Service: [**Company 191**] MED.
CHIEF COMPLAINT: Hematocrit drop from 30 to 23 over the
period of one week.
HISTORY OF THE PRESENT ILLNESS: This a 56-year-old male with
end-stage renal disease status post cadaveric renal
transplant times three with recent ileostomy reversal on
[**2166-10-21**]. He presents with generalized fatigue and
decreased hematocrit from 30 to 23 over one week, while in
rehabilitation. The patient's history dates back to [**6-13**],
at which time he underwent colonoscopy for bleeding polyps,
which was complicated by valve perforation of the cecum. He
was taken to the operating room for emergent right ileal
cystectomy with Hartmann pouch and end ileostomy in the right
lower quadrant. The patient underwent ileostomy reversal on
[**2166-10-21**] without complication. The patient returned to
[**Hospital1 69**] on [**2166-10-31**] two days
after discharge from the hospital with complaints of nausea,
vomiting, and bloating. He was felt to have postoperative
ileus. He was discharged to rehabilitation on [**2166-11-5**].
At rehabilitation, he was noticed to have a decreased
hematocrit, as well as fatigue. He had no chest pain,
shortness of breath, or light headedness, no melena, no
hematochezia, no nausea, vomiting, or abdominal pain, no
fevers, chills, or rash.
Examination revealed the patient afebrile with a heart rate
of 72, blood pressure of 162/64. He had heme-positive brown
stool. He had NG lavage of 600 cc showing stomach contents
and negative for blood. The patient was also noted to have a
calcium of 5.9 at that time. However, he did have a low
albumin. He also had a positive urinalysis. He received one
unit of packed red cells in the emergency department. He
also received 2-g of calcium gluconate.
PAST MEDICAL HISTORY:
1. Renal transplant, cadaveric times three in [**2134**], [**2158**],
and [**2161**] on chronic immunosuppression including
cephalosporins, steroids, and CellCept.
2. Chronic renal insufficiency.
3. Coronary artery disease status post MI in [**2160**], status
post stent.
4. Peripheral neuropathy secondary to hemodialysis.
5. Gastroesophageal reflux disease.
6. Bilateral hip replacement and left shoulder replacement
secondary to steroid-induced avascular necrosis.
7. Right foot cellulitis on 6/[**2164**].
8. Hypertension.
9. Hemicolectomy as per history of present illness.
10. Echocardiogram [**3-/2163**] showed akinesis of the
inferoposterior wall, mild LV dilation, EF 40% to 45%.
11. History of alcohol abuse.
12. History of seizures.
13. Status post subtotal parathyroidectomy.
SOCIAL HISTORY: The patient is currently staying [**Hospital 1315**] Rehabilitation. He does not smoke. He is a former
binge drinker. He quit in [**2160**]. He is single.
FAMILY HISTORY: History is positive for stroke in a
grandparent.
MEDICATIONS:
1. Cyclosporin 175 mg in the morning; 150 mg in the evening.
2. Prednisone 5 mg q.d.
3. CellCept 1 mg b.i.d.
4. Nortriptyline 25 mg b.i.d.
5. Atenolol 50 mg q.d.
6. Zantac 150 mg b.i.d.
7. Folate 1 mg q.d.
8. FESO4, 500 mg q.d.
9. Allopurinol 100 mg q.d.
10. Aspirin 81 mg q.d.
11. Neurontin 100 mg t.i.d.
12. Lipitor 10 mg q.d.
13. Os-Cal.
ALLERGIES: PENICILLIN causes a fever.
REVIEW OF SYSTEMS: Review of systems is also notable for
perioral tingling and tingling in his fingers.
PHYSICAL EXAMINATION: On physical examination the patient
was a 56-year-old white male in no acute distress who was
alert and oriented times afebrile with a heart rate of 91,
blood pressure of 151/79, respiratory rate 19, room air
saturation 97%. SKIN: The skin was warm, dry, and
anicteric. HEENT: Exam showed bilateral cataracts;
conjunctival pallor. Neck was supple. There was a
horizontal surgical scar at the base of the neck. LUNGS:
Lungs showed a few bibasilar crackles. CARDIOVASCULAR: Exam
showed S1 and S2 with a regular rate and rhythm, no murmurs,
rubs, or gallops. ABDOMEN: Exam showed healed midline
surgical scars and scars related to his kidney transplants
and ileostomy. He had normoactive bowel sounds. Abdomen was
soft and nontender. Kidney grafts were palpable per the
emergency department. RECTAL: Rectal examination was
heme-positive. EXTREMITIES: Extremities were without
clubbing, cyanosis or edema. NEUROLOGICAL: Examination
showed a right foot tremor.
LABORATORY DATA: Labs on admission revealed a white count of
7.4, which was 80% neutrophils, and 13% lymphocytes,
hematocrit 23.4, platelets 384, MCV 83, sodium 141, potassium
4.4, chloride 107, bicarbonate 23, BUN 23, creatinine 1,
glucose 117, INR 1.2, PTT 24.2, calcium 5.9, magnesium 1.5.
Urinalysis showed 21 to 50 white cells with many bacteria,
less than 1 epithelial, positive nitrates, less than 1 RBC.
The EKG showed a QTc of 416 with left axis deviation and left
anterior fascicular block. T-wave flattening was noted in 3
and AVF.
ASSESSMENT: This was a 55-year-old male with end-stage renal
disease status post renal transplant on chronic
immunosuppression, who had a seven-point hematocrit drop in
one week after recent ileostomy reversal on [**2166-10-21**], now
presenting with heme-positive stool. The patient was
evaluated by surgery in the emergency department. It was
felt that there was [**Last Name **] problem with the anastomosis and that
his abdominal examination was entirely benign. The most
recent cadaveric graft is functioning well.
HOSPITAL COURSE: Hospital course by system:
HEMATOLOGY AND GASTROINTESTINAL: The patient was transfused
an additional three units of packed red blood cells during
his stay. The hematocrit bumped appropriately. He was given
iron replacement. Hemolysis slides were sent and were
negative. The Department of Surgery felt that there was [**Last Name **]
problem with his anastomosis and that the abdominal
examination was benign; recommended on intervention.
Gastrointestinal consultation was obtained and they
recommended deferring colonoscopy, as the patient has been
through multiple recent colonoscopies without any lesions
noted, and that there was no evidence of an acute bleed. EPO
level was sent and needs to be followed up at rehabilitation.
The aspirin was discontinued. The urinary tract infection
was treated initially with Ciprofloxacin. This was changed
to Bactrim, as Ciprofloxacin interferes with cyclosporin
levels. The patient's urinary tract infection was attributed
to an E. coli bacteria recovered on urine culture. The
sensitivities of this E. coli need to be evaluated by the
rehabilitation staff in a few days to make sure he is
receiving adequate coverage. The the hypocalcemia, he
received 2-g of calcium gluconate in the emergency department.
He was restarted on his calcium trial, and it is
felt that his hypocalcemia may be related to not being able
to received calcium trial as an outpatient. He was also
given Os-Cal with vitamin D 500 mg two tablets b.i.d.
Calcium gluconate was given a second time for 2-g on the
afternoon of the 31st and the Os-Cal with vitamin D was
changed to Tums, three tablets p.o. t.i.d. The calcium trial
dose was changed to .25 mcg p.o.q.d. starting on the morning
of the lst. Calcium gluconate was repeated a third time on
the morning of the lst as well. The magnesium was also
treated with IV replacement. Note is made of the fact that
cyclosporin can cause renal magnesium wasting, therefore, the
patient was given IV magnesium and is to start a regimen of
p.o. magnesium supplementation at rehabilitation. Neuropathy
was treated with Percocet, Nortriptyline, and Neurontin, per
his home regimen. He was also given OxyContin q.h.s. on the
31st.
Cardiovascular disease was treated with his home Atenolol and
Lipitor. The aspirin was held in the setting of GI bleed.
Of note, the patient apparently got two times his usual
morning dose of Neoral and a resultant Neoral level on [**11-12**]
was elevated. Therefore, his [**11-13**] morning dose was held.
However, once it was realized that this was due to a double
dosing the day before, the Neoral dose was given.
Plan is for rehabilitation to give him his p.o. dose this
evening and for a level to be checked before he is given his
a.m. dose in the morning with the belief that the level will
be acceptable once he is on a regular schedule. The renal
consultation team followed the patient in house and confirmed
his immunosuppressive regimen.
LABORATORY DATA: Laboratory studies during his stay showed
the white count to remain stable in the 7.4 to 9.1 range.
The hematocrit bumped appropriately after transfusions from
23.4 to 35.1. Coagulations were stable with an INR of 1.2
and PTT of 24.2. The patient's BUN remained in the range of
18 with a creatinine of 1. The bicarbonate was well
controlled at 24, potassium was well controlled at 4.4.
Labs, including LDH were normal at 233 with the T bilirubin
of .3. Calcium after repletion was 7.7 in the context of an
albumin of 3.1. Ionized calcium was obtained. The free
calcium improved from .87 to 1.07, which is in the
near-normal range. The cyclosporin level, initially high at
1,072, returned to 132 holding a single dose. The PTH was
sent, but pending. The haptoglobin was elevated at 434 and
TIBC was decreased at 248, not indicating a chronic
iron-deficiency state. Ferritin was 61 and normal.
Transferrin was 191. EPO level at the time of discharge and
E. coli sensitivities are still pending.
CONDITION ON DISCHARGE: Stable.
PHYSICAL EXAMINATION: Physical exam at discharge is
unchanged.
DISCHARGE STATUS: Full code.
DISCHARGE DIAGNOSES:
1. Hematocrit drop attributed to redistribution of blood
volume postoperatively, as well as anemia of chronic disease.
2. Hypocalcemia.
3. Urinary tract infection. (see past medical history).
DISPOSITION: The patient is to be returned [**Hospital 1316**]
Rehabilitation Center.
FOLLOW-UP CARE: Followup is to be with the patient's
nephrology in one week. Gastroenterology is also planning to
followup with the patient secondary to his heme-positive
stool while he is at rehabilitation.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg p.o.q.d.
2. Calcitriol 0.025 mcg p.o.q.d. (if unavailable, the
patient is to receive ....................2.5 mcg p.o.q.d.
3. Tums, three tablets p.o.t.i.d.
4. Bactrim double strength, 1 p.o.q.a.m.
5. OxyContin 10 mg p.o.q.h.s.
6. Percocet 1-2 tablets p.o.q.4h.p.r.n.pain.
7. Ambien 10 mg p.o. q.h.s., p.r.n. insomnia.
8. FESO4, 325 mg p.o.b.i.d.
9. Nortriptyline 75 mg p.o.b.i.d.
10. CellCept 1-g p.o.b.i.d.
11. Allopurinol 100 mg p.o.q.d.
12. Folate 1 mg p.o.q.d.
13. Protonix 40 mg p.o.q.d.
14. Neurontin 100 mg p.o.t.i.d.
15. Atenolol 50 mg p.o.b.i.d.
16. Prednisone 5 mg p.o.q.d.
17. Neoral 175 mg p.o.q.a.m.; 150 mg p.o.q.p.m.
18. Magnesium oxide 800 mg p.o.q.d.
OTHER NEEDS AT REHABILITATION: (These results should be
called to his nephrologist).
1. Daily hematocrit.
2. Calcium.
3. Cyclosporin levels.
4. Daily Chem 7s.
5. Daily magnesium.
DISCHARGE DIET: Cardiac.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**]
Dictated By:[**Last Name (NamePattern1) 1317**]
MEDQUIST36
D: [**2166-11-13**] 14:06
T: [**2166-11-13**] 14:14
JOB#: [**Job Number 1318**]
|
[
"2851",
"5990"
] |
Admission Date: [**2136-9-6**] Discharge Date: [**2136-9-12**]
Date of Birth: [**2083-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Shortness of breath
Major Surgical or Invasive Procedure:
[**2136-9-6**] - Coronary artery bypass graft x4 (Left internal mammary
artery to left anterior descending coronary artery, reverse
saphenous single vein graft from the aorta to the second obtuse
marginal coronary artery, reverse saphenous vein, single vein
graft from the aorta to the first diagonal coronary artery, and
reverse saphenous vein graft, single graft from the aorta to the
posterior descending artery.
History of Present Illness:
53 year old gentleman with three vessel disease transferred from
outside hospital after presenting with chest and jaw pain as
well as shortness of breath which have all increased over the
past 6 weeks. He now presents for surgical revascularization.
Past Medical History:
Hyperlipidemia
HTN
Obesity
Umbilical hernia
New onset diabetes type 2
Past laminectomy
Social History:
Retired semi-pro football player. He is know a trucking company
manager. He drinks 5 drinks per week. Denies tobacco use.
Family History:
Father with CAD at age 53.
Physical Exam:
Admission
Ht 70" Wt 282Lb
VS T 98 degrees BP 138/72 HR 67 SR RR 20 O2sat 95% RA
NAD
CV RRR, No M/R?G
Lungs CTAB
Abd obese, soft, NT/ND
EXT: No edema, 2+ pulses, no varicosities, no carotid bruits.
Discharge
VS T 98.6 HR 89SR BP 144/72 RR 20 O2sat 90% RA
Gen: NAD
Neuro: A&Ox3, nonfocal exam
Pulm: CTA bilat
CV: RRR, S1-S2. Sternum stable incision CDI
Abdm: Soft, NT/ND/+BS
Ext: warm, 1+edema bilat. SVG site w steri's CDI
Pertinent Results:
[**2136-9-6**] 04:44PM PT-10.6 PTT-23.9 INR(PT)-0.9
[**2136-9-6**] 04:44PM WBC-7.0 RBC-4.92 HGB-15.2 HCT-43.5 MCV-89
MCH-30.9 MCHC-34.9 RDW-13.7
[**2136-9-6**] 04:44PM ALT(SGPT)-55* AST(SGOT)-24 ALK PHOS-98
AMYLASE-41 TOT BILI-0.2
[**2136-9-6**] 04:44PM GLUCOSE-160* UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-31 ANION GAP-14
[**2136-9-6**] 05:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2136-9-11**] 06:20AM BLOOD Hct-30.0*
[**2136-9-10**] 11:45AM BLOOD Glucose-225* UreaN-13 Creat-0.9 Na-135
K-4.7 Cl-97 HCO3-31 AnGap-12
[**2136-9-6**] 04:44PM BLOOD %HbA1c-8.3*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2136-9-10**] 2:50 PM
CHEST (PA & LAT)
Reason: eval effusions, atelectasis
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval effusions, atelectasis
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Evaluate pleural effusions, patient post-CABG.
Comparison is made with prior study dated [**2136-9-7**].
There has been interval decrease in the mediastinal widening and
enlarged cardiac silhouette seen postoperatively. There are
small bilateral pleural effusions. There is no pneumothorax.
Mild atelectasis is in the left lower lobe, otherwise the lungs
are clear. Patient is post-median sternotomy and CABG;
retrosternal air is likely due to recent surgery.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Brief Hospital Course:
Mr. [**Known lastname 75255**] was admitted to the [**Hospital1 18**] on [**2136-9-6**] for surgical
management fo his coronary artery disease. He was worked-up in
the usual preoperative manner and was found to be ready for
surgery. On [**2136-9-7**], Mr. [**Known lastname 75255**] was taken to the operating room
where he underwent coronary artery bypass grafting to four
vessels. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for monitoring. Later
that evening, he awoke neurologically intact and was extubated.
On postoperative day one, beta blockade, aspirin and his statin
were resumed. He was then transferred to the step down unit for
further recovery. Over the next several days he was gently
diuresed towards his preoperative weight. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. His chest tubes and epicardial wires were
removed. On POD 5 it was decided he was stable and ready to be
discharged home with visiting nurses.
It should be noted that while Mr [**Known lastname 75255**] was an inpatient he was
seen in consultation by the [**Hospital **] clinic for diabetes
management.
Medications on Admission:
Aspirin 325mg QD
Lopressor 25mg [**Hospital1 **]
Zocor 40mg QD
Diclonfenac 50mg PRN
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q 3-4 hrs as
needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*QS 1 month* Refills:*0*
8. Diabetic Supplies
Lancets
Test Strips
Insulin Syringes
9. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD s/p CABG
Hyperlipidemia
Obesity
Umbilical hernia
Diabetes mellitus type 2
HTN
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increasing pain. Please contact surgeon ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Please shower daily. You may wash incision and gently pat
dry. You may have steri-strips on incisions which should fall
off on their own. If still intact after 3 weeks, you mat remove
them. No lotions, creams or powders to incision until it has
healed. No swimming until wound has healed. Use sunscreen on
incision when out in sun after it has healed.
3) No lifting greater then 10 pounds for 10 weeks from the date
of surgery.
4) No driving for 1 month.
5) Report any fever greater then 100.5.
6) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with cardiologist Dr. [**Last Name (STitle) 32255**] in 2 weeks.
Please follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16412**] in [**2-18**] weeks.
[**Telephone/Fax (1) 75256**]
Please follow-up with [**Last Name (un) **] diabetes service as instructed.
Completed by:[**2136-9-12**]
|
[
"41401",
"2724",
"4019",
"25000"
] |
Admission Date: [**2188-10-15**] Discharge Date: [**2188-11-1**]
Date of Birth: [**2122-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cortisone / Flovent
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR/MVR/LVAD placement
Past Medical History:
1. Aortic Valve Replacement [**2181**] (St. Jude's Valve)
2. HTN
3. DM (dx 1 year ago)
4. Hypercholesterolemia
5. Hypothyroidism
6. COPD
7. Atrial Fibrillation, on Coumadin, s/p multiple cardioversions
without success
8. Cardiac cath [**8-12**] showed NORMAL coronary arteries,
moderate/severe AR:
Cath Report:
1. Coronary arteries are normal.
2. Severe aortic regurgitation.
3. Moderate diastolic ventricular dysfunction.
Social History:
SOCIAL HISTORY: Patient lives with husband in [**Name (NI) 1411**], supportive
family. Reports 40-year smoking history, smoked 1 pack/week. No
ETOH, no IVDA.
Family History:
FAMILY HISTORY: Patient did not grow up with her family, so
family history is unknown. Brother did have CEA.
Brief Hospital Course:
1. CV: Pt was admitted with stable hemodynamics on [**2188-10-15**]. She
has been in atrial fibrillation since that time. Exam has shown
a stable III/VI SEM. Lungs have been clear to auscultation and
she has had no lower extremity edema or increased JVP. Pt was
taken off of Coumadin and started on heparin gtt upon admission
and was taken to CT surgery on [**2188-10-22**] to replace her prosthetic
aortic valve.
2. ID: Pt had originally had her surgery delayed due to molar
abscess and a elevated WBC which remained high for weeks as she
was treated with antibiotics. Upon admission, she had no signs
of molar abscess and between admission and surgery she was
afebrile without focal signs of infection. Her WBC was elevated
on [**10-21**] to 11.7 and then 14.8, but was WNL at 10.8 on the day of
surgery.
3. Renal: Patient's creatinine was consistently in the 1.0-1.3
range from admission until day of surgery.
4. Pulm: Patient has a hx of COPD but experienced no SOB from
admission until day of surgery.
5. DM: Patient's blood glucose on CMP ranged from 121 to 227
from admission until day of surgery. Her Metformin was
discontinued on [**2188-10-20**] and she was started on ISS in
preparation for her surgery.
Taken to the operating room on [**2188-10-22**] for an aortic valve
replacement and mitral valve replacement. After the valves were
placed, she suffered a catastrophic separation of her LA from
her LV after weaning from cardiopulmonary bypass. Please see
the operative note for detail of surgical events. She went back
on bypass, and had an LVAD placed. She was admitted to the CSRU
from the OR late that evening in critical condition. She had
significant bleeding problems, and was re-explored at the
bedside a number of times during her course. She remained on
inotropes and pressors, received multiple units of blood
products, and her condition ultimately began to stabilize. On
[**10-30**], she was noted to have increasing acidosis, and became
aneuric. CVVH was initiated, and her abdomen was explored at
the bedside by Dr. [**First Name (STitle) **]. Her bowel was ischemic, and her
abdomen was left open. The following day, her acidosis remained
profound, and she was taken for angiography of her SMA. This
showed no acute clot, but rather diffuse spasm. Papaverine
intra-arterial infusion was begun. By the following morning,
[**11-1**], she'd continued to deteriorate. Her acidosis had
worsened. Her LVAD flows began to decrease. She ultimately
became bradycardic, which progressed to asystole. She was
pronounced dead at 1115 on [**2188-11-1**].
Discharge Disposition:
Expired
Discharge Diagnosis:
aortic stenosis
mitral regurgitation
atrial fibrillation
cardiac failure
Discharge Condition:
EXPIRED
Completed by:[**2188-11-2**]
|
[
"9971",
"0389",
"99592",
"78552",
"5849",
"42731",
"4280",
"496",
"2762",
"25000",
"2720"
] |
Admission Date: [**2122-10-20**] Discharge Date: [**2122-10-29**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2122-10-25**] - Dental Extractions
[**2122-10-23**] - Placement of a [**Company 1543**] Dual Chamber Pacemaker
([**Company 1543**] Sensia DR [**Last Name (STitle) **] via left cephalic)
History of Present Illness:
88 year old female s/p CABG/AVR on [**2122-10-12**] with Dr. [**Last Name (STitle) **]. She
was discharged to rehab on postopertaive day five. This morning
she developed shortness of breath, wheezing and was taken to the
[**Hospital3 **] ED. She was found to be in atrial fibrillation with
runs of nonsustained ventricular tachycardia and amiodarone was
started. She was thus transferred to the [**Hospital1 18**] for further
management.
Past Medical History:
Chronic Diastolic Cardiac Dysfunction
Hypertension
Aortic stenosis
Dyslipidemia
Glaucoma
s/p appendectomy, left knee surgery, cataract surgery and
hysterectomy
Social History:
Distant smoking history, occasional alcohol, no illicit drug
use, lives alone in Rye [**Location (un) 3844**], has daughter who is HCP
[**Name (NI) **] [**Telephone/Fax (1) 95201**] or [**Telephone/Fax (1) 95202**]
Family History:
No family history of early cardiac events or sudden death.
Physical Exam:
51 irregular 20 144/85
4'[**24**]" 59kg
GEN: Elderly female with SOB
SKIN: Sternal wound c/d/i, staples inplace, stable. Left leg
endovein incision C/D/I.
HEENT: Unremarkable
NECK: Supple, No JVD
LUNGS: Decreased BS at right base.
HEART: Irregular rate and rhythm, I/VI systolic ejection murmur
ABD: Soft/Nontender/Nondistended/NABS
EXT: Warm, well perfused, 3+ LE Edema, Pulses 1+ throughout
Pertinent Results:
[**2122-10-20**] 10:12PM PT-15.2* PTT-23.7 INR(PT)-1.3*
[**2122-10-20**] 10:12PM WBC-14.6* RBC-3.09* HGB-9.8* HCT-28.2* MCV-91
MCH-31.9 MCHC-34.9 RDW-15.7*
[**2122-10-20**] 10:12PM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-1.7
[**2122-10-20**] 10:12PM ALT(SGPT)-43* AST(SGOT)-29 LD(LDH)-534* ALK
PHOS-74 TOT BILI-1.8*
[**2122-10-20**] 10:12PM GLUCOSE-153* UREA N-25* CREAT-1.0 SODIUM-142
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-30 ANION GAP-16
[**2122-10-20**] 10:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
[**2122-10-20**] CXR
Moderate bilateral pleural effusion, left greater than right,
increased since [**10-16**]. Moderate-to-severe enlargement of
the cardiac silhouette may be due in part to pericardial
effusion, but there is no substantial azygous distention to
suggest hemodynamic significance. Left basal atelectasis
increased due to pleural effusion. Upper lungs clear. No
pulmonary edema.
[**2122-10-28**] 05:35AM BLOOD Hct-28.9*
[**2122-10-26**] 05:35AM BLOOD WBC-9.5 RBC-2.87* Hgb-8.8* Hct-26.1*
MCV-91 MCH-30.6 MCHC-33.7 RDW-15.5 Plt Ct-418
[**2122-10-20**] 10:12PM BLOOD WBC-14.6* RBC-3.09* Hgb-9.8* Hct-28.2*
MCV-91 MCH-31.9 MCHC-34.9 RDW-15.7* Plt Ct-460*#
[**2122-10-28**] 05:35AM BLOOD PT-29.7* INR(PT)-3.0*
[**2122-10-20**] 10:12PM BLOOD PT-15.2* PTT-23.7 INR(PT)-1.3*
[**2122-10-28**] 05:35AM BLOOD K-3.7
[**2122-10-26**] 05:35AM BLOOD Glucose-77 UreaN-17 Creat-0.8 Na-141
K-3.3 Cl-101 HCO3-31 AnGap-12
[**2122-10-26**] 05:35AM BLOOD Calcium-8.3* Mg-2.0
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 6811**] R
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 6811**] on TUE [**2122-10-27**] 5:42
PM
Name: [**Known lastname **], [**Known firstname **] M. Unit No: [**Numeric Identifier **]
Service: Date: [**2122-10-26**]
[**Year (4 digits) **]: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2866**], DENT [**Numeric Identifier 95206**]
Ms. [**Known lastname **] was admitted to the hospital a few weeks ago for
AVR surgery. She was admitted emergently. The patient had
poor dentition. It was decided to take the patient to the
operating room to take care of the heart valve. The patient
was discharged to follow up with outside dentist for
extraction of numerous infected teeth. The patient was
admitted to the [**Hospital1 **] two weeks later with uncontrolled atrial
fibrillation. The patient now in-house, [**Hospital1 **]. Dental
situation reevaluated, called to evaluate dental situation.
Decided to take the patient to the operating room to
surgically extract teeth #17, #18, #19, #29, #30 and #32 and
#5, all caries, nonrestorative infected teeth.
Patient interviewed in the holding area, consent signed.
OPERATIVE NOTE: The patient was taken to the operating room.
The patient was prepped and draped, nasally intubated in the
usual oral maxillofacial surgical manner. Oral cavity
suctioned free of saliva. Moistened throat pack placed.
Attention directed to all four quadrants, placing 8.5 cubic
centimeters, 0.25% Marcaine, no epinephrine, infiltration and
block followed by development of flaps and elevation with
teeth #17, #18, #19, #29, #30, #32 and #5 with the use of
periosteal elevators and forceps, [**Doctor Last Name **] drill and elevated.
Area copiously irrigated. Bacitracin irrigation. Closed all
wound sites with 3-0 chromic gut and Surgicel in sockets on
lower left quadrant to maintain heme. The patient's oral
cavity was suctioned free of saliva and blood and moistened
throat pack removed. The patient was extubated PACU stable.
FINAL DIAGNOSIS: Caries, nonrestorable infected teeth #17,
#18, #19, tooth #5, tooth #29, #30 and #32.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2866**], DENT [**Numeric Identifier 95206**]
I certify that I was present in compliance with HCFA
regulations.
Dictated By:[**Doctor Last Name 95207**]
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] cardiac surgical intensive
care unit on [**2122-10-20**] for further management of her atrial
fibrillation. The EP service was consulted and amiodarone and
beta blockade were continued. Heparin was started for
anticoagulation. Diuresis was initiated as she had bilateral
pleural effusions and peripheral edema. A chest tube was placed
in her right pleura which drained 450ml. The oral surgery
service was consulted for her teeth extraction which was
originally planned for her last admission. Ms. [**Known lastname **] continued to
have runs of rapid atrial fibrillation alternating with pauses
and sinus bradycardia. The EP service recommended placement of a
permenant pacemaker for adequate treatment of her atrial
fibrillation. On [**2122-10-23**], Ms. [**Known lastname **] [**Last Name (Titles) 1834**] placement of a
dual chamber pacemaker without complication. Postoperatively she
was sent to the cardiac surgical step down unit for further
recovery. Her teeth were sxtracted on [**2122-10-25**] without issue.
Coumadin and heparin were then resumed. She continued to require
aggressive diuresis but responded well to metolazone and lasix.
Her INR was 2.6 on [**2122-10-27**] (up from 1.3 on day prior) and her
coumadin was held. INR on [**10-28**] was 3 and she was given 0.5 mg PO
coumadin per Dr [**Last Name (STitle) **]. She remained stable and was discharged
to rehab on [**2122-10-28**].
Medications on Admission:
colace 100'', zantac 150', zocor 20', brimonidine 0.15%''',
latanoprost 0.005%hs, brinzolamide 1%''', ultram 50prn, asa 81',
amio 200', lopressor 12.5''
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. Brinzolamide 1 % Drops, Suspension Sig: One (1) gtt/ou
Ophthalmic TID (3 times a day).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop(s)/ou Ophthalmic
HS (at bedtime).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 7days then 200mg QD.
12. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: target INR 2-2.5.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2122-10-12**]
s/p PPM [**2122-10-23**]
AF
Tachy-brady syndrome
Pleural effusion
Dyslipidemia
HTN
Chronic Diastolic Dysfunction
Glaucoma
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 73**] as instrcuted
Please follow-up with Dr. [**Last Name (STitle) 1270**] in 2 weeks.
Device clinic in 1 week
Completed by:[**2122-10-28**]
|
[
"42731",
"5119",
"4280",
"2724",
"5859",
"V4581"
] |
Admission Date: [**2104-9-8**] Discharge Date: [**2104-10-2**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
dehydration, seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65yo M with EtOH cirrhosis, HCC, s/p RFA of segment 5 lesion s/p
OLT [**2104-8-22**], presents with dehydration and seizure en route to
[**Hospital1 18**]. He was in his USOH until the morning of presentation,
when his wife noted the onset of confusion. They were going to
get routine labs drawn at an outpatient lab, when she noted that
he seemed not to know where he was going. He did recognize her,
however. This confusion continued for a couple of hours (he
again knew her but did not
know how to find the bathroom from the garage), during which
time they had called his transplant surgeon at [**Hospital1 18**] and made
arrangements to come in for evaluation. However, before they
were able to leave, he had the first of three seizures. His wife
notes that she was in the other room when her friends (one of
whom is a physician, [**Name10 (NameIs) **] other a nurse) called her in to witness
the
seizure. She reports that all four limbs were shaking, his jaw
was clenched, his eyes rolled back, and his head was turned to
the right. This lasted ~90 seconds and resolved spontaneously.
They called EMS. En route to [**Hospital **] [**Hospital **] hospital, he is
reported to have another seizure similar to the first, although
specific details are not available at this time, as the wife was
not there. Finally, shortly after arrival to the OSH, the wife
witnessed a third seizure, similar in description to the first
and again lasting only 1-2 minutes. A Head CT performed there
was by report normal. The patient's wife denied that he had had
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denied
difficulties producing or comprehending speech. Denied focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denied difficulty with gait. The pt's
wife reported only soft, loose stool that he has had since
starting tube feeds in [**Month (only) 547**]. She also noted that his BP was
elevated at 165/100 when she first took it in the morning. She
denied that he had recent fever or chills. No night sweats or
recent weight loss or gain. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, constipation or
abdominal pain. No dysuria. Denied arthralgias or myalgias.
Denied rash. Following stabilization at [**Hospital3 **] Hospital, he
was then transferred to the [**Hospital1 18**] SICU for further evaluation
and management.
Past Medical History:
liver transplant from 19 y.o. brain dead donor ([**2104-8-22**])
EtOH cirrhosis, diagnosed 06/[**2103**].
HCC
Anemia
Essential thrombocytosis
Prior complications of ascites, malnutrition (now on tubefeeds),
portal hypertension with grade 2 esophageal varices. Peritonitis
[**7-17**], Duodenitis [**7-17**], Grade I rectal varices
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
PE: 98.4 F, P 117 BP 158/101, RR 31, Sat 100% 2L O2 via NC.
Weight 45.7 kg(down from 48.6 [**9-2**]). Glucose 140.
GEN: Very thin man with temporal wasting.
Neuro: Attempts to open eyes to voice, moves all extremities.
HEENT: Pupils equal, no scleral icterus, no thrush, PPFT in R
nare
No JVD, 2+carotids without bruits
Lungs: Clear to auscultation bilaterally
Cor: S1S2 nl, no murmurs
Abd: Soft, nontender, nondistended, normoactive bowel sounds.
His
chevron incision is well-healed with staples in place.
Ext: No peripheral edema
Vasc: 2+ DPs Bilaterally
Pertinent Results:
On Admission: [**2104-9-8**]
WBC-15.8* RBC-4.62 Hgb-14.1 Hct-43.3# MCV-94 MCH-30.6 MCHC-32.7
RDW-15.8* Plt Ct-565*
PT-12.6 PTT-34.9 INR(PT)-1.1
Glucose-110* UreaN-59* Creat-1.4* Na-139 K-6.9* Cl-110* HCO3-17*
AnGap-19
ALT-19 AST-17 AlkPhos-97 Amylase-73 TotBili-3.7* Lipase-26
Albumin-3.6 Calcium-10.1 Phos-4.8*# Mg-1.9 FK506-8.8
[**2104-9-18**] 04:10AM BLOOD calTIBC-187* VitB12-717 Folate-7.7
Ferritn-GREATER TH TRF-144*
On Discharge: [**2104-10-2**]
UreaN-31* Creat-1.0 Na-143 K-4.9 Cl-113* HCO3-19* AnGap-16
ALT-28 AST-18 AlkPhos-87 TotBili-1.2
Albumin-3.0* Calcium-9.1 Phos-2.3* Mg-1.7
FK506-5.0
WBC-6.5 RBC-3.30* Hgb-9.9* Hct-29.6* MCV-90 MCH-29.9 MCHC-33.3
RDW-16.2* Plt Ct-595*
Brief Hospital Course:
Admitted to SICU on [**9-8**]
Imaging on arrival to [**Hospital1 18**] ([**9-8**]): CXR - Marked decrease of
bilateral pleural effusions and bibasilar
atelectasis/consolidation. US liver - Contiguous
well-circumscribed 2.5 cm anechoic lesions within the right lobe
of the liver, with an appearance consistent with cysts, small
amount of perihepatic ascites, and normal vascular study. [**Hospital1 18**]
Neurology consulted to evaluate seizures. Per neuro exam, mental
status was depressed on arrival and he had an upgoing toe on the
left. He was placed on Keppra IV for seizure prophylaxis along
with Ativan 2 mg IV prn for seizures lasting > 5 minutes or more
than 3 seizures per hour and received EEG. EEG ([**9-9**])
demonstrated intermittent right-sided blunted sharp wave and
sharp and slow wave discharges with a right fronto central
predominance at a maximal frequency of 1 Hz. No clear evidence
for ongoing seizures was seen although the presence of these
discharges suggested a potential area for epileptogenesis. The
intermittent mixed frequency slowing seen in the right
hemisphere suggested an area of underlying cortical or
subcortical dysfunction. Neurology recommended repeat EEG to
evaluate focality initially documented and determine if Keppra
should be continued. EEG repeated [**9-13**] revealed an abnormal
routine EEG in the waking and drowsy
states due to the persistent right posterior quadrant slowing as
well as
the less frequent right posterior quadrant blunted sharp and
slow waves. No electrographic evidence of seizure was noted.
Immunosuppression - prednisone and MMF continued, FK held until
HD 2. On admit, K=6.9, received kayexalate x1, calcium
gluconate, and NaHCO3. Had diarrhea while in SICU; Cdiff sent
and placed on empiric vancomycin in addition to previous
antibiotic regimen of bactrim, fluconazole, and valcyte. Rectal
tube was additionally placed due to copious output per rectum.
Nasointestinal feeding tube placed [**9-10**] for nutritional support.
Per nutrition recommendations, Nutren Renal was started,
advanced to goal of 40cc/hr.
On HD 4, patient received CT abdomen which revealed:
-High-density collections along the inferior right aspect of the
liver and liver dome that are most consistent with hematomas.
-Low-density fluid dissecting along the biliary tree in the
central portion of the liver may represent a biloma. A HIDA scan
is recommended for further evaluation to exclude a bile leak.
-Interval improvement in ascites and left pleural effusion.
-Postpyloric position of the nasogastric tube.
He was placed on a regular diet + Boost tid + TF at 40cc/hr.
Nutrition has recommended increasing tube feed goal to 45
cc/hour.
While inpatient, he was seen by physical therapy. Mental status
/ confusion improved throughout course of hospital stay. He was
started on Remeron as well as he has been evaluated by our Psych
service and has been followed by the Transplant social worker
who have found him to be depressed and have recommended the
initiation of Ritalin in addition to the Remeron that was
started on [**9-23**]. The Ritalin does have a risk of lowering
seizure threshold, so we have elected not to start Ritalin at
this time.
On [**9-24**] the patient was noted to have fever to 101, a CT of the
abdomen was performed showing an interval increase in the
low-density fluid collection extending along the porta hepatis
into the hepaticoduodenal ligament. There was concern for a
biloma and a drain was placed. About 250 cc of yellow clear
fluid was removed and the drain was left in place. Culture on
this fluid was no growth. Drain output was low, the repeat CT
showed interval improvement so the drain was removed.
Fevers defervesced, antibiotics that had been started
empirically were discontinued.
His testosterone level was found to be low and he was started on
a transdermal patch.
He was started on low dose aspirin due to his thrombocytosis.
Patient has been seen and evaluated by heme-onc in the past for
this condition, with current recommendation being the aspirin
therapy.
The patient continued to work with physical therapy, however
they found him to be quite debilitated, requiring frequent rest
during ambulation and a high risk for falling based on the
Tinetti score for balance and gait.
He was deemed to require a structured, consistent physical
rehabilitation program that would not be able to be accomplished
in the home setting.
He will require both PT and OT to increase his activity and
endurance. Rehabilitation goals and outcomes for distance walked
and exercises performed should be communicated to the transplant
team during clinic visits so assessment of progress and
appropriate timing of discharge to home can be managed. This
activity should be increased over time.
In addition the patient has had difficulties with his dentures.
Due to his weight loss his dentures are not fitting properly. He
will require a dental examination and refitting of the dentures.
Medications on Admission:
Tacrolimus 3 mg PO Q12H
Mycophenolate Mofetil 1000 mg PO BID (2 times a day).
Pantoprazole 40 mg PO Q24H (every 24 hours).
Fluconazole 400 mg PO Q24H
Prednisone 20 mg PO DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY (Daily).
Valganciclovir 450 mg PO DAILY
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily):
Drop to 10 mg on [**2104-10-9**].
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
13. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p OLT [**8-16**], with dehydration and seizures
Discharge Condition:
stable
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office ([**Telephone/Fax (1) 673**]) if patient
experiences temperature >101.5, chills, nausea, vomiting,
inability to tolerate tube feeds, abdominal distention,
jaundice, unable to take pills, or have any seizures.
Labs to be drawn on Friday [**10-3**] and faxed to the transplant
office at [**Telephone/Fax (1) 697**]. Please draw trough Prograf level and
then give his immunosuppression.
Labs will then be drawn every Monday and Thursday
CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili and trough
Prograf level
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2104-10-8**]
2:40
Completed by:[**2104-10-2**]
|
[
"2767"
] |
Admission Date: [**2167-9-25**] Discharge Date: [**2167-9-27**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex / Bupropion
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
syncope/ hypotension
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
For full details please see full admission note from MICU. in
brief, the patient is a 59 year old male with history of ESRD on
HD< DM, CAD who was in his USOH until [**2167-9-25**] when he
experienced dizziness and lightheadedness with standing with
some resolution by the next morning. When walking the next day
he experienced some dyspnea and chest pressure. On arrival to
[**Last Name (un) **] that day for a planned appointment he syncopized in the
lobby. At that time the patient was found to he hypotensive to
70/30 for which he was taken to the E.D. immediately. There is
no report of aura prior to this episode, seizure, or post-ictal
state.
.
On arrival to the ED the patient was with following vitals:
T97.0, HR55, BP 84/53, O2 95%RA with ECG revealing a junctional
rhythm. IJ was placed and cardiology consulted with impression
that this was secondary to nodal effect of both Toprol and Dilt,
recommendation to monitor overnight holding BB and CCB. In the
ICU the patient regained sinus rhythm and pressure improved to
104/70 without other intervention. CXR unremarkable and lactate
WNL. The patient was monitored overnight and has remained
hemodynamically stable, had HD today. The patient had Metoprolol
Tartrate 37.5 PO tid started today and tolerating well thus far.
The patient is now transferred to the medical floor for ongoing
care.
.
On arrival to floor the patient feels well. He denies currently
chest pain, dyspnea, dizziness. He reports stable symptoms of
chest pressure with exertion, particularly climbing stairs, that
have stable over 1 year.
Past Medical History:
# ESRD - on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia. c/b wound dehiscence.
# Diabetes - followed by [**Last Name (un) **]
# Hep C - genotype 1 c hepatitis C viral load of 18,400,000 I.U.
Followed by Dr. [**Last Name (STitle) 497**]
# Diastolic CHF - last ECHO [**4-20**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA
moderately dilated; LVEF>55%
# GERD
# Former Substance Abuse - alcohol, cocaine, heroine; clean
since '[**64**], 1 relapse with cocaine in '[**65**]; attends [**Hospital1 **] and NA
# Renal cell carcinoma s/p removal [**2162**] followed w/o recurrence
# Pericardial effusion [**2165**], presumed viral; required
pericardiocentesis for tamponade physiology
# Depression- no suicide attempts, +passive thoughts about
suicide with no plan
# Barrett's Esophagus (from OMR)c/b Anemia
# Carpal Tunnel Syndrome - used wrist splints
# Sleep Apnea
Social History:
Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse.
Family History:
Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas
Physical Exam:
Vitals: T- 98.9 lying: BP- 140/60 HR- 80 standing: BP 120/60 HR
80 RR-18 O2- 97% on RA
.
General: Patient is a well appearing African American Male,
pleasant, in NAD
HEENT: NCAT, EOMI, sclera muddy brown, conjunctiva WNL. OP: MMM,
no lesions
Neck: Obese, JVP difficult to assess [**1-16**] body habitus
Chest: Relatively clear to auscultation anterior and posterior,
few end expiratory course wheezes
Cor: RRR, normal S1/S2. No murmurs appreciated. + S4
Abdomen: Obese, mod distended. Soft, non-tender. + well healed
RLQ surgical scar
Ext: Trace lower extremity edema
Pertinent Results:
Trop: .02 - .03
WBC: 12.1
Imaging:
[**2167-9-25**] CXR - no acute process, line in place
Micro:
[**2167-9-25**] Blood - PENDING UPON DISCHARGE
[**2167-9-25**] Urine - PENDING UPON DISCHARGE
Catheter TIP culture: PENDING UPON DISCHARGE
ECG: Sinus Brady, LAD. Qs III, aVF. no acute ST/TW changes
[**2167-9-25**] 03:13PM LACTATE-1.4
[**2167-9-25**] 12:45PM K+-4.5
[**2167-9-25**] 12:35PM GLUCOSE-100 UREA N-44* CREAT-8.3*# SODIUM-139
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-20
[**2167-9-25**] 12:35PM CK(CPK)-119
[**2167-9-25**] 12:35PM cTropnT-0.02*
[**2167-9-25**] 12:35PM CK-MB-3
[**2167-9-25**] 12:35PM WBC-11.6* RBC-3.99* HGB-11.2* HCT-35.6*
MCV-89 MCH-28.0 MCHC-31.5 RDW-20.7*
[**2167-9-25**] 12:35PM NEUTS-58 BANDS-0 LYMPHS-23 MONOS-12* EOS-5*
BASOS-1 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-2*
[**2167-9-25**] 12:35PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ TEARDROP-OCCASIONAL
[**2167-9-25**] 12:35PM PLT SMR-NORMAL PLT COUNT-374
Brief Hospital Course:
Bradycardia / Hypotension - Likely related to bradycardia with
possible contribution from volume depletion. No evidence by labs
or exam for infectious etiology. Patient was on dilt 360mg po
daily and Toprol 100mg po daily. His EKG showed marked sinus
bradycardia with a rate in the 20s and a junctional escape
rhythm with a rate in the high 50s. He was hypotensive and
fluid resuscitated, his hypotension resolved and his rhythm
returned to sinus. His medications were adjusted to Toprol 50mg
daily. Diltiazem was discontinued. EP was consulted and helped
direct the plan. The patient's primary cardiologist was
notified of the changes.
Diabetes - blood glucoses well controlled as inpatient.
ESRD- on HD, rec'd HD as inpatient on Saturday [**9-26**].
Hep C - no active issues. Outpatient follow up.
Medications on Admission:
ASA 81mg daily
Citalopram 20mg daily
Dilt SR 360 daily
Valsartan 320 daily (patient not taking)
Gabapentin 100mg TID
Lantus 30 units
Reglan 10mg daily
Prilosec 20 mg daily
Vit B
Vit C
Folic acid
Cinacalcet 30mg daily
Toprol XL 100 daily
Allopurinol 100 daily
Calcium acetate
sevelamer 800 TID with meals
Mirapex 0.25 QHS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
11. Insulin Glargine Subcutaneous
12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Neurontin 100 mg Capsule Sig: Three (3) Capsule PO as
directed: take 3 pills after dialysis sessions.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Syncope
Sinus Bradycardia with junctional escape rhythm
Secondary Diagnosis:
ESRD on HD
HTN
DM II
Discharge Condition:
sinus rhythm, not symptomatically orthostatic, stable
Discharge Instructions:
You were admitted for a fall probably related to your
medications. Please note the following medication changes:
PLEASE STOP TAKING YOUR DILTIAZEM. ALSO, DECREASE YOUR TOPROL
XL DOSE TO 50MG DAILY.
Please call your doctor or go to the emergency room if you fall,
if you have lightheadedness, shortness of breath, chest pain, or
any other symptoms that concern you.
Followup Instructions:
Please follow up with your primary care physician and your
kidney doctors [**Name5 (PTitle) 176**] 4 weeks of your discharge.
You have the following appointments:
1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-10-5**]
5:00
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2167-10-7**] 8:00
3. [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-10-14**] 9:30
|
[
"42789",
"4280",
"53081"
] |
Admission Date: [**2153-8-10**] Discharge Date: [**2153-8-18**]
Date of Birth: [**2077-6-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
76M with a +ETT in w/u for hernia surgery.
Major Surgical or Invasive Procedure:
CABG X 5, MV Repair, Maze, LAA ligation [**2153-8-10**]
Pacemaker placement [**2153-8-15**]
History of Present Illness:
This 76M is preop for R hernia repair and had a +ETT during the
preop workup. A cardiac cath on [**2153-7-30**] revealed: 70% LAD
[**Last Name (un) 2435**]., 90% mid [**First Name9 (NamePattern2) 8714**] [**Last Name (un) 2435**]., 100% mid RCA lesion and a 60-65% LVEF.
An echo on [**2153-6-22**] showed: mod. LVH w/ inf. wall HK, 60-65%
LVEF, mod. MR, and LAE. He is now admitted for elective CABG/MV
repair/ cryo MAZE.
Past Medical History:
Coronary artery disease
[**Date Range **]
[**Date Range **]
Diet controlled DM
R groin hernia
Afib
bil. leg cellulitis
Mitral regurgitation
s/p L CEA [**5-11**]
s/p L hernia repair
Social History:
Retired, lives with wife and daughter.
Cigs: quit 25 yrs. ago
ETOH: heavy in past, quit w/AA 20 yrs. ago
Family History:
unremarkable
Physical Exam:
WDWNWM in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign, edentulous
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat.
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E, fem pulses 2+ bilat., DP and PT 1+ bilat.,
and radial 2+ bilat.
Neuro: nonfocal
Pertinent Results:
[**2153-8-18**] 05:15AM BLOOD WBC-23.1* RBC-3.20* Hgb-9.9* Hct-29.5*
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.5 Plt Ct-269
[**2153-8-18**] 05:15AM BLOOD PT-23.8* PTT-28.3 INR(PT)-2.4*
[**2153-8-18**] 05:15AM BLOOD Glucose-101 UreaN-16 Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-29 AnGap-11
RADIOLOGY Final Report
CHEST (PA & LAT) [**2153-8-16**] 8:51 AM
CHEST (PA & LAT)
Reason: Lead placement
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with s/p dual pacer pacer implantation
REASON FOR THIS EXAMINATION:
Lead placement
PA & LATERAL VIEWS CHEST.
REASON FOR EXAM: Check location of pacemaker leads.
Comparison is made with prior study dated [**2153-8-14**].
New dual lead pacemaker with tip in standard positions in the
right atrium and right ventricle. There is no pneumothorax.
Stable mild bilateral pleural effusions greater in the left
side. Persistent left lower lobe retrocardiac
consolidation/atelectasis. Moderate cardiomegaly and mediastinal
widening are stable. Patient is s/p median sternotomy, CABG and
MVR.
IMPRESSION: Dual pacemaker leads with tips in standard
positions. No pneumothorax. Persistent left lower lobe
atelectasis/consolidation. Stable small right pleural effusion
and moderate left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]RADIOLOGY Final Report
CHEST (PA & LAT) [**2153-8-16**] 8:51 AM
CHEST (PA & LAT)
Reason: Lead placement
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with s/p dual pacer pacer implantation
REASON FOR THIS EXAMINATION:
Lead placement
PA & LATERAL VIEWS CHEST.
REASON FOR EXAM: Check location of pacemaker leads.
Comparison is made with prior study dated [**2153-8-14**].
New dual lead pacemaker with tip in standard positions in the
right atrium and right ventricle. There is no pneumothorax.
Stable mild bilateral pleural effusions greater in the left
side. Persistent left lower lobe retrocardiac
consolidation/atelectasis. Moderate cardiomegaly and mediastinal
widening are stable. Patient is s/p median sternotomy, CABG and
MVR.
IMPRESSION: Dual pacemaker leads with tips in standard
positions. No pneumothorax. Persistent left lower lobe
atelectasis/consolidation. Stable small right pleural effusion
and moderate left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: [**Doctor First Name **] [**2153-8-16**] 11:54 AM
Cardiology Report ECHO Study Date of [**2153-8-10**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. Mitral valve disease.
Mitral valve prolapse.
Status: Inpatient
Date/Time: [**2153-8-10**] at 11:07
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**Known firstname 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *7.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *5.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.8 cm
Left Ventricle - Fractional Shortening: 0.34 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% to 60% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: 2 mm Hg (nl <= 10
mm Hg)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aorta - Arch: 2.6 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *2.6 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 4 mm Hg
Aortic Valve - Mean Gradient: 2 mm Hg
Aortic Valve - Valve Area: 3.0 cm2 (nl >= 3.0 cm2)
Mitral Valve - Pressure Half Time: 107 ms
Mitral Valve - MVA (P [**1-8**] T): 2.6 cm2
Pulmonary Artery - Main Diameter: *3.7 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement. Elongated LA. Moderate to
severe
spontaneous echo contrast in the LAA. Depressed LAA emptying
velocity
(<0.2m/s) Cannot exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Normal regional
LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV
systolic
function likely depressed given the severity of valvular
regurgitation.]
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. Mild
global RV free
wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Mildly dilated
descending aorta. There are complex (>4mm) atheroma in the
descending thoracic
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Myxomatous mitral
valve leaflets. Mild MVP. Moderate mitral annular calcification.
Mild
thickening of mitral valve chordae. No MS. Moderate to severe
(3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Dilated main PA.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
PreBypass: The left atrium is markedly dilated. The left atrium
is elongated.
Moderate to severe spontaneous echo contrast is present in the
left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s).
A left atrial appendage thrombus cannot be excluded. No atrial
septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function
is normal (LVEF>55%). [Intrinsic left ventricular systolic
function is likely
more depressed given the severity of valvular regurgitation.]
The right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly
dilated. There is mild global right ventricular free wall
hypokinesis. There
are simple atheroma in the ascending aorta and aortic arch. The
descending
thoracic aorta is mildly dilated with complex (>4mm) atheroma.
An epiaortic
exam revealed no significant athermoa at the planned sites of
cannulation,
cross clamping, or proximal graft anastamosis. There are three
aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic
valve stenosis. Trace aortic regurgitation is seen. The anterior
mitral valve
leaflet is moderately thickened and myxomatous. There is mild
mitral valve
prolapse involving the posterior leaflet. Moderate to severe
(3+) mitral
regurgitation is seen. The MR jet is central. The vena contract
is 6mm and
there is severe blunting of the pulmonary inflow pattern. The
mitral annulus
is dilated (over 4 cm). The main pulmonary artery is dilated.
Post bypass: Patient is AV paced, on phenylepherine, milranone,
and
norepinepherine infusions. There is a mitral annuloplasty ring
in place, well
seated, with trace mitral regrugitation. Peak gradients on the
mitral valve
ranged from [**3-16**] with mean gradients of [**1-9**]. The left atrial
appendage is no
longer visible. The aortic conours are preserved. LVEF is >55%
on ionotropes.
The remaining exam is unchanged.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2153-8-10**] 17:03.
Brief Hospital Course:
The patient was admitted on [**2153-8-10**] and underwent
CABGx5(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **](seq), SVG->AM, PDA(seq))/MV
repair (28mm ring)/Cryo MAZE/Removal of L atrial appendage.
Cross clamp time was 175 min, total bypass time was 220 mins.
He tolerated the procedure well and was transferred to the CSRU
in stable condition on Levo, Neo , and Propofol. He had some
post op bleeding and was extubated on POD#1. He was pacer
dependent and was in underlying afib. He was started on Amio
and followed by EP.
His chest tubes were d/c'd on POD#3 and he underwent pacer
placement on POD#5. He was transferred to the floor on POD#4.
His epicardial pacing wires were d/c'd and he was coumadinized.
He continued to progress and was discharged to home in stable
condition on POD#8. His INR will be checked by the VNA on Mon.,
Wed., and Fri. and Dr. [**Last Name (STitle) 12593**] will follow his coumadin dosing.
Medications on Admission:
Atenolol 25 mg PO daily
Coumadin
Zestril 20 mg PO daily
MVI 1 PO daily
HCTZ 12.5 mg PO daily
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then decrease dose to 200 mg daily until d/c'd by
Dr. [**Last Name (STitle) 68076**].
Disp:*60 Tablet(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
AF
AV block
MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
DM
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] in 4 weeks
with Dr. [**Last Name (STitle) **] in [**2-9**] weeks
with Dr. [**Last Name (STitle) 12593**] in [**2-9**] weeks
PLease call device clinic for pacemaker check & follow-up ([**Telephone/Fax (1) 30924**]
Completed by:[**2153-8-20**]
|
[
"4240",
"42731",
"9971",
"41401",
"4019",
"4168",
"25000"
] |
Admission Date: [**2186-2-3**] Discharge Date: [**2186-2-11**]
Date of Birth: [**2106-5-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Heparin Sodium,Porcine
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
79 yo male with hx of CAD s/p MI with EF 35%, PAF on coumadin
and recent Right MCA stroke now presents from rehab with altered
mental status. He was admitted [**Date range (1) 96329**] to the Neurology service
for left sided weakness and altered mental status found on MRI
to have a right MCA stroke. He has a history of PAF, for which
he was not anticoagulated; given allergy to heparin, he was
bridged with argatroban to coumadin. That hospital course was
also noted for atrial fibrillation with RVR requiring diltiazem
gtt and eventual transition to PO metoprolol. He failed a speach
and swallow evaluation, therefore a PEG tube was placed by
gastroenterology. He also had a coagulase negative
Staphylococcus bacteremia for which he received vancomycin and
his PICC was pulled. He was discharged to complete a course of
levofloxacin and metronidazole for an aspiration pneumonia. At
the rehabilitation facility, he had a fever on [**2-1**] with a
erythema at the site of his midline. This was pulled and US was
negative for DVT. On [**2-2**] a neurology consult was obtained due
to worsening mental status who recommended repeat CT head to
assess for hemorrhagic tranformation or edema from his CVA. He
was evaluated by CT at [**Hospital 882**] hospital which showed edema
without shift; given a possible new area of hemorrhage, he was
transferred to the [**Hospital1 **] for further workup.
In ED repeat CT head showed area of laminar necrosis in
parietotemporal area but no hemorrhage or edema. EEG was
negative for acute seizure activity and LP was deferred due to
elevated INR but he was given 10U SC vit K. He also developed
fever to 101.5 and Afib with RVR and was given lopressor 5mg IV
x2, 25mg of PO lopressor, and empirically treated with 2g
Ceftriaxone, 1g Vancomycin, and 800mg of Acyclovir for possible
meningitis. He was admitted to the ICU for further management.
Past Medical History:
1. s/p right MCA stroke, discharged [**2186-1-27**]
2. PAF now on anti-coagulation
3. CAD s/p MI (posterolateral [**2162**] s/p Lcx stent, IMI [**2179**] s/p
RCA stent with subsequent mid LAD
4. s/p R THR
5. Idiopathic thrombus of L eye that spontaneous resolved ([**2183**])
6. Bilateral cataract surgery
7. Status post hernia repair
8. Diffuse osteoarthritis
9. Right renal fistula
10. BPH
11. s/p vasectomy
12. CRI (baseline around 1.3)
Social History:
Retired internist. Former chief resident at [**Hospital1 **] in [**2138**].
Widower for 6 yr. Has 3 kids, 10 grandchildren and 1 great
grandchild. Past smoking hx (from age 16 to [**2162**] ~1 pack a
day). Has 2 shots of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] daily prior to last admission,
none since discharge.
Family History:
Father died at age 78 of lung cancer. Had two brothers who died
of prostate cancer at the ages of 73 and 78. Mother died of an
MI at the age of 91. Extensive colon cancer on mother??????s side.
Physical Exam:
Physical exam on admission
Vitals: T 98.2 HR 130 BP 112/67 RR 6 O2 Sat 96% 2L
General: somnolent but arousable often falling asleep mid
conversation with [**Last Name (un) 6055**] [**Doctor Last Name **] respirations
HEENT: left pupil surgical rt reactive
Neck: no carotid bruit, no elevated JVP, supple when pt awake
Chest: crackles at left base
Hrt: irreg irreg, nS1S2 nor MRG
Abdomen: PEG site w/o erythema, soft, NT, ND, no HSM
Extremity: 2+ rad and dp pulses, trace LE edema bilat worse on
left, rt antecub eruthema
Neuro: unable to comply with neuro exam, increase tone diffusely
worse on LUE and LLE, hyperreflexia in bicep, brachiorad and
patellar on left, distal sensation intact. Could not assess
strength due to somnolence although moves all 4 extremities. (+)
left facial droop, tongue midline
Pertinent Results:
Laboratory studies on admission:
[**2186-2-3**]
WBC-13.1 HGB-13.6 HCT-39.4 MCV-89 RDW-13.7 PLT COUNT-308
NEUTS-75.4 LYMPHS-14.7 MONOS-6.5 EOS-3.0 BASOS-0.4
PT-28.2 PTT-41.2 INR(PT)-2.9
CK-MB-NotDone cTropnT-<0.01
ALT(SGPT)-62 AST(SGOT)-58 ALK PHOS-88 AMYLASE-82 TOT BILI-0.9
LIPASE-64
GLUCOSE-107 UREA N-26 CREAT-1.0 SODIUM-133 POTASSIUM-4.5
CHLORIDE-94 TOTAL CO2-33
U/A: BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG RBC-18 WBC-0
BACTERIA-RARE YEAST-NONE EPI-<1
[**2186-2-7**] ALT-46 AST-35 CK(CPK)-84 AlkPhos-76 TotBili-1.0
Lipase-32
Laboratory studies on discharge:
[**2186-2-10**] WBC-9.7 Hgb-11.0 Hct-32.6 MCV-89 RDW-13.9 Plt Ct-295
Glucose-130 UreaN-18 Creat-1.1 Na-136 K-3.9 Cl-102 HCO3-28
AnGap-10
[**2-3**] EKG: Sinus rhythm with atrial premature beats. Left
anterior fascicular block.
Poor R wave progression. Consider anterior myocardial
infarction, age
indeterminate but could also be due to left anterior fascicular
block. Compared
to the previous tracing of [**2186-1-23**] no significant change
[**2-3**] EEG: This is an abnormal EEG due to the presence of a slow
and
mildly disorganized background consistent with a mild to
moderate
encephalopathy of toxic, metabolic, or anoxic etiology. No
evidence of
ongoing or potential seizure activity was seen.
[**2-3**] head CT: A large area of hypodensity within the right
middle cerebral artery territory is largely unchanged in terms
of size compared to [**2186-1-26**]. There is new hyperdensity along the
cortex of this area of infarction extending into the temporal
lobe and insular area. This finding is consistent with laminar
necrosis, a sign of a subacute infarct. There is no new edema or
associated mass effect. No areas of acute hemorrhage are
identified. No new areas of infarction are visualized. There is
no hydrocephalus or shift of normally midline structures. The
remainder of the density values of the brain parenchyma remain
within normal limits. A small area of isodensity within the
right frontal bone is not changed compared to [**2182-5-16**]. The soft
tissues and osseous structures as well as the visualized
paranasal sinuses are unremarkable.
IMPRESSION: Laminar necrosis in a subacute right middle cerebral
artery territory infarct.
[**2-3**] CXR: Minimal blunting of the left costophrenic angle could
represent atelectasis or small effusion.
Brief Hospital Course:
79 yo male with hx of CAD s/p MI with EF 35%, PAF and recent
right MCA stroke presents with delirium. A head CT showed
laminar necrosis in the right parietotemporal area but no
hemorrhage or edema. He was initially covered empirically for
meningitis (CTX/Vanco/Acyclovir); no LP was attempted given
elevated INR. He was admitted to the ICU, where his antibiotics
were changed to Zosyn/vancomycin to cover possible nursing home
acquired pneumonia and possible line infection (erythematous
midline removed [**2-1**]), given low suspicion for meningitis. His
mental status improved and he was transferred to the general med
floor [**2-3**].
1) Altered mental status: Most likely due to the pneumonia and
possible line infection. Head CT was without acute hemorrhage
and EEG was consistent with encephalopathy without epileptiform
activity. The patient's mental status gradually improved on
Zosyn and vancomycin, and, on discharge, was close to his [**1-27**]
baseline. The neurology service followed him throughout his
hospital stay and recommended outpatient follow-up. Additional
toxic/metabolic work-up included vitamin B12 (normal), TSH
(elevated at 5, but free T4 normal at 1.2 - repeat as an
outpatient in [**4-14**] weeks), and an infectious work-up (urine
culture negative, blood cultures no growth to date). The
patient's neurologic status remained stable (improved since
admit) despite elevated INR on discharge; if mental status
worsens, head CT should be obtained to rule out hemorrhage in
the setting of INR 4.3.
2) Pneumonia and possible line infection: Although CXR was
without clear infiltrate, the patient did have a cough and
fever; he clinically improved on Zosyn/vancomycin and will
complete a 14 day course. At time of discharge, he was afebrile
with a normal wbc count.
3) Atrial fibrillation: The [**Hospital 228**] hospital course was
complicated by atrial fibrillation with rapid ventricular rate
to the 120s-140s. He was continued on metoprolol (titrated up to
100 mg PGT TID) and was started on diltiazem (titrated up to 60
mg four times a day). At time of discharge, his heart rate was
stable in the 60s-80s. He was transitioned to coumadin on an
argatroban drip (given heparin allergy). The day prior to
discharge, his INR rose to 5 and his coumadin was held. At time
of discharge, his INR was 4.3. His PTT was mildly elevated,
which may be due to residual argatroban (LFTs wnl, albumin 3.1,
fibrinogen elevated, not consistent with DIC). He should
continue off coumadin and have an PTT and INR rechecked on
Monday [**2186-2-12**] and coumadin restarted as needed for a goal INR
[**2-11**].
4) Coronary artery disease: EKG was without acute changes and
cardiac enzymes were cycled without evidence of acute ischemia.
He was continued on aspirin, simvastatin, and metoprolol
5) Anemia: At time of discharge, the patient's hematocrit was
stable at 31.9. Iron studies/vit B12/folate were not consistent
with deficiency. As an outpatient, his hematocrit should be
monitored closely, particularly given his anticoagulation.
Oupatient colonoscopy may be considered as an outpatient to
evaluate for occult sources of GI bleeding.
6) FEN: The patient ws continued on tube feeds. He is NPO
given risk of aspiration.
Full Code
Medications on Admission:
ASA 81mg po daily
RISS
Metoprolol 50mg po tid
Provigil 100mg po daily
Zocor 40mg po daily
Warfarin 5mg qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Month/Day (3) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
5. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
6. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) gram Intravenous
twice a day for 8 days.
7. Piperacillin-Tazobactam 4.5 g Recon Soln [**Last Name (STitle) **]: 4.5 grams
Intravenous Q8H (every 8 hours) for 8 days.
8. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary: change in mental status
Secondary: pneumonia, atrial fibrillation, coronary artery
disease, anemia, right MCA stroke.
Discharge Condition:
Stable
Discharge Instructions:
Please follow-up as indicated below.
Please come to the emergency room with worsening mental status,
fevers, chills, bleeding, or other symptoms that concern you.
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]
([**Telephone/Fax (1) 2936**]) within 1-2 weeks after being discharged from the
rehabilitation facility
2) Neurology:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-3-20**] 1:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2186-2-11**]
|
[
"486",
"42731",
"2859"
] |
Admission Date: [**2199-6-30**] Discharge Date: [**2199-7-20**]
Date of Birth: [**2149-3-24**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
male who on [**2199-6-30**], was caught and dragged by a train car.
Abrasions were noted all over his right abdomen and right
thigh as well as degloving injury to the right elbow and a
partial amputation of the right ankle.
PAST MEDICAL HISTORY: Not significant.
MEDICATIONS ON ADMISSION: The patient did not take any
medications.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs revealed blood pressure
110/palpable ranging to 129/107, temperature 98.9, heart rate
69 to 97, oxygen saturation 91 to 97% in room air. The
patient was awake and alert, GCS 15, with a head laceration.
The lungs were clear to auscultation bilaterally. The heart
was regular rate and rhythm, S1 and S2 noted, no murmurs,
rubs or gallops. The abdomen is soft, nontender,
nondistended. The pelvis was stable. Rectal examination was
normal tone, no blood. Skin noted with a road rash right
abdomen, right thigh, normal shoulder, arm. Extremities
noted with a degloving injury above the right elbow, no clear
fractures. Below the left elbow, there is a bump 2.0 by 5.0
centimeters on the forearm. According to the patient, it is
chronic. The patient does not know the cause of the finding.
There are +2 radial pulses. On the right leg, partial
amputation at the level of the ankle on the right foot.
Dorsalis pedis seen pulsating. Posterior tibial pulses were
palpable bilaterally. The patient can move his toes and has
sensation over the foot on the right.
LABORATORY DATA: White blood cell count 9.8, hematocrit
39.9, platelet count 273,000. Prothrombin time 12.7, partial
thromboplastin time 24.9, INR 1.1. Fibrinogen 218.
Urinalysis was negative. Sodium 143, potassium 4.1, chloride
108, bicarbonate 23, blood urea nitrogen 14, creatinine 1.0,
glucose 140, amylase 55. Arterial blood gases revealed pH
7.43, pCO2 35, paO2 156, bicarbonate 24, base excess 0.
RADIOLOGIC STUDIES: CT of the abdomen was negative. CT of
the chest noted minimal atelectasis over the right. Cervical
spine plain films were not taken. Right elbow shows a medial
epicondyle fracture. Right knee films - no fractures. Right
tibia fibula shows a comminuted oblique fracture of the
fibula. Right ankle and foot films show the tibia fibula
completely disconnected from the foot. On the right ankle,
there are multiple fractures including the fibula but no
tibia fractures. First metatarsal fracture of the intrinsic
bones of the foot were also noted.
HOSPITAL COURSE: Orthopedics was consulted regarding the
patient's partial amputation and degloving injury. Initial
attempt of orthopedic surgery was to take the patient to the
operating room for an attempt to save the right foot and also
for washout of the right elbow degloving injury. There was a
traumatic disruption of the right ulnar nerve. Therefore,
an incision and drainage of the ankle foot crush with
application of X-fix was tried. Incision and drainage, open
reduction and internal fixation of the right elbow fracture
was also performed. Plastic surgery was consulted via
telephone and plastics and vascular surgery were consulted
regarding the assessment of salvageability of the right foot.
In the meantime, the patient was admitted under Trauma
Surgery service into the Surgical Intensive Care Unit.,
The patient was maintained on sedation with Propofol as well
as pain control with Morphine Sulfate initially in the
Surgical Intensive Care Unit. The patient was extubated on
[**2199-6-30**], in the morning. The patient was made NPO, and
Protonix was started for gastrointestinal ulcer prophylaxis.
Hematocrit was followed and regular insulin sliding scale was
instituted for the patient's blood sugar fluctuations.
On [**2199-7-1**], orthopedics requested vascular surgery
consultation regarding the patient's salvageability of the
right foot. It was discussed with Trauma. On [**2199-7-1**], a
central venous line was placed in preparation for the
surgery. Vascular surgery saw the patient on [**2199-7-1**].
Thoracic and lumbar spine films performed on [**2199-7-1**], were
negative. A pulmonary artery line was put in the patient on
[**2199-7-2**] and the patient was started on tube feeds. On
[**2199-7-2**], the patient had an incision and drainage of the
right foot by orthopedic and noted that the right foot was
compromised given soft tissue, bony and vascular injuries.
Therefore, the patient would need primary amputation and
therefore it was felt per Dr. [**First Name (STitle) **] that this was the
patient's best option.
On [**2199-7-3**], the patient was noted to have respiratory
failure with decreasing saturation. Chest x-ray was obtained
which showed bilateral infiltrates consistent with adult
respiratory distress syndrome, but no pulmonary embolus was
noted. It was agreed per vascular surgery, orthopedic
surgery as well as plastic surgery that a right below the
knee amputation of the patient would be the best option.
Right below the knee amputation was performed on [**2199-7-6**],
done by vascular surgery, Dr. [**Last Name (STitle) **]. Postoperatively, the
patient was continued on ventilator support, one unit of red
blood cells was transfused postoperatively. The patient was
started on Vancomycin and Gentamicin as well as Ceftazidime.
Morphine Sulfate was given for postoperative pain control.
The most likely etiology due to pneumonia, sepsis related.
The patient was continued with antibiotic treatment. On
[**2199-7-8**], Ceftazidime was changed to Ceftriaxone. The
patient was continued on Vancomycin and Gentamicin.
The patient was followed daily by the vascular surgery, as
well as orthopedic surgery staff. Dressing changes were
daily. Per nutrition, the patient had TPN as well as tube
feeds implemented for the patient's nutrition and diet. On
[**2199-7-9**], the patient had TPN discontinued but continued on
tube feeds. On [**2199-7-10**], cultures of the sputum grew
positive for Serratia as well as Streptococcus pneumonia. On
[**2199-7-10**], the patient's Vancomycin, Gentamicin and
Ceftriaxone were continued although there was consideration
on whether to change the antibiotic regimen in light of the
new sputum culture results. On [**2199-7-13**], the patient again
extubated. The patient's Morphine Sulfate was decreased and
interval was increased between doses. Chest physical therapy
was continued. On [**2199-7-14**], Vancomycin was discontinued, and
Gentamicin and Ceftriaxone were continued. On [**2199-7-16**], the
patient's Ceftriaxone was discontinued. The patient was
transferred to the floor on [**2199-7-16**], as well, having made
very significant improvements in the Surgical Intensive Care
Unit.
On [**2199-7-16**], case manager was consulted to start
rehabilitation screening for the patient since per physical
therapy, the patient would not be able to be discharged home
immediately due to disposition. Case manager spoke with the
patient who prefers [**Hospital3 **]. Orthopedics
was following and on [**2199-7-16**], did note that the patient had
an ulnar nerve palsy, and noted plastic surgery would repair
the ulnar nerve in two to three weeks after discharge.
On [**2199-7-17**], the patient had splints removed. The patient
needed a cast now that would allow weight-bearing as
tolerated on a platform crutch. The patient's tube feed was
discontinued on [**2199-7-17**], and diet was converted to house
diet with supplemented protein shakes, which the patient
initially had a question of toleration, question of
aspiration, but upon further examination of the patient while
eating, in conjunction with calorie counts that were started
on behalf of nutrition consultation, the patient appeared to
be doing well and improving p.o. intake during the rest of
hospital stay.
On [**2199-7-18**], a psychiatric consultation was suggested. The
patient was continued on calorie counts. The patient was
also seen by psychiatry on [**2199-7-18**]. Their impression was
that the patient had resolving delirium as well as cognitive
disorder, not otherwise specified. Adjustment disorder was
also suggested as well as .............. in sustained
remission. The patient had speech and swallow consultation.
ON [**2199-7-18**], they recommended that the patient continue with
the regular diet with nurse supervision. They also noted a
follow-up with Speech Therapy for cognition would be needed
in rehabilitation setting. The patient was made out of bed
with weight-bearing as tolerated per physical therapy. The
patient was discharged on [**2199-7-20**].
CONDITION ON DISCHARGE: Noted as being good.
DISCHARGE DIAGNOSES: Status post train collision with a
resultant right below the knee amputation, right elbow
fracture with status post open reduction and internal
fixation, adult respiratory distress syndrome, ulnar nerve
palsy.
FOLLOW-UP:
1. The patient is to follow-up with Plastic Surgery, Dr.
[**Last Name (STitle) 13797**], within one week of discharge for ulnar nerve
repair, telephone [**Telephone/Fax (1) 42929**]. Need to call to make an
appointment.
2. The patient is also to follow-up with Dr. [**Last Name (STitle) **],
vascular surgeon, the week of [**2199-7-28**]. He can be reached at
[**Telephone/Fax (1) 42930**].
3. The patient is also instructed to follow-up with Dr.
[**First Name (STitle) **], the orthopedic surgeon, within one week of discharge.
MEDICATIONS ON DISCHARGE:
1. Thiamine HCl 100 mg p.o. once daily.
2. Folic Acid 1 mg p.o. once daily.
3. Metoprolol 75 mg p.o. twice a day.
4. Furosemide 25 mg intravenously twice a day.
5. Clonidine TTS two patches, one patch transdermal every
Saturday.
6. Albuterol nebulizer solution, one nebulizer inhaled
q4-6hours p.r.n.
7. Ipratropium Bromide nebulizer, one nebulizer inhaled
q6hours.
8. Colace 100 mg p.o. twice a day.
9. Ibuprofen 400 mg p.o. q8hours p.r.n. pain.
10. Artificial Tears one to two drops O.U. p.r.n.
11. Acetaminophen 325 to 650 mg p.o. q4-6hours p.r.n. pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 17322**]
MEDQUIST36
D: [**2199-7-20**] 10:16
T: [**2199-7-20**] 10:33
JOB#: [**Job Number 33289**]
cc:[**Hospital3 **]
|
[
"51881",
"486"
] |
Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-6**]
Date of Birth: [**2114-7-7**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female admitted to [**Hospital1 18**] ICU via [**Location (un) **] from [**Hospital 8**]
Hospital on [**2174-6-6**] at 17:42. The patient was recently
discharged from [**Hospital 8**] Hospital on [**2174-8-1**] after
undergoing an exploratory laparotomy, lysis of adhesion, and
small bowel resection on [**2174-7-27**] for a small bowel
obstruction and ischemic/necrotic small bowel. The patient
was readmitted to the [**Hospital 8**] Hospital 1 day prior to
admission complaining of fatigue, nausea, and vomiting x2
days; and a presyncopal episode. The patient denied
abdominal pain at that time and was found to be tachycardiac
to 128, systolic blood pressure in the 80s with a saturation
of 89 percent. The patient's white count at this time was
27.4 and ABG was 7.45/26/80/19; and of note, had a positive
UA. The patient, in addition, had extensive history of UTIs
and pyelonephritis.
HOSPITAL COURSE: The patient was admitted for antibiotics,
fluid resuscitation with some improvement. Early on the day
of admission, the patient acutely decompensated with
tachypnea, heart rate in the 120s, systolic blood pressure
less than 60. The patient was intubated, resuscitated with
IV fluids, and pressors were initiated. The patient was
transferred to [**Hospital1 18**] Surgery Service for definitive
treatment. On arrival, the patient was bradycardiac with
heart rate in the 40s with systolic blood pressure less than
50 during transfer requiring epinephrine and atropine. The
patient arrived to [**Hospital1 18**] intubated with IV fluids running and
Pitressin at 0.04, Neo-Synephrine at 8 and Levophed at 1.
PAST MEDICAL HISTORY: The patient's past medical history
includes gastroesophageal reflux disease, history of UTIs,
hypertension, and seizure disorder.
PAST SURGICAL HISTORY: Past surgical history includes
cholecystectomy, TAH/BSO, arthroscopies, and exploratory
laparotomy, lysis of adhesions, and small bowel resection as
mentioned above.
MEDICATIONS: At home,
1. Dilantin.
2. Protonix.
3. Topamax.
4. Verapamil.
ALLERGIES: NKDA.
PHYSICAL EXAMINATION: On exam, the patient was intubated,
unresponsive, cool, and cyanotic. The patient's temperature
was 98.4, heart rate 128, blood pressure 110/78, and
saturating at 90 percent, intubated. Physical exam was
remarkable for coarse breath sounds bilaterally and distended
soft abdomen with a clean, dry, and intact incision.
Extremities were cool and cyanotic.
LABORATORY DATA: On admission, white count 4, hematocrit
27.4, platelets 342, PTT 44, PT 16.5, INR 1.8, and fibrinogen
329. Electrolytes were 138, 3.6, 112, 15, 40, 1.6, and 129.
LFTs were within normal limits. Albumin was 1.6.
RADIOGRAPHIC STUDIES: A CAT scan of the abdomen and pelvis
showed ascites and thickened small bowel, question of free
air and pneumatosis. CT of the chest, abdomen, and pelvis
showed no pulmonary emboli or evidence of mesenteric vessel
compromise.
After lengthy discussion with the patient's family who were
present, which included 2 brothers and a sister, Dr.
[**Last Name (STitle) **], and Dr. [**Last Name (STitle) 51267**], the family made a decision to
withdraw all care and to stop all medications and to extubate
the patient. The patient was pronounced dead at 21:50 of
[**2174-8-6**] with a diagnosis of overwhelming sepsis. The
medical examiner was called at this time, Dr. [**Last Name (STitle) 104583**] [**Name (STitle) 7324**],
who waived the case. The family requested an autopsy and the
department pathologists were contact[**Name (NI) **] regarding this issue.
DISCHARGE DISPOSITION: Expired at the time mentioned above.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern1) 4881**]
MEDQUIST36
D: [**2174-8-6**] 22:54:46
T: [**2174-8-7**] 03:05:30
Job#: [**Job Number 104584**]
|
[
"0389",
"4019",
"53081"
] |
Admission Date: [**2174-2-28**] Discharge Date: [**2174-3-11**]
Date of Birth: [**2090-10-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2174-3-7**]
History of Present Illness:
Ms [**Known lastname 24195**] is an 81-year old female with past medical history
of insulin dependent diabetes (>30 years), hypertension and
hyperlipidemia who presented with progressive shortness of
breath over one week's time.
.
Patient is accompanied by her two daughters and son. They report
patient had been in her usual state of health until
approximately 3 weeks ago, when she had a "stomach flu" that
caused her nausea, diarrhea and decreased oral intake. The
patient attempted to stay hydrated after this event by taking in
more fluids and eating "a lot of soup". She reports that for the
past two weeks, she has noted her ankles are swollen, worse at
nighttime. For the past week, she has been having episodes of
shortness of breath with less activity than usual and even
waking from sleep because she is unable to "get air" in. Patient
reports that for the past 3 days she has been needing two large
pillows to sleep more upight to help her breathing.
.
Today, patient reports she went to the supermarket but was
unable to do her shopping due to difficulty breathing. She
returned home and when speaking to her son, he noted she was
very winded on the phone and decided to take her in to the ED
for further evaluation.
.
Patient denies any chest pain, diaphoresis, palpitations, but
does report some tingling of the fingers in the right hand that
started a few days ago. Denies any cough, blood in stool,
syncope or presyncope. Denies any history of abnormal heart
rythms but does report she has a "hole in her heart" (PFO) for
which she is on daily coumadin.
.
At [**Hospital3 4107**], VS 98.3 96 142/74 16 4L NC% NRB. Patient
given IL NS, 20mg IV Lasix, aspirin (81mg), Atorvastatin 40mg
and tranferred to [**Hospital1 18**] for further management. Here in the
[**Hospital1 18**] ED, VS: 97.7F, BP 135/67, HR 94, RR 26, O2 sat 94% on 4L
NC. Patient given regular insulin dose and admitted after
discussion with cardiology fellow. No heparin, plavix given. She
was maintained on a low dose nitroglycerin drip. On arrival to
the medical floor she was in no apparent distress and oxygen
saturation still 94-96% on 4L O2 NC.
.
Past Medical History:
-- Insulin dependent diabetes x 30+ years
-- Hypertension
-- Hyperlipidemia
-- H/O PFO, had been on anticoagulation therapy
Social History:
Lives with her husband, has five children who are very involved
with her care. She denies any alcohol or cigarette use.
Family History:
No family history of early MI, otherwise non-contributory.
.
Physical Exam:
VS: 97.4F, BP 146/78, HR 88, RR 20, O2 Sat 96% 4L NC
GENERAL: Well appearing elderly woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the ear at ~14cm, even at 90 degrees
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, I/VI systolic mid peaking low pitched
murmur on apex, and high pitched mid peaking systolic murmur at
RUSB, soft S3.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles [**3-15**] of the way
up posterior lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ bilateral and symmetric LE pitting edema. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2174-2-28**] 07:10AM GLUCOSE-173* UREA N-27* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-30 ANION GAP-12
[**2174-2-28**] 07:10AM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2174-2-28**] 07:10AM WBC-6.4 RBC-3.51* HGB-10.5* HCT-30.1* MCV-86
MCH-29.8 MCHC-34.8 RDW-15.0, PLT COUNT-248
[**2174-2-28**] 07:10AM PT-24.8* PTT-35.3* INR(PT)-2.4*
.
CARDIAC ENZYMES:
[**2174-2-28**] 03:30PM CK(CPK)-188*
[**2174-2-28**] 03:30PM CK-MB-10 MB INDX-5.3 cTropnT-0.75*
[**2174-2-28**] 07:10AM CK(CPK)-207*
[**2174-2-28**] 07:10AM CK-MB-16* MB INDX-7.7* cTropnT-0.77*
[**2174-2-28**] 01:08AM CK(CPK)-241*
[**2174-2-28**] 01:08AM cTropnT-0.58*
[**2174-2-28**] 01:08AM CK-MB-20* MB INDX-8.3* proBNP-[**Numeric Identifier 24196**]*
.
URINE STUDIES:
[**2174-2-28**] 01:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2174-2-28**] 01:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2174-3-3**] 09:03PM URINE RBC-68* WBC->1000* Bacteri-FEW Yeast-NONE
Epi-0
[**2174-3-6**] 12:10AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2174-3-6**] 12:10AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2174-3-6**] 12:10AM URINE RBC-13* WBC-78* Bacteri-FEW Yeast-NONE
Epi-11
.
MICROBIOLOGY:
[**2174-3-10**] MRSA SCREEN (Final [**2174-3-10**]): No MRSA isolated.
.
[**2174-3-3**] 9:03 pm URINE
Source: Catheter. **FINAL REPORT [**2174-3-7**]**
URINE CULTURE (Final [**2174-3-7**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
CITROBACTER KOSERI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
KLEBSIELLA PNEUMONIAE
| CITROBACTER KOSERI
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
.
[**2174-3-7**] CARDIAC CATHETERIZATION:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
severe three vessel disease. The LMCA was heavily calcified but
free of
critical stenoses. The LAD had serial 99% lesions in the
proximal and
mid vessel. The LCx had a 90% origin lesion in a major OM1
branch and
was sub-totally occluded in its inferior pole, which filled via
left to
left collaterals. The RCA had a 90% origin stenosis and 80%
stenosis at
the acute marginal branch; the distal vessel filled via
antegrade and
left to right collaterals.
2. Resting hemodynamics revealed elevated right and left heart
filling
pressures with a mean RA of 16mmHg and mean PCWP of 27mmHg. The
LVEDP
was 35mmHg. The cardiac index was preserved at 3.3l/min/m2.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe diastolic biventricular dysfunction.
.
.
[**2174-3-7**] EKG: HR 80s, Baseline artifact. Sinus rhythm. Consider
left atrial abnormality. Left bundle-branch block. Since the
previous tracing of [**2174-2-28**] the rate has decreased.
.
[**2174-3-5**] RENAL ULTRASOUND
IMPRESSION: No hydronephrosis. Simple appearing renal cysts
noted
bilaterally.
.
[**2174-3-2**] TTE: The left atrium is mildly dilated. The right atrial
pressure is indeterminate. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is probably severely depressed
(LVEF= 25-30 %). Despite limited image quality, there appears to
be global hypokinesis with inferior and infero-lateral akinesis.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**2-11**]+) 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.
.
[**2174-3-2**] PERSANTINE STRESS TEST:
IMPRESSION: No anginal symptoms with ST segments that are
uninterpretable for ischemia in the presence of the underlying
LBBB.
Nuclear report IMPRESSION: 1. Multiple predominately fixed
lesions. 2. Severe hypokinesis with EF 14%. 3. Severe
ventricular dilation (EDV greater than 150 cc).
.
[**2174-2-28**] PORTABLE CXR: PORTABLE UPRIGHT FRONTAL CHEST: Lungs
volumes are low, which results in bronchovascular crowding.
There is mild superimposed interstial pulmonary edema and a
small right effusion. The aortic arch is densely calcified.
.
DISCHARGE LABS:
[**2174-3-11**] BLOOD WBC-6.7 RBC-3.45* Hgb-9.9* Hct-28.8* MCV-84
MCH-28.8 MCHC-34.5 RDW-14.9 Plt Ct-252
[**2174-3-11**] BLOOD Glucose-76 UreaN-46* Creat-1.3* Na-140 K-3.8
Cl-99 HCO3-33*, Mg-2.0
Brief Hospital Course:
In summary, the patient is an 81-year-old female with past
medical history of IDDM, hypertension, and hyperlipidemia, who
presented with a new CHF exacerbation, presumed new LBBB on ECG,
and elevated cardiac enzymes. She improved with diuresis, but
had some acute renal failure and a urinary tract infection which
complicated her hospital course. Dyspnea gradually tapered with
diuresis and she underwent a cardiac catheterization during her
stay which was significant for extensive 3-vessel coronary
artery disease. Patient noted to have very high right sided
pressures on cardiac catheterization and was not felt to be
stable for any interventions. Furthermore, she had such severe
CAD that there were limited locations for viable touch-down
sites to ensure any successful future bypass procedures.
Ultimately, the team and patient/family opted to continue to
optimize Mrs.[**Known lastname 24197**] medical therapy while she continued
to recover back to baseline from her congestive heart failure
flare-up. Overall, on discharge the plan was for her to
follow-up in several weeks as an outpatient to explore
additional options should medical therapy alone fail to prevent
ischemic events and/or repeated CHF exacerbations.
.
#Coronary Artery Disease: On admission, Mrs. [**Known lastname 24195**] had no
chest pain complaints despite mildly elevated enzymes. Diabetic
history made her subjective sensation of chest pain a somewhat
limited ACS indicator. Clinical presentation of rales, dyspnea,
lower extremity edema and elevated JVP were all indicative of
acute systolic heart failure. Unclear if her cardiac enzyme
elevations were secondary to volume overload and demand vs. a
resolving prior silent MI given her LBBB on EKG. No prior EKG
records were available for comparison. Enzymes trended down with
diuresis. PMIBI showed fixed defects at apical, inferior and
anterior areas. ECHO with LVEF 25% and global hypokinesis with
infero-lateral akinesis. Cardiac catheterization showed diffuse,
severe 3-vessel CAD but no interventions due to poor hemodynamic
status with LVEDP was 35mmHg and mean RA 16mmHg, PCWP was
27mmHG. Despite these results she remained clinically stable
with no chest pain complaints for her entire hospital stay.
Continued on medical therapy with aspirin, statin, beta blocker,
[**Last Name (un) **] and set up for close follow-up within days of
discharge.Also, Plavix added to CAD regimen after 3-vessel CAD
discovered. After discharge she will follow-up as an outpatient
to discuss need for additional viability studies and possible
CABG/PCI options at later juncture once she has stabilized from
her CHF exacerbation.
.
#History of PFO: The patient was admitted on Coumadin therapy
which she was taking for a diagnosed PFO. Team weighed benefits
and risks and felt the patient had no indication for
anticoagulation based on fall risks and non-definitive
guidelines. No history of any prior strokes.
.
# Systolic Heart Failure: Mrs.[**Known lastname 24197**] new diagnosis of CHF
was likely promoted by her recent high fluid intake and salt
intake in the form of abundant sodium [**Doctor First Name **] soups and hydration
in the setting of a recent gastrointestinal infection with
vomiting and diarrhea about 10 days prior to her gradual
dyspnea, and lower extremity. On ECHO the left ventricular
cavity was moderately dilated and left ventricular systolic
function was severely depressed (LVEF= 25-30 %) with some global
hypokinesis with inferior and infero-lateral akinesis. Given her
3-vessel CAD recognized on cardiac catheterization and her LBBB
on EKG and elevated troponins on admission the team suspected a
possible silent ischemic event leading up to her new found CHF
as well. Alternatively, she may have developed elevated cardiac
enzymes as a consequence of CHF exacerbation secondary to
increased demand and stress. Several liters of fluid were
removed during her hospital course with IV Lasix. Diuresis
tapered mid-way through hospital course due to acute renal
failure, but once she had renal recovery a lower dose of lasix
was restarted along with Spirinolactone.
Nutrition consult called to reinforce the importance of a fluid
restricted diet and a low sodium diet. Other CHF management
included her Cozaar which was restarted after her renal function
improved, and metoprolol.
.
#Acute Renal Failure: After aggressive diuresis the patient
unfortunately had some worsening renal function and her
creatinine increased from 1 to 2.0, but after discontinuation of
Lasix for several days and gentle IVFs her creatinine came down
to 1.3 range by time of dischargea. She also had a urinary [**Last Name (un) **]
infection with urine WBCs grossly elevated >1000 with +Leuks,
+Bacteria. Initial urine eosinophils negative and her FEUrea
calculated to be 29% which indicated more of a pre-renal
etiology. Urine culture showed >100,000 gram negative rods and a
follow-up renal ultrasound showed no evidence of hydronephrosis.
Microbiological speciation of cultures showed Klebsiella
Pneumoniae and Citrobacter Koseri. She had strict I/Os
monitored, and she was given a course of Ciprofloxacin with
marked improvement in her dysuria and frequency.
.
# Diabetes/type II: She was placed on a sliding scale as patient
is on 70/30 at home and team was uncertain of her oral intake
and coverage needs. Hgb A1c returned slightly high at 7.1%. This
figure corresponded to her fleeting high FSGs in the 200-300
range at times. Therefore, her regular sliding scale insulin was
adjusted several times to attain better glucose control by the
time of discharge. She was continued on q.i.d. fingersticks and
a diabetic healthy diet. At time of discharge she was placed
back on her usual 70/30 home regimen and encouraged to keep a
glucose level diary at home after discharge so that she could
bring this information with her to her upcoming PCP visit for
any neccessary adjustments for optimal glycemic control. No
retinopathy noted but she did have some decreased sensation in
her lower extremities bilaterally which was felt to be
consistent with mild diabetic neuropathy changes.
.
#. Hypertension: Mrs. [**Known lastname 24195**] had predominantly
well-controlled blood pressures throughout her hospital course
with measures mainly in the 100-130s/50s-80s ranges. Cozaar was
held in the setting of her acute renal failure but eventually
restarted. Amlodipine was discontinued for additional space to
uptitrate her beta-blocker therapy, and given that she was being
started on two new diuretics as well. She tolerated these
medication changes well and she was discharged on Toprol XL,
Cozaar, Lasix and Spirinolactone.
.
# Fluids, Electrolytes and Nutrition: She was maintained on a
cardiac/diabetic healthy PO diet and electrolytes were closely
monitored and repleted as needed.
.
# Prophylaxis: Bowel regimen with Colace, SC heparin for DVT PPX
.
# Code Status: The patient was maintained as a full code status
for the entirety of her hospital course.
.
Medications on Admission:
Atenolol 50mg daily
Cozaar 100mg daily
Amlodipine 10mg daily
Lipitor 40mg daily
Zetia 10mg
Warfarin
NPH 70/30, 15 units AM, 16 units PM.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
7. Insulin Therapy
Please continue your usual home insulin regimen.
--Take NPH 70/30 insulin 15 units every AM
--Take NPH 70/30 insulin 16 units every PM
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
-- Congestive Heart Failure
-- Coronary Artery Disease
Secondary:
-- Insulin dependent diabetes x 30+ years
-- Hypertension
-- Hyperlipidemia
-- History of Patent Foramen Ovale(PFO)
Discharge Condition:
Afebrile, vital signs stable, 93% on RA.
Discharge Instructions:
It was a plesure taking care of you here at [**Hospital1 771**] ([**Hospital1 18**]).
.
You were admitted with shortness of breath due to fluid overload
on your heart and lungs from a condition called congestive heart
failure or CHF. You had a cardiac catheterization which showed
coronary artery disease (or atherosclerosis); due to the extent
of the disease, there were no interventions performed. Your
medications were changed in order to optimize your regimen for
heart disease and congestive heart failure.
.
Because of you CHF history, it is important that you weigh your
self daily every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L daily
The following medication changes were made:
1. Please discontinue your amlodipine.
2. Please start aspirin 325 mg daily
3. Please continue your lipitor 40 mg daily
4. Please start plavix (clopidogrel) 75 mg daily
5. Please continue losartan (cozaar) 100 mg daily
6. Please stop your atenolol and start metoprolol 50mg three
times daily
7. Please start spironolactone at 12.5 mg daily for blood
pressure
8. Please start lasix at 40 mg PO BID dose for your congestive
heart failure
9. Please discontinue your zetia.
10. Please discontinue your coumadin. Please discuss this change
with your primary care physician. [**Name10 (NameIs) **] are now on two other
medications for blood thinning (aspirin and plavix).
Followup Instructions:
An appointment has been scheduled for you with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 24198**], on Thursday [**3-17**] at 10:45am. Please call
[**Telephone/Fax (1) 14328**] if you need to change this appointment.
.
An appointment has been scheduled for you to follow up with your
new cardiologists Dr. [**Last Name (STitle) 696**] and Dr. [**First Name4 (NamePattern1) 4135**] [**4-21**] at 8am.
[**Hospital Ward Name 23**] building, [**Location (un) 436**]. Call [**Telephone/Fax (1) 62**] with any
questions or if you need to cancel.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-4-21**] 8:00
.
In addition, we have made you an appointment in heart failure
clinic with Dr. [**First Name (STitle) 437**]. We have made you an appointment for
Monday [**4-11**] at 10 am. [**Hospital Ward Name 23**] 7.
Completed by:[**2174-3-22**]
|
[
"5849",
"5990",
"4280",
"4019",
"41401",
"25000",
"2724",
"V5867"
] |
Admission Date: [**2195-8-5**] Discharge Date: [**2195-8-17**]
Date of Birth: [**2195-8-5**] Sex: M
HISTORY OF PRESENT ILLNESS: This 31+ two week gestation,
Twin B was delivered early due to preterm labor.
Maternal history - Mother is a 34 year old Gravida 2, Para
fertilization. Estimated date of confinement of [**10-5**],
unresponsive, Rubella immune, hepatitis B surface antigen
negative, Group B Streptococcus unknown, pregnancy was
complicated by twin gestation, complete placenta previa.
Mother presented to [**Hospital3 **] on [**2195-7-26**]
with bleeding and contractions and was commenced on magnesium
[**Hospital6 256**] where her course of
Betamethasone was completed. Her labor slowed until the
and bleeding and was therefore delivered by cesarean section
under general anesthesia. Artificial
rupture of membranes at delivery. There was no history of
maternal fever. This twin emerged with spontaneous cry and
required only blow-by oxygen and routine care in the Delivery
Room. His Apgars were 8 and 9. He was transferred to the
Neonatal Intensive Care Unit secondary to his prematurity.
PHYSICAL EXAMINATION: On admission his vital signs were
within normal limits except for intermittent apnea. His
weight was 1640 gm (70th percentile), length 44 cm (80th
percentile), head circumference 31 cm (85th percentile).
General, he is nondysmorphic with an overall appearance
consistent with known gestational age. Head, eyes, ears,
nose and throat, anterior fontanelles soft open and flat.
Red reflexes deferred. Palate intact. Respiratory, minimal
intercostal retractions. The breath sounds were fairly clear
and equal bilaterally. Cardiovascular, regular rate and
rhythm, S1 and S2 without any audible murmurs. Abdomen,
benign without any hepatosplenomegaly. He had a three vessel
cord. Genitourinary, he had normal male external genitalia
for gestational age. His testes were in the canal
bilaterally. Extremities, 2+ femoral pulses, normal
extremities. Tip examination deferred. Skin pink and well
perfused. Neurological: Appropriate tone and strength.
Initial D-stick was 52.
ASSESSMENT: He was assessed as 31+ 2 week gestation,
appropriate for gestational age, male twin B who was
delivered premature due to preterm labor by cesarean section
for placenta previa. Complete now with mature lungs but
intermittent apnea, likely due to a combination of maternal
anesthesia, magnesium sulfate, and prematurity.
HOSPITAL COURSE: Respiratory - His initial chest x-ray
showed evidence of mild hyaline membrane disease. He was
initially placed on CPAP with a positive end-expiratory
pressure of 6 cm of water, however, he developed frequent
apnea desaturations and required to be intubated and placed
on assisted ventilation. His maximum ventilation settings
were pressures of 21/6 with a rate of 18 and FIO2 of 0.21.
He received one dose of Survanta. His ventilation settings
were weaned and he was placed on nasal CPAP on day of life
#3. He successfully transitioned to nasal cannula oxygen on
day of life #5 and subsequently to room air on day of life
#7. However, he required to go back onto the nasal cannula
after a few hours and remained so until day of life #8. He
has been in room air since about 6 PM on [**2195-8-14**]
and has had the occasional spell. Caffeine was commenced on
day of life #2 and he continues on this.
Cardiovascular system - His blood pressure has been stable
throughout. There have been no audible murmurs.
Fluids, electrolytes and nutrition - Feeds were initiated at 30
cc/kg/day on day of life #1 and was advanced by 15 cc/kg
t.i.d. He is currently on full feeds of 140 cc/kg/day of PE
20 (calories are made up with NTTRL and ProMod). He has had
intermittent feeding intolerance with some spitting up of his
feeds. His feed volume therefore was reduced from 150
cc/kg/day to 140 cc/kg/day on the morning of [**2195-8-14**]. His birthweight was 1640 gm. His current weight is
1695 gm.
Gastrointestinal - He developed hyperbilirubinemia of
prematurity and required phototherapy from day #2 to day #5
of life with maximum bilirubin of 7.2 occurred on day of life
#2. His rebound bilirubin was 2.2. He has been stooling from
shortly after birth.
Heme - His initial hematocrit was 47.4, following birth
subsequent hematocrit was 45 on day of life #3.
Infectious disease - He initially underwent a sepsis
evaluation and was not commenced on antibiotics in view of
minimal risk for sepsis. His initial white cell count was
8.5 with a differential of 38 segments and 0 bands, 44
lymphocytes. His blood cultures were negative, however, in
view of increased frequency of apneas on day of life #1, he
was recultured and commenced on Ampicillin and Gentamicin
until his blood cultures were negative for 48 hours. He has
had no other infectious disease issues since then.
Neurology - He had a head ultrasound scan on day of life #7.
This revealed a small cystic area versus small bleed in the
caudothalamic groove and Radiology has recommended that he
undergo a follow up head ultrasound scan in about one week, i.e.
this should be scheduled for [**2195-8-30**] in the hospital.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Level 3 Unit at [**Hospital 28978**] Medical Center. Primary pediatrician is pending at
this stage.
CARE RECOMMENDATIONS:
1. Feeds at discharge - PE 26 (including MCT Oil 2 cal/oz
and ProMod .5 tsp per 90 cc formula was given q. feed)
2. Medications - Caffeine 10 mg p.o. p.g. q. day, Fer-In-[**Male First Name (un) **]
0.15 cc p.o. p.g. q. day
3. State newborn screening - Sent on [**8-8**].
4. Immunizations - He has not received any immunizations
yet.
DISCHARGE DIAGNOSIS:
1. Prematurity at 31+ 2 weeks gestation
2. Twin gestation pregnancy
3. Hyaline membrane disease requiring artificial Surfactant
4. Sepsis evaluation
5. Hyperbilirubinemia of prematurity
6. Gastroesophageal reflux
7. Small cyst versus germinal matrix hemorrhage
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Name8 (MD) 43814**]
MEDQUIST36
D: [**2195-8-14**] 15:29
T: [**2195-8-14**] 16:04
Edited: [**2195-8-17**]
JOB#: [**Job Number 45034**]
|
[
"7742",
"53081",
"V290"
] |
Admission Date: [**2177-7-2**] Discharge Date: [**2177-7-4**]
Date of Birth: [**2116-6-29**] Sex: F
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Nausea and vomiting.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female
with a past medical history significant for insulin dependent
diabetes mellitus, bipolar disorder and numerous diabetic
ketoacidosis admissions. She presents with a one week
history of nausea and vomiting, weakness, constipation,
lightheadedness, tachypnea and chills. In the Emergency
Department, her vitals were stable, blood sugar in the low
400s, with an anion gap of 42. Patient was treated for
diabetic ketoacidosis with an insulin drip, intravenous
potassium chloride, and more than three liters of intravenous
fluid. Patient was initially treated in the Medical
Intensive Care Unit, but subsequently did much better,
feeling stronger, and able to tolerate po. Patient was
switched over to her normal insulin regimen of 21 units
subcutaneous of Lantus, and a regular insulin sliding scale.
Her blood sugars were stable in the low 100s.
On the day of her transfer to the regular floor, the patient
had no complaints other than a slightly sensitive stomach,
otherwise, she denies abdominal pain, nausea, vomiting, chest
pain, shortness of breath, headache, fever and chills. She
denies dysuria, but has increased frequency of urination, but
endorses a feeling of urgency.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus. Complicated by
neuropathy, retinopathy, nephropathy.
2. Bipolar disorder.
3. Vasculopath, status post aortofemoral bypass.
4. Hypercholesterolemia.
5. Status post appendectomy.
6. Hypothyroidism.
7. Gastroesophageal reflux disease.
8. Colon polyps.
9. Internal hemorrhoids.
10. Status post total abdominal hysterectomy.
11. Anemia. Baseline hematocrit is 35-40.
12. Baseline creatinine is 0.8.
MEDICATIONS:
1. Protonix 40 mg po q.d.
2. Premarin 0.625 mg po q.d.
3. Lipitor 20 mg po q.d.
4. Norvasc 5 mg po q.d.
5. Zestril 20 mg po q.d.
6. Levoxyl 100 mg po q.d.
7. Depakote 1000 mg po b.i.d.
8. Lasix 20 mg po b.i.d.
9. Trilafon 16 mg po q.h.s.
10. Lantus 21 units subcutaneous q.h.s.
11. Regular insulin sliding scale.
12. Diazepam 1-5 mg po prn.
ALLERGIES: Penicillin, sulfa.
SOCIAL HISTORY: The patient is an 80 pack year smoker. She
lives at home alone.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.5. Pulse
81. Respiratory rate 18. Blood pressure 138/88. Oxygen
saturation 95% on room air. In general, patient is
comfortable in no apparent distress. Head, eyes, ears, nose
and throat: Mucous membranes moist. Pupils equal, round and
reactive to light and accommodation. Neck: No jugular
venous distention or carotid bruits. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, no murmurs, rubs or gallops. Abdomen: Soft,
nontender, nondistended, normal active bowel sounds
bilaterally. Extremities: No cyanosis, clubbing or edema.
Neurological: Alert and oriented times three, no focal
findings.
LABORATORIES ON ADMISSION: White blood cell count 15.6,
hematocrit 39.9, platelet count 277,000. Sodium 140,
potassium 3.5, chloride 92, bicarbonate 6, BUN 38, creatinine
2.0, glucose 480, calcium 10.2, magnesium 2.3, phosphorus
7.0. Liquid gas showed PHF 7.42, PA02 of 84, PACO2 of 22,
total bicarbonate of 15. CK was 146. MB fraction was 4.
Troponin was less than 0.3.
STUDIES: Chest x-ray showed calcific aorta, no congestive
heart failure. Electrocardiogram: Normal axis, sinus,
normal intervals, good R wave progression, no ST changes.
HOSPITAL COURSE: In short, this is a 61-year-old female with
a history of insulin dependent diabetes mellitus who
presented in diabetic ketoacidosis, which was largely
resolved during her Medical Intensive Care Unit stay.
1. Endocrine: The patient's blood sugars were stable
between 100 and 230. After discontinuing her insulin drip
and placing back on her Lantus and regular insulin sliding
scale, it is still unclear the cause of her diabetic
ketoacidosis. The patient has numerous other diabetic
ketoacidosis admissions.
2. Infectious Disease: Although the patient was afebrile,
and her white blood cell count came down to 7.3, she was
noted to have a urinalysis significant for urine nitrate
positive, large leukocyte esterase and 7 white blood cells.
The urine culture had greater than 100,000 colonies/units of
gram negative rods. The patient was placed on levofloxacin
500 mg po q.d. for an intended one week course.
3. Cardiovascular: The patient's blood pressure was stable
through her admission. Patient ruled out for myocardial
infarction.
4. Gastrointestinal: The patient initially presented with
an increased amylase of 251 and a lipase of 524. However,
these recovered to an amylase of 69 and a lipase of 104 on
discharge. It is very unlikely that she had any kind of
pancreatitis.
5. Psychiatric: The patient has a history of bipolar
disease. She is currently on valproate 1000 mg po b.i.d.
During her admission, her level was 85. The normal level is
50 to 100. She did not have any psychiatric exacerbations.
CONDITION OF DISCHARGE: Good.
DISCHARGE STATUS: Patient is to go home with the following
medications:
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q.d.
2. Premarin 0.625 mg po q.d.
3. Lipitor 20 mg po q.d.
4. Norvasc 5 mg po q.d.
5. Zestril 20 mg po q.d.
6. Levoxyl 100 mg po q.d.
7. Depakote 1000 mg po b.i.d.
8. Lasix 20 mg po b.i.d.
9. Trilafon 16 mg po q.h.s.
10. Lantus 21 mg po q.h.s.
11. Regular insulin sliding scale.
12. Diazepam 1-5 mg po prn.
13. Levofloxacin 500 mg po q.d. through [**2177-7-8**].
DISCHARGE FOLLOW-UP: The patient is to follow-up with her
Endocrinologist, Dr. [**First Name (STitle) **], at [**Last Name (un) **] on [**7-7**] at 1 p.m.
The number is area code [**Telephone/Fax (1) 10805**].
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Insulin dependent diabetes mellitus.
[**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17046**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2177-7-8**] 22:45
T: [**2177-7-8**] 22:45
JOB#: [**Job Number 17268**]
|
[
"5990",
"2449",
"53081"
] |
Unit No: [**Numeric Identifier 7764**]
Admission Date: [**2108-10-1**]
Discharge Date: [**2108-10-6**]
Date of Birth: [**2029-6-4**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This gentleman presented with
symptoms of shortness of breath and chest tightness for
approximately one month. He had a known myocardial infarction
with tPA in [**2098**] and known aortic stenosis, which was
followed up annually. He had more recent complaints of chest
tightness and shortness of breath on exertion for
approximately one month with no rest pain or orthopnea with
moderate exertion. His echocardiogram showed a severe aortic
stenosis with an aortic valve area of 0.8 cm squared with a
peak gradient of 74 and a mean gradient of 48 with an
ejection fraction of 60 percent. On cardiac catheterization
prior to his admission showed severe aortic stenosis with an
ejection fraction of 60 percent and the coronaries did not
show any significant disease. He was referred for aortic
valve replacement to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY: Myocardial infarction with tPA in
[**2098**].
Aortic stenosis.
Gastric ulcer at approximately age 20.
Hypertension.
Gastroesophageal reflux disease.
Cholesterol.
PAST SURGICAL HISTORY: Hernia repair, polypectomy and
hemorrhoidectomy.
PREOPERATIVE MEDICATIONS:
1. Cartia XT 120 mg p.o. once daily.
2. Zocor 5 mg p.o. once daily.
3. Rhinocort two puffs once daily.
4. Enteric coated aspirin 325 mg p.o. once daily.
5. Multivitamins daily.
6. Prevacid 30 mg p.o. daily.
ALLERGIES: No known allergies.
SOCIAL HISTORY: He stopped smoking 30 years ago and drinks
one glass of [**Doctor First Name **] per day. He has one son and lives alone.
FAMILY HISTORY: Positive family history for IHD.
PHYSICAL EXAMINATION: On examination, he was alert and well
oriented. He had no anemia, cyanosis, clubbing, jaundice or
pedal edema. His jugular venous pressure was within normal
limits. His heart rate was 60 and regular, saturation of 93
percent on room air, afebrile with blood pressure 159/75,
respiratory rate 18. SHEENT examination was normal. He had a
grade 3/6 systolic ejection murmur over the aorta. His
abdomen was soft with no masses or tenderness. He was
neurologically grossly intact. Extremities were warm. He had
lipomas in both arms and his back. His pulses were well felt
peripherally. He had no carotid bruits and no varicosities in
his legs.
PREOPERATIVE LABS: White count 4.3, hematocrit 42.3,
platelet count 162,000. Sodium 142, potassium 4.2, chloride
107, CO2 27, BUN 20, creatinine 1.0 with an INR of 0.9, ALT
13, AST 27, alkaline phosphatase 67, total bilirubin 1.4,
amylase 63, albumin 3.7. Electrocardiogram showed sinus
rhythm at a rate of 55. His urinalysis was negative.
The plan was for him to be discharged and return several days
later for surgery. He also had positive femoral, dorsalis
pedis, posterior tibial and radial pulses on examination.
HO[**Last Name (STitle) **] COURSE: The patient returned as a same day admit on
[**2108-10-1**] and underwent aortic valve replacement by Dr. [**Last Name (Prefixes) **] with a 27 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve.
He was transferred to the Cardiothoracic Intensive Care Unit
in stable condition on Levophed drip at 0.03 mcg per kg per
minute, an amiodarone drip at 1 mg per minute and a propofol
drip at 20 mcg per kg per minute.
On postoperative day one, he remained on an amiodarone drip
at 0.5 mg per minute. He was AV paced. His postoperative labs
were as follows. White count 13.1, hematocrit 34.9, platelet
count 131,000, INR 1.1, potassium 4.6, BUN 15, creatinine 0.8
with a blood sugar of 88. His lungs were clear bilaterally.
He had 1 plus peripheral edema. He was extubated, sating 95
percent on 4 liters nasal cannula. He was alert and oriented
and following commands.
On postoperative day two, he was in sinus rhythm at 67. His A-
wires were determined not to be working. He was on an insulin
drip at 1.0 units per hour. His white count remained stable
at 9.2. His INR rose slightly to 1.3. His creatinine was
stable at 0.8 with a blood sugar of 66, which was treated
appropriately. He had decreased breath sounds bilaterally.
Had some peripheral edema. His heart was regular in rate and
rhythm. He continued his diuresis and was transferred out to
the floor in the afternoon of postoperative day number two.
He was receiving Percocet and Tylenol for pain with good
control, sating 97 percent on 3 liters. His vital signs were
stable. His heart rate dropped occasionally while he was
sleeping overnight to a heart rate of 48 but he remained in a
sinus range of 58-60 and was monitored appropriately by
telemetry.
On postoperative day three, he had a T-max of 99.2. He was in
sinus rhythm at 78-80 with a blood pressure of 120/60. He was
hemodynamically stable with an unremarkable examination. His
wound showed no signs of infection. His sternum was stable.
He was oriented. His pacing wires were discontinued and he
continued to work with Physical Therapy aggressively to
increase his level of activity. He was also seen by Case
Management for evaluation of having VNA home services after
he was discharged from the hospital.
On hospital day four, he did do a level 5 with Physical
Therapy. He had a repeat chest x-ray in the morning. EP was
asked to see the patient because of an 18 beat run of
ventricular tachycardia overnight. He received some Percocet
for pain, was showering independently with plans to hopefully
discharge him after he was evaluated by EP. They did not see
for an immediate intervention but recommended putting [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts monitor on him for one month and have an EP study
done if there were any positive findings on the [**Doctor Last Name **] of
Hearts and to consider amiodarone as the patient does not
tolerate any beta blockers. There was only that single
episode of asymptomatic nonsustained ventricular tachycardia.
On postoperative day four, he was awake and alert, as
previously reported, with a relatively benign examination.
After his first dose of Lopressor of 12.5 mg, 45 minutes
after his dose he bradyed down to a 34-36 range on the heart
rate. The CT resident was aware and the next dose was held.
On[**10-6**], the day of discharge, he was receiving Percocet
with good effect for a little bit of sternal discomfort. He
was in sinus rhythm with an occasional PVC. He was going to
the Holter Lab for a Holter monitor for 24 hours and then to
return for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for a two week
examination of telemetry. Teaching was done. The patient was
given postoperative instructions and was told to report back
to Dr. [**Last Name (Prefixes) **] in one month for his postoperative
surgical visit and to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1104**], his cardiologist,
in two weeks and also with a visit to the [**Hospital **] Clinic after his
[**Doctor Last Name **] of Hearts monitor had been placed with two week
telemetry. EP agreed to follow him postoperatively with the
event recorder. The patient was discharged to home with VNA
services on [**2108-10-6**], with the previously mentioned
discharge instructions.
DISCHARGE DIAGNOSES: Status post aortic valve replacement
with pericardial tissue valve.
Status post myocardial infarction with tPA.
Hypertension.
Hyperlipidemia.
Gastroesophageal reflux disease.
Status post hernia repair.
Status post polypectomy.
Status post hemorrhoidectomy.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Enteric coated aspirin 325 mg p.o. once a day.
3. Tylenol 650 mg p.o. q 4 hours p.r.n. pain.
4. Percocet 5/325, 1-2 tablets p.o. p.r.n. q 4 hours for
pain.
5. Zocor 5 mg p.o. once a day.
6. Lansoprazole 30 mg enteric coated p.o. once a day.
7. Metoprolol 12.5 mg p.o. twice a day.
8. Lasix 20 mg p.o. once a day for five days.
9. Potassium chloride 20 mEq p.o. once a day times five days.
The patient was reminded again to check up with the
Electrophysiology Clinic and was given the phone number, [**Telephone/Fax (1) 7765**], to follow-up for his appointment for Holter
monitoring to be placed before he left the hospital and [**Doctor Last Name **]
of Hearts monitoring for two weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2108-12-6**] 12:41:03
T: [**2108-12-6**] 13:59:31
Job#: [**Job Number 7766**]
|
[
"4241",
"412",
"2720",
"4019",
"53081"
] |
Admission Date: [**2101-1-27**] Discharge Date: [**2101-1-31**]
Date of Birth: [**2037-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HPI: This is a 63 year old man with ahistory of hariy cell
leukemia that reportsseveral weeks of generalized fatigue and
myalgia. He has been seeing his PCP for this, [**Name Initial (PRE) **] rheumatology
consult was being arranged. One week ago he developed headaches
in the occipital region radiating to the rioght frontal area.
They were daily and once associated with "flashing light". 2-3
days after the headaches started he was getting out of bed, his
right knee buckled, he fell on his buttock and lightly hit his
head on the bed. He reports no other trauma, nausea, emesis,
visual changes, dizziness.
For the past several days he and his wife noticed that he had
difficulty with some daily task such as tieing shoes or putting
on a watch. His PCP ordered [**Name Initial (PRE) **] CT head which showed a R frontal
SDH and he was transfered to [**Hospital1 18**] for further evaluation.
Past Medical History:
PMHx: hairy cell leukemia, thrombocytopenia, gout, chol, thyroid
ds, heriarraphy, colon poly removal, lung bx, Bilateral hearing
aides.
Social History:
Social Hx: He is a married right handed man who works in
secutiry. He stopped smoking 7 yrs ago. He has [**12-29**] ETOH/day. No
drug use.
Family History:
Family Hx:NC
Physical Exam:
PHYSICAL EXAM:
O: T: 98.8 106 136/85 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**1-25**] EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to2
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. Bil. hearing aides
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-30**] throughout. No pronator drift.
No dysmetria.
Sensation: Intact to light touch.
Pertinent Results:
[**2101-1-27**] ct brain
FINDINGS: Again seen is a right frontal subdural hematoma with
hyper- and
hypodense components, reflecting acute on subacute/chronic
hemorrhage. The
size of this collection is approximately unchanged, measuring
2.3 cm in
greatest depth. There is diffuse sulcal effacement and
compression of the
right lateral and third ventricles. There is stable 7-mm
leftward shift of
the normal midline structures. The basal cisterns are tight, but
there is no
evidence of uncal or tonsillar herniation.
Again seen is mild-to-moderate mucosal thickening and partial
fluid
opacification throughout the paranasal sinuses. Some mucosal
retention cysts
are noted in the sphenoid sinuses. The mastoid air cells are
partially
opacified bilaterally. The orbits and soft tissues are
unremarkable.
IMPRESSION:
1. Unchanged right frontal subdural acute on subacute/chronic
hematoma.
Unchanged extent of mass effect and leftward shift of midline
structures.
2. Paranasal sinus disease.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 78975**] M 63 [**2037-9-7**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2101-1-31**]
6:03 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG FA11 [**2101-1-31**] 6:03 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 78976**]
Reason: evaluate for interval change. Please obtain By 7AM
[**2101-1-31**]
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with R SDH with midline shift please obtian
by 7AM [**2101-1-31**]
REASON FOR THIS EXAMINATION:
evaluate for interval change. Please obtain By 7AM [**2101-1-31**]
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: CXWc MON [**2101-1-31**] 7:47 AM
Stable exam. Right frontal SDH unchanged in extent, with no
change in 7mm
leftward subfalcine herniation. No new bleeding or herniation.
Final Report
INDICATION: 63-year-old man, followup evaluation of right
subdural hematoma.
COMPARISON: Head CT is obtained [**1-27**], 5th and 6th, [**2100**].
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: The heterogeneous subdural collection overlying the
right frontal
convexity is unchanged in extent, again demonstrating both low
and high
attenuation components, indicating acute on chronic bleeding.
Effacement of
the underlying sulci is stable. There is a stable degree of
subfalcine
herniation, now measuring 7 mm. There is unchanged mass effect
upon the right
lateral ventricle.
There is no new intracranial hemorrhage, edema, new shift of
midline
structures or herniations, or evidence of infarction. The
[**Doctor Last Name 352**]-white matter
differentiation is preserved. A nodular soft tissue density in
the posterior
[**Doctor Last Name 534**] of the left lateral ventricle is unchanged. An 8 x 19 mm
ovoid,
relatively hyperdense lesion abutting the left tentorium at the
left
cerebellopontine angle is unchanged, likely representing a
meningioma.
The basilar cisterns are symmetric. No fractures are identified.
Paranasal
sinuses are well aerated. Mastoid air cells again demonstrate
relative
non-[**Name2 (NI) 70320**] on the left. The frontal air cells are not
pneumatized.
IMPRESSION:
Overall stable exam compared to prior, with heterogeneous right
frontal
subdural collection consistent with subacute on chronic
bleeding, unchanged.
Stable leftward subfalcine herniation with no new or herniation
or bleeding.
NOTE ADDED AT ATTENDING REVIEW: I agree that the right frontal
subdural
hematoma appears chronic. However, the high density regions may
reflect
vascular membranes rather than superimposed acute hemorrhage.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Pt was admitted to the hospital for headaches, several weeks of
generalized fatigue and myalgia. He has been seeing his PCP for
this. His headaches were
in the occipital region radiating to the rioght frontal area.
They were daily and once associated with "flashing light". [**12-29**]
days after the headaches started he was getting out of bed, his
right knee buckled, he fell on his buttock and lightly hit his
head on the bed. He reports no other trauma, nausea, emesis,
visual changes, dizziness.
He was admitted to the ICU for close observation and possible
evacuation of the subdural collection. He was transfussed plts
to bring count >50.
Ultimately he was followed conservatively - he was transferred
to the floor and serial CT scans were read as stable. His plt
count remained stable for him as well.
On day of discharge his CT was stable and reviewed by dr.
[**First Name (STitle) **]. His plts were 63. The plan is to d.c home wiht close
follow up in about 1 weeks time with a CT scan of the brain.
This was discussed with him and his family. They agreed with
the plan and danger signs were discussed at length. He was
instructed to not drive or consume alcoholic beverages at this
time.
Medications on Admission:
not listed
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
RIGHT CHRONIC SUBDURAL HEMATOMA
THROMBOCYTOPENIA
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.
you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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.
[**First Name (STitle) **], to be seen in ONE week.
??????You will need a CT scan of the brain without contrast prior to
your appointment.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2101-2-10**] 11:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2101-2-10**] 10:15
Completed by:[**2101-1-31**]
|
[
"2875",
"2720"
] |
Admission Date: [**2140-8-31**] Discharge Date: [**2140-9-3**]
Date of Birth: [**2066-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
black stools
Major Surgical or Invasive Procedure:
EGD with epinephrine and cautery
History of Present Illness:
73 yo male with history of DM, HTN and PUD, who presented
initially with a 3-day history of black stools and dizziness. Pt
had a BM 2 days PTA, subsequently went to his bedroom and
"passed out onto bed". He felt dizzy and diaphoretic at that
time. The following day, his BP was 124/54 with FSG 143. He had
two episodes of dark stool that day, with a BP of 98/54 the
following day, with multiple black stools and BRBPR. He saw his
PCP, [**Name10 (NameIs) **] noted to be orthostatic with guaiac positive stools and
was referred to the ED.
.
On presentation, the pt reported lightheadness, but denied SOB,
CP, palpations, N/V, hematemesis, weight loss, changes in diet,
or change in BM caliber. Denied recent NSAID use.
.
In [**Last Name (LF) **], [**First Name3 (LF) **] NG tube was placed and lavage significant for coffee
grounds. He received 2 units PRBC and 1L NS. He was admited to
MICU on [**2140-8-31**]. Hct on admission was 25, and remained 25
despite 2U PRBC, without melena. He had an EGD on [**2140-9-1**], which
revealed a spurting vessel without obvious ulcer, consistent
with Dieulafoy's lesion, in duodenal bulb. Epi was applied
successfully. Electrocautery was applied for further hemostatis.
He was transfused 4 units PRBCs after EGD on [**2140-9-1**] and Hct
increased appropriately. He was hemodynamically stable in MICU.
He receievd an additional 2 unit PRBCs on [**9-2**].
Past Medical History:
1. Borderline DM
2. HTN
3. PUD: twenty years ago
4. Cataracts s/p extraction and Lens implantation
5. Psoriasis
Social History:
Lives with wife, who is disabled and granddaughter, [**Name (NI) **], who
is caretaker. [**Name (NI) **] tobacco, half cup of alcohol per day.
Family History:
Not done
Physical Exam:
Vitals: Tm 99.3 Tc 97.6 BP 128/63 (99-128/48-67) HR 82 (74-91)
RR 24 O2sat 98%RA
Gen: well-appearing man sitting up in bed, NAD
Derm: scattered erythematous patches with white scale on
anterior chest, elbows, scalp
HEENT: surgical pupils, EOMI, dry mucous membranes
Neck: supple, large
CV: RRR, nml S1S2, +S4, systolic murmur appreciated at LLSB
Pulm: CTA bilaterally
Abd: obese, soft NTND, NABS
Ext: no evidence of c/c/e
Pertinent Results:
CBC: WBC 13.3* Hct 25.3* Plt 209
Chem: Na 143 K 4.4 Cl 109* HCO3 47 BUN/Cr 12/1.0 Glu 113
.
CXR: There is mild cardiomegaly. The superior mediastinum
appears widened, likely due to vascular structures. The lung
fields are clear. There are no pleural effusions.
.
EKG: Sinus rhythm with top normal P-R interval 0.20. Low QRS
voltage in the limb leads.
.
EGD: Spurting vessel without obvious ulcer consistent with a
Dieulafoy's lesion was found in the duodenal bulb. 1 cc.
Epinephrine 1/[**Numeric Identifier 961**] injection was applied with successful
hemostasis. [**Hospital1 **]-CAP Electrocautery was applied for further
hemostasis. Blood in the antrum and fundus
Brief Hospital Course:
1. GIB: The patient presented with black tarry stools and
lightheadedness. Was noted in the ED to have a hct of 25,
guaiac-positive stools and orthostasis. He was admitted to the
ICU for hemodynamic monitoring. He underwent an EGD on [**2140-9-1**]
which revealed a Dieulafoy's lesion in duodenal bulb, now s/p
epi injection and electrocautery. The patient's hematocrit
bumped appropriately with blood transfusions after the EGD and
the patient remained hemodynamically stable. The patient's
serology was positive for H pylori and the patient was started
on triple therapy for two weeks as an outpatient. The patient's
aspirin was held during his acute GI bleed and should be
restarted as an outpatient.
.
2. HTN: The patient's blood pressure was initially low in the
setting of an active GI bleed. Her BP increased steadily since
EGD and treatment of Dieulafoy's lesion. Once he was determined
to be hemodynamically stable s/p procedure with no evidence of
continuing bleeding, he was restarted on his outpatient
antihypertensive.
.
3. Borderline DM: According to pt, he has been diagnosed with
"borderline DM". As his diet was advanced, his low-dose
glyburide was restarted and his sugars were under good control.
Medications on Admission:
ASA 81mg daily
Glyburide 1.25mg daily
Atenolol 100mg daily
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic PRN (as needed).
2. Glyburide 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
6. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. GI bleed from Dieulafoy's lesion, s/p EGD with epinephrine
and cautery
Secondary Diagnoses:
1. Borderline DM
2. Hypertension
3. Psoriasis
Discharge Condition:
Good, stable hematocrit without further bleeding
Discharge Instructions:
You are discharged to home and should continue all medications
as prescribed. Please discuss restarting your aspirin with your
primary care physician. [**Name10 (NameIs) 357**] do not take any NSAIDS at home.
Please contact your physician or present to the ER if you
experience black tarry stools, blood from your rectum, shortness
of breath, chest pain or other concerns.
Followup Instructions:
You have a follow-up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2140-9-14**] on 8:30AM. Provider:
[**Name10 (NameIs) 1576**],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2140-9-14**] 8:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2140-10-31**] 9:15
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"2851",
"4019",
"25000"
] |
Admission Date: [**2117-1-14**] Discharge Date: [**2117-1-28**]
Date of Birth: [**2033-12-10**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
left femoral to posterior tibial artery bypass
left below knee amputation
History of Present Illness:
Pt is an 83 y.o male with h.o CAD, s/p CABG [**2103**], HTN, PVD,
COPD, CHF, who presented to [**Hospital3 **] with difficulty ambulating
d/t PVD. There, he developed rapid aflutter and was noted to
have NSTEMI with elevated biomarkers. Stress test showed
reversible ischemia (anterior and inferior walls). Cards there
did not feel comfortable cathing the pt with PVD. Pt noted to
have NSVT-short runs. He was noted to have ABI 0.54 on R and
0.56 on Left. B/L foot "ischemia noted" L>R.
.
Pt reports chronic "angina" L.chest/neck/back/L.arm pain ~[**6-10**]
days that is not accompanied by SOB/LH/palp/diaphoresis or
nausea. He states that he takes a nitro this relieves his pain.
HE denies any increase in severity of symptoms prior to [**Hospital3 **]
admit. In addition, he denies any CP while hospitalized.
.
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, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for current absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: # severe native 3vd, patent LIMA-LAD, SVG-OM, 90% [**Hospital3 **]
ostial lesion, diffusely diseased RCA with 85% lesion and patent
SVG-RPDA. stenting of SVG-RCA [**2115-1-14**].
.
CAD s/p CABG in [**2103**] with a LIMA to the LAD, SVG to the PDA, SVG
to the OM ([**2103**])
.
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
IDDM
PVD s/p bilateral LE bypass now with dry gangrene of l 2-3rd
toes.
COPD
carotid disease
CKD 4
BPH s/p TURP
nephrolithiasis
history of thrombocytopenia
CHF
chronic thrombocytopenia
sciatica
Social History:
Pt lives at home with his wife with [**Name (NI) 11964**] dementia. Quit
smoking.
Family History:
No family history of early MI, otherwise non-contributory.
History of heart disease in mother and father with DM.
Physical Exam:
VS: t 97.9, BP 155/80, HR 20 sat 100% on 2L
GENERAL:NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
dry mucous membranes.
NECK: Supple with no elevation of JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: +stasis dermatitis, +L.foot 2nd and 3rd toe arterial
ulcers,
PULSES:
Right: Carotid 2+ Femoral 2+ trace DP PT trace+
Left: Carotid 2+ Femoral 2+ trace DP PT trace+
Pertinent Results:
CXR (portable AP) [**2117-1-15**]: No evidence of pneumonia.
.
CT head w/o contrast [**2117-1-15**]: Limited CT due to patient motion;
however, no acute pathology identified. If clinical concern for
ischemia persists, an MRI with DWI is more sensitive.
.
ECHO [**2117-1-27**] - Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild to moderate global left
ventricular hypokinesis with relative preservation of apical
function (LVEF = 35 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-1-14**],
biventricular systolic function is more depressed and the
severity of mitral regurgitation (previously minimal on review)
is increased. Right ventricular free wall hypokinesis is also
now apparent.
Brief Hospital Course:
Pt is a 83 y.o male with h.o CAD s/p CABG, HTN, PVD, DM, COPD,
CKD, CHF, chronic thrombocytopenia who presented to OSH with
weakness, was found to have afib Vs. flutter, NSTEMI, reversible
defect on PMIBI and transferred for possible cath.
.
# Coronary Artery Disease: Per last catherization, the patient
has severe native 3-veseel disease, patent LIMA-LAD, SVG-OM, 90%
[**Year (4 digits) **] ostial lesion, diffusely diseased RCA with 85% lesion and
patent SVG-RPDA. stenting of SVG-RCA [**2115-1-14**]. Pt had cardiac
enzyme elevations at OSH, likely [**3-9**] demand ischemia in the
setting of rapid Aflutter. PMIBI showed anterior/inferior
reversible perfusion defects. The interventional cardiology team
felt that there was no indication for PCI. Enzymes continued to
trend down. Continued aspirin, Plavix, beta blocker, statin,
Imdur. However, on [**1-27**] the patient had an second NSTEMI 3
days post-op with resulting Hypotension. He was transferred to
the CCU for further management. PCI again was not thought to be
an option for this patient based on his previous cath results.
He was managed medically on a heparin drip. He remained
hypotensive requiring pressors. Discussions with the patient's
family were held on on [**1-28**] and they decided to change his code
status to DNR/DNI based on his wishes. Later in the day on
[**1-18**], he became acutely bradycardic to the 30s, requiring
atropine, and had profound hypotension not reponding to maximum
dose of 3 pressors. The patient's EKG showed ST elevations in
V1-V2 with an new LBBB; the patient cath images and EKGs were
again reviewed and cath was not felt to be an option. The
patient was made comfortable and he passed away with his family
by his side at 5:30pm.
.
# PVD/gangrene: Patient with bilateral peripheral vascular
disease who was admitted with with dry gangrene of left 2nd and
3rd toes. ABI's ~.50 bilaterally. Vascular surgery was
consulted, and the patient was transferred to the vascular
surgery service. Angiography indicated a femoral to posterior
tibial bypass was a resonable option. Patient was taken to the
OR on [**2117-1-21**] and he underwent left common femoral to posterior
tibial artery bypass with PTFE. Patient tolerated the procedure
well, recovered in the PACU then transferred back to [**Hospital Ward Name 121**] 5
VICU. On [**2117-1-24**] patient was going through lower extremity
bypass pathway, was found to have lost pulse signals on the
operative side, since this was a PTFE bypass and without bypass
option, option of LBKA was discussed with patient and family
which they agreed. Patient underwent a left BKA on [**2117-1-25**] and
tolerated the procedure well without complication.
Medications on Admission:
Toprol 25mg daily
lipitor 40mg daily
neurontin 300mg [**Hospital1 **]
vicodin daily
glyburide 5mg [**Hospital1 **]
lasix 80mg Qam and 40mg Qpm
flomax 0.4mg daily
nitro
MVI
asa 325mg daily
procrit
plavix 75mg daily
Imdur 120mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
NSTEMI followed by Massive STEMI on [**1-18**]
Gangrene of LLE s/p LE bypass followed by amputation
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2117-1-31**]
|
[
"41071",
"5849",
"40390",
"5859",
"496",
"2875",
"V4581"
] |
Admission Date: [**2157-12-21**] Discharge Date: [**2157-12-29**]
Date of Birth: [**2087-2-5**] Sex: M
Service: Cardiothoracic Service
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old man
with a history of hypertension and hypercholesterolemia, who
presented to primary care provider with [**Name Initial (PRE) **] [**2-16**] week history of
burning in his chest while exercising. He was treated with
GERD without relief of symptoms. He returned to his primary
care provider, [**Name10 (NameIs) **] was referred to cardiologist, who
recommended a cardiac catheterization.
Catheterization was done on [**2157-12-20**] at [**Hospital6 **], and showed LAD with a 90% occlusion, proximal
circumflex occlusion of 60%, OM-2 70-80%, RCA 90% and an EF
of 50-55%. Patient was transferred following catheterization
to [**Hospital1 69**] for coronary artery
bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Tinnitus.
4. Anxiety.
5. Benign prostatic hypertrophy.
6. Open cholecystectomy in [**2131**].
7. Polio as a child.
SOCIAL HISTORY: Retired postal carrier. Lives with his
wife. Social alcohol use. Tobacco one pack per day x7
years, quit 47 years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS AT TIME OF ADMISSION:
1. Toprol XL 50 q.d.
2. Hyzaar 50 q.d.
3. Cardura 4 q.d.
4. Aspirin 81 q.d.
5. Isordil 30 q.d.
6. Nexium 40 q.d.
7. Xanax 0.5 q.h.s. prn.
REVIEW OF SYMPTOMS: No visual changes, no dysphagia.
Positive shortness of breath with exertion. Positive
palpitations with exertion. No GERD, no melena, no
hematochezia, no CVA, no TIA, no diabetes, no vein stripping.
PHYSICAL EXAMINATION: General: Pleasant man in no acute
distress. HEENT: Pupils are equal, round, and reactive to
light. Extraocular movements are intact. Pharynx is clear.
Neck is supple, no JVD, no bruits. Chest: Diffuse macular
rash with dry skin at edges. Lungs are clear to auscultation
bilaterally. Heart: Regular rate and rhythm, S1, S2 with no
murmur. Abdomen is soft, nontender, nondistended with
positive bowel sounds and a well-healed right subcostal
incision. Extremities: No clubbing, cyanosis, or edema.
Right lower extremity with posterior varicosities. Dorsalis
pedis and posterior tibial pulses are 2+ bilaterally. Radial
pulses are 2+ bilaterally. Neurological exam: Alert and
oriented times three, nonfocal examination.
Patient was admitted to the Cardiothoracic Service. On
[**12-23**], he was brought to the operating room at which
time he underwent coronary artery bypass grafting x3. Please
see the OR report for full details. In summary, the patient
had a CABG x3 with a LIMA to the LAD, saphenous vein graft to
OM, and saphenous vein graft to RCA. His bypass time was 74
minutes with a cross-clamp time of 42 minutes. He tolerated
the operation well, and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit.
At time of transfer, the patient's mean arterial pressure was
80. CVP was 12. She was A paced at a rate of 88 beats per
minute. She only had propofol running at the time of
transfer.
Patient did well in the immediate postoperative period as
anesthesia was reversed. Was successfully weaned from the
ventilator and extubated. On postoperative day one, the
patient remained hemodynamically stable, although he did
require Neo-Synephrine infusion to maintain adequate blood
pressure.
On postoperative day two, the patient continued to do well.
He was weaned off his Neo-Synephrine infusion. His chest
tubes were removed. His central venous catheters were
removed, and he was transferred from the Cardiothoracic
Intensive Care Unit to [**Hospital Ward Name 121**] 2 for continuing postoperative
care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. With the assistance of the nursing
staff and Physical Therapy staff, his activity level was
gradually increased until on postoperative day five, it was
decided that the patient would be ready for discharge to home
on postoperative day #6.
At that time patient's physical exam is as follows: Vital
signs: Temperature 98.3, heart rate 70 sinus rhythm, blood
pressure 100/61, respiratory rate 20, and O2 saturation 98%
on room air.
LABORATORY DATA: White count 7.5, hematocrit 29.6, platelets
281. Sodium 139, potassium 4.1, chloride 104, CO2 25, BUN
14, creatinine 0.9, glucose 99, magnesium 1.9.
General: Alert in no acute distress. Neurologic: Alert and
oriented times three, moves all extremities, and follows
commands. Cardiovascular: Regular rate and rhythm, S1, S2.
Sternum is stable. Incision with Steri-Strips open to air,
clean and dry. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended. Extremities are
warm and well perfused with no edema. Left lower leg
incision with Steri-Strips open to air clean and dry.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets p.o. q.6h. prn.
2. Enteric coated aspirin 325 q.d.
3. Colace 100 mg b.i.d.
4. Metoprolol 25 mg b.i.d.
5. Doxazosin 4 mg q.d.
6. Patient is also to resume his Nexium 40 mg q.d and Xanax
0.5 q.h.s. prn following discharge to home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x3 with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to obtuse
margin, and saphenous vein graft to right coronary artery.
2. Hypertension.
3. Hypercholesterolemia.
4. Tinnitus.
5. Anxiety.
6. Benign prostatic hypertrophy.
7. Status post open cholecystectomy.
8. Polio as a child.
DISCHARGE STATUS: The patient is to be discharged to home
with visiting nurses.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He is to have followup with Dr.
[**Last Name (STitle) **] in [**12-16**] weeks. Follow up with Dr. [**Last Name (STitle) **] in [**1-17**] weeks
and follow up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2157-12-29**] 10:03
T: [**2157-12-29**] 10:18
JOB#: [**Job Number 52991**]
|
[
"41401",
"53081",
"4019",
"2720"
] |
Admission Date: [**2183-11-25**] Discharge Date: [**2183-12-1**]
Date of Birth: [**2100-3-7**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Horse Blood Extract / Minocycline
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 year old female with chief complaint of severe shortness of
breath, cough and generalized weakness for 2-3 days. Has
long h/o copd, pulmonary nodules (? NSCLC), and atrial
fibrillation on coumadin. Pt notes worsening shortness of
breath, myalgias, and general malaise over past 2-3 days with
subjective fevers. Cough is non-productive. Denies feeling
lighthead or dizzy. No chest pain or subjective palpitations.
She was seen in office by PCP, [**Name10 (NameIs) 8706**] to have BP 98/62, p 140-160
irreg irreg, and O2 sat 79% RA, RR 28. Therefore she was sent to
the ED.
In the ED T 101.7, HR in 150, BP 112/86, R 24, 100% on
Non-rebreather
She was given 2 L NS bolus, 30 mg PO diltizam with improvement
in HR to 115 and O2Sats to 97% on 5L NC. Also given ASA,
combivent, solumedrol 125 IV x1. Started on levaquin 750 mg IV
x1, and ceftriaxone 1 gm IV x1 as CXR demonstrated pneumonia.
On arrival to the MICU the patient continued to have SOB,
although improved since arrival. Denied CP or palpatations.
Complained of insomnia.
Past Medical History:
Past Med hx:
* COPD
* Atrial fibrillation on coumadin
* h/o breast cancer
* h/o lung nodules likely NSCLC, s/p RFA treatment in [**12-24**]
* hypothyroidism
* osteoporosis
* hyperlipidemia
Social History:
SHx:
Lives alone (widowed in [**2169**]). Hospital volunteer. Family in
[**Doctor First Name 26692**]. Smoked 1PPD until age 58 (quit 20 years ago).
Family History:
Noncontributory.
Physical Exam:
PE: T: 97.7 BP: 93/35 HR: 104 RR: 12 O2 92% on 5 L NC
Gen: Pleasant elderly female in minimal distress, able to
complete a full sentence but has to catch breath at end of
sentence
HEENT: no scleral icterus, tongue dry
NECK: supple, no LAD, no appreciable JVP elevation
CV: tachycardic and irregular, no murmur
LUNGS: difficult to hear breath sounds
ABD: soft, nontender throughout, normoactive bowel sounds
EXT: warm, dp pulses 2+ bilaterally
SKIN: no rash
NEURO: face symmetric, moving all extremities without difficulty
Pertinent Results:
**ADMISSION LABS**
[**2183-11-25**] 02:30PM LACTATE-1.6
[**2183-11-25**] 02:38PM PT-18.3* PTT-25.1 INR(PT)-1.7*
[**2183-11-25**] 02:38PM NEUTS-85.9* LYMPHS-8.1* MONOS-5.5 EOS-0.3
BASOS-0.2
[**2183-11-25**] 02:38PM WBC-11.4*# RBC-3.98* HGB-12.4 HCT-35.1*
MCV-88 MCH-31.1 MCHC-35.3* RDW-13.0
[**2183-11-25**] 02:38PM CK-MB-NotDone cTropnT-<0.01
[**2183-11-25**] 02:38PM LIPASE-60
[**2183-11-25**] 02:38PM ALT(SGPT)-32 AST(SGOT)-54* CK(CPK)-84 ALK
PHOS-66 TOT BILI-1.3
[**2183-11-25**] 02:38PM GLUCOSE-108* UREA N-24* CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-30 ANION GAP-14
.
CXR: FINDINGS: There is airspace consolidation at the left lung
base, consistent
with atelectatic changes, however, an underlying infiltrate
cannot be
excluded. There is post-ablation right middle lobe opacity that
is unchanged
from prior chest CT from [**2183-11-7**]. There is calcification within
the right
breast that projects over the right lower lobe lung fields. The
cardiac and
mediastinal contours are stable in appearance. The visualized
osseous
structures are unremarkable. There is no evidence of
pneumothorax. There is
blunting of the left costophrenic angle consistent with possible
small pleural
effusion. There is no evidence of congestive heart failure.
IMPRESSION: Right lower lobe patchy opacity consistent with
atelectatic
changes, however, an underlying infiltrate cannot be excluded.
.
CXR [**2183-11-27**]
IMPRESSION: Evidence of chronic lung disease including prominent
interstitial
markings and probable underlying emphysema. Slightly interval
worsening of
bilateral pleural effusions compared to examination of two days
prior.
Bibasilar atelectasis. No definite consolidation.
.
ECHO [**2183-11-28**]
The left atrium is normal in size. The right atrium is
moderately dilated. The estimated right atrial pressure is 0-5
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 60-70%).
There is no ventricular septal defect. The right ventricular
cavity is dilated with borderline normal free wall function.
There are focal calcifications in the aortic arch. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
***LABS AT DISCHARGE***
[**2183-12-1**] 06:35AM BLOOD WBC-9.1 RBC-3.72* Hgb-11.6* Hct-33.9*
MCV-91 MCH-31.1 MCHC-34.1 RDW-13.2 Plt Ct-301
[**2183-12-1**] 06:35AM BLOOD Plt Ct-301
[**2183-12-1**] 06:35AM BLOOD PT-18.7* PTT-26.1 INR(PT)-1.7*
[**2183-12-1**] 06:35AM BLOOD Glucose-87 UreaN-9 Creat-0.6 Na-142 K-4.1
Cl-97 HCO3-40* AnGap-9
[**2183-12-1**] 06:35AM BLOOD ALT-46* AST-32 AlkPhos-65 TotBili-0.4
[**2183-12-1**] 06:35AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9
[**2183-11-30**] 07:20AM BLOOD TSH-4.6*
Brief Hospital Course:
83 y/o woman with increasing SOB and cough over last few days
presents with pneumonia and atrial fibrillation with RVR.
.
# Hypoxia: Patient's symptoms on admission, including dyspnea,
cough, and fever over past few days with myalgias in setting of
leukocytosis and CXR findings, were suggestive of PNA. On
repeat CXR, a clearly defined pneumonia was less evident, and
chest film showed worsening of bilateral pleural effusions. Pt
was given Lasix 10mg IV x 1 with thought that hypoxia would
improve with diuresis, but clinical response was limited. Given
pt's initial improvement on antibiotics and high fever on
presentation, antibiotic coverage was continued. She was
switched from Ceftriaxone and Azithromycin to Levofloxacin 750mg
PO (initially q48 [**1-18**] decreased CrCl, now daily) as she started
having a mild transaminitis, thought to be possibly secondary to
the Ceftriaxone. She will be completing a total of 7-days course
(3 doses remaining at time of discharge.) DFA and Legionella Ag
were negative. Sputum culture was sent, but sample was
insufficient. Blood cultures are still pending.
Given her history of COPD, and underlying flare was also
considered as a contributor to her hypoxia. However, she was not
particularly wheezy during her stay. Hence, steroids were not
continued beyond the Solumedrol 125mg IV x 1 dose in the ED. She
was continued on Albuterol/Ipratropium nebs. On day of
discharge, she was switched back to her home dose of Spiriva
with PRN Albuterol. She fluctuated between 3 and 4L throughout
most of her time on the floor, satting in the mid-90's at best.
She had a persistent cough that became more dry toward the end
of her hospital stay.
It was also thought that pt's Afib with RVR was likely
contributing to the development of the pleural effusions and
associated hypoxia. Pt had HR in the 150s on presentation to the
ED, and HR was as high as the 120s on the floor. HR responded
favorably to fluid boluses. Pt's home Diltiazem Extended Release
was converted to qid dosing, and uptitrated to 90mg PO qid to
maintain HR in 70s-80s. Systolic BP was stable in the 90s-100s
on day of discharge. O2 requirement had improved from 4->3L on
day of discharge.
.
# Atrial fibrillation with RVR: It is likely that patient's
underlying infection and volume depletion contributed to her
RVR. Rate was much improved after IVF and po rate control
(diltiazem). First set of cardiac enzymes were negative, and was
not cycled as rate may cause slight demand ischemia with
elevation in CE's. Additionally, patient's other symptoms were
not particularly cardiac in origin.
It was also thought that pt's Afib with RVR was likely
contributing to the development of the pleural effusions and
associated hypoxia. Pt had HR in the 150s on presentation to the
ED, and HR was as high as the 120s on the floor. HR responded
favorably to fluid boluses. Pt's home Diltiazem Extended Release
was converted to qid dosing, and uptitrated to 90mg PO qid to
maintain HR in 70s-80s. Systolic BP was stable in the 90s-100s
on day of discharge. O2 requirement had improved from 4->3L on
day of discharge. Excessive albuterol was avoided to prevent
further tachycardia. Coumadin was initially held due to guiaic
positive stools, but as crits and vitals were stable, Coumadin
was resumed on [**11-28**]. INR was uptrending, 1.7 at discharge, and
will need to be followed with Coumadin dose adjusted accordingly
to maintain INR [**1-19**].
.
# Guaiac positive stool: Pt was found to have a guiaic positive
brown stool in the ED. She has a history of colonic polyps, and
was actually due for an outpt colonscopy this week. Her previous
baseline Hct was near 40. Crit has been stable here around 33.
Pt has been hemodynamically stable, and has not had any melena
or hematochezia. Pt is to follow-up after discharge for
outpatient colonoscopy. Pt initially also had hematuria,
secondary to foley placement with resolved after foley removal.
.
# COPD: Pt has had a long history of COPD, but has not required
O2 at home. Therefore, the oxygen requirement here is likely
secondary to the acute infection/ effusions. She was continued
on her home Advair. Spiriva was initially held, but was resumed
at discharge. Steroids were not contiued as pt was not
particularly wheezy on exam, and pneumonia and pleural effusions
were thought to be the likely etiology for her hypoxia given her
fever, leukocytosis, and positive response to rate control.
.
#Transaminitis: Pt has mildly elevated transaminases seen on
transfer to the floor. There was no documented hypotension to
suggest shock liver (and not significantly elevated). It was
thought that Ceftriaxone might be contributing, and it was
discontinued, with LFTS trending downward. LFTs should be
monitored at rehab for continued downward trend. If not, other
etiology should be considered.
.
#Hypothyroidism: Stable. Pt was continued on home Levothyroxine.
TSH was checked and elevated, but should be re-checked outside
of acute infection.
.
#FEN: Regular cardiac diet. Replete lytes PRN.
.
# PPx: Coumadin (INR 1.7 on day of discharge), BM reg, Trazodone
PRN sleep
.
# CODE: Full, confirmed with patient
.
# COMM: with patient and family, daughter [**Name (NI) 553**] ([**Telephone/Fax (1) 101831**])
and son [**Name (NI) **] ([**Telephone/Fax (1) 101832**])
.
# DISPO: To [**Hospital 100**] Rehab for continued improvement of
respiratory status. Pt to continue physical therapy at rehab,
and to complete remaining 3 days of 7-day course of
Levofloxacin.
Medications on Admission:
Meds:
DILTIAZEM HCL [CARTIA XT] - 240 mg Capsule PO daily
lunesta 3mg qhs
adviar 250mcg/50mcg 1 puff [**Hospital1 **]
levothyroxine 75 mcg PO daily
tiotropium 18mcg inh daily
warfarin 5mg daily.
Allergies:
Tetracycline
Horse Blood Extract (?)
Minocycline
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO four times
a day: Hold for SBP<100 or HR<55.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff inhaled Inhalation Q4H (every 4
hours) as needed for dyspnea.
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO once a
day for 3 days.
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane every four (4) hours as needed for cough.
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
13. Trazodone 50 mg Tablet Sig: [**12-18**] Tablet PO at bedtime as
needed for insomnia.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Good, hemodynamically stable, afebrile, satting in the mid-90s
on 3L
Discharge Instructions:
You were admitted for management of low oxygen saturation and
fever. You also had a very high heart rate with your atrial
fibrillation. You were treated with antibiotics for a possible
pneumonia, and treated with high levels of oxygen initially in
the ICU. As you got better, you were transferred to the floor.
Your blood pressure medication dosing was adjusted, and you were
doing well on day of discharge.
.
If you experience any worsening shortness of breath, fever,
chills, chest pain radiating to your arms, funny heart beats, or
.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2183-12-15**] 8:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 569**],EAST PROCEDURES ENDOSCOPY SUITES
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2183-12-15**] 8:00
.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**]
after you are discharged for rehab.
- F/u TSH
- F/u heart medications and blood pressure
Completed by:[**2183-12-1**]
|
[
"486",
"5119",
"42731",
"2724",
"2449",
"V5861",
"2859"
] |
Admission Date: [**2147-2-6**] Discharge Date: [**2147-2-14**]
Date of Birth: [**2092-6-30**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
abdominal pain, BRBPR
Major Surgical or Invasive Procedure:
Paracentesis
Flexible sigmoidoscopy
History of Present Illness:
Pt is a 54-year-old female with ESLD [**1-5**] HCV and ETOH c/b
esophageal varices and refractory ascites requiring weekly
paracentesis who presented with worsening abdominal
distention/pain and two episodes of painless BRBPR. Pt has a h/o
of several SBOs and multiple hospitalizations for abdominal pain
most recently on [**1-28**] (Dx: ileus, Rx: conservatively). Patient
recieved her weekly paracentesis on Wednesday ([**1-/2064**]) but only
had 3L of fluid removed(Normal being 6-7L but tap was difficult
due to bowel distention). Post-tap developed worsening abdominal
distention and on Friday night, developed sharp pains ([**8-14**]) in
the lower quadrants. Pain is not affected by eating, bowel
movements, or position changes. Pt reports no bowel movements or
flatus for last two days despite taking increasing amounts of
lactulose. Has had nausea but no emesis. Has not been eating for
the last two days.
On Saturday evening, she went to bathroom for what she
thought was a bowel movement and noticed blood dripping from her
rectum. There was no stool. She has been wearing a pad ever
since and pad has been soaked with blood. Denies hematuria or
vaginal bleeding. She has never had any history of GI bleeding.
Last endoscopy was done on [**2147-1-4**], which showed two
grade 1 varices as well as two areas of previous banding.
In the ED, she had stable vitals and a
diagnostic/theraputic paracentesis (took off 4L) that showed no
evidence of SBP. Cr was 2.5 (baseline 1.5-1.9) and Na 131.
Rectal exam showed streak of blood, no stool. KUB thought to be
c/w SBO but were unchanged from most recent KUB with ileus. She
received 4mg IV morphine prior to transfer to floor.
Once on the medical floor she had a fever to 102.0 last
night. Pt also reports that she is now passing flatus and
having two small BM's, once bloody and one nonbloody. Her SBP's
were subsequently in the low 70's, in conjunction with a Hct of
22.6, prompting transfer to the MCIU.
On arrival to the MICU, pt is A&Ox3, only complaining of
abdominal and low back pain.
Once transfered back to the medical floor the patient was
maintained on clears and was given moviprep. She did not move
her bowel after the moviprep despite recieving 2L. The next
morning the patient still was not having BMs. She complained of
diffuse abdominal pain. An NGT was placed and 1700cc of gastric
contents were removed. She was then transferred to be under the
care of the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service
Past Medical History:
- HCV/EtOH cirrhosis (dx [**2140**]; c/b ascites, esophageal varices
s/p clipping x2, encephalopathy)
- Coma [**2145**]
- Chronic kidney disease
- Adhesion lysis for bowel obstruction [**2145**]
- ex-lap [**10-15**] for mesenteric ischemia
- s/p ex-lap LOA [**2146-10-20**]
- s/p Ex-lap/SBR x2 for perforation from blunt trauma [**2120**]
- s/p RIHR [**2112**]
- s/p Laparoscopic tubal ligation [**2125**]
Social History:
On disability, former surgical tech [**Hospital1 2177**]. 4 children and 8
grandchildren. 30 pack/year history of tobacco use, quit [**2138**].
EtOH: 12 beer/d x30yrs, has not been drinking since [**2140**]. IVDU
for 7 months in [**2114**].
Family History:
Mother: depression
Physical Exam:
VS - 98.6 120/60 109 16 95%RA
GENERAL - Alert, somewhat somnolent, NAD
HEENT - PERRL, EOMI, sclerae anicteric, dry MM, OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, severely distended, soft, no rebound/guarding;
rectal exam showing skin tags, no stool, pink blood
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - ecchymoses on RUQ abdomen
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, +asterixis
Pertinent Results:
Labs on admission:
[**2147-2-6**] 12:05AM BLOOD WBC-11.8*# RBC-3.41* Hgb-9.1* Hct-27.4*
MCV-80* MCH-26.7* MCHC-33.2 RDW-17.4* Plt Ct-101*
[**2147-2-6**] 12:05AM BLOOD Neuts-86.6* Lymphs-5.7* Monos-5.2 Eos-2.0
Baso-0.5
[**2147-2-6**] 12:05AM BLOOD PT-14.2* PTT-37.3* INR(PT)-1.3*
[**2147-2-6**] 12:05AM BLOOD Glucose-83 UreaN-45* Creat-2.5*# Na-131*
K-4.8 Cl-100 HCO3-19* AnGap-17
[**2147-2-6**] 12:05AM BLOOD ALT-48* AST-94* AlkPhos-231* TotBili-2.8*
[**2147-2-6**] 12:05AM BLOOD Lipase-62*
[**2147-2-7**] 04:48PM BLOOD CK-MB-3 cTropnT-<0.01
[**2147-2-6**] 06:55AM BLOOD Albumin-3.0* Calcium-8.2* Phos-6.4*#
Mg-2.9*
[**2147-2-6**] 12:05AM BLOOD Ammonia-75*
[**2147-2-6**] 12:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-2-7**] 01:22PM BLOOD Lactate-2.0
Labs on Discharge:
[**2147-2-14**] 06:20AM BLOOD WBC-4.3 RBC-3.23* Hgb-8.9* Hct-27.6*
MCV-86 MCH-27.6 MCHC-32.2 RDW-18.1* Plt Ct-68*
[**2147-2-14**] 06:20AM BLOOD PT-16.9* PTT-45.9* INR(PT)-1.6*
[**2147-2-14**] 06:20AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-135
K-3.9 Cl-106 HCO3-20* AnGap-13
[**2147-2-14**] 06:20AM BLOOD ALT-20 AST-37 LD(LDH)-183 AlkPhos-112*
TotBili-2.1*
[**2147-2-14**] 06:20AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.6
Microbiology:
[**2147-2-6**] 10:57AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2147-2-6**] 10:57AM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE
Epi-2
[**2147-2-6**] 10:57AM URINE CastGr-3* CastWBC-1*
[**2147-2-6**] 10:57AM URINE Hours-RANDOM UreaN-538 Creat-154 Na-LESS
THAN K-39
[**2147-2-6**] 10:57AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2147-2-6**] 12:25AM ASCITES WBC-69* RBC-2505* Polys-10* Lymphs-34*
Monos-42* Eos-1* Mesothe-2* Macroph-11*
[**2147-2-6**] 12:25AM ASCITES TotPro-0.9 Glucose-82
[**2147-2-7**] 6:04 am URINE Source: CVS.
**FINAL REPORT [**2147-2-8**]**
URINE CULTURE (Final [**2147-2-8**]): <10,000 organisms/ml.
[**2147-2-6**] 12:25 am PERITONEAL FLUID
GRAM STAIN (Final [**2147-2-6**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2147-2-6**] 10:57 am URINE Source: CVS.
**FINAL REPORT [**2147-2-7**]**
URINE CULTURE (Final [**2147-2-7**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Blood cx [**2147-2-7**]: pending
Imaging:
CT Abdomen [**2-7**]:
IMPRESSION:
1. Multiple dilated loops of small bowel with no evidence of
high-grade small-bowel obstruction; however, there are two
points in which there is
fecalization in the small bowel, one in the proximal jejunum and
one in the distal ileum. Oral contrast does not transit beyond
the distal ileum where fecalization begins. Downstream, there is
no abrupt caliber change; however, the terminal ileum is normal
in caliber. Sites of artial small-bowel obstruction are
considered, possibly related to adhesions.
2. Evidence of prior omental surgery. Of note, small bowel is
located anterior to the colon with surgical reports of extensive
lysis of adhesions and omental dissection. Internal hernia
cannot be excluded.
3. Cirrhosis with sequelae of portal hypertension. There is
moderate residual or recurrent ascites.
CXR [**2-7**]:
PA AND LATERAL CHEST RADIOGRAPH: Cardiac silhouette is normal.
Both lungs
show no evidence of focal consolidation or pneumothorax. Mild
blunting of the left costophrenic angle may represent pleural
scarring, unchanged from [**2147-1-10**]. Calcified granulomas
are noted within the. There is no evidence of free air under the
diaphragm. Lucency along the right upper abdomen appears similar
in appearance to images from [**2146-11-21**] and appears
consistent with air-filled loops of bowel displaced in a
subdiaphragmatic location. Additionally, the location is not
typical for
pneumoperitoneum which would have be seen at the highest point
of the
diaphragm.
IMPRESSION:
No free intraperitoneal air. A repeat radiograph can be obtained
if patient's symptoms persist.
KUB [**2-6**]:
IMPRESSION: Increased small bowel dilation and thickening of the
folds.
Intestinal obstruction cannot be excluded.
KUB [**2147-2-10**]:
Note is made of diffuse gas and fluid distention of the small
bowel as well as dilated loops of right-sided colon. The small
bowel is markedly distended, appearing slightly progressed from
that seen on the comparison CT. Notably, oral contrast from
that CT study is no longer visualized, presumed to have passed.
In addition, there are small locules of gas seen at the level of
the rectum. There is no pneumoperitoneum or pneumatosis. Given
the absence of the oral contrast from the comparison study,
these findings are most suggestive of severe ileus, however a
partial bowel obstruction may have a similar appearance.
Brief Hospital Course:
Primary Reason for Hospitalization:
54-year-old female with ESLD [**1-5**] HCV and ETOH complicated by
esophageal varices, ascites and encephalopathy who presented
with worsening abdominal distention/pain as well as 2 episodes
of BRBPR with course c/b hypotension requiring MICU transfer.
Active Issues:
# Abdominal pain: Pt presented with abdominal pain/distension
and nausea/vomiting. She had a diagnostic para which showed no
e/o SBP. Imaging was c/w small bowel ileus, and she was made
NPO and had NGT placed to suction. Her discomfort improved and
her diet was advanced. However her pain and nausea/vomiting
recurred after starting prep for colonoscopy. NGT was re-placed
and evacuated most of the movi-prep she had consumed, which
suggested recurrence of ileus.
#Hypotension: Likely [**1-5**] hypovolemia in setting of low BP at
baseline. Pt presented with poor PO intake and nausea/vomiting.
She was transferred briefly to the ICU and started on broad
spectrum antibiotics (IV vanc/zosyn) due to concern for sepsis,
however she remained afebrile and had no focal s/sx infection
including normal UA and CXR, no e/o SBP on diagnostic
paracentesis. Her blood pressure responded well to 3L NS and 2
units of PRBC's and remained stable. Antibiotics were
discontinued and she returned to the medical floor, BP remained
stable for remainder of hospitalization.
# BRBPR: Pt presented with 2 episodes of small amount of
painless BRBPR at home. Felt most likely [**1-5**] internal
hemorrhoids vs diverticulosis. Pt had a Hct drop from 27--> 22
during hospitalization, but this was felt most likely [**1-5**]
hemodilution as she had only one bowel movement with small
amount of gross blood. She received 2 units pRBCs and her Hct
remained stable. Initially planned for inpatient colonoscopy,
however she did not tolerate movi-prep [**1-5**] small bowel ileus.
After resolution of ileus, she had flexible sigmoidoscopy which
showed rectal varices with no stigmata of recent bleeding and
Grade 1 internal hemorrhoids.
# Acute kidney injury: Cr elevated to 2.5 on admission from
baseline of 1.3-1.4, urine lytes c/w pre-renal etiology which
was c/w pt's history of recent nausea/vomiting. Her creatinine
normalized with IV fluids and on discharge creat was 0.7.
Chronic Issues:
# ESLD: Secondary to alcohol and hepatitis C. LFTs remained
stable. On discharge she was continued on lactulose, rifaximin,
furosemide, spironolactone. She is currently active on the liver
transplant waiting list.
Transitional Issues:
-Medication changes: Restarted lasix and spirinolactone,
increased lactulose, stopped tramadol, decreased ciprofloxacin
to 250mg daily.
-She has f/u scheduled with her PCP and Dr. [**Last Name (STitle) **] after
discharge.
-Code status: Full
Medications on Admission:
1. ropinirole 1 mg Tablet Sig: 0.25 mg PO QHS PRN () as needed
for restless legs .
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO [**1-6**]
times daily : Goal [**2-6**] bowel movements daily .
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain .
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing .
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO three times a
day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
13. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for restless legs.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) cap Inhalation once a day.
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Ensure that you have [**2-5**] bowel movements per day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation q4-6h as needed for shortness of breath
or wheezing.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
15. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Orazinc 220 (50) mg Capsule Sig: One (1) Capsule PO three
times a day.
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcoholic and hepatitis C cirrhosis
Rectal varices
Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with abdominal distention, abdominal pain, and rectal
bleeding. You were treated for an ileus (or difficulty with
your bowel mobility). While you were in the hospital, you also
had an episode of rectal bleeding. Your blood counts
subsequently remained stable and you underwent a flexible
sigmoidoscopy on [**2147-2-14**] that showed hemorrhoids and rectal
varices.
Changes to your medications:
Increase lactulose to 30ml by mouth three times daily
Stop tramadol
Decrease ciprofloxacin 250mg by mouth daily
Restart lasix 20mg by mouth daily
Restart spironolactone 50mg by mouth daily
Followup Instructions:
You have the following appointments scheduled in follow-up:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: FAMILY PRACTICE
Location: STEWARD HEALTH [**Hospital **] MEDICAL GROUP
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 9587**]
Appointment: TUESDAY [**2-21**] AT 1PM
**You will be seeing Dr [**Last Name (STitle) 90766**] [**Name (STitle) **] at this visit.**
Department: LIVER CENTER
When: WEDNESDAY [**2147-2-22**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"5849",
"2761",
"V1582"
] |
Admission Date: [**2183-10-3**] Discharge Date: [**2183-11-13**]
Date of Birth: [**2111-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ceclor / Heparin Agents
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
72 y/o male w/known CAD, s/p PTCA in [**2171**]. 3 wk. hx. of GI
distress/epigastric pain. Adm. to OSH [**2183-10-2**], + enzymes. Tx.
to [**Hospital1 18**] for cath.
Major Surgical or Invasive Procedure:
[**10-4**] CABG X 3 (SVG > LAD, SVG > OM, SVG > PL) (Dr. [**Last Name (STitle) **]
[**10-21**] Tracheostomy (Dr. [**Last Name (STitle) 952**]
[**10-28**] RIJ permacath placement (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
[**11-7**] PEG placement (Dr. [**Last Name (STitle) **]
History of Present Illness:
72 y/o male w/known CAD, s/p PTCA in [**2171**]. 3 wk. hx. of GI
distress/epigastric pain. Adm. to OSH [**2183-10-2**], + enzymes. C/O
DOE for few years, recent fatigue. Tx. to [**Hospital1 18**] for cath.
Past Medical History:
known CAD, s/p PTCA [**2171**]
DM-2
HTN
hypercholesterolemia
chronic renal insufficiency (1 kidney since birth)
gout
s/p cholecystectomy
osteo as a child, s/p mult. surgery, locked left hip
s/p retinal hemmorhages
Social History:
married, lives w/wife
30 pk/yr smoker, quit 25 years ago
denies ETOH
retired
Family History:
none known
Physical Exam:
Gen: 25 # wt. loss past year
Skin: chronic left leg open area/? infection
Lungs: clear
Cor: gr. II/VI SEM
Abd: benign
Extrem: unremarkable
Pre-op labs:
Creat 2.4
BUN 56
Glucose 216
other labs WNL
Pertinent Results:
[**2183-11-10**] 02:55AM BLOOD WBC-15.1* RBC-3.45* Hgb-10.1* Hct-30.8*
MCV-89 MCH-29.2 MCHC-32.7 RDW-18.4* Plt Ct-146*
[**2183-11-10**] 02:55AM BLOOD PT-22.7* PTT-77.5* INR(PT)-3.3 (ON
ARGATROBAN)
[**2183-11-10**] 02:55AM BLOOD Glucose-60* UreaN-86* Creat-5.6* Na-139
K-4.5 Cl-98 HCO3-27 AnGap-19
[**2183-10-29**] 05:43PM BLOOD ALT-85* AST-24 AlkPhos-144* TotBili-0.8
Brief Hospital Course:
Adm. as above, Cardiac cath: 90% LM & 3vCAD, no LV [**Last Name (LF) **], [**First Name3 (LF) **] by
echo 30%. IABP placed at cath.
To. OR on [**2183-10-4**], for CABG X 3
post op TEE: EF 30%, moderate MR, on propofol, neosynephrine,
epinephrine, milrinone, insulin, dobutamine, and amiodarone IV
gtts.
Initial post-op had rapid AFib, and worsening renal function.
POD # 1: IABP D/C'd, worsening acidosis, remained sedated, CVVH
started
POD # 2: remained on Epi, neo, milrinone, amiodarone, and
propofol gtts.
POD # 3: weaning vasoactive gtts
attempted to wake patient over next few days, but very slow to
wake.
POD # 4 Cardioverted from AFib
Neuro Consult called on POD # 5 due to minimal responsiveness
after sedation d/c'd.
Head CT showed multiple pld strokes, w/1 area of possible new
infarct.
After first week:
Neuro: has recovered significantly. Presently moves arms
independently, is awake and responsive, moves legs, but weakly.
Pulmonary: Tracheostomy on [**10-21**] due to prolonged ventilator
support. Has been off ventilator since [**10-31**] (on 35% trach
mask). Uses Passey Muir valve to speak.
Cardiac: in AFib, rate 80-90's, anticoagulated.
GI: Had diarrhea initially, CDiff negative, but had rectal tube,
and subsequent rectal excoriation. (Colonoscopy on [**10-26**]:
rectal ulcers). PEG placed on [**11-7**], tolerating full strength
Nepro at 45cc/hour (goal).
GU: Permacath placed in Right IJ ([**10-28**]). Transitioned from
CVVH to hemodialysis (3X/week), initially became hypotensive
during treatments and fluid removal, but has been tolerating the
HD treatments well for the past week.
Heme: HIT +, all heparin D/C'd, Argatroban started. Coumadin
started [**11-8**] (after PEG placed).
ID: Sternal wound was locally debrided, and wound is being
dressed with collagenase dressings daily. Had MRSA sputum
culture, treated with Linezolid for 14 day course. Presently on
Levofloxacin for gm neg. UTI (day 5 of 10).
Medications on Admission:
ASA 325 QD
Lipitor 20 QD
Lisinopril 10 QD
Nifedipine 90 [**Hospital1 **]
Doxazosin 4 QD
Plavix 75 QD
FeSO4
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD ().
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
().
5. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
7. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: dose for INR target 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease
Mitral Regurgitation
Hypertension
Renal Failure
Respiratory failure
Heparin Induced Thrombocytopenia
Superficial Sternal wound infection
Discharge Condition:
Fair
Discharge Instructions:
no lifting > 10 #
no creams or lotions to incisions
Followup Instructions:
With Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 656**], and Dr. [**Last Name (STitle) **] upon discharge from
rehab
With Dr. [**Last Name (STitle) **] when ready for removal of PEG
Completed by:[**2183-11-10**]
|
[
"4280",
"5845",
"40391",
"42731",
"4240",
"5180",
"5990",
"2762",
"41401",
"2859",
"25000",
"V5867",
"2720"
] |
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