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Admission Date: [**2103-7-3**] Discharge Date: [**2103-7-26**]
Date of Birth: [**2072-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Occipital Bleed, Fever, Septecemia
Major Surgical or Invasive Procedure:
Extra ventricular drain placement and removal
History of Present Illness:
30 YO M s/p recent hospitalization at [**Hospital1 18**] [**Date range (1) 85383**] with
endocarditis. On [**2103-6-14**], he underwent aortic valve replacement
with repair of mitral valve and repair of several aortic root
abscesses. He was discharged on [**6-22**] to rehab. Of note, during
his post-op cardiac surgical course, he was noted within the
first 24h to have garbled speech, left facial droop, and left
sided weakness. Urgent head CT was negative. MRI of the head was
done on [**6-18**] findings were suggestive of infarction, but
inconclusive. He continued to gain strength of the left side and
repeat MRI was done on the day of discharge which demonstrated
an area of subacute infarct in the right precentral gyrus.
.
On [**2103-7-1**] while at the rehab facility, Mr. [**Known lastname 85379**] was noted to
have left-sided headaches, garbled speech, somnolence,
nausea/vomiting and was transferred to OSH. There, lab testing
was revealing for supratheraputic INR of 6.0 (since corrected to
1.3 prior to txfr) and head CT was performed where an occipital
hemorrhage measuring approx 5cm with and intraventricular
extension identified. He was loaded with Dilantin. Subsequent
hospital course was complicated by development of Torsades de
Pontes, for which he required defibrillation and had been
sustained on Isoprel. Once he was noted to be medically stable,
he was transferred to the MICU at [**Hospital1 18**] for definitive
evaluation and treatment.
.
On [**2103-7-3**], pt was evaluated by N-[**Doctor First Name 147**] who placed a bedside
ventricular shunt. Pt. also developed a few ([**3-8**]) short bursts
of tachycardia to 150-160, followed by a brief episode of
bradycardia, lowest HR was 34 usually would transiently go to
40s. Hydralazine was started for elevated BP (SBP goal
120-160).
.
On [**2103-7-4**], pt was exutubated, the ventricular drain was removed
and heparin sq was held for 5 days. Anticoagulation was
discussed thoroughly between N-[**Doctor First Name **] & CT-[**Doctor First Name **]. EP was
consulted, and believed that arrythmia was polymorphic VT. Some
decreases in mental status were noted - CT/CTA of head performed
urgently and showing some bleeding in the shunt tract. Fluid
bolus was given to maintain BP, there was questionable
increasing somnolence this morning, spoke with neurosurgery and
got repeat head CT.
.
On [**2103-7-5**], anisocoria was present in the morning, but reactive,
repeat head CT without change in bleed. Echo was performed
showing probable vegetation on aortic valve and new 2+ MR. Pt.
expressed desire for no further intervention, so TEE that was
ordered for Friday afternoon was canceled. Heparin gtt was
restarted without bolus in conjunction with NSG and CT surgery
attendings. Pt. was bolused for low Urinary output, vanco was
d/c'ed per N-[**Doctor First Name **] rec.
.
On [**2103-7-6**], CT head was stable, Hep gtt was continued. Pt had
supratherapeutic ptt, so values were decreased, and weight based
dosing began. Decided not to do BB test given stability and
lack of rhythm changes.
.
On [**2103-7-7**], Coumadin was restarted, PTT was therapeutic, CT head
maintained stable, per N-[**Doctor First Name **], BP goal was not as strict, and
N-[**Doctor First Name **] signed off.
.
On [**2103-7-8**], pt. was admitted to our floor/service, VS were:
T: 101, BP: 133/90, HR: 112, RR: 23, O2sat: 98%. Pt. was aware
of person, but lacks awareness of place and time. Neuro: A&Ox1,
unable to recall 3 words, CN II-XII intact, though L pupil
larger than R, Hyperreflexia to L 3+ UE & LE, L sided weakness
[**4-9**] UE & LE, L palmar drift.
.
On [**2103-7-9**], VS: 98.6 (101-98.6), 157/80 (157-80-132/80), 98
(112-98), 18 (23-18), 99% (100-98). CXR, in comparison with the
study of [**7-4**] shows no evidence of focal consolidation to
suggest pneumonia. Vancomycin, Cefepime and Gentamicin were
dosed per ID recs; Foley was d/c at midnight.
.
On [**2103-7-10**]
ID was consulted, and recommended continuation of Vanco,
Cefepime & gentamycin at current doses. PICC was pulled, and
peripheral access was was obtained.
.
On [**7-18**]
Broad spectrim ABx were d/c, and pt. was placed solely on
Ceftriaxone per ID recs.
.
[**2103-7-14**] - [**2103-7-16**], labs, VS & physical exam/neuro stable at
current baseline
CT head showed improvement from last CT head in the MICU. PICC
was put back in place b/c peripheral line was inadequate.
.
On [**2103-7-17**], tt. showed consistent neuro exams, more awake, but
increased WBC from 10-15.5. Pt. was then sent to get a CXR to
rule out pneumonia, blood cultures were taken and urine cultures
were taken. Neuro appointments were scheduled for a CT, folled
by an appointment with Dr. [**First Name (STitle) **] in [**Month (only) 216**].
.
On [**2103-7-18**]
We continued bridging to coumadin in an attempt to achieve
therapeutic INR. Neuro exams were mildly improved. There was a
mild elevation of WBC and temperature that returned to previous
baseline levels.
.
[**7-19**]-Present
Patient lost some hope about leaving, and we decided to start an
antidepressant. Throughout this time we started a 5 day
vancomycin antibiotic regimen per Infectious Disease's
recommendation (we also pulled your PICC line). We continued to
slowly increase your Coumadin levels to achieve a therapeutic
INR to protect your artificial heart valves.
.
[**7-24**]: d/c planning, scheduled PICC placement so pt. can maintain
heparin drip since subtherapeutic INR. OT/PT evaluated for
rehab. Granted stop at [**Hospital3 **] center, awaiting
insurance approval.
Past Medical History:
- Endocarditis
- Aortic Valve Replacement with a [**Street Address(2) 6158**]. [**Male First Name (un) 923**] Mechanical
Valve. Mitral Valve Repair with 28mm [**Company 1543**] Future Ring with
Repair of Anterior Leaflet of Mitral Valve. Repair of Two Aortic
Root Abscesses ([**2103-6-14**])
- PICC Lines
- History of ETOH Abuse
- s/p Tympanostomy Tubes
- s/p Dental surgery for "tooth growing into his sinuses"
- Possible drug abuse
- Prolonged QT/Torsades de Pointes
Social History:
Prior to recent admission and d/c to Newbridge on the [**Doctor Last Name **],
he was living at home with his parents, 2 cats, 1 dog, and fish.
He has no history of international travel, and no recent travel.
He works handling shipping products. Reports he drank 5+ shots
per night prior to admission, more on the weekends, smokes [**3-8**]
ppd x 15 years, denies illicit drug use, and specifically denies
IVDU. 1ppd.
Family History:
Mother with diabetes and hypertension. Father with hypertension.
Physical Exam:
Vitals (7/20@00:00) T:98.6, BP 98/65 (98-114/65-82, HR: 90
(90-104), RR: 18, O2: 93%
GEN: NAD, laying comfortably in bedside
HEENT: Healed surgical scar overlying the skin of R forehead, no
erythemia no drainage. MMM no lymphadenopathy
CV:RRR; III/VI systolic murmur at LUSB no rubs/gallops
PUL: CTA B/L, L basilar crackles that resolved after a couple of
deep inhalation with spirometer
ABD:soft, nontender, non descended, BS normoactive
EXT: L sided weakness 4/5, and L sided hyperreflexia 3+
NEURO: AOx2 fluctuating awareness of location, occasionally
believes he is not in [**Location (un) 86**] and is near his [**Location 27224**] & does not
know what day it is. Ansicoria L>Rm CNIII-XII intact, and
symmetric. Motor: LUE: [**4-9**] RUE: [**5-9**] RLE:[**5-9**] LLE:[**4-9**]. Sensation
to light touch perserved BL in Upper and Lower extermities.
Reflexes: R biceps: 2+ L biceps 3+, R Brachiorad 2+ R Brachiorad
3+, R patellar 2+ L patellar 3+. L palmar drift.
Pertinent Results:
Discharge labs:
[**2103-7-26**] 05:58AM BLOOD WBC-6.7 RBC-2.98* Hgb-8.7* Hct-27.2*
MCV-91 MCH-29.3 MCHC-32.1 RDW-17.8* Plt Ct-655*
[**2103-7-26**] 05:58AM BLOOD PT-17.8* PTT-96.2* INR(PT)-1.6*
[**2103-7-25**] 06:40AM BLOOD Glucose-89 UreaN-13 Creat-0.6 Na-140
K-4.6 Cl-102 HCO3-31 AnGap-12
[**2103-7-24**] 06:35AM BLOOD ALT-41* AST-33
[**2103-7-25**] 06:40AM BLOOD Calcium-9.7 Phos-5.5* Mg-2.1
[**2103-7-21**] 11:30PM BLOOD Vanco-15.1
.
Microbiology:
PICC tip: ([**7-19**]) (Final - no growth)
urine cx ([**7-18**])- (Final - no growth)
blood cx x1 ([**7-17**]) - STAPHYLOCOCCUS, COAGULASE NEGATIVE
Other blood cx X 9 from [**Date range (1) 85384**] - no growth to date
.
WBC:
[**7-17**] 15.5
[**7-18**] 11.3
[**7-19**] 11.4
[**7-20**] 7.7
[**7-21**] 8.3
[**7-22**] 7.1
[**7-23**] 6.0
[**7-24**] 5.6
[**7-25**] 6.2
[**7-26**] 6.7
.
TEE ([**2103-7-10**]): No vegetation of mitral valve or annuloplasty
ring. The mechanical aortic valve leaflets are not fully seen
but there is no overt vegetation. There is an echolucent area
posterior to the aortic root with flow that is new compared with
[**2103-7-5**]. This lucency has developed in the region of prior
phlegmon/abscess visualized in the [**2103-6-14**] transesophageal
echocardiogram (and probably also in the [**2103-7-5**]
transthoracic echocardiogram). There is also an echolucent area
anterior to the prosthetic aortic valve (similar to
transthoracic echocardiogram of [**2103-7-5**]) consistent with
aneurysmal right sinus of Valsalva in the region of prior
anterior aortic root abscess visualized in [**2103-6-14**] the
transesophageal echocardiogram. - Per Dr. [**Last Name (STitle) **], most likely
post-operative changes.
.
MRI/MRA Brain ([**2103-7-11**]): No significant change since the CT of
[**2103-7-7**]. Stable appearance to the left occipital hemorrhage
with intraventricular extension. Stable right frontal
ventriculostomy tract hematoma. No new sites of hemorrhage.
.
CT Head ([**2103-7-13**]): 1. No new intracranial hemorrhage. No acute
major vascular territorial infarct. No developing hydrocephalus.
2. Expected evolution of the known multifocal intraparenchymal
hemorrhages, with each focus decreased in size and attenuation.
.
CXR ([**2103-7-17**]):
In comparison with study of [**7-8**], there is the suggestion of some
vague asymmetry in opacification at the bases, with slightly
more prominent on the left. This is not definitely seen on
lateral projection, though it could represent a region of
developing pneumonia.
.
UE US ([**2103-7-17**]):
IMPRESSION: No DVT of the left upper extremity.
.
CXR [**7-24**]: IMPRESSION: New left subclavian PICC line with the
catheter tip in the azygous vein, retraction of the catheter by
3 cm is recommended.
Brief Hospital Course:
30 year old gentleman with a PMH significant for S. viridans
endocarditis, s/p 4 wk course of ceftriaxone (last day [**7-13**]) with
AV abscess s/p aortic valve replacement, mitral valve repair,
initially admitted for new occipital hemorrhage in the setting
of supratherapeutic INR (6) and 2 episodes of Torsades de Pontes
on [**2103-7-3**] requiring cardioversion, presented initially to the
MICU then was transferred to the medicine floor on [**2103-7-8**] once
stable.
.
(#)Occiptal Head bleed - presented with occipital hemorrhage in
setting of suprapeutic INR level of 6. The patient's INR was
reversed and was evaluated by Neurosurgery. A VP shunt was
placed briefly and removed once CT scans stabilized with no
evidence of midline shift. The patient was monitored closely
with q8H Neuro exams. He initally was unresponsive, L sided
aniscoria, hyperreflexia on the L UE and LE, left sided weakness
and L palmar drift. All of this has improved prior to
discharge, however her persists with confabulation, left sided
aniscoria, and mild weakness. He will require neuro rehab in
the future. Anticoagulation for prostetic valve was restarted
per N-[**Doctor First Name **] & CT [**Doctor First Name **] recommendations without changes in neuro
exam or CT findings.
.
(#)Prolonged QT / Torsades de Pointes - No subsequent episodes
following hospitalization. The cause was likely was related to
pt's concurrent intracranial process. Pt not on any notable
QT-prolonging drugs and normal QT interval seen on prior ECG
from [**6-14**]. The patient was monitored on Telemetry with no signs
of ectopy. Beta blocker was held since pt. did not exceed 120's
for extended time.
.
(#)Fever - Unclear etiology of initial fever on [**2103-7-8**], however
as below developed coag neg line infection on [**7-17**]. Given prior
endocarditis, TEE was repeated with no evidence of mass and two
aneurysms that were determined to be most likely post operative
changes by CT surgery. He was empirically treated with broad
spectrum antibiotics however given no obvious source of
infection his 4 week course of Ceftriaxone was completed on [**7-13**].
Following, Cefazolin was administered for 6 days for
superficial infection from staples & sutures to skull. At that
time, PICC tip cultures showed no growth, Blood & Urine cultures
show no growth
.
(#) Coag Neg Line Infection: On [**7-17**] the patient was found to
have positive blood cultures with coag neg staph from the PICC
line. Peripheral cultures were all negative. In consultation
with ID, the patient was treated with vancomycin for 5 days
(completed [**7-25**]) and the line was removed. WBC trended down to
5.6 and afebrile since [**7-8**] (elevated [**7-17**] to 100). Repeat blood
cultures are no growth to date.
.
(#) Endocarditis - s/p AVR & MV repair from prior admission.
Completed 4 week course of ceftriaxone on [**2103-7-13**] for S. viridans
on AV pathology. Recent TEE shows no mass as per CT sx &
healing processes.
.
(#) Prosthetic AV - As above restarted anticoagulation at the
recommendation of Neuro and CT surgery with stable appearance of
frontal hemorrhage. The patient is currently on heparin drip to
coumadin on discharge. Instructions on discharge plan.
Discharged with INR 1.6 on 7mg of coumadin, 1350units/hr of
heparin IV. His goal INR is 2.5 to 3.0, per CT surgery.
.
(#) Recent bouts of depression & confabulation- being in
hospital for extended stay. Celexa 10mg qDaily was ordered for
depression. Can think about increasing dose gradually if no
noticeable improvement. Thiamine 100 mg is also ordered for
confabulation, even though unlikely to have Wernickes. Folate,
B12, TSH and RPR all negative.
.
.
The patient was full code throughout this hospitalization.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
2. Aspirin 81 mg Tablet
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
4. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gms Intravenous Q24H (every 24 hours) for 3 weeks.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.5-3.0 for mech AVR.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Medications at OSH (per discussion with [**Name8 (MD) **] RN at OSH):
Fentanyl drip
Propofol drip
Isuprel drip
Saline 75 cc/hr
Rocephin 2 gm daily
Protonix 40 mg IV daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for depression.
4. Warfarin 6 mg Tablet Sig: One (1) Tablet PO Once daily at 4pm
(16:00): Please take a total of 7mg Warfarin a day (one 6mg tab
& one 1mg tab) with daily INR level checks. .
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once daily at 4pm
(16:00): Please take a total of 7mg Warfarin a day (one 1mg tab
& one 6mg tab) with daily INR level checks.
6. Outpatient Lab Work
Please monitor PTT levels [**Hospital1 **] and adjust Heparin accordingly
according to scale. Discontinue heparin drip once INR above 2.5
consecutively for two days.
7. Outpatient Lab Work
Please take daily INR levels. Therapeutic goal is 2.5-3.5.
Once INR stable above 2.5 for two consecutive days, can
discontinue heparin drip
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Heparin (Porcine) in NS 10 unit/mL Kit Sig: IV sliding scale
Intravenous continuous: Current infusion: 1300 units/hr
Target PTT: 60 - 100 seconds
If PTT <40: provide 1700 units bolus, then increase infusion
rate by 200 units/hr
If PTT 40 - 59: provide 900 units Bolus, then Increase infusion
rate by 100 units/hr
If PTT 60 - 100*: maintain infusion rate
If PTT 101 - 120: Reduce infusion rate by 150 units/hr
If PTT >120: Hold 60 mins, then Reduce infusion rate by 250
units/hr.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: 2 mL IV
PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
13. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Principle Diagnosis:
Fever, Parieto-Occipital Hemorrhagic Stroke, Prosthetic AV heart
valve
Secondary Diagnosis:
Endocarditis, Prolonged QT/Torsades de Pointes, Memory deficit
Discharge Condition:
Mental Status: Confused at baseline
Activity Status: Ambulatory - requires assistance or aid
(personal assistant).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Thank you for letting us participate in your care. You were
admitted to the hospital for a change in mental status. You
were found to have a bleed in your brain. This has been treated
by the neurosurgeons and is stable. Your neurologic recovery
has been steady. You will continue to require neurologic rehab
on discharge. If there is any change in mental status,
immediately contact neurologist for further examination.
You were restarted on anticoagulation during this
hospitalization. You are currently taking both coumadin and
heparin, until your INR is therapeutic for two consecutive days
(goal 2.5-3.5 per CT-surgery & Neurosurgery recommendations).
If you develop sudden headaches, nausea, vomiting, change in
mental status, or other neurologic symptoms please go to the ED
immediately. You are NOT to drive & you cannot fully take care
of yourself.
.
START:
Take [**1-6**] of a 20mg Citalopram Hydrobromide tablet (10 mg) DAILY
Take one Thiamine 100 mg tablet DAILY
Take one Warfarin 6mg tablet & one Warfarin 1mg (total 7mg)
tablet DAILY @ 4pm (16:00)
Heparin IV Sliding Scale as provided
Take one Levetiracetam 500mg tablet two times a day (every
12hrs) for 2 weeks
One Nicotine patch once a day
One multivitamin every day
Followup Instructions:
Department: CARDIAC SURGERY
When: WEDNESDAY [**2103-8-1**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: THURSDAY [**2103-8-16**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2103-8-16**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2103-8-1**]
|
[
"3051",
"311",
"2859"
] |
Admission Date: [**2101-3-17**] Discharge Date: [**2101-3-25**]
Date of Birth: [**2029-1-21**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 72 year old
woman admitted to the [**Hospital6 33**] on [**3-15**]
with the complaint of substernal chest pain. She had a
positive ETT done on [**3-16**] with ischemic changes. A
subsequently cardiac catheterization revealed 40% left main
and three vessel disease with a normal ejection fraction.
She was transferred to [**Hospital1 69**]
for coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Significant for hypercholesterolemia.
2. Hypertension.
3. Degenerative joint disease.
4. Status post right total hip replacement status post
hysterectomy.
SOCIAL HISTORY: Married and lives with husband. Denies
tobacco use; denies alcohol use.
MEDICATIONS AT HOME:
1. Hydrochlorothiazide 25 mg q. day.
MEDICATIONS AT [**Hospital6 **]:
1. Lopressor 25 mg twice a day.
2. Aspirin 325 q. day.
3. Hydrochlorothiazide 25 mg q. day.
4. Lipitor, no dose.
5. Lovenox 0.7 twice a day.
6. Xanax 0.25 p.r.n.
ALLERGIES: Include penicillin, sulfa, erythromycin,
Lisinopril, atenolol and Donnatal. The patient is unsure of
adverse reactions. She states that she can only tolerate
enteric coated aspirin.
LABORATORY: PT 12.4, PTT 29.0, INR 0.9. Sodium 143,
potassium 3.7, chloride 103, CO2 29, BUN 17, creatinine 0.7,
glucose 85. White blood cell count 5.8, hematocrit 43.1,
platelets 252.
REVIEW OF SYSTEMS: Neurological: Occasional migraines. No
cerebrovascular accidents, transient ischemic attacks or
seizures. Pulmonary: No asthma, cough. Positive dyspnea on
exertion. Cardiovascular: Chest pain with exertion. No
paroxysmal nocturnal dyspnea, no orthopnea. GI: Rare acid
reflux. No diarrhea, constipation, nausea or vomiting.
Genitourinary: No frequency, no dysuria. Endocrine: No
diabetes mellitus, no thyroid problems. [**Name (NI) **] hematological
issues. Musculoskeletal: Chronic back and neck pain.
PHYSICAL EXAMINATION: In general, this is a 72 year old
woman lying in bed in no acute distress. Neurological
grossly intact. No carotid bruits noted. Pulmonary with
lungs clear to auscultation bilaterally. Cardiac is regular
rate and rhythm with no murmur noted. Abdomen is obese,
soft, nontender, positive bowel sounds. Extremities with
bilateral varicosities, left greater than right.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] and followed by the Medicine Service
with Cardiology consultation. On [**3-21**], she was
brought to the Operating Room where she underwent coronary
artery bypass grafting times four. Please see the Operative
Report for full details.
In summary, she had a coronary artery bypass graft times four
with the left internal mammary artery to the left anterior
descending, saphenous vein graft to the ramus, saphenous vein
graft to the obtuse marginal, saphenous vein graft to the
right coronary artery. Her bypass time was 73 minutes with a
cross clamp time of 64 minutes. She tolerated the operation
well and was transferred from the Operating Room to the
Cardiac Intensive Care Unit. At the time of transfer, her
mean arterial pressure was 90 with a CVP of 11. She was
A-paced at 88 beats per minute. She had Nitroglycerin at 1
mic kilogram per minute and Propofol at 30 mics per kilogram
per minute.
She did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from the ventilator
and successfully extubated. She remained hemodynamically
stable on the operative day with Neo-Synephrine infusion.
On postoperative day one, she remained hemodynamically
stable. Her chest tubes were discontinued. Her
Neo-Synephrine was weaned to off and she was transferred to
[**Hospital Ward Name 7717**] for continuing postoperative care and cardiac
rehabilitation. On [**Hospital Ward Name 7717**] the patient remained
hemodynamically stable. She was started on beta blockade as
well as diuretics.
Over the course of the next several days, her activity level
was advanced with the assistance of the nursing staff and
Physical Therapy. Her stay on [**Hospital Ward Name 7717**] was uneventful. On
postoperative day four, it was decided that the patient was
stable and ready to be discharged to home.
At the time of discharge, the patient's physical examination
is as follows: Vital signs with temperature of 97.3 F.;
heart rate 77 in sinus rhythm; blood pressure 100/50;
respiratory rate 14; O2 saturation 93% on room air. Weigh
preoperatively 72.5 kilos and at discharge 71.5 kilos.
Laboratory data revealed white blood cell count of 6.7,
hematocrit 27.2, platelets 247. Sodium 142, potassium 3.7,
chloride 107, CO2 27, BUN 12, creatinine 0.8, glucose 92.
On physical examination she was alert and oriented times
three. Moves all extremities and follows commands. Breath
sounds with scattered rhonchi throughout. Cardiac is regular
rate and rhythm, S1, S2, with no murmurs. Sternum is stable.
Incision with staples, open to air, clean and dry. Abdomen
is soft, nontender, nondistended with positive bowel sounds.
Extremities are warm and well perfused with one to two plus
edema bilaterally, right slightly greater than left. Right
leg incision with Steri-Strips, open to air, clean and dry.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. day times ten days.
2. Potassium 20 mEq q. day times ten days.
3. Aspirin 325 mg q. day.
4. Plavix 75 mg q. day.
5. Atorvastatin 10 q. day.
6. Metoprolol 25 twice a day.
7. Dilaudid 2 to 4 mg q. four hours p.r.n.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft times four.
2. Hypercholesterolemia.
3. Hypertension.
4. Degenerative joint disease.
5. Status post right total hip replacement.
6. Status post hysterectomy.
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged home with [**Hospital6 1587**] services.
2. She is to have follow-up in the [**Hospital 409**] Clinic in two
weeks.
3. Follow-up with Dr. [**Last Name (STitle) 13175**] and/or [**Last Name (un) **] in three weeks.
4. Follow-up with Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], NP
MEDQUIST36
D: [**2101-3-25**] 17:21
T: [**2101-3-25**] 19:04
JOB#: [**Job Number 52860**]
|
[
"41401",
"5990",
"4019",
"2720"
] |
Admission Date: [**2173-4-14**] Discharge Date: [**2173-4-21**]
Date of Birth: [**2104-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p Coronray Artery Bypass Graft x 2 (LIMA to LAD, SVG to Ramus)
on [**2173-4-14**]
History of Present Illness:
68 y/o female w/ h/o HTN, ^Chol, DM, CHF w/ cc of SOB and recent
+ETT. Referred for cardiac cath which revealed 2 vessel disease.
Past Medical History:
Hypertension
Hypercholesterolemia
Diabtes Mellitus
Congestive Heart Failure
GERD
Colon CA s/p coloectomy on 5FU and leucovorin
Anemia
DJD-neck
h/o GI Bleed (negative EGD/colonoscopy)
Thrombophlebitis R Leg
Anxiety
s/p C-sectionx4
s/p Cataract surgery
s/p T&A
Social History:
Lives w/ husband. -ETOH/Tobacco
She is a retired teacher who lives with her
husband and cat. She denies alcohol or smoking history.
Family History:
non-contributory
Physical Exam:
VS: 57SR 119/70 20 100%2L 5'[**77**]" 130lbs
General: Lying in Bed, NAD
Neuro: A&Ox3, MAE, Follows commands, non-focal
HEENT: PERRLA, EOMI
Neck: Supple, -JVD, -Bruits, Wears soft collar for DJD
Chest: CTAB -w/r/r
Heart: RRR +S1S2 -c/r/m/g
Abd: Soft NT/ND/NABS well-healed midline incision
Ext: Warm, well-perfused -c/c/c
Pulses: Carotids/Radials/Fem Bilat. 2+, DP 1+
Pertinent Results:
[**2173-4-14**] 11:33AM BLOOD WBC-4.2 RBC-2.43*# Hgb-7.4*# Hct-21.8*#
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.7 Plt Ct-93*#
[**2173-4-20**] 05:19AM BLOOD WBC-11.6* RBC-3.71* Hgb-11.0* Hct-33.2*
MCV-90 MCH-29.6 MCHC-33.1 RDW-15.2 Plt Ct-284
[**2173-4-14**] 11:33AM BLOOD PT-19.7* PTT-48.7* INR(PT)-2.6
[**2173-4-17**] 03:26AM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1
[**2173-4-14**] 01:15PM BLOOD UreaN-13 Creat-0.5 Cl-108 HCO3-22
[**2173-4-18**] 03:23AM BLOOD Glucose-277* UreaN-11 Creat-0.6 Na-130*
K-4.0 Cl-96 HCO3-28 AnGap-10
[**2173-4-20**] 05:19AM BLOOD Glucose-127* UreaN-13 Creat-0.7 Na-134
K-4.1 Cl-96 HCO3-30* AnGap-12
[**2173-4-15**] 12:54AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.5*
[**2173-4-20**] 05:19AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.5*
[**2173-4-14**] 09:17AM BLOOD freeCa-1.23
[**2173-4-19**] 03:06AM BLOOD freeCa-1.18
Brief Hospital Course:
As mentioned in the HPI, pt. had cath on [**2173-3-17**] which revealed
2 VD (LAD 80%, LCx 80%) and was a same day admit on [**2173-4-14**] for
bypass surgery. Once in the OR, pt underwent a CABGx2 after
general anesthesia. Please see op note for full surgical report.
Pt tolerated the procedure well with a total bypass time of 38
minutes and cross clamp time of 21 minutes. She was transferred
to CSRU in stable condition with a MAP of 68, CVP 4, HR of 80
A-paced and being titrated on Neo, Propofol, and an Insulin gtt.
Later on op day, pt was weaned from propofol and mechanical
ventilation and was successfully extubated. He was awake, alert,
MAE and following commands. She remained hypotensive throughout
the night and received Neo and also 1 unit PRBCs with
improvement. On POD #2 chest tubes were removed. Pt. remained
stable and slowly improved but still required Neo for pressure
support. Diuretics started per protocol. POD #3 pt. still
remained on Neo and was transfused 2 units of PRBCs (HCT 24).
Insulin started at 1/2 home dose and foley removed. Pt. remained
stable through POD #4, started on B-blockade and was getting OOB
and ambulating well. His epicardial pacing wires and central
line were removed on POD #5. His exam was unremarkable and
besides extended pressure support via Neo had uncomplicated
post-op course. Transferred to telemetry floor on POD #5 and on
POD #6 appeared very well and at level 5. On POD#7 she was ready
for discharge. Her physical exam was unremarkable besides some
pedal edema. She was alittle above her pre-op wt and lasix would
be continued at home.
Medications on Admission:
1. Atenolol 50mg qd
2. Lisinopril 10mg qd
3. Lipitor 10mg qd
4. Insulin NPH 25 units AM 3 PM
5. RISS
6. FeSO4
7. Lorazepam 1mg PRN
8. Tylenol PRN
9. TUMS PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
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:*1*
3. Pantoprazole Sodium 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:*1*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous qAM: And 3 units qPM.
Disp:*7 units* Refills:*2*
10. Insulin Regular Human 100 unit/mL Solution Sig: [**12-2**] units
Injection once a day as needed for blood glucose: Take as
directed by PCP (sliding scale based on blood glucose).
Disp:*1 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronray Artery Bypass Graft x 2
Hypertension
Hypercholesterolemia
Diabtes Mellitus
Congestive Heart Failure
GERD
Colon CA s/p coloectomy on 5FU and leucovorin
Anemia
DJD-neck
h/o GI Bleed (negative EGD/colonoscopy)
Thrombophlebitis R Leg
Anxiety
s/p C-section
s/p Cataract surgery
s/p T&A
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and mild soap.
Gently pat dry.
Do not take bath or swim.
Do no apply lotions, creams, or ointments to incisions.
Do not lift greater then 10 pounds for 2 months.
Do not drive for 1 month.
Make/keep all follow-up appointments.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks.
Follow-up with Dr. [**Last Name (STitle) 9006**] in [**11-29**] weeks.
Follow-up with Dr. [**Last Name (STitle) **] in [**12-31**] weeks.
|
[
"41401",
"4280",
"4019",
"2720",
"2859",
"25000",
"53081",
"V5867"
] |
Admission Date: [**2156-3-12**] Discharge Date: [**2156-4-5**]
Date of Birth: [**2104-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mental status changes secondary to acute hemmorrhagic cva.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 yo M s/p mechanical redo-AVR for endocarditis in [**1-23**] c/b
take back for tamponade. He completed his antibiotic course at
home but then was hospitalized on [**2-23**] for PICC line sepsis with
serratia sensitive to Cipro. He was started on Cipro, the PICC
was dc'd and he was discharged. He was readmitted on [**3-6**] with
altered mental status and found to have an acute hemoorhage in
the left parietal lobe iwht breakthrough hemorrhage in the left
lateral ventricle and third ventricle with subfalcine shift up
to 7mm. Craneictomy was performed, he was stabilized and
transferred to [**Hospital1 18**] for further management of his ID issues.
Past Medical History:
PMH thrombocytopenia, COPD, HepC, endocarditis/diskitis,
depression, anxiety, AVR '[**45**]
Social History:
+ tobacco 20 pack years
denies etoh
unemployed
Family History:
NC
Physical Exam:
NAD, A&O x 3
RRR, no M/R/G
Lungs CTAB
Abdomen benign
Extrem no edema
Skin MSI well healed, Left craniotomy c/d/i with staples.
Left UE & LE strenth [**3-19**], Right UE & LE strength 3/4
Pertinent Results:
[**2156-4-5**] 07:45AM BLOOD WBC-3.2* RBC-3.59* Hgb-10.7* Hct-32.2*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.6* Plt Ct-93*
[**2156-4-5**] 10:00AM BLOOD PT-24.7* PTT-37.2* INR(PT)-2.4*
[**2156-4-5**] 07:45AM BLOOD Glucose-94 UreaN-24* Creat-0.7 Na-135
K-5.2* Cl-98 HCO3-30 AnGap-12
[**2156-3-12**] 05:25PM BLOOD ALT-20 AST-26 LD(LDH)-265* AlkPhos-90
Amylase-94 TotBili-0.6
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2156-4-4**] 3:53 PM
CT HEAD W/O CONTRAST
Reason: please assess ICH
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with s/p ICH x 2 / now on anticoagulation
REASON FOR THIS EXAMINATION:
please assess ICH
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 51-year-old male status post intracranial
hemorrhage, now on anticoagulation.
Heterogeneous focus of high-attenuation is seen within the left
frontoparietal with surrounding vasogenic edema, slightly
improved compared to prior exam from [**2156-3-28**]. Mixed
density extra-axial collection persists along the left cerebral
convexity subjacent to the craniotomy site. A new 4-mm focus of
high- attenuation is seen within the right occipital lobe
(series 2, image 14), likely representing a hemorrhage.
Compared to the prior exam, the degree of sulcal effacement in
the left cerebral hemisphere and mass effect exerted upon the
left lateral ventricle is unchanged. There is no hydrocephalus
or shift of normally midline structures. The visualized sinuses
and mastoid air cells remain normally aerated.
IMPRESSION:
1. Evolving intraparenchymal hemorrhage within the left parietal
lobe, with minimal improvement in the surrounding vasogenic
edema since [**2156-3-28**].
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76735**]Portable TTE
(Complete) Done [**2156-3-29**] at 12:21:04 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-9-3**]
Age (years): 51 M Hgt (in): 71
BP (mm Hg): 110/70 Wgt (lb): 130
HR (bpm): 95 BSA (m2): 1.76 m2
Indication: Left ventricular function. Endocarditis.
ICD-9 Codes: V42.2, 424.1, 424.2, 424.0, 424.90
Test Information
Date/Time: [**2156-3-29**] at 12:21 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**]
[**Last Name (un) 16813**], RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 26 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.14
Mitral Valve - E Wave deceleration time: *348 ms 140-250 ms
TR Gradient (+ RA = PASP): 13 to 19 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2156-3-13**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Mild regional LV systolic
dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated aortic arch. No 2D or
Doppler evidence of distal arch coarctation.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Increased
AVR gradient. Small vegetation on aortic valve. Trace AR. [The
amount of AR is normal for this AVR.]
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Trivial MR. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve
leaflets. Physiologic (normal) PR.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is very mild regional left
ventricular systolic dysfunction with septal hypokinsis. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. A bileaflet aortic valve
prosthesis is present. The transaortic gradient is higher than
expected for this type of prosthesis. There is a small
vegetation/?thrombus (0.5cm x 0.4cm) on the aortic valve (clip
[**Clip Number (Radiology) **]). Trace aortic regurgitation is seen. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. The estimated pulmonary artery systolic pressure is
normal. The pulmonic valve leaflets are thickened.
Compared with the prior study (images reviewed) of [**2156-3-13**],
the small mass on the prosthetic aortic valve is new with
increased transvalvular gradient. The left ventricular systolic
function may be better.
RADIOLOGY Preliminary Report
CAROT/CEREB [**Hospital1 **] [**2156-3-23**] 11:16 AM
CAROT/CEREB [**Hospital1 **]
Reason: Was recurrent left parietal bleed caused by a mycotic
aneury
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with history of endocarditis and AVR who had a
recurrent left parietal bleed.
REASON FOR THIS EXAMINATION:
Was recurrent left parietal bleed caused by a mycotic aneurysm
or AVM?
HISTORY: 51-year-old male patient with history of endocarditis
and aortic valve replacement had recurrent left parietal bleed.
Evaluate for mycotic aneurysm or arteriovenous malformation.
PROCEDURE PERFORMED: Right common carotid arteriogram, right
internal carotid arteriogram, left internal carotid arteriogram,
left external carotid arteriogram and right vertebral artery
arteriogram.
2. New 4-mm punctate focus of high-attenuation in the right
occipital lobe, consistent with hemorrhage.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Brief Hospital Course:
He was admitted to cardiac surgery. He was started on vanco,
cipro and gent. He was seen by neurosurgery and restarted on
coumadin and heparin secondary to the risk of embolic stroke
from his mechanical valve. TEE showed no evidence of recurrent
endocarditis. Vanco and gentamycin were dc'd. MRA showed no
evidence of mycotic aneurysm. Prostate u/s was negative as
well, and his cipro was dc'd. Repeat head CT on [**3-21**] showed
worsening intracranial hemorrhage, and he was transferred to the
ICU for closer monitoring. His anticoagulation was held and he
received 4 units of FFP. Angiography on [**3-23**] which demonstrates
no aneurysm, vascular malformation or arteriovenous fistula. He
was transferred back to the floor. Anticoagulation continued to
be held. Prior to restarting anticoagulation, repeat head CT on
[**3-27**] showed Slight improvement in trapping of left temporal
[**Doctor Last Name 534**]. Otherwise minimal change compared to prior study. [**3-30**] HIT
[**Doctor First Name **] was found to be positive, argatroban and coumadin were
started. A serotonin assay was sent.Infectious Diseases was
consulted for recommendations if deemed necessary. He awaited
therapeutic INR for discharge to home with VNA. [**2156-4-4**] Head
CT showed an evolving intraparenchymal hemorrhage within the
left parietal lobe, with minimal improvement in the surrounding
vasogenic edema since [**2156-3-28**].And new 4-mm punctate focus
of high-attenuation in the right occipital lobe, consistent with
hemorrhage. Neurosurgery was reconsulted and a repeat head CT
was performed prior to discharge which showed no short-term
interval change compared to CT from [**2156-4-4**] at 15:57.
Neurosurgery recommended anticoagulation with Coumadin.Mr.[**Known lastname **]
was discharged to home with VNA services on [**2156-4-5**].
Medications on Admission:
naficillin 2gm q4h (staph), ASA, Lasix 40', KCL, Methadone 15"',
Roxicodone 15 prn, rifampin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR
results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**].
11. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2
days: please take 7.5mg on mon [**4-5**] and tues [**4-6**] - have inr
checked [**4-7**] for further coumadin dosing .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
ICH
Heparin induced thrombocytopenia
PMH
Chronic diastolic heart failure
Endocarditis
bacteremia
bentall w/ homograft '[**45**]
Hepatitis C
Chronic pain
depression
Anxiety
Discharge Condition:
Good
Discharge Instructions:
PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR
results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**].
No lifting greater than 10 pounds for 10 weeks from date of
surgery
Call for fevers greater 100.5 redness or drainage from wounds
No driving until cleared by neurology
Shower daily, wash and pat incisions dry
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) 656**] (neurology) 2 weeks [**Telephone/Fax (1) 1694**]
Dr [**Last Name (STitle) 39975**] in 3 weeks
Dr [**Last Name (STitle) **] in 3 weeks
PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR
results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**].
Completed by:[**2156-4-6**]
|
[
"496",
"4280",
"41401",
"V4581",
"3051",
"V5861"
] |
Admission Date: [**2138-9-8**] Discharge Date: [**2138-9-25**]
Date of Birth: [**2056-8-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. Removal of hardware (old gamma nail)
2. Acetabuloplasty with girdlestone procedure, debridment of
nounion-malunion callous and debridment of psudoacetabulum and
true acetabulum superior dome.
3. Acetabular reconstruction with femoral head autograft with
ORIF of superior acetabular dome using the autograft and pelvic
plates along the posterior wall and column
4. Excision of heterotopic ossification from gluteal muscle
5. Right cemented total hip arthroplasty
.
IVC FILTER PLACEMENT
1. Ultrasound-guided puncture of right common femoral vein.
2. Placement of Bard G2 IVC filter.
3. Inferior venacavogram.
Colonoscopy
History of Present Illness:
Pt is an 82 yo F with a R hip fracture in [**6-27**] s/p failed ORIF
c/b LE DVT now on coumadin who presents with anemia noted on
routine lab draws and guaiac positive brown stool. Pt's fall
and surgery occured in FL where she lived; she moved to [**Location (un) 86**]
after the surgery failed for further medical care and to be
closer to her [**Location (un) 802**].
.
Pt reports constipation when she was in FL, but she relates this
to her percoset use post-op. Pt had several days of n/v/d one
week prior to admission, which pt relates to "food poisoning"
which has now resolved. In general over past several months, pt
denies change in weight, change in bowel movements, n/v/d,
melena, bloody stool, abdominal pain, bloating, vaginal
bleeding, tea colored urine or pale stool. She has never had a
colonoscopy; her last mamogram was years ago.
.
Over the past month pt's Hct has trended 32->26->24. At [**Location (un) **]
on the day of admission, her INR was >5, so she received 5 mg PO
vitamin K and was transferred to the [**Hospital1 18**] ED.
.
In the ED, she was hemodynamically stable: 97.3, 82, 109/45,
18,97% RA.
.
On the floor, she has no complaints. She denies CP, SOB,
palpitations, abdominal pain, dysuria, fever, night sweats,
fatigue, poor energy, or any other symptoms.
Past Medical History:
Dementia
Hyperchol
R hip fx s/p ORIF [**6-27**] in FL, c/b post-op DVT, on coumadin. Seen
here by ortho, Dr. [**Last Name (STitle) 1005**], with planned repair and ?IVC prior
to surgery
"murmur"
"mild CHF"
Social History:
Pt lived in FL, now moved to [**Hospital1 **] Home for the Aged, an
[**Hospital3 **] facility. She normally walks with a cane, but
has been bedbound due to her non-healed ORIF. She has a 40
pack-year smoking history but quit 20 years ago. She denies ETOH
or drug use. Her [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 80291**] is her HCP [**Telephone/Fax (1) 80292**].
Family History:
no hx of colon ca, ovarian ca, breast ca
Physical Exam:
On admission::
VS: 98.8, 108/60, 73, 18, 94%RA
Gen: obese elderly woman, hard of hearing, NAD
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: RR, nS1 S2, II/VI holosystolic murmur
Pulm: CTAB anteriorly
Abd: +BS, NTND, No HSM. No CVAT. No spinal tenderness
Extrem: large legs, no pitting edema, R leg shorter and
internally rotated. No tenderness to palpation at wound site.
Rectal: G+ in the ED
Neuro: A&O x 3
.
At discharge::
97.8 / (129/61) / 84 / 97% on room air
-I/VI holosystolic murmur
-lungs clear bilaterally, poor effort, distant
-abdomen obese, soft, nontender
-scar on right hip with staples, minimal erythema, overlying
sheets stained with yellow serous fluid
-legs are obese and symmetrically large. unclear how much of leg
distension is a result of fluid overload vs obesity. non
pitting.
Pertinent Results:
[**2138-9-8**] 08:53PM BLOOD WBC-6.1 RBC-2.79* Hgb-7.6* Hct-23.3*
MCV-83 MCH-27.1 MCHC-32.5 RDW-16.0* Plt Ct-376
[**2138-9-23**] 05:50AM BLOOD WBC-9.1 RBC-3.22* Hgb-9.2* Hct-28.1*
MCV-87 MCH-28.6 MCHC-32.8 RDW-16.7* Plt Ct-181
[**2138-9-24**] 05:45AM BLOOD WBC-11.1* RBC-3.48* Hgb-9.9* Hct-30.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.1* Plt Ct-239
[**2138-9-25**] 05:35AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* Plt Ct-308
[**2138-9-9**] 06:30AM BLOOD Ret Aut-2.2
[**2138-9-8**] 08:53PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-139
K-3.3 Cl-103 HCO3-28 AnGap-11
[**2138-9-24**] 05:45AM BLOOD Glucose-65* UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-105 HCO3-25 AnGap-14
[**2138-9-25**] 05:35AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-139
K-3.8 Cl-103 HCO3-26 AnGap-14
[**2138-9-22**] 02:41AM BLOOD Calcium-7.5* Phos-2.2* Mg-1.9
[**2138-9-10**] 04:28AM BLOOD VitB12-933*
[**2138-9-9**] 06:30AM BLOOD calTIBC-250* Hapto-313* Ferritn-19
TRF-192*
[**2138-9-13**] 06:30AM BLOOD CEA-4.4* CA125-11
=====================
CXR ([**9-23**]): improving retrocardiac density and small left
effusion.
=====================
Distal sigmoid, biopsy: Adenocarcinoma
=====================
Cardiac ECHO: Normal global and regional biventricular systolic
function. Moderate pulmonary artery systolic hypertension. Mild
aortic stenosis.
=====================
CT of chest abdomen pelvis:
1. Thickening of the mid segment of the sigmoid colon with no
proximal
obstruction is compatible with the patient's known sigmoid
cancer.
2. 7-mm right lower lobe pulmonary nodule. Considerations
include
metastatic focus or inflammatory/infectious process. FDG- PET
can be obtained for further evaluation but lesion is borderline
in size for detection by FDG-PET. Pulmonary edema and
atelectasis limits evaluation for pulmonary nodules; dedicated
repeat chest CT could be obtained after optimization of
pulmonary status for better assessment.
2. Colonic diverticulosis with no evidence of diverticulitis.
3. Cholelithiasis. Dilated CBD and possible focal pancreatic
ductal
dilation (vs small pancreatic cystic lesion). MRCP could be
obtained for
further evaluation.
4. Relative enlargement of the right ovary which is unusual for
the patient's age. This can be further evaluated by pelvic
ultrasound.
5. Large axial hiatal hernia.
6. Bilateraly hypodense renal lesions, too small to
characterize, and 31-mm right renal lesion possibly representing
a hyperdense cyst but indeterminate.
MR of the abdomen can be obtained for further characterization.
9. Chronic fracture of the right femoral neck which is
associated with
displacement of the femoral neck and head fracture fragments,
not in
contact with the dynamic hip screw.
Brief Hospital Course:
82 yo F with hx of CHF, dementia and hip fx s/p ORIF on Coumadin
presented with asymptomatic anemia and supratherpeutic INR,
found to have 6 cm fungating mass in sigmoid colon on
colonoscopy. Pt underwent substantial surgery of the right hip
(description attached). Surgical and medical oncology agreed
that the pt must recover functional status (ie be able to walk)
in order to be a candidate for surgical resection of her colonic
mass and subsequent chemotherapy. Repeat LENIS sowed no remaing
DVT. Coumadin was discontinued and the pt was stater on lovenox
(prophylactic dose) prior to discharge. Hospital course by
problem:
.
# Anemia: Pt's HCT was in the 30s 1 mo ago; on admission, HCT
was 23 and dropped to 21 with guaiac positive stool but no frank
blood in stool. EGD was performed which showed large hiatal
hernia but no source of bleed. Colonoscopy was performed, which
showed a 6 cm fungating mass in the sigmoid colon which was the
likely source of the pt's anemia. Pt was also found to be iron
deficient and she was started on supplemental iron. B12 was WNL.
Pt's Hct in 30-31 range and stable on day of discharge.
Reccommened checking CBC at least twice per week or more often
if grossly bloody bowel movements present.
.
# Colon Cancer: Adenocarcinoma by biopsy. General surgery and
oncology were consulted. Per oncology, pt is unable to receive
chemotherapy until she can walk. chemo should be done approx 1
mo after surgery. Pt has follow-up with surgical oncology
scheduled.
==CT chest/abdomen/pelvis was done for staging.
--7mm RLL nodule noted; FDG-PET can be obtained for further
evaluation.
--Relative enlargement of the right ovary which is unusual for
the patient's age. This can be further evaluated by pelvic
ultrasound (US showed complex cyst which should be followed in
[**1-23**] months).
--31-mm exophytic cyst of the lower pole of the right kidney,
does not have
the complete appearance of the simple cyst. MR of the abdomen
can be obtained
for further characterization.
.
# Hx of DVT: LENIs were negative for DVT. Given pt's recent DVT
and high risk for thrombosis given malignancy, she was started
on lovenox at prophylactic dose (30 subQ [**Hospital1 **]). IVC filter also
placed.
.
# Hip repair: Surgical intervention is outlined in "major
surgical procedures" section. At time of discharge, scar has
minimal erythema, staples are in place, there is no overt sign
of infection. Overling sheets become damp with serous
discharge--this is expected to the current degree. Pt has
follow-up scheduled with orthopedics. Requiring rehab as per
Physical Therapy reccomendations.
.
# Hx of "mild CHF": pt was on Lasix at home, but this was held
on admission due to GI bleed. She received 20 IV Lasix and O2
sats improved. Pt also had TTE which showed nl EF, mild AS, mild
TR, mod PAH, and some signs of early diastolic CHF. Given good
response to Lasix IV, would dose on a prn basis for low 02
saturation and dyspnea.
Medications on Admission:
Warfarin 2.5 mg daily
Simvastatin 40 mg qhs
Aspirin 81 daily
lasix 20 mg QD
KCL 10 mEQ QD
Acetaminophen-oxycodone prn
Acetaminophen prn
MVI
Bisacodyl prn
Docusate
Senna
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).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Ferrous Sulfate 325 mg (65 mg Iron) 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 once a day.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Pain.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours). mg
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO qhs prn as needed
for sleep.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] HOSP. AT [**Location (un) **]
Discharge Diagnosis:
1. COLON CANCER
2. Failed gamma nail fixation with cutout and acetabular
destruction.
3. Deep Vein Thrombosis
4. Dementia
Discharge Condition:
medically stable for transfer to rehab
Discharge Instructions:
Dear Ms. [**Known lastname 40553**],
You were admitted to the hospital initially because you were
loosing significant amounts of blood in your stool. A work-up
revealed that you have colon cancer. While you were here, your
hip was repaired. The surgical and medical cancer specialists
agree that you have to regain your strength before proceeding
with removal of the mass in your colon and the chemotherapy
which is required after surgery. For this reason, you will be
going to a facility where you will receive physical
rehabilitation.
Your medications have changed substantially during your recent
hospitalizations. An updated list will be available to you and
the rehabilitation facility where you will be.
If you note significant blood in your stool or if the scar on
hip appears to be infected please return to the hospital. Please
note the follow-up appointments that have been scheduled for you
below. You should also try to see your primary care physician
[**Name Initial (PRE) 176**] 2-3 weeks. You have not been scheduled for an
appointment with medical oncology, this is because this will be
arranged for you after you have been seen by surgical oncology.
Followup Instructions:
ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2138-9-30**] 2:55
Orthopedics: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2138-9-30**] 3:15
SURGICAL ONCOLOGY: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2138-10-14**] 1:00
Completed by:[**2138-9-25**]
|
[
"4280",
"2720",
"4168",
"V5861"
] |
Admission Date: [**2181-8-16**] Discharge Date:
Date of Birth: [**2115-1-26**] Sex: M
Service: CARDIOTHORACIC SURGERY
This is an addendum to the [**8-25**] discharge summary.
On [**8-26**], postoperative day #6, the patient continues to do
well and was started on hydralazine 5 mg q 6 to help control
the hypertension. On postoperative day #7, the patient
continued to do well and had no other issues. The patient
will be discharged today as planned.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2181-8-27**] 07:33
T: [**2181-8-27**] 09:25
JOB#: [**Job Number 41493**]
|
[
"41401",
"9971",
"42731",
"4280",
"4241",
"496"
] |
Admission Date: [**2105-1-12**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2040-2-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64F active smoker with h/o CHF (EF 40% [**2103-12-12**])and COPD (on 3L
at home when compliant) who presents with worsening dyspnea x 1
day. Patient reports a long standing history of COPD for which
she has been on home oxygen. She reports that her breathing was
tolerable in that she was able to perform activities of daily
life up until a knee surgery in [**2104-9-15**]. Since the knee
surgery, she has experienced worsening difficulty breathing and
leg swelling.
.
She saw her [**First Name9 (NamePattern2) 99701**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] on [**2104-12-12**], at which
time he suspected she had a combination of left and right-sided
CHF per notes and increased her lasix from 60 to 80 mg po. He
recommended 24 hr-O2 although patient now reports that she only
wears oxygen when her symptoms bother her. She was admitted
[**Date range (1) 99702**] of this year for foot pain and worsening SOB thought
to be secondary to a combination of CHF exacerbation and COPD.
She was diuresed with IV lasix 80 [**Hospital1 **] and eventually refused
further diuresis and requested to be discharged per notes. She
was discharged on a steroid taper. She now reports that she was
still having difficulty breathing at the time of discharge.
.
On [**2105-1-10**], she [**Date Range 653**] her PCP with complaints of difficulty
breathing and was told to increase her lasix to 80 mg [**Hospital1 **] which
she did over the weekend. She continued to have SOB and saw her
PCP today who sent her to the ED after her sats were 80% at rest
and 60s with ambulation. Of note, she only took 40 mg lasix
this AM because she had decided that she would be coming to the
hospital.
.
She also reports greenish sputum that differs from her normal
sputum that is crystal white. She is unable to quanitfy how
long she has had green colored sputum and says that it is
complicated by her having been intermittently on antibiotics,
although she cannot recall dates/durations. She denies fevers,
runny nose, and sick contacts although she says that people
around her have certainly had the common cold.
.
In the ED, she was given lasix 40 mg IV, prednisone 60 mg,
albuterol/ipratropium, azithromycin 500 mg, and
hydrocodone-acetaminophen. CTA r/o'd PE and LENIs were negative
for DVT. CXR prelim read concerning for mild CHF and evidence
of COPD. Per ED resident, her sx improved dramatically with
above treament.
.
Currently, she reports feeling "not good". She continues to
complain of shortness of breath and leg swelling. She feels
that she has been unable to normally perform activities of daily
life such as climbing a flight of stairs since her knee surgery
and would like to have her breathing problems resolved this
admission. She continues to smoke and thinks she should start
drinking alcohol. Current VS: 124/60 rr16 94% on3L HR 74
afebrile.
Past Medical History:
HTN
CHF: systolic and diastolic
Cardiovascular procedures/symptoms: echo w/low EF 25-30%, 42% by
cath [**3-19**], has chronic LE swelling
COPD
pulmonary nodules and lymphadenopathy on CT
Diabetes: diet controlled
hypercholesterolemia
GERD that she reports is better since partial colectomy
RA X 15 years but no flares recently
reports LBP for many reasons including weight but also reports
OA
Social History:
TOB [**1-16**] ppd X 30 years -> now smokes 1 cigarette every 2-3 days.
Denies etoh, illicits. Lives with daughter.
Family History:
Non-contributory
Physical Exam:
GENERAL - NAD, comfortable, appropriate, able to speak in full
sentences
HEENT - sclerae anicteric, MMM,
LUNGS - bilateral rales, diffuse wheezes bilaterally,
HEART - irregular rhythm, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - 3+ pitting edema, excoriations
NEURO - awake, A&Ox3, CNs II-XII grossly intact
At discharge:
same as above except:
LUNGS - poor air entry diffusely, no rales, faint end expiratory
wheezes diffusely
EXTREMITIES - 2+ pitting edema to 2/3 up calf b/l, R slightly
greater than L, no calf tenderness
Discharge weight: 84.2kg (standing)--this is not considered her
dry weight
Pertinent Results:
ADMISSION LABS:
[**2105-1-12**] 02:15PM BLOOD WBC-8.4 RBC-4.98 Hgb-12.9 Hct-43.4 MCV-87
MCH-25.9* MCHC-29.8* RDW-20.1* Plt Ct-260
[**2105-1-12**] 02:15PM BLOOD Neuts-86.1* Lymphs-10.8* Monos-2.5
Eos-0.5 Baso-0.2
[**2105-1-12**] 02:15PM BLOOD Glucose-136* UreaN-19 Creat-0.7 Na-143
K-3.8 Cl-94* HCO3-39* AnGap-14
.
DISCHARGE LABS:
[**2105-1-16**] 07:05AM BLOOD WBC-10.4 RBC-4.46 Hgb-11.4* Hct-38.7
MCV-87 MCH-25.6* MCHC-29.5* RDW-20.2* Plt Ct-219
[**2105-1-16**] 07:05AM BLOOD Glucose-95 UreaN-18 Creat-0.6 Na-144
K-3.3 Cl-95* HCO3-44* AnGap-8
[**2105-1-16**] 07:05AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.0
................................................................
MICRO:
[**2105-1-12**] Blood Cx: NG (final)
[**2105-1-13**] Sputum Cx: commensal resp flora
[**2105-1-13**] Rapid Resp Viral Screen: negative
................................................................
IMAGING:
[**2105-1-12**] CXR: Cardiomegaly, no definite signs of CHF or
pneumonia.
.
[**2105-1-12**] Bilateral LE LENI: No evidence of DVT.
.
[**2105-1-12**] CTA Chest:
1. No evidence of pulmonary embolism.
2. Multiple stable bilateral pulmonary nodules.
3. Non-specific mildly prominent mediastinal and hilar lymph
nodes.
.
[**2105-1-13**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF 75%). The right ventricular free
wall is hypertrophied. The right ventricular cavity is dilated
with normal free wall contractility. The aortic valve is not
well seen. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
The mitral valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. Compared with
the findings of the prior study (images reviewed) of [**2103-12-12**], the left ventricle now appears hyperdynamic. Diastolic
dysfunction of the left ventricle is likely present.
.
[**2105-1-13**] CXR: In comparison with the study of [**1-12**], there is
increased
engorgement and indistinctness of pulmonary vessels, consistent
with the
clinical impression of elevated pulmonary venous pressure
related to volume overload. Otherwise, little change.
.
[**1-15**] CXR: Cardiomegaly is stable. There is no pneumothorax or
enlarging pleural effusions. Mild pulmonary edema is stable.
There are no new lung opacities.
Brief Hospital Course:
64F active smoker with h/o CHF (EF 40% [**2103-12-12**]) and COPD (on 3L
at home when compliant) who presents with worsening dyspnea x 1
day.
.
# Shortness of Breath:
Patient taken to the floor, given 40mg IV Lasix, started on 60mg
prednisone, continued on Azithromycin 500mg, and initially
saturating 90% on 3L NC. Overnight, patient desaturated to
70-80%, stat CXR showed worsening fluid overload, switched to 5L
by FM and placed on continuous O2 monitoring and was given nitro
SL for possible flash pulmonary edema. ABG showed worsening CO2
retention. Antibiotic coverage was broadened to IV
vancomycin/cefepime. Patient was also noted to be intermittently
somnolent, so was transferred to the MICU for further
evaluation. CTA chest was negative for PE. An ECHO showed
diastolic dysfunction with an EF 75%. Given the CXR findings,
elevated BNP, and LE edema, the hypoxia was felt to be partially
secondary to decompensated heart failure, though unknown
trigger. Lasix was held given relative hypotension and
aggressive diuresis on the floor. Given her wheezing and cough
there was also concern for a COPD exacerbation and infection
such as influenza vs. bronchitis. She was continued on the
Azithromycin, Prednisone, Advair, and Combivent. Prednisone 60mg
x 5 days was completed on [**1-16**] and she was restarted on her home
dose of 5mg daily. Azithromycin was given for total 5 days,
completed [**1-16**]. The vancomycin/cefepime were stopped as there was
no clear evidence of pneumonia on CXR. Rapid viral screen was
negative and empiric oseltamivir was discontinued. Her
oxygenation improved and she was transferred back to the floor,
where her requirement improved to 5L NC at time of discharge
with SpO2 in the mid 90s. She was counseled on the importance of
smoking cessation and wearing her BiPAP at night (she should be
discharged from rehab with BiPAP). She walked with PT but
desaturated to t he mid 80s after approx. 100 feet. Advair and
Spiriva restarted at time of discharge and albuterol switched to
nebs. PCP was [**Name (NI) 653**] re: metoprolol vs diltiazem to try and
reduce bronchospasm and agreed with plan to transition to
diltiazem but had already received metoprolol dose on day of
discharge. Rehab should consider switching from metoprolol to
diltiazem. Patient should also be offered all forms of smoking
cessation therapy (nicotine patch started inhouse) prior to
discharge.
.
# Altered Mental Status/Hypercarbia: Pt noted to be somnolent
prior to MICU transfer. ABG showed pCO2 of 66 at that time. Pt
likely has elevated pCO2 at baseline but seems to have narrow
window before becoming somnolent from hypercarbia. HCO3 rose to
44 on day of discharge (baseline likely low 30s). Aggressive
diuresis should be balanced against worsening contraction
alkalosis.
.
# Leukocytosis: Likely related to bronchitis and steroids. No
clear evidence of pneumonia on CXR so the vanc/cefepime were
stopped. Blood culture and viral resp screen were negative.
Persistent leukocytosis likely [**12-17**] prednisone burst. Afebrile on
floor.
.
# HTN: Normotensive this admission without amlodipine and
lisinopril. Meds were both stopped and should be restarted if BP
worsens, in order to optimize diastolic CHF.
.
# CAD: Aspirin not on med list but pt reports taking and PCP
[**Name Initial (PRE) 99703**]. Was discharged on ASA 81mg daily.
.
# Transitional issues:
- Continue diuresis with IV furosemide (not at dry weight yet)
and balance against worsening contraction alkalosis (HCO3=44 at
discharge) and transition to PO dosing
- Consider changing metoprolol to diltiazem to reduce
bronchospasm
- Continue to encourage smoking cessation, d/c with nicotine
patch
- Restart lisinopril and/or amlodipine if hypertensive
- Discharge to home with supp oxygen and BiPAP
Medications on Admission:
Lipitor 80 mg Tab
1 Tablet(s) by mouth at bedtime
Calcarb 600 With Vitamin D 600 mg-400 unit Tab
1 (One) Tablet(s) by mouth twice a day
hydrocodone-acetaminophen 5 mg-500 mg Cap
1 Capsule(s) by mouth four times a day as needed for pain
Advair Diskus 500 mcg-50 mcg/Dose for Inhalation
one inhalation twice daily
Spiriva with HandiHaler 18 mcg & inhalation Caps
Contents of one capsule inhaled once a day
nystatin 100,000 unit/mL Oral Susp
5 ml by mouth three times a day
Proventil HFA 90 mcg/Actuation Aerosol Inhaler
2 puffs inhaled up to four times a day as needed for shortness
of breath or wheezing
furosemide 40 mg Tab
2 (Two) Tablet(s) by mouth once a day
Lisinopril 40 mg Tab
1 Tablet(s) by mouth once a day
Omeprazole 20 mg Cap, Delayed Release
1 (One) Capsule(s) by mouth once a day
prednisone 5 mg Tab
2 Tablet(s) by mouth once a day with food for one week and then
one tab daily
Methotrexate (Anti-Rheumatic) 2.5 mg Tabs in a Dose Pack
6 Tablets(s) by mouth one day per week
potassium chloride SR 10 mEq Cap
2 (Two) Capsule(s) by mouth once a day
Nitroglycerin 0.3 mg Sublingual Tab
1 Tablet(s) sublingually under the tongue prn chest pain
Plaquenil 200 mg Tab
1 (One) Tablet(s) by mouth twice a day
Metoprolol Tartrate 50 mg Tab
1.5 Tablet(s) by mouth twice a day
Ultram 50 mg Tab
2 Tablet(s) by mouth tid prn
Docusate Sodium 100 mg Cap
1 Capsule(s) by mouth twice a day
oxycodone 5 mg Tab
1- Tablet(s) by mouth every 4-6 hours as needed for Pain do not
drink, drive, or operate heavy machinery while taking this
medication. take a stool softener
Amlodipine 10 mg Tab
1 (One) Tablet(s) by mouth once a day
Folic Acid 1 mg Tab
1 Tablet(s) by mouth once a day
FreeStyle Test Strips
for blood sugar testing once a day or as directed
Aspirin 81mg daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcarb 600 With Vitamin D 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
3. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash: Please apply under right
breast.
6. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
disk Inhalation twice a day.
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO three
times a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Six (6) Tablets, Dose Pack PO once a week.
12. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO once a day.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual Q5min as needed for chest pain: Max 3 5 min apart
then go to ER.
14. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. insulin lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED).
20. furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
[**Hospital1 **] (2 times a day).
21. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q4H
(every 4 hours).
23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb treatment Inhalation Q6H (every 6
hours) as needed for sob./wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Hosptial
Discharge Diagnosis:
Acute on chronic diastolic congestive heart failure exacerbation
Acute on chronic chronic obstructive pulmonary disease
exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for shortness of breath. You were
found to have worsening congestive heart failure and chronic
obstructive pulmonary disease. There was concern for infection
as well. You were treated with diuretics, steroids, and
antibiotics. Your condition improved and you did not require as
much oxygen at time of transfer.
The following changes were made to your medications:
STOP oral furosemide
STOP albuterol inhaler
STOP lisinopril
STOP oxycodone
STOP amlodipine
START IV furosemide and adjust dose as needed
START miconazole powder as needed for rash under R breast
START albuterol nebs, both every four hours and as needed every
six hours
START nicotine patch
Please stop smoking. Please maintain a low salt diet. Weigh
yourself every day and call your doctor if your weight goes up
by 3 pounds or more. Please take all medications as instructed.
Followup Instructions:
The following appointments have been made for you:
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2105-1-30**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: FRIDAY [**2105-1-30**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You should schedule an appointment with Dr. [**Last Name (STitle) 5263**] once you are
discharged from rehab.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"51881",
"4280",
"32723",
"3051",
"53081",
"25000",
"2720"
] |
Admission Date: [**2181-5-30**] Discharge Date: [**2181-6-27**]
Service: Vascular Surgery
CHIEF COMPLAINT: Aortoiliac aneurysm.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old
nondiabetic white male with hypertension, chronic low back
pain secondary to spinal stenosis, who complained of
increased lower back pain since [**2181-3-6**]. The patient was
evaluated by an orthopedic surgeon with an MRI that showed an
abdominal aortic aneurysm.
The patient was referred to Dr. [**Last Name (STitle) **] for further
evaluation. He underwent an outpatient arteriogram on [**2181-5-10**]. He was admitted for an elective aortoiliac aneurysm
repair.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Herpes zoster of the right trigeminal nerve.
3. Bacterial meningitis.
4. Increased intraocular pressure.
5. Spinal stenosis.
6. Right sciatica.
7. Degenerative joint disease.
PAST SURGICAL HISTORY:
1. Carpal tunnel release.
2. Left total knee replacement.
3. Right total hip replacement.
ALLERGIES:
1. Percodan causes hallucinations.
2. Vicodin causes a rash.
3. Benadryl causes hives.
ADMISSION MEDICATIONS:
1. Atenolol 25 mg p.o. q.d.
2. Aspirin 325 mg p.o. b.i.d.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a retired electrical
engineer. He stopped smoking cigarettes 30 years ago. He
drinks two to three alcoholic drinks per day. He lives with
his wife. His daughter lives next door. He ambulates with a
cane.
PHYSICAL EXAMINATION: Vital signs were pulse 87, respiratory
rate 21, blood pressure 145/60, oxygen saturation equals 98%
on room air. General: Alert, cooperative white male in no
acute distress. HEENT: Normocephalic. Pupils were equal,
round and reactive to light. Tongue was in the midline.
Neck: Range of motion was within normal limits. There was
no lymphadenopathy. Chest: Heart was regular rate and
rhythm without murmur. Lungs: Clear bilaterally. Abdomen:
Soft. Nontender. Bowel sounds present. Aorta palpable.
Rectal: Examination deferred. Extremities: Arthritic
changes present. Pulse examination: Carotid, radial,
femoral, popliteal, dorsalis pedis pulses were all 2+
bilaterally. Posterior tibial pulses were 1+ palpable
bilaterally. Neurologic: Examination nonfocal. Alert and
oriented x 3.
LABORATORY STUDIES: On [**2181-5-11**] the white blood cell count
was 7.8, hemoglobin 12.1, hematocrit 34.6, platelet count
173,000, sodium 138, potassium 4.3, chloride 105, bicarbonate
24, BUN 15, creatinine 1.0, glucose 96. EKG on [**2181-5-25**]
showed a sinus rhythm with a rate of 67. Borderline
intraventricular conduction delay. Compared to previous
tracing of [**2181-5-10**], sinus rate is faster and sinus
bradycardia no longer is present. Chest x-ray on [**2181-5-25**]
showed emphysema.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2181-5-30**] following an aortobi-iliac bypass graft. At the end
of surgery the patient had equally warm feet with Doppler
signals of the dorsalis pedis bilaterally. He was given
Kefzol perioperatively. He was transfused two units of
packed red blood cells immediately postoperatively.
The patient's postoperative course was complicated. Shortly
after surgery he developed episodes of bradycardia to a rate
of 30-40 with associated hypotension. Cardiology was
consulted. A TEE was done that was negative. The patient
was transferred to the SICU on a dopamine drip. Heparin was
removed from all of his lines after platelets drifted down
from 136,000 to 95,000. He was given Ativan 1 mg IV q. 6
hours for ethanol withdrawal prophylaxis. Fentanyl was given
p.r.n. A nasogastric tube was kept in place and IV Protonix
was ordered. Anesthesia capped his epidural catheter.
The electrophysiology service was consulted. The patient's
heart rate was in the 70s after the dopamine drip was weaned
off. No further immediate treatment was necessary. The
following day the patient had a VT arrest twice. He was
cardioverted successfully twice. Beta blocker was started.
Amiodarone and propofol drips were started following his
second VT arrest. The patient was transfused packed red
blood cells to keep his hematocrit greater than 30. The
amiodarone drip was stopped after two days.
The patient was weaned off of his IV Ativan for alcohol
withdrawal prophylaxis. Diuresis was continued. On
postoperative day number seven the patient had a fever spike
to 101.2. Vancomycin was added to levofloxacin already on
board. The following day the patient spiked to 104.1.
Sputum, blood cultures and urine cultures were sent. Flagyl
was added to the vancomycin and levofloxacin. General
surgery was consulted to evaluate for a possible
intra-abdominal process. They felt there was more likely a
septic process going on. Infectious disease service was
consulted. They recommended stopping the vancomycin,
levofloxacin and Flagyl. Zosyn 4.5 grams IV q. 6 hours was
ordered. Blood cultures grew E. coli. Sputum grew Proteus.
Urine culture grew E. coli and 10-100,000 Enterococcus.
Vancomycin was continued to cover the Enterococcus. Lines
were changed. Blood cultures were repeated. A chest x-ray
showed right lower lobe pneumonia.
The patient failed extubation on postoperative day number
eight. He was finally extubated on postoperative day number
10. The vancomycin was stopped. Aggressive pulmonary toilet
was ordered. Dilaudid subcutaneous was given for incisional
pain. The nasogastric tube had over 400 cc of guaiac
positive fluid. This was felt to be old postoperative blood.
The patient was continued on IV Protonix.
Infectious disease recommended changing the IV Zosyn to
ceftriaxone for a combined total of 14 days. This was to be
followed by two to four weeks of oral antibiotics. The
patient was started on levofloxacin on [**2181-6-19**] and will be
finished on [**2181-7-4**].
On [**2181-6-12**] bedside swallow study showed that the patient had
a nonfunctioning swallow. Nasogastric tube continued. The
patient had had a Dobbhoff placed on [**2181-6-8**] to initiate
tube feedings when the catheter was postpyloric.
The patient was transferred to the VICU on [**2181-6-12**]. Video
swallow done on [**2181-6-13**] was not possible because the patient
could not follow commands. He continued to be confused,
sometimes combative, and required a sitter.
The electrophysiology service was consulted again regarding
the placement of AICD. The EPS agreed to place the device
after a total of two weeks on antibiotic therapy. A right
PICC line was placed for TPN and IV antibiotic therapy.
However, the patient pulled out the PICC line five days after
placement. This was not replaced. Video swallow done on
[**2181-6-18**] showed normal swallow, no aspiration, but decreased
pharyngeal sensitivity. The patient was able to tolerate a
regular diet and therefore did not require any further TPN.
The Dobbhoff catheter was removed.
Repeat blood cultures were negative. An AICD via the left
cephalic vessel was placed on [**2181-6-21**]. Three days of
vancomycin were ordered post device placement. The patient
was to follow up in the Device Clinic one week after
insertion.
The patient remained somewhat agitated. He required a sitter
for several evenings because of combativeness and climbing
over bed rails. He is slowly improving and at the time of
dictation, is much clearer mentally and able to have short
conversations.
The patient developed an area of thrombophlebitis over his
left arm puncture site. He was started on Kefzol on
[**2181-6-24**].
Physical therapy was consulted on [**2181-6-25**] for full
weight-bearing ambulation. The patient did fairly well with
a rolling walker, but required constant supervision because
of poor concentration and unsteadiness. The patient is being
screened for [**Hospital 3058**] rehabilitation. At the time of
dictation, his abdominal incision is clean, dry and intact.
His feet are equally warm with palpable pedal pulses. His
left arm puncture site is slightly red and firm.
DISCHARGE MEDICATIONS: Will be dictated in the addendum.
DISPOSITION: To [**Hospital 3058**] rehabilitation facility.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS: Aortoiliac aneurysm.
SECONDARY DIAGNOSES:
1. Postoperative bradycardia and hypotension.
2. Ventricular tachycardia arrest x 2 on [**2181-6-2**].
3. Automatic implantable cardioverter-defibrillator placement
on [**2181-6-21**].
4. Right lower lobe pneumonia with Proteus; treated.
5. E. coli urosepsis; treated.
6. E. coli bacteremia; treated.
7. Respiratory failure with prolonged intubation; extubated
on postoperative day number 10, [**2181-6-10**].
8. Blood loss anemia; multiple transfusions.
9. Heparin-induced thrombocytopenia; transient.
10. Malnutrition; short-term TPN.
11. Left arm thrombophlebitis; treated.
12. Ethanol withdrawal prophylaxis with Ativan.
13. Postoperative delirium; improving.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2181-6-26**] 14:02
T: [**2181-6-26**] 14:22
JOB#: [**Job Number 49120**]
|
[
"2851",
"5990",
"2875",
"51881"
] |
Admission Date: [**2137-11-20**] Discharge Date: [**2137-11-24**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine / Xanax
/ Oxycodone
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation
paracentesis
hemodialysis
History of Present Illness:
Pt admitted to the MICU 2 days ago and now being transferred
from the MICU. Please see original admission note for full H&P,
PMH, home meds, SH, and FH. Briefly, this is a 59yo male with a
past medical history of ESRD, ESLD, and epilepsy who was
admitted from the ED with altered mental status and s/p seizure.
He was found confused and lethargic at his [**Hospital3 **]
facility and trasferred to [**Hospital1 18**] where he had a witnessed
seizure. He reports that he was recently started on dilantin at
his last hospitalization, which his neurologist was currently
weening. He was hypersensive upon admission, and he was
intubated for hypoxia and airway protection. He was given a
head CT which was unremarkable, received kayexalate for
hyperkalemia to 5.8, 2mg ativan x 2, ceftriaxone IV, and
lopressor IV. He has multiple admissions for confusion, SOB,
HTN, and falls in the past year. In the MICU, he was rapidly
extubated and his blood pressure normalized. He was called out
after stabilization and extubation. He had no further seizure
activity.
.
When I saw him upon transfer, he was comfortable and only
complained of itchiness of his left arm. He does not remember
the seizure. He denies headache, dizziness, CP, abdominal pain.
He was scheduled for an outpatient paracentesis this morning,
which he missed because he was in the hospital.
Past Medical History:
-Seizure disorder
-ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2
failed renal transplants
-labile hypertension
-hypothyroidism
-peripheral [**Hospital1 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-systolic w/ EF 45% and diastolic dysfunction (echo
[**12/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
-Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
-h/o mechanical falls admitted [**1-16**]
-h/o VRE, MRSA
Social History:
Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called
[**Hospital1 **] at
[**Hospital1 1426**], on disability, has two sons. smokes 1ppd x 40 yrs, no
etoh, drugs.
Family History:
Mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
PHYSICAL EXAM:
T 38.0 / HR 87 / BP 109/83 / RR 13 / 100% room air / 24hr I/O
+530, +2243 for entire length of stay.
Gen: pleasant, NAD
HEENT: NCAT, eomi grossly, MMM
CV: RRF, NL S1, S2. No m/r/g
LUNGS: bibasilar crackles and decreased bs diffusely, no w/r
ABD: Soft, mildly tender in epigastric region, mildly distended
but not tense, no obvious fluid wave, no hsm, no masses
EXT: No c/c/e
SKIN: No rash
NEURO: AOx4, cn 2-12 intact grossly, strenth [**6-15**] throughout, no
asterixis
Pertinent Results:
Admission Labs:
[**2137-11-20**] 11:50PM GLUCOSE-92 UREA N-25* CREAT-4.3*# SODIUM-139
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2137-11-20**] 11:50PM CALCIUM-7.8* PHOSPHATE-6.1*# MAGNESIUM-2.0
[**2137-11-20**] 11:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2137-11-20**] 11:50PM WBC-4.4 RBC-3.32* HGB-9.3* HCT-27.6* MCV-83
MCH-28.0 MCHC-33.8 RDW-19.5*
[**2137-11-20**] 11:50PM NEUTS-63.1 BANDS-0 LYMPHS-23.8 MONOS-12.3*
EOS-0.4 BASOS-0.4
[**2137-11-20**] 11:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-OCCASIONAL
OVALOCYT-NORMAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
[**2137-11-20**] 11:50PM PLT SMR-NORMAL PLT COUNT-273
[**2137-11-20**] 11:50PM PT-12.9 PTT-81.9* INR(PT)-1.1
[**2137-11-20**] 03:46PM AMMONIA-35
[**2137-11-20**] 03:38PM GLUCOSE-92 UREA N-40* CREAT-6.0*# SODIUM-137
POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-23 ANION GAP-24
[**2137-11-20**] 03:38PM ALT(SGPT)-13 AST(SGOT)-30 ALK PHOS-213*
AMYLASE-55 TOT BILI-0.3
[**2137-11-20**] 03:38PM LIPASE-24
[**2137-11-20**] 03:38PM CK-MB-5 cTropnT-0.08*
[**2137-11-20**] 03:38PM ALBUMIN-3.6 CALCIUM-7.7* PHOSPHATE-8.2*#
MAGNESIUM-2.1
[**2137-11-20**] 03:38PM LACTATE-1.1
[**2137-11-20**] 03:38PM WBC-6.7 RBC-3.71* HGB-10.5* HCT-31.8* MCV-86
MCH-28.2 MCHC-32.9 RDW-19.5*
[**2137-11-20**] 03:38PM NEUTS-63.9 BANDS-0 LYMPHS-26.3 MONOS-9.1
EOS-0.3 BASOS-0.4
[**2137-11-20**] 03:38PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-2+
[**2137-11-20**] 03:38PM PLT SMR-NORMAL PLT COUNT-307
[**2137-11-20**] 03:38PM PT-14.3* PTT->150* INR(PT)-1.3*
.
Discharge labs:
[**2137-11-24**] 07:05AM BLOOD WBC-6.3 RBC-3.49* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.2 MCHC-33.7 RDW-19.1* Plt Ct-345
[**2137-11-24**] 07:05AM BLOOD PT-11.9 INR(PT)-1.0
[**2137-11-24**] 07:05AM BLOOD Glucose-101 UreaN-27* Creat-4.3*# Na-138
K-5.1 Cl-96 HCO3-28 AnGap-19
[**2137-11-22**] 03:22AM BLOOD ALT-12 AST-26 LD(LDH)-208 AlkPhos-197*
Amylase-41 TotBili-0.4
[**2137-11-22**] 03:22AM BLOOD Lipase-14
[**2137-11-24**] 07:05AM BLOOD Calcium-8.3* Phos-7.3*# Mg-2.3
[**2137-11-24**] 07:05AM BLOOD Phenyto-12.2 Phenyfr-LESS THAN
.
Micro:
WOUND CULTURE (Final [**2137-11-25**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
.
STUDIES:
CXR - [**2137-11-20**] -
1. Satisfactory positioning of the endotracheal tube.
2. Enlarged cardiac silhouette likely due to stable cardiomegaly
with low lung volumes.
3. Retrocardiac opacity either representing infiltrate or
atelectasis.
.
Echo [**2137-8-22**] - moderately dilated LA; no ASD; symmetric LVH; EF
40-50%; elevated LV filling pressure; RV free wall hypertrophy;
trace AR; 1+ MR; moderate PA systolic hypertension
.
CT HEAD W/O CONTRAST Study Date of [**2137-11-20**] 3:40 PM
IMPRESSION: Motion limited. No evidence of intracranial
hemorrhage. Stable exam.
.
ECG Study Date of [**2137-11-20**] 5:06:34 PM
Sinus rhythm with atrial premature depolarizations. Left axis
deviation. Possible left anterior fascicular block. Left
ventricular hypertrophy by voltage criteria in precordial leads.
Delayed anterior precordial R wave progression with
non-diagnostic repolarization abnormalities consistent with left
ventricular strain pattern. Compared to previous tracing of
[**2137-9-25**] multiple abnormalities as previously noted persist
without major change.
.
PARACENTESIS DIAG. OR THERAPEUTIC [**2137-11-22**] 3:07 PM
IMPRESSION: Ultrasound-guided paracentesis, removal of 3 liters
of fluid.
Brief Hospital Course:
59 yo male with past medical history of ESRD on HD, ESLD, and
seizure disorder was admitted with altered mental status and
seizures.
.
1. Seizure/altered mental status
He had a seizure at home and another witnessed seizure in the
ED. Patient with multiple admissions previously. Differential
included hypertensive encephalopathy, hepatic encephalopathy,
post-ictal state, electrolyte imbalances in the setting of
missing HD, poorly controlled seizure disorder in the setting of
medication noncompliance, and infection. Infection appeared less
less likely given that patient was afebrile, normal WBC, and no
localizing symptoms. He was briefly intubated for airway
protection and then extubated. Now patient is stable without
further seizure for past two days. Mostly likely explanation is
probably low dilantin level vs electrolyte imbalance. He had no
further seizure activity. In addition to continuing his home
regimen, he was reloaded with dilantin. During his stay his
catheter site was cultured and grew out coag negative staph
which was sensitive to everything but penicillin. The results
came back after he left so this was communicated by email to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] of hepatology, who is the next provider to see
him. He was afebrile during the last few days of his stay. He
received Vancomycin during his stay per HD protocol.
.
2. ESRD
Followed closely by Dr. [**Last Name (STitle) 1366**] and dialyzed at [**Location (un) **] [**Location (un) **].
He was dialyzed in the MICU and then returned to his regular HD
schedule. Renal was consulted. He was continued on his home
regimen and also given cinacalcet.
.
4. Hypertension
Patient was significantly hypertensive on admission, which came
undercontrol during his stay. His clonidine was stopped. His
dose of metoprolol was changed to 150mg daily. His nifedipine
was changed to nifedipine sustained release 180mg daily. On day
of discharge, his lisinopril was also restarted at his home
dose. His regimen should be titrated as needed and his clonidine
should be restarted as well if his BP tolerates.
.
5. Cirrhosis
He was given rifaximin and lactulose as well as an elective
paracentesis as he had already had one scheduled.
.
6. Peripheral [**Location (un) **] Disease. Stable
His plavix 75mg PO qdaily and aspirin 81mg PO daily were
continued.
.
7. Depression:
His nortriptyline was continued.
.
8. Hypertensive Cardiomyopathy
His beta blocker was continued and his HTN control was
maximized.
.
9. CODE: DNR, confirmed with son [**Name (NI) **] [**Name (NI) 93850**] on [**2137-11-20**] over
the phone
.
10. COMM: [**Name (NI) **]; Health Care Proxy [**First Name8 (NamePattern2) **] [**Known lastname 93850**]
[**Telephone/Fax (1) 93897**]; Health Care Proxy [**First Name8 (NamePattern2) 3640**] [**Known lastname 93850**] [**Telephone/Fax (1) 93898**]
Medications on Admission:
nifedipine ER 60 mg every eight hours
lisinopril 20 mg daily
metoprolol 50 mg t.i.d.
Lamictal 250 mg b.i.d.
Keppra 375 mg b.i.d.
Dilantin 300 mg once daily
Plavix 75 mg once daily
Ecotrin 81 mg once daily
Prevacid 30 mg once daily,
nortriptyline 10 mg once daily
Sensipar 30 mg daily.
Discharge Medications:
1. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO every
twenty-four(24) hours.
3. LaMOTrigine 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times
a day).
4. Lamictal 25 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO twice a day.
5. Famotidine 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q24H (every 24
hours).
6. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Cap
PO DAILY (Daily).
8. Lactulose 10 gram/15 mL Syrup [**Telephone/Fax (1) **]: Thirty (30) ML PO TID (3
times a day).
9. Aspirin 81 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Rifaximin 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3 times
a day).
11. Levetiracetam 250 mg Tablet [**Telephone/Fax (1) **]: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Phenytoin Sodium Extended 100 mg Capsule [**Telephone/Fax (1) **]: One (1)
Capsule PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Telephone/Fax (1) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Nifedipine 90 mg Tablet Sustained Release [**Telephone/Fax (1) **]: Two (2)
Tablet Sustained Release PO DAILY (Daily).
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Telephone/Fax (1) **]: One (1)
Intravenous HD PROTOCOL (HD Protochol).
16. Cinacalcet 30 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
17. Lisinopril 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
epilepsy
.
Secondary:
ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2
failed renal transplants
Labile hypertension
Hypothyroidism
Peripheral [**Telephone/Fax (1) 1106**] disease
Hypoparathyroidism
Hepatitis C
CHF-systolic w/ EF 45% and diastolic dysfunction (echo [**12/2135**])
SVT/AVNRT s/p ablation
Multiple fistulas
H/O MRSA line infection
Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
h/o mechanical falls admitted [**1-16**]
h/o VRE, MRSA
Discharge Condition:
Good
Discharge Instructions:
You were seen at [**Hospital1 18**] for seizure. You were transferred to the
MICU where your were briefly intubated. You were stabilized,
your BP was controlled, you were extubated, and you were sent
out of the MICU to the regular medicine floor. You received
hemodialysis while you were in the hospital as well as a
therapeutic paracentesis (3 liters were taken off). Neurology
was consulted and you can continue your dilantin 300mg daily as
you were taking before you came in to the hospital. You should
discuss with your neurologist about your dose of dilantin in the
future. You should resume your outpatient hemodialysis as
recommended by your kidney doctor.
.
Your dose of metoprolol was changed to 150mg daily. Your
nifedipine was changed to nifedipine sustained release 180mg
daily. On day of discharge, your lisinopril was also restarted
at your home dose. Your PCP should titrate doses as needed and
should restart your clonidin as well if your BP tolerates.
.
You were started on other medications called cinacalcet,
rifaximin, lactulose, vitamin B/vitamin C/folic acid, senna, and
colace.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Call your primary care physician or return to the ED if you
experience worsening SOB, fever greater than 101.4 degrees F,
seizures, worsening abdominal distension or discomfort,
confusion, or any symptoms that concern you.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-11-28**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2137-11-28**] 10:40
Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2137-12-5**]
1:45
.
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) 1216**] [**Initial (NamePattern1) **] [**Hospital6 29**], [**Location (un) **]
NEUROLOGY UNIT CC8 (SB) [**2137-12-20**] 10:30a
.
You should call to make an appointment to follow up with your
primary care physician [**Last Name (NamePattern4) **] 1 week from now ([**Last Name (LF) **],[**First Name3 (LF) **] R.
[**Telephone/Fax (1) 608**]). He should adjust your blood pressure medications
as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
|
[
"4280",
"2449"
] |
Admission Date: [**2172-7-14**] Discharge Date: [**2172-7-17**]
Date of Birth: [**2122-2-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
CC:[**Hospital1 107175**]
Major Surgical or Invasive Procedure:
Endotrachial intubation
History of Present Illness:
Ms. [**Known lastname 107176**] is a 50 year old woman with h/o prior traumatic
brain injury, epileptic and nonepileptic seizures, recent
concussion s/p fall ([**2172-6-30**]), who presents from a Code Blue in
the Ophthalmology department for unresponsiveness.
The patient had a concussion 2 weeks prior to admission s/p fall
from a ladder. Since this time, she has had persistent HA, N/V,
gait instability, and blurry vision. The patient was in the
ophthalmology clinic on [**2172-7-13**] when she fell out of her
wheelchair and was found to be unresponsive and a Code Blue was
called. Ms. [**Known lastname 107176**] does not recall the events surrounging the
episode but does recall she had constipation, poor PO intake,
and nausea prior to the event.
Her VS were stable during the code - satting well on room air,
BP 130s/90s, P90s. The patient was presumed to be having a
seizure and received a total of Ativan 4mg. She was intubated by
Anesthesia for airway protection prior to transfer to the [**Hospital Ward Name 12837**] ED. She required a significant amount of Propofol to stay
sedated.
In the ED she remained ventilated and sedated. Imaging of her
head and neck were normal. Initial labs were notable for normal
CBC and chemistries. UA and tox screen were negative. She had
purposeful movement in the ED and no obvious seizure activity by
report.
After arrival to the medical ICU on [**7-14**], she was extuabted. The
neurology team is unclear what caused her event, but do not
think it was consistent with a seizure.
Past Medical History:
- Hypothyroidism
- TBI [**1-21**] assault resulting in ICH
- Reported history of epilepsy. Was admitted in [**11-26**] for
further evaluation, and at that time EEG showed no interictal
spikes, and pushbutton events did not show an EEG correlate. It
was felt that her events were mostly non-epileptic, and she was
taken off Keppra at that time and bridged back to gabapentin
- Almost blind [**1-21**] prior assault and subsequent macular
degeneration
- DJD with spondylosis and foraminal narrowing at C6-7
- S/p arthroscopy
- HCV
Social History:
She reports no cigarettes, etoh, or illicit durgs.
Family History:
No family history of seizures by report
Physical Exam:
Vital Signs: T 98.2, P 68, BP 125/71, 96% on RA.
Physical examination:
- Gen: Thin, tan female in NAD. Keeps eyes closed during most of
the exam.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: PMI normal size and not displaced. Regular rhythm. Normal
S1, S2. No murmurs or gallops. JVP 6 cm. No ankle edema.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
- Neuro: Alert, oriented x3. Good fund of knowledge. CN 2-12
intact other than decreased vision. Has flat affect. Declines
gait exam.
Pertinent Results:
[**7-13**] CT head
1. No acute intracranial process.
2. Increased secretions within the nasopharynx are likely
secondary to recent intubation.
CTA head and neck [**7-13**]
1. Slightly suboptimal study due to inadequate contrast
enhancement as well as artifacts from the adjacent bone/venous
contrast.
2. Within these limitations, the major arteries of the head and
neck are
patent without focal flow-limiting stenosis or occlusion. The
left posterior inferior cerebellar artery is not visualized and
may relate to a normal variant appearance. There is no definite
outline of the vessel noted to suggest thrombotic occlusion.
3. Significant amount of secretions in the nasopharynx and
trachea, do
correlate clinically.
4. Mild degenerative changes in the cervical spine without
significant canal stenosis; mild-to-moderate neural foraminal
narrowing, inadequately assessed on the present study.
5. Non-visualization of the thyroid, do correlate with clinical
history.
Brief Hospital Course:
1. Syncope. The presentation was most consistent with a
syncopal episode, possibly related to her reported vomiting.
She was monitored on telemetry for 48 hours (bradycardia to 50s
but no other events) and an echo was obtained (mitral valve
prolapse). Neurology also followed by the patient and agreed
that the presentation was more consistent with syncope.
2. Post-concussive syndrome. Since recent trauma, patient has
suffered from headaches and nausea. Neurology followed and felt
this could be consistent with a post-concussive syndrome. She
has neurology follow-up scheduled.
3. Neck pain / Vertigo. This is a long-standing issue. CTA
shows no evidence of
an acute arterial abnormality. Neurology wondered if this might
suggest a chronic vestibular disorder and recommended outpatient
ENT follow-up.
4. Hypothyroidism. Continue home Levothyroxine 150/175mg PO on
alternating days
5. Social work. Patient reported recently having been kicked
out of her boyfriend's home (along with her 12 year-old son).
Social work met with the patient and provided resources.
Given the complexity of her care, a new PCP appointment was
scheduled for Monday [**7-20**].
Medications on Admission:
- Levothyroxine 150/175mg PO on alternating days
- Gabapentin 300mg PO TID
- Xatalan OU HS
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours).
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
6. 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:*0*
7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Synocpe
2. Post-concussive syndrome
3. Hypothyroidism
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were admitted after passing out (syncope). Your heart was
evaluated and only showed mild mitral valve prolapse.
For you headache and neck pain, you should continue using NSAIDs
and cyclobenzaprine, as prescibed. Given that the doses you are
using may irritate the stomach, we have also prescribed a
medication to protect the lining.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2172-7-20**] at 2:35 PM
With: [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 30891**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2172-8-11**] at 8:30 AM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 857**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2172-11-16**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"2449"
] |
Admission Date: [**2169-11-9**] Discharge Date: [**2169-11-16**]
Date of Birth: [**2095-1-20**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Vancomycin / Ambien / Augmentin / Cephalexin / IV Dye,
Iodine Containing
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Pacer firing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 M with h/o dialated cardiomyopathy s/p AICD placement
presents following firing of pacer. Patient has been having
shortness of breath over the past couple weeks. He was recently
discharged from [**Hospital1 2177**] on [**10-30**] after being admitted for CHF
exacerbation. At that time, it was noted by EP that he would go
into NSVT in the setting of volume overload. Patient eloped
before being staffed by EP. This afternoon, after taking his
nebs, his IACD fired for a reason that was unclear to him. He
called an ambulence and was taken to the ED. He had a second
pacer shock en route.
In the ED, he was started on amiodorome bolus. At that time, he
had a 40 run beat VT and dropped SBP to 85. He was givin a
fluid bolus, and a CCU bed was requested.
On arrival in the CCU, he had some residule pain from being
shocked but no other chest pain. He denied significant
shortness of breath. He notes sleeping on two pillows at night.
Past Medical History:
Hypertension
Hyperlipidemia
Dialated cardiomyopathy. EF 25% on Echo in [**2-/2169**]
Atrial fibrillation s/p DCCV x 2 with recurence and AV nodal
ablation [**2169-10-13**]
Congestive heart failure, dry weight 196 lbs
H/O Pulmonary embolism
Rectal adenocarceinoma s/p transanal excision [**2166**]
s/p umbilical hernia repair with mesh
LLE insificienct s/p ablation of L greated saphenous vein, c/b
ulcer formation.
Osteoarthritis s/p knee surgery
Spinal stenosis s/p back surgery
Allergic rhinitis
s/p nasal surgery
rosacia
actinic eratosis
decreased hearing
h/o psychogenic polydipsea.
h/o SIADH
Subclavian artery steonsis causing chronic low L arm blood
pressures
Social History:
Lives in [**Location **] with younger sister who has [**Name (NI) 2481**].
IADL. Divorced with 3 children. Worked as firefighter and
retired in [**2134**] [**1-28**] smoke inhalation. Currently works as
groundskeepr for [**University/College 5130**] 10 hours per week.
Smoked 2 PPD for 20 years quit at 41 years. Drinks 1-2 beers a
few days per week. Denies drug abuse.
Family History:
Brother with "colitis" died in 70s. Children heathy. No family
history of early MI, otherwise non-contributory.
Physical Exam:
HR 87 BP 108/67 RR 25 Sat 97% Wt. 199.5 lbs
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of > 18 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1-2/6 systoloic murmur at LLSB without
radiation. No thrills, lifts. No S3 or S4.
LUNGS: Diffuse wheezing. Scattered crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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:
[**2169-11-15**] 05:25AM BLOOD WBC-10.2 RBC-4.05* Hgb-11.2* Hct-34.8*
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.6* Plt Ct-199
[**2169-11-8**] 10:50PM BLOOD WBC-14.1*# RBC-4.80 Hgb-13.2* Hct-41.9
MCV-87 MCH-27.4# MCHC-31.4# RDW-16.3* Plt Ct-287
[**2169-11-15**] 05:25AM BLOOD PT-31.8* PTT-43.0* INR(PT)-3.3*
[**2169-11-15**] 05:25AM BLOOD Glucose-109* UreaN-29* Creat-1.4* Na-130*
K-3.4 Cl-90* HCO3-32 AnGap-11
[**2169-11-12**] 05:44AM BLOOD ALT-164* AST-80* LD(LDH)-251* AlkPhos-94
TotBili-0.9
[**2169-11-8**] 10:50PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 40416**]*
[**2169-11-9**] 05:01PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2169-11-14**] 05:15AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0
[**2169-11-12**] 05:44AM BLOOD TSH-2.6
[**2169-11-13**] 09:28AM URINE Hours-RANDOM UreaN-472 Creat-47 Na-54
[**2169-11-13**] 09:28AM URINE Osmolal-369
BCx [**11-9**] neg, [**2076-11-8**] pending
UCx [**11-9**] neg x 2
SCx [**11-9**] sparce oropharyngeal flora
ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV negative
CXR [**11-12**]: The right basilar opacification probably represents
asymmetric pulmonary edema, though some atelectatic change
cannot be excluded.
Brief Hospital Course:
74 M with dialated cardiomyopathy s/p AICD placement admitted
for hypotension in setting of amiodorone loading for VT.
VENTRICULAR ARRYTHMIA: Thought to be ventricular tachycardia.
A-fib with aberrancy unlikely given history AV nodal ablation.
Etiology was likely volume overload and infection, as ischemia
ruled out and PE unlikely with therapeutic INR. Pt was
aggressively diuresed as tolerated by his renal function. He was
also started on a beta blocker and amiodarone to suppress
ectopic ventricular source. After several days of amiodarone
loading, pt was noted to have elevated LFTs, requiring stopping
of Amiodarone. His beta-blocker was increased while the
amiodarone washed out. Pt was anticoagulated with warfarin with
an INR goal [**1-29**], with doses altered based on interacting drugs
(amiodarone, levaquin).
INFECTION: Patient with leukocytosis (although on chronic
prednisone), temperature to 103.2, dropping systolic BPs,
tachypnea, and productive cough. Source was thought to be
pulmonary although no cultures grew is most likely source. Pt
improved dramatically when started on Levaquin, and Vancomycin
was added given positive MRSA screen. Pt is to finish a 7 day
course of abx.
Systolic CONGESTIVE HEART FAILURE: Pt diuresed aggressively as
tolerated by his blood pressures and renal function.
HYPERTENSION: Controlled with Cozaar and higher dose Metoprolol
COPD: Pt did not appear to be in acute flair and was continued
on his home regimen of Albuterol/ipratroprium nebs, advair, and
prednisone.
ACUTE ON CHRONIC RENAL FAILURE: Creatinine was somewhat above
baseline on admission and rose with agressive diuresis. It was
trending down at discharge. Discharge Cr was 1.9
Medications on Admission:
Toprol XL 25 mg
Cozaar 100 mg
Furosemide 40 mg daily
Lipitor 10 mg QHS
Coumadin 2.5 mg M, 5mg Tu-[**Doctor First Name **]
Prednisone 10 mg daily
Advair discus
Spireva
Combiven
Rhinocort
MVI
Vit C
Glucosamine
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed as needed for chest pain.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Glucosamine 500 mg Tablet Sig: One (1) Tablet PO three times
a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not resume until after your procedure on [**2169-11-20**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Systolic congestive Heart Failure
Pneumonia
Chronic Obstructive Pulmonary Disease
Dilated Cardiomyopathy
Discharge Condition:
Stable
HR= 68
BP= 105/66
BUN= 41
Creat= 1.9
INR= 2.7
Discharge Instructions:
yYou had an exacerbation of your congestive heart failure and
the ICD fired because of this. We have increased your diuretics
and have removed fluid weight. Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pouonds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters or about 7 eight ounce cups of
fluid per day.
The electrophysiology doctors saw [**Name5 (PTitle) **] and recommended increasing
your Toprol to keep your heart rate low. We tried a new
medicine, amiodarone, but had to discontinue it because it
affected your liver. You will return on [**2169-11-20**] for an
ablation. This is to eliminate the ventricular tachycardia that
is causing your ICD to fire. The nurses in the lab will call you
with instructions. Do not take your coumadin over the weekend at
all, you will resume this after the ablation.
.
You were diagnosed with a pneumonia and have been on
antibiotics.
.
Medication changes:
1. We increased your Toprol to 100mg
2. We increased your furosemide to 60mg.
3. We lowered your Cozaar to 25mg.
4. We discontinued your coumadin for now.
5. You will take Levofloxacin for 2 more days to treat your
pneumonia.
.
Please call Dr. [**Last Name (STitle) 98254**] or Dr. [**Last Name (STitle) 98255**] if you have any chest
pain, trouble breathing, palpitations or fevers. Please call Dr.
[**Last Name (STitle) **] if your pacemaker fires.
Followup Instructions:
Cardiology:
Dr [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 98255**] Phone: Date/time: [**2169-11-22**] at 9am
.
Cardiac Device clinic at [**Hospital6 **]: [**2170-1-29**] at 2:20pm
.
Electrophysiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2169-11-29**] at 10:20pm
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98254**] Phone: ([**Telephone/Fax (1) 98256**] Date/time: please call
office to make an appt in [**2-28**] weeks.
.
****pt noted to be OB positive on last admission at [**Hospital1 2177**] with
history of adenocarcinoma, should have repeat colonoscopy if
indicated.
Completed by:[**2169-11-17**]
|
[
"5849",
"486",
"4280",
"40390",
"5859",
"42731",
"496",
"2724"
] |
Admission Date: [**2145-6-22**] Discharge Date: [**2145-7-5**]
Date of Birth: [**2072-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2145-6-23**] Endovascular Stent Repair of Thoracic Aortic Aneurysm
[**2145-6-25**] Bronchoscopy
History of Present Illness:
The patient is a 72-year-old gentleman who presented to [**Hospital3 12748**] with chest and back pain. He ruled out for MI.
Dobutamine stress testing was negative for ischemia. SPECT
showed LVEF of 64%. Chest CT scan was suggestive of probable
contained rupture of mid-thoracic aorta saccular aneurysm. He
was urgently transferred to the [**Hospital1 18**] for further evaluation and
surgical intervention. Of note, patient was recently treated
with Bactrim DS for a recent pneumonia.
Past Medical History:
Thoracic Aortic Aneurysm, Chronic Obstructive Pulmonary Disease,
Emphysema, History of Asbestosis versus Mesotheilioma - s/p RUL
lung resection, Hypertension, Renal Cell Carcinoma - s/p
Nephrectomy, Depression, Cholelithiasis
Social History:
Lives in nursing home. Admits to 100-120 pack year history of
tobacco. Admits to [**2-1**] ETOH drink daily.
Family History:
Denies premature CAD.
Physical Exam:
Vitals: T 96.3, BP 150/60, HR 70-80, 97% on 2L
General: elderly male in no acute distress, nasal cannula in
place
HEENT: oropharynx benign, PERRL
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally, decreased at bases, absent RUL
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: decreased distally, bilateral femoral bruits
Neuro: alert and oriented, nonfocal
Pertinent Results:
Chest CT [**6-22**]: Penetrating ulcer of the descending thoracic
aorta at the level of inferior pulmonary vein, surrounded by
somewhat hyperdense soft tissue mass measuring 4.3 x 2.9 cm and
50 [**Doctor Last Name **] on noncontrast scan, worrisome for mediastinal hematoma in
the setting of underlying penetrating ulcer. Urgent clinical
attention is needed. (Other possibility of the metiastinal soft
tissue mass includes metastatic disease in this patient with
history of renal cell carcinoma, or esophageal in origin.
However, the soft tissue is most closely related to the aorta,
and is asymmetrically located on the side of penetrating
ulcer.). Coronary artery calcifications. Asbestos-related
pleural disease. Bilateral pleural effusion with right lower
lobe consolidation, representing pneumonia versus atelectasis.
Clinical correlation is recommended. Extensive emphysema. 3.2 cm
infrarenal abdominal aortic aneurysm with mural thrombus.
Atherosclerotic disease of thoracoabdominal aorta. Status post
left nephrectomy. Right renal cyst. Calcified sludge in the
gallbladder. Somewhat prominent loops of small bowel in the
lower pelvis measuring up to 2.2 cm filled with fluid. Clinical
correlation is recommended. Dilated fluid-filled upper
esophagus, with thickend lower esophagus. Please evaluate for
the possibility of esophageal disease.
Echo [**6-23**]: Pre stent: Overall left ventricular systolic function
is normal (LVEF>55%). There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. Approximately 6 cm below the left subclavian, an
outpouching is seen consistent with a contained rupture of the
thoracic aorta. The outpouching is at least 2.5 cm in diameter;
there is no flow in this area. A wire is seen in the lumen of
the thoracic aorta during the procedure. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. No aortic regurgitation is seen. Evidence of a
Thoracic endostent is seen in the descending thoracic aorta in
the area previously described as a probable contained rupture.
The graft appears well seated. There is no evidence for
endoleak.
Chest CT [**6-30**]: Patient is status post endoluminal stent graft
placement for penetrating aortic ulcer without evidence of
endoleak, and decreased size of surrounding hematoma. Large
subcutaneous anterior abdominal wall hematoma at site of
surgical incision and partially involving the left rectus
abdominis muscle. Post- surgical focal dilatation of left common
iliac bifurcation consistent with Dacron graft insertion and
hematoma. Stable 3.2-cm infrarenal aortic aneurysm with
calcifications and mural thrombus. Stable bilateral pleural
effusions. Bilateral centrilobular emphysema with scarring at
the right lung base in this patient status post right
thoracotomy. Retained mucous retention cyst in the distal
trachea and right main stem bronchus, with fluid layering in a
superiorly dilated esophagus. Clinical correlation is
recommended. Status post left nephrectomy. Right renal artery
stenosis with evidence of infarction. Multiple right renal cysts
requiring ultrasound or MRI for further evaluation.
Asbestos-related pleural disease. Gallstones. Right adrenal
adenoma.
CXR [**7-1**]: Compared with [**2145-6-29**], the infiltrates in the right mid
and lower lung fields appear slightly more confluent. There
appears to be increased volume loss on the right, as evidenced
by slightly more shift of the heart and mediastinum, although
this has not changed dramatically. The left lung appears grossly
clear with interval re-expansion of the left lower lobe
atelectasis.
[**2145-6-22**] 06:50PM BLOOD WBC-14.3* RBC-3.97* Hgb-11.7* Hct-34.4*
MCV-87 MCH-29.5 MCHC-34.0 RDW-15.7* Plt Ct-321
[**2145-6-22**] 06:50PM BLOOD PT-12.4 PTT-21.0* INR(PT)-1.1
[**2145-6-22**] 06:50PM BLOOD Glucose-110* UreaN-9 Creat-1.0 Na-135
K-4.7 Cl-96 HCO3-30 AnGap-14
[**2145-6-22**] 06:50PM BLOOD ALT-14 AST-14 CK(CPK)-10* AlkPhos-84
Amylase-59 TotBili-0.4
[**2145-6-22**] 06:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2145-6-22**] 06:50PM BLOOD Calcium-9.0 Phos-4.3
[**2145-7-2**] 04:30AM BLOOD WBC-10.6 RBC-3.39* Hgb-10.0* Hct-29.0*
MCV-86 MCH-29.4 MCHC-34.4 RDW-16.0* Plt Ct-247
[**2145-6-30**] 01:31AM BLOOD PT-12.7 PTT-31.7 INR(PT)-1.1
[**2145-7-1**] 06:32AM BLOOD Glucose-82 UreaN-20 Creat-1.0 Na-134
K-4.1 Cl-102 HCO3-22 AnGap-14
[**2145-7-2**] 04:30AM BLOOD UreaN-19 Creat-1.0 K-3.9
[**2145-7-1**] 06:32AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.3
[**2145-6-30**] 03:14PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2145-6-30**] 03:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-NEG
Brief Hospital Course:
Mr. [**Known lastname 67535**] was admitted and underwent CTA which demonstrated a
penetrating ulcer of his descending thoracic aorta at the level
of inferior pulmonary vein, surrounded by somewhat hyperdense
soft tissue mass measuring 4.3 x 2.9 cm and 50 [**Doctor Last Name **] on noncontrast
scan, worrisome for mediastinal hematoma. The CTA was also
notable for coronary artery calcifications, asbestos-related
pleural disease, bilateral pleural effusions with right lower
lobe consolidation, extensive emphysema, and a 3.2 cm infrarenal
abdominal aortic aneurysm with mural thrombus. Based on these
results, the patient was referred through Dr. [**Last Name (STitle) 1391**] for stent
graft repair. The patient was felt to be a good candidate for
stent graft repair because the penetrating ulcer was fairly
localized to the junction between the proximal and middle third
of the descending thoracic aorta with good landing zones for a
stent graft proximally and distally. The patient and the
patient's family understood the risks and benefits of the
procedure, and wished to proceed. On [**6-23**], Drs. [**Last Name (STitle) 914**] and
[**Name5 (PTitle) **] performed an endovascular stent repair of his
thoracic aortic aneurysm. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated. Due to
some mild respiratory distress and thick secretions with
hypoxia, therapeutic bronchoscopy was performed on postoperative
day two. He was aggressively diuresed and required pulmonary
toilet, frequent intranasal suctioning and nebulizer treatments.
Due to his tenous respiratory status and fear of aspiration, a
Dobboff feeding tube was placed for nutritional support. He was
initially kept NPO and remained on broad spectrum antibiotics.
Sputum cultures were sent off, eventually growing out
Pseudomonas aeruginosa. Antibiotics were titrated accordingly,
and a course of Meropenum was initiated. Over several days, his
pulmonary status gradually improved. A bedside swallow
evaluation on [**6-29**] demonstrated no signs or symptoms of
aspiration or oropharyngeal dysphagia. He made slow clinical
improvements and eventually transferred to the SDU on
postoperative day seven. A PICC line was placed in his right
upper extremity on [**7-2**] for long term IV antibiotics. A
course of Meropenum will continue for 2 weeks with the last dose
on [**7-11**]. He needs follow up of his psuedomonas pneumonia with a
CXR on [**7-11**] or prior if clinically indicated. Medical therapy
was optimized as he continued to work with physical therapy to
regain strength and mobility. He ws ready for discharge on
[**2145-7-3**].
Medications on Admission:
Protonix 40 qd, Enalapril 5 qd, Lasix 20 qd, KCL , Prednisone 10
qd, Remeron 15 qhs, Mucinex, Ativan qhs, Iron, Zithromax,
Diltiazem 180 qd, Aspirin 162 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*1*
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 1* Refills:*2*
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily). Capsule,
Sustained Release(s)
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days: last dose on [**7-11**].
16. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
six (6) hours for 6 days: last dose on [**7-11**].
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: each lumen Daily
and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **] - [**Location (un) 7661**]
Discharge Diagnosis:
Thoracic Aortic Aneurysm - s/p Endovascular Stent, Postop
Pneumonia(Pseudomonas), Chronic Obstructive Pulmonary Disease,
Emphysema, History of Asbestosis versus Mesotheilioma - s/p RUL
lung resection, Hypertension, Renal Cell Carcinoma - s/p
Nephrectomy, Depression
Discharge Condition:
Stable
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving when taking pain medications. No heavy
lifting. Monitor wounds for signs of infection. Please call with
any concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks - call for appt
Chest Xray on [**7-11**]
CT Scan with MMS 3 months
Dr. [**Last Name (STitle) 26770**] in 4 weeks - call for appt
Dr. [**Last Name (STitle) **] in 2 weeks - call for appt
Completed by:[**2145-7-5**]
|
[
"5119",
"496",
"4019"
] |
Admission Date: [**2121-7-19**] Discharge Date: [**2121-7-30**]
Date of Birth: [**2058-3-26**] Sex: M
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 63 yo man with pmh significant for recent CABG in [**5-/2121**]
at [**Hospital1 336**] who was transferred to [**Hospital1 18**] MICU from OSH where he had
an upper GI bleed shortly after EGD dilitation of a shatzski's
ring.
Past Medical History:
PAF
CABG
CAD
Social History:
Lives with wife in the [**Hospital3 **]. He works as a welder. He
drinks about 12-20 beers
per week. He smoked approximately [**12-20**] pack for years but quit in
[**2084**].
Family History:
non contributory
Physical Exam:
On physical examination, he is a healthy-appearing
male in no distress. Pulse was 84 and regular, blood pressure of
118/85 and a respiratory rate of 12.
There were no skin lesions. His HEENT exam had no oropharangeal
thrush and no conjunctival abnormalities. There was no jugular
venous distension, thyromegaly, or cervical lymphadenopathy. His
chest examination was pertinent for left sided basliar rales,
otherwise clear to auscultation
and percussion. His cardiac exam had no murmur, rub,
or gallop. His abdomen was non-tender and had no
liver or spleen enlargement. There was no peripheral
cyanosis, clubbing, or edema.
Pertinent Results:
ECHO-Conclusions:
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic
function is normal (LVEF 60-70%). There is no ventricular septal
defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened but not stenotic. No aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve
prolapse. There is a small posterolateral pericardial effusion.
There are no
echocardiographic signs of tamponade.
WOUND CULTURE (Final [**2121-7-29**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ 0.25 R
CXR ([**2121-7-29**])-IMPRESSION: Two subtle patchy opacities at both
lung bases which may represent atelectasis. However, a pneumonia
cannot be excluded. Unchanged small left pleural effusion.
Brief Hospital Course:
Pt was admitted to the MICU from OSH for management of GI bleed.
Pt required minimal blood support in the MICU as active
bleeding had subsided. Hospitalization was complicated by
multiple episodes of chest pain without consistent presentation
or relation to exertion. Myocardial infarction was ruled out
each time with negative cardiac enzymes and EKG's showing no
acute changes. Towards the end of Mr. [**Known lastname 41592**] hospitalization
he developed fevers, a cough, and CXR showing possible
pneumonia. He was treated with Levofloxacin and he central line
was pulled, growing CoNS also sensitive to Levofloxacin. Pt had
multiple episodes of atrial fibrillation throughout the
hospitalization, for which he had a known history. This was
difficult to manage as he was unsuitable for anti-coagulation
with coumadin and so aspirin was used alone due to recent
history of GI bleed with need to repeat EGD in near future.
Additionally, rate control was difficult due to patient's low
normal blood pressures. The rate was eventually controlled
without affect on the blood pressure, patients pneumonia
symptoms improved, and he was discharged to follow up with his
primary care physician, [**Name10 (NameIs) 151**] the plan to restart the
anti-coagulation at a later time. Pt was discharged to complete
a course of Levofloxacin as treatment for line infection and
pneumonia.
Medications on Admission:
-Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours). Disp:*1 * Refills:*0*
-Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30
Tablet, Delayed Release (E.C.)(s)* Refills:*0*
-Salumedrol
-Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
-Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day):
please stop taking after [**7-31**], and continue after your EGD
procedure.
-Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day). Disp:*90 Tablet(s)* Refills:*0*
-Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*0*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day) for 10 days: please continue until directed otherwise by
Dr. [**Last Name (STitle) 17863**].
Disp:*10 Tablet(s)* Refills:*0*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day):
please stop taking after [**7-31**], and continue after your EGD
procedure.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day): continue until otherwise
directed by Dr. [**Last Name (STitle) 17863**].
Disp:*1 1* Refills:*0*
10. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Upper GI Bleed
Pneumonia
Atrial Fibrillation
Discharge Condition:
Pt has a mild cough, no sob or desaturation at rest or with
ambulation. Pt is afebrile without tachycardia. Stools are
without blood.
Discharge Instructions:
Please call your primary physician or go to the emergency
department id you develop chest pain, difficulty breathing, or
bleeding with your bowel movements.
Followup Instructions:
Appointment for EGD procedure to evaluate your esphagus and
stomach at [**Hospital1 18**] on [**2121-8-11**] - arrive at [**Hospital Ward Name 516**] main
lobby at 9:30 am. Appointment is with Dr. [**Last Name (STitle) **] [**Name (STitle) 2161**] - you will
need to get a referral form Dr. [**Last Name (STitle) 17863**], no eating after midnight
the night before, and someone will need to drive you home. Call
[**Telephone/Fax (1) 463**] for further instructions.
Please make an appointment to see Dr. [**Last Name (STitle) 17863**] next Monday or
Tuesday.
Completed by:[**2121-8-10**]
|
[
"42731",
"5990",
"486"
] |
Admission Date: [**2170-1-22**] [**Year/Month/Day **] Date: [**2170-2-9**]
Date of Birth: [**2093-3-2**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Golytely / Fortaz / Levaquin in D5W / Fluconazole /
Clindamycin / Trimethoprim / Sulfamethoxazole / aspirin /
ciprofloxacin / clopidogrel / Zolpidem / ceftazidime
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with biopsy, bronchial brush, bronchoalveolar
lavage [**2170-1-30**]
PICC line placement [**2170-2-5**]
History of Present Illness:
76-year-old male with complicated past medical history of dCHF,
PVD, COPD, HTN, esopageal CA s/p esophagectomy who was diagnosed
with bilateral PEs on [**2169-12-22**] and started on anticoagulation who
now presents from OSH with GI bleed.
.
Per the [**Date Range **] summary, the patient was diagnosed with a
bilateral PE on [**2169-12-22**] at [**Hospital3 417**] Hospital. He was
started on a lovenox bridge and transitioned to warfarin. Per
report, his INR has remained at goal since that time. Since this
time he has developed pneumonia requiring courses with meropenem
and vancomycin and imipenem.
.
Sometime prior to [**2170-1-18**] he developed frank rectal bleeding with
a hematocrit drop to 23. His anticoagulation was discontinued
and he had ultrasounds done of his extremities. His legs and
left upper extremity were normal. His RUE showed extensive clot
burden and an SVC filter was placed on [**2170-1-18**]. The Hct continued
to trend down and he required transfusion with 2 u PRBC. The
patient was transferred to [**Hospital1 18**] for evaluation of GIB.
.
Of note, the patient was empirically placed on antibiotics for
pneumonia, however, these were discontinued by the primary
physician prior to transfer to [**Hospital1 18**].
.
The patient notes that he has some shortness of breath and
lightheadedness. He notes an oxygen requirement since his
diagnosis of pulmonary emboli. He denies chest pain, abdominal
pain, back pain or other symptoms. He denies fevers but endorses
cough with some yellow sputum. His last GI bleed was prior to
the weekend per patient report.
Past Medical History:
- esophageal cancer s/p esophagoectomy with colon interposition
- COPD
- HTN
- HLD
- Cardiomyopathy
- Diastolic CHF
- PVD
- AAA
- bilateral pulmonary emboli [**2169-12-22**]
- horseshoe kidney
- cataract surgery
- bladder stricture
- h/o [**First Name8 (NamePattern2) **] [**Location (un) **] syndrome
- Ileocolostomy
- tonsillectomy
- tracheostomy [**4-26**]
- G-tube placement
Past Surgical History
[**2169-10-18**] Direct laryngoscopy with left vocal fold injection
with Radiesse Voice Gel
[**2169-10-16**] Esophagogastroduodenoscopy and dilation
Cataract surgery
Tonsillectomy as a child
[**2168-5-13**] Tracheostomy
[**2168-5-4**] Redo neck exploration; redo laparotomy with harvesting
of left colon, substernal colon interposition
[**2167-9-8**] Esophagogastroduodenoscopy with guidewire-assisted
dilatation
Social History:
Home: Bachelor, lives with sister (former RN) and two dogs in
[**Name (NI) 5165**] (though more recently at rehab)
Occ: Retired/disabled letter carrier
Travel: none recently
Tob: 1.5-2ppd x 60 years, quit [**2166**]
EtOH: rare
Illicits: denies
Family History:
Liver cancer in father (deceased at 54). CAD in mother
(deceased at 79).
Physical Exam:
Physical Exam on Admission:
VS - Temp 95.6 F Ax, BP 120/51, HR 77, R 20, O2-sat 94 % 4L
GENERAL - ill appearing male, comfortable, tired
HEENT - dry MM, OP without lesions
NECK - supple, low JVD
LUNGS - Anterior exam, no wheezes, decreased breath sounds
HEART - RR, nl rate, no MRG
ABDOMEN - NABS, soft/NT/ND, multiple scars, GTube in place c/d/i
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - sacral pressure ulcer
NEURO - awake, A&Ox3, weak throughout, unable to ambulate
Physical Exam on [**Year (4 digits) **]:
VS - Tc 97.6 HR 69 BP 100/55 RR 20 O2 98% 4L NC
General: Cachectic elderly male, AOx3, good affect, in no acute
distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear.
Temporal wasting bilaterally.
Lungs: Mild wheezes in all lung fields; upper airway + LUL
rhonchi; mild dry crackles at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. J-tube in
place, small region of erythema around site, unchanged from
prior, clean/dry/intact, bandaged. Multiple surgical scars,
well-healed.
Ext: extremities warm, 1+ pulses b/l, no clubbing or cyanosis,
trace pedal edema.
Derm: Stage II decubitus ulcer noted on sacrum, mildly improved
from prior.
Pertinent Results:
ADMISSION LABS:
[**2170-1-22**] 11:58PM BLOOD WBC-1.9*# RBC-3.82* Hgb-11.0* Hct-33.8*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.2* Plt Ct-289
[**2170-1-22**] 11:58PM BLOOD Neuts-59 Bands-1 Lymphs-21 Monos-17*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2170-1-22**] 11:58PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2170-1-22**] 11:58PM BLOOD PT-11.1 PTT-28.8 INR(PT)-1.0
[**2170-1-22**] 11:58PM BLOOD Glucose-82 UreaN-19 Creat-0.3* Na-138
K-4.6 Cl-101 HCO3-31 AnGap-11
[**2170-1-22**] 11:58PM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
[**2170-1-26**] 06:35AM BLOOD WBC-3.0* RBC-3.82* Hgb-10.9* Hct-33.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-17.3* Plt Ct-348
[**2170-1-30**] 11:45PM BLOOD WBC-12.1* RBC-3.83* Hgb-10.7* Hct-33.1*
MCV-87 MCH-28.1 MCHC-32.4 RDW-16.8* Plt Ct-444*
[**2170-1-31**] 06:00AM BLOOD WBC-9.2 RBC-3.27* Hgb-9.4* Hct-28.5*
MCV-87 MCH-28.7 MCHC-33.0 RDW-16.3* Plt Ct-414
[**2170-2-1**] 06:53AM BLOOD WBC-8.6 RBC-3.08* Hgb-9.0* Hct-26.9*
MCV-87 MCH-29.3 MCHC-33.5 RDW-16.7* Plt Ct-386
[**2170-2-6**] 04:49AM BLOOD WBC-7.6 RBC-3.13* Hgb-8.9* Hct-27.2*
MCV-87 MCH-28.5 MCHC-32.8 RDW-16.4* Plt Ct-579*
[**2170-1-30**] 06:44PM BLOOD Type-ART pO2-60* pCO2-36 pH-7.51*
calTCO2-30 Base XS-5 Intubat-NOT INTUBA Comment-O2 EDELIVE
[**2170-2-1**] 03:51PM BLOOD Type-ART FiO2-50 pO2-64* pCO2-41 pH-7.51*
calTCO2-34* Base XS-8 Intubat-NOT INTUBA
[**2170-2-3**] 09:30PM BLOOD Type-ART FiO2-91 O2 Flow-4 pO2-75*
pCO2-40 pH-7.49* calTCO2-31* Base XS-6 AADO2-535 REQ O2-89
[**Month/Day/Year 894**] LABS:
[**2170-2-9**] 05:25AM BLOOD Hct-25.7*
[**2170-2-9**] 05:25AM BLOOD PT-13.1* PTT-98.2* INR(PT)-1.2*
[**2170-2-9**] 05:25AM BLOOD Glucose-101* UreaN-16 Creat-0.2* Na-135
K-4.8 Cl-98 HCO3-32 AnGap-10
[**2170-2-8**] 04:59PM BLOOD Mg-2.1
CT CHEST W/O CONTRAST [**2170-1-23**]:
1. Large necrotizing pneumonia, incipient lung abscess, left
upper lobe, probably due to aspiration, given more severe
bibasilar peribronchial infiltration around chronic
bronchiectasis and retained secretions in the bronchial tree.
2. New left hilar adenopathy could be reactive or malignant,
mildly narrows but does not obstruct the upper lobe bronchus.
Mild generalized mediastinal adenopathy, unchanged since [**Month (only) 359**]
[**2166**]. No good evidence for active recurrence of esophageal
carcinoma.
3. Severe emphysema.
4. Gastrostomy balloon at the pylorus might interfere with
gastric emptying.
ART DUP EXT UP UNI OR LMTD RIGHT [**2170-1-25**]: There is no evidence
of arterial stenosis in the right upper extremity.
UNILAT UP EXT VEINS US RIGHT [**2170-1-25**]: Non-occlusive DVT in the
axillary and one of the brachial veins. Nearly completely
occlusive thrombus involving the basilic vein.
G/GJ/GI TUBE CHECK [**2170-1-28**]: The tip appears to be in the loops
of the jejunum in the right mid-lower quadrant. No extravasation
of contrast is demonstrated on this limited one static image.
ECG Study Date of [**2170-1-30**]: Sinus tachycardia. Frequent
ventricular ectopy. Left axis deviation. Non-specific ST-T wave
changes. Compared to the previous tracing of [**2169-9-28**] the rate
is faster and ventricular ectopy is new.
CHEST (PORTABLE AP) [**2170-1-30**]: The substantial increase in
consolidation in the necrotizing left upper lobe pneumonia that
took place between [**1-22**] and [**1-30**] after left upper
lobe bronchoscopic biopsy, has improved little, but is still
quite substantial. There is no pneumothorax or appreciable left
pleural effusion. Cardiac silhouette is normal. Right lung is
grossly clear.
CHEST PORT. LINE PLACEMENT [**2170-2-5**]: Interval placement of left
subclavian PICC line with its tip at the superior aspect of a
superior vena caval filter. There is persistent opacity in the
left upper and mid lung suggestive of pneumonia. The right lung
is grossly clear. No pneumothorax is seen. No evidence of
pulmonary edema.
CXR [**2170-2-8**]: Cardiomediastinal contours are unchanged. Left
upper lobe opacity, consistent with known pneumonia, is grossly
unchanged. Increasing opacities in the left lower lobe are
consistent with increasing atelectasis. Right lower lobe
opacities could be atelectasis or pneumonia. Surgical clips
project in the right upper hemithorax. There is scoliosis.
Patient has severe emphysema.
LEFT LUNG, UPPER LOBE BIOPSY [**2170-1-30**]: Lung tissue and vessels
with mild chronic inflammation, fibrosis, and hemorrhage. No
malignancy identified.
MICROBIOLOGY:
[**2170-1-24**] Legionella Urinary Antigen: negative
[**2170-1-30**] Blood cultures: negative
[**2170-1-30**] LUL tissue: proteus vulgaris
[**2170-1-30**] Bronchial brush: proteus mirabilis, proteus vulgaris
[**2170-1-30**] BAL: PROTEUS MIRABILIS
| PROTEUS VULGARIS
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S 4 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
76M with a complex medical history, most notably including T1
esopheageal cancer s/p esophagectomy [**2166**] and colonic
interposition/J-tube placement in [**2167**], diastolic CHF, COPD,
PVD, hypertension, recent bilateral PEs [**12/2169**], multiple recent
aspiration PNAs, who developed GIB in setting of being started
on warfarin for PEs. Initially presented to OSH where he was
transfused 2 units pRBCs and had SVC filter placement,
transfered to [**Hospital1 18**] for further evaluation of GIB, with course
notable for LUL necrotizing pneumonia.
# GI bleed: Pt initially presented to OSH with BRBPR and Hct
drop to 23 in setting of recently being started on warfarin for
bilateral PEs. Warfarin d/c'd and pt transfused 2 units pRBCs.
Of note, patient also had SVC filter placed after he was found
to have RUE DVT. Was transferred to [**Hospital1 18**] for further eval.
Here, Hct initially remained stable, and patient did not have
further GI bleeding. GI was consulted, and once Hct stable,
they felt that need for anticoagulation outweighed risk of
further bleeding, despite increased risk due to his many
surgical anastamoses. EGD/colonoscopy were recommended, though
given tenuous respiratory status these will be deferred to the
outpatient setting. Patient will likely need MAC anesthesia for
the procedure. Will follow-up with GI in one month, and they
will reassess plan for procedures at that time. Patient was
continued on [**Hospital1 **] PPI this admission. Was restarted on
anticoagulation as below. Did have one 6 point drop in Hct,
though this was in setting of probable dilutional effect and
hemoptysis. He did not require additional tranfusions.
# LUL necrotizing pneumonia: Pt w/extensive recent history of
consolidations beginning [**2169-11-27**]. Treatment of these probable
aspiration pneumonias (which grew Klebsiella, Morganella, and
Pseudomonas) was c/b pt's extensive antibiotic allergies. Prior
antibiotic courses included tigecycline, tetracycline, and most
recently a 6 day course of vancomycin and meropenem that was
discontinued just prior to transfer to [**Hospital1 18**] with concern with
developing neutropenia. His admission exam was less concerning
for an acute respiratory process. He was weaned from 4L to 1L
over the first 6 days of his hospital course, with subjective
improvement in breathing. However, in setting of increased
rhonchi on lung exam, CT chest obtained and demonstrated a LUL
necrotizing pneumonia and developing abscess. Interventional
pulmonology consulted, and recommended bronchoscopy. Infectious
Disease also consulted, and recommended holding antibiotics
until culture results could be obtained from bronchoscopy
samples. Rigid bronchoscopy done [**2170-1-30**], with two biopsy
samples, bronchial brush, and BAL collected. Post-procedure,
patient required brief admission to MICU for stabilization of
tachycardia, tachypnea, and increased oxygen requirement. Did
have 6 point drop in Hct at this time, in setting of receiving
IVF and developing blood-tinged secretions and a mild amount of
frank hemoptysis. However, Hct subsequently remained stable, and
frank hemoptysis resolved. Post-bronch, patient started on
broad spectrum antibiotics with vanc/meropenem, and abx were
later narrowed to just meropenem after cultures demonstrated
proteus. Per ID, patient was continued on meropenem, and will
be transitioned to ertapenem on [**Month/Day/Year **] to complete a total
four week course of abx to end [**2170-2-28**]. Patient continued to
require 3-5L NC, with occasional desats to the 80s. These may
have been secondary to mucous plugging, as patient would quickly
respond with improvement in sats when placed on oxygen face
mask, and with nebulizer treatments and clearance of secretions.
At time of [**Month/Day/Year **], oxygen requirement 4L NC.
# Pulmonary embolism: Pt diagnosed with bilateral PEs [**2169-12-22**]
at [**Hospital3 417**] Hospital. Warfarin, started after this event,
was d/c'd on [**2170-1-18**] at OSH after GI bleed. Given GIB and high
risk for repeat events given numerous surgical anastamoses, was
concern for restarting anticoagulation. However, given known
large clot burden, including not only the PEs but also a RUE DVT
(for which SVC filter placed at OSH), was felt that benefits of
anticoagulation outweighed risks. For easy titration and
reversibility, heparin gtt drip was chosen for initial
prevention of clot extension, rather than immediately restarting
warfarin. Heparin was started without bolus and titrated to goal
of PTT 60-80. Heparin gtt was held prior to bronch on [**2170-1-30**],
and was not restarted until [**2170-2-2**] after patient developed 6
point drop in Hct post-bronch with increased bloody secretions.
However, Hct remained stable thereafter, and heparin gtt
restarted without issue. Warfarin was restarted on [**2170-2-6**] at 5
mg daily. INR only 1.2 at time of [**Date Range **]. Patient will
continue on heparin gtt until INR has been therapeutic >48
hours. Goal INR [**1-19**], and patient will need at least 6 months of
anticoagulation.
# Right upper extremity DVT: Noted at OSH, and patient had SVC
filter placed prior to transfer as his anticoagulation was being
held in the setting of GIB. Ultrasound of RUE on HD4 revealed
no arterial obstruction or stenosis, but did show non-occlusive
venous embolism in the axillary and brachial veins and nearly
complete obstruction of the basilic vein. The patient was
anticoagulated as above, with heparin gtt and restarting of
warfarin prior to [**Month/Day (3) **]. After discussion with IR, decision
was made to leave SVC filter in place, as given large clot
burden was felt risks of removing filter outweighed the
benefits.
# Tachycardia: Patient noted to have intermittent sinus
tachycardia, occasionally with frequent PVCs and ventricular
trigeminy. Patient was asymptomatic during these episodes, with
stable BP. He responded well to IVF boluses of 500cc NS.
Electrolytes were WNL. He was switched from carvedilol to
metoprolol, though dose could not be uptitrated due to blood
pressure (SBP in high 90s-low 100s).
# COPD: Pt was on prednisone taper initially begun for COPD
exacerbation at OSH on [**2170-1-2**]. Initial dose was 60 mg/day;
dose was at 40 mg/day on admission. On HD2, decision was made to
taper dose to prevent immunosuppressive effects in the face of
neutropenia and pneumonia. Accordingly, tapering was initated
with 20 mg HD2-4, 10 mg HD5-8, and 5 mg HD9-11. Prednisone was
d/c'd on HD11. Patient received albuterol/ipratropium nebs Q6H,
with additional albuterol nebs as needed. He was also restarted
on Advair this admission, with good effect.
# Leukopenia: The patient was noted in his last ([**2170-1-22**])
[**Month/Day/Year **] summary to be leukopenic, with concern expressed that
it may be related to antibiotics. Accordingly the patient was
transferred to [**Hospital1 18**] with no active antibiotic prescriptions.
His admission WBC count was 1.9; he remained in the 1.8-2.7
range on HD2-4. On HD5 his WBC rose to 3.0 and on HD6 to 6.9.
Concern remained through HD6-9 that WBC may be rising in setting
of developing PNA. WBC count briefly spiked to 12.1 post-bronch
while patient in MICU, but returned to <10 on HD10 and remained
in the 7-9 range afterwards despite the restart of meropenem on
HD9.
# Diastolic CHF: Per a [**2168**] report, patient's CHF diastolic in
nature with a known EF of > 55%. Patient was on furosemide and
spironolactone at time of admission, though these were held in
setting of lower BPs, with SBP in 90s-110s throughout much of
hospital course. Patient did not have evidence of pulmonary
edema on exam or imaging, and he did not appear volume
overloaded on exam. Furosemide and spironolactone held on d/c,
but may need to be restarted in outpt setting as pt recovers
from his infection.
# Tube feeds s/p colonic interposition: The patient arrived with
a previously placed J-tube in situ. Due to anticipated EGD, his
feeds were not immediately restarted. Once EGD was deferred,
tube feeds were restarted to titrate up to the previous (OSH)
goal of 60 mL/hr. TF were d/c'd late on HD8 in preparation for
his bronchoscopy on HD9, and were restarted post-procedure.
# Decubitus ulcer: Pt arrived with a Stage II decubitus ulcer on
the buttocks. Wound care was consulted, who oversaw dressing of
the ulcer throughout the patient's stay. The ulcer remained
approximately stable throughout his stay.
Transitional issues:
-Patient was a FULL CODE this admission. He was seen by both
Social Work and Palliative Care.
-Once acute issues resolved, consider removal of SVC filter.
-Patient noted to have left hilar lymphadenopathy on imaging
this admission, possibly reactive vs. malignant. This should be
reassessed after acute infectious issues have resolved, and if
not improved would consider biopsy to exclude malignancy.
-Patient will follow-up with GI, and ultimately may need outpt
EGD/colonoscopy.
-Patient should continue on ertapenem through [**2170-2-28**] and
follow-up with ID as scheduled. PICC line in place.
-Patient should continue on heparin gtt until INR therapeutic
for >48 hours. Goal INR [**1-19**]. Warfarin dose may need adjusting.
-Patient should have periodic monitoring of Hct, given recent
GIB and ongoing anticoagulation.
-Would recommend nutrition follow patient as outpatient, given
recent weight loss. Would consider increasing tube feed rate if
patient will tolerate.
-Please check weekly CBC, chem 7, LFTs while patient on
antibiotics and send results to ID nurses via fax at
[**Telephone/Fax (1) 1419**].
-Hct on [**2-9**] was 25.7.
Medications on Admission:
MEDICATIONS AT [**Month/Year (2) 894**]:
- acetaminophen 325 mg PO q4hours prn
- calcium carbonate 500 mg calcium (1,250 mg) PO three times a
day via G-tube
- carvedilol 6.25 mg PO BID
- spironolactone 25 mg PO DAILY
- ipratropium bromide 0.02 % Solution Sig: [**12-18**] Inhalation Q8H
- furosemide 20 mg PO DAILY
- prednisone 50 mg PO DAILY
- guaifenesin 100 mg/5 mL Fifteen (15) ML PO Q6H
- Ativan 1 mg PO at bedtime prn insomnia
- Protonix 40 mg PO twice a day
- Glucose Gel 40 % Gel 30 mg PO before meals and at QHS
- Tube feeds - isosource 1.5 @ 60cc/hr 150ml flush 4x per day
.
MEDICATIONS AT TRANSFER:
- Esomeprazole 40mg Gtube Q12H
- Calcium Carbonate 1250mg Gtube TID
- Carvedilol 6.25mg GTube [**Hospital1 **]
- Spironolactone 25mg GTube daily
- Furosemide 20mg GTube daily
- Miconazole nitrate application [**Hospital1 **]
- Prednisone 40mg GTube daily
- Albuterol/Ipratropium duoneb inhaler q6H
- Vancomycin 1 gram IV BID until [**1-25**] (on hold)
- Imipenem/Cilastatin 500mg IV q6hrs until [**1-25**] (on hold)
- Acetaminophen 325mg gtube q4H prn
- Guaifenesin syrup 300mg GTube q6H prn
- Lorazepam 1mg GTube qHS prn
[**Month/Day (4) **] Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day): via
J-tube.
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for shortness of breath or wheezing.
6. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough: via J-tube.
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
10. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Colace 60 mg/15 mL Syrup Sig: One Hundred (100) mg PO twice
a day.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: may need dose adjustment pending INR.
17. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: as directed Intravenous ASDIR (AS DIRECTED).
18. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 17 days: last day [**2170-2-28**].
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
20. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO BID (2 times a day) as
needed for unclog J-tube.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital1 **]/ [**Location (un) **], ma
[**Location (un) **] Diagnosis:
Primary diagnoses:
Gastrointestinal bleed
Pulmonary embolism
Pneumonia
Secondary diagnoses:
Decubitus ulcer
Deep venous thrombosis, right upper extremity
Chronic obstructive pulmonary disease
Congestive heart failure, diastolic type
Hypertension
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
Mr. [**Known lastname 82149**],
You were initially transferred to [**Hospital1 18**] with bleeding from your
gastrointestinal tract. While you were here, the bleeding
stopped and your blood counts stabilized. You were seen by the
gastroenterology doctors, who recommended that you follow-up
with them after you leave the hospital. You may need an
endoscopy and colonoscopy to look for potential causes of the
bleeding.
While you were here, a CT scan of your chest showed a severe
pneumonia in your left lung. You underwent a procedure called a
bronchoscopy, in which they looked inside the lung with a small
camera and took biopsies. You were started on antibiotics for
your pneumonia, and will continue receiving an antibiotic called
ertapenem through [**2170-2-28**]. You will follow-up with the
Infectious Disease doctors after [**Name5 (PTitle) **] leave the hospital.
Once your bleeding stabilized, we started you back on heparin to
help thin the blood. This is treatment for the blood clots in
your lung. We also restarted your Coumadin.
Your breathing improved while you were here, but you are still
requiring oxygen at this time. You should continue using the
nebulizer treatments after you leave the hopsital.
You had a filter placed in your SVC (superior vena cava) at the
other hospital. This filter is intended to prevent the blood
clot in your arm from going to the lung. Right now, it is too
risky to remove the clot, but you should talk to you doctors
about whether the filter should be removed in the future.
We made the following changes to your medications:
STARTED:
-Warfarin 5 mg daily
-Heparin IV sliding scale
-Bowel regimen with colace, senna, bisacodyl (for constipation)
-Advair 250/50 inhaled twice a day
-Metoprolol 25 mg twice a day
-Vitamin D 800 units daily
-Ertapenem 1 gram daily until [**2170-2-28**] (for pneumonia)
-Pancrealipase 5000 units, 2 caps twice daily as needed to
unclog J-tube
CHANGED DOSING OF:
-calcium
-guiafenesin
STOPPED:
-Carvedilol
-Spironolactone
-Furosemide
-Prednisone (you completed a taper for your COPD exacerbation)
We did not make any other changes to your medications. Please
continue to take them as you have been doing. Please keep
follow-up appointments as below, and please follow-up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2170-2-20**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2170-3-6**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2170-3-13**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2170-3-13**] at 2:30 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for [**Location (un) **].
|
[
"486",
"51881",
"4280",
"496",
"4019",
"V5861"
] |
Admission Date: [**2189-1-16**] Discharge Date: [**2189-1-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Percutaneous Coronary Intervention with Bare Metal Stents
History of Present Illness:
87F with unknown PMH p/w LM STEMI. Pt initially evaluated at
[**Location (un) 620**] for 30min crushing substernal CP while at rest. Not
radiating, + diaphoresis, +/- SOB. Transferred for EKG ST
elevations.
.
In the ED, initial vitals were HR 100, ill appearing. Pt
received ASA, Plavix, Integrillin and taken to cath which
revealed LMCA prox 50%, LAD TO thrombotic prox -> 80% diffuse
after recanulization. LCX TO thrombotic prox. RCA mid heavily
calcified with mid 80% stenosis. 5 stents were placed in prox
LAD and LCX and IABP placed. Pt received 250ml contrast. RHC
revealed CO 3.26, CI 1.99, PCWP 27-33, PA 44/24. Step up in
oxygenation from RV 57 to PA 73. Echo was done and not
officially read at time of admission.
Past Medical History:
1. CARDIAC RISK FACTORS: none
2. OTHER PAST MEDICAL HISTORY:
Hip fracture.
Mild dementia.
Social History:
Lives with daughter and husband. [**Name (NI) 482**] [**Name2 (NI) 483**] and French.
Husband Finnish. [**Name2 (NI) 3003**] h/o falls. Otherwise independent. Has
some dementia.
-Tobacco history: Unknown
Family History:
Unknown
Physical Exam:
Admission Exam:
VS: T=98.8R BP=119/50 HR=98 RR=18 O2 sat= 99% 6L
GENERAL: frail elderly female, comfortable, supine. Oriented x 2
(not hospital).
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No extra sounds when IABP
paused
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles bilaterally,
worse at lower [**12-13**].
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left groin with sheath, right groin
nontender, no hematoma or bruit. Right DP palp, left
dopplerable, both feet cool.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2189-1-17**] 12:29AM BLOOD WBC-15.9* RBC-4.12* Hgb-12.3 Hct-36.6
MCV-89 MCH-29.8 MCHC-33.5 RDW-12.6 Plt Ct-396
[**2189-1-21**] 05:10AM BLOOD WBC-10.3 RBC-3.46* Hgb-10.6* Hct-30.4*
MCV-88 MCH-30.7 MCHC-35.0 RDW-13.0 Plt Ct-251
[**2189-1-21**] 05:10AM BLOOD PT-12.6 INR(PT)-1.1
[**2189-1-17**] 12:29AM BLOOD Glucose-196* UreaN-21* Creat-0.9 Na-135
K-3.8 Cl-100 HCO3-26 AnGap-13
[**2189-1-21**] 05:10AM BLOOD Glucose-110* UreaN-23* Creat-0.6 Na-135
K-3.8 Cl-102 HCO3-27 AnGap-10
[**2189-1-17**] 12:29AM BLOOD CK(CPK)-5512*
[**2189-1-17**] 06:23AM BLOOD CK(CPK)-4364*
[**2189-1-19**] 04:42AM BLOOD CK(CPK)-259*
[**2189-1-17**] 12:29AM BLOOD CK-MB- >500 cTropnT-23.9*
[**2189-1-17**] 01:59PM BLOOD CK-MB-300* MB Indx-10.5* cTropnT-14.92*
[**2189-1-19**] 04:42AM BLOOD CK-MB-14* MB Indx-5.4 cTropnT-6.78*
[**2189-1-17**] 12:29AM BLOOD %HbA1c-5.2 eAG-103
[**2189-1-17**] 12:29AM BLOOD Triglyc-85 HDL-60 CHOL/HD-3.1 LDLcalc-108
[**2189-1-16**] 09:53PM BLOOD Type-ART pO2-82* pCO2-41 pH-7.31*
calTCO2-22 Base XS--5 Intubat-NOT INTUBA Comment-O2 DELIVER
[**2189-1-18**] 11:40AM BLOOD Type-ART pO2-58* pCO2-32* pH-7.46*
calTCO2-23 Base XS-0
[**2189-1-16**] 09:53PM BLOOD Glucose-246* Lactate-1.3 Na-133* K-3.3*
Cl-98*
[**2189-1-18**] 08:39AM BLOOD Lactate-1.2
[**2189-1-19**] 05:03AM BLOOD freeCa-1.13
Cardiology Report Cardiac Cath Study Date of [**2189-1-16**]
INDICATIONS FOR CATHETERIZATION:
STEMI
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.63 m2
HEMOGLOBIN: 12.5 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} [**2190-11-25**]
RIGHT VENTRICLE {s/ed} 44/12
PULMONARY ARTERY {s/d/m} 44/25/31
PULMONARY WEDGE {a/v/m} 27/33/25
AORTA {s/d/m} 124/65/87
**CARDIAC OUTPUT
HEART RATE {beats/min} 96
RHYTHM NSR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 43
CARD. OP/IND FICK {l/mn/m2} 4.7/2.9
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1294
PULMONARY VASC. RESISTANCE 102
FICK
**% SATURATION DATA (FL)
SVC LOW 64
RA MID 58
RV MID 57
PA MAIN 73
AO 97
FICK
**SHUNTS
PULMONARY BLOOD FLOW 5.2
SYSTEMIC BLOOD FLOW 3.13
O2 STEP UP (VOL %) 15
PULMONARY/SYSTEMIC FLOW RATIO 1.6
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DISCRETE 80
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 50
6) PROXIMAL LAD DISCRETE 100
12) PROXIMAL CX DISCRETE 100
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate ventricular diastolic dysfunction.
3. Moderate pulmonary hypertension.
4. Possible left to right intracardiac shunt at the atrial
level.
5. Successful PCI of the LAD.
6. Successeful PCI of the LCX.
7. Successful placement of IABP.
8. Successful deployment of angioseal closure device.
[**Known lastname 86449**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86450**]Portable TTE
(Focused views) Done [**2189-1-16**] at 11:37:07 PM FINAL
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
regional left ventricular systolic dysfunction with severe
hypokinesis to akinesis of the anterior, septal and
distal/apical segments (proximal LAD territory). The remaining
segments contract normally (LVEF = 25-30%). No left ventricular
thrombus seen. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w CAD. Mild aortic and mitral regurgitation.
Limited emergency study.
[**Known lastname 86449**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86450**]Portable TTE
(Focused views) Done [**2189-1-18**] at 9:52:04 AM FINAL
There is severe regional left ventricular systolic dysfunction
with LVEF 25%. Right ventricular chamber size and free wall
motion are normal. Mild (1+) aortic regurgitation is seen. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
LVOT VTI on milrinone and IABP 1:1 was 12 cm at 115 bpm --> C.O.
= 3.9 l/min
LVOT VTI off milrinone and IABP 1:1 was 12.7 cm at 117 bpm -->
C.O. = 4.1 l/min
LVOT VTI off milrinone and IABP 1:2 was 11.1 cm at 115 bpm -->
C.O. = 3.6 l/min
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w LAD-territory infarction. Mild mitral and
aortic regurgitation. Minimal change in cardiac output during
inotrope and IABP weaning.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2189-1-17**] 3:39 PM
IMPRESSION:
1. Streak artifact from an intra-aortic balloon pump markedly
limits
evaluation of the lower descending thoracic aorta and abdominal
aorta, though
no overt abnormality. There is atherosclerotic disease in the
abdominal aorta
and common iliac arteries.
2. Small bilateral pleural effusions with atelectasis and likely
aspiration.
3. 1.4 x 0.8 cm nonspecific renal lesion for which further
evaluation with
MRI is recommended (as clinically indicated).
Radiology Report CHEST (PORTABLE AP) Study Date of [**2189-1-20**] 8:25
AM
IMPRESSION:
1. Worsening perihilar edema with worsening bilateral moderate
pleural
effusions and moderate bibasilar atelectases.
2. New left lower lobe opacity is concerning for atelectasis or
pneumonia in
the correct clinical setting.
Cardiology Report ECG Study Date of [**2189-1-20**] 1:36:24 PM
Sinus tachycardia. Right bundle-branch block. Anterior wall
myocardial
infarction. ST-T segment elevation in leads V1-V4 suggests
acute/subacute
process. Lateral ST-T wave changes suggestive of myocardial
ischemia. Low
QRS voltages in the limb leads. Compared to the previous tracing
of [**2189-1-19**]
anterior myocardial injury pattern persists. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 170 130 350/434 67 0 65
Cardiology Report ECG Study Date of [**2189-1-16**] 10:44:14 PM
Borderline sinus tachycardia with ventricular premature beat or
aberrant
conduction. Indeterminate axis. Possible anterior wall
myocardial infarction of
indeterminate age. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
100 176 96 372/442 75 0 90
Brief Hospital Course:
Mrs. [**Known lastname **] is an 87 year old woman who presented with chest
pain, found to have three-vessel CAD and proximal LAD and LCX
total thrombotic occlusion, transferred to [**Hospital1 18**] for cardiac
catheterization.
.
# s/p STEMI:
Patient presented from outside hospital with CKMB >500,
immediately sent for Cardiac Catheterization. During the
procedure, she was found to have diffuse coronary disease with
80% stenosis of the mid RCA, 50% Left Main stenosis, and 100%
stenosis, total thrombotic occlusion, of the proximal LAD and
proximal Circumflex. After the total thrombotic occlusion in the
proximal LAD was removed, 80% stenosis was found in the mid LAD.
A total of 5 bare metal stents were placed, and the patient was
transferred to the CCU with an intra-aortic balloon pump still
in place to help augment pressures and coronary flow. Patient
was started on aspirin, plavix, heparin, statin, and finished an
18hour course of integrilin. Her cardiac enzymes trended down
appropriately. She was weaned off the intra-aortic balloon pump
after about 36 hours. She was transitioned to coumadin with
lovenox bridging to prevent intraventricular thrombus formation.
Her visiting nurse will draw her INR and send results to her
new PCP who will manage her coumadin dosing.
.
HbA1c and lipid panel were checked to assess her cardiac risk
factors, as she does not follow with a primary care physician.
.
# Cardiogenic Shock:
The patient is s/p STEMI, found to have diffuse coronary artery
disease, including the left main. Echo showed severe regional
left ventricular systolic dysfunction with EF 25%. Patient was
noted to have poor cardiac output, leading to low blood
pressures and low urine output. A Swan-Ganz catheter was placed
in order to more accurately measure her volume status and manage
appropriately. She was started on a milrinone drip which
initially supported her cardiac output, but when it was used
again its proarrhythmic effects put her into atrial
fibrillation, so it was stopped.
.
# Atrial Fibrillation
On Day 4 of hospitalization, when the patient was re-started on
a milrinone drip to improve forward cardiac flow, its
pro-arrythmogenic effects put her into atrial fibrillation with
rapid ventricular response in the 140s-160s with blood pressures
in the 90s systolic. Her ventricular response responded to
metoprolol 5mg intravenously x2, then given an intravenous
amiodarone bolus of 150mg, after which she converted back to
normal sinus rhythm.
.
# Abdominal and Back Pain:
Patient concerned of vague abdominal and back pain after her
Catheterization, but CT scan was negative for retroperitoneal
bleed and mesenteric ischemia, and her hematocrit was stable.
There had been concern for mesenteric ischemia with her history
of atherosclerosis and with intra-aortic balloon pump in place.
Patient's daughter mentioned that the patient had been
complaining of vague pains all over her body for years.
.
# Goals of Care
Patient has poor overall prognosis, heart with poor inotropy,
allowing poor forward flow, low cardiac output. The CCU team
met with the patient and her daughter to explain her prognosis.
The patient herself did not wish to discuss goals of care and
left decision making to her daughter. Palliative [**Name2 (NI) **] was
consulted. The patient's daughter signed as her Health Care
Proxy and changed the patient's code status to DNR/DNI. She was
sent home with VNA services with Home Hospice services.
.
Medications on Admission:
None
Discharge Medications:
1. Oxygen
2-5L continuous pulse dose for portability
2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-15 mg
sublingual PO q1h as needed for pain, air hunger: For hospice
care.
Disp:*20 mL* Refills:*0*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 7 days.
Disp:*14 syringes* Refills:*0*
9. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 tablets* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
14. [**Name2 (NI) 86451**] 125 mcg Tablet Sig: [**12-13**] Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
You need to have your INR drawn on Saturday, [**2189-1-24**], and faxed
to Dr. [**Last Name (STitle) 86452**] at [**Telephone/Fax (1) 86453**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
ST Elevation Myocardial Infarction
Secondary Diagnoses:
Cardiogenic Shock
Acute Heart Failure
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital because you had a very large
heart attack and were taken for Cardiac Catheterization. You
had multiple stents placed into your coronary arteries to keep
them open, and you were started on some new medications, listed
below, that are very important to continue. After the heart
attack, your heart is weak and has difficulty pumping your blood
effectively to the rest of your body. You were discharged home
with oxygen as needed. You were also discharged home with blood
thinning medications in order to prevent a blood clot from
forming inside your heart. While on the coumadin, you will need
to have your blood monitored regularly to make sure the level in
your blood fits within the appropriate range; until it reaches
this range, you will need twice daily Lovenox shots to help thin
your blood. You will need to have the blood labs faxed to Dr.
[**First Name4 (NamePattern1) 86454**] [**Last Name (NamePattern1) 86452**] at [**Telephone/Fax (1) 86455**].
Your new medications are as listed below.
- Warfarin 2.5mg by mouth daily
- Lovenox Injections, daily, until warfarin level at goal -
discuss with your primary care physician
[**Name Initial (PRE) **] [**Name Initial (NameIs) 86451**] 0.0625mg by mouth daily
- Furosemide 20mg by mouth daily
- Captopril 6.25mg by mouth three times a day
- Colace 100mg by mouth twice a day
- Senna 1 tab by mouth twice a day as needed for constipation
- Lorazepam 0.25mg by mouth every 6 hours as needed for anxiety
- Atorvastatin 80mg by mouth daily
- Clopidogrel 75mg by mouth daily - do not stop this medication
for any reason. Only your cardiologist should stop this
medication.
- Aspirin 325mg by mouth daily
- Morphine elixir 2-15mg by mouth every hour as needed for pain
or air hunger. [**Month (only) 116**] start with 2mg and then increase as
necessary at a time to not over-sedate.
Please be sure to keep your followup appointments. They are
listed below.
Followup Instructions:
Please schedule an appointment with Dr. [**First Name4 (NamePattern1) 86454**] [**Last Name (NamePattern1) 86452**].
The phone number to set this appointment up is [**Telephone/Fax (1) 67509**]. He
will follow your INR levels as above. You should contact him
with any questions or concerns or needs for new medications or
refills.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Street Address(2) **]. [**Location (un) **]
([**Telephone/Fax (1) 8937**]
Wednesday, [**1-28**] at 10:00. Please arrive by 9:30am.
|
[
"41401",
"4280",
"42731",
"4168"
] |
Admission Date: [**2155-10-22**] Discharge Date: [**2155-10-22**]
Date of Birth: [**2085-7-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Cefadroxil
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
transferred from OSH with ICH and IVH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 16008**] is a 70 y/o male with a history of mental
disability per the coordinator at the [**Hospital3 **] center
where he lives. Neighbors at the center heard a loud sound in
his room and found him unresponsive. It was assumed he
sustained
a groud level fall. He was taken to an OSH where he received
etomidate, vecuronium, and versed approximately 90 minutes ago.
A head CT without contrast revealed acute intraventricular
hemorrhage in all 4 ventricles with associated cerebellar
hemispheres intraparenchymal hemorrhages (left>right) and small
amount of interhemispheric fissure subarachnoid hemorrhage. He
was transferred to [**Hospital1 18**] ED for neurosurgical evaluation.
Past Medical History:
Friedreichs ataxia
HTN
Social History:
lives in group home, has legal guardian, sister is also very
involved
Family History:
has 2 brothers with Friedreichs ataxia
Physical Exam:
Upon admission:
T: 98.9 BP: 144/74 HR:89 R12 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 mm bilaterally and sluggish EOMs no eye
movement
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: comatose
Orientation: none
Recall: none
Language: intubated
Cranial Nerves:
I: Not tested
II: Pupils 2.5 bilaterally - minimally reactive
III, IV, VI: Extraocular movements cannot be tested
V, VII: Facial strength and sensation cannot be tested
IX, X: cannot be tested
[**Doctor First Name 81**]: cannot be tested.
XII: cannot be tested
Motor: Normal bulk and tone bilaterally. No movement to noxious
stimuli
eyes closed
negative corneal reflexes
occulocephalic reflex negative
no cough
no gag
Sensation: cannot be adequately tested
Reflexes: B T Br Pa Ac
no reflexes on ecam
Toes downgoing bilaterally
Coordination: cannot be tested
Pertinent Results:
1.8 x 2.1 cm ruptured aneurysm at the left CA-PCOM. Massive
intraventricular hemorrhage. Subarachnoid hemorrhage.
Effacement of the sulci.
Brief Hospital Course:
The patient was admitted after sustaining a massive IVH, ICH
from a ruptured aneurysm. He had a very poor exam upon
admission. The patient was admitted to the ICU and required
vasopressors to keep his blood pressure elevated. He had been
intubated at the OSH. He did not require any sedation. Later in
the day the patient progressed to brain death. He died at 14:07.
His whole family was present during the day. The patient's legal
guardian was also spoken to several times. The family did not
want an autopsy.
Medications on Admission:
omeprazole 20 mg po qd
metoprolol 25 mg po qd
lamisil
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2155-10-22**]
|
[
"4019"
] |
Admission Date: [**2166-8-24**] Discharge Date: [**2166-11-24**]
Date of Birth: [**2166-8-24**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname 18488**] [**Known lastname 29571**] was born at 25
4/7 weeks gestation to a 35 year old gravida 3, para 2, now 3
woman. The prenatal screens were blood type 0 positive,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
surface antigen negative and Group Streptococcus unknown.
This pregnancy was uncomplicated until the day of delivery
with the onset of preterm labor. The infant was delivered by
cesarean section for breech positioning and question of
abruption. The infant emerged without respiratory effort,
required intubation in the Delivery Room. Apgars were 1 at
one minute, 6 at five minutes and 7 at ten minutes.
The birth weight was 980 gm, birth length was 36 cm and the
birth head circumference was 24.5 cm.
ADMISSION PHYSICAL EXAMINATION: The admission physical
revealed an extremely premature, nondysmorphic infant. Her
anterior fontanelle was open and flat. Her palate was
intact. Her eyelids were still fused. She had bruising of
her arms and legs. She had fair air entry bilaterally after
intubation. Her heartsounds were normal with no audible
murmurs. The abdomen was soft, no organomegaly. She had
rigid tone throughout. She was pink and well perfused.
HOSPITAL COURSE: (By systems)
Respiratory status - She was intubated in the Delivery Room.
She received two doses of Surfactant. She successfully
weaned to nasopharyngeal continuous positive airway pressure
on day of life #27 and weaned to nasal cannula oxygen on day
of life #36 and then weaned to room air on day of life 79
where she has remained. She was treated with caffeine for
apnea of prematurity from day of life #20 to day of life #57.
Her last episode of bradycardia was on [**2166-10-8**]. On
examination her respirations are comfortable and her lung
fields are clear in each lung.
Cardiovascular status - She initially received a fluid bolus
for hypotension and has been normotensive since that time.
She was treated with one course of Indocin for a patent
ductus arteriosus which was confirmed by echocardiogram on
day of life #2. Her heart was otherwise structurally normal
on that echocardiogram. A follow up echocardiogram on day of
life #4 showed a tiny insignificant patent ductus arteriosus
and no further treatment was given. On [**2166-8-28**]
she had a cardiac echocardiogram again due to clinical
decompensation. There was no patent ductus arteriosus at
that time, and she had a normal arteriotomy. She continues
to have an intermittent Grade I to II/VI systolic ejection
murmur at the left upper sternal border consistent with
peripheral pulmonic stenosis. She is pink and well perfused.
Fluids, electrolytes and nutrition status - Her discharge
weight is 3,090 gm. Her length is 50 cm, and her head
circumference is 35.5 cm. Enteral feeds were begun on day of
life #7. She had reached 100 cc/kg/day of enteral feeds on
day of life #12 and she had a clinical presentation of
necrotizing enterocolitis and feedings were stopped for 14
days. She was treated with hyperalimentation and interlipids
during that time. Feeds were restarted on day of life #27.
She reached full volume feed on day of life #34, and then
increased to a maximum calories of 30 cal/oz with added
ProMod. At the time of discharge she is eating formula,
Enfamil 26 cal/oz on an adlib schedule.
Gastrointestinal status - [**Known lastname 18488**] was treated with
phototherapy for hyperbilirubinemia of prematurity from day
of life #1 until day of life #8. Her peak bilirubin occurred
on day of life #6 and was 4.7, direct 0.4.
On day of life #32 her bilirubin was checked again due to her
jaundice color and her total was 9.4 and her direct was 2.5. At
that time she was six days into her refeeding after being treated
with hyperalimentation for approximately three weeks. On day of
life #67, a repeat bilirubin was total 5.3, direct 3.6. Her
liver function studies showed ALT of 66 and AST of 128, urine
cytomegalovirus at that time was negative. Hepatitis B
surface antibody was negative. Hepatitis B surface antigen
was negative. Hepatitic C antibody was negative. An
abdominal ultrasound done on [**2166-11-4**] was within
normal limits although no gall bladder was visualized. Her last
bilirubin on the day of discharge was total of 4.2 and direct
2.9. She was evaluated by [**Hospital3 1810**] Gastrointestinal
Service on [**2166-11-19**]. They requested an Alpha 1-
antitrypsin and PI-Typing stat, that was done on [**2166-11-20**] and was pending at the time of discharge. She is scheduled
to have a HIDA scan to rule out biliary atresia at [**Hospital3 18242**] on [**2166-11-27**]. She was started on Phenobarbital
at 3 mg/kg/day on [**11-22**] to be continued until the HIDA
scan.
She was also treated for medical necrotizing enterocolitis.
She received 14 days of Ampicillin, Gentamicin and
Clindamycin and bowel rest from day of life 12 until day of
life #26. Blood cultures from that time remained negative.
Hematology - [**Known lastname 18488**] received multiple transfusions of packed
red blood cells during her Neonatal Intensive Care Unit stay.
Her last hematocrit on [**2166-11-1**] was 26.1,
reticulocyte count 6%. She was receiving supplemental iron
approximately 2 mg/kg/day.
Infectious disease status - [**Known lastname 18488**] was started on Ampicillin
and Gentamicin at the time for sepsis suspected. She
completed seven days for presumed sepsis. Blood cultures and
cerebrospinal fluid cultures from that time remained
negative. Ampicillin, Gentamicin and Clindamycin were begun
on day of life #12, for medical and necrotizing
enterocolitis. She completed 14 days of those antibiotics.
Blood cultures remained negative. She has remained off
systemic antibiotics since that time. On [**2166-10-9**]
she completed five days of erythromycin ophthalmic ointment
for conjunctivitis.
Orthopedics - She had a hip ultrasound on the day of
discharge due to her breech presentation, in accordance with
the AAP recommendations, and this was normal.
Neurologic - Head ultrasound on [**8-27**], [**9-1**],
and [**9-24**], were within normal limits.
Audiology - Hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Ophthalmology - The infant's eyes were examined most recently
on [**2166-11-22**] and revealed retinopathy of prematurity,
Stage 2, Zone 2 in both eyes, 5 o'clock hours in the eye and
6 o'clock hours in the left eye with mild plus disease in the
left eye. She will have a follow up ophthalmology
appointment at [**Hospital3 1810**] with Dr. [**Last Name (STitle) 36137**] on
[**2166-11-28**].
Psychosocial - The parents have been very involved in the
infant's care throughout her Neonatal Intensive Care Unit
stay.
CONDITION ON DISCHARGE: The infant is discharged in good
condition.
DISPOSITION: The infant is discharged home with her parents.
PRIMARY PEDIATRIC CARE: Provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44797**], [**Hospital3 50291**], [**Hospital1 8**] [**State 350**], phone
[**Telephone/Fax (1) 47150**].
CARE/RECOMMENDATIONS:
Feedings - 26 cal/oz formula made with 4 cal/oz by
concentration and 2 cal/oz of corn oil on an ad lib schedule.
Medications - 1. Phenobarbital 9 mg p.o. q. day to be
continued until the HIDA scan; 2. Iron Sulfate (25
mg/ml), 0.3 cc p.o. q. day
Carseat test - The infant has passed carseat position
screening test.
State newborn screen - Her last state newborn screen was sent
[**10-23**] and [**2166-11-3**].
Immunizations - The infant has received the following
immunizations: Hepatitis B vaccine #1 on [**2166-9-28**];
hepatitis B vaccine #2 on [**2166-10-31**]. dTaP #1 on
[**2166-10-25**], he had HIB #1 on [**2166-10-25**], IPV #1
on [**2166-10-25**]. Prevnar (pneumococcal 7-Valent
conjugate vaccine) [**2166-10-25**] and Synagis #1 on
[**2166-11-17**].
Recommended immunizations: I. Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: 1. Born at less than 32 weeks; 2. Born between
32 and 35 weeks with two of the three of the following -
Daycare during respiratory syncytial virus season, with a
smoker in the household, neuromuscular disease, airway
abnormalities or school-age siblings; or 3. With chronic lung
disease.
II. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
FOLLOW UP: Follow up for this infant includes-
1. Outpatient HIDA scan at [**Hospital3 1810**] [**2166-11-27**], at 10am. Needs to be NPO for four hours prior to the
study.
2. Follow up in the [**Hospital 6283**] Clinic with Dr. [**Last Name (STitle) 50292**]
[**Name (STitle) **] after the HIDA scan, the clinic is held on Monday
morning, phone #[**Telephone/Fax (1) 46320**]. Dr. [**Last Name (STitle) **], [**Hospital3 1810**]
Beeper #[**Pager number **].
3. Ophthalmology, appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36137**] of
[**Hospital3 1810**], Ophthalmology on [**2166-11-28**],
telephone #[**Telephone/Fax (1) 36249**].
4. [**Hospital3 1810**] Infant Follow up Program, phone
#[**Telephone/Fax (1) 37126**], they will call the parents for an appointment.
5. Early Intervention of the [**Location (un) 86**] Regional Child
Developmental Center, phone #[**Telephone/Fax (1) 38334**].
6. [**First Name (Titles) 407**] [**Last Name (Titles) **] Network, phone
#1-[**Telephone/Fax (1) 12065**].
DISCHARGE DIAGNOSIS:
1. Status post prematurity at 24 4/7 weeks gestation
2. Status post respiratory distress syndrome
3. Status post apnea of prematurity
4. Status post patent ductus arteriosus
5. Status post medical necrotizing enterocolitis
6. Status post hyperkalemia
7. Neonatal cholestasis
8. Status post unconjugated hyperbilirubinemia of
prematurity
9. Anemia of prematurity
10. Status post presumed sepsis
11. Status post conjunctivitis
12. Retinopathy of prematurity
13. Status post chronic lung disease
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2166-11-24**] 07:00
T: [**2166-11-24**] 09:20
JOB#: [**Job Number 50293**]
|
[
"7742",
"2767"
] |
Admission Date: [**2123-6-24**] Discharge Date: [**2123-7-17**]
Date of Birth: [**2083-12-18**] Sex: M
Service: PLASTIC
Allergies:
Novocain
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
Periurethral abscess and Fournier's Gangrene
Major Surgical or Invasive Procedure:
1. Laparotomy and end-ileostomy
2. 1. Removal of back bolster.
3. Examination under anesthesia with partial release of his
gracilis inset and washout of his prerectal space and
drain tracts space.
4. Lavage of rectum and lower sigmoid intraluminal contents
with Ortho enema.
5. Distal rectal fecal diversion by way of Flex-Seal
intrarectal drainage tube placement.
6. Replacement of skin graft bolster dressing
7. 1. Irrigation and debridement of perirectal cavity.
8. Right gracilis flap transposition into the perirectal
cavity.
9. Excisional preparation of skin graft recipient site.
10. Split-thickness skin graft coverage of penile shaft,
left testicle and perineal cutaneous defect measuring
over 500 cm2 in surface area.
11. Application of negative pressure sponge bolster.
12. Laparoscopic diverting end loop sigmoid colostomy
13. Suprapubic tube placement.
14. Right orchiectomy.
15. Perineal and abdominal debridement.
16. Urethrectomy
History of Present Illness:
39 M with h/o alcoholism (now sober for 20 years) who noted
penile and scrotal swelling approximately one week ago. He was
seen by his primary care physician, [**Name10 (NameIs) 1023**] placed him on
antibiotics for four days (unclear which one). The swelling did
not improve significantly, and earlier today, he presented to
[**Hospital3 635**] hospital, where he was immediately transferred to [**Hospital1 18**]
for workup and treatment of ?Fournier's gangrene. Urology was
consulted and a CT with IV contrast was recommended, which
showed significant air within what appears to be a penile
abscess. He denies fevers/chills/nausea/vomiting. He last
urinated earlier today, and also had a recent bowel movement.
No dizziness, lightheadedness, chest pain, or shortness of
breath.
Past Medical History:
PMH: alcoholism (goes to AA, been sober for 19-20 yrs)
PSH: none, but was scheduled to have L inguinal hernia repair
Social History:
Works as tow truck driver for last 6 yrs. nonsmoker, former
alcoholic, now sober.
Family History:
Noncontributory
Physical Exam:
On initial evaluation:
Tm 101.0 Tc 97.0 HR 107 BP 118/70 RR 18 O2Sat 95 on RA
Sitting in bed, in no acute distress
Tachy, regular
CTAB
Abd S, NT, mildly distended, nonperitoneal
Penis with massive edema, tense, fluctuant, pain on palpation,
noncircumcized. Scrotum bilaterally edematous, testicles unable
to be palpated, mildly tender to palpation, no fluctuance noted.
Legs c/c/e
Pertinent Results:
Labs on admission:
[**2123-6-24**] 05:41PM BLOOD WBC-24.1* RBC-4.45* Hgb-10.9* Hct-33.4*
MCV-75* MCH-24.4* MCHC-32.5 RDW-14.7 Plt Ct-1019*
[**2123-6-24**] 05:41PM BLOOD Neuts-91.2* Lymphs-4.7* Monos-3.5 Eos-0.4
Baso-0.2
[**2123-6-24**] 05:41PM BLOOD PT-15.2* PTT-25.9 INR(PT)-1.3*
[**2123-6-24**] 05:41PM BLOOD Glucose-104 UreaN-12 Creat-0.7 Na-133
K-4.5 Cl-95* HCO3-26 AnGap-17
[**2123-6-24**] 05:41PM BLOOD ALT-15 AST-22 LD(LDH)-291* AlkPhos-89
[**2123-6-24**] 05:41PM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.8 Mg-1.9
[**2123-6-24**] 05:40PM BLOOD Glucose-108* Lactate-1.4 Na-133* K-4.0
Cl-93* calHCO3-28
Labs prior to discharge:
[**2123-7-12**] 09:27PM BLOOD Hct-29.3*
[**2123-7-12**] 04:58PM BLOOD WBC-4.6 RBC-3.53* Hgb-9.5* Hct-28.6*
MCV-81* MCH-27.0 MCHC-33.3 RDW-17.7* Plt Ct-636*
[**2123-7-12**] 04:58PM BLOOD PT-13.2 PTT-23.4 INR(PT)-1.1
[**2123-7-15**] 06:38AM BLOOD Glucose-127* UreaN-14 Creat-0.8 Na-137
K-4.6 Cl-100 HCO3-26 AnGap-16
[**2123-7-15**] 06:38AM BLOOD Phos-3.7 Mg-1.9
Imaging:
CT PELVIS W/CONTRAST Study Date of [**2123-6-24**] 6:00 PM
1. 7 x 7 cm abscess involving nearly the entire length of the
corpus
spongiosum with resulting superior displacement of otherwise
normal-appearing corpi cavernosum. Innumerable locules of gas
within the corpus spongiosum. These findings are consistent with
Fournier's gangrene.
2. Air in the nondependent portions of the bladder indicating
possible
progression of infection into and possibly involving the
bladder. Foci of air is also seen within the prostatic urethra.
3. No pelvic abscesses identified. Nonobstructed fluid-filled
loops of bowel are present likely due to ileus due to patient's
severe illness.
4. Marked soft tissue swelling of the scrotum, penile, and
perineal soft
tissue but no evidence for subcutaneous gas in these tissues.
CT CYSTOGRAM (PEL) W/CONTRAST Study Date of [**2123-6-30**] 3:12 PM
Contrast leakage with the likely source at the level of the
urethral ligation. There is also a fistula with the bowel and
contrast seen in the rectum. Contrast is also seen leaking
inferior to the penis and tracking anteriorly into the patient's
wound.
CT ABD/PELVIS W/CONTRAST Study Date of [**2123-7-11**] 5:22 PM
1. Extensive inflammatory changes in the pelvis involve the
distal small
bowel, urinary bladder and rectum, with stellate fistulous
tracts connecting all structures. Dense contrast material in the
rectum, refluxing to the level of the colostomy likely
originates in both urinary bladder and small bowel. In
comparison with the original exam on [**2123-6-24**], abnormalities
around the cecum suggest this process may have originated with
an intra-abdominal process such as perforated appendicitis or an
exacerbation of Crohn's disease.
2. Dilated left ureter, with bilateral ureteral contrast
excretion to the
urinary bladder. This suggests that the nephrostomy catheters,
particularly on the left, may not be providing adequate urinary
diversion.
3. Left renal medial lower pole persistent contrast enhancement
suggests
renal injury due to trauma, or infection.
4. 3-cm heterogeneous collection adjacent to the left perineal
wick,
containing contrast material on delayed images, indicates
fistulous connection from the perirectal or peri-urinary bladder
inflammatory collections. The material may be too thick to be
drianed by the wick.
5. Congested, mildly dilated large bowel extending to the ostomy
raises the question that the diverting ostomy may not be
draining well.
Micro:
[**6-24**] wound culture: mixed bacteria; PREVOTELLA SPECIES
(anaerobic)
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP (PAN SENSITIVE)
Brief Hospital Course:
Patient was immediately taken to the OR for emergent debridement
of fournier's gangrene by urology. Please see Dr.[**Name (NI) 11306**]
operative note for details. Postoperatively, the patient was
initially on pressor support for sepsis. ID was consulted,
recommending broad spectrum antibiotic therapy. The patient was
off pressors and extubated by POD2. He was transferred to the
floor POD3. His wound has been managed with wet-to-dry
dressings. A small area of necrosis along the R edge of the
defect was debrided at the bedside on POD5. Plastic surgery was
consulted for assistance with closure, and the patient was
scheduled for his initial skin-grafting procedure on POD7. On
POD6, however, he was noted to have a large amount of urine
passing onto his bed. It was unclear whether this was
associated with bowel movements and was also unclear whether it
was passing from his rectum or from the lower aspect of his
wound. To clarify matters, a CT cystogram was obtained, showing
a rectourethral fistula at the level of the prostate with urine
leaking into rectum as well as from distal aspect of residual
urethra. The patient??????s plastic surgery was delayed. General
surgery was consulted, and the patient underwent lap diverting
loop sigmoid colostomy on POD8. With a plan for initial
proximal urine diversion via B PCNs with eventual IC after wound
healing from below, the patient underwent B PCN placement POD11.
On [**2123-7-9**] patient underwent multiple STSGs to perineum as well
as a gracilis transfer flap to inferior perineal cavity defect.
Intraoperatively a large amount of stool was evacuated from the
rectum before he was prepped and draped. Please see Dr. [**Name (NI) 83165**] operative note for details. Patient tolerated the
procedure well and was transferred to the PACU and then to floor
in stable condition. Postoperatively, his pain was well
controlled with IV and then PO narcotics. He was continued on
vanc/levo/flagyl. On POD1, he was noted to have a significant
amount of stool per rectum. It was unclear at that time whether
this stool represented failure of the diverting colostomy.
Patient returned to the OR for irrigation of wound. A small
amount of pus was evacuated around the gracilis flap. Wounds
were thoroughly irrigated and a penrose drain was placed into
inferior perineal wound. A rectal tube was placed to divert
stool. On POD2 and 3 patient continued to have a significant
amount of stool from rectum. On POD 3 we also noted urine again
draining from his rectum. Concurrently, his left nephrostomy
tube dropped in output. IR was reconsulted. We obtained an
I+/O+ abd/pelvis CT at that time, which showed PO contrast to
the rectum and IV contrast in bladder on delayed imaging. Also
noted were multiple areas of stellate fistulous tracts
connecting distal small bowel, urinary bladder and rectum. This
represented failure of both urinary and fecal diversions.
The following day, his left nephrostomy was replaced. He
returned to OR by general surgery for a ileostomy and mucous
fistula creation. Please see Dr.[**Name (NI) 3377**] operative note for
details. Postoperatively, his diet was slowly advanced. His
pain was well controlled with IV and then PO narcotics. His
nephrostomy tubes were regularly flushed. His ostomy was
functional with good stool output and GI was consulted for a
flex sigmoidoscopy to r/o rectal/sigmoid mass to explain his GI
findings in total. Mr. [**Known lastname **] [**Last Name (Titles) 83166**] refused a flex sig during
this hospital stay. He was strongly encouraged to go to his GI
appointment for a flex sig scheduled on [**8-13**].
In regards to ID, patient will receive 7 more days of
levofloxacin and flagyl.
He will follow up in plastics clinic in [**1-29**] weeks. He will
follow up with Dr. [**Last Name (STitle) 3748**] for exchange of his suprapubic
catheter in 2 weeks. He will follow up with Dr. [**Last Name (STitle) 1120**] in 2
weeks.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, and pain
well controlled. He is being discharged today to rehab.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety, insomnia.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash on buttocks.
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
10. 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:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]
Discharge Diagnosis:
1. Fournier's gangrene
2. Enterovesical and enterocolitis fistulae
3. Perineal wound with STSGs
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Take all antibiotics as prescribed.
Followup Instructions:
Please schedule a [**1-29**] week follow up with Dr. [**Last Name (STitle) 23606**] at
[**Telephone/Fax (1) 4652**].
Please schedule a 2 week appointment with Dr. [**Last Name (STitle) 3748**]. Your
suprapubic catheter will be exchanged at that time. It is very
important that you schedule and attend this appointment.
Please schedule a 2 week appointment with Dr. [**Last Name (STitle) 1120**].
Please follow up with gastroenterology for a flexible
sigmoidoscopy on [**2123-8-13**] (see below). It is very important that
you go to this appointment.
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2123-8-13**] 11:30
Completed by:[**2123-7-17**]
|
[
"78552",
"99592"
] |
Admission Date: [**2183-10-14**] Discharge Date: [**2183-11-4**]
Date of Birth: [**2134-10-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Status post motorcycle accident.
Major Surgical or Invasive Procedure:
Exploratory laparotomy with splenectomy.
Open reduction internal fixation of right anterior/posterior
pelvic rings.
Open reduction internal fixation of left anterior column
fracture. Open reduction internal fixation left tibial plateau
fracture.
Placement of IVC filter.
Past Medical History:
Hypertension, hyperlipidemia, Diabetes Mellitus (type 2), s/p
ORIF right Tib-fib.
Family History:
Noncontributory.
Physical Exam:
On arrival:
GEN- intubated, sedated
PULM: equal breath sounds bilaterally, adequate/equal chest wall
excursion, good color change
EXT: skin mottled
Pertinent Results:
[**2183-10-14**] 12:15AM ASA-NEG ETHANOL-156* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
---
TECHNIQUE: Cervical spine CT, with sagittal and coronal
reformatting without intravenous contrast.
IMPRESSION:
1. No evidence of traumatic injury.
2. Likely prominent, but normal epidural venous plexus. If
there is a
persistent concern, then a contrast-enhanced CT can be helpful
to confirm
this supposition.
----
CT L-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 55949**]
IMPRESSION: Comminuted fracture of the right sacral ala. Small
osseous
fragments along the inferior aspect of the left L3/4 facet joint
complex,
likely fracture fragments of indeterminate age.
-----
CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 55950**]
IMPRESSION: No evidence of traumatic injury of the thoracic
spine. Right
lower lobe consolidation, which may represent atelectasis or
aspiration.
Clinical correlation recommended.
------
CT PELVIS ORTHO W/O C Clip # [**Clip Number (Radiology) 55951**]
IMPRESSION:
1. Complex left acetabular fracture. The more comminuted
complex fracture
involves the anterior acetabulum with a small minimally
displaced
posterolateral acetabular component of the fracture.
2. Right sacral fracture. No SI joint widening.
3. Right pubic symphysis/inferior ramus and left inferior pubic
ramus
fractures. No widening at the pubic symphysis.
4. Laterally displaced left greater trochanteric fracture.
5. Minimal impaction fracture at the anterior left femoral
head.
6. Retroperitoneal/presacral fluid/blood. The patient is
status post a
recent laparotomy.
-------------------
Brief Hospital Course:
Mr. [**Known lastname 55952**] was transferred to [**Hospital1 18**] from [**Hospital3 **] with unstable vital signs and hemorrhagic shock
refractory to resuscitation. He was emergently taken to the OR
for exploratory laparotomy and splenectomy secondary to CT
findings of a ruptured spleen. Postoperatively, he was
transferred to the TSICU. He returned to the OR on [**2183-10-17**] for
placement of an IVC filter and ORIF of his pelvic fractures, and
his left tibial plateau. He tolerated the procedures well and
continued to progress in the TSICU. He did have some difficulty
with slowly improving mental status and a repeat head CT was
obtained on hospital day 5 which did not reveal any new changes.
On hospital day 8, the patient was placed on precidex, weaned,
and extubated successfully. He was transferred to the floor on
hospital day 10, where he continued to improve. He was
administered the meningococcal, pneumovax, and haemophilus
influenza vaccinations prior to discharge as asplenic
prophylaxis. On hospital day 21, the patient was cleared by
physical therapy for discharge to home with services.
Medications on Admission:
Amlodipine, allopurinol, lisinopril, glypizide
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Acetaminophen 160 mg/5 mL Solution Sig: [**12-9**] PO Q4-6H (every
4 to 6 hours) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) tsp PO TID
(3 times a day).
9. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO DAILY (Daily).
13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
16. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
17. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
18. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
19. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
20. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
1. Status-post MVC.
2. Status-post splenectomy.
3. Status-post IVC filter placement.
4. Status-post ORIF right anterior pelvic ring, right posterior
pelvic ring, anterior column acetabular fracture, and left
tibial plateau fracture.
Discharge Condition:
Good.
Discharge Instructions:
Call your doctor or return to the emergency department if you
experience any of the following: worsening pain, inability to
eat or drink, chest pain, shortness of breath, redness, pain, or
swelling at your incision sites, any new or concerning symptoms.
Please take all of your prescribed medications.
Followup Instructions:
Please follow-up in the [**Hospital 5498**] clinic with Dr. [**Last Name (STitle) 1005**] in
two weeks. You will need to call [**Telephone/Fax (1) 1228**] for an
appointment.
You will also need to follow up in the trauma clinic in two
weeks. Call [**Telephone/Fax (1) 6429**] for an appointment.
|
[
"4019",
"2724",
"25000",
"3051"
] |
Admission Date: [**2105-6-30**] Discharge Date: [**2105-7-1**]
Date of Birth: [**2078-11-6**] Sex: M
Service: MEDICINE
Allergies:
clindamycin / vancomycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The patient is a young caucasian male who was found unresponsive
in the Fens by EMS, and who was subsequently intubated in the
field and transferred to [**Hospital1 18**] ED. No other pre-hospital data or
documentation is available.
.
In the ED, initial vs were: T95.9 P69 BP128/76 R14 O2 sat100% on
CMV set at Vt500/R14/PEEP5/Fi021.00. He was placed on
fentanyl/midazolam gtt for sedation. A trauma series was
negative, including a normal FAST panel and a CT head/neck which
were unremarkable for acute fracture. An NGT was placed though
no output retrieved when placed to suction. He was initially
hypothermic to 91F and bearhugger was placed with good effect.
He received 3L NS in the ED and was transferred to the [**Hospital Unit Name 153**].
.
Upon arrival to the [**Hospital Unit Name 153**], his initial VS were T96.4 BP120/73
RR14 P71 Sat100% on Fi0250%. His sedation was lightened and he
was able to interact with staff and nod for questioning. He had
a license identifying him as [**Known firstname 429**] [**Known lastname 1968**], and he was able to
confirm that this is true. He is in no significant pain. Limited
history suggests that he was drinking alcohol last night. He had
a bottle of clear liquid in his personal belongings, though he
does not know was this is.
.
Review of his previous records shows that he presented to the ED
last [**Month (only) 216**] for help with daily use of amphetamine. A psych note
from that time revealed that he was then homeless with a history
of polysubstance abuse, particularly with almost daily
amphetamine use in addition to gamma-hydroxybutyric acid (GHB),
though he had also experimented with cocaine, MDMA, though no
IVDA. He was engaging in sexual activity to fund his drug habit.
.
He has a history of depression and anxiety, though had never
been consistently treated. He a suicide attempt several years
ago in which he overdosed on xanax, drank alcohol to excess, and
took GHB. He had been hospitalized several times for his
depression.
Past Medical History:
- depression
- anxiety
- history of suicide attempt
- polysubstance abuse (particularly methamphetamine, GHB)
- Ventricular septal defect
Social History:
Occupation: Works at [**Company **]
Drugs: clean x6months, polysubstance abuse in past with GHB and
amphetamine
Tobacco: smokes [**1-25**] PPDx5yrs
Alcohol: 5 drinks per setting x2 weekly
Other: Lives with grandmother in [**Name2 (NI) **]
Family History:
father died from cirrhosis, mother died from heroin overdose.
Physical Exam:
Vitals: T95.9 P69 BP128/76 R14 O2 sat100%
Vent: CMV set at Vt500/R14/PEEP5/Fi021.00General: Alert,
oriented, no acute distress
HEENT: pupils are 3mm and reactive bilaterally without
nystagmus. MMM. ETT in place. Cervical collar is in place.
Neck: supple, cervical collar in place
Lungs: Anterior exam clear to auscultation bilaterally, no
wheezes, rales, rhonchi
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, DP, PT pulses could not be palpated
though were present with doppler U/S. several abrasions over
ankles bilaterally.
NEURO: Nodding y/n to questions. Opens eyes and follows
commands. 2+ DTR in [**Name2 (NI) 15219**].
Physical Exam on Day of Discharge
HEENT: pupils are 3mm and reactive bilaterally without
nystagmus. MMM. ETT in place. Cervical collar is in place.
Neck: supple, cervical collar in place
Lungs: Anterior exam clear to auscultation bilaterally, no
wheezes, rales, rhonchi
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, DP, PT pulses could not be palpated
though were present with doppler U/S. several abrasions over
ankles bilaterally.
NEURO: Nodding y/n to questions. Opens eyes and follows
commands. 2+ DTR in [**Name2 (NI) 15219**].
Pertinent Results:
Labs on Admission:
[**2105-6-30**] 08:38AM BLOOD Glucose-123* UreaN-11 Creat-1.0 Na-146*
K-4.0 Cl-107 HCO3-25 AnGap-18
[**2105-6-30**] 08:38AM BLOOD WBC-9.3 RBC-4.99 Hgb-16.0 Hct-46.4 MCV-93
MCH-32.0 MCHC-34.4 RDW-14.1 Plt Ct-197
[**2105-6-30**] 08:38AM BLOOD PT-12.1 PTT-27.0 INR(PT)-1.0
[**2105-6-30**] 08:38AM BLOOD Fibrino-295
[**2105-6-30**] 08:38AM BLOOD Lipase-19
[**2105-6-30**] 08:38AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
[**2105-6-30**] 05:40PM BLOOD Osmolal-287
[**2105-6-30**] 08:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2105-6-30**] 08:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2105-6-30**] 08:45AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
[**2105-6-30**] 08:38AM BLOOD ALT-20 AST-23 AlkPhos-54 TotBili-0.4
[**2105-6-30**] 08:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2105-6-30**] 08:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Labs on Discharge:
[**2105-7-1**] 03:49AM BLOOD WBC-9.3 RBC-4.26* Hgb-13.5* Hct-38.6*
MCV-90 MCH-31.7 MCHC-35.0 RDW-13.4 Plt Ct-196
[**2105-7-1**] 03:49AM BLOOD Glucose-111* UreaN-8 Creat-0.9 Na-139
K-3.7 Cl-104 HCO3-29 AnGap-10
[**2105-7-1**] 03:49AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. [**Known firstname 429**] [**Known lastname 1968**] is a 27yoM with a history of polysubstance
abuse, depression, and anxiety who was intubated in the field
for management of altered mental status presumably due to a drug
intoxication. He is transferred to the [**Hospital Unit Name 153**] for further care.
# RESPIRATORY DEPRESSION: Though we lack records of the patients
status in the field, he was intubated for altered mental status
and respiratory protection. The precipitant is unknown, though
he has experimented with numerous CNS depressants in the past
that can suppress normal respiration (GBH, ketamine,
benzodiazepines). Patient was extubated successfully. After
extubation, he endorsed taking EtOH as well as GBH. Upon
discharge, he was alert, awake, oriented without focal deficits
on neurological exam.
# ALTERED MENTAL STATUS: Limited history is available from the
patient initially. He has several scrapes on his lower extremity
though CT head and neck show no obvious fracture or bleed.
Though initial urine and serum tox screens are negative, he has
previously used substances that are not normally identified on
routine screens such as GBH and ketamine. Each of these drugs
have relatively short half lives and should be clearing, which
may explain his improving mental status. After extubation,
patient endorsed drinking EtOH and GBH. His initial prolonged
QTc, likely related to hypothermia, resolved.
# URINARY KETOSIS: Ketones to 40 noted on admission UA, unclear
cause as he is not spilling glucose. Does not appear
malnourished. He was drinking alcohol last night which may have
induced ketosis.
# ACIDEMIA: pH noted to be acidemic at 7.32, though gas is
confusing with normal bicarbonate and pC02. Unclear precipitant
though his clinical improvement is ultimately reassuring.
# H/O POLYSUBSTANCE ABUSE: Long history of drug use. Patient
was evaluated by SW after extubation. He ultimately decided to
seek long term detox program and called [**Hospital 12671**] Hospital, which
did not have a bed for him today. They asked the patient to
call again on [**2105-7-2**] to inquire for a bed. At the same time,
follow up appointment was set up for him to establish care with
a new PCP so that he could be better followed mediaclly.
# DEPRESSION/ANXIETY: Current status is unclear. However, he
will need to have psychiatric evaluation in the outpatient
setting to further address this issue. He currently does not
have a regular psychiatrist but does see a therapist weekly per
patient. Upon discharge, patient reports feeling safe and is
planning to go to his grandmother's house. He is planning to
call [**Hospital 12671**] Hospital again on [**2105-7-2**] to set up follow up/long
term de-tox program.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Intoxication
Secondary diagnoses:
- Polysubstance abuse
- Depression
- Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1968**],
You were admitted after you were found to be unconscious in the
[**Hospital1 778**] area. You were intubated (breathing tube placed) by the
EMS workers in the ambulance. You were able to be extubated once
you woke up in the ICU. You then revealed that you had taken GHB
as well alcohol. You decided that you would need more assitance
with your drinking and using of substances, so you are planning
to attend a more long term program for your current substance
use issue. Currently you feel safe and is planning to return to
your family's home.
You are advised to stop drinking and using illicit drugs,
because persistent use of these substances can lead to death.
Please note that there is NO change in your medications.
It is VERY IMPORTANT for you to follow up with your mental
health provider, [**Name10 (NameIs) 19566**] [**Name Initial (NameIs) **] psychiatrist, as well as
establishing care with a primary care physician.
Followup Instructions:
Thursday, [**2105-7-2**] at 1pm with Dr. [**Last Name (STitle) 71076**].
[**Street Address(2) **]
[**Location (un) 1294**], [**Numeric Identifier 44211**]
Appointment Tel: [**Telephone/Fax (1) 66403**]
You said that you are calling your mental health provider at
[**Name9 (PRE) 12671**] Hospital at [**Telephone/Fax (1) **] today to set up a follow up
appointment so that you can be seen today or tomorrow for your
recent admission to the hospital and to set get set up for the
detox program.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2105-7-1**]
|
[
"51881",
"2762",
"3051"
] |
Admission Date: [**2136-4-22**] Discharge Date: [**2136-4-26**]
Date of Birth: [**2090-2-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Status post ? fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 year old male found down by EMS; intubated for airway
protection for initial GCS 3 in emergency deoartment. Underwent
trauma related radiologic testing.
Past Medical History:
Hyperlipidemia
Tib-fib fracture on right
Social History:
Currently homeless
Recently lost both parents in past year
Has 2 brothers and 3 sisters
Unemployed
+ETOH
Family History:
Both parents with +ETOH abuse
Physical Exam:
HEENT - Abrasion left eyebrow and right chin; clear fluid from
nose
Neck - cervical collar in place; no crepitus
Back/spine - no stepoffs/deformities; right flank abrasion
Chest - clear to auscultation
Cor- RRR
GI - soft, ND
Rectum - normal tone; guaiac negative
Skin - warm & dry
Musculoskeletal - MAE X 4
Pertinent Results:
[**2136-4-22**] 07:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
[**2136-4-22**] 07:52PM GLUCOSE-86 LACTATE-2.9* NA+-147 K+-4.0
CL--102 TCO2-30
[**2136-4-22**] 07:52PM HGB-13.8* calcHCT-41
[**2136-4-22**] 07:51PM UREA N-10 CREAT-0.8
[**2136-4-22**] 07:51PM CK(CPK)-592* AMYLASE-62
[**2136-4-22**] 07:51PM CK-MB-5 cTropnT-<0.01
[**2136-4-22**] 07:51PM ASA-NEG ETHANOL-391* ACETMNPHN-10.2
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-4-22**] 07:51PM WBC-14.6* RBC-4.67 HGB-13.1* HCT-39.1* MCV-84
MCH-28.2 MCHC-33.7 RDW-14.0
[**2136-4-22**] 07:51PM PLT COUNT-278
[**2136-4-22**] 07:51PM FIBRINOGE-420*
[**2136-4-22**] Head CT scan - no intracranial hemorrhage
[**2136-4-22**] Cervical Spine CT scan - no fraccture or malalignment
[**2136-4-22**] Pelvis/Abdomen CT scan - periportal lymph nodes and
edema, ? suspicion for liver disease. Possible old frature of
right 4th rib
Brief Hospital Course:
Patient admitted to trauma bay via EMS; intubated in ED for
airway protection and initial GCS 3. Underwent trauma series
radiologic testing; no acute injuries identified. Did identify
closed right tib-fib fracture with old ORIF hardware in place;
degenerative changes lower lumbar spine; possible old fracture
or osteochondroma right 4th rib; T12 compression fracture, age
indeterminate. Patient weaned and extubated on following day;
transferred to regular unit. He was seen and evaluated by
Psychiatry while here because of suicidal ideation; placed on
1:1 sitters initially which were discontinued after evaluated by
Psychatry and deemed not suicidal. Recommended patient for
inpatient drug and alcohol treatment.
Medications on Admission:
Vicodin prn
Protonix 40 mg qd
Amoxicillin 500mg tid (for reported sinusitis)
Amytriptiline 25mg qhs
Methadone 30mg
Lipitor 10 mg qd
Colace 100mg qd
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
3. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
7. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Status post ? fall (found down by EMS)
Old right tibial fibula fracture, s/p ORIF [**2134**]
Chronic non-[**Hospital1 **] disdtal tibia with distal failed hardware
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Orthopedics as instructed
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1228**] in [**12-29**] weeks; call for an
appointment
Follow up with outpatient Psychiatry after your discharge from
inpatient drug & alcohol treatment center
Completed by:[**2136-4-24**]
|
[
"2724"
] |
Admission Date: [**2146-12-12**] Discharge Date: [**2146-12-17**]
Date of Birth: [**2061-4-9**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
ANTERIOR fusion T11-L1 with T12 partial corpectomy
History of Present Illness:
Mr. [**Known lastname 6164**] [**Last Name (Titles) 18095**] a T12 burst fracture and underwent
posterior decompression and stabilization T10-L2 on [**2146-11-29**].
He was discharged to rehab with the plan of returning to the OR
for a partial corpectomy T12.
Past Medical History:
PMH: CAD, HTN, HL, BPH, BPPV, spinal stenosis, pacemaker
,tinnitus, renal insufficiency (lasix recently stopped for Cr
2.2, new baseline since [**2145**] 2.1-2.3)
PSH: pacemaker implantation, CABG x 4 [**2145**], AVR with St.[**Male First Name (un) 923**]
Epic Tissue Valve [**2145**], TURP, back surgery for spinal stenosis,
bilateral knee replacement
Social History:
-Tobacco history: never
-ETOH: never
-Illicit drugs: never
Pt is a former [**University/College **] design and land development professor.
Lives in [**Location **] with grandson and a close friend. His friend
helps out with cooking, and he bathes himself. Pt is still
active in planning an intergenerational apartment complex in
[**Hospital1 8**].
Family History:
Father died at [**Age over 90 **] yo of CHF. Mother had a "[**Last Name **] problem" since
her youth but died at [**Age over 90 **] yo of complications after hip fx. Two
sisters both 80 and 82 yo with hx of colon cancer.
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2146-12-16**] 09:00AM BLOOD WBC-7.8 RBC-3.49* Hgb-10.6* Hct-33.0*#
MCV-95 MCH-30.2 MCHC-32.0 RDW-15.2 Plt Ct-206
[**2146-12-15**] 05:00AM BLOOD WBC-11.5* RBC-2.80* Hgb-8.5* Hct-25.5*
MCV-91 MCH-30.2 MCHC-33.3 RDW-17.1* Plt Ct-175
[**2146-12-14**] 03:11PM BLOOD WBC-13.7* RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.4 MCHC-34.0 RDW-17.3* Plt Ct-188
[**2146-12-14**] 01:50AM BLOOD WBC-13.1* RBC-3.20* Hgb-9.7* Hct-28.0*
MCV-88 MCH-30.4 MCHC-34.8 RDW-17.4* Plt Ct-199
[**2146-12-12**] 08:30PM BLOOD WBC-9.5 RBC-3.31* Hgb-9.9* Hct-30.3*
MCV-92 MCH-30.1 MCHC-32.8 RDW-17.1* Plt Ct-283#
Brief Hospital Course:
Mr. [**Known lastname 6164**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
T12 corpectomy. He was informed and consented and elected to
proceed. Please see Operative Note for procedure in detail.
Post-operatively he was given antibiotics and pain medication.
He was transfered to the SICU for further evaluation. A hemovac
drain was placed intra-operatively and this was removed POD 2.
His bladder catheter was removed POD 3 and his diet was advanced
without difficulty. He was able to work with physical therapy
for strength and balance. He was discharged in good condition
and will follow up in the Orthopaedic Spine clinic.
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for congestion.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for congestion.
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for congestion.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for congestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
T12 burst fracture
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR fusion
T11-L1 with T12 partial corpectomy
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2146-12-16**]
|
[
"2851",
"5119",
"2724",
"5859",
"40390",
"V4581"
] |
Admission Date: [**2147-9-17**] Discharge Date: [**2147-9-21**]
Date of Birth: [**2082-4-20**] Sex: M
Service: NEUROLOGY
Allergies:
Aspirin / Motrin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Speech arrest
Major Surgical or Invasive Procedure:
Thrombolysis
History of Present Illness:
65 y/o RH man with a previous medical history significant for
HTN
and HLD presents with new onset of speech arrest.
Mr [**Known lastname 106930**] was with his wife placing a nail in the
wall to hang a picture at 11: 45. His wife reports that he he
suddenly looked confused and stopped hanging the picture.
He was not able to reply when his wife enquired about what was
happening to him. He could not follow commands, but remained
alert. His wife reports no limb weakness, but she thinks he
could
have had a facial droop (though she cannot recall in which
side).
He had no other focal deficits per history. She reports he had a
headache earlier in the day, but is unable to determine whether
it was of throbbing or pressure quality, for how long it lasted,
or any other features. According to his wife, he had never
experienced this type of event. He has no previous history of
intracranial bleed or recent surgery or trauma.
She called EMS, who brought him to [**Hospital1 18**] ED:
Afebrile, 160/ 95. 90 bpm. RR 18 SO2 100% in RA. FSG 149.
ROS: No fever, no diarrhea, no cough, no chest pain. The rest of
ROS is negative.
Past Medical History:
HTN
HLD
s/p TURP
GERD
Nephrolithiasis
Inguinal hernia
Social History:
Lives with his wife and two children.
Denies drinking or smoking. No illicit drugs.
Owns a cleaning company.
Family History:
His sister died from breast cancer.
Another sister died of stroke at age 40.
Physical Exam:
Afebrile at 98.3 F, 162/84, 90 bpm; RR 12 with SaO2: 100% in RA
Alert.
Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Guaiac negative (per ER team).
Neurological exam:
Alert. Frustrated, nonverbal.
Follows simple commands (i.e. squeeze my hand, raise your arm):
preserved comprehension. Verbal perseveration. Nomination
impaired. Non-fluent.
No apraxia (ideomotor), no agnosia, no field cuts. No
extinction.
CN
Fundi w/ sharp discs. PERRL. VFIC. No ptosis. EOMI.
Facial sensation intact.
Hearing intact to finger rub.
Palate elevates at midline.
SCMs intact.
Tongue protrudes midline.
Motor
R UE [**5-22**]. L UE [**5-22**]. R LE [**5-22**]. L LE [**5-22**].
No drift.
Tone
normal.
DTRs: L/R: bic [**2-18**], br [**2-18**], tri [**2-18**]; pat [**3-20**], Ach 2+/2+.
Plantars
bilaterally flexor.
Sensory: Light touch, temp, pinprick and vibration intact
Coord/Gait: No dysmetria. No dysdiadochokinesia. Normal FFT.
Normal FTN.
His NIH stroke score was 5. Hence he received tpa and was
transferred to the Unit in CC7 B.
As compared to the initial exam in the ER, the patient seems to
be more interactive and able to follow commands more easily. His
speech impairment has not changed. I discussed the case with Dr.
[**Last Name (STitle) 18530**] and also with the nursing team in the unit at CC7.
Pertinent Results:
CT: no hemorrhage; no signs of early infarction
CTA: no major vessel cutoff. Large calcification/plaque in
distal L CCA.
CTP: Elevated Mean Transient Time with a normal Cerebral Blood
Volume in left parietal region; wedge-shaped.
MRI CNS w and w/o contrast: Redemonstration of subacute left
posterior temporal/occipital infarct.
[**2147-9-17**] 12:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2147-9-17**] 12:15PM TSH-0.86
[**2147-9-17**] 12:15PM cTropnT-<0.01
[**2147-9-17**] 12:15PM TOT PROT-7.2 ALBUMIN-4.5 GLOBULIN-2.7
[**2147-9-17**] 12:15PM WBC-6.4 RBC-4.71 HGB-15.1 HCT-41.1 MCV-87
MCH-32.1* MCHC-36.8* RDW-13.3
[**2147-9-17**] 12:15PM ALT(SGPT)-33 AST(SGOT)-29 LD(LDH)-320*
CK(CPK)-260* ALK PHOS-81 TOT BILI-1.2
[**2147-9-18**] 07:08AM BLOOD Triglyc-195* HDL-33 CHOL/HD-6.7
LDLcalc-148*
TTE:The left atrium is elongated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). 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. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
TEE: PFO with left to right shunting, minor descending aortic
atheromatous plaque. No thrombus of the left atrium or LAA seen.
Brief Hospital Course:
Mr [**Known lastname 106931**] speech has improved s/p tpa. He has improved ability
to produce phrases in both English and Portugese though his
fluency is still sharply decreased. He can name high but not low
frequency objects. The patient has difficulty with repetition.
He is able to follow crossed body commands. He has shown a
complete motor recovery.
The left parietal acute infarct may have been due to thrombosis
of the left inferior division of the left MCA or possibly
embolism. His left internal carotid artery is 40-59% stenosed.
This was not considered a high grade enough lesion for him to be
a good candidate for CEA or stent. His carotid arteries should
be re-examined in six months. TEE showed a PFO with a left to
right shunt. This is another possible embolic source, but given
his age and the fact that it is a left to right shunt, it is not
highly probable. He was started on Plavix 75mg daily.
Medications on Admission:
Lisinopril, HCTZ, Atenolol, Zocor
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
LEFT MCA stroke.
HTN
Discharge Condition:
Stable. His language exam remains impaired: for low frequency
object nomination and repetition.
Otherwise, he has shown a complete motor recovery.
Discharge Instructions:
You have had a stroke. You have recovered after receiving
therapy with tpa (a thrombolytic medication)
Followup Instructions:
You will follow up with Dr. [**Last Name (STitle) **] in the stroke clinic. Please,
call to make an appointment at [**Telephone/Fax (1) 2574**].
|
[
"4019",
"53081"
] |
Admission Date: [**2128-3-24**] Discharge Date: [**2128-3-27**]
Date of Birth: [**2056-5-8**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 19684**]
Chief Complaint:
71 y/o M with fevers, chills, shakes, N/V, foul smelling urine
x3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
On day of admission, pt felt warm at 3PM, possibly dizzy, then
fell on L knee, laid down, and felt chills/shakes and dry
heaves. Came in for evaluation. Also notes foul-smellng urine,
dysuria, which he describes as a similar sensation to previous
UTIs. He claims he has been trying to keep up with hydration,
but appetite poor. Coughing in ED, not at home. Also in ED,
had rigors and temp from 102.4 on admission to 103.1 with rising
lactate. No other symptoms of chest pain, SOB, or diarrhea.
In ED: cipro 500mg IV x1, tylenol 1g, IVF x2L, anzemet 12.5mg IV
x1, tylenol 650mg po x1. Code sepsis called, as met MUST
criteria with spiking temps, tachycardia, elevated lactate.
Past Medical History:
1. Charcot [**Doctor Last Name **] Tooth
2. hypertension
3. benign prostatic hypertrophy
4. melanoma s/p excision
5. anxiety
6. PVD s/p stent
Social History:
lives alone, no tobacco or EtOH
Family History:
noncontributory
Physical Exam:
VS: Tm 103.1 Tc 103.1 116/88 123 26 96% on 3L
Gen: A&O, NAD, anxious
HEENT: PERRL, MMM, clear OP, supple neck, flat JVP
CV: RRR, tachycardic, no murmurs
Pulm: CTAB
Abd: soft, NT/ND, +BS, guaiac negative, no CVA tenderness
Ext: CMT deformities, no edema; abrasion of L knee
Pertinent Results:
Admission Labs:
WBC-11.4*# RBC-4.46* HGB-13.5* HCT-38.9* MCV-87 MCH-30.2
MCHC-34.7 RDW-16.3* PLT COUNT-204
NEUTS-93.0* BANDS-0 LYMPHS-3.0* MONOS-2.9 EOS-0.8 BASOS-0.2
CRP-2.31*
CORTISOL-42.8*
ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-1.6* MAGNESIUM-1.4*
ALT(SGPT)-39 AST(SGOT)-30 ALK PHOS-49 AMYLASE-60 TOT BILI-0.7
LIPASE-17
GLUCOSE-142* UREA N-27* CREAT-1.3* SODIUM-141 POTASSIUM-3.6
CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
LACTATE-3.5*
URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
RBC-[**7-2**]* WBC->50 BACTERIA-OCC YEAST-NONE EPI-0-2
BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD
[**2128-3-24**] 02:53AM LACTATE-4.4*
PT-13.7* PTT-38.0* INR(PT)-1.2
%HbA1c-5.2
Studies:
CXR: Low inspiratory lung volumes. No acute cardiopulmonary
process.
Brief Hospital Course:
71 yo man with hx of Charcot-[**Doctor Last Name **] Tooth, HTN, BPH, h/o
recurrent UTI's p/w 3days of fevers to 103, chills, dysuria, and
foul smelling urine found to have pyelonephritis. Urine culture
grew Corynebacterium. Initially amitted to ICU for sepsis.
Initial lactate of 4.4 trended down. Required 4 units of fluid.
He had one episode of hypotension that responded to fluid
boluses and did not require pressors. He remained
hemodynamically stable throughout his stay. He was initially
started on Ceftriaxone empirically given hx of coag neg staph
and enterobacter UTI. This was changed to Levoflox once stable.
He was also given one dose of Flagyl when he became hypotension.
Foley was removed when he arrived in the ICU however he was
unable to void. Foley was replaced with 700 cc of urine output.
He was also noted to have a distended abdomen which he reports
is chronic. He denies N/V/abd pain/constipation. He had an abd
CT in [**2123**] which revealed diverticulosis.
1. Sepsis secondary to pyelonephritis. Intially met MUST
criteria based on spiking temps, tachycardia, and elevated
lactate. BP stable after 4 Liters of NS. Remained afebrile
during his stay.
- levoflox x 14 days for Corynebacterium in urine
- repeat Urine Cx on [**2128-3-25**] NGTD
- Bld cultures NGTD
2. BPH. Pt has had scraping in the past. Will likely need TURP
as outpt. Pt failed voiding trial and was d/c'ed home with a
foley. He has an outpt appointment with Dr. [**Last Name (STitle) 365**] on [**4-7**] at
8:30 AM.
3. ARF, resolved. (baseline Cr 1.1) Etilolgoy ikely secondary to
prerenal azotemia. Creat back to baseline from 1.3 on admission
with fluid hydration.
4. Anemia. Initial Hct of 38- down to 31 after hydration.
Improved to 36 prior to discharge. Guaiac negative in ED. Iron
studies reveal anemia of chronic disease.
5. Abd distention, chronic. Etiology unclear. Pt reports abd
distention unchanged x4 years. CT abd done in [**2123**] revealed
diverticulosis.
6. Tachycardia, resolved. Etiology ikely secondary to
dehydration, fevers and anxiety.
7. HTN, BP well controlled. Restarted lisinopril prior to
discharge.
8. PVD s/p stent placement 3 months ago. Started on full dose
ASA. Fasting lipid profile revealed TC of 105, LDL of 37, HDL of
23. Did not start lipid lowering [**Doctor Last Name 360**] at this time. Encouraged
exercise. He will follow-up with his PCP.
9. Charcot [**Doctor Last Name **] Tooth. Stable hereditary neuropathies
10. Anxiety: known history. Doing well currently. Did not
require valium during this admission.
11. Melanoma. Will follow up with derm.
Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Terazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Diazepam 5 mg Tablet prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Terazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Urinary Tract Infection
Benign Prostatic Hypertrophy
Hypertension
Charcot-[**Doctor Last Name **]-Tooth Disease
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician or return to hospital if
you experience pain with the bladder catheder, fever, chills,
lightheadedness, or any other concerns.
Please follow up with your primary care physician in the next
1-2 weeks.
Followup Instructions:
1. You have an appointment with the urologist, Dr. [**Last Name (STitle) 365**] on [**4-7**] at 8:30 AM. Please call [**Telephone/Fax (1) 25366**] to find out location.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Where: LM [**Hospital Unit Name 20843**] MEDICINE Phone:[**Telephone/Fax (1) 142**] Date/Time:[**2128-5-10**] 10:00
3. Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2128-6-3**] 9:45
|
[
"0389",
"78552",
"5849",
"99592",
"2859",
"4019"
] |
Admission Date: [**2124-10-10**] Discharge Date: [**2124-10-14**]
Date of Birth: [**2079-9-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
pulmonic valve mass
Major Surgical or Invasive Procedure:
[**2124-10-10**] Resection of pulmonary valve mass
History of Present Illness:
This 44 year old female with fatigue and postive family history
for coronary artery disease was found to have a mass proximal
to/on pulmonic valve. She was referred for surgical resection.
Past Medical History:
Hypertension
Social History:
Occupation: Cardiac tech
Last Dental Exam: 1 month ago
Lives with Husband
[**Name (NI) **]: Caucasian
Tobacco: 1 ppd x 31 yrs
ETOH: Occ.
Family History:
Twin sister with multiple [**Name (NI) 5290**] in 40's. Father with multiple
MI's prior to age 42.
Physical Exam:
Admission:
Pulse: 84 Resp: 20 O2 sat: 100%
B/P Right: 117/77 Left: 110/77
Height: 5'7" Weight: 162lbs
General: well-developed, well-nourished female in no acute
distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI []
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None
[X]
Neuro: Grossly intact
Pulses:
Femoral Right/Left: 2+
DP Right/Left: 2+
PT [**Name (NI) 167**]/Left: 2+
Radial Right/Left: 2+
Carotid Bruit Right/Left: None
Pertinent Results:
[**2124-10-10**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
There is a mobile 1.1 x .8 cm pedunculated mass on the posterior
leaflet of the pulmonic valve. There is trivial PR. Post-CPB:
The pulmonic valve mass has been removed. There is trivial PR.
Normal biventricular systolic fxn. Aorta intact. Other
parameters as pre-bypass.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 84886**] F 45 [**2079-9-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2124-10-12**] 9:54
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2124-10-12**] 9:54 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 84887**]
Reason: ? ptx after CT removal
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with pulmonic valve mass excision
REASON FOR THIS EXAMINATION:
? ptx after CT removal
Final Report
REASON FOR EXAMINATION: Followup of the patient after excision
of pulmonic
valve mass.
Portable AP chest radiograph was reviewed in comparison to
[**2124-10-10**].
The patient was extubated in the meantime interval. The NG tube,
mediastinal
drains, and right internal jugular line have been removed. There
is no chest
tube seen as well. The cardiomediastinal silhouette is stable
compared to
immediate postoperative study. There is small right apical
pneumothorax.
There is no obvious left pneumothorax seen. There is minimal
amount of
bilateral pleural effusion and bibasal atelectasis.
ADDENDUM: Findings were communicated to nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 84888**] over
the phone by Dr. [**Last Name (STitle) **] approximately at 10:55 a.m. on
[**2124-10-12**].
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: [**Doctor First Name **] [**2124-10-12**] 3:26 PM
[**2124-10-12**] 07:20AM BLOOD WBC-8.7 RBC-3.04* Hgb-9.2* Hct-27.5*
MCV-91 MCH-30.4 MCHC-33.6 RDW-12.9 Plt Ct-281
[**2124-10-10**] 10:32AM BLOOD PT-13.5* PTT-32.7 INR(PT)-1.1
[**2124-10-12**] 07:20AM BLOOD Glucose-104 UreaN-8 Creat-0.5 Na-138
K-3.9 Cl-107 HCO3-23 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname 31603**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**10-10**] she was brought to the
Operating Room where she underwent resection of a pulmonary
valve mass. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke neurologically intact and extubated.
She was transferred to the floor in stable condition with CTs in
place secondary to serosanguinous drainage. CTs and temporary
pacing wires were removed on POD 2 and gentle diuresis was
begun. Physical Therapy worked with her for mobilization and
strengthening. The remainder of her post-op course was
uneventful. She developed a mild rash on her torso on POD 4 and
Lasix and Toprol were discontinued. She was started on Bumex
and Lopressor and discharged home with visiting nurses on POD4.
Medications on Admission:
HCTZ 25mg daily
Lisinopril 10mg daily
Lipitor 10mg daily
Aspirin 81mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO twice a day for 7 days.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for rash.
Disp:*1 tube* Refills:*0*
11. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
mass on pulmonary valve
s/p excision of pulmonic mass
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
Please shower daily. Wash incision with soap and water. No
lotions, creams or powders to incision for 6 weeks.
No driving for 1 month and taking narcotics.
No lifting greater then 10 pounds for 10 weeks.
Please call with any questions or concerns.
Take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-4**] weeks
Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (un) **] in [**12-3**] weeks ([**Telephone/Fax (1) 6699**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Completed by:[**2124-10-14**]
|
[
"4019",
"3051"
] |
Admission Date: [**2109-3-5**] Discharge Date: [**2109-3-15**]
Date of Birth: [**2030-1-22**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Verapamil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
C. difficile and ascites
Major Surgical or Invasive Procedure:
Paracentesis
Arterial Line Placement
History of Present Illness:
Mrs. [**Known lastname 100616**] is a 79 year old female with a history of
hypertension, coronary artery disease, congestive heart failure,
COPD and lung cancer who was admitted to [**Hospital3 7569**] on
[**2109-2-23**] with worsening diarrhea. The patient has been in and out
of the hospital for most of the winter with recurrent pneumonia.
Her most recent infection was approximately three weeks ago.
She was discharged to rehab and ultimately home. Three days
after returning home she began to experience diarrhea, up to [**3-26**]
bowel movements per day. She presented to [**Hospital3 7569**] on
[**2109-2-23**] for her diarrhea. On admission she was found to have a
WBC count of 40,000 with a diffusely tender abdomen. She was
found to be c. diff positive. She was initially started on IV
flagyl for c. diff as well as levofloxacin and prednisone out of
concern for a COPD flare. Her antibiotics were switched to PO
flagyl and PO vancomycin on [**2109-2-25**] out of concern that she was
not improving. On this regimen she reports that the frequency
of her diarrhea did decrease to [**11-21**] bowel movements per day.
Her white blood cell count decreased from 42k on admission to
15.7 on [**2109-3-5**]. There was concern, however, that she was
developing abdominal distention. She underwent an abdominal CT
scan on [**2109-3-4**] which showed significant ascites throughout the
abdomen, mucosal enhancement throughout the colon with probable
diffuse wall thickening and thickening of the terminal ileum
without evidence of obstruction. Given concern for the ascites,
the primary team at [**Location (un) **] wanted to pursue paracentesis. Her
INR has fluctuated throughout her hospitalization at [**Location (un) **] and
on [**2109-3-4**] was 7.0. She received vitamin K 10 mg PO x 1. Her
family requested that she be transferred to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] hospital
for further care.
On review of systems she denies fevers, chills, chest pain,
shortness of breath, palpitations, PND, orthopnea. She does
endorse lightheadedness and feeling dehydrated. She endorses
right sided abdominal pain, [**11-21**] bowel movements per day. She
continues to pass flatus. Her abdomen has become increasingly
distended over the past week. She denies dysuria or hematuria.
She endorses chronic leg swelling which she reports has not
worsened significantly over the past week.
Past Medical History:
Hypertension
Coronary Artery disease s/p MI and CABG x 2
Tachybrady syndrome s/p pacemaker placement
Atrial Fibrillation
Diastolic CHF (EF 60%)
COPD - previously on home oxygen but not currently
Squamous Cell Lung Cancer - s/p ressection in [**2098**]
Small Cell Lung Cancer - s/p chemotherapy and radiation in [**2101**]
as well as cranial XRT.
Social History:
She lives in [**Location 11269**] in an [**Hospital3 **] facility. She has a
50 pack year smoking history but quit many years ago. She is
divorced. She occassionally drinks alcohol.
Family History:
Mother died at age 54 of heart disease. Her father was an
alcoholic. She has one sister who died of cancer of the back.
Physical Exam:
Vitals: 96.3 BP: 82/58 HR: 117 RR: 18 O2: 98% on 2L
General: Elderly female, lying in bed, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, MM dry, oropharynx with
trace thrush
Neck: JVP flat at 30 degrees, no LAD
CV: irregularly irregular, s1 + s2, soft SEM at LUSB, no rubs or
gallops
Resp: bronchial breath sounds at bases, no wheezez, rales
GI: distended, + fluid wave, mild tenderness to palpation in
RLQ, no rebound tenderness or guarding, +BS
GU: foley in place draining clear yellow urine
Ext: WWP, 1+ pulses, 3+ pitting edema to thighs
Neuro: Alert and oriented x 3, no focal deficits
Pertinent Results:
Hematology:
[**2109-3-6**] 06:00AM BLOOD WBC-10.8 RBC-4.28 Hgb-12.4 Hct-37.3
MCV-87 MCH-29.0 MCHC-33.3 RDW-15.6* Plt Ct-205
[**2109-3-13**] 06:05AM BLOOD WBC-8.8 RBC-3.94* Hgb-11.7* Hct-34.6*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.9* Plt Ct-212
[**2109-3-6**] 06:00AM BLOOD Neuts-94.4* Bands-0 Lymphs-2.9* Monos-2.2
Eos-0.4 Baso-0.1
[**2109-3-15**] 07:10AM BLOOD PT-32.0 INR-3.3
Chemistries:
[**2109-3-6**] 06:00AM BLOOD Glucose-75 UreaN-26* Creat-1.3* Na-132*
K-3.5 Cl-101 HCO3-18* AnGap-17
[**2109-3-13**] 06:05AM BLOOD Glucose-64* UreaN-17 Creat-1.0 Na-136
K-4.0 Cl-107 HCO3-18* AnGap-15
[**2109-3-7**] 09:35AM BLOOD ALT-15 AST-26 LD(LDH)-212 CK(CPK)-46
AlkPhos-85 TotBili-0.4
[**2109-3-6**] 06:00AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8
Other:
[**2109-3-7**] 02:57PM BLOOD calTIBC-127* Ferritn-513* TRF-98*
[**2109-3-7**] 09:35AM BLOOD Cortsol-25.9*
Hepatology Workup:
[**2109-3-7**] 02:57PM BLOOD CEA-53* CA125-487*
[**2109-3-8**] 08:45PM BLOOD AFP-9.1*
[**2109-3-8**] 08:45PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2109-3-7**] 09:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2109-3-7**] 09:35AM BLOOD HCV Ab-NEGATIVE
[**2109-3-7**] 02:57PM BLOOD ALPHA-1-ANTITRYPSIN-208H
[**2109-3-7**] 02:57PM BLOOD CERULOPLASMIN-22
Urinalysis:
[**2109-3-6**] 08:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2109-3-6**] 08:07PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2109-3-6**] 08:07PM URINE RBC-[**4-30**]* WBC-[**4-30**]* Bacteri-OCC Yeast-MOD
Epi-0
[**2109-3-6**] 08:07PM URINE Hours-RANDOM UreaN-209 Creat-35 Na-34
[**2109-3-6**] 08:07PM URINE Osmolal-296
Paracentesis:
[**2109-3-8**] 03:32PM ASCITES TotPro-1.8 Albumin-1.3
[**2109-3-8**] 03:32PM ASCITES WBC-100* RBC-9500* Polys-63* Lymphs-2*
Monos-28* Mesothe-3* Macroph-4*
EKG: Atrial fibrillation Premature ventricular contractions or
aberrant ventricular conduction Extensive ST-T changes may be
due to myocardial ischemia Repolarization changes may be partly
due to rhythm Low lead voltage
Imaging:
CHEST (PORTABLE AP) [**2109-3-5**] 9:05 PM
The patient has had median sternotomy and coronary bypass
grafting. Transvenous right atrial and right ventricular pacer
wires extend continuously from the left axillary pacemaker,
terminating alongside remnant leads originating in the right
axilla. No pneumothorax present. Pleural effusion, if any, is
minimal. Lungs grossly clear. Heart size top normal.
PORTABLE ABDOMEN [**2109-3-5**] 9:05 PM
There is apparent centralization of the bowel loops suggesting
the presence of ascites. No evidence of free intraperitoneal air
is visualized. No concerning bowel gas pattern is noted. The
small bowel and large bowel loops are unremarkable. The
visualized portion of the lung bases demonstrates small
bilateral effusion. Mild degenerative changes of the lumbar
spine is noted. Severe degenerative changes of both hip joints
are also identified.
Echocardiogram [**2109-3-6**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with basal
infero-lateral hypokinesis. There is no ventricular septal
defect. The right ventricular cavity is dilated The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
ABDOMEN U.S. (COMPLETE STUDY) PORT [**2109-3-7**] 9:18 AM
The liver is markedly heterogeneous in echotexture with nodular
contour, likely representing cirrhosis or fibrosis. There is no
focal liver lesion or intra- or extra-hepatic ductal dilatation.
Gallbladder is normal. Common bile duct measures 3.4 mm. There
is large amount of ascites in the right upper and bilateral
lower quadrants. Spleen is normal in size. Right kidney measures
8.9 cm. Left kidney measures 8.1 cm. There is a hypoechoic
nodule in the right upper pole measuring 1 cm, likely
representing complex cyst. There is no other solid lesion or
stone or hydronephrosis. On Doppler ultrasound study, patency
and appropriate waveforms are seen in bilateral and main portal
veins, main and left hepatic arteries, and three hepatic veins.
ART EXT (REST ONLY) [**2109-3-12**] 10:28 AM
FINDINGS: The ABI on the right is 0.96 and on the left is 0.81.
Doppler tracings demonstrate triphasic waveforms diffusely on
the right and through to the popliteal level on the left. Volume
recordings are in [**Location (un) **] with the Doppler tracings.
Upper extremity ABI demonstrates 1.27 at the wrist level on the
right and 1.17 on the left. Arterial tracings demonstrate
triphasic waveforms through to the radial levels bilaterally,
ulnar waveforms are monophasic. Volume recordings are in [**Location (un) **]
with the Doppler tracings.
Microbiology:
Blood Cultures [**2109-3-7**]: negative
Peritoneal Fluid Culture [**2109-3-8**]: Gram stain with 2+
polymorphonuclear cells, no microrganisms. Aerobic culture
negative. Anaerobic culture no growth to date.
Peritoneal Cytology [**2109-2-25**]: Negative for malignant cells.
Brief Hospital Course:
Mrs. [**Known lastname 100616**] is a 79 year old female with a history of
hypertension, coronary artery disease, congestive heart failure,
COPD and lung cancer who was admitted to [**Hospital3 7569**] on
[**2109-2-23**] with worsening diarrhea. Triggered this morning for
hypotension.
Clostridium Difficile: The patient presented with clostridium
difficle colitis which was refractory to initial management with
PO flagyl and PO vancomycin. On admission she was also taking
levofloxacin for presumed COPD exacerbation. The levofloxacin
was discontinued on admission to this hospital and she was
placed on PO vancomycin alone. When she was transferred to the
ICU she was also started on IV flagyl. On this regimen she
showed significant clinical improvement with resolution of her
leukocytosis and her diarrhea. Prior to discharge the IV flagyl
was discontinued. She will complete a ten day course of
antibiotics from the date of discontinuation of levofloxacin.
Peripheral Vascular Disease: During this admission the patient
was noted to have cool, cyanotic upper and lower extremities.
She was seen by the vascular surgery consult service and
underwent non-invasive vascular studies which showed
mild-to-moderate left-sided tibial disease and small vessel
disease in both hands. Given her lack of symptoms, no
interventions are planned. She can follow up with vascular
surgery if she were to develop pain or claudication.
Hypotension: During this admission the patient's blood
pressures were consistently in the 80s to 90s systolic. While
in the medical intensive care unit she had an arterial line
placed which recorded arterial blood pressures which were [**9-9**]
mm Hg higher than cuff pressures recorded. Given her peripheral
vascular disease her systolic blood pressures were maintained in
the 90s systolic to ensure adequte perfusion.
Atrial Fibrillation/Tachy-brady syndrome: The patient is s/p
pacemaker placement for tachy-brady syndrome. On admission she
was taking digoxin alone with suboptimal rate control. She was
started on low dose metoprolol with improvement in her rate
control and no change in her systolic blood pressures. She was
continued on her coumadin with fluctuating INRs. On discharge
she was taking 3 mg daily. She will need to have her INR
monitored closely at rehab with her coumadin adjusted to acheive
a target INR between [**12-23**].
Acute on Chronic Diastolic Heart Failure: During this admission
she had an echocardiogram which demonstrated a preserved
ejection fraction. Clinically she showed evidence of total body
volume overload with peripheral edema but also appeared
intravascularly dry. On [**2109-3-6**] she developed acute respiratory
distress and hypoxia. This was attributed to her chronic lung
disease as well as acute pulmonary edema. She was treated with
intravenous lasix with rapid improvement but required a short
stay in the medical intensive care unit. Given her ascites her
diuretic regimen was changed to include lasix and
spironolactone. Given her hypotension her diuretics were kept
at low doses. On discharge she continued to have significant
lower extremity edema and ascites but her respiratory status was
stable.
COPD: The patient has a history of COPD and has required low
dose home oxygen in the past. Patient is not on home oxygen but
has been in the past. On presentation she was being treated for
a COPD exacerbation with levofloxacin and prednisone. On
admission her CXR and lung exams were clear. Her levofloxacin
and prednisone were discontinued. As above, she did have a
significant episode of respiratory distress during this
hospitalization which required transfer to the ICU. It was
thought that her respiratory distress was most likely secondary
to pulmonary edema in the setting of borderline respiratory
function at baseline. She was continued on her home doses of
advair and spiriva. She also received albuterol nebulizers on a
PRN basis.
Osteoporosis: No active inpatient issues. Her alendronate was
held in the setting of her acute illness but was restarted at
the time of discharge.
Anxiety: No active inpatient issues. She was continued on
lorazepam 0.5 mg daily.
Restless Legs: No active issues. She was continued on
ropinirole.
Diet: During this admission there was concern that the patient
might be aspirating while eating given her recurrent episodes of
pneumonia this year. She was noted in the medical intensive
care unit to have significant coughing while eating. Serial
CXRs showed no evidence of infiltrates. She was evaluated by
our speech and swallow team who recommended ground solids while
the patient was unable to wear her dentures and chew
appropriately. By discharge they did not think that she
exhibited signs of aspiration with thin liquids. Her diet can
be advanced from ground solids to regular consistency when she
is able to wear her dentures.
Vaccinations: The patient recieved pneumovax during this
admission.
Code: Full Code
Communication: Daughter [**Telephone/Fax (1) 100617**] (h), [**Telephone/Fax (1) 100618**] (c).
[**Telephone/Fax (1) 100619**] (w)
Medications on Admission:
Coumadin 4 mg [**Hospital1 **]
Digoxin 0.125 mg every other day
Alendronate 70 mg qweekly
Lasix 80 mg daily
Klor-con 20 meq daily
Lorazepam 0.5 mg daily
Pantoprazole 40 mg daily
Ropinirole 1 mg PO daily
Advair 250/50 daily
Tiotropium 1 cap daily
Benzonate 100 mg PO daily
Multivitamin
Discharge Medications:
1. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO once a
day.
11. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16): Please check patient's INR on Saturday, [**3-16**]. Please titrate coumadin for target INR between [**12-23**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Clostridium Difficile
Atrial Fibrillation
Chronic Diastolic Heart Failure
COPD
Peripheral Vascular Disease
Discharge Condition:
Stable. Requiring significant assistance with ambulation.
Breathing comfortably on room air.
Discharge Instructions:
You were seen and evaluted for your diarrhea. You were treated
for clostridium difficile with antibiotics. You were also
evaluate by our liver service for the swelling in your abdomen
and our vascular surgery service for your blue toes.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take lasix 20 mg daily instead of 40 mg daily
2. Please take spironolactone 50 mg daily
3. Please take Toprol XL 25 mg daily
4. Please take coumadin 2 mg daily instead of 4 mg daily. Her
INR should be checked on Saturday, [**3-16**] and her coumadin
adjusted to achieve a target INR between [**12-23**].
Please keep all your follow up appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers > 101.5 degrees, chest pain, shortness of breath,
worsening abdominal pain or distension, worsening diarrhea or
any other concerning symptoms.
Please keep all your follow up appointments as schedule.
Please seek immediate medical attention if you experience any
fevers > 101.5 degrees, chest pain, difficulty breathing,
worsening abdominal pain, increased abdominal swelling or any
other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] one
week after you are discharged from rehab. The office phone
number is [**Telephone/Fax (1) 16827**].
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2109-6-24**] 9:30
|
[
"51881",
"42731",
"4280",
"496",
"V4581"
] |
Admission Date: [**2152-6-3**] Discharge Date: [**2152-6-7**]
Date of Birth: [**2070-9-11**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB, decreasing O2 sats
Major Surgical or Invasive Procedure:
PICC line placed on [**6-6**].
History of Present Illness:
Ms. [**Known lastname 68259**] is an 81 yo F with h/o aspiration PNA, COPD and
CVA/aphasia, who presented to the ED from [**Hospital 100**] Rehab with SOB,
wheezing and low O2 sats (92% on 2LNC). Her daughter states
that she became progressively more SOB with cough and inc sputum
and decreasing PO intake for the past 2 weeks. 2 days ago she
ran a temp to 100.1 F and she was given two doses of levaquin at
the rehab yesterday (unclear if had gotten more) for increased
secretions. She was also given lasix 40 mg PO x1. She initially
presented to the [**Hospital1 882**] ED this afternoon but was transferred
to the [**Hospital1 **] per the request of her family.
.
At [**Hospital1 882**], VS were 99.8, 106, 22, 142/68, and 92% 2LNC. WBC
was 28.1 w/ 19% bands, trop < 0.04, BNP 38, bicarb 26; ABG was
7.46/32/91 on ? O2. She was given solumedrol, duonebs,
Tylenol, ceftriaxone x 1, and flagyl x 1. She had one set of
cardiac enzymes that were nagtive and CXR reportedly had a LLL
PNA. VS on arrival to [**Hospital1 18**] were 99.5, HR 134, BP 100/78, RR
22, 92% on 4L NC. She was given 3 L NS as well as vancomycin 1
g IV, azithromycin 500 mg IV and cefepime 2 g IV.
.
Per daughter: She was placed in long-term care facility ~3.5 yrs
ago for alzheimer's dementia. About 1-2 years ago she fell out
of bed at NH and fx'ed her hip. She has not ambulated since
then. She had 2 strokes in summer of [**2150**] that left her with an
expressive aphasia. She can speak in simple sentences/phrases
when well. She will often string together non-coherent words
and believe she is communicating coherently. Daughter states
the current babbling of word fragments is worse than her
baseline.
Past Medical History:
COPD
Dementia
HTN
Hypothyroidism
CVA-- aphasic, right sided weakness; has G tube
Legally blind (macular degeneration)
Pulmonary hypertension
CHF
Depression
Left hallux ulceration
s/p R humerous and pelvic fx
s/p CCY
s/p TAH for adenocarcinoma
Osteoporosis
Social History:
Currently at [**Hospital 100**] Rehab. No tobacco or EtOH. Has 2 daughters.
Family History:
Non-contributory
Physical Exam:
Tmax: 35.8 ??????C (96.4 ??????F)
Tcurrent: 35.8 ??????C (96.4 ??????F)
HR: 95 (95 - 104) bpm
BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg
RR: 18 (18 - 19) insp/min
SpO2: 99%
.
General Appearance: Well nourished, Overweight / Obese, No(t)
Diaphoretic
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases b/l, Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended,
No(t) Tender: , Obese, G tube
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: No(t) Follows simple commands, Responds to: Tactile
stimuli, No(t) Oriented (to): cannot communicate, Movement: Not
assessed, Tone: Not assessed, rt arm contracture; rt foot fixed
extension;RU/LE weakness/paralysis; CN II - XII symmetric;
aphasic
Pertinent Results:
ADMISSION LABS:
[**2152-6-3**] 08:27PM BLOOD WBC-22.4* RBC-4.57 Hgb-12.8 Hct-39.3
MCV-86 MCH-28.1# MCHC-32.7 RDW-13.9 Plt Ct-338
[**2152-6-3**] 08:27PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.4*
Monos-1.7* Eos-0.4 Baso-0.1
[**2152-6-3**] 08:27PM BLOOD Plt Smr-NORMAL Plt Ct-338
[**2152-6-3**] 08:27PM BLOOD Glucose-187* UreaN-15 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-20* AnGap-20
[**2152-6-4**] 06:15PM BLOOD ALT-17 AST-24 CK(CPK)-264* AlkPhos-91
TotBili-0.2
[**2152-6-4**] 06:15PM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
CARDIAC ENZYMES:
[**2152-6-3**] 08:27PM BLOOD CK(CPK)-134
[**2152-6-4**] 06:15PM BLOOD CK(CPK)-264*
[**2152-6-5**] 07:27AM BLOOD CK(CPK)-224*
[**2152-6-3**] 08:27PM BLOOD CK-MB-5 cTropnT-0.04*
[**2152-6-4**] 06:15PM BLOOD CK-MB-11* MB Indx-4.2 cTropnT-0.02*
[**2152-6-5**] 07:27AM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.03*
MICROBIOLOGY:
[**2152-6-3**] Blood cultures: pending
[**2152-6-3**] Urine cultures: negative
[**2152-6-4**] Sputum cultures: contaminated
Urine legionella negative
.
trends:
WBC improved to 16 on discharge.
HCT 34.8 - stable
creatinine - stable
.
Vanco trough on am of discharge 35
AMDISSION EKG: noisy background, sinus tach at 130; poor R wave
progression; no ST seg changes or TWI; LAD.
ADMISSION CXR:
AP upright chest radiograph is reviewed and compared to
[**2151-6-3**].
Evaluation is limited by rotation, despite technologist's
attempts to properly position the patient. Evaluation is also
limited by low lung volumes. There is no large consolidation,
though retrocardiac area cannot be reliably assessed. There is
no definite pleural effusion or pneumothorax.
IMPRESSION: Limited exam. No focal consolidation.
.
[**6-6**] CXR:
HISTORY: PICC line placement.
FINDINGS: In comparison with the earlier study of this date,
there has been placement of a left subclavian PICC line that
extends to the mid portion of the SVC. Little change in the
appearance of the heart and lungs
.
Echo:
The left atrium is dilated. The left ventricle is not well seen.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve is not
well seen. The mitral valve leaflets are not well seen.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. Valvular function could not be
evaluated
Brief Hospital Course:
81 yo F w/h/o aspiration PNA and COPD, admitted from NH with
SOB, wheezing and hypoxia w/ possible LLL opacity on OSH film.
ICU course by problem:
.
#. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR;
WBC 22-28; resp status thought [**12-25**] PNA (either NH/CAP vs.
aspiration). Her PNA was supported by possible infiltrate but
also by heavy secretions. Secretions improved within 2 days.
We suspect PNA may have triggered COPD flare. Minimal evidence
of CHF exacerbation on imaging, exam and labs, but does have CHF
history. We treated her as follows:
- PNA: treated with vanco, ceftaz, flagyl for nosocomial
coverage with plans for an 8 day course. She will need 4 more
days of this regimen. Note that her vanco trough on am of [**6-7**]
was 35 so we recommend rechecking vanco trough on [**6-8**] and dose
1gm q24 for trough<20. We also treated with azithromycin to
cover atypicals. She will need two more doses of this.
- COPD: We treated with prednisone 40mg daily and tapered down.
Recommend 20mg daily x3d, 10mg daily x3d then stop. We also
treated with q1-2h albuterol nebs and q6h ipratropium nebs.
This was spaced out to q4h with breakthrough prn nebs.
- UCx negative but BCx still pending
- low suspicion for MI. CE as above
- she was on 4L NC prior to discharge from the hospital.
.
#. COPD:
-- management as above
.
#. chronic systolic CHF: no evidence of volume overload on exam;
BNP 38 (negative) at OSH. Echo here was of poor quality but did
not reveal obvious wall motion abnl. We gently diuresed with
lasix 10mg IV to keep her even to slightly negative. She
tolerated this well.
.
#. HTN: Initially held her metoprolol but this was restarted.
.
#. Hypothyroidism
-- continue levothyroxine 88 mcg QD
.
#. Dementia: not currently on medications
.
#. Depression: was on venlafaxine in past; held on last
admission for c/f NMS. Nothing on med list currently.
.
#. Osteoporosis: currently on calcium supplements
-- cont calcium;
-- fall precautions
.
#. FEN: on admission, takes ProBalance 65 ml/hr; on at 9 pm, off
at 6 am. 200 cc free water flushes Qshift. we used Replete
w/fiber Full strength during her ICU stay. Nutrition recs
included in d/c paperwork.
.
#. PPX: no indication for PPI currently; SHQ (wears boots at
rehab); bowel regimen
.
#. Code: DNR/DNI, confirmed with family by ED staff.
.
#. Contacts: Spoke with daughter [**Name (NI) 1123**] [**Name (NI) 68259**] (HCP)
[**Telephone/Fax (1) 68260**] for ICU consent and confirm code status.
.
#. Dispo: to [**Hospital 100**] Rehab [**Hospital 15159**] from the ICU.
.
#. Access: PICC placed on [**6-6**]. It was confirmed on CXR.
Please d/c PICC when done with IV abx.
Medications on Admission:
Synthroid 88 mcg QD
Albuterol nebs Q4 hours PRN
Ipratropium neb Q6 hours PRN
levaquin 250 mg PO qday (day [**12-30**])
Prednisone 5 mg QD
Senna, colace, MOM
[**Name (NI) 68261**] [**Hospital1 **]
Metoprolol Tartrate 25 mg [**Hospital1 **]
Calcium carbonate
hyocysamine 0.25 mg Q4 hours PRN
MVI, Vit C
Tylenol 325-650mg PO PRN
Discharge Medications:
1. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation q2-4h as needed for
shortness of breath or wheezing.
3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours).
4. Prednisone 10 mg Tablet [**Hospital1 **]: variable Tablet PO DAILY (Daily)
for 9 days: take 3 tabs x3d, take 2 tabs x3d, take 1 tab x3d.
Disp:*18 Tablet(s)* Refills:*0*
5. Flagyl 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day
for 4 days.
6. Ceftazidime 2 gram Recon Soln [**Hospital1 **]: Two (2) grams Injection
Q8H (every 8 hours) for 4 days.
7. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
8. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
9. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: variable units
Subcutaneous ASDIR (AS DIRECTED) for 10 days: sliding scale
insulin while on prednisone.
10. Azithromycin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
11. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) capsue PO BID
(2 times a day).
14. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
15. Calcium 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day.
16. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
17. Levsin 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO every four (4)
hours as needed for pain.
18. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 4 days: PLEASE CHECK VANCO TROUGH BEFORE GIVING.
Please given if vanco trough<20.
19. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
20. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
21. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Hospital6 15159**]
Discharge Diagnosis:
Primary:
- acute COPD exacerbation
- nosocomial pneumonia - suspected
- chronic systolic CHF
Secondary:
- hypergylcemia thought [**12-25**] steroids
- dementia
- HTN
- hypothyroidism
- pulmonary hypertension
- depression
Discharge Condition:
stable on 4L.
Discharge Instructions:
The patient came in with acute shortness of breath. She had
nosocomial pneumonia and acute COPD exacerbation. She was
treated in the ICU and her secretions improved after aggressive
pulmonary toilet. She was treated with antibiotics, nebs, and
steroids.
Please continue Abx for 4 more days. Please wean prednisone as
recommended.
Followup Instructions:
Please followup with your doctors at the [**Name5 (PTitle) 15159**]
|
[
"5070",
"51881",
"4280",
"4019",
"4168"
] |
Admission Date: [**2176-12-17**] Discharge Date: [**2176-12-23**]
Date of Birth: [**2125-8-4**] Sex: F
Service: SURGERY
Allergies:
Paxil
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Lt. lower extremity claudication and rest pain
Major Surgical or Invasive Procedure:
[**2176-12-17**]: Left femoral to dorsalis pedis bypass graft with
in-situ greater saphenous vein.
History of Present Illness:
51F admitted on [**2176-12-17**] for left femoral to dorsalis pedis
bypass
graft with in-situ greater saphenous vein.
History of: DM 2, HTN, CVA x 2, asthma, reflux, s/p renal artery
stent placement, s/p SFA stent L.
Past Medical History:
CVA X 2 on coumadin
Asthma
RAS
HTN
myofascial pain syndrome
Social History:
35 pack year smoking history, lives with boyfriend
Family History:
n/c
Physical Exam:
VS: 97.8, 70, 112/56, 16, 95%RA
ABD: soft, n-tender
Lungs: CTA
Incision: CDI
Pulses: graft palp, DP-pulse
Pertinent Results:
[**2176-12-23**] 05:35AM BLOOD WBC-7.4 RBC-3.66* Hgb-10.9* Hct-31.7*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.5 Plt Ct-334
[**2176-12-23**] 05:35AM BLOOD Plt Ct-334
[**2176-12-23**] 05:35AM BLOOD Glucose-152* UreaN-10 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-26 AnGap-15
[**2176-12-23**] 05:35AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
Brief Hospital Course:
[**2176-12-17**]: Admitted for left femoral to dorsalis pedis bypass
graft with in-situ greater saphenous vein. Uneventful
perioperative course. Extubated in the OR, and transferred to
PACU in stable condition.
[**2176-12-18**]: Low grade temp, using IS, palp graft and DP on left,
D/C a-line, advance diet, started heparin gtt for CVA hx.
[**2176-12-19**]: Temp 100, OOB, coumadin restarted. Palp graft and DP,
no hematoma. PCA changed to oral pain meds.
[**2176-12-20**]: Temp 98.1, Heparin gtt continued for ptt goal of 40.
OOB, daily dose of coumadin.
[**2176-12-21**]: afebrile, Heparin gtt adjusted to maintain ptt goal, PT
evaluation today.
[**2176-12-23**]: Stable, cleared by PT for home discharge.
Medications on Admission:
lopressor, glipizide, plavix, coumadin, flexeril, lipitor, asa,
albuterol, flonase, zestril, theophylline
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Theophylline 300 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO DAILY (Daily).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Continue taking while taking narcotics for pain
relief to prevent constipation. .
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: do not exceed more than
4,000mg of tylenol in a 24 hour period.
Disp:*40 Tablet(s)* Refills:*0*
12. coumadin
Continue pre-hospital dose of coumadin, and follow up with
Primary care physican to adjust dose for a INR goal 2.0-3.0.
13. Coumadin 2 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 3 tablets daily .
Disp:*90 Tablet(s)* Refills:*2*
14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Flexeril 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
Disp:*14 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Have INR drawn weekly or as directed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 35967**].
He will continue to manage your anticoagulation.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity claudication s/p Left femoral to dorsalis
pedis bypass graft with in-situ greater saphenous vein on
[**2176-12-17**]
Discharge Condition:
Stable:
VS: 97.8,70,112/56,16, 95%RA
Labs:
Hct: 31.7
Plt: 152
Cr: 0.6
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-23**]
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
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Please call Dr.[**Name (NI) 7257**] office at ([**Telephone/Fax (1) 1798**] to schedule a
follow-up appointment in [**11-2**] days.
Completed by:[**2176-12-23**]
|
[
"4019",
"49390",
"25000",
"53081",
"3051"
] |
Admission Date: [**2134-5-12**] Discharge Date: [**2134-6-14**]
Date of Birth: [**2071-5-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Bactrim / Prazosin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
CT guided aspiration and drainage
Posterior decompression w/instrumented fusion L1-S1
History of Present Illness:
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
62 yo female with multiple medical problems including obesity
and idiopathic lymphedema with recurrent cellulitis recently
admitted for L3-L4 osteomyelitis was admitted with a newly
diagnosed epidural abscess.
She was admitted from [**Date range (1) 99244**]/10 with back pain and found to
have L3-4 osteomyelitis. Upon discharge, the plan was to
complete an 8 week course of vancomycin and ceftriaxone on
[**2134-4-14**] and then to have repeat outpatient imaging. She was
actually seen in [**Hospital **] clinic on [**2134-4-5**] at which time her clinical
exam and inflammatory markers were improved; so antibiotics were
discontinued at that time. She was discharged home from rehab
approximately one week ago. She was scheduled to have an MRI on
[**2134-4-27**] and then follow-up on [**2134-5-4**] with infectious disease.
She was unable to tolerate the MRI on [**2134-4-27**] and cancelled her
[**Hospital **] clinic follow-up on [**2134-5-4**]. She was able to undergo an MRI
on [**2134-5-5**] which revealed a paraspinal abscess. Upon discharge
from [**Hospital3 **] on [**2134-5-4**], she reports that she felt
generally well and was ambulating with her walker. However, over
the last 5 days, she reports increasing back pain with
associated lower extremity weakness and inability to ambulate.
Additional review of systems was notable for intermittent fecal
incontinence, although it is unclear if this is old or new. She
was then called by her primary care physician regarding the MRI
results to go to the ED for further evaluation.
Upon arrival in the ED, temp 96.9, HR 80, BP 143/104, RR 18, and
pulse ox 96% on room air. Exam was notable for being
uncomfortable appearing, tenderness in the left lateral spine
and left buttock with She received ceftriaxone and vancomycin in
the ED. She was evaluated by neurosurgery in the ED who had
recommended IR guided drainage.
Review of systems:
(+) Per HPI. back pain, difficulty ambulating, lower extremity
weakness, nasal congestion, occasional fecal / urinary
incontinence
(-) Denies fever, chills, night sweats, weight loss, headache,
sinus tenderness, rhinorrhea, [**Date Range **], shortness of breath, chest
pain or tightness, palpitations, nausea, vomiting, constipation,
abdominal pain, dysuria, arthralgias, or myalgias.
Past Medical History:
WOUND HISTORY:
Previous hospitalization history for cellulitis:
- [**2-25**] hospitalized for LLE cellulitis, treated with
linezolid/unasyn
- [**4-27**] admitted for recurrent cellulitis, treated with
unasyn/augmentin x14 days
- [**6-27**], treated for cellulitis with linezolid, switched to
augmentin when she could not get approval, followed by
doxycycline suppressive therapy.
- [**2132-7-30**] to [**2132-8-4**] for RLE cellulitis, treated with 14 day
course of linezolid and Augmentin, but did not take linezolid
due to
insurance issues and discontinued Augmentin after one week due
to diarrhea.
- [**8-14**], switched from suppressive doxycyline to PCN V 500 mg po
BID.
- [**8-19**], VNA providing wound care noted increased drainage and
purulnce from both LE wounds.
- [**2132-10-22**] to [**2132-10-24**] w/ progressive edema, erythema and serous
exudate from her legs at home. ID & Derm were [**Month/Day/Year 4221**] who did
not think it was infectious but rather progression of her
chronic lymphedema. Her suppressive penicillin was continued.
Wound culture was polymicrobial, with rare pseudomonas growth.
Derm recommended topical mupirocin and avoiding pressure wraps
until skin repair/integrety improved.
- [**11-28**] hospitalized for cellulitis -- Wound culture grew pan
sensitive pseudomonas and enterococcus, which was treated with
14 days ciprofloxacin and Augmentin.
-[**7-29**] hospitalized for cellulitis - Wound culture grew pan
sensitive proteus vulgaris, with rare enterococcus and rare
psuedomonas aeruginosa, which was treated with 14 days of cipro
and 11 days penicillin (initially Augmentin, which was
discontinued due to associated diarrhea).
OTHER PAST MEDICAL HISTORY:
1. Chronic idiopathic lymphedema
2. Recurrent lower extremity cellulitis
3. Obesity
4. Hypertension
5. paroxysmal atrial fibrillation on ASA
6. Back pain s/p multiple surgeries for cervical stenosis
7. Cervical myelopathy
8. h/o ARF [**12-22**] rhabdo
9. Anemia
PAST SURGICAL HISTORY:
1. CCY
2. Tonsillectomy
3. TAH
4. C5-7 fusion on [**2127-1-14**]
5. lumbar laminectomy on [**2131-3-14**]
6. Left ankle fracture with screw placement
Social History:
Home: typically lives with her mother and 2 cats but has been at
rehab for the last 2 months
Occupation: Previously worked as a microbiologist but had to
leave due to chronic medical problems
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
Father - died at 82 due to CHF
Mother - alive at 90, hypertension and diabetes
Brother - healthy
Physical Exam:
T 96.3 / BP 130/60 / HR 62 / RR 18 / Pulse ox 97% on room air /
Weight 5 ft 7 in / Weight 281 lbs
Gen: no acute distress when lying still but very uncomfortably
with minimal movement
HEENT: normocephalic, atraumatic, Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: obese, Soft, NT, ND. NL BS. No HSM
BACK: no spinal or paraspinal tenderness to palpation (somewhat
limited exam due to patient's marked pain with movement)
EXT: bilateral lymphedema, fully wrapped (will evaluate with
wound care nurse later today)
NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5/5 strength in upper
extremities bilaterally. 5-/5 in lower extremities bilaterally
although it appears primarly limited by pain. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately but
frequently tearful due to frustration with her situation.
Pertinent Results:
ADMISSION LABS:
[**2134-5-11**]
Na 142 / K 4 / Cl 104 / CO2 27 / BUN 44 / Cr 1.2 / BG 123
WBC 10.9 / Hct 32.2 / Plt 280
N 74 / L 18 / M 4 / E 4 / B 0
INR 1.2 / PTT 26
Lactate 1
UA - straw, clear, 1.011, pH 5, negative for all else
Baseline Hct 28-30
DISCHARGE LABS:
. . .
MICROBIOLOGY:
[**2134-5-11**] Bloodx x 2 pending
[**2134-5-12**] Blood Cx x 2 pending
[**2134-5-12**] Tissue Gram Stain - no polymorphonuclear leukocytes
seen; no microorganisms
[**2134-5-12**] Tissue Cx pending
STUDIES:
[**2134-5-5**] MRI L spine
1. Interval development of well-defined, rim-enhancing
collection in the L3-4 interspace measuring up to 3.3 cm
compatible with abscess. To determine whether this abscess
extends lateral to the disc space into the paraspinous soft
tissues as images suggest, CT may be useful.
2. Further bony collapse of the superior endplate of L4.
3. Persistent severe canal stenosis at L3-4 at the site of
infection.
4. No evidence of epidural abscess at this time.
[**2134-5-12**] CT L Spine -
1. Destructive process centered about the L3-L4 disc space,
consistent with stated history of discitis/osteomyelitis.
Allowing for differences in imaging modality, no significant
change in the degree of endplate osseous destruction and
collapse, compared to the recent MR [**First Name8 (NamePattern2) **] [**2134-5-5**].
2. Persistent severe canal stenosis at L3-L4 secondary to
combination of pre- existent dextroscoliosis and the infectious
process.
Brief Hospital Course:
62yo female with complicated recent medical history including
L3-4 osteomyelitis S/P 6 weeks of treatment with vancomycin and
ceftriaxone was admitted with increased low back and left leg
pain and bilateral LE weakness. On imaging of the spine it was
felt that a fluid collection between L3 and L4 had developed
which represented a vertebral abscess. She was started
empirically on vancomycin, ceftazidime, and metronidazole IV. At
admission, her ESR was slightly elevated at 35, CRP was 15, and
WBC count was 10,900. She was afebrile.
.
She was examined by her Neurologist, Dr. [**Last Name (STitle) **], on
admission and was felt to have bilateral lower extremity
paraparesis, decreased joint position sense, and decreased
reflexes in her lower extremitis. Neurosuregry was [**Last Name (STitle) 4221**] but
she initially refused any surgical intervention. Over the next
few days after admission, with better pain control, her lower
extremity strength improved. She had antigravity strength of all
major muscle groups in both lower extremities, and was able to
[**Hospital 99245**] transfer to a commode with a walker without
assistance on hospital day 2.
A CT-guided drainage of the vertebral abscess was performed,
though her cultures remained negative. Upon the return of her
neurosurgeon, the decision was made that she would need a spinal
surgical procedure, probably fusion and washout of abscess. ID
recommended continuation of her triple antibiotics. Her pain
remained well controlled otherwise with stable neurological
exam.
She went to the OR on [**2134-5-27**] for posterior decompression
w/instrumented fusion L1-S1 with Dr. [**Last Name (STitle) **]. Her surgery was
uneventful she monitored for 48 hours in the ICU, post op CT
showed good alignment of the hardware. On post op day 2 she was
transferred to the surgical floor. She has been followed by ID
during her hospitalization. Micro thus far has been unreavling
except gram negative rods in one blood culture that showed no
growth. Has been treated with Vancomycin, Ceftaz and Flagyl.
Final cultures showed 1+ gram negative rods on gram stain from
[**5-27**]. All other cultures were negative. Her ESR was 135 and CRP
110. ID's final recommendations were to continue IV antibiotics
for 6 weeks (end [**6-28**]). She is to have weekly ESR, CBC W/ diff,
and CRP for 4 weeks.
Her lumbar wound was noted to be ischemic appearing in the
center with no drainage or redness, nursing and patient are
encouraged to turn Q2 hours. Sutures were removed on [**6-8**] and a
clean dressing applied. The wound appearance was concerning so
she had a wound wash-out and closure on [**6-13**] those sutures
should stay in place until [**6-26**]
.
2. Depression:
She was continued on her home regimen of duloxetine.
.
3. Sciatica:
She was continued on her home regimen of gabapentin.
.
4. Benign Hypertension:
She was continued on her home regimen of labetalol and lasix
.
5. Constipation:
Patient has a history of constipation but has been having loose
stools now. Her bowel regimen was initially held during this
admission.
.
6. Chronic idiopathic lymphedema:
Wound care was [**Month/Day (4) 4221**] during this admission and recommended:
Wound care:
Site: left heel - plantar aspect
Type: Other
Cleansing [**Doctor Last Name 360**]: Other
Dressing: Hydrocolloid (Duoderm)
Change dressing: Other
Comment: Blister - intact. [**Month (only) 116**] be pressure-related but location
not typical. Duoderm q3 days and prn to protect blister from
shearing forces
.
7. Paroxysmal atrial fibrillation
Patient's aspirin was held initially during this admission due
to the likely procedure but was then restarted.
.
8. Anemia NOS:
Likely related to chronic disease given previously high ferritin
and low retic count and blood loss during surgery as drain was
in place. The patient initially refused blood transfusion but on
[**6-2**] she was noted to have a crit of 19, she agreed to two units
of PRBC which post transfusion increase to 24. Crit on discharge
was 30.
9. Right lower calf pain. The patient was exquisitely tender in
right calf starting on [**5-30**]. She had LENIs which were negative
for dvt except peroneal veins were not visualized, the pain
continued so on [**6-2**] she had an MRI on [**6-3**] showed no evidence
of DVT.
.
# COMM: [**Name (NI) **]; Mother [**Name (NI) **] [**Name (NI) 99238**] [**Telephone/Fax (1) 99246**]
Medications on Admission:
1. Duloxetine 90 mg PO daily
2. Furosemide 80mg PO bid
3. Aspirin 325 mg PO daily
4. Gabapentin 800 mg PO 5x per day
5. Labetalol 400 mg PO bid
6. Naproxen 375 mg PO bid
7. Docusate Sodium 100 mg PO bid
8. Magnesium Hydroxide prn constipation
9. Bisacodyl 10mg PO daily
10. Miralax daily
11. Senna PO bid prn constipation
12. Dilaudid prn constipation
Discharge Medications:
1. Outpatient Lab Work
CRP, ESR, CBC with diff Weekly X 4 weeks. Please fax result to:
[**Telephone/Fax (1) 1419**]
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO 5X PER DAY
().
4. Labetalol 200 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Fungal infection.
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
20. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
21. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours).
22. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Paraspinal Abscess
2. Osteomyelitis
SECONDARY DIAGNOSES:
1. Depression
2. Paroxysmal Atrial Fibrillation
3. Hypertension
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
You were admitted to the hospital with a paraspinal abscess
associated with your recent osteomyelitis. You underwent a
drainage and biopsy of this fluid and tissue, which revealed no
clear bacteria. You were treated with antibiotics in the
hospital. You underwent a posterior decompression
w/instrumented fusion L1-S1 with Neurosurgery.
.
Medication changes:
-Vancomycin, Ceftazidime, and Flaygl for a total 8 week course
.
You will need to follow up with infectious disease and
neurosurgery
Followup Instructions:
You will need your wound assessed on or around [**6-26**] for
suture removal please call Dr [**Last Name (STitle) **] office for removal sutures
at that time.
Dr. [**Last Name (STitle) **] wants to see you in the office immediately following
the completion of your antibiotics, in 6 weeks (end [**6-28**]), you
will need an MRI+/-gado of your L-spine. Please call [**Location (un) 3230**]
[**Telephone/Fax (1) 3231**] to make these appointments.
Please follow up with your PCP as soon as possible:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
Please follow up with ID on:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2134-6-22**] 10:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2134-7-21**] 10:00
Completed by:[**2134-6-14**]
|
[
"42731",
"2859",
"311"
] |
Admission Date: [**2167-1-26**] Discharge Date: [**2167-2-2**]
Date of Birth: [**2089-10-11**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Hydantoins / Trimethadione/Paramethadione
/ Phenacemide / Barbiturates / Primidone / Gadolinium-Containing
Agents / Mysoline
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 80433**] is a 77yo gentleman with h/o COPD and recurrent
aspiration pneumonia who presented to the ED with complaint of
shortness of breath and productive cough.
He reports that symptoms began about 1 day ago with difficulty
breathing and a cough. He is not sure if the cough is
productive. He has had episodes of vomiting following coughing
fits but denies nausea. He denies fevers, chest pain, or
myalgias. He is not sure about diarrhea, but thinks he has had
some loose stools. Of note, he received his seasonal flu
vaccine but not the H1N1 vaccine this year.
In the ED, initial VS were 101.2 125/60->95/61 116 40s 100% on
NRB (had been 70% on RA at his NH). He was markedly tachypneic
with decreased breath sounds on the left. His UA was noted to be
positive. ABG was 7.42/43/85 on a non-rebreather; lactate was
1.9. He was started on biPAP with improvement in his dyspnea and
tachycardia. He received zosyn and vancomycin as well as
solumedrol. He had a swab for the flu and was started on
tamiflu. He was given a 500cc bolus of IVF just prior to
departure from the ED.
.
Upon arrival to the ICU, he was insistent on sitting as upright
as possible to help his breathing. Denied thirst.
Past Medical History:
COPD with multiple admissions for exacerbations, not on home O2
Recurrent aspiration PNA, particularly of LLL, s/p G tube
placement
Chronic elevation of left hemidiaphragm
Parkinson's Disease
h/o C. diff requiring MICU stay
h/o UTIs with E coli and Pseudomonas resistant to quinolones;
h/o chronic indwelling Foley for urinary retention
AFib, not on anticoagulation
h/o multiple DVTs, s/p IVC filter. Anticoagulation stopped after
GI bleed in fall [**2165**]
Severe degenerative disk disease
h/o Basal cell Cancer
Severe thoracic Scoliosis and spinal stenosis with chronic back
pain
GERD
h/o Sacral decubitus ulcer
h/o childhood encephalitis
Anxiety
h/o right shoulder surgery, no hardware in place
Social History:
Single, never married. Lives in [**Location **] b/c of disability from
Parkinsons. Nephew is HCP & visits pt regularly. Was discharged
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] after [**Hospital1 18**] admission in [**Month (only) **]. Smoked 2
packs once, but was never a regular smoker. Unable to ambulate
at baseline.
Family History:
No significant history as pertains to patient's condition.
Physical Exam:
VS: 98.3 113/76 95 32-40 100% NRB
GENERAL: Pleasant, in acute respiratory distress, only able to
speak a few words at a time, but even then has a tremor as he
speaks, quite thin.
HEENT: No conjunctival pallor. No scleral icterus. Left pupil is
larger than right, which he reports is chronic. EOMI. Mucous
membranes are dry. Poor dentition. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Borderline tachycardia, normal rhythm. Normal S1, S2.
No murmurs, rubs or [**Last Name (un) 549**]. JVP not elevated
LUNGS: Tachypneic with accessory muscle use. Diffuse expiratory
wheezes with inspiratory rhonchi. Markedly decreased breath
sounds on left.
ABDOMEN: G tube in place with some erythema at the site. +BS,
soft, not tender or distended.
EXTREMITIES: Wasted lower extremities. No edema or calf pain,
palpable distal pulses.
SKIN: Chronic stasis changes.
NEURO: A&Ox3. Appropriate. Preserved sensation throughout. [**6-10**]
strength in UE; able to move LE against gravity b/l but weak
against resistance. Resting tremor in his legs as well as a
marked tremor in both UEs. Seems to have a tremor when he tries
to speak.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2167-1-26**] 09:15AM WBC-10.2# RBC-4.29* HGB-13.6* HCT-41.8 MCV-97
MCH-31.6 MCHC-32.5 RDW-15.4
[**2167-1-26**] 09:15AM PLT COUNT-196
[**2167-1-26**] 09:15AM PT-11.7 PTT-22.6 INR(PT)-1.0
[**2167-1-26**] 09:15AM GLUCOSE-215* UREA N-27* CREAT-1.0 SODIUM-138
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
[**2167-1-26**] 09:15AM CK(CPK)-201*
[**2167-1-26**] 09:15AM cTropnT-0.02*
[**2167-1-26**] 09:37AM TYPE-ART PO2-85 PCO2-43 PH-7.42 TOTAL CO2-29
BASE XS-2
CXR [**1-26**]: Persistent severe scoliosis and extensive elevation
of the left hemidiaphragm are unchanged since [**2166-5-31**].
The cardiac and mediastinal contours are unchanged since
[**2166-12-28**]. There
are no new focal opacities. There is no pneumothorax or pleural
effusion.
Mild left basilar atelectasis is stable. IMPRESSION: Stable
elevated left hemidiaphragm and severe scoliosis. No acute
intrathoracic process.
CXR [**1-30**]:
As compared to the previous examination, there is a minimal
improvement with a small left apical portion of lung parenchyma
that is
ventilated. Otherwise, the radiograph is unchanged. Subtotal
opacification
of the left hemithorax, severe scoliosis, no evidence of newly
appeared focal parenchymal opacity in the right lung.
Brief Hospital Course:
This is a 77-year-old man with h/o COPD (no firm diagnosis and
no smoking history) as well as severe restrictive lung disease
from scoliosis, Parkinson's disease, and severe left
hemidiaphragm elevation who was admitted with respiratory
distress in the setting of fever and cough. He has frequent
hospitalizations with empiric steroid and antibiotic treatments
with only short term improvement. During this admission, he was
placed on BiPAP which helped his respiratory distress. He was
initially started on broad coverage with Vancomycin, Zosyn, and
Levaquin for possible HAP. He was also given Solu-Medrol x 3
days, then transitioned to oral prednisone taper. However, we
discontinued the steroids as his severe restrictive lung disease
and pneumonia could explain his wheezing and other respiratory
symptoms. Eventually, his sputum grew pseudomonas which was
sensitive to ciprofloxacin. The antibiotic coverage for HAP was
narrowed to this single antibiotic. However, we changed it to
Meropenem to cover the resistant PSEUDOMONAS AERUGINOSA isolated
from a urine sample. He had a midline placed for Meropenem
treatment until [**2167-2-7**] to treat both HAP and UTI related to
Foley catheter. He needs aggressive pulmonary therapy to prevent
re hospitalizations and re infections. Goal of care and
palliative care should be involved if he continues with these
admissions with only marginal improvement.
# Fever: Fever most likely from PNA or UTI. His Foley was
changed and he was treated with antibiotics as above. Fevers
eventually resolved.
# Urinary Tract Infection: Urine grew out pseudomonas sensitive
to meropenem.
# Tachycardia: Tachycardia on admission felt to be due to
respiratory distress and dehydration. He was given IVF for
volume resuscitation and his tachycardia improved.
# Parkinson's disease: Continued on Sinemet and hyoscyamine.
# AFib: He was continued on amiodarone and was not on
anticoagulation given h/o GI bleed.
# H/o Hyperlipidemia: Continued statin and ASA
# H/o DVTs: His physical exam was closely monitored given his
history of line-associated and unprovoked DVTs in the past. He
was not on anticoagulation given h/o GI bleed.
total discharge time 56 minutes.
Medications on Admission:
(per recent DC summary):
Aspirin 81 mg daily
Amiodarone 200 mg daily
Carbidopa-Levodopa 25-100 mg TID
Simvastatin 20 mg daily
Prednisone taper to off
Robitussin Cough & Cold TID
Albuterol nebs Q4-6H prn
Ipratropium nebs Q4-6H prn
Lactinex 100 million cell Granules in Packet [**Year/Month/Day **]: One (1)
packet PO once a day.
Acetaminophen 325-650 mg PO Q6H as needed for pain/fever.
Omeprazole-Sodium Bicarbonate 20-1,680 mg [**Hospital1 **]
Trazodone 25mg HS
Hydrocodone-Acetaminophen 5-500 mg Q6-8H prn pain
Hyoscyamine Sulfate 0.125 mg/5 mL QID
Lorazepam 0.5mg Q8H prn anxiety
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day) as needed for agitation/anxiety.
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
congestion.
7. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Carbidopa-Levodopa 25-100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
TID (3 times a day).
9. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day) as needed for constipation.
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: 325-650 MG PO Q6H
(every 6 hours) as needed for fever, pain.
12. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough, congestion.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as
needed for wheeze, SOB.
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours) as needed for wheeze and sob.
15. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ML PO BID (2 times a
day) as needed for constipation.
16. Meropenem 500 mg IV Q6H
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**]
Discharge Diagnosis:
Pseudomonas pneumonia
urinary tract infection
restrictive lung disease from scoliosis, parkinsons, and
elevated left diaphragm
parkinsons
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Bedbound
Discharge Instructions:
You have pneumonia related to pseudomonas and urinary tract
infection. You have advanced baseline restrictive lung disease.
You need aggressive lung therapy with chest therapy, incentive
spirometry, bronchodilators, and coughing. You need additional
antibiotics for more 5 days.
Followup Instructions:
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 18325**]
|
[
"51881",
"5990",
"496",
"42731",
"53081",
"2724",
"2767"
] |
Admission Date: [**2182-8-6**] Discharge Date: [**2182-8-21**]
Date of Birth: [**2100-3-18**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
HD tunneled line catheter insertion ([**2182-8-9**]) and removal.
History of Present Illness:
Mr. [**Known lastname **] is a 82yoM with multiple medical problmes including
CAD, CHF (EF 30-35%), CKD (Cr 3.2 on admission to rehab) who was
brought to the ED from rehab with SOB and confusion. In the ED,
he was combative and initially refusing vital signs. Initial
vitals: 97.8 74 136/53 18 96% 4L np. While in the ED, he calmed
but was noted to be delerious. When he fell asleep, O2 sats
dropped. He he was temporarily placed on a non-rebreather, but
when awoken was easily weaned back to nasal canula. On exam in
the ED, crackles were noted in the in right base. In the ED, UA
was done and was negative. Head CT negative. CXR was notable for
new R-sided opacity. No consults were called in the ED. VItal
prior to transfer: 154/63, P76, RR18, 100% on 3L NC
.
In her ED call-in, PCP was concerned about uremia. Pt has a
documented "cognitive impairment," but it is unclear what this
entails from the notes in OMR. Otherwise, the patient had been
quite functional at home prior to his [**2182-5-22**] admission, after
which he went to rehab where he has been since. Of note, last
admission, poor responsse to 120mg Lasix with metolazone 5mg.
.
On the floor, pt is unable to articulate words and not following
commands.
.
Review of systems: Unable to obtain
Past Medical History:
CAD ([**Doctor Last Name **]- cath '[**66**] - LAD -> stent)
HTN
CHF (EF = 30-35% in [**6-1**] 2+ MR, 2+ AI, 2+ TR)
renal cancer ([**Doctor Last Name **])
CRI (2.4-2.7) ([**Doctor Last Name 4883**])
hyperlipidemia,
Prostate cancer ([**Doctor Last Name **])([**Hospital1 656**])
h/o colitis,
cataracts,
seasonal allergies,
bilateral knee OA,
GERD,
iron deficiency anemia,
cervical and lumbar DJD,
right testicular atrophy secondary to mumps
Social History:
He lives alone. He is a retired barber. Originally from [**Country 5976**].
Denies tobacco, recreational drugs, or alcohol excess. Per
nephew drinks 2 shots of schnapps nightly.
Family History:
Father died at 41 of nephritis. Mother with aortic stenosis.
Physical Exam:
Admission Physical Exam:
154/63, P76, RR18, 100% on 3L NC
General: AxO x 0, speech difficult to understand, copious
bruises noted across body. No Fentanyl patch noted.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: limited exam [**1-23**] patient positioning and mental status,
CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
GU: no foley
Ext: warm, well perfused, bilateral [**12-23**]+ edema to the knees.
Erythema to above the ankle on the left. Both ankles are
bandaged with Kerlix.
Neuro: Unable to engage in coversation, not following comands,
no focal deficit, but jerking of the B/L UE
.
Discharge Physical Exam:
Vitals: [**Doctor First Name **] protocol
Gen: NAD AOx2
HEENT: EOMI, PERRL, oropharynx clear
CV: RRR s1/s2 -m/r/g
R: minor bibasilar rales, otherwise CTA b/l -w/r/
A: +BS soft NTND -HSM
Ext: -c/c/e
Skin: -rash/new lesions, diffuse echymoses over his arms and
legs.
Neuro: AOx2-3, follows commands.
Pertinent Results:
Admission Labs:
[**2182-8-6**] 01:30PM BLOOD WBC-9.7 RBC-4.03* Hgb-11.3* Hct-34.2*
MCV-85 MCH-27.9 MCHC-32.9 RDW-20.9* Plt Ct-161
[**2182-8-6**] 01:30PM BLOOD ALT-18 AST-32 CK(CPK)-95 AlkPhos-84
TotBili-1.0
[**2182-8-6**] 01:30PM BLOOD Calcium-8.6 Phos-6.2* Mg-1.8
[**2182-8-12**] 06:27AM BLOOD VitB12-1567* Folate-17.7
[**2182-8-12**] 06:27AM BLOOD TSH-24*
[**2182-8-6**] 01:30PM BLOOD TSH-13*
[**2182-8-12**] 06:27AM BLOOD Free T4-0.57*
[**2182-8-10**] 07:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2182-8-17**] 06:20AM BLOOD WBC-11.8* RBC-3.81* Hgb-10.9* Hct-33.0*
MCV-87 MCH-28.6 MCHC-33.0 RDW-20.2* Plt Ct-121*
[**2182-8-16**] 06:35AM BLOOD WBC-8.4 RBC-3.66* Hgb-10.4* Hct-31.1*
MCV-85 MCH-28.6 MCHC-33.6 RDW-20.2* Plt Ct-108*
[**2182-8-8**] 07:45AM BLOOD Neuts-87* Bands-0 Lymphs-4* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
Discharge Labs:
[**2182-8-17**] 06:20AM BLOOD PT-16.1* PTT-38.0* INR(PT)-1.4*
[**2182-8-17**] 06:20AM BLOOD Glucose-100 UreaN-30* Creat-2.5* Na-140
K-4.0 Cl-98 HCO3-28 AnGap-18
[**2182-8-16**] 06:35AM BLOOD Glucose-98 UreaN-52* Creat-3.2* Na-137
K-3.9 Cl-98 HCO3-27 AnGap-16
[**2182-8-15**] 06:20AM BLOOD Glucose-106* UreaN-36* Creat-2.5* Na-137
K-3.8 Cl-97 HCO3-28 AnGap-16
[**2182-8-14**] 06:36AM BLOOD Glucose-112* UreaN-59* Creat-3.1* Na-139
K-3.6 Cl-97 HCO3-30 AnGap-16
[**2182-8-17**] 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
Studies:
CXR ([**2182-8-6**])
Limited study due to rotation demonstrates bilateral pleural
effusions with bibasilar airspace opacities, worst on the left
than the right, possibly due to atelectasis though infection is
not excluded.
CT HEAD W/O CONTRAST ([**2182-8-6**])
No acute intracranial process.
RENAL U.S. ([**2182-8-7**])
1. Stable large left mid-to-lower pole renal mass.
2. Mild stable left-sided pelviectasis.
3. Unchanged atrophic, slightly echogenic right kidney.
LIVER OR GALLBLADDER US ([**2182-8-7**])
1. Trace perihepatic ascites.
2. Doppler assessment of the hepatic portal veins and inferior
vena cava (retrohepatic and mid) shows patency and appropriate
directionality of flow. No evidence of thrombus.
TTE ([**2182-8-8**])
there is a mobile echodensity seen in the left atrium at the
base of the mitral leaflet, near the aorto-mitral fibrous
continuity. This could be a vegetation or part of the myxomatous
mitral valve. A TEE would help clarify, if clinically relevant.
Moderate focal LV systolic dysfunction. Dilated and depressed
right ventricle. Mild to moderate mitral regurgitation. Mild to
moderate aortic regurgitation. Moderate to severe pulmonary
artery hypertension.
MR HEAD W/O CONTRAST ([**2182-8-15**])
1. No evidence of new hemorrhage, edema, masses, mass effect or
infarction. Study is somewhat limited by motion artifacts.
2. Small focus of altered signal intensity, unchanged from
previous study, likely representing hemorrhagic residuum in
right frontal lobe.
3. Increasing confluence of FLAIR hyperintensities seen in the
periventricular white matter, most likely indicating progression
of chronic small vessel infarction.
Brief Hospital Course:
Assessment and Plan: 82yo M with CKD, CHF (EF 30-35%), and CAD
who was brought to the ED with AMS and hypoxia and admitted to
the ICU and later transfered to the medical floor and
hemodialysis was intiated.
# AMS:
The patient's altered mental status was thought to be possibly
due to delirium from an infection or toxic metabolic cause or
due to his uremia secondary to worsening chronic renal failure.
He was found to have LLE cellulitis and RLL PNA and was started
on broad antibiotics for these (initially vanc/zosyn then
changed to vanc cefepime). His mental status improved
dramatically on the antibiotics. An LP was considered, but not
performed as it was thought his pneumonia accounted for the
source of infection. It was felt that while his uremia was not
the cause of such an acute change in his mental status, it was
felt that this was at least contributing to his apparent
baseline confusion. His mental status continued to fluctuate
between AOx1 to AOx2-3, with obvious inattention and confusion
at times.
# Acute on chronic renal failure:
The patient was found to have a high BUN:Cr, although his feUrea
was not consistent with pre-renal. The patient also had
recently started on colchicine which was inappropriately dosed
for his GFR. He was resuscitated with IVF and his renal
function improved somewhat. Renal was consulted and recommended
hemodialysis be started. His feelings towards dialysis were not
fully known and it was determined that he did not have capacity
at this time to make the decision. It was felt that by
initiating hemodialysis on this admission, the correcting of his
uremia may help his mental status to the point where Mr. [**Known lastname **]
could make his wishes known. His health care proxy consented to
begin hemodialysis.
The patient underwent HD and tolerated it well. Aggressive
amounts of fluids were removed. The patient became more alert
and awake, indicating that HD was helping with his overall
mental status, however he also began to endorse visual
hallucinations and paranoid delusions. He was typically only
oriented to self, but occasionally also to place. After
thorough discussion, it was felt that given the patients
multiple complex medical problems continued hemodialysis was not
recommended.
Two family meetings were held with the healthcare proxy to
discuss goals of care. Ultimately it was decided that Mr [**Known lastname **]
would be transitioned to hospice care, as his multiple
comorbidities and likely untreated renal cell carcinoma would
shorten his overall prognosis regardless of HD.
# Dementia
While his functioning prior to this episode was not entirely
clear, multiple report indicated that this was a relatively
rapid decline in Mr. [**Known lastname **]. He was reported as ambulatory and
interactive as late as the spring. While it was clear that he
was delirious due to his infection and uremia, it also became
clearer that his underlying dementia was more significant than
was thought. A work up for possible reversible causes of
dementia was done, including thyroid studies, syphilis testing,
vitamin B12 and folate levels, and a MRI of the brain. The only
revealing study was an elevated TSH, however he was treated for
this during this admission.
# Pulmonary hypertension
As the patient was significantly volume overloaded, and
transthoracic echocardiogram was done which revealed pulmonary
artery hypertension. The pulmonary service was consulted who
said that they felt that this was most likely due to his
significant left sided heart disease leading to pulmonary venous
hypertension. The recommended volume reduction through HD and
diuresis. Also, a mobile echodensity was incidentally seen in
the left atrium at the base of the mitral leaflet; the echo
report felt that this could be a vegetation or part of the
myxomatous mitral valve. Further work up was deferred due to
his concurrent kidney failure and worsening mental status.
# Renal mass
An renal ultrasound was done in order to rule out obstructive
causes of kidney failure. It did not show obstruction, however
it did show the persistence of a known renal mass that was felt
to be increasing in size. In his medical chart, it appears to
suggest that Mr. [**Known lastname **] knew this was likely a malignancy and did
not chose to take action at that time. While it is not known
what his cognitive status was at that time, given his multitude
of medical problems, further work up of this mass was deferred
to see if dialysis might have improved his mental status.
# Decreasing platelets
The patient was noted to have a decreasing platelet count from
161k to 105k. The diagnosis of heparin induced thrombocytopenia
was considered. Heparin dependant antibodies were negative.
# Hypernatremia:
The patient was found to be hypernatremic on admission. This
was likely a result of his AMS rather than the etiology. The
patient was replete with free water and his sodium levels
improved.
# Depression:
The patient's antidepressants were held in the setting of
altered mental status.
# Hypothyroidism:
The patient was continued on his home levothyroxine, the dose of
which was increased
# CAD:
The patient was continued on his home medications.
___________________________________________
.
Goals of Care:
A meeting was held with the [**Hospital 228**] health care proxy to
discuss what Mr. [**Known lastname **] would have wanted going forward.
Hemodialysis was initiated to see if resolving the patient's
uremia may have helped his mental status improve to the point
that he would be able to fully express his wishes. This was not
the case however, and while it did help the patient to be more
awake and alert, he continued to lack capacity to make medical
decisions. The futility in continuing with hemodialysis was
discussed in light of his multiple organ dysfunction - dementia,
ESRD, severe pulmonary hypertension, and likely malignancy. It
was decided to discontinue hemodialysis and Mr. [**Known lastname 4675**] code
status was made DNR/DNI. Goals of care were discussed a second
time with the HCP, and the decision was confirmed to transition
to hospice care.
Medications on Admission:
Per last d/c summary
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. balsalazide 750 mg Capsule Sig: Three (3) Capsule PO twice a
day.
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
.
List from rehab:
ASA 81
balsalazide 750mg 3 tablets [**Hospital1 **]
Seoquel 50mg qHS
acetaminophen 325 2 tablets q6 hours PRN
bisacodyl 10mg suppository
Fleet enema 1 daily PRN
MoM 30ml daily PRN
citalopram 20mg daily
fluticasone 1 spray per nostril daily
furosamide 80mg [**Hospital1 **]
metolazone 2.5mg 30 mins before Lasix
metop succinate 50mg daily
MVI
niferex-150 cap daily
omeprazole 20mg daily
Colcrys 0.6mg po TID ([**2182-8-1**])
levothyroxine 37.5mcg qAM (recent increase from 25mg on [**2182-8-1**])
Renvela 800mg 1 tab TID
Keflex 250mg tab TID x 7 days (start [**2182-8-5**])
Fentanyl 12.5mcg patch (started [**2182-8-6**])
.
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not exceed 8 tablets daily.
7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Renvela 800 mg Tablet Sig: One (1) Tablet PO three times a
day: Please take with meals.
10. haloperidol lactate 5 mg/mL Solution Sig: One (1) 0.25mg
Injection [**Hospital1 **] (2 times a day) as needed for agitation/anxiety.
11. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for agitation.
12. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
End stage renal disease
Secondary Diagnoses:
Pneumonia
Cellulitis (left lower extremity)
Demenita
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted because you were having
difficulty breathing and you were confused. When you arrived,
we found that you had pneumonia in your lungs as well as an
infection in the skin of your legs. You were treated with
antibiotics. We also found that your kidneys were no longer
functioning well enough. You continued to be confused and very
tired and we felt that this may have been due to your kidneys
not functioning. We started you on temporary dialysis, however
we do not recommend continued dialysis.
Followup Instructions:
None
|
[
"486",
"5849",
"40391",
"2760",
"4280",
"53081",
"2449",
"2724"
] |
Admission Date: [**2143-4-27**] Discharge Date: [**2143-5-5**]
Date of Birth: [**2083-6-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Prograf / Phenergan / Haldol
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Chest tube placement
Thoracentesis
History of Present Illness:
The patient is a 59 M with h/o ESRD s/p failed renal transplant,
HTN, DM, PVD, chronic diarrhea; now presents w/ nausea,
vomiting, and abdominal pain x 3 days. Sent from nursing home.
He missed dialysis yesterday because he felt too sick to go. He
reports the sudden onset of abdominal pain, cramping, not
related to food. He describes it as diffuse. Improving since
early today. + diarrhea. No fevers or chills. + fatigue over
last few days. Denies chest pain, + shortness of breath, no
urinary symtoms, + weight loss - "alot", unable to say over how
long.
.
In the ED, initial vital signs were 94.8, 87, 132/93, 16,
100%RA. A CT abdomen showed a dilated common bile duct with mild
intrahepatic ductal dilatation and markedly dilated pancreatic
duct. The ERCP fellow was called from the ED and did not want to
do an urgent intervention. Surgery was called and recommended
ERCP to evaluate for pancreatitis/pancreatic mass. CXR showed an
entrapped lung. He received a dose of levo/flagyl in the ED.
.
He then had an MRCP which demosntrated a dilated main pancreatic
duct with multiple large cystic areas that appear to be in
communication with the main pancreatic duct, most prominent at
the tail of the pancreas. His CBD was 6 mm. His overall picture
was thought to be consistent with chronic pancreatitis. After
dialysis on [**4-29**] he was found to hypothermic to 93.1 with a BP of
96/70 depressed from baseline of SBP 110-120. He was also found
to have bandemia of 15%. This am he was hypothermia and
hypotension persisted despite 500 cc bolus and ceftriaxone and
vancomycin. A detailed discussion about code status was held
with his wife the evening prior to his tranfer and he remained
full code. He was transferred to [**Hospital Unit Name 153**] for further treatment.
.
In ICU, found to have multiloculated pleural effusion w/
purulent aspiration under ultrasound guidance by IP. Continued
on broad antibiotics, and chest tube placed for drainage.
However, given progressive decline with multiple co-morbidities,
code discussion was undertaken with family and the decision was
made to make patient CMO. Transferred out to medical floor on
morning of [**5-4**].
Past Medical History:
**ESRD s/p transplant (left kidney from brother) at [**Name (NI) 112**] [**1-/2134**], w/
h/o of complications from rejection, now stable with prednisone
tapered to 10 mg/d. On cellcept and neoral. s/p av fistula [**2131**],
s/p jump graft revision [**12/2133**] of AV fistula which had clotted.
s/p excision of pseudoaneurysm [**7-/2134**] of rt brachiocephalic
fistula. Followed by Dr. [**Last Name (STitle) **].
[**12/2139**]-follwed by [**Location (un) **] diaylsis-dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]-
cell-[**Telephone/Fax (1) 106545**],office-[**Telephone/Fax (1) 34044**], dialysis
unit-[**Telephone/Fax (1) 55520**] 3 x per week
**Type I DM X 28 yrs. DM secondary to pancreatitis (h/o etoh
abuse).
Has been on insulin 23 yrs.
*HTN
*Neuropathy
*Back pain
*Anemia
*Pancreatitis
*Penile prosthesis
*PVD - s/p left 5th toe and right all 5 toes amputation
-hx DVT with PE
*Sleep disorder
*Pain medicine contract
*vocal cord polyps - h/o squamous cell in situ
*Dysphagia
*GERD
*idiopathic meningoencephalitis
*R shoulder arthroplasty [**8-27**] and I&D in [**12-28**]
*s/p L femoral neck fx [**9-28**]
*Right tib-fib fx nonunion s/p external fixation
*chronic diarrhea
*dementia
Social History:
Patient lives in Nursing Home. He has a wife named [**Name (NI) **]. [**Name2 (NI) **]
was a heavy drinker but quit several years ago. [**10-12**] pack year
smoker. Reportedly has been victim of domestic violence at hands
of his teenage daughter.
Family History:
Noncontributory.
Physical Exam:
VS: 96.6 118-126/73-83 79 24 97%3L
GEN: very thin/emaciated, older than stated age
HEENT: PERRL, EOMI, sclera anicteric, very dry mucous membranes
CV: RRR, no Murmurs
PULM: Pt unable to sit up or turn, but very scant BS on left,
coarse BS on right ant and lat
ABD: soft, + BS, nildly tender throughout
EXT: amputation of toes on left foot, no edema in lower
extremities
NEURO: alert & oriented x 3
Pertinent Results:
[**2143-4-30**] 07:50AM BLOOD Cortsol-29.5*
[**2143-4-28**] 10:43AM BLOOD PTH-154*
[**2143-4-28**] 05:53AM BLOOD calTIBC-39* VitB12-GREATER TH
Folate-GREATER TH Ferritn-410* TRF-30*
[**2143-5-3**] 04:30AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.2
[**2143-4-27**] 12:38PM BLOOD cTropnT-0.08*
[**2143-4-30**] 07:50AM BLOOD proBNP-9843*
[**2143-4-27**] 12:38PM BLOOD Lipase-6
[**2143-4-28**] 05:53AM BLOOD Lipase-5
[**2143-4-29**] 04:57AM BLOOD Lipase-5
[**2143-4-27**] 12:38PM BLOOD ALT-17 AST-29 CK(CPK)-8* AlkPhos-188*
Amylase-9 TotBili-0.8
[**2143-4-28**] 05:53AM BLOOD ALT-12 AST-9 LD(LDH)-114 AlkPhos-135*
Amylase-6 TotBili-0.7
[**2143-4-30**] 07:50AM BLOOD LD(LDH)-74*
[**2143-4-27**] 12:38PM BLOOD Glucose-104 UreaN-32* Creat-3.5* Na-143
K-4.7 Cl-102 HCO3-31 AnGap-15
[**2143-4-29**] 04:57AM BLOOD Glucose-85 UreaN-63* Creat-4.3* Na-139
K-6.2* Cl-102 HCO3-25 AnGap-18
[**2143-5-2**] 06:16AM BLOOD Glucose-107* UreaN-28* Creat-1.9*#
Na-147* K-3.5 Cl-106 HCO3-33* AnGap-12
[**2143-5-3**] 04:30AM BLOOD Glucose-56* UreaN-40* Creat-2.3* Na-149*
K-3.3 Cl-106 HCO3-32 AnGap-14
[**2143-4-28**] 01:50AM BLOOD D-Dimer-891*
[**2143-4-29**] 02:36PM BLOOD Thrombn-21.3*
[**2143-4-27**] 12:38PM BLOOD PT-40.3* PTT-49.4* INR(PT)-4.5*
[**2143-4-27**] 12:38PM BLOOD Neuts-25* Bands-9* Lymphs-28 Monos-19*
Eos-0 Baso-0 Atyps-1* Metas-18* Myelos-0
[**2143-4-29**] 07:49PM BLOOD Neuts-82.6* Bands-0 Lymphs-10.4*
Monos-6.7 Eos-0.1 Baso-0.2
[**2143-4-27**] 12:38PM BLOOD WBC-3.1* RBC-3.85* Hgb-12.0* Hct-38.9*#
MCV-101*# MCH-31.1 MCHC-30.8* RDW-18.8* Plt Ct-73*
[**2143-5-3**] 04:30AM BLOOD WBC-8.9 RBC-1.97* Hgb-6.2* Hct-19.5*
MCV-99* MCH-31.5 MCHC-31.7 RDW-19.2* Plt Ct-32*#
[**2143-5-1**] 05:43PM PLEURAL WBC-3850* RBC-300* Polys-91* Bands-7*
Lymphs-0 Monos-1* Metas-1*
[**2143-5-1**] 05:43PM PLEURAL TotProt-3.7 Glucose-0 LD(LDH)-4380.
.
FLUID CULTURE (Final [**2143-5-4**]):
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
CT ABDOMEN WITH IV CONTRAST WITHOUT ORAL CONTRAST: There are
bilateral pleural effusions, left large in size, right moderate
in size. The large left pleural effusion has a dense rim. The
liver, gallbladder, spleen are within normal limits. There is a
mild amount of intrahepatic ductal dilatation and moderate
extrahepatic ductal dilatation with the common bile duct
measuring 9 mm in diameter. The pancreatic duct is markedly
dilated measuring 8 mm in diameter through its entire course.
There are coarsened calcifications through out the pancrease
with no large masses or intraductal stones identified. There are
marked vascular calcifications throughout the entire abdominal
vasculature. The kidneys are atrophic and there is a simple
renal cyst within the mid pole of the left kidney. There are
multiple additional hypodense foci within both kidneys that are
too small to characterize. The small and large bowel are within
normal limits. There are no large free-fluid pockets within the
abdomen. There is no free air. There is no retroperitoneal or
mesenteric lymphadenopathy.
.
CT PELVIS WITH IV CONTRAST: The left pelvic kidney appears
normal in morphology. However, there is no evidence of perfusion
within the left pelvic transplant kidney. This is consistent
with the provided history of chronic failure. The rectum and
sigmoid colon are unremarkable. The urinary bladder is not well
visualized. A penile implant is present.
.
IMPRESSION:
1. Dilated common bile duct with mild intrahepatic ductal
dilatation and markedly dilated pancreatic duct throughout a
calcified pancreas. These findings are more consistent with
chronic pancreatitis. There is no evidence of an obstructing
lesion.
2. Moderate-to-large bilateral pleural effusions as described
above. The left pleural effusion contains a dense rim that may
represent findings that are related to a prior pleurodesis, but
contrast enhancement of the pleura in the setting of infection
cannot be excluded.
.
MRI ABDOMEN WITHOUT GADOLINIUM: Images are limited due to
inability of the patient to cooperate with breath-hold
instructions. No IV contrast was administered. There is mild
prominence of the extra-hepatic bile ducts with maximal
dimension of the common bile duct of 7 mm. There is no
intrahepatic biliary ductal dilatation. Gallbladder and cystic
duct are unremarkable. The main pancreatic duct is dilated with
multiple large multiloculated cystic areas that appear to be
emanating from the pancreatic ducts. There is smooth distal
tapering of both the common bile duct and the main pancreatic
duct at the ampulla. Within the limits of this study, no
pancreatic head mass is identified. No focal liver lesions are
seen. The spleen and bone marrow demonstrate low signal
intensity on T2-weighted images consistent with
reticuloendothelial pattern of iron uptake. There are bilateral
well- circumscribed renal cysts, the largest at the interpolar
region of the left kidney measuring 6 mm. There are large
bilateral pleural effusions, subcutaneous edema, and small
perihepatic ascites.
.
IMPRESSION:
1. Limited study with no definite pancreatic head mass seen.
2. Dilated main pancreatic duct with multiple large cystic areas
that appear to be in communication with the main pancreatic
duct, most prominent at the tail of the pancreas, also seen on
previous imaging studies. Given the patient's clinical history
and diffuse parenchymal calcifications seen on previous CT
scans, findings are most consistent with changes related to
chronic pancreatitis. A main duct IPMT is felt to be less likely
given the other imaging and clinical findings.
3. Reticuloendothelial pattern of iron deposition.
4. Large bilateral pleural effusions, subcutaneous edema, and
small perihepatic ascites.
.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: Evaluation of the
right pulmonary artery and proximal segmental branches
demonstrates no filling defects consistent with pulmonary
embolism. There is no pulmonary embolism identified within the
left-sided branches of the pulmonary arteries. There is a large,
left-sided pleural effusion with attenuation characteristics
consistent of more complex fluid (Hounsfield unit equals 30).
Thus, an underlying component of loculation is likely. There is
associated compression of the entire left lung. There is a
moderate right pleural effusion that appears to be more simple
by attenuation characteristics. The visualized portion of the
anterior right lung appears grossly unremarkable. There is shift
of the mediastinum to the right secondary to the large left
pleural effusion. There is a small pericardial effusion as well.
There is no aortic dissection and the heart and great vessels
are otherwise grossly unremarkable. Limited views of the upper
abdomen are unremarkable.
.
IMPRESSION:
1. No evidence of left-sided pulmonary embolism.
2. No pulmonary embolism of the right pulmonary artery and
proximal segmental branches. A more thorough evaluation cannot
be performed secondary to respiratory motion within the
remaining aerated portion of the right lung.
3. Large left pleural complex effusion with associated
compressive atelectasis of the left lung. If indicated,
ultrasound characterization or guidance for thoracentesis may be
pursued for better evaluation of the pleural collections given
previous thoracentesis complication.
4. Multiple foci of air within the esophagus could be aspiration
risk.
5. Small pericardial effusion.
.
Brief Hospital Course:
See HPI. Pt expired was called out to the floor Comfort
Measures only and expired at 8:30 am on [**2143-5-5**].
Medications on Admission:
(Confirmed with [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] NH)
dilt SR 120 Qday
Vit C 500 mg QDay
Vit B complex
Synthroid 100 mcg
Chloestyromine
Pangestyme EC 1 cap TID
Tums 500 TID
Folic acid 1 mg QD
Lomotil 0.25 mg QID
Celexa 20 mg QDay
Oxycodone 10 mg QHS, 30 mg Q6AM
Catapress 0.2 mg Wed
Norvasc 5 mg Qday
ferrous sulfate daily
insulin sliding
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
ESRD s/p transplant
TypeI DM X 28 yrs.
Pancreatitis
Empyema with Sepsis
Pancytopenia
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"0389",
"40391",
"5180",
"V5867"
] |
Admission Date: [**2189-8-3**] Discharge Date: [**2189-8-17**]
Date of Birth: [**2113-6-21**] Sex: M
Service: SURGERY
Allergies:
Augmentin / Cipro / Keflex / Insulins
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Non-healing R foot ulcers and severe hammer 2nd toe
Major Surgical or Invasive Procedure:
Transmetatarsal amputation of the right foot and Tendo Achilles
lengthening of right lower extremity [**2189-8-3**]
History of Present Illness:
76 y/o M with diabetes, hypertension, hyperlipidemia with
non-healing diabetic R foot ulcer admitted for R TMA and
tendo-achilles lengthening. Pt has history of a R third
metatarsal head resection in [**Month (only) 404**] and additional debridement
in [**2189-2-17**]. Pt underwent Clindamycin therapy from [**7-22**] until
his present admission without improvement.
Past Medical History:
Chronic systolic CHF
Atrial fibrillation
CAD
Diabetes type II (allergy to insulin) on oral medications
CHB s/p ppm ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**], [**2183**])
Left TMA in [**2187**]
Social History:
Married, lives with wife. Retired police officer. Quit smoking
40
years ago (5 pack-year history), drinks wine occasionally
Family History:
N/C
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Respiratory: CTAB, no wheezes/rhonchi/rales - coarse
upper airway sounds
Cardiovascular: RRR
Abdomen: Soft, NT/ND, + BS
Extremities: No C/C/E bilaterally. Right foot is post-op without
any noted discharge or blood on
Skin: no rashes or lesions noted.
Pertinent Results:
CT SCAN OF THE RIGHT ANKLE AND DISTAL LOWER LEG WITH CONTRAST.
INDICATION: 76-year-old man status post right transmetatarsal
amputation with
poor healing and wound drainage. Persistent fevers.
TECHNIQUE: CT scan of the right lower leg and ankle was
performed with
intravenous contrast. Images were acquired in the axial plane.
Coronal and
sagittal reformats were created and reviewed. No comparisons.
FINDINGS: Post-surgical changes of the mid foot are seen
following
transmetatarsal amputation. At the distal aspect of the foot,
there is a
large rim-enhancing fluid collection that represents either
postoperative
seroma or abscess. There is extensive rim enhancement and
reticular edema of
the residual mid foot as well. Evaluation of the underlying
osseous
structures is suboptimal but no definite evidence of frank
erosion is seen
apart from the post-surgical changes following previous
osteotomy. Osseous
alignment is preserved.
There is lucency at the medial aspect of the talar dome that
could reflect
overlying osteochondral abnormality. There is edema along the
medial aspect
of the ankle. Dense atherosclerotic vascular calcification is
seen. Within
limits of technique, the tendons are grossly intact. No
additional loculated
fluid collection is identified.
IMPRESSION:
1. Large loculated, rim-enhancing fluid collection in the foot
adjacent to
the metatarsal amputation sites. The possibility of infection
must be
excluded.
2. No definite evidence of underlying osseous abnormality to
suggest
osteomyelitis, although evaluation is severely limited by the
previous post-
surgical changes in this area.
[**2189-8-16**] 12:30PM BLOOD
WBC-8.4 RBC-3.47* Hgb-10.6* Hct-32.5* MCV-94 MCH-30.6 MCHC-32.7
RDW-13.9 Plt Ct-560*
[**2189-8-16**] 12:30PM BLOOD
Plt Ct-560*
[**2189-8-15**] 05:00AM BLOOD
Glucose-112* UreaN-10 Creat-0.9 Na-140 K-3.8 Cl-107 HCO3-26
AnGap-11
[**2189-8-15**] 05:00AM BLOOD
Calcium-8.0* Phos-3.1 Mg-1.8
[**2189-8-8**] 08:41PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-[**1-21**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-<1 TransE-0-2
[**2189-8-12**] 9:06 pm SWAB Source: TMA drainage.
GRAM STAIN (Final [**2189-8-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2189-8-15**]):
ESCHERICHIA COLI. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
FECAL CULTURE (Final [**2189-8-10**]): NO SALMONELLA OR SHIGELLA
FOUND.
OVA + PARASITES (Final [**2189-8-10**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2189-8-10**]): NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2189-8-10**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2189-8-11**]):
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2189-8-10**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2189-8-9**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Pt admitted [**8-3**] for non-healing diabetic R foot ulcer
IV antibiotics
pre-op'd
EP consulted to interrogate Pacer pre-op
Podiatry:
NAME OF PROCEDURE: Tendo Achilles lengthening of right lower
extremity.
Vascular:
NAME OF PROCEDURE: Transmetatarsal amputation of the right
foot.
Pt extubated in the [**Hospital **] transfered to the PACU in stable
condition. Once recovered from anesthesia. Pt transfered to the
floor in stable condition.
EP reconsulted interrogated pacer post op
Pt experienced frank melena with drop of BP to 90 from 140,
transfered to the CVICU. GI consulted. 2units of [**Name (NI) 9087**], pt
tranfused 2 units of RBC's. EGD performed, Saw duodenal ulcer
with active bleeding. Injected with epi and clipped. Complete
resolution of bleeding. Protonix IV BID. Serial HCT followed.
ID coinsulted for persistant fevers.Recommended broad spectrum
AB with blood cx's. Vanco, Aztreonam and flagyl started.
Pt also. Pain medications held confused post operatie period.
Pt still confused, mental status changes. Neurology consulted.
No folcal signs of acute stroke seen.. Low dose serequel given.
No haldol. pain meds held to minimum.
Pt confusion improved.
Diet advanced. Pt delined. Pt consult obtained
Pt did require some lasix for Systolic / chronic CHF. Improved
wit lasix.
Pt still febrile. CT scan of foot obtained. Showed fluid.
Lateral incision opened. Old hematoma expressed, CX's taken.
Vanco decreased to 750 [**Hospital1 **].
Bedside swaalow exam done
Medications on Admission:
Meds: Coumadin 2.5, toprol xl 100, digoxin 250, lisinopril 40,
hctz 12.5, metformin 1000, glyburide 5, lovastatin
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
8. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. Aztreonam 1 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 10 days: DC on [**8-28**].
12. Vancomycin 500 mg Recon Soln Sig: 1.5 750 mg Intravenous
twice a day for 10 days: moniter creatinine and trough.
13. COUMADIN
PATIENT WAS ON COUMADIN FOR AFIB. PLEASE HOLD FOR NOW. PT HAD GI
BLEED. [**Month (only) **] ALSO NEED FURTHER SURGERY.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4444**] health care center
Discharge Diagnosis:
Diabetic foot ulcers
PMH:
DM type 2
CAD
CHF (EF unknown)
Afib P
Pacemaker
HTN
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING Transmetatarsal Amputation
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s) .
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET :
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
PATIENT WAS ON COUMADIN FOR AFIB. PLEASE HOLD FOR NOW. PT HAD GI
BLEED. [**Month (only) **] ALSO NEED FURTHER SURGERY.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2189-9-3**] 2:00
Fax weekly CBC / BMP/ Vanco trough / ESR / CRP to [**Telephone/Fax (1) 432**]
Dr [**First Name (STitle) 27106**]. While on Antibiotics.
Completed by:[**2189-8-17**]
|
[
"4280",
"41401",
"4019",
"2724"
] |
Admission Date: [**2186-1-11**] Discharge Date: [**2186-1-15**]
Date of Birth: [**2111-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Endoscopy
blood transfusion
History of Present Illness:
74 yo man with h/o CAD s/p MI x3, CHF (EF 40%), HTN, chronic a.
fib (off coumadin since [**9-/2185**] [**2-3**] to GI bleed) who p/w
melanotic stools for the 3rd time since [**Month (only) **].
.
He reports that he noticed dark black stools since the morning 1
day PTA ([**2186-1-10**]). He denies diarrhea as well as any bright red
blood. He further denies lightheadedness/dizziness even with
ambulation. No chest pain/palpitations. He believes that his
breathing is slightly worse than his most recent baseline on
recent discharge from the hospital on [**2187-1-1**]. He has been
ambulating with PT at home with dyspnea after approx 20 steps
and after [**3-5**] stairs. He reported the dark stool to his
daughter who is [**Name8 (MD) **] RN who then requested that VNA draw labs
which revealed hct of 18. He was then brought to [**Hospital1 18**] ED for
low hct in the setting of melanotic stool.
.
In the ED, vitals revealed HR 84, BP 88/42, T 96.9, RR 18 O2 sat
98% on 2L (his home O2 level). Hct in the ED was 21.7 (down
from 24.9 on recent [**2186-1-1**] discharge). His pressure
transiently dipped to 70s systolic and was responsive to 1L NS
and returned to mid to high 90s systolic (recent baseline per
daughter has been 100-110s systolic). NG lavage was negative
for blood. He has had no further stools. He has MDS with
assoc. anemia at baseline and hct appears to run 27-29
generally.
.
Per his daughter, EGD was performed at the time of his [**9-7**]
bleed at OSH and revealed a large gastric ulcer. It is unclear
whether this was biopsied and if H. pylori studies were sent,
but it does not appear that he has been treated for H. pylori.
Additionally he has been taking only once daily PPI. His
coumadin (which he was on for chronic a. fib) was discontinued
at that time. He was placed on ASA and plavis following his BMS
which was placed in [**11-7**].
.
ROS: No fevers/chills/URI sx/cough. No
lightheadedness/dizziness, no changes in vision, no focal
numbness/tingling/weakness, no CP/palpitations, no
dysuria/hematuria/trouble starting/stopping stream. + urinary
frequency [**2-3**] to lasix. He denies orthopnea/PND, does
occasionally have LE edema, but not since his last admission and
feels that his abdominal girth and weight is down if anything.
.
Past Medical History:
1. CAD status post MI [**2167**], s/p PTCA [**2167**], s/p 2-vessel CABG in
[**12/2182**], with LIMA to LAD, SVG to OM1; s/p BMS to LCx in [**11/2185**]
2. CHF, [**2185-12-27**] echo EF 40%, No AR, 2+ MR, 4+ TR.
3. Aortic stenosis status post porcine AVR [**12/2182**] - normal AV
gradient
4. Hypertension
5. Hypercholesterolemia
6. Chronic atrial fibrillation, Coumadin D/C'd [**2185-9-17**]
secondary to GI bleed.
7. Bilateral fibrothoraces and history of recurrent pleural
effusions. Status post right total decortication; pleural
biopsies and fluid cytology benign. Status post left-sided
decortication in [**11/2185**] complicated by hemothorax.
8. Thrombocytopenia, likely MDS. Baseline platelets 75-100K.
Primary hematologist-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**].
9. Status post admission for UGI bleed [**9-/2185**], Coumadin D/C'd.
10. Pulmonary HTN
Social History:
Lives at home in [**Location (un) 17927**]. His daughter lives there as well
and she is a nurse. He quit smoking in [**2167**], but prior to that
has approx. 40pack yr smoking hx. He also rarely drinks EtOH,
also since his MI in [**2167**]. Retired telephone technician.
Family History:
F d. 72 MI. M d. in 80s, uncertain cause.
Physical Exam:
Vitals: T 98.3 HR 84 A. fib BP 124/84 RR 20 O2 sat 100% 3lNC
(80% RA)
Gen: NAD, pleasant
HEENT: MMM, EOMI
Neck: JVP 7cm, supple, no LAD
CV: Irreg. irreg. 3/6 systolic murmur heard best RUSB, but also
appreciated diffusely. No radiation to the neck.
Resp: decreased BS through apically as well as bibasilar.
Abd: Obese, appears sl. distended, but pt. states his abd. girth
has [**Month (only) **]. since his last admission. NTTP. No rebound/guarding.
+BS.
Ext: No C/C/E
Neuro: A and Ox3, strength 5/5 throughout, sensation and CN 2-12
intact grossly.
Pertinent Results:
[**2186-1-11**] CXR:
Persistent moderately sized left-sided pleural effusion. No
evidence of acute interval change.
.
[**2185-12-27**] Echocardiogram: LVEF 40%, 2+MR, 4+TR, moderate
pulmonary htn.
.
[**2182-12-31**] EGD: Esophagitis in the middle third of the
esophagus and lower third of the esophagus. Food in the stomach
body and antrum
Erythema and friability in the fundus compatible with gastritis
The stomach walls could not be completely visualized due to the
food in the body. Otherwise normal EGD to pylorus.
.
[**2185-1-12**] EGD: mild gastritis. No clear source of bleeding to
the 2nd portion of the duodenum.
[**2186-1-11**] 06:40PM BLOOD WBC-5.2 RBC-2.21* Hgb-7.3* Hct-21.7*
MCV-98 MCH-32.9* MCHC-33.4 RDW-22.5* Plt Ct-115*
[**2186-1-12**] 02:57AM BLOOD WBC-5.0 RBC-2.36* Hgb-7.6* Hct-21.9*
MCV-93 MCH-32.2* MCHC-34.7 RDW-21.6* Plt Ct-100*
[**2186-1-12**] 07:48AM BLOOD Hct-23.6*
[**2186-1-12**] 01:49PM BLOOD WBC-5.3 RBC-3.01*# Hgb-9.5* Hct-27.1*
MCV-90 MCH-31.7 MCHC-35.2* RDW-21.2* Plt Ct-92*
[**2186-1-12**] 09:59PM BLOOD Hct-25.9*
[**2186-1-13**] 05:41AM BLOOD WBC-4.2 RBC-2.95* Hgb-9.2* Hct-26.9*
MCV-91 MCH-31.2 MCHC-34.2 RDW-20.9* Plt Ct-82*
[**2186-1-13**] 02:53PM BLOOD WBC-4.7 RBC-2.97* Hgb-9.4* Hct-27.5*
MCV-93 MCH-31.5 MCHC-34.1 RDW-20.9* Plt Ct-80*
[**2186-1-11**] 06:40PM BLOOD Neuts-76.3* Lymphs-15.5* Monos-5.5
Eos-2.4 Baso-0.4
[**2186-1-11**] 06:40PM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2*
[**2186-1-12**] 02:57AM BLOOD PT-14.7* PTT-32.4 INR(PT)-1.3*
[**2186-1-13**] 05:41AM BLOOD PT-14.6* PTT-31.9 INR(PT)-1.3*
[**2186-1-11**] 06:40PM BLOOD Glucose-113* UreaN-29* Creat-0.8 Na-137
K-3.6 Cl-98 HCO3-30 AnGap-13
[**2186-1-12**] 02:57AM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-136
K-4.1 Cl-103 HCO3-26 AnGap-11
[**2186-1-13**] 05:41AM BLOOD Glucose-87 UreaN-22* Creat-0.7 Na-138
K-3.6 Cl-102 HCO3-29 AnGap-11
[**2186-1-11**] 06:40PM BLOOD ALT-12 AST-14 AlkPhos-85 Amylase-61
TotBili-0.6
[**2186-1-11**] 06:40PM BLOOD Lipase-23
[**2186-1-12**] 02:57AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.6 Mg-1.8
[**2186-1-13**] 05:41AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
EGD [**2186-1-12**]: Granularity, erythema and congestion in the antrum
and stomach body compatible with gastritis
Erosions in the antrum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Per daughter's history, patient was found to have gastric ulcer
on OSH EGD so this was considered a likely possibility.
However, his gastric lavage was negative in the ED and repeat
EGD in house showed only mild gastritis without evidence of
active bleeding. A lower source seemed less likely given
melanotic stools as well as a recent colonoscopy at outside
hospital which showed multiple polyps which were removed at that
time. Following EGD his PPI was decreased to once daily. His
diet was advanced. He was restarted on once daily aspirin.
However, as he had already received >4weeks of plavix following
bare metal stent placement, his plavix was not restarted. This
decision was discussed with his Cardiogist who was agreeable
with that plan. He had no further melanotic stools. He
received a total of 4 units PRBCs over the course of the
admission with appropriate response in his hematocrit and no
further evidence of bleeding. He was hemodynamically stable
throughout his hospital course. His beta blocker and ace
inhibitor were also held on admission in the setting of GI
bleed, restarted prior to discharge.
In the ICU He received 1.5L NS and 4U prbcs during his MICU
course. He tolerated the volume well without evidence of volume
overload on exam. He maintained O2 sats without any increase in
dyspnea. As above, his beta blocker and ace inhibitor were held
in the setting of GIB. Also held were his aldactone and lasix.
Following his EGD, he was restarted on an IV dose of lasix
equivalent to his po home dose. He diuresed well. However, his
blood pressures became low. Patient remained asymptomatic. But
it was thought that he was overly diuresed and his lasix were
again discontinued. eventually restarted on the floor with
normal BP.
Patient on metoprolol and digoxin as an outpatient. Not
anticoagulated with h/o GI bleed. He remained well rate
controlled in the hospital.
prior to discharge his statin was restarted as well.
Pt to follow up with Dr. [**Last Name (STitle) **] for a small bowel capsule
endoscopy per GI consult. He will make this apppointment as an
outpatient.
Medications on Admission:
1. ASA 81mg
2. Plavix 75mg daily
3. Zoloft
4. Colace 100mg [**Hospital1 **]
5. MVI
6. Iron
7. Folic acid
8. Zinc sulfate 50mg
9. Digoxin 125mcg
10. Aldactone 25mg
11. Zestril 5mg
12. Lopressor 50mg
13. Lasix 80mg [**Hospital1 **]
14. Nexium 40mg daily
15. Zocor 40mg daily
16. Albuterol prn
17. Magnesium hydroxide prn
18. Combivent MDI prn
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Prilosec 20 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*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) puffs
Inhalation twice a day.
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
11. Zestril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Acute Blood Loss Anemia
Erosive Gastritis
CHF
Hypertension
Atrial Fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000ml
Return to the hospital if you experience black-tarry stools,
abdominal pain, blood in your stool, nausea/vomitting,
fever/chills
Followup Instructions:
You will need to make an appointment with your primary care
doctor in the next 2-3 weeks ([**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 4475**])
Please schedule a Capsule Endoscopy to examine your small bowel
by calling the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 2306**]
in the next 2-3 weeks at the request of the gastroenterologist
|
[
"4280",
"2851",
"42731",
"4240",
"V4581",
"412",
"4168",
"4019",
"2720"
] |
Admission Date: [**2129-6-29**] Discharge Date: [**2129-7-5**]
Date of Birth: [**2049-3-23**] Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 76105**] is an 80 yoM with PMH significant for COPD, PHTN,
PVD, HTN was sent from rehab for chills, nausea/vomiting and
paleness. Pt states that he was woken up from sleep because of
nausea the night before presentation. Also unable to tolerate
POs. Went to scheduled outpt appt with podiatric surgeons who
performed archilles tendon surgery. Felt chills upon return from
the appt, went to bed to warm up, and pt does not remember
anything from that point on until he woke up in the hospital.
.
Per records from NH, patient complained of nausea over the past
2 days. He had also had a non-productive cough over the past few
days as well. No report of fevers. At 1pm on the day of
admission he vomited up a moderate amount which was heme
positive. His oxygen saturation dropped to 80% on 3L and
increased to 89-90% on 5L. His vitals at this time were T 99.9
BP 80/40 AR 129 RR 26-28 O2 sat 87% on 5L. He appeared dusky and
was then transferred to [**Hospital1 18**] ED for further work-up.
.
Of note, the patient was discharged from [**Hospital1 18**] on [**6-21**]. He
underwent lengthening of his achilles tendon on [**6-14**].
Post-operatively his O2 saturation was 80% on RA. His O2 sats
remained low despite being on a non-rebreather and dropped to
the 70's while sleeping. He was transferred to the MICU for
closer monitoring. The pulmonary service was also consulted
during this time. The patient was treated with Cefpodoxime for
an aspiration pneumonia during this admission.
.
In the ED, initial vitals were T 100.5 BP 134/50 AR 119 RR 20 O2
sat 93% NRB. His O2 saturation dropped to 80% RA, then increased
to 87% on 5L NC. He was given 2L NS. He also received
Ceftriaxone 1gm, Vancomycin 1gm IV, Levaquin 750mg IV, and
Methylprednisone 125mg IV.
.
In the MICU, pt was continued on Vancomycin and Zosyn for
treatment for HAP, given pt's recent prior hospitalization and
rehab stay. Blood cultures were sent on [**2129-6-29**], which showed no
growth in 2 days (final result pending). IVFs were given to
maintain MAP>60. Pt was continued on ventimask with plan to
transition to NC. Pt continued to require ventimask during her
ICU stay. Pt's home antihypertensives were held while pt's blood
pressures normalized with IV fluids. Cr dropped to baseline with
hydration. Pt was transferred to floor in stable condition on
Hospital Day 3.
Past Medical History:
1. Chronic Lung disease with Pulm htn and low DLCO: Spirometry
FEV-1 85% of predicted
FVC 123%, FEV1 108%, ratio 87%, TLC 111%, DLCO 23%, pormovement
with broncodilator
2.Peripheral [**Date Range 1106**] disease: s/p bypass in legs, and on
coumadin
3.Pulmonary [**Date Range 1106**] disease
4.Chronic hypoxemia - on chronic O2
5.Renal insufficiency.
6.Ulcerative colitis
7.Hypertension
8.Seizure disorder
9.Peripheral edema associated with his PVD
11.Hypertension
12. Achiles contraction
13. Right lung spiculated mass, followed by outpatient
pulmonologist
Social History:
90 pack years smoking, quit 15 years ago, denies ETOH.
Family History:
DMII, CAD
Physical Exam:
vitals T 97.7 BP 88/46 AR 126 RR 23 O2 sat 93% on 50% VM
Gen: Awake and alert, responsive to commands
HEENT: Dry mucous membranes
Heart: RRR
Lungs: CTAB, poor airmovement at right lower base posteriorly,
+crackles at posterior bases.
Abdomen: Soft, NT/ND, +BS
Extremities: LLE in boot, no edema in RLE
Rectal: Guaiac negative
Pertinent Results:
[**2129-6-29**] 03:30PM BLOOD WBC-23.8*# RBC-4.09* Hgb-10.7* Hct-34.9*
MCV-85 MCH-26.1* MCHC-30.6* RDW-14.2 Plt Ct-584*#
[**2129-7-1**] 04:32AM BLOOD WBC-19.8* RBC-3.21* Hgb-8.3* Hct-27.4*
MCV-85 MCH-26.0* MCHC-30.4* RDW-14.0 Plt Ct-421
[**2129-6-29**] 03:30PM BLOOD Neuts-94.9* Bands-0 Lymphs-2.4* Monos-2.3
Eos-0.1 Baso-0.1
[**2129-6-29**] 03:30PM BLOOD Plt Smr-HIGH Plt Ct-584*#
[**2129-6-29**] 05:54PM BLOOD PT-24.9* PTT-29.4 INR(PT)-2.4*
[**2129-6-29**] 03:30PM BLOOD UreaN-40* Creat-1.6* Na-136 K-5.5* Cl-102
HCO3-22 AnGap-18
[**2129-7-1**] 04:32AM BLOOD Glucose-111* UreaN-29* Creat-1.3* Na-144
K-3.6 Cl-114* HCO3-21* AnGap-13
[**2129-6-29**] 03:30PM BLOOD ALT-14 AST-46* CK(CPK)-1277* AlkPhos-123*
TotBili-0.3
[**2129-6-29**] 03:30PM BLOOD Calcium-9.2 Mg-2.4
[**2129-6-29**] 06:36PM BLOOD Lactate-2.1* K-3.8
[**2129-7-4**] 04:35AM BLOOD WBC-8.6 RBC-2.92* Hgb-7.7* Hct-24.6*
MCV-84 MCH-26.4* MCHC-31.5 RDW-13.9 Plt Ct-441*
[**2129-7-4**] 04:35AM BLOOD Glucose-100 UreaN-15 Creat-1.2 Na-139
K-3.2* Cl-106 HCO3-24 AnGap-12
[**2129-7-4**] 04:35AM BLOOD calTIBC-255* VitB12-236* Folate-18.6
Hapto-433* Ferritn-55 TRF-196*
[**2129-7-4**] 04:35AM BLOOD Ret Aut-1.3
[**2129-7-4**] 04:35AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 Iron-10*
.
Relevant Imaging:
CXR [**2129-6-29**] There is focal area of pneumonic consolidation at
the right lung base. Left lung is clear. Surgical clips are seen
in the right axilla. Please followup the right lung base
pneumonic consolidation to clearance.
.
CXR [**2129-6-30**] The right lower lobe consolidation is grossly
unchanged but the left lower lobe linear opacities most likely
consistent with atelectasis have slightly improved. The upper
lungs demonstrate severe emphysema, but otherwise clear. Note
is made that the left costophrenic angle was not included in the
field of view. There is no appreciable pleural effusion or
pneumothorax.
.
CXR [**2129-7-1**] Little change with persistent right lower lobe
consolidation.
Brief Hospital Course:
Mr. [**Known lastname 76105**] is an 80 yo male with PMH as listed above who
presents with hypoxia, RLL infiltrate, and hypotension.
.
1)Hospital aquired pneumonia: Patient initially presented with
early sepsis physiology. He was tachycardic, hypotensive, and
had a significant leukocytosis. He had a RLL infiltrate on chest
Xray consistent with HAP (given his recent hospitalizations) and
was started on Vancomycin and Zosyn on [**6-29**] for 7 day
course. His hypotension resolved within 24 hours after he
received multiple fluid boluses. He was transferred to the floor
on [**7-1**] and did well with decreased oxygen requirement. Blood
cultures x 1 were NGTD at time of discharge. He was afebrile x
36 hours.
.
2)Hypoxia: At baseline, patient has COPD with cor pulmonale. Pt
states that he has emphysema, and is followed by a pulmonologist
in [**Location (un) 5131**]. Pt has been told that he requires 3L NC during
the day and a 40% ventimask at night but he is not always
compliant. Pt does use oxygen concentrator. Pt likely
decompensated in the setting of the pneumonia. He recieved 1
dose of steroids in the ED but this was stopped in the ICU since
his clinical presentation was not consistent with a COPD
exacerbation. During his stay in the MICU he was placed on nasal
cannula but required the 50% ventimask. He was continued on
antibiotics as above. On the floor, pt desatted to 70s on RA but
was satting in mid 90s on 5L NC at time of discharge. Goal will
be for patient to return to baseline of 3L nasal cannula with
40% facemask at night.
.
4)s/p Achilles tendon repair: Stable at this time. Should avoid
fluoroquinolones given increased risk for tendon rupture.
Podiatry (Dr. [**Last Name (STitle) 1140**] following. Per their recs: place in MP boot
while in-house and discharge in [**Hospital1 **]-valve cast. Sutures removed
on Monday [**2129-7-4**]. No dressing changes Please make sure patient
has b/l bivalve splints on.
.
5)Hypertension: Baseline blood pressures in low 100's. Decreased
to 80's at NH and upon transfer to the MICU. SBP 140s on tx to
floor with holding of home HTN regimen in MICU. Amlodipine and
HCTZ were restarted at home doses upon transfer to the floor. Pt
was not taking Lisinopril at home, although was listed in the
home med list. His SBP was 100s on Amlodipine and HCTZ. For
improved renoprotection, Amlodipine was D/C'd and was restarted.
SBP 100s-120s at time of discharge.
.
6)Acute on chronic renal insufficiency (GFR=42, Stage III):
Baseline creatinine is 1.2. Was elevated to 1.6 on admission,
however, Cr returned to baseline quickly with hydration. Was
likely pre-renal given history of nausea, vomiting, and
extremely dry mucous membranes on admission and rapid
improvement with fluids. Creatinine back to baseline 1.2 at time
of discharge.
.
7)Ulcerative colitis: Stable. Continued Asacol.
.
8)Peripheral [**Month/Day/Year **] disease: He is on Plavix and Coumadin 3 mg
PO daily as outpt. Coumadin was held for three days due to his
supratherapeutic INR (which is likely [**1-8**] his antibiotic
regimen), and was restarted at 2mg daily on [**2129-7-2**] and then 1
mg daily while we were following his INR and daily dosing
Coumadin. He will need to have his INR closely monitored as
outpatient with goal [**1-9**] while he is still on antibiotics. INR
2.1 [**7-4**] and 1.9 [**7-5**] on Coumadin 1mg PO daily so dose increased
to 2mg PO daily. Patient should have his INR checked on
Thursday, [**7-7**] and his dose adjusted for a target INR
between [**1-9**].
.
9) Anemia: Baseline HCT around 30. HCT dropped to 25 over
several day course of admission. He was transfused 1 unit PRBCs
on [**7-4**] for HCT 24.6. Studies revealed low iron, elevated
haptoglobin, low transferrin and borderline low TIBC and B12
with normal ferritin and folate. He likely has iron deficiency
anemia although would expect elevated TIBC and decreased
ferritin. He is currently on iron supplements. B12 levels also
low so started on B12 injections once daily x 7 doses and then
will need once weekly injections. He has a h/o UC and may have
occult bleeding but stool guaiacs were negative x2. He was
encouraged to follow up with his outpatient gastroenterologist
.
10) Code Status: Full Code, discussed at length with patient
Medications on Admission:
Docusate Sodium 100mg PO BID
Acetaminophen 325mg PO Q6H PRN
Clopidogrel 75mg PO daily
Omeprazole 20mg PO daily
Folic Acid 1mg PO daily
Tamsulosin 0.4mg PO QHS
Simvastatin 20mg PO daily
Mesalamine 1600mg PO TID
Lyrica 100mg PO TID
Ferrous Sulfate 325mg PO daily
Hydrochlorothiazide 12.5mg PO daily
Amlodipine 5mg PO daily
Warfarin 3mg PO daily
Lisinopril 10mg PO daily (on OMR, but pt states he stopped
taking this a long time ago)
Senna 8.6mg PO BID
Tramadol 50mg PO Q6H PRN
Albuterol Neb Q4H PRN
Oxycodone 5mg PO Q6H PRN
Tiotropium Bromide MDI
Advair MDI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Clopidogrel 75 mg Tablet Sig: One (1) 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. Lyrica 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a day for 7 days: After should recieve one injection once a
week. .
18. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please check patient's INR on Thursday, [**7-7**]. Please
adjust coumadin for target INR between [**1-9**]. .
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every
six (6) hours for 1 days: Patient should complete antibiotic
course after nighttime dose on Wednesday, [**7-6**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis:
Recurrent aspiration pneumonia
COPD
.
Secondary:
1. Chronic Lung disease with Pulm htn and low DLCO: Spirometry
FEV-1 85% of predicted
FVC 123%, FEV1 108%, ratio 87%, TLC 111%, DLCO 23%, pormovement
with broncodilator
2.Peripheral [**Location (un) 1106**] disease: s/p bypass in legs, and on
coumadin
3.Pulmonary [**Location (un) 1106**] disease
4.Chronic hypoxemia - on chronic O2
5.Renal insufficiency, baseline Cr 1.2-1.3.
6.Ulcerative colitis
7.Hypertension
8.Seizure disorder
9.Peripheral edema associated with his PVD
10. Hypertension
11. Archilles tendon contraction s/p repair
12. Right lung spiculated mass, followed by outpatient
pulmonologist
Discharge Condition:
Fair. Currently satting mid 90s on 5L nasal cannula.
Comfortable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you had a fever, low
blood pressure, and low oxygen content in your blood, which were
likely due to a recurrent pneumonia. We treated you with
antibiotics, intravenous fluids, and oxygen. Please continue to
use oxygen at home, via nasal cannula on [**2-8**] L of oxygen during
the day, and via face mask on 40% during the night. Use of
oxygen is the only therapy definitively proven to extend life
expectancy of patients with COPD.
.
Please complete the 7 day course of antibiotics as instructed.
The last day of your antibiotics (Zosyn) is [**7-6**].
.
If you experience fevers, chills, nausea, vomiting, severe
coughing, shortness of breath, chest pain, or any other
worrisome symptoms, please call your primary care physician or
return to the emergency room.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6481**], at
[**Telephone/Fax (1) 4775**] to make an appointment for follow-up within the
next 2 weeks.
Please have your INR checked to determine your Coumadin dosing
on Thursday, [**7-7**]. Please adjust for target INR [**1-9**].
Please attend the following appointments that have been made for
you:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2129-7-13**] 11:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 16550**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2129-7-21**] 10:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-10-5**] 1:00
|
[
"5070",
"5849",
"40390",
"4168",
"V5861"
] |
Admission Date: [**2166-12-14**] Discharge Date: [**2166-12-18**]
Date of Birth: [**2112-12-28**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Aspirin / Codeine / Erythromycin Base / Tetracycline /
Bactrim / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**Doctor First Name 3290**]
Chief Complaint:
abdominal pain, fever, chest pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Ms. [**Known lastname 61387**] is a 53 year female with PMH of HCV, anxiety,
colitis, s/p CCY in [**2147**], 2 ERCPs & sphincterotomy in [**2159**] &
[**2164**] for biliary pain & gallstone pancreatitis, who is now
transferred from [**Hospital6 10353**] to [**Hospital1 18**] for definitive
treatment for cholangitis w/ ERCP.
Pt was in her usual state of health until 1 week ago, when she
experienced fatigue and general malaise. She then developed a
fever to 103F 5d prior along with nausea, but no vomiting. Pt
has felt progressively worse w/ anorexia and "12"/10 abdominal
pain, mainly epigastric, but radiating to RUQ and R flank. Pt
has not been able to eat since 5 days ago, and has only been
drinking ginger ale to keep hydrated. Of note, she developed an
isolated episode of R sided chest pain 4 days ago while she was
in bed, which lasted 20 minutes and resolved on its own. Pt has
also had stomach cramps and loose diarrhea, not black or bloody.
Reports decreased urination.
Pt's symptoms did not improve, and she presented to [**Hospital1 9487**], where she was found to have elevated LFTs, BiliT
6.5, WBC 4.1 -->5.1, Plt 127 --> 86, INR 1.4. Her EKG showed
ischemic changes in the pericordial leads, but trops were
negative X 2. By the Pt's report, she was evaluated by
cardiology there, who "told her that she was fine." Pt had an
MRCP at [**Hospital1 392**] (no report is available) and was transferred to
[**Hospital1 18**] for ERCP.
.
On arrival to the ICU, Pt's vitals were 98.6F, HR 69, BP 87/58,
RR 14, sat 95% RA.
.
Review of systems:
(+) fever, chills, reports isolated chest pain as per HPI,
reports nausea and loose stool, abdominal pain, and anorexia.
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies , chest
pressure, palpitations, or weakness. Denies, vomiting,
constipation. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- anxiety
- colitis
- depression
- HCV dx [**2154**]
- HBV dx in childhood
- chronic back pain
- neuropathy
- recurrent small bowel obstructions
- migraines
- hypertension
- Meckel's diverticulum s/p repair
.
Past surgical history:
- lap cholecystectomy
- hysterectomy
- ? abdominal operation for ?volvulus (per patient description)
Social History:
Lives in [**Location 38**] with fiance. Has 3 adult children. Finished
school for medical administration.
- Tobacco: 30 pack years, currently smoking 1 pack daily
- Alcohol: none
- Illicits: none
Family History:
father - alcoholism
mother - kidney cancer in 60s
maternal uncle - kidney cancer
Physical Exam:
Admission Exam:
Vitals: 98.6F, HR 69, BP 87/58, RR 14, sat 95% RA.
General: Alert, oriented, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral expiratory wheezes, no rales or rhonchi.
Somewhat reduced air movement on L lung.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present. Marked
tenderness to palpation in epigastric and RUQ.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
Abdomen: + distension, normal bowel sounds, +RUQ tenderness,
epigastric tenderness. No rebound or guarding.
Pertinent Results:
[**2166-12-14**] 05:40PM BLOOD WBC-3.6* RBC-3.82* Hgb-11.5* Hct-32.4*
MCV-85 MCH-30.2 MCHC-35.6* RDW-13.7 Plt Ct-76*#
[**2166-12-18**] 08:35AM BLOOD WBC-4.3 RBC-3.83* Hgb-11.3* Hct-33.6*
MCV-88 MCH-29.5 MCHC-33.5 RDW-14.9 Plt Ct-91*
[**2166-12-18**] 08:35AM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-143 K-3.5
Cl-110* HCO3-25 AnGap-12
[**2166-12-14**] 05:40PM BLOOD ALT-813* AST-566* LD(LDH)-212
AlkPhos-204* TotBili-5.1* DirBili-4.4* IndBili-0.7
[**2166-12-16**] 05:30AM BLOOD ALT-663* AST-402* LD(LDH)-173
AlkPhos-224* TotBili-8.3* DirBili-6.5* IndBili-1.8
[**2166-12-18**] 08:35AM BLOOD ALT-363* AST-145* AlkPhos-326*
TotBili-5.3*
ERCP result: Evidence of a previous sphincterotomy was noted in
the major papilla. Bile was draining from the major papilla,
however a small stenosis was noted at the sphincterotomy. Bile
duct was successfully cannulated A mild diffuse dilation was
seen at the main duct with the CBD measuring 10 mm. No filling
defects were noted in the bile duct
A sphincterotomy was performed. Balloon sweeps were performed
in the bile duct but they did not yield any debris. Otherwise
normal ercp to third part of the duodenum
ultrasound: LIVER AND GALLBLADDER ULTRASOUND: The liver appears
without evidence of focal liver lesions. There is a right
pleural effusion. There is trace ascites present. The patient is
status post cholecystectomy with an echogenic structure just
inferior to the gallbladder fossa measuring 5 mm, likely
representing a dropped stone. The common bile duct measures 0.3
cm. The right kidney measures 10.6. The left kidney measures 9.8
cm. Both kidneys show no evidence of hydronephrosis or renal
calculi. The spleen measures 12.9 cm. Upper abdominal aorta, and
visualized portions of the IVC and hepatic veins are
unremarkable.
IMPRESSION:
1. Right pleural effusion.
2. Ascites.
3. Status post cholecystectomy with an echogenic focus just
inferior to the
gallbladder fossa, which likely represents a dropped stone.
CT scan:
IMPRESSION:
1. Findings suggest duodenitis and jejunitis with stranding in
the
surrounding mesentery. If clinically indicated, this could be
reached by
endoscopy. No evidence of colitis.
2. Small bilateral pleural effusions, right larger than left,
with adjacent
compressive atelectasis.
2. Diffuse body wall edema, intra-abdominal ascites and
periportal edema may
be related to liver disease and low albumin.
3. Indeterminant pancreatic lesion. While it looks like fat, it
does not
clearly measure fat attenuation. Follow up MRCP is recommended
in 6 months.
4. No evidence of portal hypertension.
Brief Hospital Course:
Ms. [**Known lastname 61387**] is a 53 year female with PMH of HBV and HCV, anxiety,
colitis, s/p CCY in [**2147**], 2 ERCPs & Sphincterotomy in [**2159**] &
[**2164**] for biliary pain & gallstone pancreatitis, who presented to
OSH with RUQ pain, fever and chills for the past 3 days,
transferred to [**Hospital1 18**] for ERCP.
.
# Abdominal pain: given history of biliary stones, gallstone
pancreatitis, and two prior sphincterotomies as well as LFTs
suggesting obstruction, it was initially suspected that Pt again
has an obstructive biliary process due to cholelithiasis.
However, ERCP did not reveal any stone or sludge or cause of
obstruction. Her prior sphincterotomy was enlarged. It is
possible that she had passed a gallstone by the time her ERCP
was done.
The patient developed significant diarrhea while on three
antibiotics for her cholangitis. Her diarrhea improved when she
was just on one antibiotic. C diff negative.
Patient complained of improved, but continued RUQ and RLQ pain
after the ERCP. On exam, she had diffuse abdominal distension
with tenderness on exam. She had normal bowel sounds. Although
she was tender on exam and complained of persistant pain, she
was seen ambulating the halls without difficulty and went out to
smoke as well, despite advice from the RN not to do so. She
also requested pain medicine despite appearing to be
comfortable.
Because she did have abdominal distension and tenderness on
exam, she went for CT scan of the abdomen. The findings showed
possible duodenitis and jejunitis. SHe was advised to go for
endoscopy with push enteroscopy, but she refused. She also had
a lot of bowel wall edema not consistent with inflammation, but
likely due to third spacing of fluids, as her albumin was 2.5.
She was advised to finish a one week course of antibiotics for
cholangitis
# Hepatitis C: Seen by liver service. Patient has outpatient
hepatologist, but has never had a liver biopsy. She states that
she became hepatitis C after a rape that occurred when she ws
15. Her daughter is also hepatitis C positive, and is a heroin
user. She was evaluated by the hepatology service here
regarding her persistantly abnormal LFTs after her ERCP, and
they felt that there was no acute hepatic process. She is
interested in following up with them for possible treatment of
her hepatitis. Her LFTs did start to improve by the course of
her discharge, and should be followed up by her PCP. [**Name10 (NameIs) 3754**] was
no clear evidence of portal hypertension on imaging.
# Anxiety: Patient continued on round the clock clonazepam.
She became so worried about her medical condition, that she
called a son that she put up for adoption at birth and told him
that she was gravely ill, and asked that he request leave from
his duties in [**Country 2451**] to come and to see her. I explained to her
that her hepatitis C is a chronic problem, and, that as she
refused EGD there was no further workup that could be done.
Medications on Admission:
clonazepam 1mg tid
Bentyl (Dicyclomine) 20mg daily
pantoprazole 40mg [**Hospital1 **]
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for
7 days: Take only if needed for pain, and please minimize its
use.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cholangitis
2. Chronic Hepatitis C
3. Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for treatment and evaluation of
cholangitis. You had an ERCP that was largely unremarkable.
Your pain and abnormal liver tests improved overall, but still
persisted so you were seen by the liver specialists and you had
a CT scan of your abdomen. The ct Scan showed that your liver
and spleen are normal sized, and that you may have some
inflammation in your small bowel. We offered you the chance to
have an endoscopy to better evaluate your small bowel, but you
refused.
Please take antibiotics for an additional 3 days. You can take
pain medicine for abdominal pain, but please do so sparingly.
Followup Instructions:
Name: PA- [**First Name8 (NamePattern2) **] [**Doctor Last Name 3694**]
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 42923**]
Appointment: Thursday [**2166-12-25**] 11:00am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Department: LIVER CENTER
When: WEDNESDAY [**2167-1-21**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"0389",
"4019",
"3051"
] |
Admission Date: [**2125-8-29**] Discharge Date: [**2125-9-7**]
Date of Birth: [**2125-8-29**] Sex: M
Service: NEONATOLOGY
DIAGNOSES: Right foot cellulitis, resolved. Term [**Year (4 digits) 19402**]. Large
for gestational age. Infant of diabetic mother.
HISTORY OF THE PRESENT ILLNESS: This is a term, large for
gestational age infant, who was delivered via cesarean
section to a 37-year-old gravida 5, para 2, now 3 mother with
rubella immune and group B strep positive. Pregnancy was
complicated by gestational diabetes, which was diet
controlled. Rupture of membranes occurred at the time of
delivery and there were no other sepsis risk factors. Apgars
were 8 at 1 minute and 9 at 5 minutes. The baby was admitted
to the [**Name (NI) **] Nursery for routine care.
PHYSICAL EXAMINATION: Examination on admission was
NURSERY COURSE:
The baby's blood sugar was monitored during transition per
routine for LGA infants. He did not have transitional
hypoglycemia.
On day of life #2, at approximately 36 hours of life, he was
noted to have erythema, warmth, and swelling on the right
foot at the site of a small abrasion from his hospital
identification bracelet. Bacitracin was applied to the abrasion,
but the swelling and erythema continued to spread. At
approximately 48 hours of life a CBC with differential and blood
culture were sent, and the baby was started on oxacillin and
gentamicin IV for treatment of cellulitis. CBC was unremarkable.
The blood culture remained negative and the physical
manifestations resolved within three days; however, he was
treated for a seven- day course, given the severity of the
initial presentation. A small abrasion on the left ankle became
slightly erythematous and swollen during the course but this
resolved quickly with removal of the ID bracelet from that side.
Peak and trough gentamicin levels were within normal limits.
The baby passed his hearing screen in both ears. He is breast
feeding and bottling expressed breastmilk well, voiding and
stooling appropriately and gaining weight. The discharge weight
is 10 pounds, 10 ounces. Birth weight was 10 pounds, 1
ounce or 4565g. Length 53 cm. Head circumference 36 cm. He is to
follow up [**Hospital1 **] in [**Location (un) 686**] on
[**Last Name (LF) 766**], [**9-10**] at noon. Visiting nurse to see patient [**9-8**]
or [**9-9**].
He received hepatitis B vaccine on [**2125-8-31**].
DISCHARGE DISPOSITION: Home with mother.
PRIMARY PEDIATRICIAN: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38832**] in [**Location (un) 686**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 38700**]
MEDQUIST36
D: [**2125-9-5**] 16:04
T: [**2125-9-5**] 16:43
JOB#: [**Job Number 43673**]
|
[
"V053",
"V290"
] |
Admission Date: [**2187-2-27**] Discharge Date: [**2187-3-29**]
Date of Birth: [**2117-6-18**] Sex: M
Service: SURGERY
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever, vomiting, stomach pain, productive cough
Major Surgical or Invasive Procedure:
[**2187-3-1**]: Tube cholangiogram
History of Present Illness:
Pt is a 69M who underwent right hepatic lobectomy,
cholecystectomy and small bowel resection [**2186-5-22**] for a primary
metastatic GI Stromal Tumor; his course was complicated by a
bile leak, pneumonia, and bacteremia.
Drainage was complicated by perforation of the diaphragm and
subsequent bilio-pleural fistula. [**Month/Day/Year **] had remained in place to
hepatic collection.
Stent was removed and then he underwent scheduled
hepaticojejunostomy with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] on [**2-12**]. He was
discharged to home on [**2-24**] and states he felt okay on Sunday and
then by [**Month/Year (2) 766**] was noting some epigastric pain. He had a fever
in the afternoon to 101 and was advised by Dr [**Last Name (STitle) 37914**] office to
start Augmentin and PO Vanco. He has since developed nausea,
vomiting x 3 (green vomit) and a cough productive of white
sputum. His last BM was 2 days ago which was loose, no blood
noted. Last meal was AM of [**2-26**]. He reports having hiccups.
Denies chest pain or difficulty with breathing.
Past Medical History:
GIST
Hypertension
Hypercholesterolemia
Benign esophageal growth
h/o prostate CA s/p resection in [**2179**]
s/p hepaticojejunostomy with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] [**2187-2-12**]
Social History:
Denies tobacco, retired, married
Family History:
Non-contributory
Physical Exam:
VS: 97.1, 60, 111/58, 16, 99% RA pain [**3-12**]
Gen: Appears pale, thin and frail. Hiccuping
HEENT: no scleral icterus, no LAD, mucous membranes and lips
appear dry
Lungs: CTA bilaterally
Card: Regular rate and rhythm
Abd: Soft, slightly distended, slightly tender epigastrum. PTC
[**Month/Year (2) 19843**] capped, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] with clear brown fluid, JP
[**Last Name (NamePattern1) 19843**]
with cloudy brown fluid, hypoactive bowel sounds.
Extr: No edema, 2+ pedal pulses
Pertinent Results:
On Admission: [**2187-2-27**]
WBC-29.7* RBC-3.51* Hgb-10.9* Hct-31.8* MCV-91 MCH-31.0
MCHC-34.2
RDW-14.0 Plt Ct-404
PT-15.1* PTT-27.9 INR(PT)-1.3*
Glucose-143* UreaN-17 Creat-1.2 Na-135 K-3.9 Cl-95* HCO3-31
AnGap-13
ALT-20 AST-16 AlkPhos-171* Amylase-52 TotBili-0.9
Albumin-3.1* Calcium-9.0 Phos-3.4 Mg-1.8
Labs [**2187-3-29**]:
[**2187-3-29**] 4:40AM WBC-12.2* RBC-3.41* Hgb-10.0* Hct-30.0* MCV-88
MCH-29.4 MCHC-33.4 RDW-16.3* Plt Ct-364
[**2187-3-29**] 12:13PM WBC-35.7*# RBC-2.98* Hgb-8.5* Hct-28.3* MCV-95#
MCH-28.7 MCHC-30.1* RDW-14.7 Plt Ct-355
[**2187-3-29**] 04:40AM Glucose-117* UreaN-45* Creat-1.1 Na-141 K-3.9
Cl-105 HCO3-30 AnGap-10
[**2187-3-29**] 12:13PM Glucose-78 UreaN-51* Creat-1.6* Na-146* K-4.4
Cl-114* HCO3-18* AnGap-18
[**2187-3-29**] 04:40AM ALT-50* AST-29 AlkPhos-201* TotBili-0.7
[**2187-3-29**] 12:13PM CK(CPK)-47
[**2187-3-29**] 04:40AM Albumin-2.6* Calcium-8.4 Phos-3.6 Mg-2.4
Brief Hospital Course:
Patient admitted and evaluated with CT of Abdomen and pelvis,
Findings:
-New/enlarging anterior perihepatic fluid collection with
multiple locules of air, concerning for spread of perihepatic
infection, despite multiple drainage catheters in place nearby.
-Small right and trace left pleural effusions.
-Unchanged mesenteric and retroperitoneal lymphadenopathy.
Cultures from [**Month/Day/Year 19843**] fluid yielded Enterococcus, Yeast (not C
albicans) Pseudomonas and he was initially started on
fluconazole for the yeast in addition to the Vanco and Zosyn
started on admission.
Cholangiogram was performed on [**2187-3-1**] showing a persistent bile
leak from the free edge of the residual liver (as previously),
and small amount of contrast seen tracking along the insertion
tract of the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] tube.
Due to poor nutritional status and decreased calorie counts the
patient had a PICC line placed and started TPN. The initial PICC
line had to be removed due to swelling in the arm with the
finding by ultrasound of Thrombus within the right basilic vein
with no flow detected and nonocclusive thrombus seen in the
right IJ.
This was treated with warm packs and elevation with good relief
of swelling.
A new PICC line was placed and TPN continued.
On [**3-8**] the drains were [**Last Name (un) 7162**] studied with individual
cholangiograms.
-Initial spot fluoroscopic image demonstrates [**Location (un) 1661**]-[**Location (un) 1662**]
[**Last Name (LF) 19843**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] catheter, biliary T-tube and biliary stent
present in the right upper quadrant:
T Tube cholangio demonstrated an approximately 2 cm long
stricture of the common duct. One end of the stent previously
placed by ERCP is located within the stricture; however, the
stent does not fully traverse the stricture. There is no
evidence of leak of contrast outside of the bile duct.
The [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**], which demonstrates a proximal sidehole
to be located outside of the liver with associated leakage of
contrast outside the liver. No communication with the biliary
tree is seen. Leakage of contrast is also noted at the
anastomosis with jejunum. There is no intraluminal opacification
of jejunum.
The [**Location (un) 1661**]-[**Location (un) 1662**] [**Location (un) 19843**] demonstrates extravasation out of the
[**Location (un) 1661**]-[**Location (un) 1662**] [**Location (un) 19843**] into a perihepatic collection along the
inferolateral liver edge. There is no intraluminal opacification
of bowel.
On [**2187-3-9**] he underwent ERCP which showed a single stricture of
benign appearance in the mid CBD. There was no post-obstructive
dilation. A leak with extravasation of contrast was noted at the
site of the stricture in the CBD. There was successful placement
of a 5cm by 10Fr double pig tail biliary stent across the
stricture and the leak.
In addition on the same day he underwent paracentesis by
Ultrasound-guidance for diagnostic and therapeutic paracentesis,
with drainage of 1 liter of clear dark yellow fluid. Cultures
did not yield any growth of organisms.
He continued to spike fevers on a daily basis. Chest xray was
done on [**3-11**] showing increased opacity at the right lung base.
[**Month (only) 116**] be due to a combination of right lower lobe atelectasis,
pleural effusion, or subpulmonic fluid. Underlying infiltrate
cannot be entirely excluded. He then underwent a thoracentesis
on [**3-12**] under CT guidance with removal of 500 cc fluid. No [**Month/Year (2) 19843**]
was left in place.
On [**3-16**] he underwent CT of abdomen showing:
1. Increased amount of air in subdiaphragmatic perihepatic
air-fluid collection when compared to the prior examination. New
small-to- moderate degree of pneumoperitoneum. Increased
ascites. If there has been no history of recent manipulation to
account for these findings, anastamotic dehiscence cannot be
excluded.
2. Stable small right loculated pleural effusion.
3. Stable spiculated left upper lobe nodules.
He spiked a fever on the evening of [**3-16**] and was taken back to
the OR on [**3-17**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
PROCEDURE PERFORMED: Exploratory laparotomy, abdominal washout,
drainage of intra-abdominal abscess.
Postoperative diagnosis was Retroperitoneal sepsis.
During the procedure it was noted initially that there was
about 30 cc of thick pus. This was aspirated and sent for
microbiologic study, which grew out yeast (presumptively not C
albicans) and Enterobacter. The small bowel and colon
were reported as plastered to the anterior abdominal wall.
These were taken down with great care. No enterotomies of the
bowel noted. The liver was then pulled off the anterior
abdominal wall and the large retroperitoneal space seen on CT
scan filled with air and pus was found. About 40-50 cc of yellow
bile stained material was aspirated. During the irrigation, the
T-tube became dislodged and was found in the intraperitoneal
space. The T-tube was removed in its entirety. The JP [**Last Name (NamePattern1) 19843**] was
pulled from the vicinity of the IVC and then a new [**Doctor Last Name 406**] was
attached running through the original tract.
He was transferred from the PACU to the SICU, where he stayed
for several days until deemed stable for transfer back to [**Hospital Ward Name 121**]
10.
ID was consulted, who recommended the initiation of Gentamycin
and the discontinuation of Cefepime due to resistance.
Caspofungin, Linezolid and PO Vanco were continued.
Patient had been maintained nutritionally on TPN, and on [**3-26**] an
attempt was made to pass a nasoduodenal tube for enteral
feeding. Despite 2 attempts on two separate days, the tube was
unable to be passed through the pyloris, and the tube was
subsequently removed. His appetite remained poor with minimal
intake, supplements offered daily.
Cultures taken from the drains on [**3-27**] continued to grow
Enterobacter and yeast-non-albicans.
CT of the abdomen was obtained on [**3-27**] showing:
1. Decreased amount of air in the subdiaphragmatic perihepatic
air-fluid collection when compared to the prior examination.
Marked decrease in intraperitoneal free air.
2. Unchanged amount of ascites as well as mild mesenteric
stranding and mesenteric lymph nodes consistent with given
history of peritonitis.
3. Small right loculated pleural effusion.
On the morning of [**2187-3-29**], the patient was noted to have
increased crackles throughout all lung fields. He received 40 mg
IV lasix. He was transferred from bed to chair around 9:30 AM
and it was noted that his O2 sat dropped to high 80's. He was
placed on O2 via NC at 4L and a chest xray was obtained.
The chest xray was read as Extensive bibasilar atelectasis with
possible additional small left pleural effusion. No evidence of
fluid overload.
The patient was having tachypnea, labored breathing and O2 sats
were difficult to maintain and he was placed on a non-rebreather
and transferred to the Trauma ICU (bed availability)
He was intubated immediately after arrival to the ICU, a BAL was
performed and an additional chest xray suggested aspiration or
pneumonia. Serial lactates were performed with rising levels,
the final Lactate was 16.
Later in the afternoon the patient was coded and subsequently
died.
Medications on Admission:
Metoprolol 25mg daily, Iron 325 mg TID, atorvastatin 10 mg
daily,
imatinab 400 mg daily, tylenol PRN, Oxycodone PRN, Colace 100 mg
hs, lactobacillus 2 caps daily, Augmentin 875 mg [**Hospital1 **], Vanco 250
mg PO TID, Ursodiol 300 TID
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
To be determined
Discharge Condition:
Death [**2187-3-29**]
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2187-3-30**]
|
[
"5119",
"0389",
"5180",
"4019",
"2720"
] |
Admission Date: [**2115-10-21**] Discharge Date: [**2115-10-28**]
Date of Birth: [**2034-9-6**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Core Valve
Major Surgical or Invasive Procedure:
CoreValve/TAVR
History of Present Illness:
Patient is an 81yo caucasian male with known aortic stenosis,
CAD s/p CABG x 3([**2088**]) and PCI-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 11641**] ([**4-8**]), ischemic
cardiomyopathy (EF20-25%),PPM/ICD, GI bleed (duodenal AVM), htn
who was undergoing evaluation for aortic valve replacement.
Serial echocardiograms demonstrated progressive aortic stenosis
with ([**Location (un) 109**] 1.0cm2, mean gradient 27mmHG, reduced EF 23%). He
reports shortness of breath walking less than 100feet, periods
of shortness of breath at rest. He is able to go up six stairs
before stopping due to shortness of breath. His daily activities
have been greatly reduced. He denies light headedness or
dizziness. He admits to occasional chest pressure, last episode
this am. He was evaluated for aortic valve replacement and he
was deemed not a surgical candidate for conventional AVR due to
heavily calcified aorta. He was referred for TAVR evaluation. He
met all inclusion criteria and did not meet any exclusion
criteria. After informed consent, he was screened and accepted
for the Corevalve/TAVR procedure.
NYHA Class: III
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension, +Dyslipidemia
2. CARDIAC HISTORY:
-CABG: CABG x3 in [**2088**] (SVG to RCA, LAD and OM1)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**3-/2115**]: DES x2 to the
ramus
-PACING/ICD: ICD placement [**2114-11-26**]
-- Device: St. [**Hospital 923**] Medical Dual Chamber Fortify DR CD2231-40Q
-- RA Lead: St. [**Hospital 923**] Medical Transvenous Tendril STS 2088TC/52
-- RV Lead: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Transvenous Dual [**Last Name (un) **]/Pace-Send [**Last Name (un) **] IS-1
-Severe Aortic Stenosis ([**Location (un) 109**] 0.9 on TTE [**3-/2115**])
-NSTEMI [**3-/2115**]
-Chronic Systolic CHF (EF 20-25%) from ischemic CMP
3. OTHER PAST MEDICAL HISTORY:
-h/o Prostate cancer - [**2096**]
-s/p CVA - [**2111**] - right sided weakness, resolved after rehab
-Nasal Polyps
-Torn Right Rotator Cuff
- Macular Degeneration s/p bilateral lens implants ([**2104**],
[**2109**])
-History tobacco use. Quit in [**2088**]
-s/p Left Hand Surgery [**11/2110**]
-s/p Bilateral Knee replacement
-s/p Appendectomy
-s/p Cholecystectomy
-GI bleed from angioectasia s/p cauterization ([**3-/2115**])
Social History:
Mr. [**Known lastname 11309**] lives with his wife [**Name (NI) 2411**] and used to work as a
mechanic. He is currently retired. He does not exercise lately
secondary to feeling fatigued.
-Tobacco history: 60 pack-year history, quit in [**2088**]
-ETOH: quit in [**2105**], heavy use for approx 30 years
-Illicit drugs: None
Family History:
Family history of heart disease but no history of hypertension,
diabetes, or stroke. His mother died at the age of 80 secondary
to cardiac disease, and his father died at the age of 79
secondary to prostate cancer.
Physical Exam:
ADMISSION:
Pulse: 71
B/P: 122/65
Resp: 18
O2 Sat: 100% (RA)
Temp: 97.9
Height: Weight: 175 lbs
General: Alert pale elderly male in NAD at rest.
Skin: color pale, skin warm and dry. Scant hair growth below
knees, no lesions noted. Turgor fair.
HEENT: normocephalic, anicteric. Oropharynx moist, upper and
lower dentures.
Neck: supple, trachea midline, bruit vs. referred murmer
Chest: no obvious deformity, surgical incisions well healed. LS
decreased bases. No rales, wheeze.
Heart: murmer RSB radiating throughout.
Abdomen: soft, nontender, nondistended, (+)bowel sounds.
Extremities: trace pedal edema bilat. lower extremities. Muscle
atrophy.
Neuro: alert and oriented, calm, receptive. Gross FROM.
Pulses: (+)peripheral pulses.
Discharge:
Afebrile, non-tachycardic, normotensive, non-tachypneic,
saturating well on RA
PE similar as above except for:
CV: RRR, no m/r/g
Pertinent Results:
ADMISSION:
[**2115-10-21**] 05:19PM BLOOD WBC-3.8* RBC-3.88* Hgb-8.2* Hct-28.2*
MCV-73* MCH-21.1* MCHC-29.1* RDW-17.1* Plt Ct-231
[**2115-10-21**] 05:19PM BLOOD PT-13.4* PTT-32.6 INR(PT)-1.2*
[**2115-10-21**] 05:19PM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-144
K-3.8 Cl-107 HCO3-28 AnGap-13
[**2115-10-21**] 05:19PM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-144
K-3.8 Cl-107 HCO3-28 AnGap-13
[**2115-10-21**] 05:19PM BLOOD ALT-14 AST-23 CK(CPK)-63 AlkPhos-102
TotBili-0.8
[**2115-10-21**] 05:19PM BLOOD CK-MB-4 proBNP-3080*
[**2115-10-21**] 05:19PM BLOOD Albumin-4.5
STUDIES:
([**10-21**]) CXR: Pacemaker leads terminate in right atrium and right
ventricle. Cardiomegaly is moderate. Mediastinal position is
stable. Diffuse interstitial opacities are unchanged since the
prior study. There is no pleural effusion or pneumothorax.
([**10-22**]) CXR: Successful Core-Valve device placement without
evidence of
increasing pulmonary congestion or pneumothorax.
[**2115-10-27**]
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20-25 %) with global hypokinesis and regional
thinning/akinesis of the mid to distal anterior wall,
antero-septum, distal LV and apex. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. An aortic CoreValve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-28**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-10-23**], no
major change.
([**10-23**]) ECHO:
The left atrium is markedly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20-25%) secondary to dyskinesis of the distal septum and
apex, akinesis of the basal-mid anterior septum and distal
anterior wall and mild-moderate hypokinesis of the remaining
segments. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
An aortic CoreValve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-4-10**],
there is a well seated aortic CoreValve prosthesis with normal
transvalvular gradients and trace aortic regurgitation. The
degree of mitral regurgitation has decreased. Moderate pulmonary
artery systolic hypertension is now appreciated (pulmonary
pressures could not be determined on the prior study).
[**10-22**] Echo
Pre valve Implant
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %). with mild global RV free wall hypokinesis. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Poor image quality. Unable to visualize
apex of LV: cant rule out apical thrombus. Dr. [**Last Name (STitle) **] was
notified in person of the results on [**2115-10-22**] at 830 am .
Post valve Implant
Corevalve seen in the aortic position. It appears well seated.
Mild perivalvular and tarce central aortic insufficiency seen.
Moderate mitral regurgitation. Rest of examination is unchanged
from preimplant
Discharge labs:
[**2115-10-28**] 10:00AM BLOOD WBC-3.3* RBC-3.50* Hgb-7.7* Hct-26.3*
MCV-75* MCH-22.0* MCHC-29.2* RDW-18.8* Plt Ct-167
[**2115-10-28**] 05:39AM BLOOD WBC-3.4* RBC-3.41* Hgb-7.6* Hct-25.5*
MCV-75* MCH-22.2* MCHC-29.8* RDW-19.0* Plt Ct-181
[**2115-10-28**] 05:39AM BLOOD Glucose-88 UreaN-16 Creat-1.0 Na-139
K-3.9 Cl-105 HCO3-30 AnGap-8
[**2115-10-28**] 05:39AM BLOOD ALT-12 AST-21 LD(LDH)-185 AlkPhos-94
TotBili-0.9
[**2115-10-28**] 05:39AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2
Brief Hospital Course:
81yo male with symptomatic severe aortic stenosis. History of
CAD, ICM, PPM/ICD, HTN, heavily calcified aorta.
Active issues:
# Severe aortic stenosis with CoreValve placement- Patient with
severe aortic stenosis causing dyspnea on exertion and
occasional chest pressure and leading to severe limitation of
daily activities. Serial echocardiograms demonstrated
progressive aortic stenosis with ([**Location (un) 109**] 1.0cm2, mean gradient
27mmHG, reduced EF 23%). Patient not a candidate for
conventional AVR due to heavily calcified aorta. He was referred
for TAVR evaluation. He met all inclusion criteria and did not
meet any exclusion criteria. After informed consent, he was
screened and accepted for the Corevalve/TAVR procedure.
Corevalve done on [**10-22**]. Beta blocker and diuretics held day of
procedure, given [**Month/Year (2) **] 325mg and [**Month/Year (2) 4532**] load 300mg dose day
before, preop teaching, and Gerontology consulted. After
CoreValve the patient required intermittent neo drip to maintain
pressures in the first 24 hrs. He was then successfully weaned
off pressors and remained stable. He was transferred to the
floor on POD 2. An ECHO post-op showed well seated aortic
CoreValve prosthesis with normal transvalvular gradients and
trace aortic regurgitation. The degree of mitral regurgitation
decreased. Pt remained hemodynamically stable in the ICU and on
the general cardiology floor.
# Anemia: Hct 23 pre-procedure, increased to 29 s/p 2 units
PRBCs given at time of procedure. Iron profile with low ferritin
and iron consistent with iron deficiency. Pt with hx of GI
bleed in past, did have Guaiac positive stool but no grossly
bloody stool or melena. He tolerated [**Month/Year (2) **]/[**Month/Year (2) 4532**]. Hct was trended
and stable. Pantoprazole was continued. Hct trended and
discharged with Hct of 26.3.
# CAD - On [**Month/Year (2) **], statin. preop EKG unchanged. BB initially held
and restarted on POD 2. Pt was discharged with dual antiplatelet
therapy, metoprolol, Losartan and Lipitor.
# ICM - PPM/ICD were interrogated and ICD was off for procedure.
It was then again interrogated on POD 1 and functioning well.
# HTN - [**Last Name (un) **] and beta blocker initially held, restarted on POD 2.
## TRANSITIONAL:
-repeat Hgb/Hct [**2115-10-30**], follow-up iron deficiency anemia at
appt on [**2115-10-31**]
-f/u with PCP
[**Name Initial (PRE) **]/u with cardiology
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 80 mg PO HS
2. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Doses
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
6. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain, temp>38.0
11. Outpatient Lab Work
[**2115-10-30**] Hgb/Hct - please fax results to [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] NP
(fax)[**Telephone/Fax (1) 32656**]
Discharge Disposition:
Home
Discharge Diagnosis:
1.Aortic Stenosis - s/p Corevalve/TAVR
2.Hypertension
3.CAD S/P MI, 3 vessel CABG [**2088**]
4.Chronic Systolic CHF
5.Ischemic Cardiomyopathy S/P ICD placement [**2114-11-26**]
Device: St. [**Hospital 923**] Medical Dual Chamber Fortify DR CD2231-40Q
RA Lead: St. [**Hospital 923**] Medical Transvenous Tendril STS 2088TC/52
RV Lead: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Transvenous Dual [**Last Name (un) **]/Pace-Send [**Last Name (un) **] IS-1
7121/65
6.History of Prostate cancer [**2096**]
7.Stroke [**2111**]
8. GI bleed - Duodenal AVM s/p
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Known lastname 11309**],
It has been a pleasure assisting in your care here at
[**Hospital1 18**]. You were admitted for treatment of your severe aortic
stenosis. You were not a candidate for conventional surgical
aortic valve replacement. Therefore you received a Corevalve
transcatheter aortic valve replacement. Your procedure went very
well. You received 2 units of blood. You had no complications.
You have progressed nicely and are now ready for discharge.
When you are at home, it is important to WEIGH YOURSELF
DAILY. Notify the doctor if you gain more than 3 lbs in 2 days,
or 5 lbs in 5 days.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] [**Location (un) **] PHYSICIANS NETWORK,
Address: [**Location (un) 10773**], [**Hospital1 **],[**Numeric Identifier 40170**]
Phone: [**Telephone/Fax (1) 40171**]
Appt: Thursday, [**10-31**] at 10am
Completed by:[**2115-10-29**]
|
[
"4241",
"2851",
"5990",
"4280",
"4019",
"412",
"2724",
"V4582",
"V4581",
"V1582"
] |
Admission Date: [**2153-4-12**] Discharge Date: [**2153-4-19**]
Date of Birth: [**2118-4-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Wegeners granulomatosis
Major Surgical or Invasive Procedure:
CT guided biopsy
Chest tube placement and removal
Kidney biopsy
History of Present Illness:
34 y/o M with PMHx of DM I who was recently admitted
[**Date range (3) 89453**] for work-up of anemia of unclear etiology. He
was found to have a hematocrit of 18.9 at his PCP's office.
During his admission he was noted to have eosinophilia,
coagulopathy, infiltrates and an anterior mediastinal mass. He
was seen by [**Location (un) 2274**] Hematology/Oncology, and [**Hospital1 18**] pulmonary and
thoracic surgery. He received two units of PRBCs and Hct at
discharge was 24.6. Haptoglobin was high. Bone marrow biopsy
showed bone marrow suppression and iron deficiency. He was
discharged with iron supplementation.
His mediastinal mass felt to most likely be a thymoma, and would
tie together all of his other findings including anemia,
atypical pneumonia and recurrent sinus infections with
eosinophilia and coagulopathy. Notably, germ cell marker HCG
neg, AFP normal. He had a bronchoscopy with BAL which was
negative for pathogens (some still pending) or eosinophilic
predominance. He had an MRI of the chest which showed Round
heterogeneous lesion in the anterior mediastinum measuring 5.4 x
3.9 x 4.7 cm without appreciable loss of signal intensity on
out-of-phase imaging with mild enhancement. Findings are NOT
consistent with thymic hyperplasia. Diagnostic considerations
include thymoma versus lymphoma. Thoracic surgery decided no
biopsy should be performed as risk of seeding the surrounding
tissue if this is malignant. He was to follow up with them next
week for further management.
Incidentally during his work up, P-ANCA was preliminarily
positive and thought to be paraneoplastic, but they were
awaiting confirmatory results from [**Hospital1 2025**]. On [**2153-4-10**] the attg was
notified from the [**Hospital1 2025**] lab that the patient was strongly positive
for PR3-ANCA - which has prompted the current admission.
Patient had labs drawn yesterday and notably his Hct was 20.1,
wbc: 12.0
On the floor, patient denies complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
DM
Social History:
Occasional EtOH. No tobacco or illicit drug use. Not currently
sexually active. Has always used condoms in previous sexual
relationships. No recent travel
Family History:
No family history of blood disorders. Lung cancer in his father
Physical Exam:
Vitals: 96 109/60 70 19 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, mild pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Mild crackles at BL Bases, otherwise clear
CV: tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2153-4-12**] 08:00PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.6* Hct-19.8*
MCV-81* MCH-27.1 MCHC-33.4 RDW-14.2 Plt Ct-440
[**2153-4-12**] 08:00PM BLOOD Neuts-76.3* Bands-0 Lymphs-9.3* Monos-3.8
Eos-10.3* Baso-0.3
[**2153-4-12**] 08:00PM BLOOD Hypochr-3+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
[**2153-4-12**] 08:00PM BLOOD Ret Man-4.8*
[**2153-4-13**] 05:45AM BLOOD Glucose-176* UreaN-21* Creat-1.2 Na-137
K-4.9 Cl-102 HCO3-28 AnGap-12
[**2153-4-12**] 08:00PM BLOOD LD(LDH)-138 TotBili-0.4
[**2153-4-13**] 05:45AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2
[**2153-4-12**] 08:00PM BLOOD Hapto-365*
[**2153-4-13**] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2153-4-13**] 05:45AM BLOOD HCV Ab-NEGATIVE
UA Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH
Leuks
[**4-13**] LG NEG TR NEG NEG NEG NEG 5.0
NEG
MICROSCOPIC URINE RBC WBC Bacteri Yeast Epi
[**2153-4-13**] 10:53 18* 4 FEW NONE 0
URINE CHEMISTRY Hours Creat TotProt Prot/Cr
[**2153-4-13**] 10:53 RANDOM 63 38 0.6*
Discharge labs:
[**2153-4-19**] 05:56AM BLOOD WBC-14.4* RBC-2.94* Hgb-7.7* Hct-23.9*
MCV-81* MCH-26.3* MCHC-32.4 RDW-13.7 Plt Ct-409
[**2153-4-19**] 05:56AM BLOOD Glucose-149* UreaN-29* Creat-1.1 Na-137
K-4.8 Cl-100 HCO3-30 AnGap-12
Pathology:
[**2153-4-17**] Renal biopsy:
DIAGNOSIS: Necrotizing extracapillary glomerulonephritis
consistent with the ANCA-associated vasculitic syndrome (see
note).
NOTE: Sections reveal fragments of renal parenchyma containing
approximately 33 glomeruli, one or two of which, depending on
the level, are globally sclerotic. Glomerular necrotizing
lesions are noted associated with mild extracapillary
proliferation (very small crescent formation). Mild
interstitial fibrosis and tubular atrophy are noted accompanied
by chronic inflammation. Of interest is the medullary thick
ascending limbs which show apoptotic/degenerative changes.
Endocapillary proliferation is minimal. The small
arteries/arterioles show mild fibrotic changes. Larger arteries
show intimal fibroplasia..
Immunofluorescence studies reveal 4 to 8 glomeruli to be present
depending on the level. There is no staining with IgG or IgM.
Mesangial IgA (minimal), kappa light chain (trace), lambda light
chain (minimal), and C1q (minimal) are seen. Trace C3 is noted
in tubular basement membranes and vessels. In the fibrin
preparations, there is considerable ([**1-14**]+) segmental staining.
Albumin stains are non-contributory.
Electron microscopy studies will be sent as an addendum. PAS
and silver methenamine stains were done to evaluate basement
membranes. Masson trichrome preparations were done to study
fibrotic changes.
Findings are those of a glomerulonephritis of the type
associated with the ANCA vasculitic syndromes. The thick
ascending limb changes have been reported as a result of drug
toxicity (Am J Kidney Dis 31:[**2153**]).
[**2153-4-13**] mediastinal mass cytology:
IMPRESSION: Technically successful aspiration of a predominantly
cystic
anterior mediastinal mass.
FNA, Anterior mediastinal mass:
NON-DIAGNOSTIC
Specimen consists of scattered macrophages.
Note: Please also refer to flow cytometry report
Imaging:
[**2153-4-16**] CXR:
Comparison chest radiographs dating between [**2153-4-4**] to
[**2153-4-15**].
FINDINGS: Tiny left apical pneumothorax has decreased in size
since the priorradiograph. Cardiomediastinal contours are
unchanged. Bilateral patchy
infrahilar opacities have slightly improved. Subtle ground-glass
opacities
are present and shown to better detail on recent CT scan.
Brief Hospital Course:
Mr. [**Known lastname 89454**] is a 34 year-old male with Type I DM and recent
complicated history and hospitalizations for a mediastinal mass
now thought to be a thymic cyst, vasculitis with DAH on BAL
thought to be Wegeners granulomatosis (also with renal
involvement confirmed on biopsy) whose course has been
complicated by pneumothorax s/p chest tube placement and removal
s/p high dose methylprednisolone and first dose of rituxan.
Active issues:
# Wegeners Granulomatosis: The patient has both pulmonary and
renal manifestations of Wegeners. He was found to have a high
titer positive for C-ANCA after extensive workup of iron
deficiency anemia on prior hospitalization. He was treated with
IV solumedrol 1gm X 3days then transitioned to prednisone 40 mg
po bid. As he did have a mediastinal mass, the concern was that
this may be lymphoma and steroids would partially treat,
obscuring a diagnosis. A CT guided biopsy of the mass was
performed on [**2153-4-13**] which revealed it was cystic in nature, not
consistent with lymphoma. He will require prolonged steroid
treatment so omeprazole, vit d, calcium and bactrim were added
for ppx. Hepatitis serologies were negative and a PPD was
negative on [**4-9**].
After renal biopsy confirmed acute changes consistent with
Wegner's in the kidney, the rheumatology and renal consult teams
conferred and decided to treat him with rituxan (instead of
cytoxan) due to rituxan's more favorable side effect profile.
He was given his first rituxan infusion on [**4-19**] without
complication and will receive 3 more infusions over the next
month.
# Hyperglycemia/Type I diabetes: The patient had worsening
control of blood sugars with high dose steroids. Despite
uptitration of his insulin he remained hyperglycemic and was
transferred to the ICU for one day for insulin gtt titration.
His blood sugars decreased on increased lantus dosing (now at 35
qam and 30 qpm) and an increased humalog sliding scale. [**Last Name (un) **]
had been consulted and educated the patient how to down titrate
his lantus dose when his steroid dose changes. He will follow
up with his endocrinologist.
# Anterior mediastinal mass: Visualized on previous imaging.
Appears to be thymic cyst based on fluid aspirated. Cytology
was nondiagnostic showing only macrophages. Per discussion with
heme/onc, we cannot definitively rule out lymphoma, but that
they felt it is very unlikely to be lymphoma. He was treated
with high-dose steroids without change in clinical status which
makes it even more unlikely this is lymphoma. Their
recommendation is to repeat an MRI of his chest in 3 months. He
does not currently need heme/onc follow up as this is unlikely
to be malignancy.
# Anemia: Thought to be secondary to blood loss from likely DAH
from Wegeners. His Hct dropped as low as 21, but then rose on
its own and was 23 by discharge. He received one unit of PRBCs
during this hospitalization and was maintained on iron and vit c
supplementation. He should have a Hct check during follow up to
ensure his anemia continues to improve.
# Hemopneumothorax: Complication of mediastinal biopsy. The
patient was found to be more hypoxic on [**2153-4-14**], tachycardic and
with chest pain on the left. Exam was significant for
hyperresonance. CXR revealed large hemopneumothorax with mild
tension. Thoracic surgery was consulted and chest tube placed.
The pneumothorax resolved within 24 hours and the chest tube was
removed. Follow up CXR on [**4-16**] showed continued resolution.
# Leukocytosis: Thought to be secondary to steroids. No
clinical evidence of infection.
Transition of care:
- Patient needs repeat chest MRI in 3 months (early [**2153-7-13**])
for follow up of the mediastinal mass.
- Patient will need continued titration of insulin dosing as his
steroid dose changes.
- Hct check to monitor anemia.
- Follow up has been arranged with his PCP, [**Name10 (NameIs) 10368**],
nephrologist, pulmonologist, and endocrinologist.
Medications on Admission:
1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous twice a day.
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Insulin Sliding Scale
Please use attached Flowsheet for regimen
Discharge Medications:
1. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: 35 units in the morning and
30 units at bedtime lantus Subcutaneous .
7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. Humalog 100 unit/mL Solution Sig: sliding scale humalog
Subcutaneous four times a day: See attached sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Wegeners granulomatosis
Thymic cyst
Hemopneumothorax
Secondary diagnoses:
Diabetes Type I
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for treatment of Wegeners
Granulomatosis. You were started on high dose steroids and
ultimately placed on 40 mg of prednisone twice daily. The
rheumatologists decided to treat you adjunctively with rituxan
as this [**Doctor Last Name 360**] has fewer sided effects then the mainline
treatment for your condition. You will need 3 more doses of
rituxan which the rheumatologists will arrange.
You had a biopsy of the mass in your chest which was found to be
a cyst. You suffered a complication of this procedure which was
a pneumothorax (collapse of part of the lung). A chest tube was
placed and then removed. Cytology from the biopsy was
nondiagnostic. Hematology/oncology had evaluated you during
your stay and felt that it was very unlikely that the mass in
your chest was a lymphoma or other cancer, but this has not been
definately ruled out. You will need a repeat chest imaging in 3
months to check for any change in the mass/cyst. We will
communicate with your primary doctor so he is aware of the need
for this repeat imaging.
It is important that you avoid non-steroidal anti-inflammatory
medications in the future (alleve, ibuprofen, ect). You can use
tylenol as need for pain control. Otherwise discuss other pain
medications with your primary doctor before using.
MEDICATION CHANGES:
INCREASE lantus to 35 units every morning and 30 units every
evening
USE NEW humalog sliding scale
Glucose Mealtime Insulin Dose Bedtime Insulin Dose
71-79 mg/dL 0 Units 0 Units
80-119 mg/dL 12 Units 0 Units
120-159 mg/dL 14 Units 0 Units
160-199 mg/dL 17 Units 0 Units
200-239 mg/dL 20 Units 3 Units
240-279 mg/dL 24 Units 5 Units
280-319 mg/dL 28 Units 9 Units
320-359 mg/dL 32 Units 13 Units
360-400 mg/dL 36 Units 16 Units
START Prednisone 40 mg twice daily
START Calcium and Vit D
START Bactrim daily
START Omeprazole 20 mg daily
Otherwise continue your outpatient medications as prescribed.
An endocrinologist from [**Last Name (un) **] helped manage your blood sugars
and recommends decreasing your lantus by 2 units each dose every
time your prednisone dose decreases by 5 mg. You should also
contact your endocrinologist when your prednisone dose changes.
Followup Instructions:
Multiple follow up appointments were made for you to follow up
with your outpatient providers. It is important that you keep
these appointments.
Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) 2277**] Rheumatology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Wednesday [**2153-4-25**] 3:50pm
Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**] Primary Care
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Friday [**2153-4-27**] 2:00pm
Name: [**Last Name (LF) 6810**],[**Name8 (MD) 6811**] MD
Location: [**Hospital1 641**] Endocrinology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday [**2153-5-3**] 8:00am
Name: [**Last Name (LF) 3112**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 641**] Nephrology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Wednesday [**2153-5-9**] 3:40pm
Name: [**Last Name (LF) 9303**], [**Name8 (MD) **] MD
Location: [**Hospital1 641**] Pulmonary
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: [**2153-7-4**] 8:40am
Dr. [**Last Name (STitle) 9303**] is out of the office and this was the first
appointment available. You should be called with a sooner
appointment when he returns. If you don't hear from their
office within a week, please call to check if your appointment
has been moved.
Completed by:[**2153-4-19**]
|
[
"5849"
] |
Admission Date: [**2202-8-10**] Discharge Date: [**2202-8-23**]
Date of Birth: [**2123-1-29**] Sex: M
Service: MEDICINE
Allergies:
Serax
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Presented to emergency room with 1 day history of nausea and
vomiting and possible aspiration pneumonia
Past Medical History:
-Parkinson disease s/p deep brain stimulator placement
-HTN
-Diabetes mellitus
-hyperlipidemia
-Shy-[**Last Name (un) **] syndrome
-diaphragmatic hernia
-ventral hernia
-GERD
-CKD
- h/o subtotal colectomy with Hartmann's pouch
- h/o end ileostomy and G-tube for sigmoid volvulus ([**2198**] -
[**Doctor Last Name **])
- ORIF R humerus fracture ([**2193**])
.
Social History:
Patient lives in [**Location **] with his wife, who has been disabled
for many decades now; and has aides to care for her and him 24
hours a day. His family owns a real estate company in [**Location (un) **].
He is retired from developing a construction company, and has 5
children. A daughter in an internist in [**Name (NI) 531**].
Family History:
Father: died of skin cancer
Brother #1: prostate cancer
Brother #2: CVA
Physical Exam:
On admission:
Temp:98.0 HR:85 BP:103/59 Resp:24 O(2)Sat:88% low
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Chest: coarse breath sounds
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffusely tender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: + increased muscle tone
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
On admission:
[**2202-8-10**] 03:40PM BLOOD WBC-7.2 RBC-4.14* Hgb-13.3* Hct-40.1
MCV-97 MCH-32.2* MCHC-33.1 RDW-13.7 Plt Ct-311
[**2202-8-10**] 03:40PM BLOOD Neuts-89.0* Lymphs-5.9* Monos-3.3 Eos-0.1
Baso-1.7
[**2202-8-10**] 03:40PM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2*
[**2202-8-10**] 03:40PM BLOOD Glucose-211* UreaN-28* Creat-2.1* Na-138
K-4.7 Cl-99 HCO3-24 AnGap-20
[**2202-8-10**] 03:40PM BLOOD ALT-14 AST-23 AlkPhos-128 TotBili-0.6
[**2202-8-10**] 03:40PM BLOOD Lipase-57
[**2202-8-10**] 03:40PM BLOOD Calcium-9.4 Phos-4.5 Mg-1.8
[**2202-8-10**] 03:42PM BLOOD Lactate-4.2*
.
On discharge:
.
[**2202-8-22**] 06:45AM BLOOD WBC-8.9 RBC-3.18* Hgb-9.6* Hct-30.6*
MCV-96 MCH-30.3 MCHC-31.6 RDW-13.7 Plt Ct-635*
[**2202-8-22**] 06:45AM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-139
K-4.0 Cl-105 HCO3-30 AnGap-8
[**2202-8-22**] 06:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8
.
Studies:
.
[**8-16**] CXR: FINDINGS: In comparison with the study of [**8-14**], there
are continued low lung
volumes. Extensive left basilar consolidation is again seen with
continued
less prominent opacifications in much of the right lung. The
findings are
consistent with widespread pneumonia, possibly complicated by
increased
pulmonary venous pressure in a patient with prominence of the
cardiomediastinal silhouette.
Deep brain stimulators are again seen.
.
[**8-22**] CXR:
There are low lung volumes. Cardiac size is top normal. Large
left lung
consolidation consistent with pneumonia is minimally improved
from prior
study. Hazy opacities in the right lung are unchanged, also
consistent with
pneumonia. There are no new lung abnormalities. There is no
pneumothorax.
If any there is a small left pleural effusion. Brain stimulators
are again
seen.
.
[**8-10**] CT abd/pelvis: 1. High-grade small-bowel obstruction at the
level of small bowel containing supraumbilical ventral abdominal
wall hernia with distal decompression. No perforation or other
complication.
2. Cholelithiasis without cholecystitis.
3. Consolidation at the left lung base posteriorly may represent
aspiration.
4. Markedly distended stomach containing fluid and gastric
contents as a
result of the small bowel obstruction.
.
[**8-16**] Video swallow study:
FINDINGS: Barium passes freely through the oropharynx without
evidence of
obstruction. There was no gross aspiration or penetration. For
details,
please refer to the speech and swallow division note in OMR.
IMPRESSION:
No penetration or aspiration.
Brief Hospital Course:
Mr. [**Known lastname 16284**] is a 79 year old gentleman with PMH s/f advanced
Parkinson's disease/Shy-[**Last Name (un) 16294**] Syndrome, DM, HTN, ventral
hernia and distant sigmoid volvulus (s/p colectomy w/ostomy in
place), who was admitted with SBO which resolved w/ conservative
management, now with aspiration PNA, likely present at
admission.
.
#SBO: The patient was admitted to the surgical service. He has a
history of subtotal coletomy with Hartmann's pouch and end
ileostomy for sigmoid volvulus. An NG tube was placed and the
patient was managed conservatively with fluids and electrolyte
repletion. His SBO eventually resolved and he maintained good
ostomy output without nausea or vomiting during his admission to
the medical service.
.
#Aspiration pneumonia: The patient was admitted with a CXR
concerning for aspiration. He was started on broad-spectrum
antibiotics, which were tapered to Levaquin. The patient was
then transferred to the medicine service where he developed
increasing hypoxia. Antibiotics were then re-broadened and the
patient was closely followed with serial chest X rays; O2
support was intitially via Venturi mask, but the patient was
weaned to nasal cannula. He completed an 8-day course of
broad-spectrum antibiotics and was discharged with home oxygen.
O2 saturations on the day of discharge were 95-96% on 1L nasal
cannula. The patient passed a video swallow study and was kept
on soft foods and thin liquids during this admission.
.
#PARKINSONS/SHY-[**Last Name (un) **]: The patient was continued on his home
medications Sinemet and [**Last Name (un) 16285**]. He is s/p placement of deep
brain stimulators. Sertraline was continued for depression.
Physical therapy was consulted and helped work with the patient
and helped him advance his activity.
.
#ACUTE ON CHRONIC RENAL FAILURE. The patient's creatinine was
closely monitored. On admission, creatinine was 1.5. With close
monitoring of the patient's output and IV fluid hydration, the
patient's creatinine stabilized at 1.0.
.
#AGITATION: The patient was maintained on his home medications
quetiapine and trazodone at night. He occasionally required
extra doses of these medications and would intermittently become
very agitated at night - this frequently led to hypoxia and
increased O2 requirement.
.
#DM: The patient's home glipizide therapy was held. Fasting AM
glucose levels were checked and ranged from 100-160s. The
patient was received SSI and a diabetic diet.
.
#GERD: The patient was continued on his home omeprazole.
.
# GROIN RASH: The patient received antifungal cream and powder
for a candidal rash.
.
# HYPERLIPIDEMIA: The patient was continued on his home
medication simvastatin.
.
# SOFT STOOL: Resolved. C. diff toxin negative x3.
.
#The patient received subQ heparin for DVT prophylaxis. He
remained full code during this admission. He was discharged with
close follow-up by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 141**].
Medications on Admission:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
2. Quetiapine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for sleep.
5. Sinemet-25/250 25-250 mg Tablet Sig: One (1) Tablet PO BID at
6:30 AM and 9AM.
6. Sinemet-25/250 25-250 mg Tablet Sig: 1.5 Tablets PO BID at
11:30AM and 4:30PM.
7. Sinemet-25/250 25-250 mg Tablet Sig: 1.75 Tablets PO qd at
2:00 PM.
8. Sinemet-25/250 25-250 mg Tablet Sig: Two (2) Tablet PO qd at
7:00PM.
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): 2 mg TID at 6:30AM, 9:00AM, and 2:00PM.
14. Ropinirole 2 mg Tablet Sig: 1.5 Tablets PO qd at 11:30AM.
15. Restasis 0.05 % Dropperette Sig: One (1) drop in both eyes
Ophthalmic twice a day.
16. Patanol 0.1 % Drops Sig: Two (2) drops per eye Ophthalmic
twice a day as needed for itching.
17. Miralax 17 gram/dose Powder Sig: One (1) 17 gram dose PO
once a day as needed for constipation.
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
2. Quetiapine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for sleep.
5. Sinemet-25/250 25-250 mg Tablet Sig: One (1) Tablet PO BID at
6:30 AM and 9AM.
6. Sinemet-25/250 25-250 mg Tablet Sig: 1.5 Tablets PO BID at
11:30AM and 4:30PM.
7. Sinemet-25/250 25-250 mg Tablet Sig: 1.75 Tablets PO qd at
2:00 PM.
8. Sinemet-25/250 25-250 mg Tablet Sig: Two (2) Tablet PO qd at
7:00PM.
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): 2 mg TID at 6:30AM, 9:00AM, and 2:00PM.
14. Ropinirole 2 mg Tablet Sig: 1.5 Tablets PO qd at 11:30AM.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
16. Restasis 0.05 % Dropperette Sig: One (1) drop in both eyes
Ophthalmic twice a day.
17. Patanol 0.1 % Drops Sig: Two (2) drops per eye Ophthalmic
twice a day as needed for itching.
18. Miralax 17 gram/dose Powder Sig: One (1) 17 gram dose PO
once a day as needed for constipation.
19. Home Oxygen
Home oxygen at 1-4 LPM continuous, pulse-dose for portability
Diagnosis: Aspiration pneumonia
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Small bowel obstruction
Aspiration pneumonia
Secondary:
Parkinson disease s/p deep brain stimulator placement
HTN
Diabetes mellitus
Hyperlipidemia
GERD
h/o subtotal colectomy with Hartmann's pouch
h/o end ileostomy and G-tube for sigmoid volvulus ([**2198**] -
[**Doctor Last Name **])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 16284**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for a small bowel
obstruction that resolved with conservative management. Your
hospital course was complicated by pneumonia - likely,
aspiration pneumonia, for which you were treated with
broad-spectrum antibiotics and oxygen support.
We made no major changes to your medication regimen and you
should continue to take your medications as directed by Dr.
[**Last Name (STitle) 141**]. We did add miconazole powder for the rash in your
groin to be used as needed.
An appointment with Dr. [**Last Name (STitle) 141**] is scheduled for next Thursday,
[**9-2**] at 4 pm. You can call his office if this needs to be
re-scheduled.
You were discharged with oxygen to be used at home and the
visiting nurses will help to wean you from oxygen as your
strength improves and as your body continues to absorb the fluid
and infection from your lungs.
Followup Instructions:
The information for your follow-up appointment with Dr. [**Last Name (STitle) 141**]
is listed below:
Department: INTERNAL MEDICINE
When: THURSDAY [**2202-9-2**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"5070",
"5849",
"5180",
"40390",
"25000",
"53081",
"2724"
] |
Admission Date: [**2199-3-8**] Discharge Date: [**2199-3-28**]
Date of Birth: [**2144-12-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Hypoglycemia, hypotension
Major Surgical or Invasive Procedure:
[**2199-3-19**];
1. Pancreatic necrosectomy.
2. Pseudocyst-gastrostomy.
History of Present Illness:
Mr. [**Known lastname 90960**] is a 54M with history of necrotizing pancreatitis c/b
pseudocyst formation who presents with weakness. Patient was
seen in clinic [**2199-3-8**] regarding operative planning for a cyst
gastrostomy. During this visit, he felt lightheaded and was
found to have a glucose of 30 and SBP in 80s. He was given juice
and felt some improvement, though not baseline. On admission
patient was
TPN dependent due to gastric obstruction from his pseudocyst.
[**First Name8 (NamePattern2) **] [**Last Name (un) **], his current TPN bag has the incorrect dose of
insulin (too high). Patient reports feeling well until this
episode. His weight has been stable. He has been drinking fluids
regularly with normal urine output. He denies nausea, vomiting,
and diarrhea. His abdominal pain is at his baseline. His blood
sugars at home have ranged from 40 to 200. Since coming to the
ED, he feels signifantly better, though he reports a headache.
Past Medical History:
1. Necrotizing pancreatitis complicated by acute fluid
collection and a small pseudocyst in the tail which gradually
disappeared over time. All this occurred in approximately [**2196**]
and his care has been at [**Hospital2 **] [**Hospital3 6783**] Hospital, [**State 17405**], and most recently [**Hospital6 **].
2. Prior celiac plexus block for pain control attempted [**4-/2197**]
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with no apparent benefit.
3. Status post ERCP in [**2196**] or [**2197**] by Dr. [**Doctor Last Name 90959**],
apparently notable only for mild biliary dilation and no sludge-
complicated by post ERCP pancreatitis according to patient
4. Status post cholecystectomy.
5. Hypertriglyceridemia.
6. Hypertension.
7. Multiple shoulder surgeries.
8. Fatty liver.
9. Schatzki's ring.
10. Gastritis.
Social History:
Currently on disability but former restaurant manager prior to
onset of pancreatitis in [**2196**]. Lives with his sister and mother
now since his wife passed away last year. Formerly very active
and has completed the [**Location (un) 86**] Marathon 4 times. Has remote
history of smoking, denies any alcohol use at this moment,
finished [**Hospital **] Rehab program.
Family History:
He has a familial history of hypertriglyceridemia. His sister
has MS. There is no family history of pancreatitis or
pancreatic cancers as far as he knows. No other family history
of GI or liver disease as far as he knows.
Physical Exam:
On Admission:
VS: 97.8 56 91/93 18 100%
Gen: Appears well, NAD
CV: RRR
Resp: CTAB
Abd: Soft, tender in epigastrium, mildly distended, ecchymosis
in
RLQ and at umbilicus (at sites of insulin injections per
patient), no rebound or guarding
Ext: Bilateral lower extremity edema
On Discharge:
VS: 98.2, 72, 116/70, 12, 100% RA
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB
ABD: Midline abdominal incision open to air with steri strips
and c/d/i. Old RLQ JP site with occlusive dressing and c/d/i.
Soft, NT/ND.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2199-3-26**] 05:12AM BLOOD WBC-4.4 RBC-3.26* Hgb-9.3* Hct-27.4*
MCV-84 MCH-28.6 MCHC-34.0 RDW-14.3 Plt Ct-217
[**2199-3-27**] 04:00AM BLOOD Hct-29.5*
[**2199-3-26**] 05:12AM BLOOD Glucose-118* UreaN-8 Creat-0.7 Na-135
K-3.7 Cl-99 HCO3-29 AnGap-11
[**2199-3-26**] 05:12AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.6
[**2199-3-26**] 06:18PM ASCITES Amylase-9
[**2199-3-8**] 3:50 pm BLOOD CULTURE #2.
**FINAL REPORT [**2199-3-14**]**
Blood Culture, Routine (Final [**2199-3-14**]):
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN >= 4 MCG/ML.
VIRIDANS STREPTOCOCCI. SECOND MORPHOLOGY.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2199-3-9**] 3:30 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT [**2199-3-15**]**
Blood Culture, Routine (Final [**2199-3-15**]):
VIRIDANS STREPTOCOCCI.
SENSITIVITIES PERFORMED ON CULTURE # 340-0091M [**2199-3-8**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Susceptibility testing requested by DR. [**Last Name (STitle) 4091**],[**First Name3 (LF) **]
PAGER [**Numeric Identifier **]
[**2199-3-13**]. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2199-3-13**] 7:50 pm BLOOD CULTURE
**FINAL REPORT [**2199-3-19**]**
Blood Culture, Routine (Final [**2199-3-19**]): NO GROWTH.
[**2199-3-19**] 10:59 am FLUID,OTHER
**FINAL REPORT [**2199-3-25**]**
GRAM STAIN (Final [**2199-3-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2199-3-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-3-25**]): NO GROWTH.
[**2199-3-8**] ABD CT:
IMPRESSION:
1. Stable peripancreatic fluid collections.
2. Possible splenic vein occlusion with mesenteric collaterals.
3. Fatty liver.
4. Splenomegaly.
[**2199-3-8**] CXR:
IMPRESSION: No acute cardiothoracic process
[**2199-3-14**] TTE/TEE:
Conclusions:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
[**2199-3-19**] EKG:
Sinus bradycardia. Low limb lead voltage. Q-T interval
prolongation. Delayed precordial R wave transition. Compared to
the previous tracing of [**2199-3-14**] no diagnostic interim change.
[**2199-3-19**] Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 90962**],[**Known firstname **] [**2144-12-1**] 54 Male [**Numeric Identifier 90963**] [**Numeric Identifier 90964**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate
SPECIMEN SUBMITTED: necrotic pancreatic tissues, pseudocyst
wall.
Procedure date Tissue received Report Date Diagnosed
by
[**2199-3-19**] [**2199-3-19**] [**2199-3-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/ttl
Previous biopsies: [**-1/4351**] GI BX'S (3 JARS)
DIAGNOSIS:
I. Necrotic pancreatic tissue, necrosectomy (A-B):
Diffusely necrotic tissue/debris; no viable pancreatic
parenchyma identified.
II. "Pseudocyst wall", gastrostomy (C-E):
Gastric corpus segment with no intrinsic mucosal abnormalities
and scant adherent cauterized fibrous tissue.
Brief Hospital Course:
Patient with history of necrotizing pancreatitis and pancreatic
pseudocyst was seen in clinic for follow up. During exam,
patient was found to have SBP in 80s and blood sugar 30. Patient
was admitted to General Surgery Service for further work up.
Blood cultures were sent on admission and was positive for Staph
COAG negative and Viridans strep. Patient's PICC line was
removed and he was started on IV Vancomycin, ID was consulted.
ID recommended 14 days course of IV Vancomycin. PICC line tip
and follow up blood cultures were negative, patient remained
afebrile with WBC within normal limits. On [**2199-3-19**], the patient
underwent pancreatic necrosectomy and pseudocyst-gastrostomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO, on IV fluids and
antibiotics, with a foley catheter, and Dilaudid PCA for pain
control. The patient was hemodynamically stable.
CV: Patient was found to have asymptomatic sinus bradycardia on
admission ECG. His Atenolol was held and he was placed on
telemetry for HR monitoring. He underwent echocardiography on
[**3-14**] which revealed normal LVEF and was grossly normal. Patient
had another episode of sinus bradycardia on [**3-14**] and repeat ECG
revealed prolonged d Q-T interval, patient's Quetiapine was
discontinued at this time. Pre-op ECG on [**3-19**] was stable and
post operatively patient remained stable from a cardiovascular
standpoint. Telemetry was discontinued on POD # 7, patient's HR
returned to sinus regular without any ectopy and home dose of
Atenolol was restarted. Quetiapine was not restarted on
discharge and patient was advised to discuss with his PCP
possible discontinue of this medication s/t causing Q-T
prolongation.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's TPN was discontinued on admission ,and on
HD # 3 patient was started on full liquids diet with
supplements. Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient completed 14 days course of IV Vancomycin for
blood infection. TTE and TEE was nagative for any vegetations.
Follow up blood cultures were negative for any growth. Patient
underwent empirical treatment post operatively with Cipro and
Flagyl for infected pseudocyst. Final pseudocyst cultures were
negative and antibiotics were discontinued. The patient's white
blood count and fever curves were closely watched during
hospitalization and remained within normal limits prior
discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. [**Last Name (un) **] Center
follow the patient daily and patient will continue to follow up
with endocrinology as outpatient.
Hematology/GI bleed: On POD # 4 patient was noticed hematemesis
x 2 and melena, his HCT had 10 points drop. The patient was
transferred in ICU for observation. Patient was transfused with
3 units of pRBC and 1 unit of FFP, his HCT improved after
transfusion (19.8->23.9). On POD # 5, patient continued to have
melena, no bloody emesis. He was transfused with 1 unit of pRBC
and transferred to the floor. Patient's HCT remains stable prior
discharge, no further transfusion were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
citalopram 20, lisinopril 10', omeprazole 20', quetiapine 100',
aspirin 81', atenolol 25', docusate sodium 100', senna 8.6'',
acetaminophen 325 q6h prn, oxycontin 20 mg Q8H.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. 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*
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours for 2
weeks: To refill this medication, please contact you PCP or [**Name9 (PRE) 1194**]
Specialist.
Disp:*42 Tablet Extended Release 12 hr(s)* Refills:*0*
11. Insulin Sliding Scale and Lantus
Insulin SC Fixed Dose Orders
Bedtime
Glargine 6 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**Name9 (PRE) **] with hypoglycemia protocol [**Name9 (PRE) **] with
hypoglycemia protocol [**Name9 (PRE) **] with hypoglycemia protocol [**Name9 (PRE) **]
with hypoglycemia protocol
71-200 mg/dL 0 Units 0 Units 0 Units 0 Units
201-250 mg/dL 3 Units 3 Units 3 Units 2 Units
251-300 mg/dL 4 Units 4 Units 4 Units 3 Units
301-350 mg/dL 6 Units 5 Units 6 Units 4 Units
351-400 mg/dL 7 Units 6 Units 7 Units 5 Units
Discharge Disposition:
Home
Discharge Diagnosis:
1. Necrotizing pancreatitis
2. Pancreatic psuedocyst
3. GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2199-4-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with [**Last Name (un) **] in [**3-8**] weeks after discharge.
Please call [**Telephone/Fax (1) 2378**] to make your appointment or if you have
any questions.
.
Please follow up with Dr. [**Last Name (STitle) 90965**] (PCP) in [**3-8**] weeks after
discharge.
Completed by:[**2199-3-28**]
|
[
"V5867",
"4019",
"2859"
] |
Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-6**]
Date of Birth: [**2112-2-27**] Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Ceclor / clindamycin / ibuprofen /
Erythromycin Base / naproxen
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 82967**] is a 59-year-old female with a history of
polycythemia [**Doctor First Name **], hypertension and chronic pain who is
presenting with altered mental status. She was in her usual
state of health the morning of admission when her wife left her
at home. In the afternoon, the patient's wife found her
confused, lethargic, and having vomited. Otherwise, the patient
is unable to provide much history; however, she did have some
pain with palpation of her right upper quadrant. Neither the
patient nor her wife can remember any trauma to her left leg
(though she had a recent fall with a fracture of her left
humerus).
In the ED, initial VS were: 102.9 108 189/81 16 98%. She was
noted to have a large area of erythema and tenderness to
palpation of the left lower extremity that was marked which
involved a large portions of her calf as well as her distal
thigh. She was given Tylenol 1g, Vancomycin 1g IV, levofloxacin,
and Zofran. CT scan of her abdomen showed a small gallbladder,
making cholecystitis unlikely although not completely excluded;
with hyperdense contents which suggest stones or sludge. Fatty
liver and splenomegaly: although splenomegaly is not specific,
concern is raised for steatohepatitis or cirrhosis. Marked fatty
replacement of pancreas. Large right adnexal cyst; ultrasound
assessment recommended when appropriate. RUQ ultrasound was
unable to be completed due to significant patient discomfort.
.
On arrival to the MICU, the patient was somewhat agitated. She
became more calm in the presence of her wife, but still removed
an IV and needed to be restrained. Vitals T 97.9 HR 109 BP
124/51 RR 16 97% on room air.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Hypertension
2. Degenerative disc disease
3. chronic pain
4. Polycythemia [**Doctor First Name **] followed by [**Last Name (LF) 1852**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Social History:
Ms. [**Known lastname 82967**] lives with her wife in [**Location (un) 83264**], [**State 350**]. She is on disability. She has a cat,
dog, and birds at home. Tobacco: Remote history of smoking for
about five years at age 15. Alcohol: None. Illicits: None.
Also no chemical or secondhand smoking exposure.
Family History:
Not known. The patient's mother and father are
deceased. She has three brothers, six sisters and two
daughters.
She is estranged from all family members and does not know their
medical history.
Physical Exam:
Admission to MICU exam:
General: Oriented x 2 (person, place), agitated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not appreciated due to habitus, no LAD
CV: S1, S2, 3/6 SEM heard best at upper sternal border
Lungs: Clear to anterior auscultation bilaterally
Abdomen: Soft, non-tender, obese, bowel sounds present, striae
Ext: Warm, well perfused
Skin: Left lower leg with significant erythem from just below
the knee to foot, especially on medial side.
Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities,
sppech incoherent but intelligible
Call out to Medicine Exam:
GENERAL - Chronically ill appearing 59yo F who appears older
than her stated age. She has an odd affect with tangential
thinking. She is lethargic but arousable, oriented to person,
place and time. Inattentive and unable to do months of the year
in reverse
HEENT - NC/AT, EOMI, sclerae anicteric, Adentulous, MMM, OP
clear
NECK - supple, no [**Doctor First Name **], no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilaterally, moving air well and symmetrically
HEART - S1 S2 clear and of good quality, tachycardic, 3/6 SEM
RUSB
ABDOMEN - NABS, Obese, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs). Chronic
venous stasis skin changed on bilateral LE. Left lower leg with
significant erythema from knee to groing along medial aspect
tracking in a linear pattern along medial aspect of thigh. Warm
to touch.
NEURO - Awake but lethargic, A&Ox3, Facial asymmetric but CNs
II-XII grossly intact, muscle strength 5/5 throughout, sensation
grossly intact throughout. Speech slurred at times though
adentulous may be contributing. Tangential thought processes
Pertinent Results:
Trends:
[**2171-4-2**] 06:38PM BLOOD WBC-29.7* RBC-7.68*# Hgb-17.3* Hct-57.0*
MCV-76* MCH-22.2* MCHC-29.3* RDW-18.7* Plt Ct-490*
[**2171-4-4**] 05:18AM BLOOD WBC-21.5* RBC-7.26* Hgb-16.0 Hct-54.8*
MCV-76* MCH-22.1* MCHC-29.2* RDW-19.0* Plt Ct-366
[**2171-4-2**] 06:38PM BLOOD Neuts-89.7* Lymphs-6.6* Monos-2.6 Eos-0.4
Baso-0.7
[**2171-4-4**] 05:18AM BLOOD PT-13.5* INR(PT)-1.3*
[**2171-4-2**] 06:38PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-135
K-3.9 Cl-94* HCO3-27 AnGap-18
[**2171-4-4**] 05:18AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-137
K-3.8 Cl-97 HCO3-27 AnGap-17
[**2171-4-2**] 06:38PM BLOOD ALT-23 AST-43* AlkPhos-205* TotBili-1.2
[**2171-4-4**] 05:18AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
[**2171-4-3**] 04:12PM BLOOD Lactate-2.8*
[**2171-4-4**] 05:47AM BLOOD Lactate-1.8
[**2171-4-2**] 10:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2171-4-2**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Discharge Labs:
[**2171-4-5**] 08:20AM BLOOD WBC-17.3* RBC-7.24* Hgb-15.7 Hct-55.3*
MCV-77* MCH-21.6* MCHC-28.3* RDW-19.1* Plt Ct-416
[**2171-4-5**] 08:20AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-4 Eos-3
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2171-4-5**] 08:20AM BLOOD Glucose-152* UreaN-10 Creat-0.8 Na-139
K-4.1 Cl-99 HCO3-30 AnGap-14
[**2171-4-5**] 08:20AM BLOOD TSH-0.24*
BCx pending:
Imaging:
CT abd/pelvis w/:
IMPRESSION:
1. Mostly decompressed gallbladder which makes cholecystitis
unlikely,
although hyperdense contents could be seen with stones or
sludge.
2. Fatty infiltration of the liver.
3. Marked fatty infiltration of the pancreas, which can be seen
as a
manifestation of chronic pancreatic inflammation, although other
etiologies
such as cystic fibrosis could generate such an appearance.
4. Mild-to-moderate splenomegaly including small infarcts.
Splenomegaly in
association with fatty liver may raise concern for
steatohepatitis or
cirrhosis with portal hypertension as the etiology for
splenomegaly, although the appearance is not entirely specific.
5. Large right adnexal cyst. Although no complex features are
apparent based on CT imaging, particularly based on size and the
limitations of CT
assessment, when clinically appropriate, evaluation with
ultrasound is
recommended. If the lesion is not accessible to visualization
with
ultrasound, then MR is recommended.
6. Mild left inguinal lymphadenopathy, likely reactive;
correlation with
physical findings involving the left lower extremity is
recommended.
LENI [**4-3**]
IMPRESSION: No evidence of deep vein thrombosis either right or
left lower
extremity.
CT LE [**4-2**]:
IMPRESSION:
1. Findings above of subcutaneous edema and circumferential skin
thickening,
which in the right clinical setting may represent [**Month/Year (2) **].
2. No focal fluid collections to suggest abscess. No
subcutaneous emphysema.
3. Scattered degenerative changes of the left lower extremity.
CXR [**4-3**]:
FINDINGS: In comparison with the study of [**2168-8-25**], there is
little change.
Continued low lung volumes most likely account for the
prominence of the
cardiac silhouette. No pneumonia, vascular congestion, or
pleural effusion.
Brief Hospital Course:
Ms. [**Known lastname 82967**] is a 59 y/o female with a history of polycythemia
[**Doctor First Name **], hypertension and chronic pain who presented with altered
mental status and [**Doctor First Name **]. Treated with IV antibiotics in
the MICU with improvement in MS [**First Name (Titles) **] [**Last Name (Titles) **] and transferred
to [**Hospital1 **] on HD2.
# [**Hospital1 **]. Non-purulent, no necrosis on CT. Tx initially
with Vancomycin/Levofloxacin given allergy profile (anaphylaxis
to PCNs and Clindamycin). Levofloxacin d/ced on HD2 as pt.
improved. LENI was negative for DVT. Although cephalosporin
regimen would be most optimal, due to severe reaction type and
potential crossreactivity, vancomycin was selected for
treatment. In preparation for discharge antibiotics changed to
Bactrim 2DS tabs PO BID to complete 5 more days for total 10 day
course.
# Altered mental status. Toxic-metabolic encephalopathy
secondary to the patient's left leg [**Hospital1 **]. Head CT not
suggestive of hemorrhage. UA negative. CT abdomen demonstrated
no site of infection. Utox/Stox negative. Improved with
treatment of [**Hospital1 **]. Initially held sedating medications but
restarted prior to discharge with improvement in mental status.
# LFTs: Isolated ALP elevation associated with slightly elevated
T.Bili to 1.2 from 0.5. AST also elevated but ALT flat would
suspect mitochondrial dysfunction. Tox screen only positive for
Methadone so ingestion less likely especially while rising in
MICU. In ED patient complained of RUQ pain and nausea consitent
with cholecystitis. RUQ ultrasound incomplete/limited given
patient agitation. CT scan could not definitely rule out
cholecystitis. Patient has habitus and epidemiology for
cholelithiasis but with improved mental status she has no RUQ
pain or [**Doctor Last Name **] sign on exam with improvement in mental status so
did not pursue a second RUQ US. Fever curve also improved on
only Vancomycin without GNR or anaerobic coverage.
# Tachycardia: Sinus tachycardia to 120s consistently in the
MICU. Initially thought related to sepsis but did not improve
with downtrend of fever curve or improvement in [**Doctor Last Name **].
Volume status euvolumic and patient with good urine output.
Tachycardia did dip to 90s when wife is around and so there may
be a psychologic component. Patient with chronic pain on
Methadone so pain may be contributing as well. Outpatient HRs in
90s per record. Low likelihood for PE without hypoxia,
tachypnea, chest pain and LENIs negative for DVT. Tachycardia
resolved prior to discharge.
# Hypertension: Chronic, Lisinopril recently restarted with
resolution of sepsis but she remained hypertensive. Amlodipine
started prior to discharge. Asymptomatic on floor. TSH checked
and was low. Continued Lisinopril 40mg PO BID and added
Amlodipine 5 mg PO/NG DAILY to augment BP control. Day of
discharge she became hypotensive and orthostatic which, per
patient's wife, usually happens when increasing BP meds.
Amlodipine was discontinued, and lisinopril to 40mg po daily and
patient discharged after BPs stabilized.
# Anxiety: Continued home regimen of Ativan.
# DJD/chronic pain: Continue methadone but tizanidine and
gabapentin were initially held in setting of delirium but
restarted prior to discharge
# [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Stable. Plavix was continued.
# Incidentalomas: Splenic infarcts likely PCV related in
addition to splenomegaly. Large right adenexal cyst can be
worked up as outpatient
TRANSITIONAL ISSUES:
- Follow up incidentalomas, patient should have adenexal cyst
monitored as an outpatient
- Better control of hypertension is essential in this patient
- Careful with BP meds given profound orthostasis when starting
CCB
- CODE STATUS: Presumed Full
- CONTACT: Wife and HCP [**Name (NI) 636**] [**Name (NI) 82967**] [**0-0-**]
Medications on Admission:
- lisinopril 40 mg PO BID
- methadone 20 mg PO QID
- methadone 10 mg PO Daily
- tizanidine 4 mg PO TID
- tizanidine 2 mg PO BID
- gabapentin 600 mg PO Q4H
- lorazepam 0.5 mgPO Q4H as needed for anxiety
- Plavix 75 mg Tablet PO once a day
- Colace 100 mg PO twice a day as needed for constipation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2
times a day).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
5. methadone 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
7. gabapentin 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. tizanidine 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check chemistry panel including sodium, potassium,
creatinine on Mon [**4-8**] and fax results to Dr. [**Last Name (STitle) 70557**]
[**Telephone/Fax (1) 83265**].
Discharge Disposition:
Home
Discharge Diagnosis:
[**Telephone/Fax (1) **]
Encephalopathy
Polycythemia [**Doctor First Name **]
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 82967**],
It was a pleasure treating you during this hospitalization. You
were admitted to [**Hospital1 69**] because of
confusion and an infection in the skin of your thigh. You were
initially admitted to the ICU because of concern for sepsis and
you were treated with IV antibiotics with improvement in mental
status and skin infection. You were switched to by mouth
medications with continued improvement in skin infection
clearing. Your mental status also improved back to baseline. You
should have a blood lab checked on Monday, which will be faxed
to your doctor and discuss the results when you see Dr. [**Last Name (STitle) **]
on Friday. Some of your medications may need to be adjusted
further.
The following changes to your medications were made:
- START Bactrim 2 DS tablets twice daily until [**2171-4-11**]
- DECREASE your lisinopril to 40mg tabs, 1 tab daily
- No other changes were made, please continue taking your home
medications as previously prescribed
Followup Instructions:
Name: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 83266**], MD
Specialty: Primary Care
When: Friday [**4-12**] at 11:30am
Location: [**Hospital3 **] HEALTH CENTER
Address: [**Street Address(2) 83267**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**0-0-**]
|
[
"42789"
] |
Admission Date: [**2112-4-25**] Discharge Date: [**2112-5-1**]
Date of Birth: [**2041-10-12**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Bladder Cancer
Major Surgical or Invasive Procedure:
radical cysto-prostatectomy with LN biopsy and ileal conduit
History of Present Illness:
This is a 70 year old man who presents with a long history of
bladder cancer, who has undergone multiple treatments including
BCG. He was found to have positive cytology on follow up and
now presents with tumor into the prostate. He is here for
cystectomy, he is otherwise without complaint.
Past Medical History:
Current medications include Lipitor, Monopril and coumadin for a
h/o CVA
Past medical history is significant for CVA and hypertension,
and
negative for myocardial infarction, angina, diabetes, colitis,
stroke, ulcer, lung disease, thyroid disease, hepatitis, gout,
sciatica or glaucoma.
Past surgical history includes a cholecystectomy in [**2094**] and an
abdominal aortic aneurysm repair in [**2100**].
Social History:
Lives at home with his wife, no tobacco
Family History:
Non-contributory
Physical Exam:
96.6 74 18 149/79 100%
NAD
RRR
CTA
Abd: Benign
Rectal: defered
Ext: warm, well perfused
GU: Nl appearing penis, no leisons
Pertinent Results:
[**2112-4-25**] 07:00AM PLT COUNT-232
[**2112-4-25**] 07:00AM WBC-7.1 RBC-4.37* HGB-13.7* HCT-39.2* MCV-90
MCH-31.3 MCHC-35.0 RDW-12.7
[**2112-4-25**] 08:30AM PT-16.1* PTT-33.0 INR(PT)-1.6
[**2112-4-25**] 08:58AM HGB-12.6* calcHCT-38
Brief Hospital Course:
The patient was admitted to the ICU overnight for observation.
He was maintained on NPO/IVF/NGT initially. He urostomy worked
well throughout his hospital course. On POD 1 he was extubated
and was given 3 doses of kefzol for peri-opertaive prophylaxis.
He was essentially without complain. He was restarted on his
coumadin. He did not pass flatus on POD 2. He was given a unit
of blood due to blood loss anemia. He self d/c'ed his NGT on
POD 3 and it was not replaced. On POD 4 he was advanced to
clear diet, which he tolerated well. On POD 6 he was tolerating
food well and he was sent home on PO pain meds to F/U with Dr.
[**Last Name (STitle) **]
Medications on Admission:
Liptitor
Coumadin
Monopril
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
bladder cancer
Discharge Condition:
good
Discharge Instructions:
take pain meds as needed, please do not drink alcohol or drive
any vehicle while taking narcotic pain meds. No driving for
about 4 weeks - unless cleared earlier at f/u visit with Dr.
[**Last Name (STitle) 261**]. please call office or return to ED with any concerning
sign including: fever >101.0, uncontrollable pain, leakage or
redness around wound, or emesis/nausea.
resume all preop medications - including regular doses of
coumadin, lipitor and zestril.
Followup Instructions:
f/u with Dr. [**Last Name (STitle) 261**], enterostomy therapy nurse
Completed by:[**2112-6-20**]
|
[
"42731",
"4240",
"V5861",
"4019"
] |
Admission Date: [**2139-3-11**] Discharge Date: [**2139-3-31**]
Date of Birth: [**2089-7-20**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
hemothorax
Major Surgical or Invasive Procedure:
Liver Biopsy.
Intubation.
Chest Tube placement.
PICC placement.
History of Present Illness:
49 M c/ PMH HCV and alcoholic cirrhosis, presented on [**3-10**] for
biopsy and fiducial placement into liver by interventional
radiology for 2 liver nodules that are being followed. The
patient has had shortness of [**Last Name (un) 6250**] and some evolving chest pain
in the setting of dizziness. Evaluation
at an outside hospital revealed a HCT of 24, down from a HCT in
the 40's in [**Month (only) 1096**]. The patient was given 2 units of blood and
imaging at an outside hospital revealed a large hemothorax in
the
R lung. HE was subsequently transferred here for further care
and
management. He now complains of dull lower R lateral chest pain.
No sharp pain, no radiation. not position dependent. No
alleviating or exacerbating symptoms other than cough and
pressure feom the outside. Notably patient had a fall several
weeks ago where he reports he was found at an outside hospital
to
have a lung contusion and possible history of broken ribs.
.
Pt has a long history of alcoholism and had his last drink 3
days
ago prior to presenting to the hospital for his biopsy.
.
The patient denies fevers, chills, nausea, vomiting.
.
Patient's hemothorax was evacuated through his chest tube, on
day of transfer he had drained approximately 120 cc over 12
hours. He received a total of 2 additional units of pRBCs during
his SICU stay and 1 unit of FFP. He required multiple boluses of
midazolam and high doses of propofol gtt to maintain sedation.
He spiked temperatures as high as 103.3- these were attributed
to administration of blood products and cultures and antibiotics
were not sent. He developed seizure-like activity on [**3-12**] at
7pm. Neurology was consulted who recommended uptitration of
versed and diazapam boluses as needed and continuous EEG
monitoring. Seizures were felt to be secondary to delirium
tremens. Patient continued to spike, suffered from decreased
urine output. Attempts were made to wean patient off propofol by
adding fentanyl, decrease midazolam. Patient was felt to be
stable from a thoracics standpoint and was transferred to the
MICU for further management.
.
On evaluation, patient was intubated, sedated, unresponsive and
actively seizing.
.
Review of systems: Unable to obtain ROS given patient's mental
status.
Past Medical History:
HCV
Alcoholism
HTN
Esophageal varices
s/p hernia repair
Social History:
Lives on [**Location (un) **] with his wife, has 2 children. Smokes [**2-1**] ppd,
drinks ~3 nips of Whiskey a few times per week. Reports he has
been in rehab for ETOH before and has experienced symptoms of
ETOH withdrawal. Reports remote history of marijuana use. Denies
IVDU.
Family History:
DM, stroke, cardiac disease.
Physical Exam:
Vitals: T: 97.8 BP: 148/84 P: 101 R: 17 O2: 100%
General: intubated, sedated, unresponsive; total body tremor
HEENT: Icteric sclerae; pupils 2mm, but b/l reactive to light;
dry MM; OG and endotracheal tube in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, distended, bowel sounds present, no rebound
tenderness or guarding; + ascites; unable to assess tenderness
given mental status
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: jaundiced
Discharge Physical Exam:
General: NAD
HEENT: Anicteric sclerae
Lungs: CTA-bilateraly
CV: Normal S1, and S2 no S3 or S4, no murmurs, rubs, or gallops
Abd: Soft, Non-tender, non-distended, non-tympanic. No
ascities.
Pertinent Results:
ADMISSION LABS
[**2139-3-11**] 06:15PM BLOOD WBC-8.3# RBC-3.01* Hgb-10.0* Hct-27.8*#
MCV-92# MCH-33.1* MCHC-35.8*# RDW-19.4* Plt Ct-44*
[**2139-3-10**] 09:30AM BLOOD PT-14.7* INR(PT)-1.3*
[**2139-3-11**] 06:15PM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-134
K-3.4 Cl-98 HCO3-25 AnGap-14
[**2139-3-11**] 06:15PM BLOOD ALT-53* AST-249* AlkPhos-104 TotBili-3.1*
[**2139-3-11**] 06:15PM BLOOD Lipase-33
[**2139-3-11**] 06:15PM BLOOD Albumin-3.0*
[**2139-3-12**] 12:57AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.2*
[**2139-3-11**] 06:30PM BLOOD Glucose-98 Lactate-3.2* Na-136 K-3.5
Cl-97* calHCO3-26
[**2139-3-11**] 11:00PM URINE Type-RANDOM Color-Amber Appear-Clear Sp
[**Last Name (un) **]->1.035
[**2139-3-11**] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-12* pH-6.5 Leuks-NEG
[**2139-3-11**] 11:00PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2139-3-11**] 11:00PM URINE CastHy-0-2
.
PERTINENT LABS
[**2139-3-15**] 03:33PM ASCITES TotPro-1.7 Glucose-142 LD(LDH)-67
Albumin-LESS THAN
[**2139-3-15**] 03:33PM ASCITES WBC-200* RBC-[**Numeric Identifier **]* Polys-43*
Lymphs-10* Monos-0 Mesothe-1* Macroph-46*
.
MICROBIOLOGY:
Blood Cultures 2/10, [**3-13**], [**3-15**], [**3-19**]: No Growth
.
URINE CULTURE (Final [**2139-3-15**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. 10,000-100,000 ORGANISMS/ML.
.
Urine Cultures 2/13, [**3-19**]: No Growth
.
[**2139-3-12**] 8:16 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2139-3-15**]**
GRAM STAIN (Final [**2139-3-13**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2139-3-15**]):
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
HAEMOPHILUS SPECIES NOT INFLUENZAE. MODERATE GROWTH.
.
[**2139-3-15**] 3:33 pm PERITONEAL FLUID
**FINAL REPORT [**2139-3-21**]**
GRAM STAIN (Final [**2139-3-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2139-3-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2139-3-21**]): NO GROWTH.
.
PATHOLOGY:
[**2139-3-10**] LIVER CORE BX (1 JAR)
1. Established cirrhosis (Stage IV). Trichrome stain evaluated
and also shows focal sinusoidal fibrosis.
2. Moderate predominantly macrovesicular steatosis. Rare cells
with balloon degeneration are seen.
3. Mild chronic inflammation of portal areas/fibrous tracts
with bile ductular proliferation.
3. Iron stain is negative.
4. No carcinoma seen. Additional levels and reticulum stain
examined.
Note: The findings are consistent with cirrhosis with focal
features consistent with a component of metabolic injury. The
patient also has a clinical history of hepatitis C.
.
CYTOLOGY
[**2139-3-15**] Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS.
.
IMAGING
[**2139-3-11**] CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST:
CT CHEST: There is a large right hemothorax with collapse of the
right lowerand middle lobes. Only a portion of the right upper
lobe remains aerated. Layering hyperdense blood products is
noted posteriorly within this hemothorax. While there is no
evidence of active extravasation on this study, the cause of
this bleeding is likely due to bleeding from an intercostal
vessel or from the diaphragm as there is a fiducial seed noted
immediately adjacent to or through the diaphragm at the dome of
the liver. No definite diaphragmatic defect. There is no
pneumothorax. The left lung is clear with minimal dependent
atelectasis. The heart size is normal.
CT ABDOMEN: The liver is nodular in contour consistent with
known cirrhosis. Three fiducial seeds are present at the dome of
the liver with the most superior seed abutting the diaphragm.
Hypodensities are again noted in the liver, unchanged since the
prior study. The portal, hepatic, splenic, and superior
mesenteric veins remain patent. Extensive varices including
paraesophageal and recannulated umbilical vein and vein of
Sappey are present. The spleen, pancreas, stomach, adrenal
glands, and kidneys are within normal limits. Small amount of
ascites is again noted surrounding the liver. This fluid remains
low density and volume is stable since the prior studies, likely
simple ascites. There is no evidence of hemoperitoneum. The
gallbladder is normal. There is no free air.
CT PELVIS: The appendix is somewhat prominent but is unchanged
in appearance over multiple prior studies. The rectum, prostate,
and bladder are within normal limits. A small amount of fluid is
noted within the pelvis, unchanged.There is no inguinal or
pelvic lymphadenopathy. Intrapelvic loops of bowel are within
normal limits.
BONE WINDOWS: Multiple old rib fractures are noted in the right
hemithorax.
No concerning osseous lesions are identified. Wedge compression
fraction of
vertebral body T6 is unchanged since [**2138-3-5**].
IMPRESSION:
1. Interval development of large right hemothorax with right
lower and middle lobe collapse. The right upper lobe remains
mostly aerated. While there is no evidence of active
extravasation on this study, the source of this bleeding could
be from an intercostal vessel or from injury to the diaphragm
from the recent procedure.
2. Cirrhotic liver with multiple varices, as seen and
characterized on
multiple prior studies.
3. Small amount of abdominal ascites, unchanged in volume with
no evidence of hemoperitoneum.
.
[**2139-3-11**] CHEST (PORTABLE AP)
Interval insertion of right-sided chest tube with re-expansion
of
the right mid and lower lobe and evacuation of large right
hemothorax.
Minimal right lower lung atelectasis persists.
.
[**2139-3-13**] EEG
This prolonged EEG recording captured three pushbutton
activations. One showed shaking activity that appeared to be
shivering
or a behavioral change and not epileptic, and the EEG at the
time showed
just the movement artifact with the same frequency as the
movements.
There was plentiful movement and muscle artifact throughout the
rest of
the recording, but the background showed a low voltage record,
often
with some generalized slowing. This suggested a widespread
encephalopathy, and the faster activity raised the possibility
that some
of this was due to medications. There were no clear seizures.
.
[**2139-3-15**] Chest (Portable AP)
The endotracheal tube is 4 cm above the carina. The NG tube tip
is
off the film, at least in the stomach. There is a right lower
lobe infiltrate that is increased in the interval. There is also
increased opacity in the left lower lung which is predominantly
due to volume loss but underlying infectious infiltrate cannot
be excluded. There is pulmonary vascular redistribution. There
is a small right effusion.
IMPRESSION: Worsening appearance of the lungs, particularly on
the right.
.
[**2139-3-16**] Abdomen (Supine Only)
here is a nonspecific bowel gas pattern with no evidence of
overt
obstruction or pneumatosis. There is graying of the abdomen
suggestive of
ascites. An NG tube is visualized with the tip in the stomach.
Visualized
osseous structures are grossly unremarkable.
IMPRESSION: Nonspecific bowel gas pattern with no evidence of
obstruction.
.
[**2139-3-18**] RUQ U/S:
The liver is nodular in contour and heterogeneous in
echotexture, in keeping with known history of cirrhosis. A cyst
with peripheral calcification measuring 1.5 cm is seen
anteriorly in the left lobe, unchanged from prior study. The
liver dome is not well visualized.
There is no intra- or extra-hepatic biliary ductal dilation.
Common bile duct is normal in caliber, measuring 5 mm. The
gallbladder is not distended, and there are no stones within,
though a small amount of sludge is present. The gallbladder is
thick-walled and edematous, though given the lack of gallbladder
distention, this likely reflects third spacing and
underlyingliver disease. Moderate ascites and right pleural
fluid is noted. The spleen measures 9.9 cm.
IMPRESSION:
1. No evidence of acalculous cholecystitis. In the setting of a
non-distended gallbladder, gallbladder wall thickening likely
reflects third spacing and underlying liver disease
2. Nodular coarsened liver, compatible with known history of
cirrhosis. A
cyst is seen anteriorly in the left lobe, as on prior CT. The
liver dome is
not well evaluated on this study.
3. Ascites and right pleural fluid.
Brief Hospital Course:
The patient is a 49 yo M with Hep C and EtOH Cirrhosis who
presented after liver biopsy with hemothorax now who was
transferred to the hepatorenal service following a prolonged
MICU course complicated by delirium tremens and pneumonia.
.
#. Ventilator Associated Pneumonia: On admission to the ICU the
patient was noted to have sputum culture growing H.Influenzae.
He had been intubated for hemodynamic instability (tachycardia,
HTN, in the presence of high grade fevers). He was treated with
ceftriaxone and azithromycin. Later in his MICU course he was
started on vancomycin and cefepime for a question of ventilator
associated pneumonia, as extubation was proving to be difficult.
He was eventually successfully extubated and called out to the
hepatorenal service. By day 2 of his antibiotics he was
breathing well on room air. His antibiotics were stopped in
sequence as he remained breathing well on room air, afebrile,
and with a decreasing white count. He received three days of
vancomycin and four days of cefepime.
.
#. Delirium Tremens / Hepatic Encepholopathy / ICU Delirium: The
patient was disoriented upon transfer to the hepatorenal
service, but showed no evidence of agitation. He was treated
with lactulose and rifaximin and quickly returned to his
baseline mental status. At the time of discharge he was not
confused or encephalopathic. He was alert and oriented x 3 at
the time of discharge.
.
#. Acute Renal Failure - The patient's creatinine increased to
1.3 from baseline of 0.6, likely due to pre-renal causes. His
lasix and aldactone were held. He was discharged home on his
home dose of aldactone. His Cr was 1.1 and will require follow
up as an outpatient.
.
#. EtOH Cirrhosis complicated by ascites, varices: The patient
was maintained on a low salt diet. He continued on lactulose
and rifaximin. Diuretics were held in the setting of acute
renal failure (see above). He did not have an EGD prior to
discharge. His last EGD was [**2136**].
.
#. Liver Lesions: The IR guided biopsy showed no evidence of
malignancy. The patient will need surveillance MRI in 3 months
time.
.
#. Hyperglycemia: The patient developed hyperglycemia while on
TPN. He was started on an insulin sliding scale which was
discontinued once he was off TPN and tolerating po's without
evidence of hyperglycemia. His TPN was discontinued prior to
discharge.
.
#. Code - Full Code.
.
# Contact: Mother: [**Name (NI) **] [**Name (NI) **] HCP: [**Telephone/Fax (1) 78895**]
.
# Possible Issues for Readmission: 1) The patient continues to
drink despite counseling. He was advised to start PT at home
with outpatient detoxification.
Medications on Admission:
chlordiazepoxide 10-20 mg q4-6H PRN shakes
magnesium oxide 400 [**Hospital1 **]
gabapentin 300 TID
spironolactone 25 daily
MVI daily
Discharge Medications:
1. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please take until you have [**4-3**] bowel movements per
day.
Disp:*2700 ML(s)* Refills:*2*
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Physical Therapy
Please do excercises to increase gain stability.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hemothorax
Ventilator associated pneumonia
Delirium secondarily to hepatic encephalopathy and ICU stay
Delirium tremens and alcohol withdrawal with possible seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 78893**]
You were admitted to [**Hospital1 69**] for a
blood in your thorax, alcohol withdrawl, penumonia and and
changes in your ability to think. You were evaluated by
physical therapy and occupational therapy who think you are safe
to return home. You will need to refrain from drinking alcohol.
The following meidcation chnages were made:
ADDED:
Lactulose, which will cause diarrhea. You must have ~3 bowel
movements a day.
Rifaximin, which will also prevent you from getting confused.
STOPPED:
Gabapentin: given your confusion.
Chlordiazepoxide
Magnesium
Followup Instructions:
Department: TRANSPLANT
When: FRIDAY [**2139-4-3**] at 10:00 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2139-4-1**]
|
[
"51881",
"5849",
"5180",
"5990",
"2875"
] |
Admission Date: [**2192-5-12**] Discharge Date: [**2192-5-22**]
Date of Birth: [**2126-6-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Right foot ulcer getting worse
Major Surgical or Invasive Procedure:
Incision and drainage, right foot with amputation of right
hallux.
Repeat incision and drainage, right foot
History of Present Illness:
65 year old male with type 2 diabetes, HTN,
Hypercholesterolemia, CAD and history of remote stroke, current
smoker, who was brought to the [**Hospital1 882**] ER by his brother
secondary to concern about the state of his R foot. They
transferred him to [**Hospital1 18**] as he gets all of his podiatric care
here with Dr. [**Last Name (STitle) **]. He has had chronic diabetic foot ulcers
of both feet, most recently a persistent ulcer on the plantar
surface of the 1st metatarsal for the last few months. He has
been non-weight bearing on his R foot for at least the last
month, however he admits to walking on it recently. His brother
says the ulcer has gotten progressively worse, with a foul odor.
His R leg has also gotten progressively more swollen over the
last week. He was scheduled for pre-operative evaluation with
Dr. [**Last Name (STitle) **] on [**5-22**], with surgery planned for [**5-29**].
At [**Hospital1 882**] his vitals were 102.0, 110, 100/60, 95% on RA. His
labs were notable for a WBC of 14 with 9% bands, as well as Na
of 129, K 5.2, BUN 12, creat 0.6. He received vancomycin and
zosyn, and was seen by surgery who recommended transfer to [**Hospital1 18**]
for probably surgery.
In the ED here his vitals were 101.3, HR 113, 95/palp, 14, 95%
RA. He was given vancomycin and clindamycin. A L IJ was placed
after unsuccessful attempts at a SC, and code sepsis was called.
His CVP was 5. He received 6L NS in the ED, and was started on
a levophed drip. He was seen by podiatry who are planning on
taking him to surgery within the next couple of days pending
"medical stability."
The patient denies fevers, but thinks he's had some "sweats"
over the last week. He says he's been feeling otherwise well.
Denies any lightheadedness, dizziness, chest pain. He gets
shortness of breath when going up a flight of stairs. At
baseline he says he can walk around without difficulty and go up
stairs without difficulty. He does not exercise.
Past Medical History:
1) Type 2 DM, with neuropathy, complicated by chronic diabetic
foot ulcers secondary to plantar flexed first metatarsal for
which he has multiple antibiotic courses.
2) HTN
3) Hypercholestremia
4) CAD
5) CVA [**95**] years ago, on ASA and plavix since
6) Carotid enderectomy
7) Status post cholecystectomy, appendectomy.
Social History:
Patient is separated from his wife for the last 10 years,
currently living with his brother. They have 5 children, some
of which are in the area. He says he just quit smoking
yesterday, but has smoked 1/2-1 PPD x 50 years. He used to
drink heavily, about a 6 pack on the weekends, but is in AA and
has been sober x 10 years. Denies IVDU.
Family History:
Mother and father both had DM, both deceased. Father with MI at
60 and PVD. Mother had a stroke.
Physical Exam:
100.4, 95, 99/69 MAP 79, CVP 10, RR 22, 94% RA.
I/O: 6214/280.
Gen: Overweight caucasian male appearing slightly disheveled.
Conversant. AAO x 3. Foul smelling.
HEENT: Dry MM.
Neck: JVP at 10 cm.
Cor: RR, normal rate, 2/6 systolic murmur at LSB without
radiation.
Lungs: CTA b/l, no w/r/r.
Abd: NABS, soft, large oblique scar in RUQ, vertical scar in
RLQ.
Extr: 2+ pitting edema of R leg up to mid-tibia. Erythema of
RLE up to ankle. L foot with strong DP/PT pulses, diminished
sensation, no active ulcers. On plantar aspect of R 1st
metatarsal there is a 2-3 cm ulcer with purulent base, marked
surrounding edema and erythema, and foul smelling odor.
Pertinent Results:
R foot plain film:
TWO VIEWS RIGHT FOOT: Deformity and cortical irregularity of the
distal first metatarsal is unchanged. Well-healed osteotomy of
the mid shaft of the second and fourth metatarsals. Improved
appearance of resected distal third metatarsal. Soft tissue
abnormality on the plantar aspect of the foot. There is slight
hallux valgus deformity.
IMPRESSION:
1. Unchanged appearance of cortical irregularity of the first
metatarsal head. No adjacent subcutaneous emphysema noted.
2. Soft tissue defect noted on the plantar aspect of the foot.
.
R foot plain film, post-amputation:
RIGHT FOOT, THREE VIEWS: Comparison with [**2192-5-12**]. There has
been interval amputation of the first great toe from the distal
portion of the first metatarsal. There is accompanying soft
tissue loss. The third distal metatarsal is noted to be
resected. Well-healed second and fourth metatarsal osteotomies
again noted.
IMPRESSION: No definite evidence of osteomyelitis after great
toe amputation.
.
PA/Lateral CXR:
PA AND LATERAL VIEWS OF THE CHEST: Right PICC tip is
demonstrated within the proximal right atrium. The heart is
normal in size. The aorta is tortuous. An opacity is present
within the medial right upper lobe, in the right suprahilar
region, which appears to have been present dating back to
[**2189-2-18**]. Although this could represent overlapping
shadows, an underlying mass cannot be fully excluded. The lungs
are otherwise clear. There is no effusions or pneumothorax.
IMPRESSION:
1. Right PICC tip in the proximal right atrium. Findings
discussed with the IV nurse at 3:30 p.m., [**2192-5-16**].
2. Opacity in the right suprahilar region, which may represent
overlapping structures, but an underlying mass cannot be
excluded. Chest CT is recommended for further evaluation.
.
Chest CT:
FINDINGS: There is no evidence of significant mediastinal or
hilar lymphadenopathy. No pericardial or pleural effusion.
Coronary arteries are extensively calcified. Note is made of
aortic wall calcification.
In the lung window, note is made of mild paraseptal emphysema.
No evidence of consolidation is noted. No nodule or mass is
identified. No endobronchial lesion. Note is made of somewhat
distorted architecture of the right middle lobes as well as
major fissure on the right, with atelectasis in the medial
aspect. Right upper lobe bronchus is not identified. Somewhat
prominent fat in the mediastinum. These findings may contribute
to the opacity seen on prior chest x- ray. Pleural calcification
on the right.
In the visualized portion of the upper abdomen, note is made of
calcified granuloma. Note is made of bilateral adrenal nodule,
measuring 2.3 cm on the right and 1.5 cm on the left, with
Hounsfield units up to 30, of indeterminate character.
There is no suspicious lytic or blastic lesion in skeletal
structures.
IMPRESSION:
1. No evidence of mass or consolidation. Somewhat distorted
appearance of the lung architecture of the right upper chest,
which may somewhat contribute to the finding on chest x-ray.
Right upper lobe bronchus not identified. Is this patient post
right upper lobectomy?
2. Bilateral adrenal nodule as described above, of indeterminant
characteristics, probably hypertrophy. Please correlate with
clinical history, and if necessary, please evaluate by adrenal
MRI.
3. Extensive coronary artery calcification and aortic valve
calcification.
4. Pleural calcification on the right.
.
[**2192-5-12**] 12:15AM BLOOD WBC-11.6* RBC-4.26* Hgb-13.1* Hct-37.2*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.0 Plt Ct-338
[**2192-5-12**] 12:15AM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2192-5-22**] 06:19AM BLOOD WBC-6.1 RBC-3.01* Hgb-9.4* Hct-27.3*
MCV-91 MCH-31.4 MCHC-34.6 RDW-15.6* Plt Ct-426
[**2192-5-12**] 12:15AM BLOOD PT-13.8* PTT-28.8 INR(PT)-1.2*
[**2192-5-12**] 12:15AM BLOOD Glucose-298* UreaN-15 Creat-0.9 Na-132*
K-4.1 Cl-95* HCO3-24 AnGap-17
[**2192-5-22**] 06:19AM BLOOD Glucose-151* UreaN-10 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
[**2192-5-12**] 12:15AM BLOOD ALT-16 AST-19 CK(CPK)-52 AlkPhos-55
Amylase-27 TotBili-0.6
[**2192-5-12**] 12:15AM BLOOD Lipase-43
[**2192-5-12**] 12:15AM BLOOD TotProt-7.3 Albumin-4.1 Globuln-3.2
Calcium-9.7 Phos-3.4 Mg-1.8
[**2192-5-20**] 06:30AM BLOOD Cortsol-7.1
[**2192-5-21**] 07:34AM BLOOD Cortsol-6.6
[**2192-5-12**] 01:45AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.037*
[**2192-5-12**] 01:45AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2192-5-12**] 01:45AM URINE RBC-21-50* WBC-[**2-26**] Bacteri-OCC Yeast-NONE
Epi-0-2
.
Micro:
R foot swab:
GRAM STAIN (Final [**2192-5-15**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2192-5-19**]):
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
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).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND STRAIN.
ANAEROBIC CULTURE (Final [**2192-5-19**]): NO ANAEROBES ISOLATED.
.
R foot tissue culture:
GRAM STAIN (Final [**2192-5-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2192-5-19**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 42657**] CC7A [**2192-5-14**].
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
VIRIDANS STREPTOCOCCI. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
PROTEUS VULGARIS. RARE GROWTH. WORK UP PER DR
[**Last Name (NamePattern4) 42658**] [**2192-5-17**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PROTEUS VULGARIS
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- 0.25 S <=0.25 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2192-5-17**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
.
R foot Swab:
GRAM STAIN (Final [**2192-5-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2192-5-15**]):
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).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PROTEUS SPECIES. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 208-7582S [**2192-5-12**].
ANAEROBIC CULTURE (Final [**2192-5-17**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 42659**] [**2192-5-12**].
.
R foot swab:
GRAM STAIN (Final [**2192-5-12**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2192-5-16**]):
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).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
PROTEUS SPECIES. SPARSE GROWTH.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
SENSITIVITIES PERFORMED ON CULTURE # 208-7582S [**2192-5-12**].
ANAEROBIC CULTURE (Final [**2192-5-16**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
.
Urine and Blood cultures: No growth
Brief Hospital Course:
65 year old male with type 2 diabetes, HTN,
Hypercholesterolemia, CAD and history of remote stroke, current
smoker, who presented with sepsis presumed from foul smelling R
foot ulcer.
1) Sepsis: Patient met criteria with fever, leukocytosis,
tachycardia, with suspected source of infection being his right
foot. He was admitted to the MICU and quickly weaned off
norepinephrine. He was started on vancomyin, levofloxacin, and
metronidazole per the recommendations of podiatry. After initial
fluid resuscitation, he was hemodynamically stable and afebrile.
His foot cultures were polymicrobial, growing coag negative
staph, strep viridans, MSSA, pansensitive proteus vulgaris,
bacteroides fragilis. After discussion with ID, antibiotic
regimen was tailored to nafcillin, to be continued until his
appointment with podiatry on [**6-1**] (will be 21 days treatment
at that point), and total 4 week course of levofloxacin and
metronidazole, to stop on [**2192-6-9**]. A PICC was placed, and he
was discharged with home VNA for antibiotics, PT, wound care.
.
2) Foot ulcer: He was seen by podiatry on arrival, who felt that
he needed semi-emergent amputation. He went to the OR within 18
hours of arrival for incision and drainage, and hallux
amputation. the procedure was without complications, and he was
taken back to the OR on [**5-15**] for repeat incision and drainage.
He had good healing, and was discharged with home VNA for home
antibiotics, PT, and wound care.
.
4) Hematuria: The patient developed grossly bloody urine after
foley placement in the ER. He described clear symptoms of BPH
with nocturia, urinary frequency with voiding of small amounts
of urine, therefore it was thought likely the he had prostate
trauma with foley placement. He was treated with CBI transiently
[**1-26**] clots and pain at the foley site. He was started on Proscar.
His hematuria gradually cleared over several days, and he never
developed recurrent clots or urinary retention.
.
5) Adrenal Nodules: Mr. [**Known lastname 27532**] had several CXR with
ill-defined R suprahilar opacity, thought to probably reflect
overlapping shadows, but could not r/o mass. A chest CT was done
to better characterize. Chest CT did not visualize suprahilar
mass, but did incidentally visualize bilateral adrenal nodules,
most likely reflecting hypertrophy. A dexamethasone suppression
test was done, which was inconclusive (AM cortisol day prior to
dex was 7.1, then 6.6 morning after dex administration). Mr.
[**Known lastname 27532**] should have these nodules worked up as an outpatient
with a dedicated MRI imaging study.
.
6) Diabetes: The patient was significantly hyperglycemic at
[**Hospital1 882**] and on arrival to [**Hospital1 18**]. He was started on an insulin
drip after arrival in the ICU, titrated to FS 80-120. His oral
hypoglycemics were initially held, but then restarted several
days prior to discharge due to hyperglycemia.
6) Vascular disease: The patient has had CEA and a stroke, and
is reported to have CAD, though there are no records here and he
denies any history of MI or abnormal stress test. He was on ASA
and plavix for his CEA/CVA, however these were held in
anticipation of surgery and in the context of gross hematuria as
above, and were restarted a few days prior to discharge.
7) FEN: He recieved a diabetic diet.
8) Code: His code was full, discussed with patient.
Medications on Admission:
Plavix
ASA
Glucophage
Glyburide
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gram
Intravenous Q6H (every 6 hours).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
13. Insulin NPH Human Recomb Subcutaneous
14. Insulin Lispro (Human) Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Infected diabetic foot ulcer
Sepsis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with an infected ulcer on your foot. You had
surgery to address this, and you are being discharged home on IV
antibiotics. You should continue to take all of your medicines
as directed. You should contact your physician if you experience
fevers, chills, worsening pain, inflammation, or pus from your
foot, or for any other problems that concern you.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 11139**] within the next 2-3 weeks.
You can call [**Telephone/Fax (1) 11144**] for an appointment.
You should follow up with Dr. [**Last Name (STitle) **] in podiatry on Friday,
[**2192-6-1**] at 9:30am
- Call ([**Telephone/Fax (1) 4335**] if you have any questions, or need to
reschedule.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"0389",
"496",
"2761",
"2720",
"4019"
] |
Admission Date: [**2167-5-27**] Discharge Date: [**2167-6-7**]
Date of Birth: [**2087-10-1**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB, increasing edema
Major Surgical or Invasive Procedure:
S/P Angioplasty L leg
EGD
Colonoscopy
History of Present Illness:
79-year-old M with prior CABG in [**2161**] (LIMA - LAD, SVG - OM2),
hypertension, hyperlipidemia, diabetes mellitus, chronic kidney
disease, peripheral arterial disease and prior episodes of heart
failure presents from [**Year (4 digits) **] clinic with incareasing SOB and
worsening edema. Pt. feeling more SOB over last month but more
so over last week. His diuretic regimen, Torsemide was recently
increased from 50mg twice a day to 100mg in am; 50mg in pm. Pt.
taking off HCTZ due to bump in creat 3.4 but pt. restarted on
own at 12.5mg daily. Nonpitting thigh edema & in lower legs.
Weight 208 & dry weight usually <200 lbs. Pt describes no Chest
pain, palpitations. At baseline, pt on home O2 at bedtime for
several years now 5L NC. Pt has also noted increasing abdominal
girth, thigh edema and worsening DOE.
.
ED COURSE: Started lasix gtt 1ml/mg/hr off at 1800, received ASA
325mg X1, NTG 0.4mg x3, GI Cocktail, morphine 2mg IV x1
Past Medical History:
1. CVA: ([**2154**]) 3-4 days of slurred speech and right facial
droop without residual symptoms. s/p CEA (documented however
patient without memory of this procedure)
2. IDDM (retinopathy, nephropathy, neuropathy)
3. CAD s/p 2V-CABG [**2161**]
4. CHF d/t diastolic + CRI EF 40-45% ([**1-13**]) baseline weight 200
5. NSVT
6. HTN
7. Hyperlipidemia
8. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**](?))
9. CRI (b/l around 2.9-3.1)
10. colon ca s/p hemicolectomy
11. h/o diverticulosis
12. h/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
13. prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
14. iron deficiency anemia on bone marrow aspirate ([**2157**])
15. interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out
sarcoidosis versus interstitial pulmonary fibrosis (IPF), versus
malignancy.) s/p flexible bronchoscopy and cervical
mediastinoscopy with biopsies ([**5-9**])
16. left cataract surgery
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: CABG, in [**2161**] anatomy as follows:
LIMA to LAD, SVG to major OM branch
.
Percutaneous coronary intervention, in [**3-8**] anatomy as follows:
1. Left main and one vessel severe coronary artery disease with
diffuse 3 vessel mild-moderate disease.
2. Normal right and left heart pressures.
.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient is widowed
and lives alone, but has assistance that comes into the home to
help around the house. He has VNA services once a week, and a
sister-in-law who assists with shopping. He is independent in
his ADLs. He is a retired foreman for [**Company 2676**]. He does have a
remote history of tobacco use, quit in his 20s. No history of
EtOH abuse or illicit drug use. At baseline, he gets short of
breath walking less than one block, and uses a walker.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - 96.0 BP 108/68 HR 80 RR 18 96%2L NC FS 131, WT 206.6
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Bibasilar crackles, no wheezing or rhonchi.
Abd: Soft, distended, NT, +BS. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits. +Fluid wave.
Ext: 2+ thigh edema, toe amputations on L and R foot,
non-palpable DP pulses, cool R foot (at baseline)
Pertinent Results:
Unilateral LE veins left [**2167-5-27**]
LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale, color, and
pulse wave Doppler demonstrates the common femoral vein,
superficial femoral vein, and popliteal veins to demonstrate
normal flow with normal phasic respiratory variation. With the
exception of the distal superficial femoral vein, which was not
visualized well enough to compress, all other veins were
compressible. Note is made of multiple left inguinal lymph
nodes, the largest of which measures 2.3 x 0.7 x 1.2 cm, but
which demonstrate likely fatty hila, evidence of benignity.
IMPRESSION: No evidence of DVT in left lower extremity.
.
Art ext [**2167-5-29**]
IMPRESSION: Significant left tibial arterial disease.
Inability to identify Doppler signal in the left posterior
arterial level.\
COMPARISON: When compared to the exam performed on [**2164-12-27**],
there are no significant changes except for the fact that no
Doppler signal was identified in the left posterior tibial
arterial level.
.
Left foot xray: [**2167-5-29**]
IMPRESSION: No radiographic evidence for osteomyelitis. Status
post first digit amputation.
.
PERTINENT LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-6-6**] 06:35AM 6.1 4.30* 10.4* 34.6* 81* 24.1* 29.9*
18.2* 159
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-6-6**] 06:35AM 154* 72* 2.6* 149* 3.6 108 30 15
.
COAGS:
PT PTT Plt Ct INR(PT) [**Name (NI) 36549**]
[**2167-6-6**] 06:35AM 19.0* 31.1 1.8
.
Digoxin
[**2167-6-5**] 01:00AM 0.7
Brief Hospital Course:
79 year old male with past medical history of CAD s/p CABG,
congestive heart failure, diabetes, and chronic renal
insufficiency here with CHF exacerbation and left foot ulcer
.
Acute on Chronic systolic and diastolic heart failure: Patient
with low EF, and diastolic failure. He presented with SOB and
weight of 206 pounds from a dry weight <200 per recent clinic
notes. He has edema to knees with clear lungs. ACS as cause for
the exacerbation was ruled out with cardiac markers x3. THe
patient was diuresed with IV lasix 80mg [**Hospital1 **] for several days
with goal net negative 2L. Daily weights were taken and strict
i/o were monitored. Once he LE edema improved and weight
approached 200, his was switched back to his home dose of
torsemide 100mg qAM and 50mg qPM. He was continued on toprol XL
100mg [**Hospital1 **] and Digoxin 0.0625. Also of note patients oxygen
requirement improved with diuresis. Per patient, he is on 5L at
home; he required 1-2L after diuresis. Subsequent to the
vascular procedure c/b GIB, his diuretics were held. His home
torsemide was resumed prior to discharge.
.
Left Toe Ulcer/Claudication/PVD: Patient complaining of
claudication when walking and at rest. s/p 2 toe amputations.
Vascular was consulted. Pt's coumadin was held prior to going to
the OR, he was placed on a hep gtt with PTT goal 60-80 prior to
going to the OR. Vascular took pt to OR for angio on Tuesday per
results of NIAS: Significant left tibial arterial disease. He
underwent Left leg arteriogram and angioplasty with below-knee
popliteal anterior tibial arteries. His course was complicated
by a GIB in setting of his known GI AVMs.
.
GIB: Pt with known AVMs and known prior GIBs. Following
heparinization for the vascular procedure pt's PTT was
supratherapeutic, Hep was reversed with potamine. Pt
subsequently started to have BRBPR in addition to melena. Pt's
HCT also dropped. He was sent to the MICU for closer monitor. He
received 2 UPRBC while in the MICU, his HCT was stable at 34, he
had no further melena or hematochezia. Pt was instructed not to
resume coumadin per Dr. [**First Name (STitle) 437**], indefinately given high risk of
rebleeding. His ASA 81mg was resumed, tolerated well.
.
CAD: PAtient ruled out for ACS with cardiac enzymes negative x3.
s/p CABG. troponins at at baseline 0.18 and CKs are flat. ASA
325 mg, toprol 100BID, Simvastatin 10mg daily, however with GIB
as above his aspirin was initially held, his BB was held
initially but resumed and titrated up slowly. At time of
discharge his Aspirin was resumed at 81mg daily. Simvastatin was
continued.
.
Adjustment disorder: Patient with difficulty adjusting to
medical problems. Psychiatry consult appreciated and they
recommened psych VNA. PAtient also with trouble sleeping. They
recommended to avoid ambien, since patient confused with this
and also avoid trazadone. They recommend to use low dose remeron
for sleep when needed. social work consult also appreciated whom
recommended using social network, given involved family to help
with coping.
.
Atrial Fibrillation: diagnosed recently, rate controlled and on
coumadin. Continued toprol 100mg [**Hospital1 **], digoxin and coumadin 1mg
daily. As noted above, his coumadin was held prior to the OR,
given GIB no anticoagulation was resumed. His BB as noted above
also held but resumed and titrated to 75mg [**Hospital1 **]. His dig was
continued.
.
Diabetes Mellitus type II: Cont home regimen of lantus and
hemalog sliding scale.
- lantus 32 units q am, humalog per sliding scale, less
aggressive in PM. No ace-i given renal insufficiency. Diabetic
diet. His lantus was decreased to 16U qam due to some episodes
of hypoglycemia. This is to be retitrated up per PCP as an
outpatient. His FS were stable at time of discharge without
further episodes of hypoglycemia.
.
acute on chronic Renal insufficiency: Patient has long standing
renal insufficiency, with recent baseline around 3.0. [**Month (only) 116**] be
secondary to poor forward flow with CHF exacerbation, improved
with diuresis. Pt also received mucomyst 1200mg [**Hospital1 **] x2 days
prior to and subsequent to his angiography. He also received
bicarb prior to the procedure. At time of discharge his Cr was
at his baseline 2.6. Epo as outpatient
Calcitriol at home dosing.
.
History of stroke: given GIB his anticoagulation was held. ASA
was resumed.
.
Hyperlipidemia: Continued home dose of simvastatin.
.
Hypertension: Continuing home medications
.
Iron deficiency: Continuing iron
.
Anemia: HCT improved with 2UPRBC as noted above, receives epo on
outpatient basis.
.
Insomnia: behavioral, low dose remeron if needed, avoid ambien
and trazadone per psychatry
.
CODE: Spoke with pt at length who was very lucid at time of
conversation. He expressed his wish to be DNR/DNI. His son is
his HCP. [**Name (NI) **] pt, family is aware of his wishes and respect his
DNR/DNI status.
Medications on Admission:
-ASA 325mg qd
-calcitriol 0.25mcg qd
-coumadin 1mg qd
-digoxin 0.0625mg qd
-colace
-epo 2,000 u/ml per renal clinic,
-iron qd
-insulin lantus 32 units q am, humalog per sliding scale,
-mag 250mg qd,
-omeprazole 20mg [**Hospital1 **]
-kcl 10meq qd
-simvastatin 10mg qd
-toprol xl 200mg [**Hospital1 **]
-Torsemide 100mg in am;50mg in pm
-HCTZ 25mg as needed
-ambien 5mg prn
Discharge Medications:
1. Torsemide 100 mg Tablet Sig: One (1) Tablet PO each morning.
2. Torsemide 100 mg Tablet Sig: [**1-7**] Tablet PO each evening.
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. 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*
5. Digoxin 125 mcg Tablet Sig: one half Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): 75mg [**Hospital1 **].
Disp:*180 Tablet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous qAM.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
-Acute on chronic systolic and diastolic CHF
-Ischemic L leg s/p angioplasty
-GIB from known AVMs
Secondary:
1. CVA: ([**2154**]) 3-4 days of slurred speech and right facial
droop without residual symptoms. s/p CEA (documented however
patient without memory of this procedure)
2. IDDM (retinopathy, nephropathy, neuropathy)
3. CAD s/p 2V-CABG [**2161**]
4. CHF d/t diastolic + CRI EF 50% ([**2-12**]) baseline weight 200
5. NSVT
6. HTN
7. Hyperlipidemia
8. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**](?))
9. CRI (b/l 2.3-2.5)
10. colon ca s/p hemicolectomy
11. h/o diverticulosis
12. h/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
13. prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
14. iron deficiency anemia on bone marrow aspirate ([**2157**])
15. interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out
sarcoidosis versus interstitial pulmonary fibrosis (IPF), versus
malignancy.) s/p flexible bronchoscopy and cervical
mediastinoscopy with biopsies ([**5-9**])
16. left cataract surgery
[**76**]. Depression w/adjustment disorder
Discharge Condition:
Stable, no further bleeding, HCT stable
Discharge Instructions:
You were admitted with a CHF exacerbation. You were diuresed
with good effect. Your home diuretic was resumed at time of
discharge.
You must weigh yourself daily, call Dr. [**First Name (STitle) 437**] if your weight
increases by more than 3pounds. You must restrict your salt
intake and fluid intake to no more than 1.5 liters.
.
If you have chest pain, shortness of breath, palpitations,
lightheadedness, dizziness or bleeding from your rectum, black
stools call your physicians or go to the emergency room.
.
Your anticoagulation was held in the setting of bleeding.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2167-6-16**] 2:00
.
Please call Dr.[**Name (NI) 72943**] office tomorrow at [**Telephone/Fax (1) 18325**] to
schedule a follow up appointment in the next week.
Completed by:[**2167-6-8**]
|
[
"2851",
"42731",
"V5861",
"4280",
"V4581",
"2724",
"40390",
"5859"
] |
Admission Date: [**2169-12-31**] Discharge Date: [**2170-1-4**]
Service: CCU/CA
CHIEF COMPLAINT: The patient is an 80 -year-old female with
acute inferior myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is an elderly female
with a history of coronary artery disease and a history of
patient has not had a prior catheterization prior to this
admission and a past medical history notable for diabetes
type II and hypertension, who is admitted for urgent cardiac
catheterization for acute myocardial infarction on [**2169-12-31**]. The patient also has a history of angina since her
prior myocardial infarction; however, she remains active and
independent, limited by sciatica and chronic low back pain.
About three days prior to admission she began to have
intermittent substernal chest pain described as sharp,
located in the middle of her chest, no radiation, no
shortness of breath, no nausea, no diaphoresis. The symptoms
were unrelated to exertion, position, or meals. The symptoms
would last anywhere between ten and sixty minutes, eventually
resolving spontaneously.
She had two to three episodes per day until the morning of
admission when her pain recurred at rest and it was more
intense than the previous episode. The pain lasted
approximately three to four hours and she came to the
Emergency Department where her electrocardiogram revealed
inferior ST elevations. She was hemodynamically stable with
a heart rate of 70 to 80, systolic blood pressure of 130 to
150, O2 saturation of 98% to 100% on four liters nasal
cannula. She denied shortness of breath, initially denied
nausea, but vomited once in the Emergency Room. She denied
paroxysmal nocturnal dyspnea, orthopnea, edema, dyspnea on
exertion.
She was brought emergently to the Catheterization Lab where
stents were placed successfully in her proximal and mid right
coronary artery. Her L-V end diastolic pressure was 16.
Subsequently she was brought to the Cardiac Care Unit for
further evaluation and management.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type II.
2. Bursitis of the right hip.
3. Sciatica down right leg.
4. Low back pain.
5. Hypertension.
6. Coronary artery disease, status post old myocardial
infarction, not documented.
7. Glaucoma.
8. Osteoarthritis.
9. History of a fall five years ago.
ADMITTING MEDICATIONS: Include Glyburide 10 mg po q day,
Nifedipine 90 mg po q day, Zestril 40 mg po q day, Motrin,
aspirin 325 mg po q day, sublingual nitroglycerin prn, eye
drops for glaucoma (the patient does know name of eye drops),
Tylenol #3 prn pain, valium prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her husband and son.
She is active and independent. No alcohol or tobacco.
FAMILY HISTORY: Bone and lymphoma cancer, coronary artery
disease, and Parkinson's disease.
PHYSICAL EXAMINATION: Vital signs: blood pressure 104/50;
pulse 82; respirations 19; O2 saturation 98% on room air.
General: the patient is in no acute distress, alert and
oriented times three. Head, eyes, ears, nose, and throat:
extraocular muscles intact, pupils constricted, mildly
reactive, dry mucous membranes, sclerae anicteric. Neck: no
elevated jugular venous pulse, supple, no lymphadenopathy, no
thyroid nodules or thyromegaly. Lungs clear to auscultation
bilaterally, anteriorly and laterally. Heart: regular rate
and rhythm, normal S1, S2, no murmurs, rubs, or gallops.
Abdomen is obese, soft, nontender, nondistended.
Extremities: there is no clubbing, feet are slightly cool, no
edema. There is a right groin hematoma that is extremely
large, about the size of a grapefruit. Distal pulses in the
lower extremities are 2+ bilaterally. Neurologic: the
patient is alert and oriented times three, moves all four
extremities symmetrically. Sensation grossly intact.
LABORATORY DATA: White blood cell count 18.3, hematocrit
37.6, platelets 242,000. Coagulation studies within normal
limits. Chem 7 within normal limits with a BUN of 19 and
creatinine of 0.6. CK 140, MB 10, index 7.1.
Electrocardiogram, pre-catheterization: sinus rhythm in the
80's with 3.0 mm to 4.0 mm ST segment elevation inferiorly,
2.0 mm ST segment depressions in V2 through V4, 1.[**Street Address(2) **]
depressions in V5 through V6. Post-catheterization: the
patient had 2.[**Street Address(2) **] elevations inferiorly. Cardiac
catheterization on [**2169-12-31**]: mild disease in left
main coronary artery, left anterior descending with diffuse
disease to mid with bulging collaterals, left circumflex
diffuse disease with 70% first obtuse marginal artery, right
coronary artery 70% mid, 100% distal. Both lesions were
stented with good flow.
HOSPITAL COURSE:
1. Cardiovascular rhythm: The patient was maintained on
telemetry in the Cardiac Care Unit and was noted to have
occasional ventricular bigeminy; however, the patient
remained hemodynamically stable and asymptomatic.
Electrocardiograms showed normalization of her ST changes and
showed no rhythm abnormalities. Status post acute inferior
myocardial infarction, status post stenting to mid and distal
right coronary artery with successful revascularization.
The patient was started on aspirin, Plavix. Beta blocker was
added after the patient's blood pressure tolerated, and an
ACE inhibitor was also added. The patient's Nifedipine was
discontinued. The patient remained hemodynamically stable
while in hospital without any further chest pain, nausea or
vomiting, or other cardiac symptoms.
Echocardiogram on [**2170-1-1**], showed an ejection
fraction of 50%, mild regional left ventricular systolic
dysfunction, basal inferior akinesis, trace mitral
regurgitation.
2. Peripheral vascular: The patient was noted to have a
large right groin hematoma, status post catheterization and
on the evening of [**2170-1-1**], the hematoma was noted to
be enlarging. Ultrasound was obtained that showed a
pseudoaneurysm. Peripheral Vascular Surgery was consulted,
who recommended Interventional Radiology. Interventional
Radiology was consulted and performed an ultrasound guided
thrombin injection on [**2170-1-2**]. On [**2170-1-1**],
the patient was also transfused two units of packed red blood
cells with stabilization of her hematocrit .
3. Fluids, electrolytes, and nutrition: The patient was
maintained on IV fluids post cardiac catheterization. She
required only small doses of Lasix on [**2170-1-1**], to
maintain net negativity. Electrolytes remained stable. The
patient was placed on cardiac, diabetic, low salt diet while
in the hospital.
4. Heme: The patient is status post infusion of two units
of packed red blood cells after catheterization and
subsequently when her hematoma was noted to be enlarging,
when she was noted to have a swollen hematoma; however,
subsequently her hematocrit remained stable and the patient
remained hemodynamically stable until the time of discharge.
5. Physical Therapy: Physical Therapy was consulted on
[**2170-1-4**], after the patient was transferred to the
Cardiac Step Down Unit to evaluate the patient's functional
status prior to discharge home.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DIAGNOSIS:
Acute myocardial infarction.
DISCHARGE MEDICATIONS: Include Atenolol 25 mg po q day,
Lisinopril 20 mg po q day, Prilosec 20 mg po q day, Lipitor
10 mg po q day, enteric coated aspirin 325 mg po q day,
Plavix 75 mg po q day times thirty days (until [**2170-1-28**]), Glyburide 10 mg po q day.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 14069**], her
primary physician, [**Name10 (NameIs) **] one weeks time and will follow up with
him regarding monitoring of her liver enzymes as she was
newly placed on Lipitor. Baseline liver function tests were
obtained prior to discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 27618**]
MEDQUIST36
D: [**2170-1-4**] 11:24
T: [**2170-1-4**] 12:04
JOB#: [**Job Number **]
|
[
"41401",
"25000",
"4019",
"42789"
] |
Admission Date: [**2119-11-1**] Discharge Date: [**2119-11-3**]
Date of Birth: [**2119-11-1**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**First Name4 (NamePattern1) **] [**Known lastname **] delivered at 35-4/7
weeks' gestation and was admitted to the newborn intensive
care nursery for management of prematurity. Admission weight:
2415 g (50th percentile), length 44 cm (50th percentile),
head circumference 34 cm (90th percentile).
Mother is a 38-year-old gravida 1 woman with estimated date
of delivery [**2119-12-2**]. Her prenatal screens included
blood type A positive, antibody screen negative, hepatitis B
surface antigen negative, rubella immune, RPR nonreactive,
and group B strep unknown. The pregnancy was conceived by in
[**Last Name (un) 5153**] fertilization resulting in dichorionic-diamniotic twin
gestation. The pregnancy was complicated by advanced maternal
age, twin gestation, and gestational hypertension treated
with Aldomet. She presented on day of delivery with preterm
premature rupture of membranes, in preterm labor. Delivery
was by cesarean section under general anesthesia secondary to
multiple gestation. The fluid was clear at delivery. There
was no maternal fever, no intrapartum antibiotics. Twin
emerged with cry, was dried and bulb suctioned. Around 4
minutes of life, he began grunting and was given continuous
positive airway pressure with bag and mask in room air for
about a minute, with improvement. His Apgar scores were 8 and
9 at one and five minutes, respectively.
PHYSICAL EXAMINATION AT DISCHARGE: A pink, slightly
jaundiced, alert, and active infant. Anterior fontanelle
open, flat. No cleft. Red reflex deferred. Breath sounds
bilateral equal and clear, with easy work of breathing. No
murmur. Normal pulses and perfusion. Abdomen soft,
nondistended. Soft bowel sounds. Umbilical cord dry. Spine
intact. Hips stable. Normal male genitalia, with testes
descended bilaterally. Active, with normal tone and reflexes
for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Was
admitted in room air, has remained in room air, with
comfortable work of breathing, respiratory rates in the 30s-
50s, no apnea.
CARDIOVASCULAR: No murmur, heart rate 120s-140s, blood
pressure 65/32 with a mean of 44.
Fluids, electrolytes, nutrition: An IV was placed, and
received IV fluids on admission. Started feeds soon after
admission, and the IV was discontinued on day of life 1. Is
taking Enfamil 20 ad lib, taking a minimum of 60 mL/kg per
day. Voiding and stooling appropriately. Discharge weight is
2410 g.
GI: Is mildly jaundiced. A bilirubin has not been drawn yet,
was planned to draw on [**2119-11-4**], or earlier if
becomes more jaundiced.
HEMATOLOGY: Hematocrit on admission 48%.
INFECTIOUS DISEASE: A CBC and blood culture were drawn on
admission. Was started on ampicillin and gentamicin. The
white count was 8.6, with 50 polys, 1 band, 303,000
platelets, hematocrit 48. Blood culture has no growth to
date. Is expected to stop antibiotics at 48 hours.
SENSORY: Hearing screening has not been performed.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to newborn nursery. Name of
primary pediatrician: [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) 70122**], [**Location (un) 8170**],
[**Apartment Address(1) 50442**], [**Location (un) **], [**Numeric Identifier 74890**]. Telephone # [**Telephone/Fax (1) 72583**].
CARE AND RECOMMENDATIONS:
1. Feeds: Enfamil 20 ad lib. Follow weight. [**Month (only) 116**] need 24
calories per ounce.
2. Medications: Is currently not receiving any medications.
Iron and vitamin D supplementation. Iron supplementation
is recommended for preterm and low birth-weight infants
until 12 months corrected age. All infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 International Units, which may be
provided as a multivitamin preparation daily until 12
months corrected age.
3. Car seat position screening test has not been performed,
will need prior to discharge.
4. State Newborn Screen: Is planned to draw with bilirubin
on [**2119-11-4**].
5. Has not received hepatitis B immunization yet.
6. Immunizations Recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria: (1)
Born at less than 32 weeks; (2) born between 32 and 35
weeks with 2 of the following: daycare during RSV
season, smoker in the household, neuromuscular disease,
airway abnormalities, or school-age siblings; (3)
chronic lung disease; and (4) hemodynamically
significant congenital heart disease. Influenza
information is recommended annually in the fall for all
infants once they reach 6 months of age, before this
age, and for the 1st 24 months of the child's life.
Immunization against influenza is recommended for
household contacts and out-of-home caregivers. This
infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at/or following discharge from the
hospital if they are clinically stable or at least 6
weeks, but fewer than 12 weeks, of age.
FOLLOWUP APPOINTMENTS RECOMMENDED: As per pediatrician.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age, preterm male infant at
35-4/7 weeks' gestation.
2. Twin #2.
3. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2119-11-3**] 02:39:46
T: [**2119-11-3**] 06:49:25
Job#: [**Job Number 74891**]
|
[
"V290"
] |
Admission Date: [**2190-11-3**] Discharge Date: [**2190-11-22**]
Date of Birth: [**2190-11-3**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 34 and [**12-22**] week
gestation infant admitted to the Neonatal Intensive Care Unit
for prematurity.
MATERNAL HISTORY: 30 year-old gravida 1 para 0 now 1 woman
with an unremarkable past medical history. Prenatal screens
O negative (received RhoGAM at 14 and at 28 weeks), RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, GBS unknown.
PREGNANCY HISTORY: Estimated date of confinement [**2190-12-14**]. Twin pregnancy with spontaneous reduction to
[**Doctor Last Name **] in first trimester. Normal fetal survey at 18
weeks. Presented in spontaneous preterm labor and progressed
to spontaneous vaginal delivery under epidural anesthesia.
Fentanyl bolused administered one hour prior to delivery.
Spontaneous rupture of membranes two hours prior to delivery,
yielding clear amniotic fluid. No intrapartum maternal fever
or other clinical evidence of chorioamnionitis.
NEONATAL COURSE: Infant initially hypotonic and apneic.
Orally and nasally bulb suctioned, dried, tactile stim
provided with continued inconsistent respiratory effort,
responsive to bag-mask positive pressure ventilation for one
minute and facial CPAP. Subsequently pink and in no
significant distress and free flow oxygen. [**Hospital **]
transferred to the Neonatal Intensive Care Unit . Apgars were
5 at one minute and 8 at five minutes.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 1860 grams
(25th percentile), length 44.5 cm (25th to 50th percentile),
head circumference 29.5 cm (10 to 25th percentile). Well
appearing infant in no distress, anterior fontanel soft and
flat. Nondysmorphic. Palate intact. Neck and mouth normal.
No nasal flaring. A mild intercostal retractions, good
breath sounds bilaterally, no crackles, mild intermittent
grunting. Well perfuse, no murmur, femoral pulses normal.
Normal S1, S2. Abdomen soft, nondistended, no organomegaly,
no masses, bowel sounds active, anus patent, three vessel
umbilical cord. Normal female genitalia. Active and
responsive to stimulus, normal tone, moving all limbs
symmetrically. Normal spine/limb/hips/clavicles.
HOSPITAL COURSE: 1. Respiratory: The infant was initially
placed on nasopharyngeal CPAP of 6 cm of water requiring 26%
oxygen. A capillary blood gas on admission showed a pH of
7.32 and a CO2 of 52. The infant transitioned to room air by
day of life one and has remained in room air with oxygen
saturations 95 to 99% with respiratory rates 40s to 50s.
Infant has not had any apnea or bradycardia this
hospitalization.
2. Cardiovascular: The infant received two 10 cc per
kilogram normal saline boluses upon admission for borderline
blood pressures in the 30s. The infant did not require
vasopressors. The infant has remained hemodynamically stable
for the rest of the hospitalization, no murmur, heart rate
130s to 140s with mean blood pressures 41 to 54.
3. Fluid, electrolytes and nutrition: Infant was initially
nothing by mouth receiving 80 cc per kilogram per day of
D10W. Enteral feedings of premature Enfamil 20 calories per
ounce were started on day of life one. The infant advanced
to total fluids of 150 cc per kilogram per day by day of life
five and had advanced to maximum caloric density of premature
Enfamil 26 calories per ounce or breast milk 26 calories per
ounce by day of life six. The infant was requiring gavage
feedings up until day of life 16. The infant is currently
taking 150 cc per kilogram per day of breast milk 26 calories
or Enfamil 26 calories per ounce po. The infant has
tolerated feedings without difficulty. Most recent weight is
2210 grams, head circumference 31 cm, length 45.5 cm. The
most recent electrolytes drawn on day of life one showed a
sodium of 140, chloride 107, potassium 5.0, PCO2 of 24.
Glucoses have been stable.
4. Gastrointestinal: The infant was placed under single
phototherapy on day of life two for a total bilirubin level
of 14.7. The infant received phototherapy for a total of
five days. A rebound bilirubin level on day of life seven
was 7.2 with a direct of 0.3.
5. Hematology: Blood type O positive, Coombs negative. The
infant has not required any blood transfusions this
hospitalization. Hematocrit on admission was 48%.
6. Infectious disease: The infant received 48 hours of
Ampicillin and Gentamycin. CBC on admission showed a white
blood cell count of 11.7, hematocrit 48%, platelets 188,000,
27 neutrophils, 2 bands. Blood cultures remain negative to
date.
7. Neurology: Normal neurological examination. Sensory
hearing screen was performed with automated auditory brain
stem responses. The infant passed both ears.
8. Psycho/social: Parents involved with infant.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23335**], phone number
[**Telephone/Fax (1) 47712**] [**Location (un) 55**] Pediatrics.
CARE AND RECOMMENDATIONS: Feedings at discharge, breast milk
26 calories per ounce or Enfamil 26 calories per ounce
(Enfamil 24 calories mixed with 2 calories per ounce of corn
oil 150 cc per kilogram per day po). Medications, none. Car
seat position screen . State newborn screens were
sent on [**11-7**] and [**11-18**], results are pending.
Immunizations the infant received hepatitis B vaccine on
[**11-16**] and received Synagis vaccine on [**11-22**].
Immunizations recommended Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: Born at less then 32
weeks; born between 32 and 35 weeks with two or three of the
following, day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or with chronic lung disease.
FOLLOW UP APPOINTMENTS: Scheduled with primary pediatrician
in approximately three days.
DISCHARGE DIAGNOSES:
1. Prematurity 34 and 1/7 weeks.
2 . Status post respiratory distress.
3. Rule out sepsis with antibiotics, ruled out.
4. Status post indirect hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 47014**]
MEDQUIST36
D: [**2190-11-22**] 11:36
T: [**2190-11-22**] 11:53
JOB#: [**Job Number 53520**]
|
[
"7742",
"V290"
] |
Admission Date: [**2201-2-28**] Discharge Date: [**2201-3-9**]
Date of Birth: Sex: F
Service: Medicine, [**Location (un) **] Firm
NOTE: The day of discharge to be dictated in an Addendum.
This is a dictation up to [**2201-3-8**].
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old
female with a history of human immunodeficiency virus, and
hepatitis C virus, and liver cirrhosis who came to [**Hospital1 1444**] Emergency Department
complaining of increasing fatigue and icterus.
The patient was also complaining of weakness, lethargy, sore
throat, and hoarseness. She had an episode of epistaxis
earlier on the morning of admission. The patient denies
fevers or chills. She complains of hoarseness and a sore
throat. The symptoms started two weeks ago with nonspecific
joint/muscle pain, increasing pruritus, fatigue, and
weakness. The patient is also complaining of a cough
productive of [**Doctor Last Name 352**] phlegm and no blood as well as occasional
shortness of breath. The symptoms have been worsening over
the past one week. The patient denies any abdominal pain.
She has no history of weight loss or weight gain. No
diarrhea. No headache. No sick contacts. [**Name (NI) **] travel. The
patient has been on prednisone for a history of hemolytic
anemia. The prednisone was stopped in [**2201-1-4**] after
a taper since smear looked okay and there was no evidence of
hemolysis by DAT test.
In the Emergency Department, the patient had a hematocrit of
24.4. The patient had a right upper quadrant ultrasound
which showed improving ascites. No common bile duct
dilatation. A chest x-ray showed no evidence of pneumonia.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus; the patient is off
antiretroviral medications since [**2200-3-4**]. Trizivir was
stopped secondary to cirrhosis. The patient's viral load was
greater than 100,000 in [**2200-6-3**]. The patient's CD4
count was greater than 800 just recently.
2. Hepatitis C virus and cirrhosis; the patient was
recently discharged from [**Hospital1 69**]
in [**2200-12-4**] with ascites. The patient is status post
interferon and ribavirin therapy which were discontinued in
[**2200-3-4**].
3. History of autoimmune hemolytic anemia; question
secondary to interferon and ribavirin versus secondary to
immune dysregulation due to hepatitis C virus and human
immunodeficiency virus. The patient has been on chronic
steroids 5 mg by mouth every day of prednisone; however,
steroids were stopped in [**2200-12-4**] because there was no
evidence of hemolytic anemia by the patient's hematologist
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22656**].
4. History of acute renal failure.
5. History of Tylenol toxicity; accidental.
6. History of pancreatitis in [**2200-3-4**].
7. History of cellulitis in [**2200-3-4**].
8. History of a gastrointestinal bleed from an esophageal
varices in [**2200-3-4**].
9. History of [**Known lastname **] cyst rupture in [**2200-3-4**].
10. Depression.
11. Hypercholesterolemia.
12. History of bullous impetigo.
13. History of Clostridium difficile colitis.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg by mouth once per day.
2. Bactrim double strength (questionable whether patient was
taking this or whether that was supposed to be discontinued).
3. Citalopram 20 mg by mouth once per day.
4. Lactulose 30 mg by mouth three times per day.
5. Nystatin swish-and-swallow.
6. Lasix 40 mg by mouth once per day.
7. Aldactone 100 mg by mouth once per day.
8. Hydroxyzine 25 mg to 50 mg by mouth q.6h. (for pruritus).
9. Sarna lotion.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married but separated. She
lives alone. She has a dog and a cat. She has children.
Positive tobacco of four to five cigarettes per day.
Positive alcohol use of one to two glasses of wine per day.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.9
degrees Fahrenheit, her blood pressure was 110/60, her pulse
was 82, her respiratory rate was 18, and her oxygen
saturation was 97% on room air. Generally, the patient was
sitting up in bed with a hoarse voice. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light and accommodation. The
extraocular muscles were intact. The mucous membranes were
moist. The neck revealed a clear-based shallow ulceration on
the posterior neck with erythematous borders. There was no
lymphadenopathy. The patient had hypopigmented lesions on
her upper back that were similar in shape to a clear-based
ulceration. Pulmonary examination revealed the lungs were
clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. There were no murmurs,
rubs, or gallops. The abdomen revealed positive bowel
sounds. Somewhat tense, but not tender, and slightly
distended. Extremity examination revealed no cyanosis,
clubbing, or edema. Pretibial area revealed palpable
pruritic nodules on the left and right tibial surface that
were painful. There were no petechiae.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 18.4, her hematocrit was 24.2, and her
platelets were 88. Differential with neutrophils of 86,
lymphocytes of 10.3, monocytes of 3.1, and eosinophils of
0.2. Her INR was 1.7, her prothrombin time was 16, and her
partial thromboplastin time was 31.2. Free calcium was 1.07.
Blood cultures and urine cultures revealed no growth to date.
CD4 count was [**Numeric Identifier 22660**]. The patient's initial creatinine on
presentation was 1.2.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed patchy
atelectasis at the bases and low lung volumes.
A right upper quadrant ultrasound showed gallstones; stable
from prior. There was decreased gallbladder wall edema.
Decreasing ascites; a very small amount. A fatty liver. No
ductal dilatation. Normal common bile duct. Normal hepatic
vein.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. ANEMIA ISSUES: This was likely anemia of chronic disease
as was evidenced by iron studies. The patient's peripheral
blood smear was initially reviewed with a hematologist.
There was no evidence of hemolysis by either looking at the
smear or by laboratories. The patient's initial fibrinogen
was normal. Her haptoglobin was normal, and DAT test was
negative. The patient initially received 1 unit of packed
red blood cells to increase caudate pressure in the setting
of acute-on-chronic renal failure. The patient was started
on iron, ascorbic acid, and Epogen.
2. INFECTIOUS DISEASE ISSUES: The patient grew out
gram-positive cocci in pairs and clusters, further identified
as methicillin-resistant Staphylococcus aureus in one of the
blood cultures. The patient was subsequently started on
vancomycin. The patient was also started on ciprofloxacin
for a presumed urinary tract infection.
The patient had a transthoracic echocardiogram which was
negative for endocarditis.
The patient was planned to undergo a bone scan to rule out
osteomyelitis of the neck which was pending at the time of
this dictation. The patient did not have any abdominal
tenderness, and a paracentesis was attempted to rule out
spontaneous bacterial peritonitis; however, no peritoneal
fluid was obtained even after an ultrasound-guided marking.
The patient was planned to undergo and ultrasound-guided
paracentesis the following morning.
3. CHRONIC LIVER DISEASE ISSUES: The patient definitely
showed signs of decompensation; especially in the setting of
a combination of worsening liver disease and acute-on-chronic
renal failure. The patient's hepatitis C viral load was
checked and was greater than 700,000. In the setting of
acute renal failure, Lasix and Aldactone were held. Bactrim
was stopped the day after admission. The patient was started
on nadolol 400 mg by mouth once per day to prevent upper
gastrointestinal bleeding from esophageal varices since the
patient had an episode of prior in the past.
The Hepatology Service was consulted since after restarting a
very low dose of Lasix and Aldactone the patient went into
rapidly progressive acute renal failure despite continued
hydration and blood transfusion for caudate pressure
increase. The patient was likely rapidly progressing into
decompensated liver failure, and Hepatology recommendations
were pending.
4. ACUTE RENAL FAILURE ISSUES: The patient initially came
in with a creatinine of 1.2; however, her creatinine
increased to 1.5 and to greater than 2 the day following
admission. This was thought to be multifactorial in the
setting of dehydration, bacteremia, using nonsteroidal
antiinflammatory drugs at home, and being started on Bactrim.
The patient's diuretics were held and intravenous fluids were
administered. The patient's sediment was benign without any
evidence of proteinuria or hematuria. There were no casts.
The patient's fractional excretion of sodium was less than
0.1%. The patient's renal ultrasound showed bilaterally
small kidneys, cortical thinning, and medullary
nephrocalcinosis.
The patient was seen by the Renal Service in consultation who
thought that they etiology of the patient's acute-on-chronic
renal failure was likely multifactorial. They entertained an
idea of human immunodeficiency virus nephropathy as an
underlying etiology of the patient's renal failure; however,
this was somewhat atypical with the absence of proteinuria.
The patient's creatinine initially improved after 2 units of
packed red blood cells; however, after re-administration of a
very low dose of Lasix and Aldactone the patient's creatinine
worsened again. The patient showed signs of fluid retention
concerning for hepatorenal syndrome. Diuretics were held. A
Renal consultation was obtained again.
5. MENTAL STATUS CHANGE ISSUES: The patient was getting
increasingly agitated and intermittently confused. An
ammonia level was checked and was only 19. The patient was
also developing progressive thrombocytopenia. The patient
has a history of thrombocytopenia in the setting of
hypersplenism; however, the patient's platelets went from 100
to 50/60. This constellation of findings was definitely
concerning for the possibility of thrombotic thrombocytopenic
purpura/hemolytic uremic syndrome. Once again, the
recommendations from the Renal Service were pending. Smear
review was also pending at this time.
6. THROMBOCYTOPENIA ISSUES: As above, the differential
diagnosis included splenic sequestration, acute decrease in
platelets secondary to bacteremia, the possibility of
heparin-induced thrombocytopenia, heparin-dependent
antibodies were sent and all heparin flushes were stopped, or
the possibility of a more serious diagnosis such at
thrombotic thrombocytopenic purpura/hemolytic uremic
syndrome. All of the above etiologies are currently worked
up.
NOTE: This Discharge Summary is to be followed by an
Addendum dictated by the physician who is taking over my
service.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2201-3-9**] 14:30
T: [**2201-3-13**] 08:23
JOB#: [**Job Number 22661**]
|
[
"51881",
"5990"
] |
Admission Date: [**2201-1-30**] Discharge Date: [**2201-2-3**]
Date of Birth: [**2183-7-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old boy
with [**Doctor First Name **] syndrome who was transferred here from
[**Hospital6 46748**] for evaluation of his right
bronchial stent. Dr. [**Last Name (STitle) **] placed a right mainstem bronchus
stent in [**Month (only) 1096**]. The patient initially required 1 L home
oxygen, but the week prior to admission was stable on room
air.
On the morning prior to admission, the patient awoke with
tachypnea and an oxygen saturation of 83% on room air and was
tachycardiac. His [**Doctor Last Name **] mother placed him on oxygen and
took him to his primary care physician's office who
discovered decreased breath sounds on the right side.
The patient was initially sent to [**Hospital6 46749**] Pediatric Unit for evaluation. He was transferred
to [**Hospital6 256**] for evaluation of his
right mainstem bronchus by rigid bronchoscopy. The patient
was admitted to the MICU and was stable over night on 4 L
nasal cannula.
The rigid bronchoscopy procedure was uncomplicated. All
stents were found to be patent. The patient was then
transferred to ................... [**Hospital 107**] Hospital under
the service of his pediatric pulmonologist.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Enalapril 2.5 mg p.o. b.i.d.
FAMILY HISTORY: The patient has two brothers with similar
syndrome.
SOCIAL HISTORY: The patient lives with his [**Doctor Last Name **] parents,
the [**Location (un) 46750**], cell [**Telephone/Fax (1) 46751**], home [**Telephone/Fax (1) 46752**]. He does
not speak. He started school one week ago. He eats a full
diet.
DISCHARGE MEDICATIONS: Enalapril 2.5 mg p.o. b.i.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2201-4-1**] 11:42
T: [**2201-4-1**] 11:45
JOB#: [**Job Number 46753**]
|
[
"5070",
"51881",
"5849",
"4019"
] |
Admission Date: [**2100-11-20**] Discharge Date: [**2100-11-22**]
Date of Birth: [**2036-5-31**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
IVC thrombus extending to the R atrium
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64-year-old man with hep C, HCC, HTN with known IVC thrombus who
presented per advice from his oncologist, Dr. [**Last Name (STitle) **], after a
recent CT showed the IVC thrombus extending to the right atrium.
The patient reports some chronic RUQ pain but denies any other
symptom. No palpitations, no chest pain, no loss of
consciousness.
.
He was recently diagnosed with HCC and underwent chemoembolism
in 7/[**2100**]. CT in [**8-/2100**] showed IVC thrombus with extension close
to the right atrium. Given history of hemoperitoneum requiring
multiple transfusions, anticoagulation was not started.
.
Patient underwent an outpatient abd CT on [**2100-11-15**] which
showed the IVC thrombus now extending into the R atrium. He was
advised by his oncologist to come to the ED.
.
On presentation to the ED, patient was stable with T 98.8, HR
82, BP 145/88, RR 18, 99%RA. Labs revealed stable Hct of 38.3.
EKG was unchanged from prior with borderline first degree AV
block. Head CT was unremarkable. Cards were consulted and, per
ED sign-out, did not want any intermediate intervetion. Heme-onc
recommended starting heparin gtt without any initial bolus.
.
On arrival to the ICU, the patient remained stable and was not
on heparin gtt yet.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
He does report chronic pain in RUQ and right side of chest.
Past Medical History:
Hep C, ?hep B, htn, ptsd, fibromyalgia, emphysema (can walk
multiple flights of stairs), fairly clean cath in [**3-5**] (60% RCA
stenosis)
Social History:
remote h/o of IVDU/cocaine (Denies any currently), no
ETOH, 50pk year tobacco, current 1 ppd. Homeless, living with a
friend now.
Family History:
N/C
Physical Exam:
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F)
HR: 66 (62 - 76) bpm
BP: 139/123(127) {106/33(58) - 141/123(127)} mmHg
RR: 10 (9 - 16) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
[**2100-11-21**] 05:45AM BLOOD WBC-4.9 RBC-3.56* Hgb-11.3* Hct-33.8*
MCV-95 MCH-31.9 MCHC-33.6 RDW-15.0 Plt Ct-171
[**2100-11-21**] 05:45AM BLOOD PT-13.8* PTT-57.8* INR(PT)-1.2*
[**2100-11-21**] 05:45AM BLOOD Glucose-86 UreaN-13 Creat-0.5 Na-137
K-4.1 Cl-106 HCO3-24 AnGap-11
[**2100-11-20**] 04:30AM BLOOD ALT-59* AST-134* AlkPhos-315* TotBili-1.1
[**2100-11-20**] 04:30AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
.
[**11-15**] CT Abd/Pelvis
1. Extension tumor from the periphery of the right lobe of the
liver medially to involve the hepatic vein confluence with
associated increase in tumor thrombus, which now extends into
the right atrium through the hepatic vein confluence.
2. Nonocclusive thrombus within the right portal vein posterior
and segmental anterior brancehes branches.
3. Right lower lobe 4 mm nodule is new since [**2100-9-13**] and may
represent
metastatic focus.
4. Ill definied enhacememt of the mesentery may represent
perioneal spread of tumor.
.
[**11-19**] Head CT
IMPRESSION: No acute intracranial abnormality. MRI is more
sensitive for the detection of mass lesion.
Brief Hospital Course:
64-year-old man with HCC, hep C, IVC thrombous now extending to
RA concerning for hemodynamic compromise and occlusive
thrombosis.
.
# IVC thrombus: Patient underwent an outpatient abd CT on
[**2100-11-15**] which showed the IVC thrombus now extending into the
R atrium. He was advised by his oncologist to come to the ED. On
presentation to the ED, patient was stable with T 98.8, HR 82,
BP 145/88, RR 18, 99%RA. Labs revealed stable Hct of 38.3. EKG
was unchanged from prior with borderline first degree AV block.
Head CT was unremarkable. Cards were consulted and, per ED
sign-out, did not want any intermediate intervetion. Heme-onc
recommended starting heparin gtt without any initial bolus. On
arrival to the ICU, the patient remained stable and was started
on a heparin gtt. The thrombus is most likely the tumor itself.
The heparin gtt was stopped on [**11-21**] and Mr [**Known lastname 79303**] was started
on lovenox 80mg (1.5mg/kg once daily) as per Dr. [**Last Name (STitle) **]. A TTE
was ordered to further evaluate the thrombus and cardiac
function, however the patient was unwilling to undergo the
procedure. The patient remained stable on lovenox prior to
discharge. Ideally life long anticoagulation is indicated in
this individual with extensive thrombus which could quickly
develop into a rapidly fatal Budd Chiari syndrome. However
monitoring for signs of bleeding should continue in this patient
with a h/o hemoperitoneum. Further discussion about
anticoagulation, prognosis, and treatment was attempted in
house, however Mr [**Name13 (STitle) **] was unwilling to discuss his wishes.
Code status and further anticoagulation vs palliative measures
will have to be further addressed as an outpatient with his
primary oncologist and PCP. [**Name10 (NameIs) **] compliance is also an issue
as the patient has limit access to housing. 10 days of lovenox
was given (the maximum attentable free of charge) to allow Mr
[**Known lastname 79303**] to be supplied until follow up. However Coumadin may
have to be considered if anticoagulation will continue.
.
# HCC: growing tumor burden per serial abd CTs, s/p
chemoembolization in [**2100-7-27**]
with new lung lesion suspicious for mets found on recent CT.
Further management per Dr. [**Last Name (STitle) **] as an outpatient.
.
# Chronic Pain: Pt with compliants of chronic abdominal pain.
Pt was started on dilaudid and increased to 2-3mg IV Q2 while in
house. He was titrated back to his home dose of medicines by
dischange. The outpt regimen (confirmed with the PCP Dr [**First Name8 (NamePattern2) **]
[**Name (STitle) 61741**] ([**Telephone/Fax (1) 68410**])) was Oxycodone SR 40 mg [**Hospital1 **] and oxycodone
5-10 mg prn q4h. He was given a Rx for 2 day since he should
have had sufficiant pain meds at home from previous
prescriptions.
.
# Psych: At times the patient was demanding and combative,
threatening to throw multiple staff members "out the window". He
frequently refused therapy and lab draws. On the night prior to
admission the patient briefly became confused after receiving
4mg of xanax overnight. He returned to baseline the next
morning.
# FEN: reg diet
.
# PPx: PPI
.
# Code: FULL
.
# Comm: [**Name (NI) 401**] [**Last Name (NamePattern1) **] (friend), ([**Telephone/Fax (1) 79304**]
Medications on Admission:
omeprazole 20 mg qday
docusate
senna
Oxycodone SR 20 mg [**Hospital1 **]
oxycodone 10 mg prn
Clonazepam 0.5 mg tid prn
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 80mg syringe
Subcutaneous Q 24H (Every 24 Hours).
Disp:*10 80mg syringe* Refills:*3*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*4 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Extensive Inferior Vena Cava Thrombus
.
Secondary Diagnosis:
Hepatocellular Carcinoma
Discharge Condition:
Stable, ambulating without assistance
Discharge Instructions:
You were admitted after a routine scan found your known thrombus
to have worsened. You were admitted to the ICU for careful
monitoring. You were started on heparain to thin you blood so
that this thrombus was less dangerous. For pain control, you
were continued on your home regimen.
.
You were converted to a regimen you can do at home to
anticoagulate your blood called lovenox. You much take this
injection every day.
.
Please follow up with Dr. [**Last Name (STitle) **] on [**2100-12-1**] at 3:00pm.
Please followup with your PCP within the week.
.
If you develop any of the following, chest pain, shortness of
breath, palpatations, cough, lightheadness, fever/chills or any
other symptoms that is concerning to you, please call your
oncologist or go to your local emergency room.
.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2100-12-1**] 3:00
.
Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 61741**], at [**Telephone/Fax (1) 68410**] to schedule a
followup appointment next week.
Completed by:[**2100-11-27**]
|
[
"4019"
] |
Admission Date: [**2145-8-12**] Discharge Date: [**2145-8-20**]
Date of Birth: [**2082-8-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:[**CC Contact Info 68511**]
Major Surgical or Invasive Procedure:
Extraventricular drain.
History of Present Illness:
62 y/o male had intercourse with wife at approximately 0830
this am developed sudden dizziness and nausea, went to
[**Location (un) 20026**] Hospital where he was awake, alert and
orientated
X3. While on the CT table he became unconscious and was
intubated and we transferred here for neurosurgical evaluation.
Past Medical History:
HTN (not treated), kidney stones
Social History:
Originally from [**Country 651**] been in US for 20 years, lives
with wife, retired Chef babysits grandchildren. Non smoker, non
drinker, no drugs
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
O: T:100.8 BP:138 /50 HR: 85 R 20 O2Sats100%
Gen: Intubated last sedation approx 1000am
HEENT: Pupils: 3mm min reactive
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Appears to be decorticate posturing
Toes downgoing bilaterally
Pupils 3mm min reactive
Pertinent Results:
[**2145-8-12**] 01:12PM PT-12.1 PTT-26.4 INR(PT)-1.0
[**2145-8-12**] 01:12PM PLT SMR-LOW PLT COUNT-116*
[**2145-8-12**] 01:12PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2145-8-12**] 01:12PM NEUTS-93.8* BANDS-0 LYMPHS-4.7* MONOS-1.2*
EOS-0.2 BASOS-0
[**2145-8-12**] 01:12PM WBC-15.5* RBC-5.94 HGB-12.6* HCT-38.5*
MCV-65* MCH-21.2* MCHC-32.8 RDW-15.6*
[**2145-8-12**] 01:12PM CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.9
[**2145-8-12**] 01:12PM GLUCOSE-159* UREA N-13 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-22 ANION GAP-19
[**2145-8-12**] 04:24PM PT-12.0 PTT-25.5 INR(PT)-1.0
[**2145-8-12**] 04:24PM PLT COUNT-123*
[**2145-8-12**] 04:24PM WBC-18.7* RBC-5.85 HGB-12.7* HCT-37.3*
MCV-64* MCH-21.6* MCHC-33.9 RDW-15.7*
[**2145-8-12**] 04:24PM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.9
[**2145-8-12**] 04:24PM CK-MB-NotDone cTropnT-<0.01
[**2145-8-12**] 04:24PM CK(CPK)-79
[**2145-8-12**] 04:24PM GLUCOSE-161* UREA N-11 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
[**2145-8-12**] 04:37PM TYPE-ART PO2-325* PCO2-33* PH-7.45 TOTAL
CO2-24 BASE XS-0
[**2145-8-12**] 07:32PM OSMOLAL-308
[**2145-8-12**] 07:32PM SODIUM-143
[**2145-8-12**] 11:30PM OSMOLAL-314*
[**2145-8-12**] 11:30PM CK-MB-5 cTropnT-<0.01
[**2145-8-12**] 11:30PM CK(CPK)-117
[**2145-8-12**] 11:30PM SODIUM-144
Brief Hospital Course:
Pt was admitted to the ICU, received mannitol and had placement
of ventricular drain for his cerebral bleed. He was monitored
closely and did improve neurologically. By HD#3 he was moving
extremities purposefully. He was extubated and followed
commands. His head Ct was stable. His dilantin level was
therapeutic. Mannitol and decadron were weaned. Ventricular
drain was removed on HD#7. He was transferred to stepdown. His
diet was advanced but swallowing needs further evaluation as he
has some difficulty with liquids. He is on bowel regimen but has
not had bowel movement yet. His foley was removed but needed to
be replaced for failure to void. His sutures should be removed
[**8-24**]. PT and OT [**Hospital **] rehab placement
Medications on Admission:
none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed for pain.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
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. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO Q8H (every
8 hours).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cerebellar hemorrhage
Discharge Condition:
neurologically stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
You will need to follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks. You need
to have your sutures removed on [**8-24**].
Followup Instructions:
Please have your sutures out on [**8-24**] at rehab. You will also
need to follow up with Dr. [**Last Name (STitle) 548**] in clinic in 4 weeks with Head
CT. Please call [**Telephone/Fax (1) 1669**] to arrange this.
Completed by:[**2145-8-20**]
|
[
"4019"
] |
Admission Date: [**2130-12-8**] Discharge Date: [**2130-12-19**]
Date of Birth: [**2091-2-1**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / picc dressing
/ lisinopril
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Chronic pancreatitis
Major Surgical or Invasive Procedure:
[**2130-12-8**]:
Distal pancreatectomy/splenectomy/cholecystectomy/J-tube
placement
History of Present Illness:
Ms. [**Known lastname **] is a 39 year old female with a history of chronic
pancreatitis complicated by necrotizing pancreatitis and
multiple pseudocysts requiring placement of multiple drains.
She presents with abdominal pain on long term TPN for distal
pancreatectomy with splenectomy, cholecystectomy, and J-tube
placement for tube feeds.
Past Medical History:
1. Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections, plans to try botox if approved
-first headaches [**2124-10-20**]
2. Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age 15
3. Type 2 Diabetes Mellitus
4. Hypertension
5. Obesity
6. Complex Regional Pain Syndrome of the right face and right
upper extremity on methadone
7. Right eye blindness
8. Left pupil dysfunction - ADIE
9. PUD
10. Rheumatoid Arthritis
11. Vitamin D deficiency
12. abnormal LFT's - no response to Hep B vaccines x3
[**32**]. Pancreatitis: complicated by necrotizing pancratitis [**5-/2130**]
w/ multiple admissions for abdominal pain
Social History:
Denies tobacco, previously drank socially (3 drinks per night
per some reports but per her report she drank no more than one
drink per day for many years, no alcohol since last admission
which was one alcoholic drink at [**Holiday **]. Denies drug use. Lives
with boyfriend, unemployed since [**2129-9-28**] but before then
she is an aquatics instructor and teaches children swimming in
addition to lifeguarding. She longs to return to aquatics and
teaching
Family History:
Father and sister with HTN. Family history of CAD. No family
history of CVA or headache.
Physical Exam:
VS: 98.7 71 100/60 12 98 RA
Gen: AOx3 NAD
Cor: RRR
Res: CTAB
Abd: Soft, NT/ND. J-tube site appears clean without erythema or
discharge. Wound: Appears C/D/I with steri-strips in place,
minimal irritation at staple site but no erythema at wound.
Ext: Warm and well perfused.
Pertinent Results:
[**2130-12-8**] 04:58PM BLOOD WBC-15.7*# RBC-3.20* Hgb-7.4* Hct-23.2*
MCV-73* MCH-23.0* MCHC-31.7 RDW-16.7* Plt Ct-453*
[**2130-12-9**] 06:28AM BLOOD WBC-15.1* RBC-3.01* Hgb-6.7* Hct-22.1*
MCV-74* MCH-22.4* MCHC-30.4* RDW-16.7* Plt Ct-504*
[**2130-12-10**] 04:53AM BLOOD WBC-25.5*# RBC-3.37* Hgb-8.2* Hct-26.0*
MCV-77* MCH-24.3* MCHC-31.5 RDW-18.2* Plt Ct-565*
[**2130-12-13**] 02:41PM BLOOD WBC-26.55* RBC-3.68* Hgb-8.8* Hct-27.8*
MCV-76* MCH-23.8* MCHC-31.6 RDW-19.0* Plt Ct-716*
[**2130-12-14**] 06:49AM BLOOD WBC-54.7*# RBC-2.98* Hgb-7.2* Hct-22.9*
MCV-77* MCH-24.2* MCHC-31.5 RDW-19.6* Plt Ct-561*
[**2130-12-16**] 06:05AM BLOOD WBC-19.7*# RBC-2.69* Hgb-6.3* Hct-21.6*
MCV-80* MCH-23.2* MCHC-29.0* RDW-19.0* Plt Ct-595*
[**2130-12-18**] 12:05AM BLOOD WBC-18.8* RBC-3.03* Hgb-7.3* Hct-23.4*
MCV-77* MCH-24.0* MCHC-31.1 RDW-18.9* Plt Ct-1118*#
[**2130-12-8**] 04:58PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-138
K-3.7 Cl-102 HCO3-26 AnGap-14
[**2130-12-9**] 06:28AM BLOOD Glucose-196* UreaN-11 Creat-0.7 Na-137
K-4.0 Cl-102 HCO3-28 AnGap-11
[**2130-12-10**] 04:53AM BLOOD Glucose-139* UreaN-5* Creat-0.5 Na-143
K-3.6 Cl-103 HCO3-30 AnGap-14
[**2130-12-11**] 04:30AM BLOOD Glucose-172* UreaN-7 Creat-0.4 Na-140
K-3.3 Cl-104 HCO3-27 AnGap-12
[**2130-12-12**] 04:16AM BLOOD Glucose-203* UreaN-8 Creat-0.5 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
[**2130-12-14**] 06:49AM BLOOD Glucose-214* UreaN-14 Creat-0.6 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2130-12-16**] 06:05AM BLOOD Glucose-276* UreaN-9 Creat-0.5 Na-137
K-4.4 Cl-102 HCO3-25 AnGap-14
[**2130-12-18**] 12:05AM BLOOD Glucose-194* UreaN-10 Creat-0.5 Na-138
K-4.5 Cl-98 HCO3-33* AnGap-12
[**2130-12-16**] 06:05AM BLOOD Vanco-10.3
[**2130-12-18**] 12:05AM BLOOD Vanco-13.7
[**2130-12-8**] 12:16PM BLOOD Type-ART pO2-88 pCO2-50* pH-7.41
calTCO2-33* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED
[**2130-12-8**] 02:19PM BLOOD Type-ART pO2-180* pCO2-42 pH-7.46*
calTCO2-31* Base XS-6 Intubat-INTUBATED Vent-CONTROLLED
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the pancreatobiliary surgery service
and underwent distal pancreatectomy, splenectomy,
choelcystectomy and J-tube placement on [**2130-12-8**]. Please see
the dictated operative note for further details of the
operation. She tolerated the procedure well and was brought to
the floor postoperatively. Initially she had poor pain control
and was started on a ketamine drip by the chronic pain service.
She had a hematocrit of 22 on POD1 and hence was transfused x1
unit. On POD3 she she began to be weaned from the ketamine
drip. Her epidural was discontinued and her foley was
discontinued. On POD4 she was started on clear liquids, her
ketamine drip had been stopped, and chronic pain was consulted
for management recommendations. She was vaccinated for
meningococcus, pneumococcus, and hemophilus influenza B.
Overnight from POD4 to POD5 she began to become mildly febrile
and tachycardic. She was treated with IV lopressor, which had
only a modest effect. Urine and blood cultures x 2 were sent,
and a chest x-ray was performed which demonstrated no
intrapulmonary source of infection. Her temperature continued to
rise to a maximum of 104, and she became hypotensive, at which
point she was transferred to the intensive care unit.
In the intensive care unit her picc line and her central line
were discontinued as possible sources of infection. She was
empirically started on vancomycin, ceftriaxone, and fluconazole,
given her history of yeast infection in the past. Blood cultures
drawn from the floor returned positive for gram positive cocci
in clusters. Her ceftriaxone was discontinued and she was
continued on vancomycin and fluconazole. She was started on
tube feeds and was slowly advanced towards her goal of
90cc/hour. She became afebrile and was transferred back to the
floor on [**2130-12-15**]. Her foley catheter was discontinued.
On [**2130-12-16**] she continued to have intermittent hypotension and
was bolused with good effect. She was started on an oral pain
medication regimen. On the next hospital day, her JP amylase
returned at 178. Her vancomycin trough was therapeutic. Her
platelet count was 1118, hence she was started on antiplatelet
therapy with ASA 325.
On [**2130-12-18**] her vancomycin dose was adjusted to [**Hospital1 **] dosing. She
was toelrating her tube feeds at goal of 90cc/hour, cycled over
16 hours.
On [**2130-12-19**] she had a picc line placed. Placement was confirmed
by chest x-ray. She was discharged home with visiting services
for vancomycin administration, which will continue for a total
of 10 days from her first day of therapeutic vancomycin levels.
She also will continue on her tube feeds for the time being.
Medications on Admission:
clonidine .2'', doxepin dose uncertain, fentanyl patch,
gabapentin 300 in am in noon, dilaudid 6 TID, needed for prn,
insulin dose uncertain, naratriptan 2.5', zofran 4'''',
promethazine 12.5'''', scopolamine patch, tizanidine 4 2-4 tabs
qhs
Discharge Medications:
1. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
2. gabapentin 600 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): AM and noon.
Disp:*120 Tablet(s)* Refills:*2*
3. gabapentin 400 mg Capsule Sig: Four (4) Capsule PO QHS (once
a day (at bedtime)).
Disp:*160 Capsule(s)* Refills:*2*
4. doxepin 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
Disp:*90 Capsule(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours): for 10 days.
8. hydromorphone 2 mg Tablet Sig: [**3-2**] (two to three) Tablets PO
Q3H (every 3 hours) as needed for pain for 2 weeks.
Disp:*240 Tablet(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety or insomnia.
11. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) for 2 weeks.
Disp:*5 Patch 72 hr(s)* Refills:*0*
12. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
13. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day.
14. Glucerna Liquid Sig: One (1) PO once a day: Please give
90ml/hour over 16 hours beginning at 1600 daily.
Disp:*qs sufficient* Refills:*15*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
s/p distal pancreatectomy/splenectomy/cholecystectomy/J-tube
placement
Discharge Condition:
Mental status clear and coherent.
Ambulating.
Voiding.
Tolerating PO and tube feeds.
Normal bowel function.
Discharge Instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Last Name (un) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medication. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office to make an appointment to be seen
in [**8-6**] days.
Please call your primary care physician's office to make an
appointment to be seen in [**1-29**] weeks.
****PLEASE NOTE****
YOU HAVE BEEN DISCHARGED WITH A 2-WEEK SUPPLY OF NARCOTIC PAIN
MEDICATIONS. YOU WILL NEED TO ARRANGE FOLLOW UP WITH YOUR
PRIMARY CARE PHYSICIAN OR [**Name Initial (PRE) **] CHRONIC PAIN PHYSICIAN [**Name Initial (PRE) **] 2
WEEKS TO ARRANGE FOR ONGOING PAIN MEDICINE. BECAUSE YOU ARE
UNDER A PAIN MANAGEMENT CONTRACT ELSEWHERE, YOUR [**Name Initial (PRE) **] CANNOT
GIVE YOU MORE THAN 2 WEEKS OF PAIN MEDICATION FOR TREATMENT OF
YOUR ACUTE PAIN.
YOU HAVE BEEN DISCHARGED WITH FENTANYL PATCH FOR LONG-ACTING
PAIN RELIEF AND DILAUDID TABLETS FOR BREAKTHROUGH PAIN. YOU
HAVE BEEN DISCHARGED WITH 240 DILAUDID TABLETS.
Completed by:[**2130-12-20**]
|
[
"0389",
"4019"
] |
Admission Date: [**2147-11-4**] Discharge Date: [**2147-11-17**]
Date of Birth: [**2103-4-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Patient seen at 3:00 am on [**2147-11-4**]
<br>
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 44 year old male with HIV x 20 years off HAART
for the past 5 years secondary to inability to swallow
medications now presents with throbbing worsening HA x 5 days. +
Fevers. + Photophobia. No changes in vision. Unclear what makes
HA better or worse. Presented to OSH where LP was performed
which was positve for cryptococcus. At OSH he was given
vancomycin, ceftriaxone and acyclovir. He also received
phenergan. He was then transferred to [**Hospital1 18**] for antifungal abx
which was not available at OSH. Per patient baseline CD4 <300.
Last tested approximately 1 year ago. ID doctor = Dr [**First Name4 (NamePattern1) 7568**] [**Last Name (NamePattern1) 79**]
at [**Location (un) 14663**].
In ED patient given dilaudid 1 mg IV x3 , ambisome, zofran 4 mg
IV x1.
ROS:
No SOB, CP, + nausea and dry heaves. No diarrhea. No other pains
apart from HA. No pain at site of LP. No arthralgias or
myalgias. Other review of systems limited by patient in
discomfort [**3-4**] abdominal pain and nausea. + weight loss [**3-4**]
dysphagia.
<br>
Does not take HIV meds because when he tries to swallow them
"his throat closes up". Negative endoscopy 1 year ago per
patient.
Past Medical History:
HIV x 20 years.
Dysphagia
Weight loss
Testosterone deficiency
Erectile dysfunction
Tobacco abuse
Depression
Social History:
Lives with male partner of 20+ year. He is the sole caretaker
for him. Partner is currently wheelchair bound [**3-4**] to HIV
medications. Lives in [**Location 12595**]. ID doctor is in Glouscester.
Smokes 1.5 ppd x 35 years. He is currently on SSDI. Limited
social supports. His family is unaware of his dx.
Family History:
Shortened interview given patient's distress. Patient has a
brother who is in good health.
Physical Exam:
Vitals: 98.5 100/54 54 18 98%RA
Pain: [**2149-2-1**] headache
Access: PIV
Gen: nad, walking around his room
HEENT: o/p clear w/o thrush
CV: RRR, no m
Resp: CTAB, no crackles
Abd; soft, nontender
Back: LP site nontender
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Pertinent Results:
CD4 116
Viral load; 103,000 copies/ml.
CSF fluid 48wbc, protein 93, Gluc 61, culture crypto
CSF [**Country **] ink and PCR ++ crypto
serum crypto titer >1:64
.
.
Imaging/results:
CT head [**11-4**]: No bleed or abnormalities
.
OSH CSF:
WBC = 108- no clear documentation of opening pressure.
Handwritten that CSF + for cryptococcus.
.
OSH Head CT:
Small linear hyperdensity within the L temporal lobe.
.
LP pressures:
[**11-4**] opening pressure 28cm, closing 10cm, drained 20cc
[**11-5**] opening pressure 48cm, closing 11cm, drained 20cc
[**11-6**] opening pressure 27.5cm, closing 15cm, drained 20cc
[**11-7**] opening pressure 24cm, closing 15cm, drained 6cc
[**11-8**] opening pressure 35cm, closing 18cm, drained 20cc
[**11-9**] opening pressure 21cm, closing 13cm, drained 5c
[**11-10**] opening pressure 26cm, closing 13cm, drained 21cc
[**11-11**] opening pressure 18cm, closing 17cm, drained 5cc
[**11-12**] No LP.
[**11-13**] NO LP.
[**11-14**] No LP.
[**11-15**] No LP
[**11-16**] opening pressure 17 cm.
Brief Hospital Course:
44 year old male with history of HIV, off HAART for the last 2
months (last CD4 count was in the 300s). He was admitted on [**11-4**]
with severe headaches for 5 days. He was found to have
cryptococcal mennigitis. He received daily LPs for elevated ICP.
Last 2 LP's on [**11-11**] and [**11-16**] showed decreased pressure of 17
and 18. ID was following. He was on flucytosine orally and IV
ambisome. Flucytosine levels were drawn 2 hours after dose to
adjust dosing. He remained on IV ambisone for 2weeks. He was
transferred to the ICU for aggressive K repletion as he required
high intravenous doses secondary to kidney loss from Ambisome.
He did not tolerate PO potassiun secondary to nausea and
vomiting.
.
.
His main issues were headaches and nausea. He was on tylenol,
toradol, and dilaudid for pain. He received zofran, compazine,
and ativan for nausea. He had issues with PO intake given his
intermittent dysphagia. Per his outpt HIV physician, [**Name10 (NameIs) **]
underwent EGD and barium swallow in the past month, both of
which were negative. He denied odynophagia to suggest
esophagitis. He was able to hold down his flucytosine down which
was good. His issues with dysphagia need to be addressed prior
to reinitiating HAART to avoid noncompliance and if dysphagia is
main issue (with negative w/u thus far) can consider PEG
placement for medication administration only as he is otherwise
a healthy person and good candidate for HARRT.
.
.
His CD4 count was 116 with viral load of 100K. He remained off
his HAART treatment during this hospitalization. He was started
on bactrim suspension for prophylaxis. Otherwise he remained
stable with no further fever spikes ( he initially had low grade
fever w/o leukocytosis thought to be related to ambisome).
.
.
He was finally discharged on [**2147-11-17**]. He wanted to be
discharged today despite my advice for him to stay for another
24 hours off the ambisome to monitor his potassium level. He
insisted on discharge today: "I can no longer stay in the
hospital". He confirmed to me that he is going to check his K
and Mg levels with his PCP/HIV M.D. on monday, 3 days from
discharge. I provided him with oral supplements to keep him
until that day. He understood all the risks of hypokalemia
including death and cardiac arrest.
.
.
.
.
.
.
total discharge time: 67 minutes.
Medications on Admission:
Ativan 1mg [**Hospital1 **] prn
Androgel 50 mg/1 packet to upper extremity qd
seroquel 25 mg qhs prn
flexeril 10 mg po tid prn
Commit 4 mg lozg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig:
Twenty (20) ML PO DAILY (Daily).
Disp:*240 ML(s)* Refills:*2*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day) for 10 doses.
Disp:*20 pakets* Refills:*0*
6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cryptococcal meningitis
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted with cryptococcol meningitis. You were placed
on IV and oral antibiotics for this and underwent daily lumbar
punctures to reduce your intracranial pressures which were
causing severe headaches. you were transferred to the ICU for
treatmment of severe hypokalemia. you potassium on discharge was
3.6.
Followup Instructions:
Please follow up with your HIV doctor 1 week after discharge
Please keep your GI appointment for work up of your difficulty
swallowing.
please check your potassium and magnesium levels on monday (3
days from now) we will provide you with oral supplements, but,
if you do not tolerate them you may need IV supplementation if
your levels are low. low potassium level can be dangerous and
deadly.
|
[
"311",
"3051"
] |
Admission Date: [**2158-1-5**] Discharge Date: [**2158-1-9**]
Date of Birth: [**2081-9-1**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
[**Known firstname **] [**Known lastname 80517**] is a 76 yo female with PMH of major depressive
disorder, afib on coumadin, CAD s/p stent (details unclear),
right ICA 60-70% stenosis, CVA in [**8-24**], aphasic at baseline,
DM, DNR/DNI presenting to [**Hospital1 18**] emergency department from
nursing home with resp distress. This AM, she was noted to have
sudden onset hypoxia, 78% on 3L NC. It appears that she is on 3L
O2 at baseline. She received neb and her O2 increased to 86% on
4L NC. At that time, HR was 119 and BP 170/100. Tube feeds were
stopped. EMS was called. Per EMS, she was 70% on RA which
improved to 90's on O2. Upon presentation, to the ED, she was
tachypneic, rhonchorous with upper airway noise. Given a ?
history of CHF, she was given lasix and nitro with no
improvement. A CXR in the ED showed LLL pna, so IVF was started
for repletion and her lasix was stopped.
.
Vitals in the ED showed T 101.2, BP154/81, tachycardic at 126,
and breathing 32/min. Her lactate was 2.8, her WBC 36, and she
was bipap dependent. She received a dose of vanc, levo, and
ceftriaxone for pna.
.
Of note, she was recently admitted to [**Hospital **] Healthcare Center
from [**Hospital1 2177**] after massive CVA. Admitted to [**Hospital1 2177**] from [**12-18**], with
CVA secondary to afib. Hypoxic event. G-tube placed.
Past Medical History:
? CHF
Massive CVA at [**Hospital1 2177**] related to afib
DM2
HTN
Afib on coumadin, last INR 1.12 (yesterday)
h/o MVA [**8-24**]
CAD
Hypothyroidism
Psychosis
h/o homelessness
Social History:
Lives in [**Hospital **] Healthcare Center. Friend [**Name (NI) **] [**Name (NI) 56494**] is
HCP. Previously homeless. Has 2 daughters, whereabouts unknown.
Family History:
noncontributory
Physical Exam:
vitals:96.1 128/88 84 20 95%RA
gen: NAD, awake and alert, aphasic
heent: NCAT
pulm: difficult exam [**12-19**] to vocalization, coarse breath sounds
no w/r/r
cv: s1s2, irregular, no m/r/g
abd: soft, NTND, +BS, no rebound or gaurding, +PEG in place
extr: no c/c/e
neuro: does not communicate effectively but makes eye contact.
Follows simple commands. Does not wiggle right toes or squeeze
with right hand. Moves left arm and leg. No spontaneous movement
of right arm/leg.
Pertinent Results:
[**2158-1-5**] 08:58AM PT-16.2* PTT-26.1 INR(PT)-1.4*
[**2158-1-5**] 08:58AM PLT SMR-HIGH PLT COUNT-590*
[**2158-1-5**] 08:58AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2158-1-5**] 08:58AM NEUTS-84* BANDS-8* LYMPHS-5* MONOS-1* EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2158-1-5**] 08:58AM WBC-36.4* RBC-4.85 HGB-15.1 HCT-45.6 MCV-94
MCH-31.2 MCHC-33.1 RDW-14.8
[**2158-1-5**] 08:58AM GLUCOSE-215* LACTATE-2.8* NA+-133* K+-5.4*
CL--88* TCO2-28
[**2158-1-5**] 08:58AM COMMENTS-GREEN TOP
[**2158-1-5**] 08:58AM CK-MB-NotDone proBNP-1686*
[**2158-1-5**] 08:58AM cTropnT-0.01
[**2158-1-5**] 08:58AM CK(CPK)-50
[**2158-1-5**] 08:58AM estGFR-Using this
[**2158-1-5**] 08:58AM GLUCOSE-235* UREA N-27* CREAT-0.8 SODIUM-129*
POTASSIUM-5.9* CHLORIDE-90* TOTAL CO2-29 ANION GAP-16
[**2158-1-5**] 09:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2158-1-5**] 09:09AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2158-1-5**] 11:18AM PT-16.7* PTT-25.8 INR(PT)-1.5*
[**2158-1-5**] 11:21AM PLT COUNT-575*
[**2158-1-5**] 11:21AM WBC-40.0* RBC-4.46 HGB-13.9 HCT-42.3 MCV-95
MCH-31.1 MCHC-32.7 RDW-14.5
[**2158-1-5**] 11:21AM ALBUMIN-4.0 CALCIUM-10.5* PHOSPHATE-5.1*
MAGNESIUM-1.8
[**2158-1-5**] 11:21AM GLUCOSE-201* UREA N-28* CREAT-0.8 SODIUM-133
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-29 ANION GAP-16
[**2158-1-6**] 03:36AM BLOOD WBC-42.3* RBC-4.03* Hgb-12.5 Hct-37.8
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.5 Plt Ct-530*
[**2158-1-9**] 05:10AM BLOOD WBC-12.2* RBC-3.69* Hgb-11.2* Hct-34.3*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.5 Plt Ct-637*
[**2158-1-9**] 05:10AM BLOOD PT-21.3* PTT-30.7 INR(PT)-2.0*
[**2158-1-9**] 05:10AM BLOOD Glucose-150* UreaN-12 Creat-0.4 Na-136
K-4.1 Cl-98 HCO3-31 AnGap-11
[**2158-1-8**] 06:00AM BLOOD ALT-15 AST-15 LD(LDH)-182 AlkPhos-107
Amylase-28 TotBili-0.8
[**2158-1-5**] 08:58AM BLOOD CK(CPK)-50
[**2158-1-8**] 06:00AM BLOOD Lipase-27
[**2158-1-5**] 08:58AM BLOOD cTropnT-0.01
[**2158-1-9**] 05:10AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1
[**2158-1-6**] 03:36AM BLOOD TSH-0.45
[**2158-1-6**] 07:23PM BLOOD Vanco-15.1
[**2158-1-5**] 08:58AM BLOOD Glucose-215* Lactate-2.8* Na-133* K-5.4*
Cl-88* calHCO3-28
Micro:
Urine [**1-5**], [**1-5**]: no growth
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2158-1-5**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2158-1-5**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Legionella Urinary Antigen (Final [**2158-1-6**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Blood Cx: NGTD
CXR [**1-5**]
FINDINGS: A single AP upright view of the chest was obtained.
The cardiac
silhouette is normal in size. There is atherosclerotic disease
of the aorta.
The right lung is clear. There is focal airspace disease noted
at the left
lung base. No pleural effusions are identified. There is no
pneumothorax.
Multiple surgical clips are noted around the epigastrium and the
right upper
quadrant. The bones are diffusely demineralized. A J-tube is
noted in the
upper abdomen.
IMPRESSION:
Left basilar airspace disease likely representing pneumonia
versus
atelectasis. The former is favored.
Brief Hospital Course:
In summary, Ms. [**Known lastname 80517**] is a 76 yo with history of stroke
(aphasic at baseline), diabetes who presents in respiratory
distress, requiring BIPAP and ICU stay secondary to LLL pna.
.
Pneumonia. Ms. [**Known lastname 80517**] initially presented with sudden onset
hypoxia, 78% on 3L NC the day of admission; pt is on 3L O2 at
baseline. A CXR showed LLL pna and she was started on
Vancomycin, zosyn, levaquin an Flagyl. She was febrile to
101.2 in the ED. She was briefly on BIPAP. Her WBC was
initially elevated to 36 but improved with antibiotics. She was
afebrile throughout the rest of her hospital stay and her
antibiotics were narrowed to vancomycin and zosyn and she will
complete a 7 day course to be completed on [**1-13**]. A PICC was
placed for IV antibiotics. Her culture data remained negative
including legionella and influenza. Her WBC count trended down
with antibiotics and was 12.2 on discharge. She continues to be
DNR/DNI.
.
A. fib. Patient is on coumadin for secondary prevention of
stroke in A. fib. She had a recent stroke at [**Hospital1 2177**] this month
believed to be embolic from afib. Her INR was subtherapeutic on
admission. She was continued on coumadin 4mg and her became the
therapeutic. Her INR on discahrge was INR 2.0 and her coumadin
was dosed at 5mg. Her metoprolol and dilt her held initially
due to her infection. She was restarted on metoprolol 12.5mg
TID for rate control. Her metoprolol should be titrated up prn.
.
History of CVA at [**Hospital1 2177**] related to afib. Patient is aphasic at
baseline and unable to move her right side. She remains awake
and alert.
.
DM2: Pt is currently on TF and was placed on a sliding scale
insulin with finger sticks. Her sugars remained stable and her
fingersticks were disocntinued.
.
HTN: Her antihypertensives were held due to her infection. Once
stablized she was restarted on metoprolol 12.5 TID and
lisinopril
.
CAD: Patient is not on aspirin or ACE-I. Metoprolol was held
initially, but was resumed after she clinically improved from
her pneumonia.
.
Hypothyroidism. She was continued on levothyroxine.
.
Psychosis. She was continued on seroquel.
.
FEN. Patient was at goal for tube feeds and continued on these
during hospital stay.
.
DNR/DNI.
.
HCP [**Name (NI) **] [**Name (NI) 56494**] (family friend) [**Telephone/Fax (1) 80518**].
.
Medications on Admission:
levothyroxine 125mcg qday
seroquel 75mg TID
diltiazem 15mg QID
metoprolol succinate 25 QID (?)
prevacid 30mg qday
coumadin 5mg qday
scopalamine 1.5 td q 72 hrs
miralax
magnesium oxide 400mg qday
levsin 0.125 q 4hrs prn secretions
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
airway secretions.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Saline Flush 0.9 % Syringe Sig: One (1) Injection once a
day: for each port of PICC line.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) 4.5g Intravenous Q8H (every 8 hours) for 4 days:
Last dose [**2158-1-13**].
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 4 days: Last dose
[**2158-1-13**].
15. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
.
Type 2 Diabetes
Atrial fibrillation
Coronary artery disease
History of CVA
Discharge Condition:
Fair. She is not requiring supplemental oxygen. SHe remains
aphasic.
Discharge Instructions:
You were admitted for pneumonia. You were given antibiotics and
your symptoms improved. You will need to continue intravenous
antibiotics until [**2158-1-13**].
.
Please follow up with your primary care physician if you develop
shortness of breath, rapid breathing, fevers/chills, cough,
sputum production or any other concerning symptoms.
Followup Instructions:
You should follow up with your primary care physician 1-2 weeks.
|
[
"5070",
"51881",
"42731",
"V5861",
"2767",
"2449",
"41401",
"V4582",
"4019",
"25000",
"4280"
] |
Admission Date: [**2133-5-24**] Discharge Date: [**2133-5-31**]
Date of Birth: [**2070-6-27**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
TIPS
Endotracheal intubation
Placement of central venous catheter
History of Present Illness:
Patient is a 63 y/o female with UC s/p colectomy and colostomy
20 yrs
ago and recently diagnosed cirrhosis after a variceal bleed in
early [**Month (only) 547**] requiring ICU stay and a total of 11 units of PRBCs.
She presented at that time with bright red blood in her ostomy.
The bleeding was eventual stopped when the surgery team put
sutures in an actively bleeding vessel at the ostomy site on
[**2133-4-26**]. Afterward, a tagged RBC scan failed to reveal any
extravazation of blood. GI scoped the ostomy and found no
further sites of bleeding. She was discharged home on [**2133-5-2**]. 5
days ago she had the sutures removed from her stoma. She now
represents with recurrent bright blood in her ostomy starting at
11 PM last night. She reported lightheadedness at the time of
the bleeding. She denies CP, SOB, N/V, hematemesis, abdominal
pain, fevers. She [**Last Name (un) 25177**] had a mild nose bleed. She was taken to
[**Hospital3 **] and then transferred to [**Hospital1 18**]. In ED at [**Hospital1 18**] she
was transiently hypotensive to SBP 70s. She received 7 Liters
normal saline and 2 units PRBCs. NG lavage in ED negative.
Currently she complains of chills, but denies lightheadedness,
SOB.
Past Medical History:
Hypothyroidism
Ulcerative colitis
GI Bleed: Bleeding vessel at ostomy
Cirrhosis, likely [**2-26**] ETOH
Anemia of blood loss and [**Month/Day (2) **] deficiency
Lower extremity cellulitis vs venous stasis
Social History:
Reports no alcohol since last admission. Prior heavy intake - 2
bottles wine/day.
No tobacco, but husband smokes 3 ppd
Family History:
NC
Physical Exam:
VS: T 99.0 HR 96 BP 85/48 (in ED: low of SBP 70--> 96/60) RR 15
97% 4L
GEN: Pale appearing, NAD
HEENT: OP clear, anicteric, MMM, PERRL
Neck: Supple
CV: RRR, no m/r/g
PUL: bibasilar crackles, o/w clear
ABD: Soft, NT, midline scar, ileostomy in RLQ recently emptied
without stool or blood present.
Ext: 3+ tense pitting edema, areas of erythema over b/l medial
shins, +warmth, no tenderness.
Neuro: A&Ox3, speech fluent, moves all extremities. no focal
deficits.
Pertinent Results:
TIPS procedure:
After risks and benefits were explained to the patient and
patient's family, written informed consent was obtained. The
patient was placed supine on the angiographic table. The
bilateral necks were prepped and draped in the standard sterile
fashion. A preprocedure timeout was performed to confirm the
patient's name, procedure, and site. Using sterile technique,
general anesthesia, and local anesthesia, an access was
established to the right internal jugular vein using
ultrasonographic guidance and micropuncture site. The access
site was dilated and a 10-French vascular sheath was placed over
the wire with the tip positioned in the superior vena cava under
fluoroscopic guidance. A 5-French modified C2 catheter was then
advanced through the sheath over the wire with its tip engaged
into the hepatic vein under fluoroscopic guidance. The catheter
was then advanced distally and venogram was performed. The
catheter was then exchanged for a balloon occlusion catheter
over the wire and CO2 portogram was performed after inflation of
the balloon. This was done in the frontal and lateral
projections. The portogram confirmed the position of the balloon
catheter within the right hepatic vein. A TIPS puncture site was
then advanced through the sheath into the hepatic vein and the
branch of the right portal vein was entered after several
attempts with the needle. A guide wire was then advanced into
the main portal vein and a multihole straight catheter was then
placed over the wire with the tip in the main portal vein.
Pressure gradient was measured at the main portal vein, which
was 34 mmHg. The venogram was performed through the catheter,
which demonstrated multiple large collateral vessels. The liver
parenchyma track was dilated with an 9-mm balloon with an
inflation pressure up to 12 atm. A 10 mm x 94 mm Wallstent was
then deployed, extending from the main portal vein into the
hepatic vein. The stent was then dilated with 10-mm balloon.
Pressure gradient decreased to 2 mmHg between the portal vein
and the right atrium. The catheter was then repositioned into
the main portal vein and followup venogram was performed. This
demonstrated patent shunt, and decreased collateral vessels. The
catheter and the sheath were then withdrawn into the IVC and
then removed. Hemostasis was achieved by direct manual pressure
for 15 minutes.
By the request of anesthesiologist, a triple-lumen central line
was placed before the procedure through left internal jugular
vein. The tip of the catheter is within the superior vena cava.
The patient tolerated the procedure well and there were no
immediate complications.
IMPRESSION:
1. Successful transjugular intrahepatic portosystemic shunt
placement with reduction of a pressure gradient between portal
vein and right atrium at approximately 2 mmHg after the TIPS
placed.
.
F/u Day 1 post-TIPS Doppler U/S:
FINDINGS:
The liver is normal in size, no focal lesions. No intrahepatic
biliary dilatation. The TIPS stent is demonstrated between the
posterior branch of the right portal vein and right hepatic
vein. The stent appears patent with wall-to-wall flow on color
Doppler. Doppler interrogation along the stent shows a velocity
of 71 cm per second in its proximal portion, an elavated
velocity of 210 and 256 cm in the mid portion and 142 cm at the
distal end. These velocities above 200 cm per second require
close followup.
Main portal vein is patent with a velocity of 41 cm per second.
There is normal hepatopetal directional flow in the main and
right portal vein towards the TIPS stent.
Inferior vena cava appears patent on color Doppler as is the
right hepatic vein. Normal arterial waveform in the left hepatic
artery.
Small amount of intra-abdominal ascites around the liver in the
right upper quadrant.
CONCLUSION:
1. Patent TIPS stent with expected hepatopetal directional flow
in the main portal vein. Elevated velocities in the mid portion
of the TIPS stent over 200 cm per second. Short interval
followup with Doppler is advised.
2. Small amount of intra-abdominal ascites.
.
F/u Day 3 Post-TIPS Doppler U/S:
TIPS ULTRASOUND: 2D, color flow, and Doppler examination of the
abdomen was performed and compared with [**2133-5-28**]. There is a
TIPS stent in the posterior branch of the right portal vein and
right hepatic vein. The stent appears patent with wall-to-wall
color flow on Doppler exam. Doppler interrogation along the
stent shows velocity of 107 cm per second in the proximal
portion, 116 to 160 cm per second in the mid portion and 129 cm
per second in the distal portion. These velocities are
appropriate and have decreased in comparison to [**2133-5-28**]. The
main portal vein is patent with velocity of approximately 59 cm
per second. There is normal hepatopetal directional flow in the
main and right portal vein toward the TIPS stent. The inferior
vena is patent. There is appropriate flow in the main hepatic
and left hepatic veins. There is normal arterial waveform in the
common hepatic and anterior right hepatic arteries. There is a
small amount of intra- abdominal ascites around the liver in the
right upper quadrant.\
IMPRESSION:
1. Patent TIPS stent with appropriate velocities ranging from
107 to 160 cm per second. This is improved in comparison to the
prior study.
2. Small amount of intra-abdominal ascites.
.
Bilateral LENIs:
FINDINGS: Grayscale, color, and Doppler images of the right and
left common femoral, superficial femoral, and popliteal veins
were obtained. Normal flow, compressibility, augmentation, and
waveforms are demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No deep venous thrombosis in right or left common
femoral, superficial femoral, or popliteal veins.
.
[**5-27**] AP CXR:
Cardiac, mediastinal, and hilar contours are unchanged. The lung
fields are clear. Bilateral small pleural effusions have
slightly improved. No evidence of CHF or pneumonia.
.
[**5-28**] AP CXR:
Compared to yesterday's portable film, there is now new opacity
in the right middle lobe, which may represent pneumonia.
Bilateral pleural effusions may be slightly decreased. Vertical
left basilar atelectasis now slightly obscures the descending
aorta and some consolidation may be present here as well.
Cardiac size is unchanged. A left subclavian central venous
catheter has been placed and the tip is located at the level of
the proximal superior vena cava. TIPS stent is identified in the
right upper quadrant, new since yesterday's exam. Lumbar
dextroscoliosis is noted.
CONCLUSION:
1. New opacities in right middle lobe and left retrocardiac
region, which could represent pneumonia or atelectasis.
2. Decreased pleural effusions.
3. Interim placement of left subclavian central venous catheter
and TIPS stent.
.
[**5-29**] PA/Lat CXR:
FINDINGS: Left internal jugular venous access catheter appears
in unchanged position with tip terminating in upper SVC. The
heart size and mediastinal contours are within normal limits.
There are bilateral pleural effusions, right greater than left,
and bibasilar atelectasis, slightly increased from the previous
examination. TIPS stent in place in right upper quadrant. No
pneumothorax.
IMPRESSION:
1. Bilateral pleural effusions and bibasilar atelectasis,
slightly increased. No definite evidence of pneumonia.
2. Left internal jugular venous access catheter in satisfactory
position.
.
[**5-31**] PA/Lat CXR:
There has been no significant change since the prior film of [**5-29**], 06, other than removal of the left jugular CV line. No
pneumothorax. Bilateral pleural effusions and associated
bibasilar atelectasis are again demonstrated and no new lung
lesions are identified.
.
[**5-24**] WBC-11.2 Hct-20.0 MCV-98 Plt Ct-273
[**5-25**] WBC-9.4 Hct-28.0 Plt Ct-201
[**5-28**] WBC-15.1 Hct-29.6 Plt Ct-190
[**5-31**] WBC-13.3 Hct-26.4 Plt Ct-207
.
[**5-24**] PT-16.1* PTT-28.9 INR(PT)-1.5*
[**5-31**] PT-15.4* PTT-32.8 INR(PT)-1.4*
[**5-28**] Fibrino-169 D-Dimer-3003*
.
[**5-24**] Glucose-99 UreaN-10 Creat-0.7 Na-135 K-3.7 Cl-105 HCO3-20
[**5-31**] Glucose-138* UreaN-13 Creat-0.8 Na-138 K-4.2 Cl-112
HCO3-18
Calcium-8.0* Phos-2.7 Mg-2.3
.
[**5-28**] ALT-21 AST-61* AlkPhos-63 TotBili-2.7* DirBili-1.5*
IndBili-1.2
[**5-31**] ALT-16 AST-34 LD(LDH)-225 AlkPhos-85 TotBili-1.4
.
[**5-28**] 05:45AM BLOOD Cortsol-10.0
[**5-28**] 08:11AM BLOOD Cortsol-9.0
[**5-28**] 08:35AM BLOOD Cortsol-9.9
.
[**5-24**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Urine Cx: GRAM POSITIVE BACTERIA. 10,000-100,000
ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Brief Hospital Course:
Patient is a 63 y/o female with UC s/p colectomy and colostomy
20 yrs ago and recently diagnosed cirrhosis after a variceal
bleed in early [**Month (only) 547**] requiring ICU stay and a total of 11 units
of PRBCs. She presented at that time with bright red blood in
her ostomy. The bleeding was eventually stopped when the surgery
team sutured an actively bleeding vessel at the ostomy site on
[**2133-4-26**]. Afterward, a tagged RBC scan failed to reveal any
extravazation of blood. GI scoped the ostomy and found no
further sites of bleeding. She was discharged home on [**2133-5-2**]. On
[**5-20**], she had the sutures removed from her stoma. She
represented with recurrent bright blood in her ostomy starting
at 11 PM on [**5-24**]. She reported lightheadedness at the time of
the bleeding. She denied CP, SOB, N/V, hematemesis, abdominal
pain, fevers. She also had a mild nose bleed. She was taken to
[**Hospital3 **] and then transferred to [**Hospital1 18**]. In ED at [**Hospital1 18**] she
was transiently hypotensive to SBP 70s. She received 7 Liters
normal saline and 2 units PRBCs. NG lavage in ED negative. On
presentation to the MICU, she complained of chills, but denies
lightheadedness or SOB.
.
During her [**4-30**] admission, Ms. [**Known lastname **] was also diagnosed with
alcoholic cirrhosis, with EGD demonstrating portal gastropathy
with grade I varices in the lower [**1-27**] of her esophagus. She
adamantly denied any resumption of her alcohol use during the
intercedent time between hospital admissions. On initial exam in
the MICU, she had no evidence of ascites, and diuretics were
held. Vitamin K was given for INR 1.5. On arrival to the MICU,
Ms. [**Known lastname **] was transfused a total of 5U PRBC. She had an
ileoscopy on [**5-26**], which found friable tissue at the ioeostomy
site exteriorly, with nonbleeding periileostomy varices. The
first ileal portion showed portal hypertension ileopathy. The
remainder of the examined ileum was normal. She was started on
octreotide, and maintained on IV protonix [**Hospital1 **]. Per GI and liver
staff, IR consulted for TIPS procedure and possible embolization
of prominent ileocolic vein. On [**5-27**], she had a 1L BRB bleed
via ostomy requiring an additional 2U PRBC and tamponade against
liver via foley. She had a successful TIPS procedure done on
[**5-27**], and fall in pressure gradient to 2mmHg. She was extubated
post-procedure without difficulty. L IJ placed by IR on [**5-27**] at
time of TIPS as well. She was started on prophylactic Rifaximin
on [**5-28**]. F/u US demonstrated resultant expected hepatopetal
flow, but with elevated velocities to >200cm/sec. She remained
stable, and octreotide was d/c'ed on [**5-29**]. She had no further
episodes of bleeding since her TIPS. Her hct has continued to
slowly trend down, but was been generally stable.
.
Ms. [**Known lastname **] has also been treated for LE erythroderma, possible
cellulitis, for which she had been treated as an outpatient with
tw weeks of Keflex. She states that her legs improved somewhat,
but remained erythematous and edematous at time of admission,
and she was switched to vancomycin on [**5-25**]. She had LENIs on
[**5-26**], which showed no evidence of DVT. Her vanc was d/c'ed on
call-out to floor on [**5-29**] since LEs did not appear cellulitic,
and unclear whether initial appearance was due to cellulitis or
venous stasis changes. She had no worsening of symptoms after
d/c'ing vancomycin.
.
Ms. [**Known lastname **] ran a low-grade temp while in the MICU, to 100.6 on
[**5-27**], and then to 102.7F with rigors on [**5-28**] after her TIPS,
with increased O2 requirements. [**5-28**] CXR demonstrated a new RML
and L retrocardiac infiltrate, c/w PNA or atelectasis. She was
started on Zosyn, and transiently required O2 by 75% FT, again,
the day after TIPS. She was placed transiently on neosynephrine
for MAPs in 50s, which was weaned off. Her AM [**Last Name (un) 104**] stim test was
abnormal (10.0 to 9.0 to 9.9), and was started on hydrocort and
fludrocort. She has been receiving finger sticks and being
maintained on a diabetic diet for blood sugars elevated to 190s,
possibly in setting of infection vs steroids. On call-out to the
medicine floor, Ms. [**Known lastname **] had been afebrile for 24 hours, and
was feeling very well. She did have one transient episode of
relative hypotension to SBP 70s on the morning of transfer,
which responded well to 500mL LR. Her baseline BBP is 90s, and
she had no further episodes of hypotension below this level.
.
Once called out to the floor, a PA/Lateral CXR was done to
better characterize opacities seen on AP film, which were read
as more consistent with atelectasis. She was diligent about
using incentive spirometry, and her O2 was quickly weaned to
off. As Ms. [**Known lastname **] was doing extremely well clinically and
afebrile, her Zosyn and vancomycin were d/c'ed. She had no
increase in oxygen requirement or new fevers after being
observed for 48 hours. She did have an elevation in her wbc,
matching the initiation of steroid therapy. Primary team
believed that episode of fever/rigors was [**2-26**] transient
bacteremia in setting of TIPS, and transiently increased O2
requirement was [**2-26**] atelectasis, which resolved with use of
incentive spirometry. Since it was not believed that Ms. [**Known lastname **]
was truly septic, but did not have appropriate response to [**Last Name (un) 104**]
stim test, she was d/c'ed home on 1 week prednisone taper. She
was instructed to f/u with her hepatologist, with whom she had
an appointment in two weeks. As she was not volume overloaded
and had a recent TIPS procedure, she was not sent out on her
home diuretic therapy. However, she was instructed to call her
physician if she had increasing LE edema or abdominal swelling
to discuss reinitiation of diuretics. She was also instructed to
return to the ED with any recurrence of fevers, shortness of
breath, or for any other concerns.
Medications on Admission:
1. Pantoprazole 40 mg Tablet
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325mg Tablet Sig: One Tablet PO DAILY
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
9. Keflex
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: [**5-31**]: 3 pills once a day
[**6-2**]: 2 pills once a day
[**6-4**]: 1 pill once a day
[**6-6**]-14: [**1-26**] pill once a day
[**6-8**]: stop.
Disp:*10 Tablet(s)* Refills:*0*
9. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
10. ostomy supplies
ConvaTec Active Life Drainable Pouch
precut 1 [**1-28**]"
#[**Numeric Identifier 109096**]
Dispense: qs one month
Refills: 2
11. ostomy supplies
[**Last Name (un) **] Wafer
#002
Disp:qs one month
Refills: 2
12. ostomy supply
Adhesive Remover Wipes
#[**Numeric Identifier 109097**]
Disp: qs one month
Refills: #2
13. ostomy supplies
No Sting Barrier wipes
Disp: qs one month
Refills:#2
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Portal ileopathy
Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a GI bleed. You had a TIPS procedure to
decrease the pressure in the blood vessels in your GI tract. You
should follow-up in liver clinic in [**1-26**] weeks and the number is
listed below. You should return to the ED with any bleeding from
your ostomy, fever, chills, shortness of breath, or for any
other problems that concern you. You should not take your lasix
or spironolactone for now. If you experience increased leg or
abdominal swelling, you should contact your physician regarding
whether you should restart these medicines.
Followup Instructions:
An appointment was scheduled with Dr. [**Last Name (STitle) **] in the Liver
Clinic, but we have decided you should see Dr. [**Last Name (STitle) **] instead.
Please call [**Telephone/Fax (1) 2422**] on Monday to make an appointment with
Dr. [**Last Name (STitle) **] in [**1-26**] weeks. When you call that number, please ask
them to cancel your appointment with Dr. [**Last Name (STitle) **] (originally
scheduled for [**6-10**]).
|
[
"486",
"5849",
"0389",
"2851",
"2449"
] |
Admission Date: [**2144-3-9**] Discharge Date: [**2144-3-16**]
Date of Birth: [**2076-9-2**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Heparin Agents / Levofloxacin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**3-11**] Placement of IVC filter.
History of Present Illness:
67 yo with recent history of diverticular abscess (s/p IR
drainage [**2-21**]) and HIT developed during that admission who
presented to an OSH ED with dyspnea.
On day of admission, in the OSH ED was found to have bilateral
segmental PEs and was noted to have a BP of 80/50. She was
transferred to the [**Hospital1 18**] ED and had the following vitals 99% 4L
NC, SBP 100-140. Due to her HIT allergy, she was started on
lepiridun and transferred to the [**Hospital Unit Name 153**] for initiation of
lepirudin and close monitoring. On arrival in [**Hospital Unit Name 153**], patient
comfortable with unremarkable vital signs.
Brief history of illness: Patient presented to PCP after
experiencing several days of increasing severe abdominal pain,
diagnosed with diverticulitis and diverticular abscess by CT at
[**Hospital1 **] [**Location (un) 620**]. CT guided drainage of abscess at [**Hospital1 18**] [**Location (un) 86**] [**2-21**],
transferred back to [**Location (un) 620**] for remainder of IV abx therapy
(Levo/Flagyl).
On discharge from hospital [**2-29**], patient was transitioned to po
antibiotic regimen including levo+flagyl. On [**3-1**], patient
developed an impressive morbilliform rash on her trunk, visited
primary surgeon the next day who removed flagyl antibiotic,
suspecting this was cause of drug rash, given prednisone course
+ benadryl. Since this time, maintained on levofloxacin
monotherapy.
Patient's rash improved slightly in interim [**3-1**] - present, but
did not completely disappear off Flagyl. On admission to the ER
today, patient had sudden increase of area and hue of rash,
becoming increasingly bright erythema with mild pruritis.
Patient notes that this was after receiving IV levofloxacin in
the ER.
Past Medical History:
1. gout
2. gerd
3. htn
4. s/p hip replacement
Allergies: Flagyl (rash as above), ?levofloxacin. Hx of HIT
Social History:
Lives in [**Location 620**] alone with cat, named "Pockets". She is a
retired retail banker. Nonsmoker, denies alcohol use. No
recent travel nor exposures.
Family History:
Family history significant for mother who died in 80's of MI.
Father with adult-onset diabetes.
Physical Exam:
T 96.3 P 111 BP 133/76 RR 16 O2 sat 99% on 4L NC Wt 168 lbs
Gen: Alert, pleasant, well.
HEENT: Anicteric, MMM, OP clear.
Neck: Supple, no LAD.
Heart: RRR, nl S1, S2, no extra sounds.
Lungs: CTA bilaterally.
Abd: Soft, NT, ND, drain in place in LLQ.
Ext: Trace pedal edema, 2+ distal pulses.
Skin: Blanching, morbilloform rash on central chest, back,
spreading to bilateral upper arms, upper legs.
Pertinent Results:
[**2144-3-13**] ECHO: 1. The left atrium is mildly dilated. 2. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. 3. Right ventricular chamber size and free wall motion
are normal. 4. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. 5. There is borderline
pulmonary artery systolic hypertension. 6. There is a
trivial/physiologic pericardial effusion. 7. Compared with the
findings of the prior study (images reviewed) of [**2144-3-10**], RV
function may have improved, although it is difficult to compare
to the previous suboptimal study.
.
[**2144-3-12**] IVC filter placement: 1. Successful placement of a
Gunther Tulip retrievable inferior vena cava filter in the
infrarenal position. This filter may be retrieved, if indicated,
within 2 weeks of placement. 2. The venogram demonstrated a
single patent inferior vena cava with no evidence of intracaval
thrombosis. Flow voids from the renal veins indicated patency of
the renal veins bilaterally. 3. This filter should be removed
within the next 2 weeks. If removing filter within this
timeframe is not feasible, consider repositioning of the filter
for a later removal.
.
[**2144-3-10**] Bilateral lower extremity ultrasound: Deep venous
thrombosis involving the left common femoral and popliteal
veins.
.
[**2144-3-10**] ECHO:
Suboptimal image quality. The left atrium is elongated. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function
appears normal (LVEF>55%). Right ventricular systolic function
appears depressed. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
.
[**2144-3-9**]: AP UPRIGHT CHEST PLAIN FILM: The heart size is normal.
The aortic contour appears ectatic. Remaining mediastinal
contours are unremarkable. The lungs are clear. There are no
pleural effusions.
IMPRESSION: No acute cardiopulmonary processes.
.
[**2144-3-9**] 06:11PM BLOOD WBC-8.6 RBC-4.35 Hgb-13.9 Hct-37.4 MCV-86
MCH-31.9 MCHC-37.1* RDW-15.1 Plt Ct-196
[**2144-3-9**] 06:11PM BLOOD PT-17.9* PTT-50.8* INR(PT)-1.7*
[**2144-3-9**] 06:11PM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-139
K-3.4 Cl-99 HCO3-26 AnGap-17
[**2144-3-10**] 02:21AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6
Brief Hospital Course:
67 yo with recent history of diverticular abscess (s/p
drainage), HIT who presents with pulmonary embolism. Given
history of heparin induced thrombocytopenia, started on
lepirudin - now on argatroban. Antimicrobial therapy is
complicated by appearance of drug rash.
.
1. PE: Left leg DVT seen on U/S seems like the most likely
source - likely from venous stasis due to recent immobility
following her diverticular abscess and drainage placement. TTE
showed some depressed RV function but was of poor technical
quality. Has been hemodynamically stable after getting IVF [**3-11**].
Will encourage po intake, supplement with IVF if needed.
Lepirudin switched to argatroban [**3-11**] (after placement of filter
- did not want to reinitiate lepirudin due to risk of
anaphylaxis), started coumadin evening of [**3-10**] - overlapped with
argatroban and coumadin per protocol in front of chart.
Currently therapeutic on coumadin. Filter to stay in place for
at least two weeks - will need to be repositioned if needed for
longer.
.
2. Diverticular abscess: Patient needs broad GI gram neg.
coverage. Came in on levofloxacin monotherapy, but given recent
increase in drug rash today (off flagyl), started on zosyn
([**3-9**]). Continue zosyn likely until abdominal surgery.
.
3. Rash: Unclear source although suspect drug induced - likely
flagyl but also potentially levo. Drug rash stable. Treated with
prednisone 60 x 3 days, atarax for pruritus.
.
4. HTN: Continued diovan, lasix with holding parameters.
.
5. GERD: Continue PPI.
.
6. H/o gout: Continue allopurinol.
.
7. F/E/N: Low residue diet.
.
8. PPX: PPI, argatroban/coumadin (no heparin), bowel regimen,
RISS with prednisone.
.
9. Code: Full.
Medications on Admission:
Diovan 80 mg po qd
Lasix 20 mg po qd
Allopurinol 200 mg po qd
Prevacid 20 mg po qd
Levofloxacin 500 mg po qd
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritus.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours).
11. sodium chloride flush for peripheral IV.
Discharge Disposition:
Home With Service
Facility:
Avory Manor
Discharge Diagnosis:
1. diverticular abscess, s/p drainage.
2. bilateral pulmonary emboli.
Discharge Condition:
Good, stable.
Discharge Instructions:
Please continue to take all medications exactly as prescribed.
If you experience any chest pain, shortness of breath, or any
other concerning symptoms, call your PCP or return to the
hospital.
Followup Instructions:
Please call to schedule an appointment with Dr. [**First Name (STitle) 2819**] from
surgery - the phone number is ([**Telephone/Fax (1) 6347**]. You will need to
have an appointment in 2 weeks.
.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]
Completed by:[**2144-3-16**]
|
[
"4019",
"53081"
] |
Admission Date: [**2170-12-1**] Discharge Date: [**2170-12-3**]
Date of Birth: [**2097-3-18**] Sex: M
Service: NEUROSURGERY
Allergies:
Narcotic Analgesic & Non-Salicylate Comb
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 9772**] is a 73-year-old man with a
history of a fib on Coumadin (INR 1.7) who presents with left
hemiplegia and unresponsiveness, found to have large right
frontal intraparenchymal hemorrhage. His exam is notable for
absent brainstem reflexes with pinpoint left pupil (right pupil
post-surgical), extensor posturing in the UEs, flexion posturing
in the LEs, diffuse hyperreflexia, and bilateral upgoing toes.
This implies little if any brainstem activity, presumed due to
compression by the large ICH. Etiology given the extent of the
hemorrhage (lobar) may be amyloid angiopathy. AVM or
uncontrolled HTN would be other options.
Past Medical History:
CAD s/p MI age of 60
A fib, anticoagulated
Glaucoma
Aneurysms "in groin and in back"
Social History:
Former smoker, quit years ago. Rare EtOH. Retired from
GE, works part time in manual labor at [**Location (un) 9773**] electronics.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 100.2 P: 108 iireg R: 12 BP: 200/90 SaO2: 100%AC
General: Unresponsive, intubated. On no sedation.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Irregular.
Abdomen: soft.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Unresponsive to pain.
-Cranial Nerves:
I: Olfaction not tested.
II: Right pupil irregular, 5 mm and fixed (reportedly
post-surgical). Left pupil 1 mm and fixed.
III, IV, VI: No OCR.
V: No corneal reflex.
VII: No facial droop, facial musculature symmetric.
VIII: No OCR
IX, X: No gag to palate stimulation or to deep suction.
-Motor: Extensor posturing of B UE to pain, triple flexion B LE
to pain. Occasional fast low amplitude movements of B UE.
-Sensory: Response to pain as above.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 4
R 3 3 3 4
Plantar response was flexor bilaterally.
-Coordination & Gait: Not tested.
Pertinent Results:
CT CNS:
There is a large right frontal hemorrhage, lobar and extending
into
the lateral ventricle. There is blood throughout the right
lateral, third and fourth ventricles, and a small amount of
blood in the occipital [**Doctor Last Name 534**] of the left lateral ventricle.
The right frontal sulci are effaced. There is a right subfalcine
herniation with extensive shift of the septum pellucidum and
third ventricle to the left.
The right lateral, third and fourth ventricles are compressed.
Dilatation of the temporal and occipital horns of the left
lateral ventricle suggests
trapping.
There is a right uncal herniation. There is no tonsillar
herniation at this time.
No fracture is identified. Mucosal thickening, fluid and
aerosolized
secretions in the paranasal sinuses may be related to
intubation.
The cavernous and supraclinoid internal carotid arteries are
calcified
bilaterally.
IMPRESSION:
1. Large right frontal lobar hemorrhage with large
intraventricular
extension.
2. Large right subfalcine and mild right uncal herniation.
3. Compression of the right lateral, third and fourth
ventricles. Dilatation of the left lateral ventricle, indicative
of trapping.
Brief Hospital Course:
The patient was intubated and sedated. He was made DNR and DNI
and eventually CMO. Then, he was extubated and placed on a
morphine drip for comfort. Eventually, he passed the way at
15:59 due to cardiorespiratory arrest.
Medications on Admission:
Atenolol 50 mg po daily
Coumadin 5 - 7.5 mg po daily
ASA 81
Simvastatin 80 mg po daily
Azopt 1% 1 drop OD daily
Tylenol prn
MVI
Gluc-Chondroitin
Discharge Disposition:
Expired
Discharge Diagnosis:
Lobar hemorrhage (RIGHT)
Discharge Condition:
expired
|
[
"42731",
"41401",
"412",
"V1582"
] |
Admission Date: [**2170-5-9**] Discharge Date: [**2170-5-11**]
Date of Birth: [**2121-2-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache hemiplegia
Major Surgical or Invasive Procedure:
angiogram [**2170-5-9**]
History of Present Illness:
49 year old female h/o MS [**First Name (Titles) **] [**Last Name (Titles) **] was at her PCP's office
today when she had sudden onset of headache and right
hemiplegia.
The patient was sent to OSH where she was intubated and given
mannitol. Her SBP was 192 at the OSH and she was given lasix and
labetolol. She was then sent here and her repeat head CT shows
increased amount of hemorrhage and increased shift. The
patient's
SBP is currently 129 and she has just received 50 grams of
mannitol per neurology. Neurosurgery was called to see the
patient STAT for anisocoria and herniation.
Past Medical History:
[**Last Name (Titles) **]
multiple sclerosis - Dr.[**Name (NI) 78170**] patient
Social History:
lives with husband, has 5 children
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T: 97.5 BP:157/91 HR:86 RR:18 O2Sats:100% vented
Gen: intubated, sedated on propofol
HEENT: Pupils:anisocoric, but reactive EOMs-unable to test
Neck:unable to assess tenderness due to mental status
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Not following commands, no eye opening,
intubated,
sedated.
Cranial Nerves:
I: Not tested
II: Pupils unequally round and reactive to light, right 3-2 mm,
left 2-1mm.
III-XII: unable to test
Motor: Left side moving spontaneously and briskly localizes with
LUE. Right side hemplegic.
Sensation: unable to test
Toes upgoing bilaterally
Pertinent Results:
HEAD CT [**5-9**]: There are two large likely contiguous areas of
intraparenchymal hemorrhage one centered at the left basal
ganglia (2:15) measuring 5.4 x 3.6 and a second in the left
parietal lobe measuring 4.4 x 4.3 cm. Compared to the study
performed approximately three hours prior, these areas of
intraparenchymal hemorrhage have significantly increased in
size. There is moderate hypodensity surrounding these
intraparenchymal hemorrhagic areas, likely due to edema. There
is resulting compression of the left lateral ventricle with
10-mm leftward shift, likely subfalcine herniation. There is
mild obliteration of the left prepontine cistern, likely
representing mild uncal herniation. Hemorrhagic material is seen
layering in the right occipital [**Doctor Last Name 534**] (2:13). Hyperdense material
is seen along the right frontal convexity (2:24 through 2:21)
representing subarachnoid hemorrhage. There is mild sulcal
effacement along the left hemisphere. No areas of territorial
infarction identified. Osseous structures appear normal and
paranasal sinuses and mastoid air cells remain well aerated. The
hemorrhagic area in the left parietal lobe (2:22) may
demonstrate a fluid-fluid level suggestive of acute on subacute
hemorrhage.
CTA HEAD [**5-9**]: In the area of intraparenchymal hemorrhage
previously described are several hyperdense foci representing
"spot signs" and are concerning for active extravasation. These
are best seen (3:103, 3:99). A linear area of hyperdensity seen
traversing through the area of hemorrhage (3:91) could represent
an area of active extravasation or a vessel which does not
appear to be contiguous with any surrounding intracranial
vessel. The distal branches of the left MCA are displaced by
this large intraparenchymal hemorrhage, however, there is no
evidence for occlusion or stenosis of any intracranial vessel.
No evidence for aneurysm or AVM is seen. Incidental note is made
of a diminutive left vertebral artery and diminutive right
posterior communicating artery.
IMPRESSION:
1. Massive intraparenchymal hemorrhage involving region of the
left basal
ganglia and left parietal lobes with multiple foci of "spot
sign" concerning for areas of active extravasation. Surrounding
vasogenic edema.
2. No evidence for AVM or aneurysm, although adjacent
intracranial vessels
are displaced by this intraparenchymal hemorrhage. No vascular
occlusion.
3. Significant mass effect caused by this enlarging
intraparenchymal
hemorrhage causing 10-mm rightward subfalcine herniation and
possible left
uncal herniation.
Repeat Head CT [**5-9**]:
Large intraparenchymal hemorrhage centered in the left
basal ganglia and temporoparietal lobes has increased in size,
measuring up to 7.5 x 4.9 cm on axial imaging (2:17), previously
measuring 5.7 x 3.6 cm at a similar level. There is increased
extension of the hemorrhage into the ventricles, now filling the
right occipital [**Doctor Last Name 534**], layering in the left
occipital [**Doctor Last Name 534**], and also seen in the fourth ventricle. There is
also
scattered subarachnoid component, with blood now seen within the
basal
cisterns. There is increased sulcal effacement, without sparing
only along
the anterior and superior convexity of the right frontal lobe.
There is
increased rightward shift of normally midline structures, from
10 mm to 14 mm, with rightward subfalcine herniation. There is
increased left-sided uncal herniation. In addition, there is
appearance of a trapped ventricles, with enlargement of both of
the lateral ventricles, which is slightly more apparent than the
right as the left frontal [**Doctor Last Name 534**] is effaced. The soft tissues,
orbits, and skull appear intact. The visualized mastoid air
cells and paranasal sinuses remain well aerated.
IMPRESSION: Since the study performed six hours prior, there is
interval
increase in size of left cerebral intraparenchymal hemorrhage
with increased mass effect with rightward subfalcine herniation,
increased left uncal herniation, and new appearance of trapped
ventricles due to the increased size of the hemorrhage as well
as increased edema.
Cerebral angiogram [**5-9**]:
no report at the time of this writing but the physician told the
neurosurgery team that there was no evidence of AVM/aneurysm
Brief Hospital Course:
The patient was evaluated in the ER by neurology and
neurosurgery was called when she starting developing anisocoria.
Her head CT at [**Hospital1 18**] showed increased hemorrhage compared to the
scan from the OSH. The patient had right hemiplegia but was
moving the left side spontaneously. She was given mannitol at
the OSH and was given another dose per neurology when her pupils
became unequal. The patient had a CTA which showed some vessels
going through the site of the hemorrhage and it was unclear if
there were any abnormalites. Therefore, the patient was sent for
a formal angiogram which showed no aneurysm or AVM. She was
admitted to the ICU for Q 1 hour neuro checks, continuation of
medical management. Due to the left sided hemorrhage, Dr. [**Last Name (STitle) **]
did not offer any surgery because chances for a meaningful
recovery after such a significant hemorrhage were very low. This
was explained to her husband in the emergency room. The plan was
to continue to do neuro checks and serial head CT scans.
Unfortunately, upon repeat imaging later that night, the
hemorrhage had again increased in size with continued
herniation. Dr. [**Last Name (STitle) **] again spoke to the family and discussed
the possibility of [**Last Name (STitle) 3225**] and extubation and the likelihood that
the patient may become brain dead in the near future. Early in
the morning on [**2170-5-10**] the patient's family came in to see her.
We had a family meeting with the social worker at the bedside.
The patient's husband and father agreed to make her [**Name (NI) 3225**]. They
also wanted her to be an organ donor since she had expressed
those wishes in the past and had it indicated on her driver's
license.
The organ bank representatives spoke to the family and the
decsion was made to keep the patient intubated until a possible
organ procurement could occur but that she would otherwise be
given comfort measures. We stopped all unneccessary medications
and kept her comfortable. She received antiseizure medications
and was kept sedated. Later in the day she was extubated. The
patient died at 2:35 in the morning on [**2170-5-11**]. She was no
longer a candidate for organ donation because of hypoperfusion
of the organs.
Medications on Admission:
atenolol
avonex
received mannitol, labetolol, lasix at OSH
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
intraparenchymal hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2170-5-11**]
|
[
"4019"
] |
Admission Date: [**2110-3-16**] Discharge Date: [**2110-3-31**]
Date of Birth: [**2049-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Acute gallstone pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 60 year old male who presented to [**Hospital 1562**] Hosp. on
[**2110-3-15**] with increasing abdominal pain. On the morning of
admission he noted abdominal discomfort following a meal that
developed into severe epigastric, non-radiating, sharp, buring
pain accomplanied by nausea and vomiting. He was taken to the
[**Hospital1 1562**] ED where he was afebrile and his admission labs were
notable for WBC 20.1 Amylase 4094 Lipase 3000 AST 288 ALT 188.
An abdominal CT showed diffuse pancreatic enlargement with
surrounding inflammation, multiple gallstones, no CBD
dilatation, no signs of obstruction and no free air. While
admitted to [**Hospital1 1562**] his enzymes and WBC began to trend down
while his K+
increased to 8 from 3.6. On [**3-16**] he was transferred to [**Hospital1 18**]
surgical ICU. His last BM was the AM of [**3-16**], described as dark
brown, and his last emesis was on arrival at [**Hospital1 18**].
Past Medical History:
PMH: CAD, DMII, HTN, Hyperlipidemia, CRI ([**Date range (1) 76919**] dialysis),
suicide attempt (antifreeze)
PSH:
-colectomy for diverticulitis w/ ostomy s/p revision and
takedown
approx 8y ago.
-ventral hernia repair with mesh
-L knee repair
-L shoulder repair
-back surgery
Social History:
lives with wife at home. Retired town administrator, non-smoker,
rare EtOH
Family History:
non contributory
Physical Exam:
VS:98.7 123 115/76 19 93%2L nc
Gen: lying in bed, mildly lethargic but responsive and
appropriate, NAD
CV:tachycardic regular S1 S2
Pulm: CTA B, no wheeze or rales
Abd: soft, distended, tympanitic, focally tender epigastrically
and LLQ. No rebound or guarding. Midline scar. LLQ transverse
scar. Supraumbilical transverse scar.
Extr: w,w-p, no edema
Skin: no jaundice
Pertinent Results:
[**2110-3-16**] 11:12PM BLOOD WBC-11.4* RBC-4.89 Hgb-14.6 Hct-42.6
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.0 Plt Ct-188
[**2110-3-18**] 06:05AM BLOOD WBC-8.1 RBC-3.96* Hgb-11.9* Hct-34.5*
MCV-87 MCH-30.1 MCHC-34.6 RDW-14.9 Plt Ct-160
[**2110-3-17**] 03:39AM BLOOD Glucose-237* UreaN-54* Creat-3.1* Na-146*
K-4.8 Cl-114* HCO3-22 AnGap-15
[**2110-3-18**] 06:05AM BLOOD Glucose-190* UreaN-59* Creat-2.6* Na-147*
K-4.3 Cl-115* HCO3-20* AnGap-16
[**2110-3-18**] 06:05AM BLOOD ALT-77* AST-57* AlkPhos-33* Amylase-562*
TotBili-2.5*
[**2110-3-16**] 11:12PM BLOOD ALT-178* AST-153* AlkPhos-36*
Amylase-979* TotBili-2.6*
[**2110-3-18**] 06:05AM BLOOD Lipase-565*
[**2110-3-16**] 11:12PM BLOOD Lipase-1892*
[**2110-3-18**] 06:05AM BLOOD Calcium-6.9* Phos-2.7 Mg-2.1
[**2110-3-17**] 11:49AM BLOOD %HbA1c-8.6*
.
ABDOMEN U.S. (COMPLETE STUDY) [**2110-3-17**] 3:55 PM
IMPRESSION: Limited study, cholelithiasis and biliary sludge. No
acute cholecystitis is evident. No ascites.
.
Brief Hospital Course:
This is a 60 year old man admitted directly from outside
hospital with acute
pancreatitis.
Acute necrotizing gallstone pancreatitis: He was NPO with IV
fluid resuscitation. His pain was adequately controlled. He had
a Foley in order to closely watch his fluid balance.
.
He had a RUQ U/S on HD 3 and this showed cholelithiasis and
biliary sludge. No acute cholecystitis is evident.
.
A CXR was done on HD 3 and showed Free air under the
hemidiaphragms. A CT abd showed extensive emphysematous
pancreatic necrosis of the neck, body and tail of the pancreas
with multiple fluid collections along the greater curvature of
the stomach. Infected necrotizing pancreatitis cannot be
excluded. Significant amount of free intraperitoneal air. This
is likely related extension of retroperitoneal air into the
peritoneal cavity as there is no extravasation of oral contrast
that would document bowel perforation. However, bowel
perforation cannot be excluded.
.
He went to the OR on [**2110-3-18**] for a necrosectomy. He was admitted
to the ICU on pressre support and broad spectrum antibiotics.
.
He self-extubated on POD 1. He was stable and transferred to the
floor on POD 2.
His incision had some spotty drainage along the right side. He
had JP drains x [**Street Address(2) 76920**]. JP#3 was removed on POD#11, as the
output was <10cc/day.
.
On POD 8, he went for CT guided drainage of necrotic debris and
fluid from the pancreatic bed. A 14 French pigtail drain was
placed and 20cc of brownish fluid and debris was aspirated.
Cultures had no growth.
.
JPs #1 and 2 and the pigtail drain were left in place upon
discharge, with VNA to provide home care.
FEN: He was started on TPN while NPO. He was started on clears
on POD 6
He was tolerating regular food by POD#9 and the TPN was weaned
off.
Hyperglycemia: His blood sugars were elevated and a HbA1C was
8.6. [**Last Name (un) **] was consulted for blood glucose control. He was
started on Lantus and a humalog sliding scale and his blood
sugars were under control upon discharge. He will follow up as
an outpatient.
Chest Pain: On the morning of POD 7, he complained of chest
pain. He was worked up with EKG, CXR, cardiac enzymes and was
ruled out for a MI. He received ASA, Morphine and his pain
resolved.
Post-op blood loss anemia: He received 2 units of PRBC on POD 8
for a HCT of 22.9, with appropriate rise in HCT to 28.3.
Post-op Delirium: He had mental status change on POD 4. A head
CT revealed no acute intracranial abnormalities or hemorrhage
identified. He had a sitter at the bed-side. His mental status
continued to slowly improve to baseline at discharge.
Acute on chronic renal failure (CRI): His Cr at admission was
3.3. After IVF, his Cr returned to his baseline.
Pt was discharged on POD#12 with VNA for diabetic
teaching/monitoring and drain and incision care, to follow up
with Dr. [**Last Name (STitle) 468**] in 2 weeks.
Medications on Admission:
metoprolol 50mg',zoloft 50mg', lisinopril 20mg', tricor 145mg',
vytorin 10/80mg', omeprazole20mg', ASA 81mg', trazodone QHS
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
6. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*90 Cap(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Sixty (60)
units Subcutaneous With breakfast.
Disp:*qs ml* Refills:*2*
14. Humalog 100 unit/mL Solution Sig: 10-40 units Subcutaneous
four times a day: Pt has instructions for sliding scale.
Disp:*qs ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
Acute gallstone pancreatitis
Necrotizing Pancreatitis
post-op hyperglycemia
post-op delerium
post-op blood loss anemia
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. His office should
get in touch with you regarding the time for your appointment,
likely [**2110-4-14**]. [**Telephone/Fax (1) 2835**]
|
[
"0389",
"5849",
"5859",
"99592",
"25000",
"2859"
] |
Admission Date: [**2122-11-4**] Discharge Date: [**2122-11-4**]
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
female who was found at home approximately at 5.00 p.m.,
complaining of abdominal pain without obvious sign of trauma.
She was taken to the referring hospital where she was
responsive and moving extremities but inappropriate. Head CT
showed right paraventricular subdural hematoma with a large
shift. She was transferred to [**Hospital1 188**] requiring intubation prior to arrival and was given
fentanyl, mannitol, and Dilantin.
PHYSICAL EXAMINATION: An intubated female with no jugular
venous distension, no signs of head trauma, pupils were 5 mm
on the right, nonreactive and 4 mm on the left, nonreactive.
Chest was clear. Cardiovascular: Regular sinus rhythm.
Abdomen: Soft without trauma. Extremities: There was a 10-
cm area of ecchymosis in the right gluteal fold. Skin was
warm. Neurologic: Withdrawing of the right upper extremity
to pain. No withdrawal on the left.
LABORATORY DATA: White count 15,000, hematocrit 32.7 and
platelets 61,000.
The patient underwent CT scan, which showed a large right
frontal subdural hematoma and paraventricular hemorrhage with
large shift.
HOSPITAL COURSE: The patient was seen in consultation with
Neurosurgery. They discussed the situation with the family
who decided that the patient should be treated with comfort
measures only. The patient was admitted to the Intensive
Care Unit and the organ bank was consulted. The patient was
subsequently declared dead on [**2122-11-4**] at 5:45. The medical
examiner accepted the case.
DISCHARGE DIAGNOSIS: Subdural hematoma with shift.
DISCHARGE MEDICATIONS: None.
FOLLOW-UP PLANS: Medical examiner case.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 16475**]
MEDQUIST36
D: [**2122-11-19**] 19:02:16
T: [**2122-11-19**] 20:34:07
Job#: [**Job Number 57919**]
|
[
"4019"
] |
Admission Date: [**2195-12-16**] Discharge Date: [**2195-12-16**]
Date of Birth: [**2175-11-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
alcohol intoxication
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 83815**] 20 year-old man was at a party with his cousins
where he reportedly drank 5 beers and subsequently was feeling
unwell and sat on the lawn and was then found unresponsive. EMS
found vitals within normal limits, no signs of trauma. He was
taken to [**Hospital **] Hospital where he was intubated for airway
protection due to obtundation, had reportedly normal head CT,
alcohol level was 314 at 0100, remainder of toxicology screen
negative. He was then transferred to the [**Hospital1 18**] ED due to lack of
ICU beds.
.
Initial vitals in the ED were 97.5 87 110/74. Labs in the ED
were notable for alcohol level of 274 with otherwise negative
serum tox and urine tox screen. He received a bannana bag and a
total of 10 mg ativan for agitation. The was subsequently
admitted to the MICU for further care. Vitals on transfer were
78 106/69 16 100% 550 5 100%.
.
On arrival to the MICU, the patient is intubated and sedated,
arousable and following commands.
Past Medical History:
- ? catecholamine-induced polymorphic VT s/p ablation in [**2192**]
(EP study did not induce VT did have ablation of anterior LV
wall at the site of work-induced spikes)
- prior admissions for alcohol intoxication
Social History:
Nursing student. 2 prior admissions for EtOH intoxication, 1
arrest, has been to AA meetings in the past.
Family History:
Non-contributory
Physical Exam:
Admission:
VS: T: 97.8, P: 94, BP: 123/74, RR: 21, 99% on ventilator
General: Intubated and sedated, arousable and following commands
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge:
VS: AF, P: 94, BP: 113/63, RR: 15, 98% on RA
GEN: thin young male in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2195-12-16**] 04:45AM BLOOD WBC-7.8 RBC-4.65 Hgb-14.5 Hct-42.0 MCV-91
MCH-31.3 MCHC-34.5 RDW-12.5 Plt Ct-304
[**2195-12-16**] 04:45AM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-144
K-4.4 Cl-112* HCO3-21* AnGap-15
[**2195-12-16**] 04:45AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.2
[**2195-12-16**] 05:37AM BLOOD Type-ART Temp-36.4 Rates-16/ Tidal V-550
PEEP-5 FiO2-100 pO2-419* pCO2-33* pH-7.39 calTCO2-21 Base XS--3
AADO2-264 REQ O2-51 -ASSIST/CON Intubat-INTUBATED
[**2195-12-16**] 04:45AM BLOOD ASA-NEG Ethanol-274* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR [**2195-12-16**]
1. Highly positioned endotracheal tube, consider advancing by
2-3 cm for
appropriate seating.
2. Clear lungs.
Brief Hospital Course:
Patient is a 20 year-old man with history of VT s/p ablation
admitted with alcohol intoxication.
# Respiratory Failure: Patient was intubated at [**Hospital **] hospital
for airway protection in the setting of obtundation. Patient was
considerably more alert on arrival to the MICU and was arousable
and follwing commands. Sedation was stopped and he was extubated
promptly.
# Alcohol Intoxication: Patient was admitted in the setting of
alcohol intoxication requiring intubation for airway protection
in the setting of obtundation. Patient has a history of
alcoholism and binge drinking. He has no history of withdrawl
from alcohol. He was given multivitamin IV bag. He was seen by
social work. He was counseled on staying abstinent from alcohol.
# History of VT - Patient has a questionable history VT s/p
ablation in [**2192**].
Medications on Admission:
- Aspirin 81 mg daily
- Flecainide 100 mg po BID
- Lexapro
Discharge Medications:
1. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
3. Lexapro Oral
4. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Alcohol intoxication, respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 83816**],
You were admitted to the intensive care unit at [**Hospital1 771**] because you needed a breathing tube
placed while you were intoxicated. As the alcohol wore off, you
woke up and we were able to remove the breathing tube.
You should avoid alcohol and should enter a program such as
alcoholics anonomyous to help you stay sober.
You should take a multivitamin daily. No other changes were made
to your medications.
Followup Instructions:
Please keep the following appointments:
Name: [**Last Name (LF) 83817**],[**First Name3 (LF) 251**] L
Address: 454 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] HWY, [**Location (un) **],[**Numeric Identifier 83818**]
Phone: [**Telephone/Fax (1) 83819**]
Appointment: Thursday [**2195-12-24**] 10:00am
|
[
"51881"
] |
Admission Date: [**2158-1-29**] Discharge Date: [**2158-2-3**]
Date of Birth: [**2083-9-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
cough and congestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 year-old man with history of stomach/bladder cancer s/p
recent chemo at [**Hospital1 1474**] VA, DM, CAD presentes wit 2-3 days of
productive cough with green sputum and sob with exertion,
fatigue and lethargy. Per girlfriend, patient had decreased PO
intake and mild confusion during that time. Patient with
witnessed fall day prior to admission without head trauma.
Patient denied dysuria, fevers, frequency. In ER patient noted
to have bilateral pneumonia, UTI, hyperglycemia. Patient was
started on insulin drip, IVF levaquin and transferred to the ICU
for management of hyperosmolar ketoacidosis. No recent med
changes.
Past Medical History:
bladder ca
stomach ca
DM2 on insulin
CAD s/p MI
recent admit for chemo tx 6 weeks ago
impotence
MRSA
HTN
anemia
lacunar CVA
CRF
glaucoma
cognitive decline
urinary incontinence, chronic
Social History:
history of alcohol abuse in past
no drugs, no smoking
Family History:
non-contributory
Physical Exam:
VS: temp: 102.4 bp: 170/91 HR: 93 RR: 20 99% rm air
general: somnolent but AAOx3
HEENT: MMM, no JVD, no Virchow's node, no nuchal rigidity
lung: rales at bases
heart: RR, S1 and S2, no murmurs, rubs or gallops
abd: +b/s, soft, non-tender, non-distended
extr: no cyanosis, clubbing or edema, 2+pulses b/l
neuro: CNII-XII intact, [**6-1**] stregnth in upper extremities, DTR's
intact
Pertinent Results:
Admit labs:
[**2158-1-29**] 12:12AM WBC-9.5 RBC-2.85* HGB-8.5* HCT-27.3* MCV-96
MCH-29.8 MCHC-31.1 RDW-14.6
[**2158-1-29**] 12:12AM NEUTS-89.3* BANDS-0 LYMPHS-7.9* MONOS-2.5
EOS-0.2 BASOS-0.2
[**2158-1-29**] 12:12AM PLT COUNT-242
[**2158-1-29**] 12:12AM PT-15.2* PTT-27.5 INR(PT)-1.5
[**2158-1-29**] 12:12AM GLUCOSE-670* UREA N-53* CREAT-2.4* SODIUM-138
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-24
[**2158-1-29**] 12:12AM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2158-1-29**] 12:12AM ALT(SGPT)-25 AST(SGOT)-28 CK(CPK)-171 ALK
PHOS-87 TOT BILI-0.8
Cardiac enzymes:
[**2158-1-29**] 12:12AM CK-MB-3 cTropnT-0.05*
Toxicology:
[**2158-1-29**] 11:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-1-29**] 08:00AM BLOOD Acetmnp-NEG
[**2158-1-29**] 03:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urinalysis:
[**2158-1-29**] 12:55AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2158-1-29**] 12:55AM URINE RBC-1 WBC->50 CLUMPS SEEN Bacteri-FEW
Yeast-NONE Epi-0-2
[**2158-1-29**] chest x-ray:
UPRIGHT AP PORTABLE CHEST: The heart size is probably normal
given the AP
technique. Bilateral patchy opacities with some nodular features
are more
pronounced in the lower lobes. The left upper lobe is relatively
clear. No
pleural effusion or pneumothorax is detected. The visualized
osseous
structures are unremarkable.
IMPRESSION: Bilateral pulmonary opacities suggesting pneumonia.
Superimposed
pulmonary nodules cannot be excluded. Follow-up examination
after treatment
is recommended to document resolution.
[**2158-1-29**] head CT:
FINDINGS: There is concordant prominence of the ventricles and
sulci,
consistent with generalized volume loss. Hypoattenuation in the
periventricular white matter most likely represents chronic
microvascular
infarction. No intracranial hemorrhage, abnormal extraaxial
fluid collection,
mass effect or midline shift is detected. The basal cisterns are
patent.
Dense atherosclerotic calcifications are noted in the internal
carotid
arteries. The visualized paranasal sinuses and mastoid air cells
are clear.
IMPRESSION: No intracranial hemorrhage or mass effect.
Brief Hospital Course:
73 year-old man with bladder cancer, stomach cancer admitted now
with nonketotic hyperosmolar state (ketones in UA felt likely
secondary to starvation/ketosis-no anion gap on Chem 7 and no
acidosis on ABG), pneumonia, UTI. Following issues addressed on
this admission:
(Patient admitted to ICU initially on [**1-29**] and transferred to
floor on [**1-30**].)
ICU course:
Concerning nonketotic hyperosmolar state: Patient initially
given insulin drip in ER, IVF for glucose in 600's, possible
DKA. Patient was not acidotic, did not have gap, but ketones on
UA, felt secondary to starvation ketosis. ON transfer to the
MICU, sugars trended down and ISS started, insulin drip d/ced.
IVF were continued-D51/2NS. On morning of transfer to floor,
patient started on NPH dosing along with ISS. TID lytes were
followed and magnesium, potassium and phosphorus were repleted
PRN. Patient never developed gap or acidosis. Fingersticks
running high 100's to low 200's on transfer.
Concerning his pneumonia/UTI: Patient febrile with elevated
white count, infiltrates on chest x-ray and urine with
pansensitive Klebsiella. Maintained on Levaquin. [**1-31**] Blood
cultures from [**2158-1-29**] with pansensitive Klebsiella. Feel that
Levaquin adequate coverage given likely CAP and rapid clinical
improvement, although did have chemo treatment as inpatient
weeks ago.
Concerning his MS change: Patient with waxing and [**Doctor Last Name 688**] mental
status, sometimes disoriented. Alert but lethargic on transfer.
Attributed to hyperosmolar state and infection and possible
sundowning. Negative head CT, negative metabolic/toxic work-up.
LP not felt to be indicated at this time given other
explanations.
Continue treatment of hyperosmolar state and pneumonia/UTI.
Concerning UTI: Cover with Levaquin. Urine culture pending.
Concerning anemia: Patient admitted with Crit of 27 (appears to
be baseline). Etiology thought to be related to hematuria
secondary to hematoma. Then had drop to 20. Felt most likely due
to hydration/dilution, but given history of CAD decision made to
transfuse 1 unit on [**1-30**] and then additional 2 Units on [**2158-2-2**].
No evidence of acute bleeding.
Bladder ca/stomach ca: Stable. Continue outpt management as per
JP VA.
Concerning hypertension: Elevated here from 150's to 180's
initially. Metoprolol titrated up to 50 TID. Additionally,
captopril 25 TID added with better control, however d/c'ed when
outpt meds known. Discharged on outpt dose of Metop Tartrate 50
mg daily.
Concerning ARF: Patient admitted with creatinine in 2's
(baseline 1.5-1.8). Down to 1.4 with hydration. Likely
component of CRI secondary to hypertension/DM. Would encourage
adequate po hydration.
Medications on Admission:
metoprolol 50 [**Hospital1 **]
dorzolamide/timolol
NPH
MV
omeprazole 20
tamsulosin .4
travoprost .004%
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days: Please take until all pills are gone. .
Disp:*9 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: INSULIN NPH HUMAN 100 U/ML INJ NOVOLIN
N INJECT 6 UNITS UNDER THE SKIN AT BEDTIME AND INJECT 24 UNITS
EVERY MORNING
(take as directed by your primary care physician).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Nonketotic Hyperosmolar State
Pneumonia
Urinary Tract Infection
Anemia
Discharge Condition:
good
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening confusion, buring on
urination, or any other symptoms.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-29**] weeks.
|
[
"5990",
"40391",
"486",
"99592",
"V5867",
"2859"
] |
Admission Date: [**2165-6-24**] Discharge Date: [**2165-7-11**]
Date of Birth: [**2110-10-11**] Sex: M
Service: MEDICINE
Allergies:
Adhesive Tape / Ibuprofen / tramadol
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
?melena vs. bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of BRBPR.
[**Name (NI) **] friend noticed dark blood vs. BRBPR (unclear which)
when she came to check up on him at home. Patient thinks that
this may have started around 10PM the night prior to
presentation. He has been 'oozing'. Becaucse he is bed-bound,
brought the patient to the ED for evaluation. Patient reports
some lightheadedness with sitting up. He has also noticed some
shortness of breath. He reports some nausea, but denies
vomiting. The patient reports that his last BM was on Friday,
which was reportedly normal per the patient. He denies any
recent antibiotic use. He denies changes to his diet reporting
that he has been eating more canned vegetables and occassionally
raw vegetables, which he states taht he washes. He reports
chills, but denies fevers. He also reports drinking botteled
water. He reports that his brother has a new puppy at home;
patient with a cat at home. Reports some abdominal pain with his
symptoms located near where his umbilicus was.
In the ED, the patient triggered on arrival for HR 180-200s with
Atrial fibrillation w/ RVR. He had 2 PIV 18 gauge IVs placed in
the ED. In, the ED, the patient received a total of 3L NS; his
HR responded to IVFs, so he was bolused again. Pressures stable
110-130s SPBs 70-80. HCT 32.2 down from 36. He was T&C for 2
units. Received no transfusions in the ED. Mentating well. GI
thought that his bleed liking from a lower source and were
planning for scope tomorrow. If HD unstable get CTA of abdomen-
needs to be done on thrid floor given the patient's body
habitus. Tried Foley placement, but this was unsucessful.
On arrival to the MICU, the patient is alert and interactive,
answering questions appropriately.
Past Medical History:
-Right hip fracture
-Hypertension
-Obesity
-Depression
-MVA - remote, with fracture right upper extremity, s/p ORIF
-Chronic right lower extremity lymphedema
-Atrial fibrillation: Previously on Coumadin. This was d/c'ed
during his last admission in [**2164-6-22**] for a large hematoma and
his low CHADS score in consultation with his cardiologist, Dr. [**Doctor Last Name 11723**].
-Gastric Bypass surgery in [**2152**] [**Doctor First Name 30929**] followed by Dr. [**Last Name (STitle) **]
currently. (Max weight 846lb, currently 450 lb).
Social History:
Non-smoker. Denies EtOH or drug use. Patient is on disability.
Lives by himself in an apartment in [**Location (un) 86**]; bed bound given his
obesity.
Family History:
Lung CA in mother and father, both were smokers, and both died
of this, his mother at age 39. His sister has ovarian ca. His
father also had gout.
Physical Exam:
ADMISSION EXAM:
VS: T99.1 BP 98/56 HR 105 RR 20 96% on RA
General: pleasant, NAD, morbidly obese
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
GI: normoactive bowel sounds, soft, obese. Large scar present.
No erythema over skin folds. No hepatosplenomegaly. Tenderness
to palpation inferior to umbilicus, and RLQ.
MSK: no joint swelling or erythema
Extremities: RLE is violaceous and chronically edematous.
Markedly tender to palpation over anterior leg just inferior to
knee. LLE is warm and well perfused.
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN 2-12 intact, [**4-27**]
strength bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect
Exam on Discharge:
98.2 80 100/60 18 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tender to deep palpation in multiple areas.
GU: no foley
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Ext: RLE is red, chronically edematous. Markedly tender to
palpation over anterior leg just inferior to knee. Right lower
extremity with chronic lymphedema and chronic venous and skin
changes including mild warmth and erythema with tenderness to
touch. LLE is warm and well perfused.
Pertinent Results:
Admission labs:
[**2165-6-24**] 09:20PM BLOOD WBC-26.3*# RBC-3.60* Hgb-10.5* Hct-32.2*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.4 Plt Ct-189#
[**2165-6-24**] 09:20PM BLOOD Neuts-89.9* Lymphs-4.4* Monos-3.5 Eos-0.1
Baso-0.2
[**2165-6-25**] 04:12AM BLOOD PT-14.5* PTT-23.6* INR(PT)-1.4*
[**2165-6-24**] 09:20PM BLOOD Glucose-164* UreaN-33* Creat-1.1 Na-130*
K-4.2 Cl-95* HCO3-22 AnGap-17
[**2165-6-24**] 09:20PM BLOOD ALT-13 AST-23 CK(CPK)-45* AlkPhos-77
TotBili-0.4
[**2165-6-24**] 09:20PM BLOOD CK-MB-1
[**2165-6-24**] 09:20PM BLOOD cTropnT-<0.01
[**2165-6-25**] 04:12AM BLOOD CK-MB-1 cTropnT-<0.01
[**2165-6-24**] 09:20PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.1*#
Mg-2.2
[**2165-6-27**] 12:02AM BLOOD CRP-GREATER TH
[**2165-6-27**] 12:02AM BLOOD Vanco-15.0
[**2165-6-25**] 06:02PM BLOOD Lactate-1.5
[**2165-7-3**] 09:10AM BLOOD WBC-12.0* RBC-2.70* Hgb-7.6* Hct-24.5*
MCV-91 MCH-28.0 MCHC-30.9* RDW-15.9* Plt Ct-480*
Discharge:
[**2165-7-11**] 08:50AM BLOOD WBC-8.9 RBC-3.03* Hgb-8.5* Hct-27.3*
MCV-90 MCH-28.0 MCHC-31.1 RDW-15.9* Plt Ct-615*
[**2165-7-10**] 07:00AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-134
K-5.0 Cl-95* HCO3-32 AnGap-12
[**6-27**] colonoscopy:
Grade 1 internal hemorrhoid without stigmata of recent bleeding.
Diverticulosis of the sigmoid colon of mild severity.
The terminal ileum was identified and no blood was seen arising
from the terminal ileum.
Old blood in the colon
Grade 1 external hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum
CT Abdomen/Pelvis:
TECHNIQUE: Non-contrast axial images were acquired from the
lung bases to the pelvic outlet. Upon review of these images,
it was decided that the study was nondiagnostic due to poor
penetration from the patient's body habitus. At that time,
radiation dose was increased and a single axial slice was
acquired. This too was deemed nondiagnostic and study was
aborted.
FINDINGS: Lung bases are clear. Heart size is normal without
pericardial
effusion. Extremely limited evaluation of the abdomen and
pelvis. Patient is status post anterior abdominal hernia
repair. No gross abnormalities evident within the liver or
spleen. No large fluid collection evident. Air noted in the
bladder, possibly due to foley instrumentation, but due to study
limitations, unabel to assess for foley. Correlate clinically.
No suspicious lytic or blastic lesions are identified.
IMPRESSION: Nondiagnostic study despite repeated attempts with
increased
radiation dose.
[**6-27**] U/S:
1. Complex fluid collection in the left flank, little changed
from [**2164**] and present since [**2161**], consistent with a chronic
organized hematoma or seroma.
2. Stable longstanding fluid collection in anterior abdominal
wall
surrounding implanted mesh, likely chronic seroma.
[**6-28**] U/S: Suboptimal study due to patient's body habitus. Mildly
distended gallbladder with multiple gallstones. No son[**Name (NI) 493**]
evidence of acute cholecystitis.
MRI [**7-1**]
IMPRESSION:
1. Extremely limited exam due to body habitus with
field-of-view excluding
known left flank fluid collection. Anterior abdominal wall
fluid collection
without evidence of superimposed infectious process, likely
represents
postoperative seroma, unchanged compared to [**2165-4-25**].
2. Cholelithiasis without cholecystitis.
3. Status post gastric bypass surgery.
CT RLE [**7-3**]
IMPRESSION:
1. Extensive circumferential right lower extremity subcutaneous
stranding and
edema centered about the right calf, compatible with known
cellulitis. No
subcutaneous gas or drainable fluid collection.
2. No evidence of arterial embolus in either lower extremity.
[**2165-7-9**]:
BILATERAL NONINVASIVE LOWER EXTREMITY VENOUS STUDY
CLINICAL INDICATION: 54-year-old male with chronic cellulitis,
lower
extremity pain, increased erythema.
This is a technically limited study due to body habitus, in
particular the
swollen legs, which limits the ability to compress venous
structures.
However, color flow and pulse Doppler waveform analysis shows
full patency of
the right and left venous system from the groin to the popliteal
fossa. Right
and left common femoral waveforms are symmetric and normal
bilaterally.
Compressibility of veins was adequate given the physical
limitations of the
study. The posterior tibial and peroneal veins could not be
identified;
however, due to the size of the swollen legs.
CONCLUSION: Technically limited study with no evidence of DVT
in right or
left lower extremity.
Brief Hospital Course:
54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of melena vs. BRBPR also found to be in
atrial fibrillation.
# BRBPR: Bleeding acutely began prior to presentation.
Differential included bleeding internal hemorrhoids versus
bleeding diverticulum versus colitis versus hemorrhagic
infectious colitis. Repeat HCT in unit [**Unit Number **].7. He had no further
episodes of large volume BRBPR. He was prepped x 2 days for
colonoscopy given h/o poor prep and overall risk associated with
endoscopy given habitus. Colonoscopy showed no clear source of
bleeding, mild diverticulosis, grade 1 internal hemorrhoid,
removed fecolith from appendiceal orifice. CTA abdomen was
attempted initially to localize source of bleed, but scan
aborted after poor image quality with double dose radiation due
to habitus. Hematocrits remained stable and he was given PO
Vitamin K for elevated INR. Transfused 1 unit PRBC at admission,
none afterwards. Cipro/Flagyl initially started for concern for
infectious colitis, stopped on hospital day #2. After transfer
to the floor the patient's Hematocrit remained stable with no
more episodes of bleeding.
#abdominal pain: evaluated by surgery, who thought that pain may
be due to discomfort at point of tenderness on exam due to thin
skin near area of mesh, no signs on exam of infected mesh and no
new hernia on limited CT scan and MRI. MRI showed seromas which
may be inflammed and contributing to pain. Pt was seen by ID who
recommended no further intervention as patients fevers subsided
and white count trended down. Pt also states abdominal pain is
improved. Can follow up with GI and consider EGD as an
outpatient.
# Atrial fibrillation: Patient responsive to IVFs in the ED. In
the unit, the patient received IVF bolus as well as IV
metoprolol with good response initially. Further beta blockade
limited by hypotension so he was given digoxin. He was
eventually started on a diltiazem drip which was weaned to PO
metoprolol, with HR still well controlled with increased dose of
metoprolol. CHADS2 score of 1, had not been on coumadin as outpt
given to hx of pelvic hematoma, did not restart in context of
GIB. Once transferred back to the floor, the patient continued
to be be in afib w/ rvr >150. Pt was switched to po diltiazem
and metoprolol was discontinued. Pt's hr was less than 100
following switch and spontaneously coverted to sinus rhyhthm on
[**7-8**].
# Lower extremity edema/Cellulitis: Chronic in nature. Patient
has had LENIs in the past that were negative. He did have
significant pain in the RLE and attempted to minimize narcotics.
Following transfer to the floor, patient notes his leg pain
became acutely worse. On physical exam, it was noted to be more
erythemic and warm. The patient was started back on Vancomycin
on [**7-2**] with concern for MRSA cellulitis. The patient also had a
RLE CT scan to rule out nectrotizing fascitis with pain out of
proportion to physical exam findings. The CT showed no NF, but
did note cellulits. The patient was started on morphine and
oxycodone for pain control as patient appeared in tremendous
pain and said it was the worst he had ever experienced. He was
transitioned to Bactrim/Keflex on [**7-5**] to complete course. LENIS
on [**2165-7-9**] were done [**1-24**] persistent pain which were negative. It
it felt that his right lower extremity skin changes and pain are
chronic which date back many years, even to [**2153**]. He has had
multiple admissions for this reason and thus after this most
recent treatment for cellulitis, pain control with increased
gapapentin, tylenol was initiated. He is not to remain on
chronic narcotics give history of abuse. The opiates were meant
as short term solution. Infectious disease has seen this patient
throughout his admission and were never convinced he had
cellulitis. They felt his coag neg staph in the blood was a
contaminent and not related to his initial leukocytosis nor
right lower extremity skin.
#Thrombocytosis: Most likely reactive however platlet count
continued to increase despite normalization of WBC. Currently at
615 from high of 750 a baseline below 300. Patient is on aspirin
325 daily.
# HTN: Low SBPs in light of atrial fibrillation at admission.
Held metoprolol and lasix initially, restarted metoprolol then
converted to diltiazem.
#Access: Right IJ was attempted on floor unsuccessfully.
Patient then triggered for afib with RVR in 140s, BP 102/palp,
which was baseline for day. Transferred to MICU, where 2 PIVs
placed until PICC placement.
# GERD: Continued home omeprazole.
# OSA: Previous diagnosis on home CPAP. Continued in house.
Transitions of Care:
-F/up with GI for further endoscopic evaluation
-Trend elevated platlet count as an outpatient.
-Full Code
-Consider starting LASIX to assist with lower extremity for
edema- this may help his pain.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
3. Gabapentin 800 mg PO TID
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
11. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol
12. Cyanocobalamin 1000 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Miconazole Powder 2% 1 Appl TP QID:PRN rash
15. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 1200 mg PO Q8H
5. Miconazole Powder 2% 1 Appl TP QID:PRN rash
6. Omeprazole 40 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Diltiazem 90 mg PO QID
hold for hr<60 or sbp<95
10. Heparin 5000 UNIT SC TID
11. OxycoDONE (Immediate Release) 10-20 mg PO Q4H:PRN pain
hold for rr<10, sedation
RX *oxycodone 10 mg [**12-24**] tablet(s) by mouth q4ht Disp #*30 Tablet
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
13. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
14. Cyanocobalamin 1000 mcg PO DAILY
15. Ferrous Sulfate 325 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
18. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary: GI bleed, cause uncertain, Atrial fibrillation
Seconary: Right lower leg lyphedema with cellulitis,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You came in due to blood in your stool and black stool. We found
you to be anemic and transfused you with blood. You had a
colonoscopy but it did not locate any bleeding. Your bleeding
stopped on admission. The bleeding was most likely caused by a
diverticular bleed.
In addition, you were having heart palpitations and were found
to be in atrial fibrillation. We controlled your heart with
medications and you rhythm returned to [**Location 213**] rhythm on [**7-8**].
Your right leg also bothered you during this admission and the
pain became increasingly worse. You had a CT scan of the leg
which showed cellulitis with no infection of the fascia. We
treated your skin infection with IV and oral antibiotics and
controlled your pain.
Please continue to take your home medications as directed.
Followup Instructions:
Department: ORTHOPEDICS
When: WEDNESDAY [**2165-7-31**] at 9:55 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2165-7-31**] at 10:15 AM
With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**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: CARDIAC SERVICES
When: FRIDAY [**2165-8-9**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appt in the Gastroenterology
Department in [**9-7**] days. You will be called at home with the
appointment. If you have not heard or have questions, please
call [**Telephone/Fax (1) 105798**].
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30375**]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2165-7-24**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"2851",
"2761",
"42731",
"4019",
"53081",
"32723"
] |
Admission Date: [**2108-3-21**] Discharge Date: [**2108-3-28**]
Service: MEDICINE
Allergies:
Codeine / Valium
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with CHB, known 13 cm AAA non-op per vascular presented to
[**Hospital3 **] with abdominal pain where CT scan showed large
(10.6 cmper report)AAA with concern for endovascular leak and
was transferred to [**Hospital1 18**] forfurther management. In the ED her
initial vitals were: In the EW, initial vitals were: T 97, HR
30, BP 180/90, RR 26, O2 99%. In the EW, she was hypertensive
and mantained on nicardipine drip from OSH. She was also given
morphine, zofran and was given a dose of zosyn for a UTI.
.
Upon arrival to the ICU her initial vitals were: HR 33 BP 146/43
RR 12 O2 sat 99%. She is sleepy and hard of hearing. She is only
able to provide limited history. She states she has not been
eating well and has some pain in her anterior abdomen. Her
daughter states that she recently had a UTI 10 days ago which
was treated with an antibiotic though she does not recall which
one. She says that her abdominal pain worsened after then and
also noted elevated blood pressures >200 routinely. She also
reports a cough that had been productive.
.
Of note she was admitted to [**Hospital1 18**] [**Date range (1) 69877**] for similar reasons
at that time it was documented that the patient did not want any
further intervention and would prefer Be DNR/DNI and mostly
focus on comfort. However the daughter insisted that she have
further interventional procedures. Ethics and social work had to
be involved. Now the patient is not alert enough to state her
wishes and her daughter insists that she reversed her decision
and want to be full code.
.
Past Medical History:
1. Bradycardia, complete heart block status post pacemaker
placement 20 years ago.
2. PPM noted to be nonfunctional and was taken out at [**Hospital3 **]. The patient developed recurrent hematoma and right-sided
system implanted. PPM then later noted to be infected and
right-sided system taken out. Now with no pacer present but
left-sided leads in place.
3. Bleeding/clotting problems, question of an ITP or factor
deficiency.
4. CAD.
5. Hypertension.
6. Diabetes.
7. Gallstones.
8. Valvular heart disease.
9. Breast cancer status post mastectomy/radiation.
10. Legally blind.
11. Hip fracture status post ORIF.
12. AAA status post endovascular repair in [**2097**]. Recently noted
to have sac expansion.
13. Thrombocytopenia, thought to be ITP, also noted to have
factor XIII deficiency per daughter report.
Social History:
Was wheelchair bound but is mostly bed bound now. She has not
been able to perform ADLS. She lives with her daughter in
[**Name (NI) **]; her daughter is reluctant to not pursue all options
for the patient. Ms. [**Known lastname 34763**] was married or about 60 years to
her husband, and has 4 children present today during the
interview (3 daughters). Remote tobacco use (former smoker who
quit 30 years ago), no history of alcohol or illicit substances.
Family History:
noncontributory, no h/o AAA
Physical Exam:
ADMISSION EXAM
Vitals: T:97 HR 33 BP 146/43 RR 12 O2 sat 99%
General: Sleepy but arousable, A&Ox1, no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear, EOMI
Neck: supple, JVP difficult to appreciate, no LAD
CV: Brady but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Mildly diminished BS at bases otherwise clear to
auscultation bilaterally, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
does have large frim mass in central adbomen without pulsation
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
VS: 98.4, 142/59 (111-142/46-59), 44 (40s), 20, 98%2L
General: awake, interactive, improved MS from previously, hard
of hearing, A&Ox2, no acute distress, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, right eye
with significant cataract (blind), left eye pupil minimally
reactive to light, hearing aid in left ear
Neck: supple, JVP minimally elevated, no LAD
CV: regular rate and rhythm, normal S1 + S2, [**1-23**] early systolic
murmur over LUSB, no rubs, gallops noted
Lungs: rales 1/3 up the lungs posteriorly, no wheezes/rhonchi.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
does have large firm mass in central abdomen without pulsation
GU: foley in place with minimal clear yellow urine in bag
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. [**12-19**]+
sacral edema and left arm with 1+ edema. Sensation intact to
light touch and temperature, toes moves bilaterally. No edema of
feet or lower legs.
Skin: old ecchymoses on forearms, thin fragile skin, stage I
wound on coccyx (3 x 2 cm intact non-blanchable erythema)
Pertinent Results:
ADMISSION LABS:
[**2108-3-21**] 10:30AM WBC-11.2* RBC-3.26* HGB-10.5* HCT-33.2*
MCV-102* MCH-32.2* MCHC-31.6 RDW-15.6*
[**2108-3-21**] 10:30AM NEUTS-77.0* LYMPHS-21.0 MONOS-1.3* EOS-0.4
BASOS-0.3
[**2108-3-21**] 10:30AM PLT COUNT-44*
[**2108-3-21**] 10:30AM PT-11.0 PTT-29.1 INR(PT)-1.0
[**2108-3-21**] 10:30AM GLUCOSE-92 UREA N-30* CREAT-1.1 SODIUM-133
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-19* ANION GAP-16
[**2108-3-21**] 10:30AM ALT(SGPT)-14 AST(SGOT)-38 ALK PHOS-52 TOT
BILI-0.3
[**2108-3-21**] 10:30AM LIPASE-30
[**2108-3-21**] 10:30AM ALBUMIN-2.8* CALCIUM-8.6 PHOSPHATE-3.9
MAGNESIUM-1.7
[**2108-3-25**] Vitamin B12: 1043
Urine studies:
[**2108-3-21**] 10:45AM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2108-3-21**] 10:45AM URINE RBC-2 WBC->182* BACTERIA-MOD YEAST-NONE
EPI-1 TRANS EPI-<1
[**2108-3-21**] 10:45AM URINE WBCCLUMP-MANY MUCOUS-RARE
[**2108-3-24**] 05:41PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2108-3-24**] 05:41PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2108-3-24**] 05:41PM URINE RBC-2 WBC-36* Bacteri-FEW Yeast-NONE
Epi-5 TransE-<1
[**2108-3-24**] 11:33AM URINE Hours-RANDOM UreaN-354 Creat-76 Na-28
K-39 Cl-16
Creatinine trend: 1.1->1.3->1.7->1.8->1.8->2.0->2.3->2.2->2.5
GFR: 21->18 ([**3-27**]->[**3-28**], day of discharge)
.
Discharge Labs:
[**2108-3-27**] 12:46PM BLOOD Hct-28.9*
[**2108-3-27**] 06:25AM BLOOD PT-11.8 PTT-31.6 INR(PT)-1.1
[**2108-3-28**] 06:20AM BLOOD Creat-2.5*
[**2108-3-27**] 06:25AM BLOOD Calcium-7.1* Phos-6.0* Mg-2.0
.
Micro:
[**2108-3-21**] Urine culture negative
[**2108-3-21**] MRSA screen negative
[**2108-3-22**] blood culture negative
[**2108-3-23**] blood culture NGTD
[**2108-3-24**] 5:41 pm URINE Source: Catheter.
**FINAL REPORT [**2108-3-26**]**
URINE CULTURE (Final [**2108-3-26**]):
YEAST. 10,000-100,000 ORGANISMS/ML.
[**2108-3-24**] 10:57 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2108-3-27**]**
GRAM STAIN (Final [**2108-3-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2108-3-27**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
Imaging:
[**2108-3-21**] ECG: Baseline artifact. Probable underlying sinus rhythm
with complete heart block and ventricular escape rhythm.
Compared to the previous tracing of [**2108-1-15**] no definite change.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
46 0 154 566/541 0 -64 -44
.
[**2108-3-21**] Sinus rhythm with complete heart block and ventricular
escape rhythm. Compared to the previous tracing no change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
34 232 152 630/[**Medical Record Number 85639**] 23
.
[**2108-3-21**] CXR: FINDINGS: Single portable view of the chest is
correlated to CT scan of the abdomen from earlier the same day
performed at an outside hospital. There are bibasilar opacities,
larger on the left than on the right which partially silhouette
the hemidiaphragms. There is engorgement of the central
pulmonary vasculature and indistinct pulmonary vascular markings
seen peripherally. Cardiac silhouette appears enlarged.
Degenerative changes noted at the right shoulder and
acromioclavicular joint. Surgical clips seen in the left axilla.
Partially visualized abdominal aortic stent. IMPRESSION:
Findings suggestive of congestive failure. Left greater than
right basilar opacities compatible with effusion and underlying
atelectasis although component of infection is not excluded.
.
[**2108-3-22**] ECG: Sinus rhythm with complete heart block and slow
ventricular escape rhythm with right bundle-branch block and
left anterior fascicular block morphology. Compared to the
previous tracing of [**2108-3-21**] no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
38 420 148 558/[**Telephone/Fax (2) 85640**]
Brief Hospital Course:
[**Age over 90 **]F with CHB, known 13 cm AAA non-op per vascular presented to
[**Hospital3 **] with abdominal pain where CT scan showed known
AAA with concern for endovascular leak and was transferred to
[**Hospital1 18**] for further management.
.
# Goals of care: Family meeting held this admission with the
patient, 3 children, cardiology, palliative care, social work,
and renal. See OMR note from palliative care. Briefly, patient
clearly stated she did not want a pacemaker placed. Patient and
family are aware of the limitation of what can be offered given
the risks and benefits of various interventions with her
comorbidities (no pacemaker, no dialysis, no AAA intervention).
Palliative care and social work have set up home hospice for the
patient with the goal of managing her symptoms at home (SL nitro
x3 for abdominal pain, then consider morphine. Call the hospice
nurses with management questions prior to considering bringing
her to the hospital). Although the patient was DNR inhouse (not
medically indicated), the daughter insists she be full code at
home. This is not incompatible with hospice. The patient would
like to live at home with medical managment and optimization of
her clinical status (i.e. blood pressure control) as well as
symptomatic control (for her abdominal pain and anxiety) given
the limitations of treatment of her significant medical problems
(i.e. no invasive procedures). The daughter is adamant that the
patient should continue to be managed aggressively and has been
having a very difficult time accepting that a pacemaker is not
an option (despite the fact that her mother has said she does
not want this herself). It is our hope that with hospice care
and good PCP oversight, her care can be effectively addressed in
the outpatient setting and hospitalizations can be avoided given
our limited therapeutic options.
.
# AAA/abd pain: Has known AAA that was evaluated by vascular on
last admission in [**Month (only) 956**]. At that time the aneurysm was 10x13
cm and vascular recommended non-operative management. The report
of the CT does not suggest AAA is enlarging though this has not
been confirmed. Vascular was re-consulted in the ED who again
recommended medical management. BP was very elevated on
presentation which may be related to her symptoms. Her blood
pressure was lowered to 140 systolic per vascular surgery
recommendations as below and her abdominal pain resolved. She
had no recurrence of abdominal pain while here and was
instructed to try nitroglycerin SL at home, as this has worked
in the past.
.
# Hypertension/Hypertensive urgency: Presented to an outside
hospital with BP >200. She was started on nicardipine gtt prior
to transfer. On admission here her blood pressure was still
elevated >170. Her nicardipine gtt was changed to nitro and her
home medications were restarted. She still required the nitro
gtt to maintain her blood pressure at the goal of 140 so her
amlodipine was increased to 10 mg daily and isosorbide
monnonitrate 60 mg daily was started. Her blood pressure
ultimately better controlled on the following regimen:
amlodipine 10, Imdur 60mg ER daily, hydralazine 50mg TID.
However, in controlling her blood pressure, she developed
[**Last Name (un) **]/ATN and oliguria. Ultimately her SBP goal was >120 and <140,
which was maintained well on the above regimen.
.
# [**Last Name (un) **]/oliguria: Patient was admitted with a creatinine of 1.1
which slowly increased as her blood pressure came under better
control. On day 4 of hospitalization, Cr was 2.0 and patient was
oliguric with 90cc out in 8hrs. FeUrea 20%. Renal was consulted
and felt that her kidney injury was likely due to her improved
blood pressure control, and her BP in the recent months has been
much higher at baseline. As a result, her renal perfusion
decreased and she developed [**Last Name (un) **]. She did not respond to a fluid
challenge, suggesting that she has developed some ATN as a
result. It is also possible that her AAA is causing some
decreased renal perfusion and resultant renal stenosis, however
given that there were no plans for intervention, a renal artery
US was not pursued. Lisinopril was stopped and goal SBP >120 was
maintained. The patient's creatinine continued to rise (see
pertinent results section) as expected with ATN and was
essentially stable in the 3 days prior to discharge (Cr
2.3->2.2->2.5, GFR 21 (with Cr 2.2) ->18 (with Cr 2.5) on
discharge). The expected course of ATN is that it will rise,
plateau and then fall, however given that the patient is [**Age over 90 **],
with multiple comorbidities and previous [**Last Name (un) **], it is unclear how
much her renal function will recover. Renal discussed with the
patient and her daughter that she is not a dialysis candidate.
The patient is going home with hospice, however the family would
like her to continue to be managed medically. It was agreed that
the patient will have weekly creatinine checks for
prognostication, and not for management as there is nothing to
be done concerning her renal function.
.
# Complete heart block: The patient has been in complete heart
block for years and stable without pacemaker. She has had
pacemaker in the past which had to be removed and replacement
attempt was complicated by significant bleeding and infection
and was subsequently unsuccessful. Has been evaluated at >4
hospitals and all have declined further intervention. Of note,
during last admission, the patient stated she would not want the
procedure. She does have pacemaker leads in place from the prior
pacemaker which would be easier to access, but it is unknown if
these leads are still functional. EP was reconsulted and again
declined to offer the procedure given patient's comorbidities
and persistent complications with from the last procedure. A
family meeting was held, and the patient clearly outlined again
that she would not want a pacemaker or any further invasive
procedures.
.
# UTI: Patient has had a UTI that has been unsuccessfully
treated with cipro and macrobid in the past. Prior to admission,
she had also recently received amoxicillin. On admission, UA
showed + Leuks, + Nitrates, >182 WBC, moderate bacteria. She was
started on vanc and zosyn in ED for possible PNA, with UTI
coverage. Urine culture from [**2108-3-20**] at OSH grew klebsiella
pneumonia, sensitive to amoxicillin, ceftriaxone, cefazolin
(resistant to cipro, bactrim, levoflox). The patient's
vanc/zosyn were discontinued and she was switched to
ceftriaxone. Patient received antibiotics from [**3-21**] to [**3-26**]. Urine
cultures x 2 at [**Hospital1 18**] have been negative for bacteria >10K. WBC
peaked at 12.5 on HD #2 and trended down to 9.8 prior to
discharge.
.
# Cough: Per patient's daughter the patient has been having
productive cough. CXR showed pulmonary edema and possible
consolidation. However, she did not have fevers or a cough,
though did appear to have sinus congestion. She initially
received vanc/zosyn but these were stopped and antibiotics were
switched to cover her UTI as above. Patient received antibiotics
from [**3-21**] to [**3-26**]. Sputum culture grew gram positive cocci in
pairs, found to be commensal flora. Patient remained afebrile.
WBC down to 9.8 on discharge.
.
# LUE swelling: Patient developed swelling of her left forearm.
Platelets were between 20-40s throughout the admission, making
DVT unlikely and prohibiting DVT any treatment. Patient was
treated symptomatically with elevation of her arm and warm
compresses. IV was moved to right arm.
.
# Bleeding disorder/thrombocytopenia: This has been a chronic
issue for Ms. [**Known lastname 34763**]. The etiology of her bleeding disorder
is unclear. It may be ITP but this is less likely to cause
bleeding complications. Throughout admission, plts ranged
between 20-40s. Hematocrit remained stable around 30.
.
# Macrocytosis: MCV 107. B12 was noted to be 1043. Patient was
given folate and a MV.
.
Transitional Issues:
Home hospice has been set up. Patient will be full code at home,
but is DNR in the hospital as it is not medically indicated.
Weekly creatinine checks for **prognostication**, and not for
management as there is nothing to be done concerning her renal
function. She is not a dialysis candidate.
Patient has been set up with PCP [**Name Initial (PRE) 648**].
Goal is to manage this patient at home with the help of hospice
and PCP [**Name Initial (PRE) 37798**].
Medications on Admission:
citalpram 10mg daily
tramadol 50 mg Q4prn
lisinopril 30 mg daily
Lasix 40 mg daily
carafate 1 gm TID
culturelle 1 daily
prevacid 30 mg daily
nystatin tid
amlodipine 5 mg daily
.
Recent abx:
augmentin 500 Q12 hrs x 10 days [**2-25**]
macrobid x7 days [**2-16**]
cipro x5 days in [**Month (only) **]
Discharge Medications:
1. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Culturelle 10 billion cell Capsule Sig: One (1) Capsule PO
once a day.
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual twice a day as needed for abdominal pain: take at the
onset of abdominal pain, and repeat in 5 minutes if not
improved.
Disp:*60 tablets* Refills:*2*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
** as well as hospice medications **
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary:
abdominal pain
hypertensive urgency
urinary tract infection
acute renal failure
Secondary:
abdominal aortic aneursym
complete heart block
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 34763**],
It was a pleasure taking care of you during this admission. You
were admitted initially from the other hospital given abdominal
pain and concerning for the abdominal aneursym. You were seen by
the vascular surgeons who felt that it was not safe or indicated
for you to have surgery. You were initially in the ICU for
optimal blood pressure control on a nitroglycerin drip. Your
blood pressure improved and we took care of you on the
cardiology floor with new medications to optimize your blood
pressure. You were treated with antibiotics for a urinary tract
infection, which were completed here, and repeat urine culture
showed that you no longer had a urinary tract infection. As your
blood pressure improved, your kidneys stopped functioning as
well. We had the kidney doctors [**Name5 (PTitle) 788**] [**Name5 (PTitle) **], who think that the
kidney function will eventually plateau and potentially get
better, though the timing of this is still unsure at this time.
amd it may be that your kidney function does not significantly
improve. Unfortunately, you are not a dialysis candidate.
We discussed at length your daughter's concerns for pacemaker
placement. The cardiologists do not feel a pacemaker will
improve your condition and would not be willing to place one.
After discussion with the cardiologists, palliative care, and
social work, you expressed to us that you did not want a
pacemaker anyway. We agreed that the likely complications and
risks far exceeded any potential for benefit of a pacemaker.
After further discussion with the palliative care team, the
cardiology team, and the nurses here, you decided that you
preferred to be at home with more help. The palliative care team
helped to arrange home hospice to help with services at home.
The following medications were changed during this admission:
- STOP Lasix
- STOP Lisinopril
- STOP recent antibiotics, including - augmentin, macrobid, and
cipro (you finished antibiotics here for your urinary tract
infection)
- START Isosorbide mononitrate ER 60mg by mouth daily
- START Hydralazine 50mg by mouth three times daily
- START Calcium acetate 1334 mg by mouth three times daily
- START Morphine if needed for pain, as directed by the hospice
nurses
- START Acetaminophen 650mg by mouth three times daily
- START Nitroglycerin 0.3mg sublingual as needed for abdominal
pain; can repeat every 5 minutes for a total of 3 doses if
continued pain
- START Docusate sodium 100mg by mouth twice daily
- INCREASE Amlodipine to 10mg by mouth daily
Followup Instructions:
Please follow-up with your primary care doctor as below. You
will also follow-up with the hospice nurses who will be in close
contact with your doctors.
Name: SIRAKOV,DIMITRE T.
Location: [**Hospital **] MEDICAL GROUP
Address: [**Apartment Address(1) 85641**], [**Hospital1 **],[**Numeric Identifier 59034**]
Phone: [**Telephone/Fax (1) 24335**]
Appointment: Thursday [**2108-4-5**] 2:30pm
|
[
"5845",
"5990",
"25000",
"41401",
"4019",
"V1582"
] |
Admission Date: [**2142-1-5**] Discharge Date: [**2142-1-11**]
Date of Birth: [**2060-12-20**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
A Fib with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 81 year old man with multiple medical
problems transferred to ICU for suctioning to protect airway.
He has multiple medical problems, including complicated post-op
course after CABG on [**11-25**], recently discharged to [**Hospital 100**] Rehab,
who presents with increasing lethargy and rising white blood
cell count for further evaluation and workup. His most recent
admission included MVR/CABG with post-op course complicated by
pneumothorax s/p R CT, respiratory distress, left pleural
effusion s/p thoracentesis, mental status changes, MSSA
pneumonia/bacteremia, tracheostomy/PEG, diarrhea. During that
hospitalization, he completed a course of Flagyl (empiric for C.
diff, ultimately negative), ciprofloxacin (for Enterobacter in
the sputum), and nafcillin (for MSSA pneumonia/bacteremia). At
rehab, he was being treated for cellulitis/abscess around the
tracheostomy site (with wound dehiscence), as well as for MRSA
in sputum, with vancomycin. His white blood cell count has been
rising, and ID consult at rehab was concerned for mediastinitis.
In addition, he has had a change in mental status since his
recent hospitalization (per his family).
Initial WBC was 22 with 88% neutrophils, no bands. His CT head
was negative for bleeding but revealed evidence of sinusitis.
His CT torso revealed b/l pleural effusions, L>R, but no
evidence of mediastinitis or fluid collection. He was on
vancomycin already for MRSA in sputum at rehab, and this was
continued to cover for cellulitis. Flagyl was added for emperic
coverage Cdiff. He triggered on the floor twice for Afib with
RVR, which responded to IV nodal agents (15mg dilt and 5mg
metoprolol). He also was requiring frequent suctioning from his
trach and thus was transferred to MICU for increased nursing
needs.
Past Medical History:
- CAD s/p MV repair/CABG on [**2141-11-24**], complicated post-op
course; post CABG echo demonstrated EF 55%
- S/p trach/PEG
- Hx of MSSA pneumonia/bacteremia
- Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].
- Hypertension
- PVD - sx of claudication, seen on MRA
- Iron-deficiency anemia - Hct around 30, no colonscopy
- Spinal stenosis
Social History:
Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids.
Family History:
Father died of influenza, mother died of old age. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
VS: T 96.7F, BP 158/37, HR 84, RR 20, Sat 100% on 60% FM
Gen: Cachectic, trach, no acute distress
HEENT: EOMI, PERRL, MM dry
Neck: no JVD
CV: Irregularly irregular, tachycardic, no murmurs appreciated
Resp: Rhonchorous throughout b/l
Chest: Midline sternotomy scar clean, mild erythma near trach,
eschar near trach site, no purulent discharge
Abd: +BS, soft, ND/NT, no peritoneal signs
EXT: LE's warm, no lower extremity edema. Left necrotic heel
ulcer, Left great toe necrosis (dry), left anterior ankle ulcer
(open), and right foot erythema.
NEURO: Oriented to hospital, [**2142**]
Pertinent Results:
STUDIES:
CT Chest/Abd/Pelvis [**2142-1-5**]: 1. Slight increased overlap of the
osseous structures at the sternotomy site suggests the
posibility of movement. 2. Large left pleural effusion with
complete left lower lobe collapse, which is stable. There may be
a loculated component to the left pleural effusion and there is
suggestion that the effusion may be entirely simple. There is
increased size of a now moderate right pleural effusion. 3. No
fluid collection in the mediastinum surrounding the tracheostomy
site. 4. Dense three-vessel coronary artery calcification and
abdominal atherosclerotic plaque. 5. Stable right
nonobstructing colonic inguinal hernia and new left colonic
inguinal hernia. Neither bowel loop protrudes significantly into
the respective inguinal canals and there is no sign of
obstruction or entrapment. Correlate with clinical exam. 6.
Stable right [**Month/Day/Year **] nodule. 7. Interval development of tiny
stones in the gallbladder.
CT Head [**2142-1-5**]: 1. No acute intracranial abnormality detected.
2. Near-total opacification of the mastoid air cells bilaterally
which has increased since previous study. There is an air-fluid
level within the left maxillary sinus with aerated secretions
which is also noted in study from [**Month (only) **] which may be
consistent with acute sinusitis.
ECHO [**2142-1-8**] - The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis of the inferior wall. The remaining segments
contract normally (LVEF = 50-55 %). 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. A mitral valve annuloplasty ring is present.
Mild (1+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
with good global function. Mild mitral regurgitation. Borderline
pulmonary artery systolic hypertension. Bilateral pleural
effusions. CLINICAL IMPLICATIONS:
Based on [**2141**] 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.
[**2142-1-10**] RUQ U/S - The liver is normal in echotexture without
focal lesion identified. There is no intra- or extrahepatic
biliary dilatation with the common bile duct measuring 3 mm. The
gallbladder is not distended and there is no pericholecystic
fluid or wall edema. In comparison to the previous study there
is significantly less sludge. A tiny echogenic shadowing foci in
the dependent portion of the gallbladder could represent a few
crystals. IMPRESSION: No evidence of acute cholecystitis.
Interval improvement in gall bladder sludge, but not complete
clearing.
MICRO:
[**2142-1-7**] Sputum -
GRAM STAIN (Final [**2142-1-7**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 4 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
81yo M with complicated recent hospitalization now with altered
mental status, cellulitis at tracheostomy site, Afib with [**Hospital 26875**]
transferred to ICU for airway protection/suctioning.
THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions. The
plan is to complete the current course of antibiotics but that
no further interventions should be performed. Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care. (The patients sister [**Name (NI) 714**] [**Name (NI) 103630**] is his HCP and can
be reached at [**Telephone/Fax (1) 103631**]).
Resp: Underwent tracheostomy during last hospitalization, now on
60% TM with thick secretions. CT chest with b/l pleural
effusions, L > R, with surrounding atelectasis, and question of
small infiltrate. Per [**Hospital 100**] Rehab, he was being treated with
Vanco for MRSA in his sputum. Requiring frequent suctioning per
floor nursing. He needs to be mainted on vancomycin for a
complete 14 day course (day #1=[**2142-1-5**]). He should be dosed for
level <20. Please check levels daily at rehab.
On [**2142-1-10**], pseudomonas grew from his sputum and he was started
on tobramycin and will need to complete a 14 day course. Also,
during his hospital course he had a left sided thoracentesis
(1.5 L taken off). The pleural fluid was transudative, likely
secondary to CHF. He should continue to be diuresed at rehab.
He is currently on lasix 20mg IV TID. The dosing frequency
should be increased for a goal urine output of -500cc-1L
negative per day until he reaches his dry weight. He was able
to be weaned from 70% O2 to 35% O2 during his ICU stay. This
should further be weaned as tolerated at rehab.
ID: Elevated WBC, no fever. Originally thought to have a
cellulitis around his trach site, but the thoracics team felt
that his site was not infected. He was started on Vanco/Unasyn
for MRSA and GNR's in the sputum. The Unasyn was stopped on
when the GNR's grew pseudomonas. He was switched to tobramycin
(day 1=[**2142-1-10**]) and will need to complete a 14 day course. He
also was c diff positive during this admission and was started
on flagyl. He should complete a 14 day course (day 1 should be
considered the last day of all other antibiotics). We did
consider biliary sources of infection because his LFT's were
slightly elevated, but a RUQ U/S was unremarkable. Vascular
surgery examined his feet ulcers and felt there was no evidence
of infection.
Atrial fibrillation. The patient had numerous episodes of A fib
with RVR during this hospital course. Metoprolol was uptitrated
to 100 QID with better rate control, but still in the low 100's.
He was then started on digoxin with great response. His HR was
then stable in the 70's.
Transaminitis. The patient did not have abdominal pain and a CT
abdomen was neg for evidence of choledocholithiasis, although
gallstones seen on scan. We proceded with a RUQ U/S that was
unremarkable. This should be followed up as an outpatient.
LE ulcers: Appear dry and necrotic on heels, but open on
anterior feet. We consulted the wound care team who gave the
following recommendations. Heels off bed surface at all times.
Waffle Boots to both lower legs. Moisturize B/L LE's and feet,
periwound tissue [**Hospital1 **] with Aloe Vesta Moisture Barrier Ointment.
Commercial wound cleanser or normal saline to cleanse all
wounds. Pat the tissue dry with dry gauze. B/L lower legs and
feet: Keep ulcers dry and eschar intact. Apply moisture
barrier ointment to the periwound tissue with each DRG change.
Apply a dry protective dressing, ABD's, with Kerlix wrap, change
daily. We also had vascular surgery evaluate his feet and they
felt that there was no evidence of infection. At some point in
the future he may be a potential candidate for amputation but
not at this time. He can follow up with vascular surgery in
clinic.
Diabetes. The patient had a number of hypoglycemic episodes
during his hospital course. His home lantus (50 units) was
held. He was restarted on 10 units of lantus daily because of
hyperglycemia and this was eventually increased further to
25units. This should be titrated up as needed to maintain blood
sugars between 120-150.
Medications on Admission:
- Colace 100mg [**Hospital1 **]
- Aspirin 81mg daily
- Metoprolol 100mg TID
- Atorvastatin 80mg PO daily
- Prilosec 20mg daily
- Lantus 50 units subQ QHS
- Lispro sliding scale q6h
- Warfarin 2mg PO daily
- Tramadol 50mg Q6H PRN
- Ipratropium-Albuterol 1-2puffs INH Q6H PRN
- Captopril 50mg TID
- Furosemide 20mg daily
- Hydralazine 5mg TID
- Vancomycin 1g daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) unit PO BID (2
times a day).
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
4. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Captopril 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times
a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QID
(4 times a day): hold for SBP <90 or HR<55.
9. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Vancomycin 1000 mg IV Q 24H
1st day [**1-6**]
no Vanco dosing until Vanco level <20
11. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Digoxin 125 mcg Tablet [**Month/Day (1) **]: 0.5 Tablet PO DAILY (Daily).
13. Ipratropium Bromide 0.02 % Solution [**Month/Day (1) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Furosemide 10 mg/mL Solution [**Month/Day (1) **]: Twenty (20) mg Injection
QID (4 times a day): please hold if SBP<90 or if creatinine
bumps.
15. Tobramycin 200 mg IV Q24H
16. Insulin Glargine 100 unit/mL Solution [**Month/Day (1) **]: Twenty Five (25)
units Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Atrial fibrillation with RVR
Bilateral Pleural Effusions
C Diff positive
MRSA Pneumonia
Respiratory distress
Discharge Condition:
Stable; oxygenating well on FIO2 35% TM.
Discharge Instructions:
You were admitted to the hospital with respiratory distress and
elevated HR. You had developed fluid build up in your lung
likely secondary to your elevated heart rate. We performed a
thoracentesis which is a procedure to remove fluid from your
lung. We were then able to decrease the amount of oxygen you
have needed to breath. We also increased your heart medications
to get your heart rate under better control. The dose of your
captorpil and metoprolol were both increased. We also started a
new medication called digoxin which was heldful in keeping your
heart rate under good control.
THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions. The
plan is to complete the current course of antibiotics but that
no further interventions should be performed. Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care.
At rehab:
-- He needs to be mainted on vancomycin for a complete 14 day
course (day #1=[**2142-1-5**]). He should be dosed for level <20.
Please check levels daily at rehab.
-- He was started on tobramycin on [**2142-1-10**] for pseudomonas
growing in his sputum. He should complete a 14 day course.
Peak and trough levels should be checked daily and the dose
adjusted accordingly.
-- He should continue to be diuresed at rehab. He is currently
on lasix 20mg IV TID. The dosing frequency should be increased
for a goal urine output of -500cc-1L negative per day until he
reaches his dry weight. He was able to be weaned from 70% O2 to
35% O2 during his ICU stay. This should further be weaned as
tolerated at rehab.
--He also was c diff positive during this admission and was
started on flagyl. He should complete a 14 day course (day 1
should be considered the last day of all other antibiotics).
--Wound care per instructions in the D/C summary
--Metoprolol was uptitrated to 100 QID with better rate control.
HE was started on digoxin and is currently well controlled on a
dose of 0.0625 daily.
-- He was restarted on coumadin prior to discharge. His INR was
1.5 today. Please adjust dose as needed (he was on 2mg prior to
this admission). Please check INR daily until level between
[**2-4**].
Followup Instructions:
--Please make an appointment to see Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2450**] within 1 week of discharge from rehab
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"5119",
"4280",
"42731",
"V4581",
"V5861"
] |
Admission Date: [**2117-12-2**] Discharge Date: [**2117-12-5**]
Date of Birth: [**2117-12-2**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] is a full-term baby born at 38-6/7
weeks, admitted to the newborn ICU for respiratory distress
and hypotonia. He was born at 38-6/7 weeks gestation to a 29-
year-old gravida 1 P0-1 white female. Prenatal screens were a
blood type A positive, antibody negative, RPR nonreactive,
Rubella immune, hepatitis B surface antigen negative, Group B
strep negative. Maternal history is significant for
depression treated with Zoloft 150 mg daily. The pregnancy
was otherwise uncomplicated. Ruptures of membranes occurred 7
hours prior to delivery. Fetal heart tracing was notable for
bradycardia which recovered with terbutaline. However, non
reassuring fetal heart tracing ensued prompting a stat C-
section. The infant emerged with poor respiratory effort. He
was suctioned and given bag mask ventilation by Anesthesia.
Apgars were assigned at 1 minute of 6, 5 minutes of 7 and 10
minutes of 8. Neonatology was called to evaluate him at about
10 minutes of age. Upon arrival, they found the infant pink
with blow-by oxygen, good respiratory effort, heart rate
greater than 100, little spontaneous activity, hypotonic in
lower extremities, hypertonic in upper extremities.
Examination was notable for upper airway congestion with
clear lungs. The infant was deleted both nares for cloudy,
white fluid, and brought to the NICU with blow-by oxygen for
monitoring.
PHYSICAL EXAMINATION: Physical examination upon admission
revealed a term, appropriately grown for gestational age
male, pink with blow-by oxygen. Temperature is 99, pulse 173,
respirations 44, blood pressure 89/49 with a mean of 73. O2
saturations were 80 in room air and 100% with blow-by oxygen.
His weight was 3795, greater than the 90th percentile. Length
was 51.5 at 90th percentile and head circumference was 34.5
at 75th percentile. The anterior fontanelle was flat. There
was molding noted. He was non dysmorphic. He had an intact
palate, upper airway congestion notably, had a hoarse cry,
but clear breath sounds. Cardiovascular - there was no
murmur, regular rate and rhythm, normal pulses. Abdomen -
soft, 3-vessel cord, active bowel sounds, no
hepatosplenomegaly. GU - normal external male genitalia,
testes descended into the scrotum. Hips - no click patent
anus. Spine - straight, no sacral dimple. Moves all
extremities equally, now with hypertonia and good perfusion.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: Initially placed in nasal cannula O2 for decreased
O2 saturations. He weaned out of his cannula within 10 hours of
age and remained in room air subsequent to that. He was noted to
have a hoarse cry with some inspiratory stridor when awake and
active, and was noted to have desaturations to the 50s with
feedings. These resolved by day of life 2 and at the time of
transfer to the newborn nursery, he had been free from
desaturations for greater than 36 hours, saturating 99%-100% in
room air without evidence of stridor or desaturations. Due to
concern for stridor upon admission, ORL from [**Hospital3 1810**]
was consulted and the baby was seen in the NICU and underwent a
flexible bronchoscopy at the bedside. This revealed normal
anatomy with some mild supraglottic swelling. There was no
further treatment indicated at that time.
Cardiovascular: The baby remained hemodynamically stable
without evidence of murmur. The heart rate was 110-140s and
blood pressure was 65/36 with a mean of 41.
Fluids, Electrolytes and Nutrition: Initially, the baby was
maintained NPO and then was offered p.o. feedings with
Enfamil 20 or breast milk. The mother was expressing breast
milk. She also put him to breast and he had some issues with
coordination of suck and swallow with some desaturations
noted at the beginning of the feeds until he was paced and
more comfortable. He currently is taking ad lib breast milk,
breastfeeding on average 45-90 cc when not at the breast. He
was noted to have normal urine and stool output and glucose
screens were in the normal range.
Heme/ID: Due to concerns for respiratory distress, a CBC and
blood culture were obtained. White count was 22.2 with 61
polys, 3 bands, 31 lymphs. Hematocrit was 56.3%, platelets
296,000. The blood culture remained sterile to date. There
were no antibiotics administered. Temperature was in the
normal range in an open crib.
Neurologic: The patient's initial hypotonia and hypertonia
appeared to resolve and the infant had an apparently normal
neurologic exam at the time of transfer and was feeding
normally.
Sensory: A hearing screen had not yet been performed at time
of transfer to the newborn nursery.
Ophthalmology: There was no eye exam performed during this
admission.
Psychosocial: The parents were involved with the infant's
care and were aware of baby's transfer to the newborn
nursery.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To the newborn nursery to the
[**Doctor Last Name 46742**] Newborn Service.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital **]
Pediatrics.
MEDICATIONS: None at this time.
STATE NEWBORN SCREENING: Obtained on [**12-5**].
IMMUNIZATIONS RECEIVED: None to date.
FOLLOW-UP APPOINTMENT: Newborn pediatrician appointment
after discharge from the hospital.
DISCHARGE DIAGNOSES: Term infant, large for gestational age,
respiratory distress, transient resolved, sepsis suspect
ruled out, no antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2117-12-6**] 14:34:48
T: [**2117-12-6**] 15:07:53
Job#: [**Job Number 65248**]
|
[
"V290",
"V053"
] |
Admission Date: [**2146-9-5**] Discharge Date: [**2146-9-13**]
Date of Birth: [**2077-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
CC - transfer from OSH for liver failure [**2-23**] ?amiodarone
toxicity
Major Surgical or Invasive Procedure:
Liver biopsy [**2146-9-6**]
Paracentesis [**2146-9-7**]
History of Present Illness:
HPI - This is a 69 y/o male with a PMH significant for CAD,
COPD, PAF, DM who presented to his PCP in [**Name9 (PRE) 205**] with symptoms of
decreased appetite, fatigue, and increased abdominal girth over
the last six months. There, he was found to have increased
ascites, worsening liver function, and increased LE edema. He
was sent to [**Location (un) **] for further evaluation.
On initial admission to [**Location (un) **], had elevated LFTs with Alk P in
500's, and AST/ALT in 200-300's range. Amiodarone was d/c'd at
that point, and Medrol 8 mg [**Hospital1 **] was started. GI followed pt
while in-house and CT of abd done showed hyperdense liver that
was c/w possible amiodarone toxicity. MRI was c/w ascites and
gallstone w/o bile duct dilitation. He had an extensive workup
for elevated LFTs, and workup for autoimminue causes, viral
causes, and hemachromatosis were all negative. During his
admission, the LFTs began to trend down to 140-150 range, 200
range for alk phos. Pt was d/c'd to rehab on high-dose steroids.
However, he represented to [**Location (un) **] with abd fullness and SOB [**2-23**]
ascites and anasarca. LFTs during the second admission were
unchanged with alk phos in the 400 range, with acute renal
function worsening (Cr 2.4 -> 3.3). This second admission was
also significant for an increase in WBC from 20 to 38, pt
remaining afebrile.
Upon review of incomplete old records that were obtained, it
appears that the patient was started on Amiodarone 200mg [**Hospital1 **] in
[**12-24**] following a valve replacement surgery c/b atrial
fibrillation. He remained on this dose of amiodarone until it
was d/c'd at [**Location (un) **].
ROS - positive for abdominal fullness, decreased appetite,
recent diarrhea, and fatigue
- negative for any H/A, vision changes, cough, SOB, CP, abd
pain, n/v, melena/hematochezia/BRBPR, tremors
Past Medical History:
PMH -
1. CAD
2. CHF
3. PAF
4. COPD on chronic steroids
5. s/p bioprstetic valve placement at [**Hospital1 336**], complicated by afib,
for which he was started on Amiodarone [**12-24**]
6. s/p right CEA
7. DM on insulin
8. diverticulitis s/p partial colectomy
9. CRI
Social History:
SH - Lives at home with his wife. Used to smoke (30 pack-year
history), but has not smoked in 30 years. Occasional EtOH (1
drink/2 weeks) previously, but no EtOH recently. No IVDA. One
tatoo on right arm, done about 45 years ago.
Family History:
FH - Father died of an MI, mother passed at 80. No known family
h/o liver diseases.
Physical Exam:
PE on admission:
VS - T 96.3, BP 123/68, HR 78, RR 18, sats 99%/RA
General - Fatigued-appearing, pleasant gentleman, AO x 3, NAD
HEENT - NC/AT, PERRL, EOMI. No scleral icterus. MM dry, OP wnl
Neck - supple, no JVD, no thyromegaly
Chest - diffuse, high-pitched expiratory wheezes throughout
CV - RRR s1 s2 normal, soft [**2-27**] SM at sternal border
Abd - distended, firm but not tense, nontender to palpation;
soft BS, alternating dullness and tympany to percussion, no
discernable fluid wave; [**Doctor Last Name 515**] sign negative
Ext - 2+ pitting edema b/l up to mid-thigh; pulses 2+ b/l
Neuro - Pt AO x 3, no asterixis
Pertinent Results:
CBC
[**2146-9-5**] 07:32PM BLOOD WBC-37.2*# RBC-4.95 Hgb-13.9* Hct-42.1
MCV-85 MCH-28.1 MCHC-33.0 RDW-17.5* Plt Ct-161
[**2146-9-6**] 07:10AM BLOOD WBC-38.6* RBC-4.86 Hgb-13.3* Hct-41.5
MCV-85 MCH-27.4 MCHC-32.1 RDW-18.0* Plt Ct-166
[**2146-9-7**] 07:00AM BLOOD WBC-38.9* RBC-4.72 Hgb-12.8* Hct-40.9
MCV-87 MCH-27.2 MCHC-31.4 RDW-17.7* Plt Ct-130*
[**2146-9-8**] 06:30AM BLOOD WBC-35.4* RBC-4.07* Hgb-11.0* Hct-35.0*
MCV-86 MCH-27.1 MCHC-31.5 RDW-17.9* Plt Ct-83*
[**2146-9-8**] 12:25PM BLOOD WBC-35.3* RBC-4.01* Hgb-11.0* Hct-34.0*
MCV-85 MCH-27.4 MCHC-32.3 RDW-17.8* Plt Ct-79*
DIFF
[**2146-9-5**] 07:32PM BLOOD Neuts-97.3* Bands-0 Lymphs-1.7*
Monos-0.9* Eos-0 Baso-0
[**2146-9-8**] 06:30AM BLOOD Neuts-96.1* Bands-0 Lymphs-2.2*
Monos-1.6* Eos-0.1 Baso-0
COAGS
[**2146-9-5**] 07:32PM BLOOD PT-17.2* PTT-34.1 INR(PT)-2.0
[**2146-9-5**] 07:32PM BLOOD Plt Smr-NORMAL Plt Ct-161
[**2146-9-6**] 07:10AM BLOOD Plt Ct-166
[**2146-9-6**] 05:19PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.7
[**2146-9-7**] 07:00AM BLOOD PT-16.1* PTT-35.0 INR(PT)-1.7
[**2146-9-7**] 07:00AM BLOOD Plt Ct-130*
[**2146-9-8**] 06:30AM BLOOD PT-17.2* PTT-38.3* INR(PT)-2.0
[**2146-9-8**] 06:30AM BLOOD Plt Smr-LOW Plt Ct-83*
[**2146-9-8**] 12:25PM BLOOD Plt Ct-79*
CHEMISTRY
[**2146-9-5**] 07:32PM BLOOD Glucose-249* UreaN-118* Creat-3.1*#
Na-136 K-4.8 Cl-102 HCO3-19* AnGap-20
[**2146-9-6**] 07:10AM BLOOD Glucose-158* UreaN-121* Creat-3.1* Na-136
K-5.3* Cl-104 HCO3-20* AnGap-17
[**2146-9-6**] 04:50PM BLOOD K-4.9
[**2146-9-7**] 07:00AM BLOOD Glucose-235* UreaN-132* Creat-3.3* Na-136
K-4.8 Cl-103 HCO3-19* AnGap-19
[**2146-9-8**] 06:30AM BLOOD Glucose-142* UreaN-132* Creat-3.4* Na-137
K-4.6 Cl-104 HCO3-18* AnGap-20
[**2146-9-6**] 07:10AM BLOOD ALT-123* AST-84* LD(LDH)-379*
AlkPhos-374* TotBili-1.7*
[**2146-9-7**] 07:00AM BLOOD ALT-108* AST-75* AlkPhos-345* TotBili-1.5
[**2146-9-8**] 06:30AM BLOOD ALT-83* AST-63* LD(LDH)-281* AlkPhos-291*
TotBili-2.1*
[**2146-9-5**] 07:32PM BLOOD Albumin-2.3* Calcium-8.6 Phos-5.0* Mg-2.1
[**2146-9-6**] 07:10AM BLOOD Albumin-2.3* Calcium-8.7 Phos-5.3* Mg-2.2
Iron-30*
[**2146-9-7**] 07:00AM BLOOD TotProt-4.9* Albumin-2.1* Globuln-2.8
Calcium-8.5 Phos-5.5* Mg-2.1
[**2146-9-8**] 06:30AM BLOOD Albumin-2.7* Calcium-8.3* Phos-5.8*
Mg-2.1
[**2146-9-6**] 07:10AM BLOOD calTIBC-100* Ferritn-762* TRF-77*
[**2146-9-6**] 07:10AM BLOOD Ammonia-81*
[**2146-9-7**] 07:00AM BLOOD Osmolal-336*
MISC
[**2146-9-7**] 07:00AM BLOOD HCV Ab-NEGATIVE
[**2146-9-7**] 07:00AM BLOOD PEP-NO SPECIFI
[**2146-9-7**] 07:00AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2146-9-7**] 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2146-9-5**] 07:32PM BLOOD TSH-2.8
URINE
[**2146-9-6**] 01:12AM URINE Osmolal-500
[**2146-9-6**] 11:40PM URINE U-PEP-PND IFE-PND
[**2146-9-8**] 04:37PM URINE Osmolal-429
[**2146-9-6**] 01:12AM URINE Hours-RANDOM UreaN-871 Creat-90 Na-137
[**2146-9-8**] 04:37PM URINE Hours-RANDOM UreaN-761 Creat-43 Na-LESS
THAN
[**2146-9-6**] 01:12AM URINE Eos-NEGATIVE
[**2146-9-6**] 01:12AM URINE RBC->50 WBC-[**12-11**]* Bacteri-FEW Yeast-NONE
Epi-[**3-26**] TransE-[**3-26**]
[**2146-9-6**] 06:44PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE
Epi-0
[**2146-9-8**] 04:37PM URINE RBC-0 WBC->50 Bacteri-FEW Yeast-NONE
Epi-0
[**2146-9-6**] 06:44PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2146-9-8**] 04:37PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2146-9-6**] 01:12AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2146-9-6**] 06:44PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2146-9-8**] 04:37PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
PERITONEAL FLUID
[**2146-9-7**] 01:58PM ASCITES TotPro-0.8 Albumin-LESS THAN
[**2146-9-7**] 01:58PM ASCITES WBC-66* RBC-26* Polys-33* Lymphs-24*
Monos-0 Macroph-43*
Brief Hospital Course:
This is a 69 y/o man with PMH significant for CAD, DM, COPD, a
fib, who was on chronic amiodarone since [**12-24**] for rhythm
control of a fib, who was transferred to [**Hospital1 18**] from OSH after an
extensive workup for liver disease of unknown origin. Workup
there was notable for hyperdense liver, ascites; and negative
for any autoimmune, viral/infectious, hemachromatosis causes. Pt
also here with ARF on CRI.
1. Liver failure/renal failure - Most likely multifactorial,
also likely that it was [**2-23**] amiodarone toxicity, based on his
prior workup. Workup at OSH for autoimmune and infectious causes
for liver failure were all negative. His hepatitis serologies
were also negative during this hospital stay. Therapeutic tap on
[**2146-8-24**] negative for SBP at the OSH with normal cytology. His
paracentesis at this hospital was also negative for SBP. He
underwent a transjugular liver biopsy which showed significant
amiodarone toxicity with severe fibrosis and incomplete nodule
formation. His venous pressure measurements revealed a Hepatic
venous pressure gradient of 28mmHg consistent with portal
hypertension. It is unclear as to whether the liver biopsy
findings were entirely related to amiodarone toxicity or whether
the amiodarone toxicty was superimposed on a background of
cirrhosis. Risk factors for cirrhosis include diabetes and NASH.
He was initially continued on the high-dose steroids that he was
transferred here with, but was started to be weaned off as they
had no clear benefit. A RUQ u/s with Dopplers showed no liver
masses, + ascites, findings c/w cirrhosis and portal
hypertension, hepatofugal flow in splenic and portal veins, nl
flow in hepatic veins. Given worsening creatinine, he was
started on octreotide/midodrine for suspected hepatorenal
syndrome, along with albumin. In addition, he developed an
Enterococcal UTI for which he was begun on ampicillin [**9-6**]. An
NG tube was placed for tube feeds as the patient had poor po
intake secondary to decreased appetite. Given his liver failure
and probable hepato-renal syndrome, he was evaluated for
potential liver transplant by Dr. [**Last Name (STitle) 497**]. Based on the patient's
cardiac risk factors/cardiac history and his poor functional
status, it was decided that the patient would not be a good
liver transplant candidate.
On [**2146-9-9**] he became hypotensive and was transferred to the MICU
for further management. Following transfer to the MICU, the
patient received 2u PRBC, 2u FFP, and Vit K with stabilization
of his blood pressure. His renal function/coagulopathy continued
to worsen, attributed to hepato-renal syndrome. Following a
family meeting on [**9-10**], the decision was made not to pursue
dialysis, as the patient is not a liver transplant candidate.
Per this family meeting, other medical treatment (octreotide,
midodrine, antibiotics, albumin) was decided to be continued,
although the patient was made DNR/DNI from a full code on
admission.
His blood pressures stabilized while in MICU and he was
transferred back to the floor as CMO per patient's and family's
wishes. He eventually expired on [**2146-9-13**].
Medications on Admission:
MEDS (on transfer)
protonix 40mg PO QAM
flagyl 500mg PO TID (started [**9-5**])
Medrol 8mg PO BID
Insulin glargine 15 U qHS
Advair 2puffs INH [**Hospital1 **]
Combivent 2puffs INH [**Hospital1 **]
fosamax 90mg PO qweek
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Completed by:[**2146-9-17**]
|
[
"5849",
"42731",
"5990",
"496",
"V5867",
"25000"
] |
Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-4**]
Date of Birth: [**2101-11-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ciprofloxacin / Clindamycin / Quinidine / Niacin /
Persantine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina, DOE, recent fatigue
Major Surgical or Invasive Procedure:
redo cabg off pump x 4 [**2174-2-24**] (LIMA to LAD, SVG to RCA with
"y" graft to SVG to OM, SVG to OM graft has "y" graft to SVG to
DIAG)
History of Present Illness:
Developed angina 13 days PTA with current SOB. Transferred in
from OSH after echo showed multiple WMAs. Ruled out for MI by
enzymes. Also had acute on chronic renal failure. Sent here for
further management and cardiac cath.
Past Medical History:
CAD with prior CABG ([**2149**])/PTCA RCA [**2161**]
Renal Failure
Diabetes Melitus
anemia
gout
HTN
pituitary adenoma
neuropathy
IBS
GERD
arthritis
frequent HAs
PSH: cabg with RFA thrombosis and angioplasty [**2149**]
right LE fasciotomies
appy
parotidectomy tumor
ovarian cystectomy
TAH-BSO
cerv. repair
cholecystectomy
AAA repair [**2165**]
Social History:
remote tobacco abuse
no ETOH abuse
Family History:
father died of CAD at 59
Physical Exam:
HR 60 RR 16 right 156/54 left 140/49
66" 144 #
NAD, well-nourished
generalized rash back, thighs, arms, abd
healed surgical scars left calf, right groin, mid-line sternal,
midline abd, left neck, midline posterior [**Last Name (un) **]
upper dentures
PERRLA 2mm, EOMI
neck supple, full ROM, no lymphadenopathy
CTAB
RRR 2/6 systolic murmur
+ BS, no palpable masses
warm, well-perfused, no peripheral edema, no varicosities
MAE, , right> left strengths, gait steady
dopplerable right fem, 2+ left
1+ bil. DP/PT
2+ bil. radials
Pertinent Results:
[**2174-3-1**] 06:08AM BLOOD WBC-9.0 RBC-3.14* Hgb-9.8* Hct-28.6*
MCV-91 MCH-31.0 MCHC-34.1 RDW-17.0* Plt Ct-188#
[**2174-3-1**] 06:08AM BLOOD PT-12.9 INR(PT)-1.1
[**2174-3-1**] 06:08AM BLOOD Plt Ct-188#
[**2174-3-1**] 06:08AM BLOOD Glucose-103 UreaN-34* Creat-1.6* Na-133
K-4.0 Cl-102 HCO3-25 AnGap-10
[**2174-2-22**] 06:25AM BLOOD proBNP-2514*
Cardiology Report ECHO Study Date of [**2174-2-24**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. H/O cardiac surgery.
Hypertension. Left ventricular function. Intraoperative TEE for
off-pump CABG.
Height: (in) 66
Weight (lb): 144
BSA (m2): 1.74 m2
BP (mm Hg): 138/46
HR (bpm): 80
Status: Inpatient
Date/Time: [**2174-2-24**] at 11:33
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW000-0:0
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: *2.8 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Aortic Valve - LVOT Diam: 2.1 cm
Aortic Valve - Valve Area: *2.2 cm2 (nl >= 3.0 cm2)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.14
Mitral Valve - E Wave Deceleration Time: 296 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Dilated LA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Severe regional LV systolic dysfunction.
Moderate global LV
hypokinesis. Moderately depressed LVEF. Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta.
Focal calcifications in ascending aorta. Complex (mobile)
atheroma in the
aortic arch. Complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. Suboptimal
image quality.
The patient appears to be in sinus rhythm. Results were
personally reviewed
with the MD caring for the patient.
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. There is
moderate
global left ventricular hypokinesis. There is moderate regional
left
ventricular systolic dysfunction with severe hypokinesis/
akinesis of the apex
with severe hypokinesis of the of all distal LV segments.
Estimated EF 30%.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal
with trivial mitral regurgitation. There is a
trivial/physiologic pericardial
effusion. There is mild TR. There is severe athersclerotic
disease of the
thoracic aorta including a large mobile plaque in the distal
aortic arch.
After completion of coronary grafting, and with epinephrine
infusion, the LV
displayed worse global and segmental function with extension of
the severe
hypokinesis towards the mid LV segments. Overall EF is
approximately 20-25%.
RV systolic function is preserved. No other changes.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2174-2-24**] 15:32.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 40349**])
Brief Hospital Course:
Admitted [**2-19**] to cardiology. Echo at OSH showed EF 30% with
mutiple wall motion abnormalities and [**11-23**]+ MR. [**First Name (Titles) 40350**] [**Last Name (Titles) **]
test positive. Cath revealed: LAD calcified prox with distal
aneurysm and bifurcating 80-90% distal Diag 1; CX distal 60%,
RCA prox. 100%, SVG to RCA 50%, to 90% PDA, SVG to LAD 100%.
Workup completed and bil. carotid dz. revealed as well as a
calcified aorta.Underwent redo cabg x4 off pump with Dr. [**First Name (STitle) **]
on [**2-24**]. Transferred to the CSRU in stable condition on
epinephrine, insulin, phenylephrine, and propofol drips.
Extubated the next morning and neurology consulted for eval. of
pituitary adenoma. Developed RUE swelling with partial occlusion
of a vein diagnosed and coumadin started.Transferred to the
floor on POD #4. Dermatology consult requested by pt. due to
faint rash that existed pre-op, but this is to be done as an
outpt.Gentle diuresis continued and coumadin stopped per Dr.
[**First Name (STitle) **].
Cleared for discharge to home with VNA services on POD #8. Pt.
to make all follow-up appts. as per discharge instructions.
Medications on Admission:
diovan 8 mg QHS
Iron 325 mg QHS
aldactone 12.5 mg [**Hospital1 **]
carvedilol 12.5 mg [**Hospital1 **]
digoxin 0.125 mg q M,T, TH, F,SUN
omeprazole 20 mg daily
folate 1 mg daily
ASA 81 mg daily
allopurinol 150 mg QHS
colchicine 0.6 mg PRN
amaryl 6 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Glimepiride 2 mg Tablet Sig: Three (3) Tablet PO daily ().
Disp:*90 Tablet(s)* Refills:*1*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Patrners Home Care
Discharge Diagnosis:
s/p redo OPCABG x4
CAD with prior CABG ([**2149**])/PTCA RCA [**2161**]
Renal Failure
Diabetes Melitus
anemia
gout
HTN
pituitary adenoma
neuropathy
IBS
GERD
arthritis
frequent HAs
PSH: cabg with RFA thrombosis and angioplasty [**2149**]
right LE fasciotomies
appy
parotidectomy tumor
ovarian cystectomy
TAH-BSO
cerv. repair
cholecystectomy
AAA repair [**2165**]
Discharge Condition:
stable
Discharge Instructions:
A 7-mm ground-glass opacity with slightly irregular margins was
seen within the right upper lobe of your lung on CT scan. Close
followup evaluation in three months' time should be obtained to
assess for interval change.
no lotions, creams, or powders on any incision
no driving for one month
may shower over incisions and pat dry
call for fever greater than 100.5, redness, or drainage
NO lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 174**] in [**11-23**] weeks
see Dr. [**Last Name (STitle) 40351**] in [**12-25**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-3-4**]
|
[
"5849",
"40391",
"2762",
"41401",
"53081",
"2859",
"V4582",
"V5867",
"25000"
] |
Unit No: [**Numeric Identifier 73910**]
Admission Date: [**2105-7-17**]
Discharge Date: [**2105-8-5**]
Date of Birth: [**2105-7-17**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] Twin B was born at 34 6/7 weeks'
gestation to a 35-year-old G4, P2 mother with prenatal labs
A+, antibody negative, RPR nonreactive, rubella immune,
hepatitis B surface antigen negative. Pregnancy was notable
for twin gestation, twin #1 w as third percentile for size at
gestational age and therefore intrauterine growth restricted,
twin #2 weight and growth were appropriate for gestational
age. The mother did have gestational diabetes which was
treated with insulin as well as an endometrial cyst removed
at 17 weeks of gestational age during this gestation. The
babies were born due to preterm labor.
Initial dimensions of Twin B were weight 2300 grams which is
50 percentile for gestational age, length of 46.5 cm which
was 50 percentile for gestational age and head circumference
of 32.5 cm which was 50 percentile for gestational age.
Initial exam was within normal limits.
PHYSICAL EXAMINATION AT DISCHARGE: Weight on [**2105-8-5**]
is 2.650 kilograms which was up 40 grams from the day prior.
AFSF. RRx2. Conjunctiva clear, no discharge status-post a
course of gentamicin eye drops. Palate intact. MMM. Neck
supple. Clavicles intact. Lungs CTA, =. CV RRR, no murmur,
2+FP. Abd s oft +BS. No HSM. Small umbilical hernia. Residual
dried cord still at base. Normal female genitalia. Perianal
rash, desitin applied. Hips stable. Ext warm, pink and
well-perfused. No sacral anomalies. Good suck, intact grasp,
plantar and symmetrical Moro reflex.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
(1) Respiratory. The patient was stable in room air since
birth and required no significant respiratory interventions.
The patient did not show signs of apnea of prematurity nor
was treated with caffeine during stay in NICU.
(2) Cardiovascular. The patient was stable without
hypotension. The patient has a history of an intermittent
very soft systolic murmur consistent with peripheral pulmonic
stenosis (PPS). The murmur was not heard at discharge.
Otherwise there are no significant findings on
cardiovascular exam.
(3) Fluids, electrolytes, and nutrition. The patient was
started on enteral feeds on day of life 2 and progressed to
full feedings at 1 week of age. The patient has been taking
full p.o. feedings since 5 p.m. on [**2105-8-2**]. The
patient's formula at discharge is Similac and/or breast
milk supplemented to 24 kilocalories per ounce.
(4) GI. The patient had a maximum bilirubin of 12.12 on day of
life 4 and underwent phototherapy for 3 days. The patient had
a rebound bilirubin of 5.5 on day of life 6.
(5) Hematology. Initial hematocrit at birth was 53, platelets
of 286,000, white count of 6.7. The patient has had no
additional hematologic work performed.
(6) Infectious disease. Antibiotics were not initiated at
delivery and initial CBC was unremarkable with a non-shifted
differential. One week of gentamicin eye drops were given
for eye discharge which grew rare growth of
methicillin-sensitive staphylococcus of both coagulase
positive and negative types. Both organisms were sensistive to
Gentamicin.
(7) Neurology. No head ultrasound was performed given near
term delivery and clinical stability.
(8) Sensory/audiology. Hearing screening was performed with
automated auditory brainstem responses and was passed.
(9) Ophthalmology. Not examined given near term gestation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 5846**] at [**Hospital **]
Medical Center.
CARE RECOMMENDATIONS:
Feeds at discharge: 24 kilocalorie per ounce either with
supplemented breast milk or Similac formula.
Medications:
1. Ferrous Sulfate (25 mg/mL) concentration 0.3 mL PO daily.
This gives approximately 2 mg/k/day.
2. Goldline Multivitamins 1 mL PO daily.
Iron and vitamin D supplementation. Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominately breast
milk should receive vitamin D supplementation at 200
international units, this may be provided as a multivitamin
preparation daily until 12 months corrected age.
Car seat positioning screening was performed and successful
prior to discharge.
State newborn screenings were sent per protocol with no
abnormal results reported.
Immunizations received: Hepatitis B vaccine was given on
[**2105-8-4**].
Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 4 criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with 2 of the following:
Daycare or a smoker in the house, neuromuscular disease,
airway abnormalities, or school age siblings.
3. Chronic lung disease.
4. Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received Rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks but few
than 12 weeks of age.
FOLLOWUP APPOINTMENTS: Scheduled with primary care physician
[**2105-8-7**]. VNA service also arranged for [**2105-8-8**].
DISCHARGE DIAGNOSES:
1. Prematurity, Twin 2
2. Intermittent murmur consistent with peripheral pulmonic
stenosis (PPS)
3. Feeding immaturity, resolved
4. Hyperbilirubinemia, resolved
5. Conjunctivitis, resolved
6. Small umbilical hernia
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 68276**]
MEDQUIST36
D: [**2105-8-4**] 15:35:35
T: [**2105-8-4**] 16:28:23
Job#: [**Job Number 73911**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2165-10-29**] Discharge Date: [**2165-11-20**]
Date of Birth: [**2114-10-29**] Sex: M
Service: MEDICINE
Allergies:
metformin
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Fever, neutropenia, hepatitis.
Major Surgical or Invasive Procedure:
[**2165-10-31**] Skin biopsy.
[**2165-10-31**] Bone marrow biopsy.
[**2165-11-1**] Bone marrow biopsy.
History of Present Illness:
51yo male with history of hypertension, hyperlipidemia,
rheumatoid arthritis and diabetes mellitus who presents to OSH
after syncopal event on [**10-26**].
.
He awoke on [**10-26**] and felt warm. His temperature at that time was
101.0 so he took two tylenol and went back to sleep. He awoke a
few hours later and again felt warm and "flush" and found his
temp to be 103.0. He got up to go to the bathroom and "the next
thing (he) knew" he was on the floor. He was found by his wife
after an unknown duration and came to quickly. Denies any
confusion. He his the right side of his face and has a large
abrasion there now. He was taken to his local ED where he was
admitted for further evaluation.
.
While at the OSH, he underwent an extensive work-up for his
syncope. During this process, he developed persistent fevers,
thrombocytopenia, leukopenia, and liver failure. He was
initially started on azithromycin and rocephin but was
transitioned to vanco and cefotaxmin to cover for CNS infection.
Neurology evaluated the patient given syncopal event and
underwent negative EEG and CT head. No LP was done as there was
no suspicion for on-going meningitis. He underwent an ECHO which
some LVH with normal EF and no pulmonary HTN. CT chest and CT
sinus were negative for any infection and he satted about 92% on
RA.
.
As mentioned, the patient was found to have acute elevation of
his liver enzymes. On admission, ALT was 89 and AST was 70. ALT
rose to 353 and then 1067 and AST rose to 472 and 1732. T-bili
and alk phos remained within normal limits. Hepatitis panel and
monospot studies were negative. He had no abdominal pain,
jaundice, nausea or vomiting. RUQ U/S did not show any
inflammation or ductal dilatation.
.
He also became leukopenic, which is of unclear etiology. There
was some concern that it could be secondary to Enabrel. WBC down
from 3.2 to 0.8 with ANC of 0.51. Hct stayed within normal
limits. In addition, thrombocytopenia develops as she went from
169 to 68. Retic count was 1%, INR 1.1, fibrinogen 240, d-dimer
3360. Smear showed leukopenia with left shift and normochromic,
normocytic anemia. There was no evidence of schistocytes, acute
leukemia, inclusion bodies or toxin granulation.
.
ID was consulted given fevers and underlying marrow suppression.
Cultures were negative and EBV is pending. He was continued
vancomycin and cefotaxime. Of note the patient denies any recent
travel, tick bites, or new rashes.
.
He is being transferred to [**Hospital1 18**] for further evaluation. On
arrival to [**Hospital1 18**], vital signs were T- 103.4, BP- 160/80, HR-
103, RR- 20, SaO2- 95% on RA. The patient reports feeling warm
but denies chest pain, shortness of breath, abdominal pain,
dizziness, LH, or syncope.
Past Medical History:
1. Diabetes Mellitus
2. Hypertension
3. Hyperlipidemia
4. RA
5. Obesity
6. Insomnia
7. Osteoarthritis
Social History:
Married. Does not smoke or use any drugs. Denies regular alcohol
use.
Family History:
Diabetes and hypertension on maternal side of his family. Colon
cancer- father.
Physical Exam:
ADMISSION EXAM:
VS: T- 103.4, BP- 160/80, HR- 103, RR- 20, SaO2- 95% on RA
GENERAL: Mildly distressed but resting. Appropriate.
HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: Tachycardic, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred.
Pertinent Results:
ADMISSION LABS:
[**2165-10-30**] 09:35AM BLOOD WBC-0.8* RBC-4.02* Hgb-12.2* Hct-34.7*
MCV-86 MCH-30.4 MCHC-35.2* RDW-13.3 Plt Ct-30*
[**2165-10-30**] 09:35AM BLOOD Neuts-53 Bands-8* Lymphs-30 Monos-5 Eos-1
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2165-10-30**] 09:35AM BLOOD PT-13.7* PTT-47.8* INR(PT)-1.2*
[**2165-10-30**] 05:10PM BLOOD Fibrino-155
[**2165-10-30**] 09:35AM BLOOD Ret Aut-0.9*
[**2165-10-30**] 09:35AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-133
K-3.7 Cl-102 HCO3-21* AnGap-14
[**2165-10-30**] 09:35AM BLOOD Calcium-7.1* Phos-1.4* Mg-1.7
[**2165-10-30**] 05:15PM BLOOD Albumin-3.1* UricAcd-2.7* Iron-58
[**2165-10-30**] 05:15PM BLOOD calTIBC-207* VitB12-1567* Folate-19.0
Hapto-76 Ferritn-[**Numeric Identifier 1097**]* TRF-159*
[**2165-10-30**] 05:10PM BLOOD HIV Ab-NEGATIVE
[**2165-10-30**] 09:35AM BLOOD Acetmnp-NEG
.
[**2165-10-30**] CT CHEST/ABD/PELV:
1. Mild gallbladder wall hyperenhancement with surrounding band
of fat
stranding, portocaval lymph nodes, and presence of peritoneal
fluid might be explained by current episode of hepatitis.
However, if cholecystitis remains a consideration clinically a
right upper quadrant ultrasound might be considered.
2. Small pulmonary nodules are non specific and ahould be
followed up with a chest CT in 12 months as [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
Society guidelines if the patient has no history of smoking or
malignancy.
3. Small bilateral pleural effusions are observed.
4. Mildly enlarged mediastinal lymph nodes were also present.
5. Left lobe liver hypodensity is too small to characterize.
.
BMBx [**2165-10-31**]: HYPERCELLULAR BONE MARROW WITH FOCAL STROMAL
DAMAGE, INCREASED APOPTOSIS AND OCCASIONAL HEMOPHAGOCYTIC
HISTIOCYTE. THESE FINDINGS, IN THE CLINICAL SETTING OF
PANCYTOPENIA, HEPATIC [**Month/Day/Year **], EXTREME HYPERFERRITINEMIA,
HYPOFIBRINOGENEMIA AND HYPERTRIGLYCERIDEMIA ARE CONSISTENT WITH
ACQUIRED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS.
.
[**2165-11-4**] ECHO: LVEF: 55% IMPRESSION: Suboptimal image quality.
Normal biventricular cavity sizes with preserved global left
ventricular systolic function. Mild right ventricular free wall
hypokinesis.
.
[**2165-11-7**] LOWER EXTREMITY DOPPLER U/S: IMPRESSION: No evidence for
DVT.
.
[**2165-11-7**] MRI HEAD: IMPRESSION: Normal MRI of the head.
.
[**2165-11-7**] EEG: IMPRESSION: These findings are consistent with
initial non-convulsive status epilepticus, resolving with
treatment (IV levetiracetam), and improvement in the background
activity to moderate diffuse slowing consistent with a moderate
diffuse encephalopathy.
.
[**2165-11-12**] CT HEAD: FINDINGS: IMPRESSION: Normal study.
.
[**2165-11-13**] CXR: Tip of the new right PIC line is in the mid SVC
alongside a right internal jugular sheath. Widening of the
mediastinum is stable, and there is no tracheal displacement or
other finding to suggest that there is any mediastinal bleeding.
There is no pleural effusion and the lungs are clear.
.
[**2165-11-20**] 04:55AM BLOOD WBC-1.0*# RBC-3.18* Hgb-9.8* Hct-26.7*
MCV-84 MCH-30.8 MCHC-36.7* RDW-13.5 Plt Ct-44*
[**2165-11-11**] 03:49AM BLOOD Neuts-69.4 Lymphs-29.2 Monos-1.0* Eos-0.2
Baso-0.2
[**2165-11-18**] 09:30AM BLOOD PT-12.1 PTT-21.9* INR(PT)-1.0
[**2165-11-18**] 09:30AM BLOOD Fibrino-356
[**2165-11-4**] 01:58AM BLOOD Fibrino-104*
[**2165-11-18**] 09:30AM BLOOD Fibrino-356
[**2165-11-11**] 03:49AM BLOOD Ret Aut-0.7*
[**2165-11-1**] 09:32PM BLOOD FacVIII-59 Fact IX-41* Fact [**Doctor First Name 81**]-66
FacXIII-NORMAL
[**2165-11-2**] 05:22AM BLOOD ACA IgG-3.8 ACA IgM-12.0
[**2165-11-1**] 04:20PM BLOOD CD3%-73.61 CD3Abs-247 16/56%-0.49
16/56Ab-2
[**2165-11-20**] 04:55AM BLOOD Glucose-117* UreaN-18 Creat-0.5 Na-135
K-3.9 Cl-102 HCO3-28 AnGap-9
[**2165-11-20**] 04:55AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8
[**2165-11-14**] 05:04AM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.9 Mg-2.1
Iron-147
[**2165-11-20**] 04:55AM BLOOD ALT-81* AST-25 LD(LDH)-365* AlkPhos-110
TotBili-1.4
[**2165-10-31**] 05:50AM BLOOD ALT-1211* AST-1850* LD(LDH)-2431*
CK(CPK)-936* AlkPhos-93 TotBili-0.5
[**2165-11-3**] 04:50PM BLOOD CK(CPK)-2685*
[**2165-11-12**] 04:03AM BLOOD ALT-111* AST-52* LD(LDH)-425* CK(CPK)-256
AlkPhos-111 TotBili-1.1
[**2165-11-18**] 09:30AM BLOOD Ferritn-[**2183**]*
[**2165-11-14**] 05:04AM BLOOD D-Dimer-[**Numeric Identifier 90624**]*
[**2165-10-31**] 05:50AM BLOOD Triglyc-344*
[**2165-11-1**] 10:45AM BLOOD Triglyc-276*
[**2165-11-8**] 03:17AM BLOOD Osmolal-322*
[**2165-10-30**] 09:35AM BLOOD TSH-1.5
[**2165-10-31**] 05:50AM BLOOD Smooth-NEGATIVE
[**2165-11-2**] 10:00AM BLOOD PSA-1.1
[**2165-10-31**] 05:50AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2165-10-31**] 05:50AM BLOOD RheuFac-234* CRP-80.6*
[**2165-11-3**] 05:32PM BLOOD Lactate-3.7*
[**2165-11-5**] 12:58AM BLOOD Lactate-1.2
[**2165-11-3**] 05:08AM BLOOD freeCa-1.08*
[**2165-11-10**] 04:00PM BLOOD freeCa-1.15
Brief Hospital Course:
51yo man with RA on etanercept, DM, and HTN who is was foung to
have [**Month/Day/Year **], pancytopenia, fevers, hyperferritinemia,
hypofibrinogenemia, and BMB confirming hemophagocytic
lymphohistiocytosis (HLH). Developed fever, pancytopenia,
[**Last Name (LF) **], [**First Name3 (LF) **] transferred to [**Hospital1 18**] [**2165-10-29**]. He was
intubated for agitation and airway protection [**2165-10-31**] after
becoming dyspneic, tachypneic, and having chest pain. Ferritin
was 57,602. BMB confirmed HLH. Started high-dose steroids (dex
20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide
150mg/m2 days 1,4,8,11. On [**2165-11-5**] he had 3 minutes of
seizure-like activity which resolved with benzodiazapines. EEG
initially showed frequent subclinical seizures. ICU course was
complicated by hypernatremia to 150 which improved with free
water boluses, agitation/delerium which improved with
levetiracetam and haloperidol, sinus tachycardia to HR 150, and
steroid-induced hyperglycemia. Extubated [**2165-11-8**]. MRI head
negative. He was transfused 5U pRBCs, cryoprecipitate for
hypofibrinogenemia. Abx were stopped [**2165-11-9**] despite fevers
(due to HLH). Dramatic improvement over this week.
.
# Febrile Neutropenia - Initially febrile when presented to
outside hospital, and with WBC of 3. He was started on vanc and
ceftriaxone. Became neutropenic down to WBC 0.8 prior to
transfer. On transfer he remained febrile up to 103 with relief
only from cooling blankets due to inability to take
acetaminophen or ibuprofen. Hem/onc was consulted for further
assistance and performed a bone marrow biopsy on [**2165-10-31**] which
was repeated [**2165-11-1**] due to inadequate specimen. Diagnosis HLH.
His antibiotic course included:
--vancomycin 1g q12hr - [**Date range (1) 90625**], [**11-1**]->approx. [**2165-11-9**]
--cefepime 2g q8hr - [**10-29**]->approx. [**2165-11-9**]
--doxycycline 100mg PO q12hr - [**10-30**]->approx. [**2165-11-9**]
--acyclovir 800mg q8hr - [**10-31**]->
- ciprofloxacin PO 750mg q12hr [**11-1**]->approx. [**2165-11-9**]
.
# Anemia - Initially his hematocrit was stable around 37 for
most of his hospitalization, but on [**11-1**] it dropped to 30 and
then subsequently to 26 later that day. His LDH was up, but
hapto was normal. This was assumed to be related to whatever
process was causing his pancytopenia.
.
# Thrombocytopenia - His platelet counts were initially normal
at the OSH and trended steadily downward to 60 on admission, and
then remained around 30.
Transfusions: Platelets - 1 bag - [**11-1**] (for PICC placement).
.
# Hepatitis - His LFTs were initially normal at the OSH, and
then began to increase, initially to ALT/AST ~400, then ~1200
but stable for two days. Then his ALT increased to 1700 and AST
to 4700. LDH continued to increase from [**2154**] to 2400 to 4300.
Bilirubin and coags remained normal. Ferritin continued to
elevate up to [**Numeric Identifier 36021**], likely acute phase reactant. Liver was
consulted for further evaluation.
.
# RA: Held etanercept. Initially concerned that this could
contribute to his pancytopenia but Rheumatology felt this
unlikely. Rheumatology was formally consulted and felt the most
likely diagnosis was HLH, and recommended starting IVIG, which
he received once.
.
# Diabetes: On U500 as an outpatient, with unclear glucose
levels or insulin requirements. Started on a regular insulin
sliding scale on this admission. Sugars initially
well-controlled in the 100s, then began to increase into the
300s.
.
# Hypertension: Held atenolol and benicar in the setting of
recent syncopal event and report of bradycardia at OSH.
Maintained on telemetry.
.
# Syncopal event- could have been vagal or secondary to
hypotension given high fevers. CT head, ECHO, EEG all negative
at OSH.
.
MICU course:
Patient transferred to MICU [**Location (un) 2452**] given new respiratory
symptoms and oxygen requirement. On arrival to the MICU, he
received IVIG (40mg over 4 days). He did not tolerate increased
rate and developed rigors and fevers, which could also have been
secondary to underlying disease process. He was treated with
tylenol and benadryl and tolerated the remained of the infusion.
His respiratory remained stable overnight. BPs were elevated
to SBP of 190. He was initially treated with hydral 5mg IV x 2
with good response. Given duration of illness and likelihood
that sepsis would have declared itself, we resumed his
beta-blockade with metoprolol 12.5mg [**Hospital1 **] with plans to resume
[**Last Name (un) **] if BPs were stable on [**11-2**]. He was started on PPI in the
setting of recent Hct drop and stools were guaiac-ed
(results**). RUQ U/S (with dopplers) showed no gallbladder
pathology with normal hepatic vasculature.
.
Heme/onc was consulted regarding his pancytopenia. A bone
marrow biopsy was done which revealed hypercellular bone marrow
with increased apoptosis and occasional hemophagocytic
histiocyte. It was felt that this was c/w acquired
hemophagocytic lymphohistiocytosis given his constellation of
symptoms. He was then transfered to the [**Hospital Unit Name 153**] for initation of
chemotherapy. Prior to transfer, the patient was noted to be
acutely agitated and had to be intubated for airway protection.
.
During his stay in the [**Hospital Unit Name 153**], the patient was noted to have
shaking episodes (low amplitude, all 4 extremities). An EEG was
performed, which was concerning for seizure activity. Neurology
was consulted who felt that he may have been having subclinical
seizures and he was started on antiepileptics. As his EEG
monitoring continued, this activity stopped and his
antiepileptics were discontinued.
.
His mental status also began to improve, albeit slowly. He was
able to be extubated without incident. The patient had a fall
out of bed that was unwitnessed. He was found at the side of
his bed, sitting on the floor. He denied hitting his head, and
there was no evidence of head trauma. A head CT was done which
did not reveal any abnormalities. Also during his ICU stay, the
patient required an insulin drip to adequately control his blood
sugars. This was felt to most likely due to steroids and his
DM. His insulin dose and sliding scale was uptitrated
accordingly and the insulin gtt was discontinued. He was then
transferred to the floor for further management.
.
# HLH: Steroids started [**2165-11-2**], IVIG x4d finished [**2165-11-6**],
cycle #1 etoposide per HLH-94 regimen started [**2165-11-4**], finished
[**2165-11-14**] (Days 1/4/8/11). Completed 2wks dexamethasone 20mg,
now on a slow taper.
- Continue etoposide 150mg/m2 qwk x6wks (Mondays), last given
[**2165-11-18**].
- Continue dexamethasone 10mg (5mg/m2) daily x2wks, then 5mg
(2.5mg/m2) x2wks, 2.5mg (1.25mg/m2) x1wk, then taper off over
1wk.
- Cyclosporine might be started week #9 pending re-evaluation.
- Follow CBC, fibrinogen, coags, LDH.
- Calcium and vitamin D to prevent bone loss while on steroids.
- PPI while on steroids.
- Continue TMP/SMX PPx.
- TMP-SMX for prophylaxis.
.
# Pancytopenia: Due to HLH and chemotherapy. Transfused 1U PLTs
[**2165-11-1**]. Transfused 8U pRBC previously and 2U pRBC [**2165-11-16**].
Trace positive stool guaic. Avoid NSAIDs and heparin with low
PLTs.
.
# Coagulopathy: PTT up to 71 (with Factor IX 41%) now
normalized. Transfused cryoprecipitate [**2165-11-4**] to keep
fibrinogen >100.
.
# [**Month/Day/Year 5779**]: Due to HLH. Hepatology consulted. Normal
hepatitis serologies from OSH. LFTs improving.
.
# Diabetes: Endocrinology consulted. Added NPH. Holding
insulin glargine until PO intake stabilizes. Increased sliding
scale per Endocrine.
.
# Respiratory failure: Extubated. Off O2.
.
# Seizure d/o and delirium: Due to HLH. MRI brain negative.
EEG confirmed seizure. Neurology consulted. Resolved.
Continued levetiracetam for seizure. Continued trazodone prn
sleep.
.
# Fever: Due to HLH. ID consulted. Abx stopped [**2165-11-9**].
Adenovirus PCR, analplasma (HGE) Ab, blastomycosis Ab,
coccidioides Ab, hepatitis E Ab, HHV-6 PCR, HSV-[**2-3**], histoplasma
Ab, leptospira Ab, parvovirus B19 Ab all negative.
.
# Thigh hematoma: Due to BM biopsy, coagulopathy, and
pancytopenia. Resolving.
.
# RA: Holding etanercept for now.
.
# Hypertension: Restarted olmesartan (initially held due to
syncope). Increased metoprolol to 25mg [**Hospital1 **]. Atenolol stopped.
.
# Hypernatremia: Due to osmotic diuresis with hyperglycemia,
resolved.
.
# FEN: Regular diabetic diet. Hypernatremia resolved with IV
fluids.
.
# DVT Prophylaxis: Pneumatic boots.
.
# Access: PICC.
.
# Precautions: Fall.
.
# Contact: Wife.
.
# Code: Full.
.
TRANSITIONAL:
# HLH: Etoposide 150mg/m2 IV weekly x5 more weeks, then
re-evaluate.
.
# Pulmonary Nodule: CT with Scattered pulmonary nodules
measuring up to 5 mm needs f/u CT in 12 months.
Medications on Admission:
1. Atenolol 25mg daily
2. Lipitor 40mg daily
3. Lasix 40mg daily
4. Benicar 20mg daily
5. Lovaza- 1gm- 2 cap in AM, 2 in PM
6. Vicotaz- 1.8u subcutaneous daily
7. U500 insulin- 14U in AM, 13U in PM
8. TriCor- 145mg PO daily
9. Enabrel
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID.
2. calcium carbonate 200 mg calcium (500 mg) PO BID.
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID.
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY.
7. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO q8HR
PRN nausea.
8. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO q8HR PRN
nausea.
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
PRN Thrush.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN pain.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS PRN insomnia.
12. olmesartan 20 mg Tablet Sig: One (1) Tablet PO Daily.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID.
14. etoposide 20 mg/mL Solution Sig: One [**Age over 90 1230**]y (150)
mg/m2 Intravenous 1X/WEEK (ONCE PER WEEK) for 5 weeks: Mondays
x5 more weeks, then treatment to be determined. Plan is to give
this in Dr.[**Name (NI) 84404**] office.
15. dexamethasone 2 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): 10mg (5mg/m2) daily x2wks (finishing [**2165-12-1**]), then
5mg x2wks, 2.5mg x1wk, then taper off over 1wk.
16. NPH insulin human recomb 100 unit/mL Sig: 12 Units SC qAM:
With breakfast.
17. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale SC QID.
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
PRN Rash.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11252**] Rehab
Discharge Diagnosis:
1. Syncope (fainting).
2. Fever.
3. Pancytopenia (low blood counts).
4. Coagulopathy (bleeding disorder).
5. Hemophagocytic lymphohistiocytosis (HLH), bone marrow
disease.
6. [**Hospital 5779**] (liver dysfunction, hepatitis).
7. Altered mental status (delirium).
8. Generalized weakness.
9. Seizure disorder.
10. Rheumatoid arthritis.
11. Diabetes.
12. Hypertension (high blood pressure).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital directly from another hospital
due to fainting (syncope), pancytopenia (low blood counts),
[**Hospital **], altered mental state, and fever. You were seen
by the Infectious Disease, Rheumatology, Neurology,
Endocrinology, Hepatology (Liver), Dermatology, and
Hematology/Oncology specialists. You needed transfusions of red
blood cells, platelets, and clotting factors for a coagulopathy
(bleeding disorder). Dermatology performed a skin biopsy of a
rash. Hematology performed a bone marrow biopsy; this confirmed
the diagnosis of HLH (hemophagocytic lymphohistiocytosis), a
bone marrow disease that destroys blood cells. This was treated
with etoposide (chemotherapy) and dexamethasone (steroids) and
you will need to continue these as an outpatient.
.
While you were in the hospital, your confusion and agitation
worsened when you were feeling short of breath. This required
intubation (ventilator/breathing machine support). During this
time, an EEG showed seizure activity, so you were started on a
seizure medication, levetiracetam (Keppra). As the steroids and
chemotherapy continued, you began feeling better, you did not
need the ventilator, fevers resolved, and the liver function
tests normalized. Your blood counts remain low, a result of the
HLH and chemotherapy, and you are continuing to need frequent
blood transfusions.
.
Initially, you should have your blood counts (CBC) checked every
other day and this can be spaced out if your need for
transfusions declines.
.
MEDICATION CHANGES:
1. Etoposide chemotherapy weekly for at least the next 5 weeks,
then additional therapy will be considered.
2. Dexamethasone tapered over then next six weeks.
3. Levetiracetam (Keppra) for seizure disorder.
4. Stop atenolol.
5. Metoprolol 2x a day.
6. Calcium and vitamin D supplements while you are on steroids
(dexamethasone).
7. Trimethoprim/sulfamethoxazole (Bactrim) SS (single strength)
once daily to prevent infections.
Followup Instructions:
HEMATOLOGY/ONCOLOGY
DR. [**First Name (STitle) **] CATCHER
APPOINTMENT: MONDAY [**2165-11-25**] AT 9:15AM
[**Hospital **] HEALTHCARE
[**Street Address(2) 90626**], [**Location (un) **], [**Numeric Identifier **]
PHONE [**Telephone/Fax (1) 90627**]
FAX [**Telephone/Fax (1) 90628**] (ATTENTION: [**Doctor First Name 6811**])
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2165-11-28**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2165-11-28**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: THURSDAY [**2165-12-12**] at 3:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19249**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"51881",
"2760",
"4019",
"25000",
"2720",
"2875",
"2859"
] |
Admission Date: [**2136-6-30**] Discharge Date: [**2108-4-9**]
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
Spanish speaking male with a history of hypertension, iron
deficiency anemia, obstructive/restrictive lung disease and
primary biliary cirrhosis who was in his usual state of
health until four days prior to admission when he developed
progressively worsening edema in his lower extremities and
dyspnea on exertion that has progressed to shortness of
breath at rest. The patient denies any recurrent or current
chest pain and pleuritic chest pain. He had a stress test in
[**2134-5-10**], consistent with average exercise tolerance and
his last echocardiogram was in [**2134-2-9**], which showed an
ejection fraction over 55 percent. The patient reports that
he is now unable to climb more than one to two stairs without
becoming short of breath and that he sleeps on a large pillow
at night although he denies that his dyspnea is positional.
In addition, the patient reports milder symptoms of shortness
of breath since being seen in the Emergency Department at
[**Hospital1 69**] in [**2136-2-9**], when he
was diagnosed with a pneumonia/upper respiratory infection.
The patient reports that he has not experienced lower
extremity swelling in the past. In addition to these
symptoms, the patient reports an unintentional weight loss of
20 pounds in the last year and five pounds in the last month
in addition to generalized fatigue.
The patient denies recent fevers, chills, night sweats,
cough, nausea, vomiting. diarrhea and proximal/distal muscle
weakness. He was treated in the Emergency Department with 20
mg of intravenous Lasix and had approximately one liter of
clear urine output. A bedside ultrasound was consistent with
pericardial effusion. A bedside echocardiogram was performed
and consistent with moderate pericardial effusion, left
atrial compression, right ventricular flap but no
compression, normal flow and ejection fraction with no
abnormalities in the left ventricular wall thickness or
motion.
PAST MEDICAL HISTORY: Primary biliary cirrhosis diagnosed by
serologic markers/liver biopsy in [**2132**].
Anemia, baseline hematocrit around 30.0 with MCV around 80,
diagnosed as iron deficiency anemia with a ferritin of 6.3 in
[**2136-5-10**].
Obstructive/restrictive lung disease diagnosed by recent
pulmonary function tests.
Benign prostatic hypertrophy.
Hypertension.
Gastroesophageal reflux disease.
Echocardiogram in [**2134-2-9**], revealed a left ventricular
ejection fraction over 55 percent, patent foramen ovale,
normal left ventricular wall thickness and motion.
Last stress test in [**2134-5-10**], revealed average functional
exercise tolerance without anginal symptoms.
MEDICATIONS ON ADMISSION:
1. Terazosin 1 mg once daily.
2. Flovent 220 mcg.
3. Ursodiol 250 mg once daily.
4. Nadolol 40 mg once daily.
5. Norvasc 5 mg once daily.
6. Protonix 40 mg once daily.
7. Iron supplementation.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is retired. He lives with his
wife and grandson in [**Name (NI) 8**]. He has a 60 pack year
smoking history. He has not drank alcohol in six years and
was a previous social drinker only. The patient denies
history of drug use.
PHYSICAL EXAMINATION: Temperature is 95, blood pressure
137/66, heart rate 52, respiratory rate 16, oxygen saturation
94 percent on two liters. In general, he is awake, alert and
oriented times three in no acute distress. Head, eyes, ears,
nose and throat examination - The pupils are equal, round and
reactive to light and accommodation. Extraocular movements
are intact. The patient has moist mucous membranes. His
oropharynx is clear. There is no rhinorrhea or frontal or
maxillary sinus tenderness. The neck is supple with no
lymphadenopathy, no masses or thyromegaly, jugular venous
pressure is estimated at ten centimeters. Lungs - The
patient has bibasilar inspiratory crackles without wheezing.
There are mild rales diffusely, no dullness to percussion, no
egophony, good respiratory effort. Cardiovascular is regular
rate and rhythm, II/VI holosystolic murmur at the inferior
sternal border, no gallops or rubs. No carotid bruits.
Pulsus paradoxus is around 12 mmHg. The abdomen is soft,
nontender, mildly distended, normoactive bowel sounds, no
rebound or guarding. There is evidence of hepatomegaly.
Extremities are warm and well perfused. Capillary refill is
less than two seconds. The patient has two plus pitting
edema in the lower extremities bilaterally extending up to
his knees. Neurologically, cranial nerves II through XII are
intact. Strength is [**6-13**] at elbows and hips bilaterally.
Sensation is intact in all fields.
LABORATORY DATA: White blood cell count was 6.2, hematocrit
32.3, platelet count 147,000. Sodium 140, potassium 4.4,
chloride 100, bicarbonate 33, blood urea nitrogen 11,
creatinine 0.9, glucose 99. ALT 13, AST 35, alkaline
phosphatase 141, total bilirubin 0.6, CK 107, CK MB 2.0,
troponin less than 0.01.
HOSPITAL COURSE: Shortness of breath - The patient was
admitted with progressive shortness of breath and bilateral
lower extremity edema and found to have an elevated jugular
venous pressure on examination. A bedside ultrasound in the
Emergency Department was consistent with pericardial effusion
and a bedside echocardiogram revealed left atrial compression
and a moderate pericardial effusion. The patient was
admitted to the general medical service and his pulsus
paradoxus was monitored. A cardiology consultation was
obtained on admission and performed a pericardiocentesis on
[**2136-7-2**]. Pericardial access was obtained on the first
attempt of the xiphoid with yellowish serosanguinous fluid.
An echocardiogram after 300cc of fluid removed showed a
smaller pericardial effusion and ultimately 600cc of bloody
serosanguinous fluid that appeared yellow in the tubing was
eventually removed with improvement in pericardial and right
atrial pressures. The patient was followed by the Coronary
Care Unit team for several days. Given continuous output
from the pericardial drain, cardiac surgery team was
contact[**Name (NI) **] and performed a pericardial window on [**2136-7-6**].
Studies on the pericardial fluid were negative for infection
and cytology. The patient had a normal TSH. The patient
notably has a positive [**Doctor First Name **] with a titre of 1:40. Looking
through the previous records, the patient had a previous
titre from [**2132-5-10**], of 1:640. The significance of this is
unclear especially given that other workup has been negative.
The etiology of the patient's pericardial effusion at this
point is considered idiopathic. The patient will be
evaluated by a repeat echocardiogram and cardiac surgery is
scheduled to remove the chest tube they placed during
pericardial window placement.
Primary biliary cirrhosis - The patient is noted to have a
history of primary biliary cirrhosis and was asymptomatic
with stable liver function tests and coagulation studies
throughout his hospitalization. He was continued on Nadolol
and Ursodiol throughout this admission. The patient also has
a history of grade I varices and esophagitis/gastritis and
was continued on proton pump inhibitor .
Anemia - The patient was admitted with a history of iron
deficiency anemia. He had a stable hematocrit throughout his
hospitalization and was continued on iron replacement with
Vitamin C for improved absorption of iron.
Hypertension - The patient was noted to be hemodynamically
stable and normotensive throughout his admission. He was
continued on Norvasc 5 mg p.o. once daily.
Pulmonary - The patient was admitted with a history of
obstructive/restrictive lung disease by recent pulmonary
function tests. The etiology of his shortness of breath as
discussed previously was considered likely secondary to his
pericardial effusion. After pericardiocentesis and
pericardial window placement, the patient's shortness of
breath improved throughout the remainder of his
hospitalization. He was continued on Albuterol and
Fluticasone inhalers p.r.n. for shortness of breath.
Benign prostatic hypertrophy - The patient was asymptomatic
throughout his hospitalization and he continued on his
outpatient dose of Terazosin.
The remainder of the [**Hospital 228**] hospital course, his discharge
medications, diagnoses and follow-up will be dictated at the
time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 99859**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2136-7-9**] 11:09:33
T: [**2136-7-9**] 12:03:15
Job#: [**Job Number **]
|
[
"496",
"5990",
"4280",
"53081"
] |
Admission Date: [**2128-7-11**] Discharge Date: [**2128-7-25**]
Service: MEDICINE
Allergies:
Feldene / Ceftriaxone / Augmentin
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Fatigue, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] y/o Russian speaking F with a PMHx of CHF with 4+
MR, dementia, parkinson's, recurrant UTIs, who presented to
[**Hospital1 18**] ED for evaluation of UTI, malasie, hypernatremia and renal
failure. Per Pt's daughter has not been feeling well for 7 days.
States mental status was intact but was just feeling
"uncomfortable, miserable" with out any localizing complaints. A
CXR was done at that time that per the daughter's report was
normal. She was felt by the nursing home staff to be dehydrated
and was given IV fluids. Per daughter's report she remained the
same few the next few days. This morning had fevers, tachypnea
and so was transferred to [**Hospital1 18**] ERD for evaluation.
.
Per NH records, on [**7-6**] had elevated WBC count of 12.7 with 76%
PMNs and 12% bands. Chemistries on that day are notable for
BUN/Cr of 62/3.2 (appears to be elevated from baseline of 1.6 to
2.0), NA of 141 and HCO3 of 21. U/A sent on [**2128-7-7**] cloudy with
LE and 187 WBC. She was started on levo/flagyl on [**7-8**]. Culture
from that urine was positive for e. coli resistant to FQs. Abx
were changed to ceftriaxone and flagyl. On [**7-9**] BUN/Cr was
77/4.2, HCO3 20 and Na 143. On [**7-10**] Na jumped to 150 BUN/Cr to
78/4.4.
.
On arrival to the ED, her VS were:T 101.6, BP 135/89 HR 150s, RR
34 97% on RA. She was given 2 L NS, 1 g vancomycin, 3.375g
pip/tazo, dilt (total of 20mg) then dilt drip, and albuterol
nebs
.
Past Medical History:
#Recurrent urinary tract infections
#Bipolar disorder
#Parkinson's disease
#Asthma
#Congestive heart failure with a normal EF, 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) 113**]
[**2121**]
#OA
#s/p DDD pacer in [**2121**] for bradycardia.
Social History:
Lives [**Hospital3 **]. Daughter is [**First Name5 (NamePattern1) 335**] [**Last Name (NamePattern1) 111445**] who is on
staff at [**Hospital1 18**] as Russian interpreter (beeper [**Numeric Identifier 111446**])
Family History:
non contributory
Physical Exam:
VS:T 96.3, HR 140, BP 130/70 RR 32 98% on 3L
GEN: elderly woman breathing fast and moaning
HEENT: PERRL, sclera white OP clear
NECK: Obese unable to assess JVP
CV: tachycardiac, difficult to hear over moaning
RESP: crackles at bases (again difficult to hear [**2-12**] moaning)
ABD: Obese, soft NT/ND BS+
EXT: contracted trace edema
NEURO: AOX3, CN II-XII intact. resting tremor
Pertinent Results:
CXR [**7-11**]: small left effusion, with atelectasis. No clear
infiltrate.
.
EKG: rapid AFib with LAD and LBBB.
Renal u/s [**2128-7-12**]-. The right kidney measures 8.3 cm. The left
kidney measures 11.5 cm. The left kidney contains a 2.1 x 2.1 x
2.2 cm rounded anechoic structure in the upper pole, most
consistent with a simple renal cyst. Neither kidney demonstrates
hydronephrosis or contains stones. The visualized bladder is
unremarkable IMPRESSION: No evidence for hydronephrosis or other
renal abnormality on this limited examination.
[**2128-7-11**] 11:20AM WBC-20.3*# RBC-3.76* HGB-12.3 HCT-35.5*
MCV-94 MCH-32.8* MCHC-34.7 RDW-14.6
[**2128-7-11**] 11:20AM NEUTS-93.1* LYMPHS-4.8* MONOS-1.3* EOS-0.7
BASOS-0.1
[**2128-7-11**] 11:20AM PLT COUNT-308
[**2128-7-11**] 11:20AM PT-16.3* PTT-21.7* INR(PT)-1.5*
[**2128-7-11**] 11:20AM GLUCOSE-100 UREA N-78* CREAT-4.4*#
SODIUM-151* POTASSIUM-4.8 CHLORIDE-120* TOTAL CO2-18* ANION
GAP-18
[**2128-7-11**] 11:20AM ALT(SGPT)-5 AST(SGOT)-21 ALK PHOS-130*
AMYLASE-33 TOT BILI-0.5
[**2128-7-11**] 11:20AM LACTATE-1.7 K+-4.6
[**2128-7-11**] 11:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2128-7-11**] 11:20AM URINE RBC-0-2 WBC-[**3-14**] BACTERIA-FEW YEAST-NONE
EPI-<1
Brief Hospital Course:
1) UTI/sepsis:
Admitted to ICU for early sepsis. Did not require pressors. Pt
started on ceftriaxone initially. E.coli from urine culture at
[**Hospital3 2558**] that was pansensitive except fluroquinolones.
However, due to concern of AIN from ceftriaxone, changed to
augmentin after 7 days. Completed 12 day course and stopped due
to drug rash. Likely cannot tolerate any PCNs or beta lactams.
.
2) Rapid Atrial fibrillation:
Has had a-fib in the past. Likley worsened given acute illness
and dehydration. On long acting Beta blocker and amio as a
outpt. Loaded with IV amio and put on PO. Also on metoprolol
25 po tid to control HR as long as BP is stable. After leaving
ICU, has been in NSR or paced. Discharged on amio 200 mg daily,
f/u in device clinic.
.
3) Valvular heart disease:
TTE showed 4+MR with normal EF. As she cannot be on an ACEI due
to renal function, was started on imdur and hydalazine.
.
4) Renal Failure:
Creatinine was up to 5 on admission while baseline is in 1's.
Renal ultrasound did not show evidence of obstruction. There
were rare urine eos on exam and renal consult felt this was
acute interstitial nephritis from ceftriaxone. The antibiotic
was changed. Cr trending down slowly, but now stable in mid 3s.
This may be her new baseline. She will f/u with Dr. [**Last Name (STitle) **].
.
5) Hypernatremia:
Secondary to poor PO intake. Has resolved with IVF with D5W.
Will need to monitor to assure stays ok.
.
6) Parkinson's - Restarted Sinemet
.
7) Arthritis - Hip XR neg for fracture but consistent with
arthritis although a limited study.
- Holding NSAIDs and ultram in light of renal failure. Daugther
brought in capasacian cream.
- Pt much more comfortable on regimen of Tylenol RTC and
dilaudid.
.
8) Drug Rash: seen by dermatology, felt to be drug rash from
augmentin, which was discontinued. Cannot tolerate beta lactams.
.
8) DVT: in right common femoral vein. Started on heparin gtt
and coumadin. Continue coumadin goal INR [**2-13**].
.
#Code - DNR/DNI and no central line (discussed with HCP/daughter
and [**Name (NI) **] Dr.[**Last Name (STitle) **])
.
Comm: Daughter's home # [**Telephone/Fax (1) 111447**]
[**Hospital1 18**] beeper #[**Numeric Identifier 111446**]
Medications on Admission:
Synthroid 88 q.d.
Multivitamin q.d.
Bisacodyl PR q.d. p.r.n.
Vitamin E.
Polyvinyl alcohol eye drops.
Senna h.s. p.r.n.
Colace b.i.d.
Tramadol 50 mg tid
Pantoprazole 40 once a day.
Carbidopa-Levodopa 25/100 one tab po q3 hours while awake.
Amiodarone 100 q.d.
Toprol XL 12.5 q.d.
Imdur 30 mg q.d.
Remeron 12.5 qhs
Trazodone 25 qhs
Lasix 10 mg qd (on hold)
Megace 100 mg qd
Seroquel 12.5 qam / 25 mg qhs
Capsaicin 0.025% cream to knees and shoulders [**Hospital1 **]
Premarin vag cream 1 applicator full qhs
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-12**]
Drops Ophthalmic PRN (as needed).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q3H (every 3 hours): While awake.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for sleep time agitation.
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
15. Hydralazine 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
17. Megestrol 20 mg Tablet Sig: Five (5) Tablet PO QD ().
18. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
23. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
24. Epoetin Alfa 3,000 unit/mL Solution Sig: 3,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
26. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Urosepsis
Secondary:
Pneumonia
Acute Renal Failure
Drug Rash
Congestive Heart Failure
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications. Please continue to
hold your coumadin until your INR is less than 3. Goal [**2-13**].
Please continue to weigh yourself daily and if you gain more
than 3lbs please call your doctor. Please continue a low salt
diet.
Followup Instructions:
1. Please follow up with your PCP in the next week.
2. Please also follow up with your new nephrologist, Dr. [**Last Name (STitle) **],
in the next 1-2 weeks.
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2128-8-6**] 10:00
|
[
"5990",
"5849",
"486",
"4280",
"40391",
"42731",
"2760",
"99592"
] |
Admission Date: [**2113-4-13**] Discharge Date: [**2113-4-14**]
Date of Birth: [**2038-3-25**] Sex: F
Service:
This is a 75-year-old patient with end-stage lung disease
from sarcoid with pulmonary fibrosis on 3 liters of home
oxygen and chronic prednisone and recent hospitalization here
for worsening sarcoid versus CHF, for which she underwent
diuresis, who was transferred from [**Hospital6 33**] ED to
[**Hospital3 **] on [**4-13**] with worsening shortness of breath and
was evaluated by the Intensive Care Unit in the Emergency
Room. At that time, she was comfortable, had stable O2
saturations and so she was admitted to Medicine Night Float
to the Medicine wards.
Over the early hours of her hospitalization, the patient had
declining mental status and worsening hypoxia, and work of
breathing. She was evaluated by her pulmonologist, Dr.
[**Last Name (STitle) 217**], who felt that if aggressive care was
indicated, she should get a trial of noninvasive ventilation,
diuresis, and possible thoracentesis as she had a large left
effusion and also by the CHF team, who felt she should have a
Natrecor diuresis with the addition of Lasix and rate
controlled with diltiazem.
After discussion with the family between the [**Hospital1 **] attending,
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] and the pulmonologist, the patient was
admitted to the Medical Intensive Care Unit for further care.
PAST MEDICAL HISTORY:
1. Sarcoid on home O2.
2. Mycobacterium gordonae lung colonization.
3. Type 2 diabetes.
4. Diastolic CHF.
5. Coronary artery disease status post four-vessel CABG in
[**2097**] with pulmonary hypertension and tricuspid
regurgitation.
6. Atrial fibrillation.
7. Multiple skin cancers.
8. Anemia felt to be from infiltrates from sarcoid.
9. Obesity.
10. Hypercholesterolemia.
11. Sleep disorder breathing.
12. Hypertension.
13. DVT complicated by pulmonary embolus.
14. Gallbladder stones complicated by cholecystectomy.
15. Pneumonia in [**2112-12-1**] and [**1-4**].
16. Cellulitis in [**1-4**].
17. Depression.
SOCIAL HISTORY: The patient has a closely involved family
and has never smoked or use alcohol to access. On her last
admission she was changed to comfort care and had a goal of
trying rehab one more time to see if she could go home, and
was pleased with having accomplished this goal prior to her
current admission.
MEDICATIONS ON ADMISSION:
1. Lasix.
2. Levofloxacin.
3. Protonix.
4. Coumadin.
5. Folate.
6. Dapsone.
7. Calcium supplements.
8. Diltiazem.
9. Tylenol.
10. Albuterol and Atrovent.
11. Insulin.
12. Prednisone.
13. Colace.
14. Potassium.
ALLERGIES: Ampicillin caused a rash.
PHYSICAL EXAMINATION: On physical exam, she had a
temperature of 99.8, sats dipping to the low 80s, and
respiratory rate up to 35, blood pressure of 100, and heart
rate of 104 in atrial fibrillation. Physical exam was
notable for the inability to follow commands or communicate
effectively and accessory muscle use. Facial surgical scars
from skin cancer therapy and an irregularly, irregular
cardiac exam obscured by rhonchorous respirations with rales
and squeaks and poor air movement, grunting abdominal
respirations, multiple skin tears, ecchymoses, and actinic
keratoses, venous stasis changes, and substantial lower
edema.
Please see OMR for laboratory studies.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit and placed on noninvasive mask ventilation. She
was continued on her antibiotics, nebulizers, and steroids,
as well as nesiritide and Lasix. Diltiazem was given for
rate control. Patient was minimally responsive throughout.
Discussion was held to see whether she should have better
access obtained through the central line and arterial line.
Family decided to avoid any procedure, which could cause
discomfort. Patient was maintained on noninvasive
ventilation until the rest of the family and a minister could
arrive.
At that point, Morphine was titrated up. Her mask
ventilation was discontinued and she died surrounded by her
family at 21:20 on [**2113-4-14**]. An autopsy was declined.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
Dictated By:[**Last Name (NamePattern1) 47584**]
MEDQUIST36
D: [**2113-4-14**] 22:54:37
T: [**2113-4-17**] 06:24:57
Job#: [**Job Number **]
|
[
"51881",
"4280",
"2762",
"496",
"42731"
] |
Admission Date: [**2140-9-16**] Discharge Date: [**2140-9-17**]
Date of Birth: [**2102-8-24**] Sex: M
Service: ICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
gentleman with C6-C7 quadriplegia, hemorrhoids, and a 3-month
history of rectal bleeding who reportedly awoke in a pool of
bright red blood per rectum around his wheelchair on the day
prior to admission.
The patient went to the commode to clean himself, and he
reports that he sustained a syncopal episode at that time.
The emergency medical technicians reportedly found the
patient unresponsive on the commode with a blood pressure of
90/50 and a heart rate of 82.
On arrival to the [**Hospital1 69**]
Emergency Department, the patient's blood pressure was 88/74
which subsequently increased to the 110 range systolically
but then decreased to the 60s to 70s systolically soon
thereafter. He received 4 liters to 5 liters of normal
saline in the Emergency Department with only 250 cc of urine
output. He refused a blood transfusion. He had
guaiac-positive brown stool in the Emergency Department where
he also complained of lightheadedness, mild dyspnea, and
rectal pain. The patient denied abdominal pain, nausea,
vomiting, or cloudy/foul smelling urine. He denied recent
substance abuse. Of note, the patient performs daily manual
rectal disimpactions.
PAST MEDICAL HISTORY:
1. C6-C7 quadriplegia complicated by a neurogenic bladder
and bowel following a motor vehicle crash in [**2119**].
2. Stage IV chronic decubitus ulcerations.
3. Recurrent urinary tract infections.
4. Peptic ulcer disease.
5. Substance abuse.
6. Positive purified protein derivative treated in the
past.
7. Hemorrhoids.
8. Labile blood pressures.
9. Chronic osteomyelitis of the right ischial tuberosity
treated with six weeks of levofloxacin and metronidazole in
[**2140-5-31**].
10. Depression and impulse control disorder.
ALLERGIES:
1. PENICILLIN (causes angioedema).
2. VANCOMYCIN (causes a rash).
3. GENTAMICIN (causes urticaria).
MEDICATIONS ON ADMISSION:
1. Docusate 200 mg by mouth twice per day.
2. Bupropion 150 mg by mouth twice per day.
3. Gabapentin 100 mg by mouth three times per day.
4. Milk of Magnesia 30 cc by mouth at hour of sleep.
5. Senna two tablets by mouth at hour of sleep.
6. Baclofen 10 mg by mouth four times per day.
7. Combivent 1 to 2 puffs inhaled q.6h. as needed (for
wheezing).
8. Diazepam 5 mg by mouth q.6h. as needed (for anxiety).
9. Ensure one can by mouth three times per day.
10. Super Cereal by mouth every other day.
11. Hydromorphone 3 mg subcutaneously before dressing
changes.
12. Iron sulfate 325 mg by mouth once per day.
13. Multivitamin one tablet by mouth once per day.
14. Pantoprazole 40 mg by mouth once per day.
15. Anusol suppositories per rectum once per day.
SOCIAL HISTORY: The patient lives at the [**Hospital **]. He smokes one pack of cigarettes per day. He
denies alcohol or illicit drug abuse.
PHYSICAL EXAMINATION ON PRESENTATION: On initial physical
examination, the patient's temperature was 96.1 degrees
Fahrenheit, his blood pressure was 52/27, his heart rate was
63, his respiratory rate was 18, and his oxygen saturation
was 99% on room air. The patient was awake, alert, and
oriented times three. He was in no acute distress. He had
slightly dry oral mucosa, and his oropharynx was clear. His
neck was supple without meningismus. His heart was regular
in rate and rhythm. There were normal first heart sounds and
second heart sounds. There were no murmurs, rubs, or
gallops. The lung examination revealed trace left-sided
basilar crackles but were otherwise clear to auscultation
bilaterally. The abdomen was soft. There was mild right
upper quadrant tenderness in the context of globally
decreased sensation. There was a normal liver span. [**Doctor Last Name **]
sign was not present. Extremity examination revealed there
was no peripheral edema. There were healed bilateral lower
extremity ulcerations and abrasions. The extremities were
warm and dry. Rectal examination demonstrated reddish brown
guaiac-positive stool (per the Emergency Department). There
was a mildly foul-smelling well granulated sacral decubitus
ulceration without obvious abscess, drainage, or fluid
collection.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratory values demonstrated a white blood cell count of
8.6 (58% neutrophils, 35% lymphocytes, and 3% monocytes), his
hematocrit was 38.7, and his platelets were 275,000. His
mean cell volume was 83. Serum chemistries were
unremarkable. Initial urinalysis was negative. Initial
urine toxicology screen was positive for cocaine.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram demonstrated
a normal sinus rhythm at 58 beats per minute. Normal axis and
intervals. A 0.5-mm J-point elevation in leads V4 through V6
that were also seen on an old electrocardiogram. There were
no acute ST segment or T wave changes.
A chest x-ray demonstrated tall lung field, poor
visualization of the left retrocardiac area, and no pulmonary
edema.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL ISSUES: There was no further
gastrointestinal bleeding following admission. A colonoscopy
done on hospital day two demonstrated ulcerations in the
distal rectum but was otherwise normal to the hepatic flexure
with no blood or other bleeding site noted.
The patient was started on daily Anusol HC suppositories and
should treat his constipation with other techniques (such as
bisacodyl suppositories or MiraLax) to avoid rectal trauma.
2. CARDIOVASCULAR ISSUES: After aggressive resuscitation
with intravenous fluids, the patient's blood pressure
remained stable. Of note, he has a labile blood pressure at
baseline and typically runs in the 80s to 90s systolic.
He was initially started on broad spectrum antibiotics
(levofloxacin and metronidazole) out of concern for possible
septic shock, but these were discontinued once his blood
pressure stabilized, and he remained afebrile without
leukocytosis. His hematocrit stabilized at his baseline at
the time of discharge. All of his culture data were negative
at the time of discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be returned to the [**Hospital **] in [**Location 1268**], [**State 350**].
MEDICATIONS ON DISCHARGE:
1. Docusate 200 mg by mouth twice per day.
2. Bupropion 150 mg by mouth twice per day.
3. Gabapentin 100 mg by mouth three times per day.
4. Milk of Magnesia 30 cc by mouth at hour of sleep.
5. Senna two tablets by mouth at hour of sleep.
6. Baclofen 10 mg by mouth four times per day.
7. Combivent 1 to 2 puffs inhaled q.6h. as needed (for
wheezing).
8. Diazepam 5 mg by mouth q.6h. as needed (for anxiety).
9. Ensure one can by mouth three times per day.
10. Super Cereal by mouth every other day.
11. Hydromorphone 3 mg subcutaneously before dressing
changes.
12. Iron sulfate 325 mg by mouth once per day.
13. Multivitamin one tablet by mouth once per day.
14. Pantoprazole 40 mg by mouth once per day.
15. Anusol HC suppositories per rectum once per day.
16. Bisacodyl suppository 10 mg per rectum once per day.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Rectal ulceration.
3. Substance abuse.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The [**Hospital3 4262**] nurse practitioner was to see the
patient at his nursing home on the day following discharge.
2. The patient's primary care physician (Dr. [**First Name8 (NamePattern2) 402**]
[**Last Name (NamePattern1) 7461**]) was to make arrangements to follow up with the
patient next week.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 5838**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2140-9-17**] 17:02
T: [**2140-9-20**] 09:22
JOB#: [**Job Number 107409**]
|
[
"311"
] |
Admission Date: [**2132-12-11**] Discharge Date: [**2132-12-22**]
Date of Birth: [**2057-11-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nitrofurantoin Mono-Macro /
Cortisone / Levoxyl
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Elective PCI for three-vessel disease complicated by dissection
of Left Main
Major Surgical or Invasive Procedure:
cardiac catheterization x2 with stents to the right coronary
artery, Left main artery, Left anterior descending artery,
obtuse marginal artery.
History of Present Illness:
This 75 year old woman has a history of obesity, hypertension,
dyslipidemia, CAD and [**Location (un) 3484**] syndrome with longstanding
steroid use and subsequent development of DM. On [**2132-10-16**] she
underwent cardiac catheterization at [**Hospital3 2358**] [**2-26**] anginal sx
and an abnormal ETT. Angiography revealed three vessel disease
with a 50%stenosis of the RCA, 40% LM, 80-90% stenosis of her
OM1 and OM2, and a 90% stenosis of distal LAD. LVEF was noted at
60%.
.
She has since been evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from cardiac
surgery. Studies have revealed no usable lower extremity veins
for CABG. In addition, it is felt that Mrs.[**Known lastname 24469**] is quite
high
risk for sternal complications. Plans were for PCI of the RCA,
OM1 and OM2 by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] with possible LIMA to LAD by
CTsurg at a later date.
.
During her catherization today her RCA was stented and while
trying to stent the OM's the Left Main was dissected then
stented. She denies any chest pain, and her EKG was not
concerning for evolving MI. Biomarkers were negative int he
immediate post-procedure period.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- [**Location (un) **] disease s/p ablation of pituitary adenoma at [**Hospital1 2025**].
- Hip replacement for osteoarthritis.
- Obesity.
- Lower back pain.
- Status post right knee patella removal after motor vehicle
accident.
- History of left lower leg hematoma after a fall 3 years ago.
- Depression.
- Hypothyroidism.
- Deep vein thrombosis in left calf 3 years ago.
- Cataract in both eyes status post extraction.
Social History:
She lives with her husband and daughter in a
house. She has 4 children. She does not use any services
currently. She is independent in her ADL's but is known to have
a gait disorder and a history of falls in the past.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: None
Family History:
Brother died from an MI at 50. Daughter had a stent at age 36.
Physical Exam:
Admission exam:
GENERAL: Obese elderly white 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 and obese. JVD not able to be assesed secondary to
body habitus
CARDIAC: S1 S2 faint SEM
LUNGS: Obese distant breath sounds. CTA BL
ABDOMEN: Obese NT +BS
EXTREMITIES: LE WWP Venous stasis dermatitis BL with exfoliative
scar on left anterior tibia. Left UE is without erythema but
mild non pitting edema. Right UE has large resolving hematoma
with pressure dressing in place.
PULSES:
Right: DP 2+ R not assesed [**2-26**] pressure dressing
Left: DP 2+ R 2+
Pertinent Results:
Admission labs:
[**2132-12-11**] 02:32PM WBC-9.4 RBC-3.67* HGB-8.9* HCT-29.0* MCV-79*
MCH-24.3* MCHC-30.7* RDW-15.7*
[**2132-12-11**] 02:32PM PT-23.8* PTT-55.5* INR(PT)-2.3*
[**2132-12-11**] 02:32PM CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-2.4
[**2132-12-11**] 02:32PM CK(CPK)-169
[**2132-12-11**] 02:32PM CK-MB-13* MB INDX-7.7
[**2132-12-11**] 02:32PM GLUCOSE-263* UREA N-45* CREAT-1.3* SODIUM-138
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2132-12-11**] 11:25PM CK-MB-62* MB INDX-8.4* cTropnT-2.74*
[**2132-12-11**] 11:25PM LIPASE-26
[**2132-12-11**] 11:25PM CK(CPK)-741* AMYLASE-31
.
Cardiac catheterization [**2132-12-14**]:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LMCA, LAD, Lcx and RCA stents.
3. Significant OM1 lesion with flow.
4. STEMI lateral.
5. Moderate biventricular diastolic dysfunction.
6. Normal cardiac index.
7. Successful PCI of OM1 with BMSx2.
.
[**2132-12-15**] Echo:
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the basal inferior and inferolateral walls
and akinesis of the distal inferior, septal, and anterior walls.
The apex is mildly dyskinetic. The remaining segments contract
normally (LVEF = 30%). Right ventricular chamber size and free
wall motion are normal. Mild (1+) mitral regurgitation is seen.
There is an anterior space which most likely represents a
prominent fat pad.
Compared with the prior study (images reviewed) of [**2043-12-12**], the
basal inferolateral and inferior walls are now hypokinetic. The
anterior wall function and global systolic function are slightly
improved.
.
Labs on discharge:
[**2132-12-22**] 07:45AM BLOOD WBC-11.0 RBC-3.70* Hgb-9.7* Hct-30.2*
MCV-82 MCH-26.1* MCHC-31.9 RDW-17.0* Plt Ct-159
[**2132-12-22**] 07:45AM BLOOD Glucose-83 UreaN-34* Creat-1.2* Na-147*
K-3.6 Cl-108 HCO3-34* AnGap-9
[**2132-12-16**] 05:55AM BLOOD CK(CPK)-542*
[**2132-12-15**] 05:50AM BLOOD CK(CPK)-843*
[**2132-12-22**] 07:45AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.3
Brief Hospital Course:
75 YO woman with CAD SP PCI of RCA and OM's complicated by
dissection of left main with subsequent stenting and right
radial hematoma.
.
# CAD: No angina or ST elevations immediately following first
catheterization. CKMB is mildly elevated which could be evidence
of evolving MI. Will obtain echo and trend biomarkers. The
patient had to return to the cath lab for revision of original
procedure. On [**2132-12-12**], the patient's sedation was lifted and
she was extubated. She almost immediately [**Doctor First Name **] to complain of
chest pain. ECG showed ST elevations, and she was brought to
cath lab again. Selective coronary angiography of her right
dominant system revealed three-vessel CAD. The LMCA had patent
stents with persistent dissection outside stents. The LAD had
patent stents with diffuse distal disease. The LCx had patent
stents; the OM1 had reopened since prior cath had had a 95%
proximal stenosis with associated limited dissection from prior.
The RCA had patent stents with a 95% PDA stenosis present on
prior
films. Successful PTCA and stenting of large OM1 with two
overlapping 2.25x12 MiniVision bare metal stents postdilated to
2.5mm. The [**Hospital 228**] medical management included aspirin,
Plavix, simvastatin, metoprolol and ezetimibe. She will be on
Plavix for the rest of her life. Do not stop Plavix without
first speaking to Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] at [**Hospital1 18**]. Her peak CK was 4332
in the setting of extensive chest pain and manipulation of
coronary arteries. Her creatinine increased to 1.3 after
contrast load, currently at 1.2.
.
# Acute systolic Dysfunction: The echocardiogram of [**2132-12-15**]
showed reduced LVEF of 30% in the setting of STEMI. Although
cardiac catheterization showed high filling pressures, she has
appeared euvolemic with no signs of fluid overload and has not
required standing diuretics. Her Lisinopril was decreased to 5
mg daily. she should have daily weights and close monitoring of
her fluid status.
.
# Atrial Fibrillation: Noted in the setting of MI. Currently in
AF with frequent bradycardia at night, she is asymptomatic with
these episodes. She is on very low dose metoprolol for MI
prevention but this can be discontinued if HR cont to be an
issue. Extensive discussion regarding coumadin. Decision made to
treat with ASA and Plavix only given hx of falls and likelihood
that EF will increase in the long term.
.
# Radial Hematoma: Resolving. No symptoms of compartment
syndrome (pain, cap refill, pulses) were noted.
.
# [**Location (un) 3484**] disease: Patient was cotinued on her home dose of
25mg of cortisef in the AM and 5mg in PM. Given the stressors,
however, of her cardiac events, dosing was increased to 100mg.
The Endocrine team was consulted, and the patient was placed on
100mg hydrocortisone IV three times a day. As her condition
stabilized, a taper was started and she is now currently back on
her home Cortisone [**Location (un) 4319**]. She will need to have stress dose
steriods for any medical procedures. Her endocrinologist at
[**Last Name (un) **] should be contact[**Name (NI) **].
.
# DM: The patient was kept on an insulin sliding scale. Her
blood sugars were quite high with stress dose steriods but are
now normalizing on a slightly decreased lantus dose.
# Depression: Continued home escitalopram.
.
# Hypothyroidism: Patient was started on home dosing of
synthroid. Given that she was intubated on multiple occasions,
however, she instead received IV levothyroxine at the same
approximate dose for several days, now back on PO dosing.
.
# Hypertension: SBP was somewhat low so her Imdur and Norvasc
was not restarted and her Lisinopril was decreased to 5 mg
daily.
.
# Dyslipidemia: Continued home dosing of simvastatin and
ezetimibe.
.
# Neuropathy: Continue neurontin but dose [**Month (only) **] to 300 mg daily.
PCP would like to d/c entirely if possible. Vicodin was
restarted at discharge at home dose per family. This medicine is
the only one that seems to alleviate pain.
.
# Delerium: Noted after extubation and thought to be related to
sedation, ICU stay and UTI. Her memory is mildly impaired at
baseline. Currently improving on scheduled Seroquel dosing in
the evening. Would recommend freq reorientation, avoidance of
benzos (tiny home dose of Aprazolam d/c'ed) and night time
interruptions. Assume that pt will return to her home where she
lives with her daughter and husband.
.
# Papillomatous rash of groin: Dermatology consulted and rec
miconazole powder. Currently improving.
Medications on Admission:
ALPRAZOLAM - (Prescribed by Other Provider) - 0.5 mg Tablet -
[**1-28**] Tablet(s) by mouth once a day
AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
BUMETANIDE - (Prescribed by Other Provider) - 2 mg Tablet - 3
Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 8 Tablet(s) by mouth x 1
on
[**2132-12-10**], then 75mg qd
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
EZETIMIBE-SIMVASTATIN [VYTORIN [**10/2102**]] - (Prescribed by Other
Provider) - 10 mg-80 mg Tablet - 1 Tablet(s) by mouth qpm
GABAPENTIN - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 2 Tablet(s) by mouth three
times
a day
HYDROCORTISONE [CORTEF] - (Prescribed by Other Provider) - 20
mg
Tablet - 1 Tablet(s) by mouth 20mg in am and 5mg in am and 5mg
PM
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 48 units am 15 units in PM
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - per sliding scale under 100 22 24 20 101-150
26 26 22 151-200 28 28 24 201-[**Telephone/Fax (2) 24470**]51-300 34 32 28
301-350 35 34 30 351-400 37 36 32
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE [SYNTHROID] - (Prescribed by Other Provider) -
150
mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a
day
PIOGLITAZONE [ACTOS] - (Prescribed by Other Provider) - 30 mg
Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIR-81] - (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
SENNA - (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth at bedtime as needed hold if diarrhea
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking this medicine unless Dr. [**Last Name (STitle) 911**] tells
you to. .
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. bumetanide 2 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 24H
(Every 24 Hours).
10. hydrocodone-acetaminophen 7.5-650 mg Tablet Sig: One (1)
Tablet PO three times a day: Home dose that works well per
family.
11. Cortef 20 mg Tablet Sig: One (1) Tablet PO qAM ().
12. Cortef 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)): Take with 20 mg tablet for total of 25 mg in
the morning.
13. Cortef 5 mg Tablet Sig: One (1) Tablet PO qPM ().
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical
three times a day as needed for [**Female First Name (un) **].
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Hold for diarrhea.
17. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO daily ().
18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold SBP < 100.
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
20. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
21. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4PM ().
22. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q10PM ().
23. insulin glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous once a day: give before breakfast.
24. Humalog 100 unit/mL Solution Sig: per fixed dose and sliding
scale units Subcutaneous four times a day: see attached scale.
25. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Coronary artery disease
Hypertension
Diabetes [**First Name9 (NamePattern2) **]
[**Location (un) 3484**] syndrome
Hypernatremia
Delerium
Acute Systolic dysfunction
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had chest pain and a heart attack. There were multiple
arteries that were blocked and over the course of 3 cardiac
catheterizations, we were able to open them. You will need to
take Plavix every day for the rest of your life. Do no stop
taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 911**] tells you it is
OK. We also changed some of your heart medicines to help your
heart pump better. You were seen by [**Last Name (un) **] doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **]
were here to manage your diabetes and Cushings disorder.
Medication changes:
1. Stop taking Aprazolam, Norvasc and Imdur
2. Start taking Miconazole powder in your groin area to treat a
yeast infection
3. Start taking Metoprolol to help your heart recover from the
heart attack
4. Start taking Quetiapine to help keep you calm in the evening
5. Increase aspirin to 325 mg daily for at least one month
6. Decrease Gabapentin to 300 mg daily because of your kidney
Function
7. Decrease Lisinopril to 5mg daily because of your kidney
function
8. Decrease your Glargine and Humalog per the sliding scale.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 911**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Department: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD
When: WEDNESDAY [**2133-6-3**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD [**Telephone/Fax (1) 11262**]
Building: [**Last Name (NamePattern1) 14648**] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: None
Department: CARDIAC SERVICES
When: WEDNESDAY [**2133-2-4**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 14591**], [**First Name3 (LF) 14590**] N. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt: We are working on a follow up appt for you within the
next two weeks. The office will call you at home with an appt.
If you dont hear from them in 48 hours, please call office
directly to book.
Completed by:[**2132-12-22**]
|
[
"41401",
"51881",
"5990",
"9971",
"2851",
"2760",
"4019",
"2724",
"2449",
"4280",
"42731"
] |
Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-12**]
Date of Birth: [**2095-4-9**] Sex: F
Service: PSYCHIATRY
Allergies:
Xanax / Lamictal
Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
"I've just been having a bit of trouble lately and it hasn't
been going away."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
27 y/o woman with chronic h/o suicidality currently BIBA on
section
12 from PHP at MMHC after speaking w/ Dr [**Last Name (STitle) 80755**] about suicidal
feelings. The patient stated that she had been trying to get a
workup done to resume maintenance ECT at [**Hospital1 18**] w/ Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2109**]. This included multiple labs and EKG and eventauly
follwed a protracted course for more than one month. After one
month the initaly EKG was outside the time frame considered
valid
for ECT. Pt found out that she needed a new EKG last friday. She
decided to give up on having outpatient ECT. Then three days ago
she began to ruminate and worry that she had been trying to help
herself but that things were not well. She saw herself repeating
the cycle of feeling good then feeling bad. Reports she told her
treater yesterday that she wasn't feeling well and was having
"thoughts and urges". The patient was supposed to check in with
Her therapist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] everyday. She spoke to her therapist
two days ago but did not call yesterday because she had cut
herself and did not want to disclose this. She stated that she
cut her wrist which she had never done before and thought using
this asa means to end her life. However she found it more
difficult than she thought. She did not tell treaters intitally
about her depressed mood because she did not want to return to
the [**Hospital1 **]. However she finally disclosed her feelings to Dr.
[**Last Name (STitle) 80755**] today and was sent to [**Hospital1 18**] for evaluation.
Past Medical History:
PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
-SA x5-6 times with OD. Intubation in ICU 3 times.
-Maintenance ECT at [**Last Name (un) **] about 3 years ago during which the
patientshe was most productive and functional
-Multiple Hospitalizations (at least 10) for depression
including
[**Hospital1 18**] inpatient psych about 1 year ago.
Most recent hospitalization at [**Hospital 882**] Hospital after SA by OD.
from [**Month (only) 462**] to [**2122-10-15**]. The patient was discharged to
[**Hospital **] hospital for intermediate care. She was recently
discharged from the [**Hospital **] Hospital in [**Month (only) 956**] to MMHC DBT
program and to live at DBT house in [**Location (un) **]
Treaters at MMHC - [**Telephone/Fax (1) 12886**]
Therapist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]
Psychiatrist: Dr [**Last Name (STitle) 18741**], Dr [**First Name (STitle) 80756**] (cuurently on vacation- Dr
[**Last Name (STitle) 80755**] covering)
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
acid reflux
ALLERGIES (INCLUDE REACTION, IF KNOWN): xanax/lamictal
Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
Denies
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Born and raised in [**Location (un) 686**]. Attended [**Location (un) 86**] Latin HS -
completed 1 yr of college at [**State 80757**].
Worked as a waitress for thelast 6 yrs. Just stopped working in
[**2122**] because of hospitalizations
Mother, [**Name (NI) **] [**Name (NI) 17926**], at [**Telephone/Fax (1) 80753**]. Father, [**Telephone/Fax (1) 80754**].
Born and raised in [**Location (un) 686**]. FTT as a baby, not very social
and cried a lot. At ten yo, started getting panic attacks. This
was treated with therapy, no meds. Pt did well in school, but
had social anxiety. No known history of abuse. No known history
of romantic relationships. Youngest of 3 (one sister and one
brother)
Family History:
Mat Grandfather committed suicide at [**Hospital1 **] in [**2074**], had been
hospitalized for ECT
Maternal aunt with manic depression
Maternal aunt ? borderline - multiple hospitalizations
Brother - became very isolated, living on streets, [**Last Name (un) 68185**]. Now
doing well.
Physical Exam:
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
APPEARANCE & FACIAL EXPRESSION: Dressed in hospital gown,
looks stated age, NAD, fair grooming
POSTURE:lying in bed,
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): no PMR/PMA
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): cooperative
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC,
ETC.):
normal rate, volume, prosody
MOOD: "I'm not feeling good"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
blunted
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): linear, goal
oriented
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): No preoccupations, no overvalued ideas, no
obsessions, no delusions,
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denies
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): Mild hypersomnia, otherwise normal
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
Currently endorsing suicidality with plan to cut her wrists or
to
overdose.
INSIGHT AND JUDGMENT: poor/poor
COGNITIVE ASSESSMENT: Alert, Oriented x3
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT):
ORIENTATION:
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.:
Intact - [**Doctor Last Name 1841**] backwards: Missed [**Month (only) 116**]
MEMORY (SHORT- AND LONG-TERM): [**3-17**] registration and
recall
CALCULATIONS: 13 q =$3.25
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE):
president: [**Last Name (un) 2753**], (missed [**Last Name (un) 2450**] [**Male First Name (un) 1573**]) [**Hospital1 1806**], [**Last Name (un) 2450**], [**Last Name (un) 38492**]
PROVERB INTERPRETATION: spilt milk-do not get upset
over things that can be easily fixed
SIMILARITIES/ANALOGIES:
thermometer/ruler - measure things
child/dwarf -dwarf can be many years old and still be small. A
child willhopefully grow to be bigger than a dwarf.
Pertinent Results:
[**2123-4-2**] 05:20PM GLUCOSE-117* UREA N-9 CREAT-0.9 SODIUM-137
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11
[**2123-4-2**] 05:20PM estGFR-Using this
[**2123-4-2**] 05:20PM ALT(SGPT)-14 AST(SGOT)-23 ALK PHOS-59
[**2123-4-2**] 05:20PM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-3.7
MAGNESIUM-2.2
[**2123-4-2**] 05:20PM TSH-2.2
[**2123-4-2**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-4-2**] 05:20PM URINE HOURS-RANDOM
[**2123-4-2**] 05:20PM URINE HOURS-RANDOM
[**2123-4-2**] 05:20PM URINE GR HOLD-HOLD
[**2123-4-2**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2123-4-2**] 05:20PM WBC-5.8 RBC-4.05* HGB-10.3* HCT-33.2* MCV-82#
MCH-25.3*# MCHC-30.9* RDW-15.3
[**2123-4-2**] 05:20PM NEUTS-60.1 LYMPHS-33.3 MONOS-4.3 EOS-2.1
BASOS-0.3
[**2123-4-2**] 05:20PM PLT COUNT-255
Brief Hospital Course:
The patient was admitted with concerns for suicidality in the
context of a two week decompensation because of diffiuclty
arranging outpatient ECT. At the time of her hospitalization the
patient was unable to say that she was safe however she seemed
fairly bright. ECT was arranged and the patient received 3
bilateral ECT treatments. There were no acute events during ECT.
The patient will continue ECT twice per week after discharge and
progress at the discretion of Dr. [**Last Name (STitle) 80758**].
There were no changes in her medications
The patient became stressed during her stay due to some
difficult family interactions. This caused an increase in
suicidality resulting in an extended stay through the weekend.
On mondya fter reassessment by the attending physician, [**Name10 (NameIs) **]
social worker and the resident physicianm the patient was
determined to be no longer at that level of acutity. She was
considered safe for discharge on [**2123-4-12**] and will go back to her
DBT house.
Medical: No acute issues
Legal: Remained on CV throughout her hospital stay.
Medications on Admission:
cymbalta 120 mg PO QAM
Abilify 25 mg PO QAM
prilosec 40 mg P oQAM
Seroquel 300 mg PO QHS
Serquel 25 mg PO Q4hr PRN: anxiety
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Aripiprazole 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Quetiapine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
AXIS I: MDD refractory
AXIS II: cluster B traits
AXIS III: GERD
Axis IV: Difficult interpersonal relationships, currently
unemployed
Axis V: 35
Discharge Condition:
Stable
Appearance: Fully dressed, fair grooming, looks stated age, NAD,
sitting in chair
Attitude: Cooperative, Good behavioral control,
Cognition: alert and fully oriented
Speech: no aphasia, no dysarthria, normal rate, volume, prosody
Abnormal Movements: no PMR/PMA
Mood: 'good' / Affect: full range
Thoughts: No overt delusions, obsessions, over-valued ideas.
Process: No FOI, No LOA, No [**Doctor Last Name **], No Circum, No Derailing, No
Thought Block, No Thought broadcast/transfer
Safety: baseline SI denies a plan at this time. Denies SIB/HI
Abnormal perceptions: No hallucinations reported. No behavior
suggesting that.
Ins/Jud : fair/fair
Discharge Instructions:
please take all medications as prescribed
please folow up all outpatient appointments as scheduled
please call 911 or return to the emergency department if you
feel unsafe
Followup Instructions:
All care provided at:
DBT Partial Program [**Hospital 350**] mental health center
[**Last Name (NamePattern1) **], [**Location (un) 538**], MA
([**Telephone/Fax (1) 80759**]
Therapist - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]: Follows weekly according to PHP
schedule
Psychiatrist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**] ([**Telephone/Fax (1) 18776**]: Follows
weekly accourding to PHP schedule
DBT PHP program: Will resume tomorrow at 9:00 am.
ECT follow up appt:
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2109**]
[**Hospital1 **], [**Location (un) 86**] MA
[**Telephone/Fax (1) 2134**]
[**2123-4-16**] at 10:00 am
Completed by:[**2123-4-14**]
|
[
"42789",
"53081"
] |
Admission Date: [**2119-8-30**] Discharge Date: [**2119-9-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Altered MS - found to have several ICH at OSH
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed man with multiple medical
problems including seizures, melanoma, afib on Coumadin and a
pacer. He was transferred this evening from [**Hospital3 19345**]. I contact[**Name (NI) **] the [**Hospital3 **] where he lives however
there was only limited documentation regarding the events
of this evening, therefore the majority of this history is from
the transfer records as the patient is unable to provide
details.
Per report, this evening he had "metal status changes"
howeverdetails of this are not available. He did not have a
history offalls. He was therefore transferred to an OSH. There
he was found to have multiple ICH, largest on the R parietal
region with a fluid level. His INN there was 3.6 and he was
given vitamin K and 2 units of FFP.
Of note, Mr. [**Known lastname **] was recently admitted to [**Hospital1 79921**] for medical management of a L hip
fracture which occurred on [**7-24**] in the same rehab parking lot -
he was visiting his wife who was admitted after stroke. Since
his admission there he has been noted to have baseline dementia
and a history of intermittent delirium, especially at night
("looking for the shot gun" the night prior).
ROS: limited, but pt denies HA, dizziness, vision changes, N,
SOB or CP.
Past Medical History:
- asthma
- HTN
- Afib s/p ablation and currently has a pacemaker.
- aortic stenosis
- Hypothyroid
- L hip fx
- seizures
- anemia
- pacer x2
- melanoma s/p surgical resection of R ear [**2-19**] - was initially
diagnosed 12 yrs ago. Recurrence in [**2-19**] - s/p R ear resection
and was diagnosed as Stage IIa. No other intervention.
Social History:
-remote tobacco hx
-denies EtOH or drugs
-lives at [**Hospital6 1293**] ([**Telephone/Fax (1) 79922**]) next
to his [**Age over 90 **] yo spouse who also resides there - been there since L
hip fracture in [**7-24**].
-HCP is son, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 79923**]
-PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66439**] at [**Location (un) 5028**] [**Telephone/Fax (1) 65735**]
- Code status DNR/DNI, confirmed per son, HCP.
Family History:
NC
Physical Exam:
Vitals: T: 98.1 P: 110 R: 16 BP: 127/70 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, R ear has large section of prior resection no
scleral icterus noted, MMM, no lesions noted in oropharynx
Neck: Supple, carotids have audible bruit however this may be
transmitted sounds as the same bruit is heard throughout the
precordium. No nuchal rigidity
Pulmonary: Lungs have decreased breath sounds at the bases
bilaterally
Cardiac: irregular, systolic ejection murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: L ankle hyperpigmentation, L hip internally rotated
with severely restricted ROM in all directions
Neurologic:
-Mental Status: drowsy but easily arousable, oriented to person,
month and year but not place, purpose or location. Unable to
relate history. Inattentive, unable to name DOW forward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name high frequency objects. Unable to read (but
does not have his [**Location (un) 1131**] glasses). Speech was not dysarthric.
CN
I: not tested
II,III: unable to cooperate with formal VF testing; pupil
1.5-.1mm bilaterally, unable to visualize fundi due to myosis
III,IV,V: EOMI aside from decreased upgaze; no ptosis; R
esotropia; No nystagmus
V: sensation intact V1-V3 to LT
VII: L NLF flattening
VIII: decreased hearing to voice bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii 5-/5 bilaterally
XII: tongue protrudes midline, mild tongue atrophy
Motor: diffusely decreased bulk throughout; motor impersistence
and paratonia; pt does not sustain elevated arms long enough to
test pronator drift. Antigravity in arms and has 5- finger
flexion; the R leg is antigravity, but the left is not. He is
able to flex and extend without at the knee. Further testing
against resistence of the L leg was deferred given his recent
hip
fracture
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1---------- tonically up
R 1---------- tonically up
-Sensory: responds to pain in all extremities symmetrically
-Coordination: pt does not cooperate with formal testing
-Gait: Deferred
Pertinent Results:
[**2119-8-30**] 12:55AM BLOOD WBC-16.0* RBC-3.50* Hgb-10.6* Hct-32.1*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.9 Plt Ct-308
[**2119-8-30**] 12:55AM BLOOD Glucose-85 UreaN-26* Creat-1.2 Na-142
K-4.3 Cl-106 HCO3-15* AnGap-25*
[**2119-8-30**] 12:55AM BLOOD ALT-15 AST-16 LD(LDH)-298* AlkPhos-136*
TotBili-0.5
[**2119-8-30**] 06:10AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0 Cholest-159
[**2119-8-30**] 06:10AM BLOOD %HbA1c-5.5
[**2119-8-30**] 06:10AM BLOOD Triglyc-97 HDL-44 CHOL/HD-3.6 LDLcalc-96
[**2119-8-30**] 06:10AM BLOOD TSH-3.8
[**2119-8-30**] 06:10AM BLOOD Phenyto-5.3*
[**2119-8-30**] 09:44AM BLOOD Lactate-1.1
TTE: The left atrial volume is markedly increased (>32ml/m2).
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area <0.8cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension.
CT HEAD [**8-30**]: Multiple round, hyperattenuating supratentorial
lesions,
including one with hematocrit level, likely related to
anticoagulation.
Underlying hemorrhagic metastases cannot be excluded, and close
correlation with available clinical data is imperative; if
warranted, enhanced MRI could be obtained for further
characterization.
Brief Hospital Course:
The pt is a [**Age over 90 **] year-old RH man with melanoma and multiple
metastasis, an extensive PMH including afib on Coumadin,
seizures, and a pacemaker. He was transferred from an OSH after
an episode of altered
mental status at the OSH and found to have multiple ICH with no
history of trauma. He was given FFP and vitamin K at the OSH to
reverse his INR. Additionally, his labs were remarkable for a
significant anion gap of 21 and a leukocytosis with L shift. He
also has Pseudomonas UTI plus positive C.diff for which he was
started on Flagyl 2 days before admission.
His brain hemorrhages were attributed to be due to metastatic
melanoma.
He was admitted to ICU and underwent TTE which showed intact
LVEF but significant AS with area < 0.8cm2.
As for his Pseudomonas UTI, he was started on Zosyn and for his
Cdiff, he was maintained on contact precautions and treated with
PO vancomycin.
On HD #3, he was transferred to neurology floor.
head CT: No change in the appearance of multiple
intraparenchymal
hematomas.
The CTA demonstrates narrowing and irregularity of the distal
left vertebral
artery, the basilar artery, and the right middle cerebral
artery, with a
pattern that suggests atheromatous disease. There are no
vascular
abnormalities associated with the hematomas.
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **] where his wife is also a patient. Son is HCP and
is in the [**Hospital3 **] area today. Grandson says that the
whole family is in agreement with comfort-focused care, do not
rehospitalize.
As per his paliative care:
1) If able to swallow, continue his usual cardiac meds
(such as b-blocker) to prevent rapid afib. However, if
swallowing is now difficult, can forgo these meds.
2) morphine 5-15 mg SL q2h prn pain or dyspnea - would use the
concentrated oral solution 20 mg/mL. This is available on POE
3) Continue for ativan prn
4) haldol 0.5-1 mg SL q2h prn agitation/delirium - He has no
signs of agitation currently. Haldol is available commercially
in a liquid form and anticipate that can be used at rehab
facility
Medications on Admission:
- Dilantin Extended 100 mg Cap Oral 1 Capsule(s) Twice Daily
- Lopressor 25mg Solution(s) Twice Daily
- Captopril 75mg Tablet(s) Three times daily
- Synthroid 0.025mg Tablet(s) Once Daily
- Lasix 40 mg Tab Oral 1 Tablet(s) Once Daily
- K-Dur 10 mEq Tab Oral 1 Tab Sust.Rel. Once Daily
- Procardia 10 mg Cap Oral 3 Capsule(s) Once Daily
- Coumadin 2.5 mg Tab Oral 1 Tablet(s) mon wed fri sun
- Restoril as needed
Discharge Medications:
1. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
2. Lorazepam 0.5-2 mg IV Q4H:PRN anxiety
3. Morphine Sulfate 1 mg IV Q4H:PRN as needed for pain
4. Lopressor 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Procardia 10 mg Capsule Sig: Three (3) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
Port Rehab & Skilled Nursing - [**Location (un) 5028**]
Discharge Diagnosis:
melanoma, Afib, HTN, seizure
Discharge Condition:
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **]
Discharge Instructions:
Mr. [**Known lastname **] is a [**Age over 90 **] yo man with melanoma, Afib, HTN, seizure who
was admitted on [**8-30**] for altered mental status, found to have
multiple sites of intracranial hemorrhage (probably due to brain
metastasis of melanoma).
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **] where his wife is also a patient. Son is HCP and
is in the [**Hospital3 **] area.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2119-9-4**]
|
[
"5990",
"2762",
"42731",
"2449",
"4241",
"49390",
"4019",
"V5861"
] |
Admission Date: [**2103-2-23**] Discharge Date: [**2103-3-2**]
Date of Birth: [**2040-4-27**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Latex
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation and mechanical ventillation
Right radial arterial line
History of Present Illness:
Ms. [**Known lastname 107247**] is a 62 yo F PMH of afib, TIA, memory loss s/p
hypoglycemic coma, chronic low back pain, anemia, GERD, asthma
recently admitted with subarachnoid hemorrhage [**Date range (1) 107248**]
readmitted with acute change in mental status and agitation.
Since her discharge on [**2-17**] her husband reports that she had been
doing well until 2 days PTA when she was more fatigued and
agitated than usual. She did not have any specific complaints
but her husband reports development of diarrhea two days PTA
which he thinks was due to metformin being started. On the day
of admission, her husband was called by the nursing facility to
report that she was not waking up and she was sent to [**Hospital1 **]. Due to concern for possible repeat or progression of
intraparencymal bleed she was transferred here for neurosurgical
evaluation.
.
On arrival in the ED T100.8 BP 106/49 HR 64 RR 12 100% on 4L NC
FSBG 271. She was intubated on arrival in the ED due to
somnolence and concern that she would not be able to protect her
airway. She was given lidocaine 100mg IV, versed 2mg and
fentanyl 100mcg for sedation. She was given an additional 4mg IV
versed, started on versed gtt at 5mg/hour and fentanyl 100mcg
following this BP dropped to 76/palp. She was given 3L IVF and A
line was placed. She was also started on dopamine gtt at 2.5.
She had a LP without evidence of infection. Head CT was done
which was stable when compared to imaging from her recent
admission. There was no evidence of new or worsened bleed. She
was also given 10mg IV decadron, 2mg ceftriaxone. Dopamine gtt
was d/c'd prior tor transfer to the floor with BP 149/51.
Past Medical History:
Left Temporal Intraparenchymal hemorrhage
afib- was on coumadin for last few years
TIA- had prior episodes of flashes of light going across her
visual field, was placed on plavix.
Dementia- secondary to diabetic coma
Chronic Low Back Pain
Anemia
GERD
COPD- no prior h/o tobacco use, + secondhand exposure
Social History:
Lives with husband until recent admission, used to
work as the press secretary to a state senator in the state
house. no [**Hospital1 **]/etoh or illicits.
Family History:
NC
Physical Exam:
VS: T98.9 BP 159/61 HR 60 RR 15 99% 100%/550/14/5
Gen: intubated, sedated
HEENT: pupils 1mm bilaterally, symmetric and reactive to light
Neck: supple
CV: RRR s1 s2 no appreciable murmur
Abd: obese, soft, non distended, no apparent tenderness, BS +
EXT: warm, 1+ pitting edema
Skin: no rashes or lesions
Pertinent Results:
Na 147 K 4.4 Cl 110 HCO 33 BUN 29 Creat 0.6 Gluc 200
WBC 7.4 HCT 28.4 PLT 215
.
[**2-23**] CSF: 29 protein, 184 glucose, 0WBC 720 RBC
.
UA: leuk neg, bld neg, nitr neg, tr protein, 0-2 rbc, 0-2 wbc,
mod bacteria, 0-2 epis
.
Micro:
[**2-23**] CSF: Gram stain no microorg, no PMN's Culture pending
.
[**2-23**] UCX: pending
.
Imaging:
[**2103-2-23**] CXR: Markedly limited study. Endotracheal tube in
satisfactory position.
.
[**2103-2-23**] Head CT: 1. Expected evolution of left medial temporal
intraparenchymal hemorrhage, with decreased intraventricular
blood in the left occipital [**Doctor Last Name 534**].
2. No new hemorrhage, herniation, hydrocephalus, or other acute
intracranial process.
[**2103-2-24**] MRI Head:
1. Subacute well-defined hemorrhage in the left medial temporal
lobe without surrounding edema. Small amount of blood products
is also seen in the ventricles, which could be secondary to
extension of blood products from this abnormality. The
appearances are nonspecific, but given the location, primary
hemorrhage is less likely and an underlying condition like
cavernous malformation should be considered. Gadolinium-enhanced
MRI can help for further assessment.
2. Increased signal in the splenium of corpus callosum can be
seen in
patients with seizure and postictal stage. However, subtle
increased signal within the pyramidal tracts bilaterally is
unusual for postictal status. This could reflect degenerative
changes within the pyramidal tract. Clinical correlation is
recommended.
[**2103-2-24**] MRA Head:
Slightly bulbous basilar artery without discrete aneurysm.
Otherwise, normal MRA of the head.
[**2103-2-24**] EEG:
This is an abnormal routine EEG due to the presence of a
slow and disorganized background with increased slowing in the
left
hemisphere. This indicates a moderate encephalopathy with an
area of
subcortical dysfunction on the left. The former finding is most
often
caused by medication, metabolic disturbances, or infection.
There were
no epileptiform features noted.
.
Labs prior to Discharge:
[**2103-3-1**] 05:16AM BLOOD WBC-8.5 RBC-3.24* Hgb-9.6* Hct-31.1*
MCV-96 MCH-29.5 MCHC-30.7* RDW-14.1 Plt Ct-280
[**2103-3-1**] 05:16AM BLOOD Plt Ct-280
[**2103-3-1**] 05:16AM BLOOD Glucose-210* UreaN-13 Creat-0.6 Na-147*
K-5.5* Cl-100 HCO3-40* AnGap-13
[**2103-3-1**] 05:16AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.2
[**2103-2-28**] 03:34PM BLOOD Type-ART pO2-44* pCO2-89* pH-7.35
calTCO2-51* Base XS-18
Brief Hospital Course:
Ms. [**Known lastname 107247**] is a 62 yo F PMH of afib, TIA, memory loss s/p
hypoglycemic coma, chronic low back pain, anemia, GERD, asthma
recently admitted with subarachnoid hemorrhage [**Date range (1) 107248**]
readmitted with acute change in mental status and agitation
intubated in the ED for airway protection. Her hospital course
is as follows:
.
# Agitation/altered mental status: Was initially unclear what
caused alteration in her mental status. At baseline she has an
odd affect and is intermittently confused. She was afebrile and
did not have any evidence of infection. LP was performed and
was unremarkable. Neurology was consulted. EEG was performed
and was negative for seizure, only with slowing near the area of
her bleed. CT scan showed her old stable bleed. Her blood
sugar was normal. MRI showed a bulbous basilar artery but
otherwise was unremarkable for a cause of her symptoms.
Psychoactive medications were held. We continued her keppra at
current dose. Her confusion returned to baseline during the
course of her admission. Her altered mental status was likely
multifactorial to include medications, as well as her
hypercarbia, OSA/COPD (see below). She should follow up with
neurology/neurosurgery as an outpatient.
.
# Hypercarbia/COPD/OSA: She was initially admitted intubated,
but was extubated after 24 hrs. ABG showed mild hypoxemia with
p02 in the 50s-60s as well as significant hypercarbia, with pC02
in the 80s-90s, occationally in the 100s. CXR was unremarkable
for infection. We continued her bronchodilators. During her
admission she had periods of somnolence possibly due to
increased carbon dioxide retention in the setting of untreated
OSA. She was tried on autoset CPAP initially however this was
not effective for her. She was briefly sent to the floor but
readmitted to the MICU after increased somnolence. Sleep was
finally consulted. She had an inpatient sleep study which
established BIPAP settings for her. She will require follow up
sleep study and titration as an outpatient. She continued to be
delirious with periods of waxing and [**Doctor Last Name 688**] agitation.
According to her husband, her mental status prior to her
discharge was similar to her baseline. AutoSet BiPAP setting:
--Emin=8cm Imax=20cm max I-E gap 10cm at night for now (can be
ordered through [**Hospital 6549**] Medical - the contact there is
[**Name (NI) **] [**Last Name (NamePattern1) **], [**Name (NI) 6549**] Medical, cell [**Telephone/Fax (1) 49797**])
--Please call [**Telephone/Fax (1) 107249**] to arrange follow-up with sleep to
arrange formal outpatient BiPAP titration to further tailor
settings in the future
.
# Recent Left temporal hemorrhage: Was stable on CT and MRI. We
continued her keppra and held her coumadin and plavix.
.
# Paroxysmal Atrial fibrillation: Was in sinus rhythm throughout
admission.
.
# Type II DM: Her oral hypoglycemics were held in favor of
sliding scale. However, her medications were restarted once she
stabilized. Januvia was not on formulary and was therefore
held. This will need to be restarted after discharge.
.
# COPD: h/o second hand smoke exposure, appears to be chronic
CO2 retainer based on her ABG, with pC02 ranging from 80-100 at
baseline. She was intermittently somnolent in relation to her
OSA.
.
# Nutrition: Regular diet
.
Medications on Admission:
Per NH medication list:
avandia 8mg daily
Avandia 4mg by mouth daily (written twice)
omeprazole 20mg daily
enalpril 20mg [**Telephone/Fax (1) **]
lasix 20mg PO daily
Lasix 40mg daily x three days (stopped [**2103-2-21**])
Acebutolol 200mg PO BID
Keppra 500mg [**Hospital1 **]
Glipizide 2.5mg [**Hospital1 **] started [**2103-2-20**]
metformin 500 [**Hospital1 **] (d/c [**2103-2-18**])--> 1,000mg [**Hospital1 **] since
januvia 100mg daily
RISS
Fioricet PRN (given dose last night, but none in previous few
days.
Albuterol PRN
simvastatin 80mg daily
fluticasone 110mcg daily
heparin SC TID
Percocet 5/325 2 tabs q6h PRN pain
Diazepam 10mg [**Name (NI) **]
MOM, mylanta, tylenol
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO [**Hospital1 **] (once a day (at bedtime)) as needed for
agitation.
13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): both eyes.
14. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): both eyes.
15. Humalog/Regular insulin sliding scale
per protocol qACHS
16. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6594**]
Discharge Diagnosis:
Primary Diagnosis:
Acute Delirium (multifactorial)
Hypercarbic respiratory failure
Sleep disordered breathing
.
Secondary Diagnoses:
Chronic Obstructive Pulmonary Disease
Atrial Fibrillation
s/p Intracranial hemorrhage
Type 2 Diabetes Mellitus
Discharge Condition:
Afebrile, hemodynamically stable, oxygenating well.
Discharge Instructions:
The patient was admitted with altered mental status and
hypercarbia. Her altered mental status was likely
multifactorial to include medications and hypercarbia. She
returned to baseline on discharge. Her hypercarbia was thought
related to her COPD and likely newly diagnosed sleep disordered
breathing. She underwent a sleep study and is being discharged
on Autoset BiPAP to follow up in sleep clinic.
.
She should also follow up with neurosurgery to address her past
bleed. Please continue all other medications as before.
.
The following medications have been held:
Metformin (diarrhea), diazepam/percocet (mental status),
enalapril (hyperkalemia). Please consider adding back these
medications at your discretion.
.
Please have patient return to the hospital if you experience
somnolence not improved with BiPAP, shortness of breath, or any
other assoicated symptoms.
Followup Instructions:
Please follow up with PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 74756**] in the next few weeks.
[**Telephone/Fax (1) 81655**]
.
Please follow up in sleep clinic at [**Hospital1 18**] in the next few weeks
to arrange for a sleep study and further titration of her sleep
machine.
[**Telephone/Fax (1) 107249**]
.
Please have patient follow up with her neurosurgeon.
|
[
"496",
"32723",
"42731",
"2859",
"53081"
] |
Admission Date: [**2156-11-9**] Discharge Date: [**2156-11-13**]
Date of Birth: [**2110-11-7**] Sex: M
Service: MEDICINE
Allergies:
E-Mycin / Aspirin / Ketorolac / Ibuprofen / Nsaids / Gabapentin
/ Levofloxacin
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46yo gentleman with history of Crohn's on prednisone, type 2 DM
on insulin, depression with h/o suicidal gestures, and CAD s/p
DES to LAD who presented with altered mental status.
Over the last two days, he has been markedly thirsty, and has
started drinking large amounts of milk or chocolate milk. He is
not sure if he took his dose of lantus the night before
admission and admits to skipping sugar checks during the day.
+Polyuria. +Cough productive of yellow sputum x 1 week.
+Nausea but no vomiting. He has been having 2 BMs per day,
which is much better than is normal for his Crohn's.
He walked a block to CVS in order to buy cigarettes and fill his
prescriptions. He was walking over to smoke his cigarette when
he noticed he was feeling unsteady. He leaned against a tree
and then slumped down to the ground. A bystander came to his
aid and EMS was called.
In the ED, initial VS were 100.2 (Tmax 102.2) 174/100 140
18 96%. He denied CP or SOB. He was profusely diaphoretic.
Neurologic exam was nonfocal but he had increased muscle tone.
He was empirically treated with stress dose hydrocortisone and
valium. Somewhat later, he became increasingly somnolent. He
received narcan, and just as the team was about to intubate him,
he sat up on the table and was entirely awake. He had a VBG,
which was 7.33/49/60 with a lactate of 4.7. EKG did not show
acute ischemia, and intervals were normal. Head CT was negative
and CXR showed what was thought to be LLL pneumonia, so he was
given vancomycin and levofloxacin. Just prior to transfer to
the ICU, he was given 10 units of IV insulin for BS 373. He
received 2.5 L IVF in ED.
Upon arrival to the ICU, he wanted to have a bowel movement and
he asked immediately for some water to drink. He specifically
denied taking any extra or new medications. He states his mood
has been good lately and that he is not suicidal: "I would not
walk in front of a bus, but if a bus came and hit me, that would
be okay."
Past Medical History:
- CAD s/p NSTEMI with BMS to LAD [**11-8**] followed by instent
restenosis with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD and POBA of jailed diagonal [**6-9**]
- Crohn's (Dx age 12, s/p multiple resections & subtotal
colectomy, s/p 5-aza, 6-MP, and remicade for 5 years. Presently
managed on prednisone 20 mg daily)
- Type II diabetes
- SBO with lysis of adhesions
- Major depressive disorder, history of SI and hospitalizations
for overdose (halcion, lisinopril and lopressor, gas stove
inhalation by report, but not clearly substantiated). Treated
with ECT.
- Borderline Personality Disorder (per review of psych notes)
- Admitted to [**Hospital3 5097**] [**Date range (1) 38649**] for possible seizure, EEG neg
- ADHD
- Osteoporosis
- Polysubstance abuse, history of cocaine and marijuana use
- Hypertension
- Migraine headaches
- Hypoandrogenism
- Hemorrhoids
- Rectal Prolapse, s/p abdominal rectopexy 5/[**2154**].
- Deep vein thrombosis in [**2130**] during bedrest for fx.
- H/o Renal stones
- H/o MRSA skin abscesses
- H/o Perirectal abscess
- H/o Lyme Disease
Social History:
Single MSM, lives in "section 8" housing in [**Location (un) **]; brother
and sister living in area but he is currently not talking to his
family after an argument a few weeks ago. Smokes [**12-6**] PPD x 29
years, uses marijuana every other day, remote h/o cocaine use.
Denies alcohol. Not currently sexually active.
Family History:
Mother - MI at age 67
Many family members with diabetes
States sister had [**Name (NI) 4522**] but "was cured when she got pregnant."
Physical Exam:
VS: 96.1 129/82 100 18 98% RA
GENERAL: Pleasant, unshaven man in no acute distress.
HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI.
++Mucous membranes dry. OP clear. Neck Supple, No LAD, No
thyromegaly or nodule.
CARDIAC: Regular tachycardia. Normal S1, S2. +[**12-9**] soft blowing
systolic murmur at apex. No rubs or gallops. JVP not elevated.
LUNGS: Moving air well. Coarse crackles at bases b/l but no
bronchial breath sounds or egophany.
ABDOMEN: Midline scar, well-healed. +BS. Soft, minimally
tender diffusely. [**Doctor Last Name 515**] sign absent. No epigastric
tenderness.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Narrowed and thickened nails on his fingers and toes b/l.
Small cuts with dirt on his fingers. Becomes diaphoretic with
minimal activity.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. Fine resting tremor b/l. Tone in UE is
normal, although there is some tremor superimposed. [**4-6**]
strength throughout. Gait assessment deferred
PSYCH: Talkative and tangential. Excitable.
Pertinent Results:
EKG: Sinus tachycardia at 136 with normal axis and QTC of
425ms. Poor R wave progression. As compared to baseline from
[**10/2156**], the rate is faster.
LABS:
WBC 14.1
Hgb 12.0
Hct 37.9
Plt 260
83% N, 14.5 L, 1.4 M, 0.3 E, 0.2 B
Na 131
K 5.3
Cl 91
Bicarb 26
BUN 20
Crt 1.0
Gluc 546
Serum tricyclics positive
Serum ASA, EtOh, Acetaminophen, Benzo, Barb: negative
Urine benzos, barbs, opiates, cocaine, amphet, methadone
negative
7.33/49/61/27/0
Lactate 4.7
U/A negative with trace blood, 30 prot, 1000 glucose
Urine Legionella Ag neg
Influenza DFA neg
CXR [**11-9**]:
Heterogeneous left lung base opacity concerning for pneumonia.
Right lung base atelectasis. Follow up radiographs after
treatment is
recommended to document resolution of this finding.
CT Head without contrast [**11-9**]: FINDINGS: There is no
intracranial hemorrhage, edema, shift of normally midline
structures, or evidence of major vascular territorial infarcts.
Ventricles and sulci are normal in size and configuration. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The basilar
cisterns are symmetric. There is no fracture. Paranasal sinuses
and mastoid air cells are well- aerated.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
# Altered Mental Status: DDx at admission hyperosmolar
hyperglycemic state (though not hyperosmolar at admission), drug
overdose (TCA level high at admission), suicide attempt, sepsis,
serotonin syndrome, or seizure. Patient's home medications of
Prednisone and metoprolol could also contribute. Most likely
developed pneumonia, which caused hyperglycemia. He then
developed marked dehydration, which led to his presentation.
Pt. had a recent w/u for questionable seizure at OSH. Patient
was given 3L NS in the ICU. Sedating medications (fentanyl,
temazepam, tizanidine) were held. Treatment was started for CAP
with levofloxacin (day 1 = [**11-9**]) for planned 5 day course. He
was treated with tamiflu X 2 days until Influenza swab was
negative. Urine legionella antigen was negative, as was a NCHCT.
His respiratory status and mental status remained stable during
this admission and he was discharged home.
# Hyperglycemia and Type 2 DM: Patient was put on a sliding
scale with home glargine (decreased dose 12/9 am as patient not
taking good PO). Serum electrolytes in the ICU were checked and
repleted twice daily. He continued to have difficult to control
blood surgars during this hospitalization. Insulin was
increased. Morning blood glucose was in the 100s, but by noon
glucose was often as high as 400, but with no gap. Patient was
seen by nurses exhibiting nonadherence to recommended diet,
often with overconsumption of diabetic products.
# Suspected Community Acquired PNA: Started on levofloxacin x
5 days (day 1 = [**11-9**]).
# Acute Respiratory Acidosis: Likely due to hypoventilation in
setting of altered mental status. Anion gap at admission 14
with a lactate of 4.7, suggesting he may have had a concurrent
anion gap acidosis, however lactate decreased day after
admission and MS improved.
# Hyponatremia and hyperkalemia: Likely has pseudohyponatremia;
elevated K+ is likely due to transcellular shifts as it
resolved.
# Leukocytosis: Likely due to pneumonia or stress reaction. No
bands.
# CAD s/p NSTEMI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD in [**2154**]: Continued plavix,
beta blocker, and statin. Pt. has ASA allergy. CEs were
negative.
# h/o Crohn's disease: Patient was continued on Prednisone and
home medications. His fentanyl patched was restarted on [**11-10**]
due to improved MS.
# h/o major depression: Continued lamictal, held nortriptyline
and lexapro, and temazepam at admission for AMS. Contact[**Name (NI) **]
psychiatrist and....
# ADHD: no need for methylphenidate in house
# h/o polysubstance abuse: tox screen negative with exception
of elevated TCA
# HTN: continued beta blocker
# Hypoandrogenism: restart androgel as outpatient
#Diaphoresis: Patient often found diaphoretic and tremulous,
which he said is is baseline and necesitates carrying around
extra shirt. Unclear if this was low-grade withdrawal vs.
autonomic dysfunction. This has been a longstanding issue.
Medications on Admission:
(confirmed with patient):
Clopidogrel 75 mg po daily
Atorvastatin 80 mg po daily
Lamotrigine 200 mg po daily
Escitalopram 20 mg po qAM, 10mg po qPM
Metoprolol Tartrate 25 mg po bid
Prednisone 20 mg po daily
Nortriptyline - "fairly new" takes 4 pills but doesn't know dose
Temazepam 15 mg po qhs prn anxiety
Testosterone Transdermal
Pantoprazole 40 mg po bid
Insulin Glargine Forty two (42) units SQ qhs
Insulin Lispro sliding scale
Dronabinol 5mg TID prn
Fentanyl 175 mcg/hr Patch (one 100mcg/hr and one 75mcg/hr) q72
hr
Tizanidine 4mg TID prn muscle spasm
Cholestyramine-Sucrose 4 gram Packet [**Hospital1 **] prn
Lomotil 2.5-0.025mg Q6H prn diarrhea
Loperamide 2-4mg QID prn
Compazine 10mg prn nausea
Nitroglycerin 0.3 mg SL Q5 MIN as needed for chest pain.
Methylphenidate 40 mg [**Hospital1 **]
Sudafed prn (took day of admission)
Vitamin D 400 unit po bid
ALLERGIES:
E-Mycin -- "heart stopped"
Aspirin -- abdominal pain
Ketorolac -- unknown
Ibuprofen -- abdominal pain
Nsaids --Crohn's Flare
Gabapentin -- swelling
Discharge Medications:
1. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Six (46)
units Subcutaneous at bedtime.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
8. Tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
10. Marinol 5 mg Capsule Sig: One (1) Capsule PO three times a
day.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Cholestyramine Light 4 gram Packet Sig: Fourteen (14) grams
PO once a day.
16. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
17. Nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at
bedtime: Home dose listed as 80mg.
18. Avelox 400 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Pneumonia
2) Mental Status Changes
3) Diabetes
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Ambulatory sat 96% on room air
Discharge Instructions:
You were admitted with a pneumonia, mental status changes, and
hyperglycemia. You were started on an antibiotic. Please resume
your usual medications and take the antibiotic as prescribed.
Please check your sugars regularly and call your PCP if your
glucose is over 400. We increased your lantus dose.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: PCP
Date and time: Thursday, [**11-25**] at 10:50am
Location: [**Hospital6 5242**] CENTER, [**Location (un) 5243**],
[**Location (un) **],[**Numeric Identifier 718**]
Phone number: [**Telephone/Fax (1) 798**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Last Name (NamePattern1) **]
Date and time: [**Last Name (LF) 766**], [**12-7**] at 10:10am
Location: [**Hospital1 41690**], [**Hospital Ward Name 121**] Complex, [**Hospital Ward Name **] Bldg [**Location (un) 3202**], [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 4335**]
|
[
"486",
"2762",
"2761",
"41401",
"4019",
"2724",
"25000",
"2767",
"311",
"412",
"V4582"
] |
Admission Date: [**2133-3-21**] Discharge Date:
Date of Birth: [**2133-3-21**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: A 32 and [**5-23**] week gestation,
twin B who was admitted due to apnea arrest, perinatal
distress. Maternal history: A 28 year-old, gravida 2, para 0,
woman with prenatal screens notable for 0 positive, direct
antibody negative, RPR nonreactive. Rubella immune and GBS
unknown.
Antenatal history: EDC [**2133-5-12**] for estimated gestational
age of 32 and 4/7 weeks at delivery. Spontaneous
monochorionic, diamniotic twin gestation. Pregnancy was
notable for elevated nuchal thickness in twin B on earlier
ultrasound. Subsequently normalizing. Mother presented with
spontaneous preterm contraction and positive fetal
fibronectin 2 weeks ago. She was treated with betamethasone
and terbutaline. She progressed to spontaneous vaginal
delivery under epidural anesthesia. She had rupture of
membranes prior to delivery and she did have clear amniotic
fluid. Intrapartum fever to 99.5 degrees was noted with no
other clinical evidence of chorioamnionitis. Antepartum
antibiotics therapy was started 19 hours prior to delivery.
On delivery, the infant was hypotonic and apneic at delivery.
She was orally and nasally bulb suctioned. Dry and tactile
stimulation was provided. She had persistent hypotonia and
intermittent apnea. She receivedV-bag mask ventilation. Heart
rate was well maintained throughout. Apgars were 5 at 1
minute, 7 at 5 minutes and 8 at 10 minutes.
PHYSICAL EXAMINATION: Moderately preterm infant, twin B on
warmer. Birth weight [**2136**] grams, head circumference 31 cm,
length 43 cm. Vital signs: D-stick 57. Temperature 99.4;
heart rate 136; respiratory rate 40 to 60; blood pressure 73
over 27 with a mean of 44. Oxygen saturation was 95% in 30%
FI02. HEENT: Anterior fontanel straight and flat. Non
dysmorphic. Palate intact. Nasal C-Pap in place. Mild
redundant scalp skin. Red reflex present bilaterally. Chest:
No retractions. Good breath sounds bilaterally. Mild
intermittent grunting. Respirations: Few scattered coarse
crackles. CVS: Well perfused, rate and rhythm regular.
Femoral pulses; normal S1 and S2 normal, no murmur. Abdomen:
Soft, nondistended, no organomegaly, no masses. Bowel sounds
active. Anus patent. 3 vessel umbilical cord. Genitourinary:
Normal female genitalia. CNS: Active, alert, responds to
stimuli. Truncal and extra axial tone decreased in
symmetrical distribution. Moves all extremities
symmetrically. Soft, intact facies, symmetrical.
Integumentary system: Normal. Musculoskeletal system: Normal
spine, limbs, hips and clavicles.
IMPRESSION: 32 [**5-23**] week gestation, twin 2, with respiratory
distress. Sepsis risk based on unexplained preterm labor,
mild intrapartum fever, unknown GBS status and aspiration,
hypotonia and apnea in the delivery room.
HOSPITAL COURSE:
1. Respiratory: She was placed on the nasal CPAP and she
continued to be on nasal CPAP for the first 2 days of
life. On day of life 2, she was trialed on room air and
was started on caffeine. She continued to be doing well
on room air and caffeine was discontinued on day of life
6. At the time of transfer, she continued to have some
occasional spells with heart rate dropping to 50 to 60's.
Some of them are quick self-resolved and others needed
stimulation.
1. Cardiovascular: There were no issues. She had normal
first and second heart sounds. Rate and rhythm regular.
No murmur. Femoral pulses were equal, brachial pulses and
2+.
1. Fluids, electrolytes and nutrition: She was n.p.o. for
the first 2 days of life and was on IV fluids. Feeds were
started with special care 24 kilocalorie per ounce on day
of life 2 and then gradually advanced. She reached full
feed at 140 cc/kg/day of Similac Special Care 20 on day
of life 7 and she was advanced on calories. At the time
of transfer, she is on special care 24 kilocalories 140
cc/kg/day which she is getting p.o. and p.g. her last
set of electrolytes were drawn on day of life 6. Sodium
was 139; potassium of 6.4; chloride 103 and bicarbonate
of 23; potassium was repeated which was 5.4.
1. Gastrointestinal. No issues. She has normal abdominal
wall and normal umbilical cord. Anus was patent. She
passed meconium stool. Her bowel sounds are present. No
hepatosplenomegaly. Nondistended and nontender. Her
maximum serum bilirubin was 8.4 total, 0.4. direct. She
had phototherapy for day of life 3 and 4. Her last serum
bilirubin was 5.7 total and 0.3 direct.
1. Hematology: Her initial CBC showed white count of 12.5K
with 23 polys, 2 bands and 62 lymphocytes. Her hematocrit
was 55.5 and her platelets were 236K. Initial blood
culture was drawn at the time of admission and she was
started on ampicillin and gentamicin. Culture was
negative at 48 hours and ampicillin and gentamicin were
discontinued. She continued to have Desitin to her diaper
area for mild diaper rash.
1. Neurology: Normal tone, normal newborn reflexes.
1. Sensory:
Audiology hearing screen: as [**First Name8 (NamePattern2) **] [**Hospital1 **] SCN
Ophthalmology: Not examined. Patient more than 32 weeks of
gestation with uncomplicated course..
1. Psychosocial: [**Hospital1 18**] social worker involved with the
family. The contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT THE TIME OF TRANSFER: Stable.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 3765**].
NAME OF PRIMARY CARE PEDIATRICIAN: to be decided at [**Hospital1 **] SCN.
CARE RECOMMENDATIONS: Feeds at discharge: Similac Special
Care 24 kilocalories per ounce at 140 cc/kg/day po/pg.
Medications: None.
Car seat position screening: as [**First Name8 (NamePattern2) **] [**Hospital1 **] SCN.
State newborn screening status: The state newborn screen was
performed on [**2133-3-24**] which showed increased 17 hydroxy
progesterone and state newborn screen was repeated on
[**2133-3-27**]. Results are pending.
IMMUNIZATIONS: Received hepatitis B vaccine on [**2133-3-23**].
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: as [**First Name8 (NamePattern2) **] [**Hospital1 **] SCN arrangement.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 4/7 weeks gestation, twin B.
2. Initial mild respiratory delay transition, rule out
sepsis.
3. Apnea of prematurity.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) 67754**]
MEDQUIST36
D: [**2133-4-1**] 16:37:12
T: [**2133-4-1**] 18:26:04
Job#: [**Job Number 71420**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2137-9-6**] Discharge Date: [**2137-9-11**]
Date of Birth: [**2062-10-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Cough, nasal congestion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 31102**] is a 74yo male with h/o polio, prostate cancer, and
type 2 DM who presents with nasal congestion and non-productive
cough. Per patient, his symptoms started last Saturday and have
not improved. He was concerned since he has been hospitalized in
the past for bronchitis given his history of polio. He denies
any fevers, chills, chest pain, SOB, abdominal pain, or dysuria.
In the ED her initial vitals were T 97.7 BP 146/34 AR 62 RR 18
O2 sat 95%RA. He received Levaquin 750mg PO x1. Cxray suggested
RML pneumonia.
On the floor, the patient states that he's feeling ok now. He
states that last week, he had some congestion, rhinorrhea, which
eventually cleared, but he has had a non-productive cough. He
states that he feels mucous in his chest, but has not been able
to produce anything. He denies fevers, chills, joint pains,
nausea, vomiting, headaches, SOB, CP, or pleuritic chest pain.
He states he otherwise feels well.
Past Medical History:
1)Klebsiella urosepsis ([**1-/2135**]) resulting in [**Hospital1 112**] ICU stay, shock
liver, MI and azotemia with placement of ureteral stent--now
recovered
2)Prostate ca s/p exploratory laparotomy with positive nodes and
[**Hospital **] medical managment, [**2124**]. PSA now wnl.
3)Renal cell ca s/p right nephrectomy '[**20**]
4)Type 2 DM
5)Depression
6)Carpal tunnel syndrome, s/p L-wrist release [**2113**]
7)Rheumatoid arthritis
8)h/o basal cell cancer (s/p excision)
9)h/o appendectomy
Social History:
Lives in [**Location 86**]. [**Hospital 8735**] rehab counselor. Divorced. Denies
tobacco, alcohol, or IVDA. Wheelchair dependent, has nursing
assistance at home.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
vitals Tm 98.8 130/56 (125-130) 69 (63-69) 24 O2 sat 94% RA
Gen: Pleasant male, lying in bed
HEENT: MMM, no LAD
Heart: RRR 1/6 systolic flow murmur at base
Lungs: poor inspiratory effort, breath sounds throughout with
increased crackles on R>L
Abdomen: obese, soft, NT/ND, normal BS
Extremities: 1+ LLE edema to knee, no edema on Right, 1+ DP/PT
pulses bilaterally. low muscle mass BLE
Pertinent Results:
Relevant Imaging:
CXRAY:IMPRESSION: Question opacity medial right middle lobe
which may represent a pneumonia particularly in light of given
symptoms. Repeat radiography recommended following appropriate
therapy to document resolution
[**2137-9-6**] 06:20AM GLUCOSE-117* UREA N-26* CREAT-0.8 SODIUM-137
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2137-9-6**] 06:20AM WBC-12.8* RBC-3.40* HGB-10.7* HCT-31.2*
MCV-92 MCH-31.3 MCHC-34.1 RDW-15.0
Brief Hospital Course:
Pt was admitted with non-productive cough of 6 days duration and
was found to have a
RML pneumonia.
.
Pneumonia: Pt was treated empirically for CAP with levofloxacin
started on [**2137-9-6**]. On the 3rd day of admission, pt was
transferred to the MICU after an episode of hypoxia to 50% on RA
during chest PT. Pt was placed on NRB with improvement of O2
Sat to 95%. Sputum cultures were contaminated x 2 and thus
levofloxacin was continued. Pt was continued on chest PT with
symptomatic improvement. Pt was also evaluated by speech and
swallow for possible aspiration. He was cleared by speech and
swallow, however pt may benefit from further work up with outpt
video swallow to evaluate for possible microaspiration. Pt
should be continued on levofloxacin for a full 10 day course
([**2137-9-6**] to [**2137-9-16**]). Pt will also need a repeat x-ray in [**5-3**]
weeks. Prior to discharge, the patient's O2 sats had improved
to >95% on RA.
.
Medications on Admission:
Flutamide 250mg PO TID
Effexor 150mg PO daily
Atenolol 25mg PO daily
ASA 81mg PO daily
Simvastatin 40mg PO daily
Metformin 250mg PO daily
Vitamin B6 50mg PO daily
Vitamin B12 25mg PO daily
Discharge Medications:
1. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: Until [**2137-9-16**].
Disp:*5 Tablet(s)* Refills:*0*
8. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
9. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
11. Metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Prostate Ca, DM type 2, Depression
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a pneumonia. You were treated with
levofloxacin, and you should continue this medication for a full
10 day course.
.
Levofloxacin was added to your medication regimen. You will
need to take this medication until [**2137-9-16**].
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pain, shortness of breath,
fevers, chills, worseing cough, nausea, or vomiting.
Followup Instructions:
We have scheduled an appointment with your primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 103527**] [**Telephone/Fax (1) 355**] on [**9-16**] at 1:20 pm.
.
You will also need a repeat chest x-ray, arranged by your PCP [**Last Name (NamePattern4) **]
[**5-3**] weeks.
Completed by:[**2137-9-16**]
|
[
"486",
"25000"
] |
Admission Date: [**2156-12-10**] Discharge Date: [**2156-12-16**]
Date of Birth: [**2086-9-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 70 y/o female with dilated cardiomyopathy (EF
20%), T2DM, HTN, and hypothyroidism who presented to [**Hospital1 **] [**Location (un) 620**]
ED with 2 days of worsening dyspnea and chest pain. Pt also
reported 2-3 days of intermitttent, diffuse back pain.
Upon arrival to the ED, vitals were BP 164/77, HR 92, RR 34, 71%
O2 sat on RA. She reported 1-2 days of worsening dyspnea and
[**11-12**] SSCP, no radiation or associated symptoms. Sats improved
to 100% on NRB. She was given 1 SL nitro, which decreased her CP
to [**6-12**] but also dropped her BP to 83/42. EKG without any acute
ST changes. There was AV pacing. She was given Lasix 40 mg IV x
1 with marked improvement in her symptoms and able to wean her
oxygen to 4L NC, satting 98%. Foley was placed. CXR reportedly
revealed pulmonary edema but report did not accompany patient.
She was given another 40 mg of IV Lasix. She was also given ASA
325 mg. The decision was made to transfer to [**Hospital1 18**] CCU for
further diuresis in the setting of hypotension.
Upon arrival to the CCU, she was in NAD and hemodynmically
stable. BP was 106/54 and HR 72, satting 100% on 4L NC, quickly
weaned to 2L NC. She still complained of [**5-13**] chest pain.
Upon further questioning, she explained that there were no
recent changes in her medication regimen. She admits to using
salt on her food but not a large amount. Followed by a
cardiologist at [**Location (un) 745**]-[**Location (un) 3678**]. She had recently had a course
of steroids for gout flare which was perhaps responsible for
fluid retention. Denies F/C. Denies N/V/D/abdominal pain. Denies
urinary symptoms. Denies palpitations or PND. Usually sleeps at
an incline so difficult to know if orthopnea worsened. No recent
travel. ROS otherwise N/C. Of note, pt is a poor historian.
Past Medical History:
Dilated cardiomyopathy, recent EF 20%, cath in 200 which
revealed no CAD, mild MR, and EF of 35%, s/p pacer/ICD placement
(unsure what kind of pacer/when placed/when was last
interrogated
T2DM
HTN
Hypothyroidism
Social History:
No prior history of smoking or alcohol use.
Family History:
Non-contributory
Physical Exam:
T 97.2 BP 106/54 HR 74 RR 20 98% 2L NC
General: WD/WN 70 y/o female in NAD.
HEENT: NC/AT. MMM. OP clear.
Neck: +JVD
CV: Normal S1, S2 without any m/r/g.
Pulm: Bibasilar crackles, no wheezes.
Abd: Soft, NT/ND with normoactive BS.
Ext: No c/c/e.
Skin: No rash.
Neuro: A/O x 3. CNs II-XII grossly intact. Good ROM and strength
in all 4 extremities. Sensation intact. No spinal tenderness.
Mild lumbar paraspinal TTP.
Pertinent Results:
[**2156-12-16**] 05:35AM BLOOD WBC-4.2 RBC-3.01* Hgb-9.4* Hct-29.4*
MCV-98 MCH-31.2 MCHC-31.9 RDW-16.6* Plt Ct-252
[**2156-12-10**] 06:09AM BLOOD Neuts-84.6* Lymphs-9.9* Monos-5.0 Eos-0.2
Baso-0.3
[**2156-12-13**] 05:45AM BLOOD PT-11.9 PTT-41.1* INR(PT)-1.0
[**2156-12-16**] 05:35AM BLOOD Glucose-88 UreaN-42* Creat-2.3* Na-138
K-5.3* Cl-102 HCO3-29 AnGap-12
[**2156-12-10**] 06:09AM BLOOD ALT-13 AST-15 CK(CPK)-31 AlkPhos-107
TotBili-0.3
[**2156-12-10**] 03:46PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2156-12-15**] 09:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.3
[**2156-12-12**] 06:03AM BLOOD TSH-8.9*
[**2156-12-12**] 06:03AM BLOOD T4-5.7 T3-53*
[**2156-12-14**] 07:06PM URINE Hours-RANDOM UreaN-188 Creat-58 Na-71
ECHO [**12-10**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 15-20%). Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is at
least mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
with elevated LVEDP. Mild aortic regurgitation. Mild mitral
regurgitation. At least mild pulmonary hypertension.
CXR [**12-10**]:
1. Right basilar area of consolidation concerning for pneumonia
or
aspiration. Left basilar atelectasis.
2. Moderate cardiomegaly.
3. No sign of failure or effusion.
Brief Hospital Course:
[**Hospital1 18**] EKG:
Mostly V-paced, occasional PVCs, no acute ST changes,
70 F with idiopathic cardiomyopathy (EF 20% in [**6-10**]), T2DM, HTN,
and hypothyrodism who presents with worsening DOE and chest
pain.
# DYSPNEA - On transfer, in the setting of pt's history, exam
(basilar crackles, JVD) and laboratory findings (OSH CXR with
volume overload, and elevated BNP), etiology of pt's dyspnea was
thought to be secondary to left sided CHF exacerbacion. Etiology
of exacerbation was thought to be partly dietary indiscretion
and more importantly a recent course of prednisone. Pt was
diuresed aggresively with IV lasix drip. CXR confirmed fluid
overload and ruled out infection. BP meds were held while
diuresing and restarted once tolerated. Pt's oxygen
supplementation was weaned as she was diuresed.
# CHEST PAIN - Not thought to be ischemic based on EKG and
cardiac enzymes.
# Hypotension - Thought to be chronic due to low EF. Pt's
beta-blocker and ace-inhibitor were initially held while
aggresively diuresing and restarted slowly prior to discharge.
# CHRONIC KIDNEY DISEASE - Pt's creatinine fluctuated around her
baseline with diuresis. She was asked to have her renal function
checked on follow up with PCP.
# DIABETES type 2 - Pt's blood sugars were controlled with
standing glarging and humalog sliding scale.
# HYPOTHYROIDISM - Pt's TSH was elevated and repeated due to
concern for contribution to CHF, but T3 and T4 were within
appropriate range, thus suggesting sick euthyroid. She was
continued on her outpt dose of levothyroxine.
# ARRHYTHMIA - Pt initially had frequent ectopy with PVCs
alternating with paced beats. Her PVCs were not perfusing and
thus her effective pulse was 40s while being paced at 70s. Pt
remained asymptomatic but EP was consulted and recommended
increasing beta-blockade to suppress ectopy. On discharge pt's
perfusing pulse was in the 70s on Toprol.
Medications on Admission:
ASA 81mg po daily
Toprol XL 50mg po daily
Amiodarone 200mg po daily
Ramipril 5mg po daily
Allopurinol 100mg po daily
Lasix 80mg po QAM, 40mg QPM
*Humalin 15/12 units SC AM/PM--Pt states recently she has been
taking 10 AM, 15 PM (3am glucose 70s, 8am glucose 240s)
*Levothyroxine 75mcg po daily + 2 tabs on saturday and tuesday
*Vitamin B12 50mcg po qd
*Prednisone 20mg po qd--Self DC'd
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
once a day.
7. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous twice a day.
8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO every
morning.
12. Furosemide 80 mg Tablet Sig: 0.5 Tablet PO at 6 pm.
13. Metoprolol Succinate 100 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*
14. Outpatient Lab Work
Please check BUN,Creatinine, Hct, K, Na when you see Dr. [**Known lastname **].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Dilated Cardiomyopathy
Daibetes Mellitus Type 2
Hypertension
Acute on Chronic systolic Congestive Heart Failure.
Bradycardia with Ventricular Ectopy
Discharge Condition:
bun=42
creat=2.3
hct=29.4
k=5.3
Discharge Instructions:
You had a congestive heart failure exacerbation that may have
been caused by a high sodium diet. it is important that you stay
active and get as much activity as you can. We gave you
intravenous furosemide to remove the fluid. Your kidney function
declined temporarily because of the stress of the fluid removal.
You should get your kidney function checked in the next week.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet, information regarding this was
discussed with you and given to you on discharge.
Fluid Restriction: 1.5 Liters, about 7 eight ounce cups per day.
.
Medication changes:
Your Metoprolol was changed to 100mg daily (long acting
medicine)
Followup Instructions:
Primary Care:
[**Known lastname **],[**First Name3 (LF) **] M Phone: [**Telephone/Fax (1) 6163**] Date/Time: Monday [**12-20**] 12:00pm
.
Cardiology:
[**Name6 (MD) 31011**] [**Name8 (MD) **], MD Phone: ([**Telephone/Fax (1) 31012**] Date/Time: [**12-22**]
at 2:15pm.
Completed by:[**2156-12-21**]
|
[
"5849",
"5180",
"5859",
"4280",
"2449",
"40390"
] |
Admission Date: [**2170-8-5**] Discharge Date: [**2170-8-8**]
Date of Birth: [**2105-7-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
aphasia, right hemiparesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient [**Name (NI) **] [**Known lastname 86382**] is a 65 yo LHM with hx L MCA
hemorrhagic stroke in [**2158**] with subsequent seizure disorder
(Status epilepticus in [**Month (only) 205**] and fall of [**2168**] with full return to
baseline, but event [**12-31**] lasting 30 minutes at [**Hospital6 3426**] with subsequent poor functional status), and multiple
recent admissions to [**Hospital1 18**]. He presents with aphasia and R
hemiparesis noticed at 17:00 today. He was last seen normal at
16:30 by nursing home staff. He was transported to [**Hospital1 18**] ED and
CODE STROKE was called. NIHSS 19.
Patient has a 10 year history of epilepsy, with GTCs, secondary
to prior L MCA hemorrhagic stroke. His events were relatively
infrequent until [**4-29**], when he had a CABGx3. After that, he had
3
episodes of status epilepticus between [**2169-6-21**] and [**2170-1-22**]. His typical seizures are GTC that last a few minutes and
which he recovers from spontaneously with a return to baseline
function within a few hours. He had one [**3-31**], a cluster a few
weeks ago, and he had another one this morning. Today, his GTC
lasted <3 minutes. As usual, his post-ictal deficits were his
prior stroke symptoms ie aphasia, R hemiparesis) and lasted a
few
hours. His wife was present at the nursing home, and reports
that
pt was walking and talking by 2pm. She then left and patient was
in common area until 16:30, then went to his room. At 17:00,
nurse checked on him to find him aphasic and weak on the right.
The patient has been asymptomatic over the past week per his
wife, denies fevers/chills, cough, rhinorrhea, GI symptoms,
headache, neck pain or stiffness, dysuria.
She does note that he has chronic sinusitis and on prior
admission increased seizure frequency was attributed to this. He
recently completed course abx.
Past Medical History:
1. L. MCA territory hemorrhagic stroke in [**2158**]. Known
hypertensive at the time, not on medications. Records suggest
that temporal and occipital lobes were most-affected. Residual
moderate aphasia and mild R. hemiparesis.
2. GTCS since this stroke, beginning 2-3y after hemorrhage.
Seizures were self limited, lasting 1-2 minutes, and occurred
2-4x per year. In [**June 2169**], had an hour-long episode of status
epilepticus. Two subsequent episodes of status, no self-limited
seizures since that time. Refractory to multiple medications -
previously on Keppra, Lamictal, and Dilantin (height of doses
unknown), currently Carbatrol and Depakote.
3. Coronary artery disease, CABG x 3 vessels in [**4-29**]. Wife
notes
a mild cognitive hit and the change in his seizure type
subsequent to this surgery.
4. HTN
5. Dyslipidemia
6. Goiter. TSH, Free T4, T3 normal at [**Hospital3 **] within
the
last month per transfer notes
7. TURP in [**2167**]
Social History:
lives at nursing facility, wife lives at home and visits
frequently. Smoked 1 pk/day for 50 yrs, quit 3 yrs ago. No ETOH
currently but drank heavily when younger. No IVDU.
Family History:
Negative for any seizure or early cognitive decline. Father
deceased at 42y of "heart disease", mother deceased in 70s with
"heart disease."
Physical Exam:
VS: T 102 HR 110 BP 194/108 --> 150/80 RR 31 02 96/RA
Genl: Awake, agitated
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake, moving left side, agitated. No verbal
output, does not appear to comprehend, does not follow any
commands. Orients to voice.
Cranial Nerves: Eyes deviated to the left, unable to cross
midline with dolls eyes. Pupils equally round and reactive to
light, 4 to 2 mm bilaterally. Blinks to threat in all visual
fields. Right facial droop.
Motor: Normal bulk. Increased tone on the right. No observed
myoclonus, asterixis, or tremor. Does not follow commands for
formal motor testing. Left upper and lower extremities moving
spontaneously, withdraws to pain bilaterally. Can hold LUE and
LLE antigravity but not RUE/RLE.
Sensation: Withdraws to pain bilaterally.
Reflexes: 2+ and more brisk on the right. Right toe up, left toe
downgoing.
Coordination: unable to assess
Gait: unable to assess
DISCHARGE EXAM:
Mental status AOx2, naming, repetition intact.
Improvement notable with Mental status AOx2, naming, repetition
intact.
full strength throughout, sensation intact to light touch
without extinction to DSS, pinprick. Right toe upgoing.
Pertinent Results:
ADMISSION LABS:
[**2170-8-5**] 05:33PM BLOOD WBC-17.2* RBC-5.19 Hgb-15.5 Hct-45.0
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.6 Plt Ct-246
[**2170-8-5**] 05:33PM BLOOD Neuts-91.8* Lymphs-4.2* Monos-3.5 Eos-0.2
Baso-0.4
[**2170-8-5**] 05:33PM BLOOD PT-12.8 PTT-20.8* INR(PT)-1.1
[**2170-8-5**] 05:33PM BLOOD Glucose-161* UreaN-18 Creat-0.9 Na-141
K-3.9 Cl-104 HCO3-20* AnGap-21*
[**2170-8-5**] 05:33PM BLOOD ALT-24 AST-22 LD(LDH)-253* AlkPhos-104
TotBili-0.3
[**2170-8-6**] 03:06PM BLOOD CK(CPK)-3562*
[**2170-8-8**] 05:15AM BLOOD CK(CPK)-1579*
[**2170-8-5**] 05:33PM BLOOD Lipase-54
[**2170-8-6**] 03:06PM BLOOD CK-MB-5 cTropnT-<0.01
[**2170-8-6**] 11:08PM BLOOD CK-MB-6 cTropnT-<0.01
[**2170-8-7**] 05:53AM BLOOD CK-MB-6 cTropnT-<0.01
[**2170-8-6**] 01:28AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
[**2170-8-5**] 05:33PM BLOOD Carbamz-8.9
[**2170-8-5**] 06:33PM BLOOD Lactate-3.0*
[**2170-8-6**] 01:58AM BLOOD Lactate-2.0
[**2170-8-5**] 06:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2170-8-5**] 06:10PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2170-8-5**] 06:10PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2170-8-5**] 06:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
[**2170-8-8**] 05:15AM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-141 K-3.5
Cl-109* HCO3-23 AnGap-13
[**2170-8-8**] 05:15AM BLOOD WBC-6.5 RBC-4.40* Hgb-13.3* Hct-38.6*
MCV-88 MCH-30.3 MCHC-34.5 RDW-13.8 Plt Ct-168
LUMBAR PUNCTURE:
[**2170-8-5**] 08:20PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1* Polys-0
Lymphs-45 Monos-55
[**2170-8-5**] 08:20PM CEREBROSPINAL FLUID (CSF) TotProt-45 Glucose-83
MICRO:
HSV PCR from CSF NEG
URINE CX NEG
BLOOD CX NGTD
CSF GRM STAIN/CX NEG
IMAGING REPORTS:
CT/CTA/CT PERFUSION (CODE STROKE PROTOCOL)
1. No definite acute intracranial abnormality. No perfusion
abnormality to
suggest a new infarct.
2. Chronic infarcts involving the left occipital lobe and the
left basal
ganglia.
3. Calcified atheromatous plaque involving the bilateral
internal carotid
arteries, cavernous and supraclinoid segments, with moderate
stenosis.
4. Scattered calcified atheromatous plaque involving the
cervical arteries
without significant stenosis. There is ectasia of the left
carotid bulb with hard and soft plaque peripherally with minimal
stenosis.
5. Lobulated enlarged heterogeneous thyroid with retrosternal
component and some effacement of the trachea. This correlates
with the patient's known goiter.
6. New right maxillary sinus opacification.
CXR: 1. Possible mild central vascular engorgement.
2. Left costophrenic angle not fully included on the image.
Otherwise, no
focal consolidation.
EEG: report pending
Brief Hospital Course:
65 YO RHM with h/o L MCA infarct with hemorrhagic conversion
with subsequent seizure disorder presents with aphasia, right
hemiparesis.
NEURO:
Pt was found in nursing facility nonresponsive and weak on the
right side. Code stroke was called. Since patient had been alone
in room, no one had witnessed seizure activity. NIHSS was 19 for
aphasia, right hemiparesis and right facial droop.
CT code stroke protocol was performed. There was no evidence of
acute stroke. There was suspicion that deficits were post-ictal,
and patient actually did begin to improve within the next hour.
He began moving right side spontaneously, but remained aphasic
with poor comprehension.
Pt then spiked fever to 102 in ED. He underwent a
toxic/metabolic/infectious workup including CXR, complete labs,
LP, which were unrevealing. Urine, blood and CSF cx were
negative. He was treated with empiric vanco and CTX for 24
hours.
Pt did have right maxillary sinus fluid in head CT, and had just
completed a course of antibiotics for sinusitis.
Pt was admitted to neuro ICU for close monitoring.
ICU Course: Pt was agitated and perseverating for a prolonged
period on morning of [**8-6**]. There was concern for possible
seizure activity and he was given IV ativan 2 mg x4 doses. EEG
was performed which showed occasional spikes over the left
temporal lobe, but no status epilepticus. He was not taking oral
meds and was given IV Keppra overnight. On [**8-7**] he was
tolerating PO again and was switched back to his oral AED
regimen including Zonisamide 400 mg qhs and Trileptal 300 mg
TID. He had ECG and cardiac enzymes done which were negative for
acute infarction. CK was elevated, but not MB component. This
was considered a result of seizures and agitation causing some
muscle breakdown, and it was trending down upon discharge.
FLOOR COURSE:
Pt was at neurologic and cognitive baseline, with exam notable
for disorientation (knows "hospital", inattention) but is calm
and cooperative with exam.
Empiric antibiotics were discontinued and he remained afebrile
and leukocytosis resolved. Pt had no sinus pain or pressure,
thus it was not considered indicated to treat the sinus findings
on CT.
Given 2 seizures in 24 hours, patient's dose of zonisamide was
increased. Given his behavoiral issues and agitation, he was
started on prn seroquel.
He will follow up with Dr. [**Last Name (STitle) 86384**] and [**Doctor Last Name **] in Epilepsy Center.
SINUSITIS:
pt recently completed abx for sinusitis but still c/o
pain/pressure bilaterally. No e/o bacterial infection warranting
further abx. Started on Flonase [**Hospital1 **], may follow up ENT if not
improved in [**2-22**] weeks on this therapy.
Medications on Admission:
zonisamide 400 mg daily
tegretol 300 mg [**Hospital1 **]
nystatin suspension QID
trazodone 50-100 qHS and q8H PRN agitation
ASA 81
Zocor 40 mg daily
Norvasc 5 mg daily
lisinopril 40 mg daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
3. Methimazole 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): pls give 25 to 50 mg qHS, and give 50 mg Q8H PRN.
7. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO QHS (once
a day (at bedtime)).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Seroquel 25 mg Tablet Sig: half Tablet PO at bedtime as
needed for agitation.
11. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 1411**]
Discharge Diagnosis:
epilepsy
s/p L MCA hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic Exam: alert, cooperative, oriented to self, hospital,
inattentive, motor and sensory exam normal, symmetric 2+
reflexes, right upgoing toe
Discharge Instructions:
It was a pleasure taking care of you. You were admitted for
difficulty speaking and moving your right side. You did not have
a stroke.
You likely had a seizure and then had post-ictal changes, you
recovered on your own.
Since you had 2 seizures in 24 hours, you will increase your
zonisamide dose to 500 mg.
You will be started on seroquel as needed for agitation/anxiety.
You will be started on Flonase for your sinuses. You may see ENT
if symptoms persist.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2170-9-6**] 11:00
|
[
"4019",
"V4581"
] |
Admission Date: [**2101-9-24**] Discharge Date: [**2101-9-30**]
Date of Birth: [**2031-7-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2101-9-26**] - Coronary artery bypass graft x4 (Left internal mammary
to left anterior descending coronary artery; reverse saphenous
vein single graft from aorta to first diagonal coronary artery;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to posterior descending coronary artery)
History of Present Illness:
70 year old male with hyperlipidemia and Type 2 diabetes has
been bothered by several months of exertional chest tightness
that has been associated with shortness of breath. This has
occured with as little as gardening and seems to respond quickly
to SL nitroglycerin. He has not had any discomfort at rest.
Recent stress testing has been notable for a large area of
ischemia involving the LAD territory. He was found to have
coronary artery disease upon cardiac catheterization and is now
being referred to cardiac surgery for revascularization.
He was originally scheduled for CABG [**2101-10-4**] and presented [**9-24**]
with repeat chest pain.
Past Medical History:
Hyperlipidemia
Non Insulin dependent diabetes
Obesity
GERD
s/p Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: 2 months ago
Lives with: wife
Contact: [**Name (NI) 91091**] [**Name (NI) 284**] (wife) Phone #[**Telephone/Fax (1) 91092**] home
Occupation: professor [**First Name (Titles) **] [**Last Name (Titles) 14925**]teaching literature
Cigarettes: Smoked no [x]
Other Tobacco use: has smoked pipes and cigars daily for
approximately 15 years. He quit 3-4 weeks ago
ETOH: < 1 drink/week [x]
Illicit drug use:denies
Family History:
No premature coronary artery disease
Physical Exam:
Pulse:65 Resp:18 O2 sat:99/RA
B/P Right:154/74 Left:151/74
Height:5'[**00**]" Weight:220 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] __none___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:N Left:N
Pertinent Results:
Admission Labs:
[**2101-9-24**] 01:00AM PT-11.5 PTT-26.0 INR(PT)-1.0
[**2101-9-24**] 01:00AM PLT COUNT-232
[**2101-9-24**] 01:00AM WBC-10.4 RBC-4.36* HGB-13.7* HCT-39.1* MCV-90
MCH-31.4 MCHC-35.0 RDW-13.1
[**2101-9-24**] 01:00AM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-2.2
[**2101-9-24**] 01:00AM cTropnT-<0.01
[**2101-9-24**] 01:00AM GLUCOSE-145* UREA N-24* CREAT-1.2 SODIUM-141
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
[**2101-9-24**] 10:31PM %HbA1c-6.9* eAG-151*
[**2101-9-24**] 11:47PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2101-9-24**] 11:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2101-9-24**] 11:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
Discahrge Labs:
[**2101-9-29**] 05:02AM BLOOD WBC-12.2* RBC-3.86* Hgb-12.1* Hct-33.9*
MCV-88 MCH-31.3 MCHC-35.6* RDW-13.4 Plt Ct-183
[**2101-9-29**] 05:02AM BLOOD Plt Ct-183
[**2101-9-26**] 01:17PM BLOOD PT-13.9* PTT-31.2 INR(PT)-1.2*
[**2101-9-29**] 05:02AM BLOOD Glucose-125* UreaN-21* Creat-1.2 Na-139
K-4.4 Cl-102 HCO3-29 AnGap-12
[**2101-9-24**] ECHO: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Chest CT [**2101-9-25**]: 1. No acute intrathoracic process. 2. No
significant tortuosity of the thoracic aorta, with common trunk
of the innominate artery and left common carotid (normal
variant).
Radiology Report CHEST (PORTABLE AP) Study Date of [**2101-9-28**] 4:50
PM
Final Report:
As compared to the previous radiograph, the right-sided chest
tube has been removed. There is unchanged appearance of the
right lung bases. No
evidence of pneumothorax. Mild areas of atelectasis. Moderate
cardiomegaly
without pulmonary edema. Moderate tortuosity of the thoracic
aorta.
Brief Hospital Course:
Mr. [**Known lastname 284**] is a 70 year old male who was originally
scheduled for coronary bypass grafting on [**2101-10-4**], he presented
to the emergency room on [**9-24**] with repeat chest pain. He
received medical management and was worked up and ruled out for
myocardial infarction. On [**9-26**] he was brought to the operating
room where he underwent a coronary artery bypass graft x4.
Please see operative report for surgical details. In summary he
had:
1. Coronary bypass grafting x4: with Left internal mammary to
left anterior descending coronary artery; reverse saphenous vein
single graft from aorta to first diagonal coronary artery;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to
posterior descending coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
3. Epiaortic duplex scanning. His bypass time was 106 minutes
with a crossclamp time of 91 minutes. He tolerated the operation
well and following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one beta blockers and diuretics were started.
Later on day one he was transferred to the step-down floor for
further recovery. One on the floor his post operative course was
uneventful, all tubes, lines and epicardial pacing wires were
removed per cardiac surgery protocol. The patient worked with
physical therapy to increase his activity level and improve
endurance. He had bursts of A Fib and was started on amiodarone.
His BBlockers were titrated as tolerated hemodynamically, and
his oral diabetes meds were resumed. On POD #5 he was discharged
home with visiting nurses. He is to follow up with Dr [**Last Name (STitle) 914**] in
one month.
Medications on Admission:
glipizide - (prescribed by other provider) - 10 mg tablet - 1
tablet(s) by mouth every morning
metformin - (prescribed by other provider) - 850 mg tablet - 1
tablet(s) by mouth twice a day
metoprolol tartrate - (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth twice a day
nitroglycerin - (prescribed by other provider) - dosage
uncertain
pravastatin - (prescribed by other provider) - 40 mg tablet - 1
tablet(s) by mouth daily every morning
isosorbide mononitrate - 30mg tablet - 1 by mouth daily
(recently started)
medications - otc
aspirin - (prescribed by other provider) - 325mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day:
start PM [**9-30**].
Disp:*60 Tablet(s)* Refills:*1*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. 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. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 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:*1*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days: 200 mg [**Hospital1 **] through [**10-5**]; then 200 mg daily
starting [**10-6**].
Disp:*60 Tablet(s)* Refills:*1*
9. glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day for 5 days.
Disp:*5 Capsule, Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x
4(LIMA-LAD, SVG->OM1,Diag,PDA)
postop A Fib
PMH:
Hyperlipidemia
Non Insulin dependent diabetes
Obesity
GERD
s/p Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg - Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] on [**11-1**] @ 2:15 pm [**Hospital Ward Name **] [**Hospital Unit Name **]
Wound check office nurse [**Last Name (Titles) **] 2A [**10-11**] @ 10:00 AM
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) 2257**] on [**10-14**] @ 8:30 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30186**] in [**5-3**] 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:[**2101-9-30**]
|
[
"41401",
"9971",
"42731",
"25000",
"2724",
"53081",
"V1582"
] |
Admission Date: [**2154-1-6**] Discharge Date: [**2154-1-14**]
Date of Birth: [**2091-10-25**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Admit to MICU for increased tachypnea
Major Surgical or Invasive Procedure:
Replacement of tracheostomy with tracheostomy "button"
decanulation
History of Present Illness:
Patient is a 62 yo man with hypercholesterolemia, hypertension,
recent admission from [**12-22**]- [**1-2**] for PNA s/p trach, STEMI
(treated primarily in [**State **] with CABG), who presents from
nursing home with tachypnea for 2 days, intermittent fevers.
.
He was transferred from [**State 108**] (where pt was visiting) to [**Hospital1 18**]
on [**2153-12-22**]. On [**2153-12-7**], he had had a STEMI s/p 6v CABG, was
extubated [**2153-12-9**], and then shortly went into PEA arrest. He
was found to have an embolic stroke in left parietal, left
internal capsule region. During post op period he was diagnosed
with HIT and Afib. He was trached on [**2153-12-18**] and started on
dialysis [**2153-12-21**]. While in house he developed fevers 100-101
with neg cultures but +LLL pna. He was treated with Cefepime,
Linezolid, and changed to Nafcillin prior to d/c with treatment
ending [**2154-1-6**].
.
On admission patient endorses pnd, orthopnea, and loose stool x
2 d. Denies chest pain, palpitations, nausea/vomiting/urinary
sx.
Past Medical History:
Hypercholesterolemia
Hypertension
CAD s/p CABG in Fl (6 grafts placed, left main, prox lad and
right post descending artery)
Afib w/ hx of embolic stroke, L parietal and L external capsule
w/ right sided hemiplegia in [**12-5**]
h/o heparin induced thrombocytopenia
PNA s/p trach [**2153-12-18**]
ARF s/p Dialysis [**2153-12-21**]
New type II diabetes mellitus
Social History:
Worked as the director at [**Hospital3 **] Health center. Married. no
smoking/drinking history
Family History:
Non-contributory.
Physical Exam:
T99.8 BP 120/70 HR 95 RR 22 O2 100% on 40% TM, FS 161
Gen: NAD,
HEENT: PERRLA, EOMI, trach in place
no obvious jvd
Lungs: bibasilar rhonchi, no wheezes, chest with cabg scar
Heart: RRR, s1 s2
Abd: Soft NT/ND +bs
Ext: 1+ edema, cool with 1+ pulses, left vein graft scar, left
quarter sized stage 2 ulcer on lower shin, right LE>Left LE,
strength 2/5 on right upper and lower ext, [**5-4**] on left
Guaiac neg in ed
AOx3
Pertinent Results:
EKG- NSR, no ischemic changes
15.4> <538
32.7
89 pmns/ 0 bands/ 3 lymphs
131 | 92 | 29 < 115
5.7 | 30 | 1.4
Trop .57
Lactate 1.4
abg 7.44/44/81 on 100% trach mask
Admit CXR: Unchanged radiograph from previous with stable
bilateral
moderate-to-large pleural effusions and stable vascular
congestion.
.
[**2154-1-6**] 04:20PM CK(CPK)-75
[**2154-1-6**] 04:20PM CK-MB-NotDone cTropnT-0.46*
[**2154-1-6**] 10:46AM TYPE-ART PO2-81* PCO2-44 PH-7.44 TOTAL
CO2-31* BASE XS-4
[**2154-1-6**] 10:41AM TYPE-ART PO2-16* PCO2-59* PH-7.36 TOTAL
CO2-35* BASE XS-4
[**2154-1-6**] 10:34AM LACTATE-1.4 K+-5.6*
[**2154-1-6**] 10:25AM GLUCOSE-115* UREA N-29* CREAT-1.4*
SODIUM-131* POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-30 ANION
GAP-15
[**2154-1-6**] 10:25AM estGFR-Using this
[**2154-1-6**] 10:25AM CK(CPK)-108
[**2154-1-6**] 10:25AM cTropnT-0.57*
[**2154-1-6**] 10:25AM CK-MB-7 proBNP-7500*
[**2154-1-6**] 10:25AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2154-1-6**] 10:25AM WBC-15.4*# RBC-3.51*# HGB-10.8*# HCT-32.7*#
MCV-93 MCH-30.7 MCHC-32.9 RDW-18.4*
[**2154-1-6**] 10:25AM NEUTS-89* BANDS-0 LYMPHS-3* MONOS-7 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2154-1-6**] 10:25AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-2+
[**2154-1-6**] 10:25AM PLT COUNT-538*#
[**2154-1-6**] 10:25AM PT-30.2* PTT-37.5* INR(PT)-3.2*
[**2154-1-6**] 10:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2154-1-6**] 10:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2154-1-6**] 10:25AM URINE RBC->50 WBC-[**3-4**] BACTERIA-MOD YEAST-NONE
EPI-0-2\
.
CXR [**2154-1-11**]:
IMPRESSION: Stable large bilateral pleural effusions. Mild
hydrostatic
edema.
Brief Hospital Course:
This is a 62 year man with coronary artery disease status 6
vessel CABG [**2153-12-7**] that was complicated by stroke (on
anticoagulation), CHF (EF 25%), pneumonia and respiratory
failure. He is status post tracheostomy placement. He was
readmitted to [**Hospital1 18**] with tachypnea from a rehabilitation
facilty. Initial differential was chiefly CHF vs. PNA. PE
appeared less likely as INR therapeutic. Of note the patient
had a recent pna with coag + staph, with hypoxia, tachypnea,
increased wbc. There was concern that he acquired noscomial
pneumonia. His presentation over the next few days appeared
more consistent with a CHF exacerbation rather than a pneumonia
so the chief goal was to optimize his volume status. A
cardiology consult was called to assist in this process.
Repeat echo revealed
EF of 40%, and a small loculated pericardial effusion, no sign
of tamponade. The patient was started on aldactone and diuresed
aggressively with furosemide. He had lost 7 kg in weight by
time of discharge and was negative 9L. His lisinopril and
Toprol doses were adjusted for low BP; he was continued on
minimal doses for secondary prevention of CHF. He will have a
repeat echocardiogram and then follow-up with Dr. [**Last Name (STitle) 171**] in
cardiology at [**Hospital1 18**] upon discharge. He should see Dr. [**Last Name (STitle) 171**]
one week after discharge. Additionally, he remained in normal
sinus rhythm. Amiodarone was discontinued. His INR was
supratherapeutic on discharge at 4.0. Coumadin was held for the
two days prior ot discharge, and INR trending down. Plan to
resume warfarin 2mg qHS when INR <3.
.
His respiratory status remained relatively stable on admission,
requiring only intermittent pressure support through the
tracheostomy. He soon was maintain good saturation on 40% trach
mask. His tracheostomy was closed with a "trach button" and he
continued to saturate well on 2L nasal cannula. On [**2154-1-13**] his
trach was decannulated. He is tolerating this well at the time
of discharge and continues to oxygenate well on 2Lnc.
.
In summary, this is a 62 year old gentleman with CHF (EF now
40%), CAD s/p recent CABG complicated by respiratory failure
requiring tracheostomy and complicated by CVA on
anticoagulation. He was admitted for tachypnea/respiratory
distress likely secondary to CHF exacerbation. Currently with
good respiratory status after diuresis and optimization of heart
failure medications. Also in the process of gettting
tracheostomy reversed. He is being transferred to
rehabilitation hospital at this time.
.
Communication is with the patient and his wife, [**Name (NI) **] [**Name (NI) 23203**] [**Telephone/Fax (1) 71007**] cell [**Telephone/Fax (1) 71008**]. He is a full code.
Medications on Admission:
Aspirin
Coumadin
Beta Blocker
Lasix
Niacin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
7. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. insulin
10 NPH qAM, 5 NPH qPM
During day use sliding scale of HUMALOG, at 151-200 give 2
units, 201-250 4 units, 251-300 6 unitS, 301-350 8 units,
351-400 10 units.
At night, dont start sliding scale until 251-300, at which point
give 2 units, 4 units for 301-350, 6 units for 351-400
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: Hold
until INR falls to 2.3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Congestive Heart Failure exacerbation
Secondary: Status post tracheostomy for respiratory failure
Status post CABG for 6 vessel coronary artery disease
Diabetes type II
Discharge Condition:
Good, breathing normally on 2 L nasal cannula. Still with some
volume overload but vastly improved compared to presentation.
Hemodynamically stable on congestive heart failure medications.
No signs of infection.
No signs of ischemia.
Discharge Instructions:
Please return pt to hospital if patient experiences chest pain,
shortness of breath or develops high fever.
Return pt to hospital for any mental status change.
Weigh pt every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc per day
Check daily INRs - hold coumadin until INR falls to 2.3, then
restart coumadin at 3mg PO qHS
Followup Instructions:
We are sending you to a [**Hospital 4487**] hospital.
Please follow up with your new cardiologist, Dr. [**Last Name (STitle) 171**], on
[**2154-1-17**].
|
[
"5859",
"4280",
"42731",
"2720",
"40390",
"V4581",
"2859"
] |
Admission Date: [**2186-4-17**] Discharge Date: [**2186-4-19**]
Date of Birth: [**2125-4-25**] Sex: F
Service: SURGERY
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
metastatic breast cancer
Major Surgical or Invasive Procedure:
s/p port removal and placement
History of Present Illness:
60 year old female with metastatic breast cancer presents for
port removal due to manufacturer recall and placement of new
port.
Past Medical History:
metastatic breast cancer
hypertension
Physical Exam:
T98.6 HR 80, BP 160/70 R 18 100% on 15L
NAD
RRR
CTA-B
s/nt/nd
no c/c/e
Brief Hospital Course:
MS. [**Known lastname 47063**] was noted to have a right apical pneumothorax on
post-operative CXR. She felt well and had minimal respiratory
complaints but was transferred to the Fenard ICU for closer
monitoring, given her high O2 requirement. Follow-up CXRs
showed no increased size to her pneumothorax.
On POD #1, she was transferred to the floor. She continued to
do well, with minimal respiratory difficulties. By POD #2, Ms.
[**Known lastname 47064**] CXRs showed a stable right apical pneumothorax, she
had no respiratory complaints, and had good pain control and was
tolerating pos.
She was discharged home in stable condition.
Medications on Admission:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO QD ().
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO QD ().
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p port removal
s/p R port placement c/b pneumothorax
L breast cancer metastatic
hypertension
Discharge Condition:
Good
Discharge Instructions:
If you have any difficulty breathing, chest pain, shortness of
breath, nausea/vomiting, or fevers/chills, please seek medical
attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2186-4-24**] 1:30
Please call [**Telephone/Fax (1) 47065**] (Radiology) to schedule an outpatint
chest x-ray for [**2186-4-21**] and [**2186-4-28**] -- and call Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 15345**] when studies are performed.
|
[
"2859",
"4019"
] |
Admission Date: [**2145-6-27**] Discharge Date: [**2145-7-16**]
Date of Birth: [**2082-11-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ancef / Keflex
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left empyema necessitans.
Major Surgical or Invasive Procedure:
[**2145-6-28**] Diagnostic thoracentesis.
[**2145-6-30**] Bronchoscopy. Left thoracotomy with drainage of left
pleural empyema, left lower lobectomy, decortication and repair
of left diaphragm.
[**2145-7-4**] Flexible bronchoscopy with therapeutic aspiration.
[**2145-7-5**] Flexible bronchoscopy and therapeutic aspiration.
[**2145-7-6**] Flexible bronchoscopy with therapeutic aspiration.
[**2145-7-7**] Flexible bronchoscopy with therapeutic aspiration.
Picc line placement
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 18734**] is a 62-year-old female with history of
rheumatoid arthritis, asthma, chronic reflux and recently
significant pneumonia of the RML and RUL in
[**11-11**]. She was treated as an outpatient with avelox for 10 days.
although she never felt totally recovered.
She presented to the ED yesterday with a history of several days
of progressive left-sided chest discomfort ("like squeezing a
sponge"), dyspnea, cough with [**Doctor Last Name 352**] sputum, chills, and night
sweats. No chest pain, pleuritic pain, fever, or chills. Her
admission CXR showed multiple air-fluid levels. Subsequently,
she underwent a CT scan that revealed a large multiloculated
left empyema, with multiple air-fluid levels, and erosion
through the left chest wall, communicating with an extrathoracic
fluid collection. She was referred for managment of the
empyema.
Past Medical History:
Kyphoscoliosis s/p multiple fusion/rods [**2127**], [**2143**]
Pyloric stenosis s/p loop gastrojej [**2117**]'s s/p Roux-en-Y [**2140**]
Multiple Pneumonias [**11-10**], [**3-12**], [**5-13**]
Rheumatoid Arthritis
Asthma
Hypertension
Anxiety
Chronic anemia
Social History:
Married, lives with husband
currently unemployed
No history of tobacco or ETOH use
Family History:
non-contributory
Physical Exam:
General: 62 year-old female in no added distress
HEENT: Sclera anicteric, Pale conjunctives. Oropharynx clear, no
gum bleeding or palatal petechiae.
[**Last Name (un) **]: Supple.
Chest: decreased breath sounds bilaterally with scattered
rhonchi on left
Heart: regular, rate & rhythm. Normal S1,S2 no murmur/gallop or
rub
Abdomen: Soft, nondistended, nontender. Neither hepato- nor
splenomegaly appreciated. normal BS
Lymph nodes: No cervical, supraclavicular, axillary, or inguinal
nodes
Ext: No edema. No swelling.
Neuro: non-focal
Pertinent Results:
ECHO [**2145-7-15**]
Conclusions:
The left atrium is normal in size. The left ventricular cavity
size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild
to moderate ([**12-8**]+) mitral regurgitation is seen. Moderate [2+]
tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
CXR [**2145-7-13**]
Status post-left lower lobectomy. Chest tube is present in the
left lower hemithorax. Since the previous study of [**2145-7-12**], there has been a significant reduction in the subcutaneous
emphysema in the left chest wall. Persistent subcutaneous
emphysema is present in both chest walls and in the neck
bilaterally. No definite pneumothorax. Ill-defined opacity in
the left lower zone is unchanged as is the pleural thickening or
fluid along the left axillary margin. Hardware present in lumbar
spine.
CBC [**2145-7-13**]
5.2 3.46* 9.7* 30.5* 88 27.9 31.7 18.9* 508*
Brief Hospital Course:
Pt was admiited to [**Hospital1 18**] w/ Left empyema necessitans. An
ultrasound guided tap was done of the left chest fluid
collection for micro. Pt was started on broad spectrum IVAB
while waiting culture data. Infectious disease was consulted and
pt was placed on resp isolation and r'd/o for TB.
Pre-op w/u revealed elevated INR of 5.3 w/o history of
anticoagulation. Hepatology was consulted and pt was found to
have VIT K deficiency. She was also transfused with PRBC for
anemia. She was given VIT K and FFP to correct her INR prior to
going to the OR on HD# 3 for Bronchoscopy,Left thoracotomy with
drainage of left pleural empyema, left lower lobectomy,
decortication and repair of left diaphragm. 3 chest tubes were
placed intraoperatively for continued draiange and lung
expansion.
Post -op pt remained intubated and admitted to the ICU for
pulmonary and hemodyanmic monitoring on neo. Extubated on POD#1.
Required serial bronchoscopies post operatively for left lung
collapse d/t secretions and inability to participate in pul
tiolet. POD#2 pt was transferred out of the intensive care unit.
She continued to required serial bronchoscopies for pul tiolet.
chest tubes placed to water seal and pt developed extensive SQ
air in the chest, neck and face. chest tubes were placed back to
sxn w/ slow resolution of SQ air over the ensuing days. One
chest tube and one [**Doctor Last Name **] were removed on POD#9 and 11. The
remaining chest tube was converted to an empyema tube w/ stable
chest XRAY.
Infectious disease followed pt closely thru out her hospital
course. Her culture data:
BAL [**6-30**] [**Female First Name (un) **]- contaminant
LLL [**6-30**] s. milleri
At this point her antibiotics were tapered and she was placed on
PCN G ( she had a questionable allergy to PCN and therefore was
moved to the ICU for her initial dosing. [**Last Name (un) **] dosing well and
was d/c'd from the ICU.
A left brachial Picc line was placed on [**2145-7-8**] with the tip in
the SVC after repostioning.
Pt progressed slowly but well and was d/c'd to home with PCN G
thru [**2145-8-11**] w/ close ID follow up and VNA/PT services.
Medications on Admission:
amirtriptyline 75, clarinex 5, clonazepam 0.5''', protonix 40,
flexeril 10prn, verapamil 120, albuterol inh prn, advair
250/50'', flonase prn, prednisone 5, ranitidine 300, lomotil
prn, darvocet prn
.
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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
8. Metoprolol Tartrate 50 mg Tablet Sig: 1 [**12-8**] Tablet PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
10. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4
million units Recon Solns Injection Q4H (every 4 hours): end
date [**2145-8-11**].
Disp:*216 Recon Soln(s)* Refills:*0*
11. Outpatient Lab Work
sma7, LFT's and cbc weekly
Fax results to infectious disease Dr. [**First Name (STitle) 1075**] [**Telephone/Fax (1) 1419**]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
kyphoscoliosis s/p fusions [**2127**]/[**2143**] (L rib bone graft in [**2143**]),
pyloric stenosis in [**2122**] s/p gastrojej [**2117**]/roux en Y [**2140**], mult
pneumonias [**2143-5-8**], seasonal affective dz, anxiety
left upper lobectomy via left thoracotomy.
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, fever, chills, redness or drainage from
your incisions or chest tube site.
If your chest or face fills up with air, call the office
immediately [**Telephone/Fax (1) 170**] and come to the [**Hospital3 **] Hospital
emergency room.
If your chest tube sutures become loose, tape the tube securely
and call the office immediately- [**Telephone/Fax (1) 170**]. If the tube falls
out, cover the site with gauze and call the office immediately.
You will need to come to the hospital emergency room.
You may not shower until the chest tube is removed.
Picc line care
intravenous antibiotic- Pen-G through [**2145-8-11**]
You are NO Longer taking verapamil.
Followup Instructions:
You have a follow up apppintment with Dr. [**Last Name (STitle) **] who is
covering for Dr. [**Last Name (STitle) **] on [**7-22**] at 10:30am on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] clinical center [**Location (un) **]. plaese arrive
45 minutes prior to your appointment for a CXR.
The VNA will draw your blood weekly - lytes, BUN/Cre and LFT's
weekly: Please Fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] [**Telephone/Fax (1) 1419**].
Please follow up with your PCP and cardiologist regarding recent
medication changes.
Completed by:[**2145-7-19**]
|
[
"4019",
"53081",
"49390"
] |
Admission Date: [**2171-5-5**] Discharge Date: [**2171-5-11**]
Date of Birth: [**2088-12-23**] Sex: M
Service: MEDICINE
Allergies:
Methyldopa / Atenolol / Codeine / Norvasc
Attending:[**First Name3 (LF) 530**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yom with history of HTN, COPD, who presents today with
shortness of breath and cough. He was in his usual state of
health until 3-4 days ago when he noticed shortness of breath
worse with exertion. He felt congested and was having an
occasionally productive cough. He tried taking mucinex which
helped somewhat but did not improve his symtpoms completely. He
notes the shortness of breath is worse at night but denies
orthopnea or sleeping on increased pillows. He had an admission
for similar symptoms in [**2169**] which were attributed to a COPD
exacerbation (though pt thought it was for pneumonia). He says
this feels the same. He is not on home O2, just advair and
combivent. He denies fevers, but did have some nightsweats over
the past couple nights.
.
In the ED, initial vs were: T 98 BP 131/56 HR: 71 RR: 30s
O2: 95-100% 3L. Patient was given albuterol/ipatropium neb and
felt better but still tachypenic and cant wean of O2 (only 90%).
Got solumederol prior to admission. CXR showed no pneumonia or
vascular congestion.
.
Upon arriving to the floor, pt appears comfortable. He is
tachypenic to 30 but otherwise looks well. He is very talkative
and not short of breath while talking
.
Review of systems:
(+) Per HPI
(-) Denies headache . Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
-hypertension
-chronic back pain
-COPD
-hyperlipidemia
-BPH
-gastritis
-DJD
Social History:
Lives alone and is independent with ADLs. He had a recent
mechanical fall with left leg bruising. He quit smoking >40
years ago. He drinks socially. No illicits.
Family History:
Positive for pancreatic cancer in his brother, positive for
diabetes in his mother, positive for CAD in his father, positive
for hypertension in his mother, positive for throat cancer in
his mother, questionable stomach cancer in his sister.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 99.6 BP: 169/74 RH: 77 RR: 20 O2: 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to angle of jaw, no LAD
Lungs: Overall decreased air movement bilaterally with bilateral
wheezes. No rales or rhonchi
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. Bruising appreciated over medial aspect of left leg
Neuro: CNs [**2-16**] intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
[**2171-5-5**] 01:04PM BLOOD WBC-11.5* RBC-4.34* Hgb-13.4* Hct-38.9*
MCV-90 MCH-30.9 MCHC-34.5 RDW-14.1 Plt Ct-165
[**2171-5-5**] 01:04PM BLOOD Neuts-84.4* Lymphs-10.1* Monos-4.2
Eos-0.7 Baso-0.7
[**2171-5-5**] 01:04PM BLOOD Glucose-110* UreaN-28* Creat-1.3* Na-141
K-4.5 Cl-102 HCO3-26 AnGap-18
.
DISCHARGE LABS:
[**2171-5-11**] 06:25AM BLOOD WBC-14.2* RBC-3.89* Hgb-12.1* Hct-34.9*
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.0 Plt Ct-172
[**2171-5-11**] 06:25AM BLOOD Glucose-113* UreaN-51* Creat-1.1 Na-143
K-4.8 Cl-104 HCO3-32 AnGap-12
.
CXR [**2171-5-5**]: There are lucencies of the apices consistent with
emphysematous change. Note is made of an azygos lobe. Chronic
basilar interstitial changes are stable in appearance. The heart
and mediastinum are within normal limits. Note is again made of
calcification of the aortic knob. There is no pleural effusion
or pneumothorax.
IMPRESSION: Emphysema, with no acute thoracic pathology.
.
[**2171-5-7**] ECG: Sinus rhythm with borderline sinus tachycardia.
Rightward axis. Prominent inferior lead Q waves are
non-diagnostic. Modest inferior lead ST-T wave changes are
non-specific. Since the previous tracing of same date sinus
tachycardia rate is slower, delayed precordial QRS transition
pattern is less prominent and inferior lead ST-T wave changes
are decreased.
.
CXR [**2171-5-9**]: IMPRESSION: Bilateral opacifications concerning for
pneumonia, unchanged since [**2171-5-7**].
.
Micro: RESPIRATORY CULTURE (Final [**2171-5-8**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Brief Hospital Course:
The patient is an 82-year-old man with medical history
significant for COPD, presenting with shortness of breath and
likely COPD exacerbation
.
# COPD exacerbation/pneumonia: Patient's symptoms and exam
point to likely COPD exacerbation as evidenced by wheezing on
exam and low O2 sats with improvement of symptoms with
nebulizers. Of note, patient did have hospitalization in [**2169**]
for COPD exacerbation. The patient did have a leukocystosis,
which resolved originally, and the patient was afebrile during
his hospitalization. Chest X-ray showed no sign of infiltrate.
Albuterol/ipratroprium nebulizers were provided. The patient was
started on prednisone 60mg daily with plan for taper. The
patient was also started on azythromycin for COPD exacerbation
and also in the less likely case of possible pneumonia. He was
weaned within a day to room air and was saturating at the low to
mid 90s. However, on HD 3, the patient developed acute
respiratory distress. He was not seen to aspirate, though his
CXR showed new bilateral lower lobe haziness. He was
transferred to the MICU and placed on Bipap. He was empirically
started on HCAP with Vanco/Cefepime/Azithro. His nebs were
increased to q2prn and over the course of 1 night on Bipap
improved. Serial CXR showed a worsening left lower lobe
infiltrate which was likely the cause for the worsening. He was
transferred back to the medical floor, where his antibiotic
regimen was tailored to cefepime and azithromycin. Patient
improved and was seen by Physical Therapy, who did not see the
need for acute physical therapy but noted tendency to desaturate
upon activity. Rehab for the continuation of antibiotics and
strengthening was determined to be the best option. The
patient's prednisone was planned for taper on discharge.
.
# [**Last Name (un) **]: Creatinine at 1.3, which was stable from last year. On
the day he was sent to the MICU his creatinine increased from
1.3 to 1.8. He was bladder scanned and had >450cc retained.
After foley put in, his creatinine decreased, so obstructive
pathology was possible. Also held ACEi and HCTZ. By discharge,
the patient's creatinine had returned to baseline or below.
.
# Indigestion/possible GI bleed: The patient complained that his
stomach felt as though he "ate something bad." His BUN is
increased out of proportion to his creatinine, which suggests he
may have a mild GI bleed. His hematocrit does not suggest a
brisk bleed. He was placed on pantoprazole and will need
follow-up.
.
# BPH: Continued on home terazosin therapy. Added finasteride 5
mg PO daily for urinary retention. Will need PRN straight caths
until this improves. It is exacerbated by Foley trauma.
.
# Hyperlipidemia: Continued on home simvastatin 10mg daily.
.
# Hypertension: Continued on home regimen of HCTZ 12.5 mg
daily, lisinopril 20 mg daily, verapamil 60mg QID until he
developed renal failure. Then lisinopril and HCTZ were held
because of acute kidney injury.
.
The patient will need outpatient follow up for possible GI bleed
causing elevated BUN.
Medications on Admission:
-albuterol nebs qid prn sob
-ipratropium nebs q6h prn SOB
-Combivent 103mcg-18mcg 2 puffs QID prn sob
-doxazosin 1mg po qhs
-advair 250/50 1 inhalation [**Hospital1 **]
-hydrocortisone cream 2.5% to the rectum [**Hospital1 **] for hemmorhoids
-lisinopril/hctz 20mg/12.5 mg daily
-simvastatin 10mg daily
-verapamil 240mg ER once daily
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulozer Inhalation Q4H (every 4
hours).
2. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours).
3. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 4 days: Continue until [**2171-5-15**].
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Hold for SBP < 100.
6. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day: Hold for SBP < 100, HR < 60.
9. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for SoB/wheeze.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for SOB/wheezing.
12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a
day: last dose [**2171-5-12**].
16. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Suppository Rectal [**Hospital1 **] (2 times a day) as needed for hemorroids.
17. 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.
18. Lidocaine Viscous 2 % Solution Sig: One (1) Appl Mucous
membrane PRN (as needed) as needed for straight cath.
19. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
-Chronic obstructive pulmonary disease
-Pneumonia (sputum culture with Gram negative rods).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 106803**],
You were admitted to the hospital for shortness of breath which
we feel was due to an exacerbation of your COPD with probable
pneumonia. We treated you with nebulizers, steroids, and
antibiotics and you improved.
We made the following changes to your medications:
STARTED prednisone.
STARTED azithromycin.
STARTED cefepime.
STARTED pantoprazole.
STARTED finasteride.
.
Please follow up with your Primary Care Physician. [**Name10 (NameIs) 6**]
appointment has been made.
Once you are home, you should continue your home inhalers and
nebulizers as needed for shortness of breath
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: THURSDAY [**2171-5-16**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"5849",
"5859",
"40390",
"2724"
] |
Admission Date: [**2136-10-7**] Discharge Date: [**2136-10-8**]
Date of Birth: [**2059-5-11**] Sex: M
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:
Attempted Right internal Jugular central line
Attempted L femoral central line
Intubation
History of Present Illness:
Mr. [**Known lastname **] is a 77 year old male with PMH significant for CAD
with 2 prior bypass surgeries and 2 PCIs, PAD s/p carotid
stenting and per patient b/l LE bypass, hypertension,
hyperlipidemia, chronic stable angina who presented with
shortness of breath in the setting of recent percutaneous aortic
valve placement at [**Hospital 69016**] Hospital in [**Location (un) 311**].
This hospitalization is the continuation of an extensive disease
course. He was admitted to the [**Hospital1 18**] recently between [**9-10**] and
[**9-11**] after VF arrest during a board meeting. He underwent CPR
with shock, was rapidly intubated and then extubated. He had
subsequent chest pain with EKG changes that led to
catheterization; Catheterization demonstrated patent stents and
LIMA and prominent severe AR.
He was transferred to [**Hospital1 3278**] because his primary cardiology, Dr.
[**Last Name (STitle) 14714**] is there. A single lead ICD was placed on [**2136-8-17**]; the
patient was discharged to home but sustained two further
ventricular fibrillation arrests. He was readmitted to [**Hospital1 3278**]
with SOB; during that admission he underwent a CT angiogram as
part of preparation for transcatheter aortic valve implantation
which resulted in contrast nephropathy. The patient was
transported on [**2136-9-23**] to [**Location (un) 311**] for TAVI procedure
(transcatheter placement of aortic valve) at [**Hospital 69016**]
Hospital. On arrival to [**Location (un) 311**] he had continued SOB with
singifcant peripheral edema. TAVI was performed on [**2136-9-26**]. He
was in complete heart block after the procedure and so his
single chamber ICT was upgraded to a dual chamber ICD. Of note,
ASA and Plavix were held on transfer from [**Location (un) 311**] back to [**Hospital1 3278**]
out of concern for dropping HCT. He was diuresed after the
procedure, but per notes continued to have some SOB upon
transfer back to [**Hospital1 3278**].
At [**Hospital1 3278**], he continued to be diuresed, and was discharged
yesterday morning. Of note, during that hospitalization the
patient requireed several blood transfusions for anemia; one
source was epistaxis.
After discharge, he immediately tried to walk around his house
and had an episode of SOB after walking that took one hour to
resolve yesterday. The patient's wife started giving him
continuous oxygen from 2L to 4L. He did not have any chest pain
during this episode. He denies any changes in his bowel or urine
habits. Again this morning around 9:30 AM, he had extreme SOB,
this time with minimal exertion when moving from bed to a chair.
This time he felt dizzy but did not have syncope and again had
no chest pain.
In the ED, initial VS were 98 111/45 16 97% 10L. The patient was
started on a Lasix bolus with drip and placed on BiPAP. His
breathing improved during his ED stay. CXR showed pulmonary
edema with possible consolidation; he was given Lasix 40 IV x1.
In the setting of WBC 20, Vancomycin was started.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY: CAD: CABG x2 [**45**] years; Cath x3 with 2
stents placed, last 2 years ago; Carotid endarterectomy 3 years
ago
3. OTHER PAST MEDICAL HISTORY:
OSA on CPAP
HTN
HL
DM
Osteoporosis
Social History:
Smokes [**12-17**] ppd
EtOH- daily wine. Occasional vodka/irish whiskey.
Family History:
CAD with MI on both mother and fathers side of the family
Physical Exam:
Admission Exam:
GENERAL: Oriented x3 and in NAD. Mood, affect appropriate.
HEENT: NCAT. Moist mucous membranes.
CARDIAC: RR, normal S1, S2. No murmur.
LUNGS: No chest wall deformities. Resp unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi. Decreased air
movement at the bases.
ABDOMEN: Soft, NTND.
EXTREMITIES: Trace lower extremity edema.
Pertinent Results:
[**2136-10-7**] 09:58PM TYPE-ART PO2-95 PCO2-24* PH-7.39 TOTAL
CO2-15* BASE XS--8
[**2136-10-7**] 09:58PM LACTATE-4.7*
[**2136-10-7**] 05:05PM GLUCOSE-149* UREA N-55* CREAT-2.5* SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
[**2136-10-7**] 05:13PM LACTATE-4.0*
[**2136-10-7**] 05:05PM CK-MB-73* MB INDX-12.2* cTropnT-1.71*
[**2136-10-7**] 05:05PM WBC-15.9* RBC-2.95* HGB-10.0* HCT-30.3*
MCV-103* MCH-33.9* MCHC-33.0 RDW-20.5*
[**2136-10-7**] 12:25PM cTropnT-0.33*
[**2136-10-7**] 12:25PM CK-MB-10
STUDIES:
CT Ab/Pelvis [**10-7**]
IMPRESSION:
1. No evidence of retroperitoneal or other hematoma. Small
region of
stranding in the right groin may relate to recent
catheterization.
2. Bilateral pleural effusions, atelectasis, and pulmonary
edema.
3. Cholelithiasis.
4. Atherosclerotic disease, infrarenal abdominal aortic
aneurysmal dilation
(2.7 cm). Apparent aneurysmal dilation at origin of bilateral
common femoral
grafts. Correlation with surgical history and any possibly
available prior
contrast enhanced studies is recommended. Evaluation of
vasculature is limited
on this noncontrast examination.
5. Small bilateral adrenal adenomas vs. nodular hyperplasia.
ECHO [**10-7**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular
chamber size is normal. A well-seated CoreValve bioprosthetic
aortic valve is seen with mobile leaflets. The transaortic
gradient is normal for this prosthesis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a prominent anterior fat pad.
IMPRESSION: Suboptimal image quality. Well-seated CoreValve
bioprosthesis with normal gradient and mild aortic
regurgitation. Mild global left ventricular hypokinesis.
Mild-moderate mitral regurgitation.
If clinically indicated, a formal complete study by lab
personnel may be useful in better defining the source of aortic
regurgitation.
Brief Hospital Course:
77 year old male with PMH significant for CAD with 2 prior
bypass surgeries and 2 PCIs, PAD s/p carotid stenting and per
patient b/l LE bypass, hypertension, hyperlipidemia, chronic
stable angina who presented with shortness of breath in the
setting of recent percutaneous aortic valve placement at [**Hospital 69017**] Hospital in [**Location (un) 311**].
His shortness of breath was attributed to PNA in the setting of
NSTEMI given rising enzymes; in addition he was thought to have
some fluid overload from a CHF exacerbation and was initially
given Lasix in the ED. On presentation, he also had an anion gap
metabolic acidosis with elevated lactate & uremia that was
thought to be due to infection; this was accompanied by
transaminitis and acute renal failure. Antibiotics were started.
A CT was done on admission to rule out RP bleed given there had
been a concern for anemia at an OSH and the patient was
complaining of severe back pain. After this was negative for
bleed, heparin drip was started for NSTEMI.
Throughout the evening, the patient developed increasing signs
and symptoms of cardiogenic shock with worsening shortness of
breath and hypotension. CPAP and BiPAP were attempted with only
temporary relief. The patient was finally intubated with the
intention of central line placement for blood pressure support.
However, immediately after intubation he developed PEA arrest.
The patient underwent two sessions of CPR for a total of 1.5
hours, regaining a pulse for only a 10 minute period between
sessions. The patient expired at 4 AM on [**2136-10-8**].
Medications on Admission:
MEDICATIONS ON LAST DISCHARGE FROM [**Hospital1 18**]:
Toprol XL 25 mg once daily
Zolpidem 5 mg Tablet QHS
Dipyridamole-Aspirin 200-25 mg Cap PO BID
Niacin 750 mg Capsule daily
Ipratropium Bromide Inhaler
Ezetimibe 10 mg daily
Clopidogrel 75 mg daily
Valsartan 80 mg daily
Allopurinol 300 mg Tablet daily
Rosuvastatin 20 mg PO daily
Folic Acid 5 mg daily
Oxycodone-Acetaminophen 5-325 mg q8h as needed for pain
Isosorbide Mononitrate 60 mg Tablet once daily
Furosemide 20 mg Tablet once daily
Namenda 10 mg once daily
Tricor 145 mg once daily
Boniva 150 mg once monthly
Zyrtec 10 mg once daily
Mucinex 600 mg twice daily
Calcium Citrate +D (600/300) daily
Nitromist 0.4 mg/Dose Aerosol
Translingual once a day as needed for chest pain.
.
MEDICATIONS ON DISCHARGE FROM [**Hospital1 **]:
Lasix 80 mg PO daily
ASA 81 mg daily
Amiodarone 200 mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
expired
|
[
"4280",
"5845",
"41071",
"486",
"2762",
"25000",
"V4582",
"V4581",
"32723",
"2724",
"3051"
] |
Admission Date: [**2190-9-19**] Discharge Date: [**2190-10-12**]
Date of Birth: [**2137-2-10**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Transferred for respiratory failure
Major Surgical or Invasive Procedure:
Intubation x2
PICC line placement
Knee Arthrocentesis x2
Septic bursectomy [**9-27**]
Tracheostomy
PEG tube placement
History of Present Illness:
53 yo F with a questionable history of prior post-surgical PE,
COPD and bullous emphysemia admitted to [**Hospital3 **] on
[**2190-9-18**] with a septic bursitis of the right knee, transferred
with acute onset hypoxia, hypotension, and tachycardia.
.
One day after attending a town fair (approximately 3-4 days
prior to admission) the patient noted right knee swelling and
discomfort. The patient attributed her symptoms to walking and
standing at the fair and took ibuprofen. Her pain and swelling
worsened. Over the following 2 days the patient developed
associated fevers, chills. She noted malaise and general
fatigue. She also endorsed a severe headache and loose stool
with associated bowel incontinence. With this constellation of
symptoms, the patient presented on [**2190-9-17**] to the [**Hospital 11373**] ED at 2345. She was noted to have a leukocytosis (14)
with bandemia (6) and to be in acute renal failure (Cr 2.1). The
patient underwent drainage of her right knee bursitis revealing
many gram positive cocci in clusters. She also had a negative
head CT and negative LP.
.
The patient was admitted to the medicine floor where she was
started on Kefzol 1g IV q6h out of concern for a septic
bursitis. Overnight with IV hydration, the patient's renal
failure resolved. On the medical floor within 24 hours of the
time of transfer, the patient developed abrupt onset of
hypoxemia, tachycardia and hypotension (with a ?chest pain?).
She was transferred to the [**Location (un) **] ICU. In the ICU, she was
noted to be in new-onset A. Fib with a troponin leak (0.14). She
received a total digoxin 0.75 mg. There was high concern for a
PE. The patient was felt too unstable to travel for a CTA and
she was started empirically on heparin gtt. Thrombolysis was
considered though her recent LP was felt to be a
contraindication. She received 3500cc NS over the last 24 hours.
She was noted to have respiratory distress following this
administration and she was given small dose of furosemide for
possible volume overload. She required a neosynephrine drip to
maintain blood pressure. A Swan-ganz catheter was placed. Her
pre-transfer CO 4.93, Index 3.01, PA 38/20, RA 11, PCWP 17, SVR
8.6, PVR 1.46. Prior to transfer she received 1amp calcium
gluconate for SVR 6.
.
ROS: Prior to admission, no chest pain, shortness of breath,
abdominal pain, melena, hematochezia, hematuria, dysuria,
hematemesis, hemoptysis, productive cough, sick contacts.
Past Medical History:
Reflux sympathetic disorder causing joint swelling and pain with
intermittent weakness.
Gluten allergy
MVA [**2182**] s/p knee arthroscopy, no known hardware
Cellulitis R arm [**2177**]
PVD
Social History:
She lives with her husband. Currently between jobs. Denies EtOH
or IV drugs. No tobacco x1 year, prior to that with 1ppd for >10
years.
Family History:
Non-contributory.
Physical Exam:
Current Exam
PE: 99.8 140 141/63 21 98% trach collar
Trach settings: PS 8/5 FiO2 50%.
Gen: NAD, comfortable on trach.
HEENT: PERRL/EOMi. Trach collar in place
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Coarse breath sounds bilaterally.
Abd: Soft, nontender, no organomegaly. +PEG tube in place
Ext: No edema.
Neuro: AAox3.
Pertinent Results:
Pertinent Lab Testing:
[**2190-9-19**] 07:26PM BLOOD WBC-18.2* RBC-3.47* Hgb-10.6* Hct-31.0*
MCV-89 MCH-30.7 MCHC-34.3 RDW-14.0 Plt Ct-292
[**2190-10-7**] 03:40AM BLOOD WBC-8.3 RBC-2.62* Hgb-8.1* Hct-24.9*
MCV-95 MCH-30.9 MCHC-32.6 RDW-16.8* Plt Ct-747*
[**2190-10-7**] 03:40AM BLOOD PT-13.1 PTT-34.0 INR(PT)-1.1
[**2190-10-7**] 03:40AM BLOOD Glucose-110* UreaN-10 Creat-0.4 Na-140
K-3.7 Cl-105 HCO3-27 AnGap-12
[**2190-9-29**] 05:15AM BLOOD LD(LDH)-180 TotBili-0.3
[**2190-9-21**] 03:13AM BLOOD ALT-29 AST-21 LD(LDH)-251* AlkPhos-256*
TotBili-0.4
[**2190-10-7**] 03:55AM BLOOD Type-ART pO2-90 pCO2-43 pH-7.46*
calTCO2-32* Base XS-5
[**2190-10-6**] 04:20AM BLOOD Type-ART pO2-96 pCO2-39 pH-7.47*
calTCO2-29 Base XS-4
[**2190-10-5**] 12:59PM BLOOD Type-ART pO2-92 pCO2-41 pH-7.46*
calTCO2-30 Base XS-4
.
MICROBIOLOGY:
[**2190-9-27**] 03:45PM JOINT FLUID WBC-7 RBC-1170* Polys-9 Lymphs-79*
Monos-5 Macro-7
[**2190-9-20**] 12:38AM JOINT FLUID WBC-9100* RBC-[**Numeric Identifier 75106**]* Polys-69*
Lymphs-16 Monos-10 Mesothe-5*
.
Swab cx
[**2190-9-20**] 12:44 am SWAB Source: R knee bursa.
**FINAL REPORT [**2190-9-24**]**
GRAM STAIN (Final [**2190-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2190-9-22**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
.
.
Imaging:
Chest CT [**9-19**]:
1. No central pulmonary embolism, however, it is not possible to
exclude a subsegmental pulmonary embolism due to extensive
interstitial lung change, pleural effusions, and atelectasis at
lung bases.
2. Extensive emphysematous changes along with interstitial and
subpleural pulmonary fibrosis, the appearances may represent
NSIP along with superimposed cardiac failure.
3. Scattered enlarged mediastinal and subcentimeter bilateral
axillary lymph nodes.
.
TTE [**9-20**]: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal (abnormal septal motion).
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
MR [**Name13 (STitle) 35632**] [**9-27**]:
1. Marked prepatellar bursitis. Equivocal overlying soft tissue
defect along the anterolateral knee is seen and correlation with
physical exam is requested.
2. Moderate joint effusion.
.
CTA [**10-1**]:
1. No visualized pulmonary embolus.
2. Interval worsening of multilobar pneumonia, likely explaining
increased hypoxia.
3. Bilateral pleural effusions.
4. No change in extensive emphysema with fibrosis and bilateral
upper lobe destruction.
.
TTE [**10-1**]:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. 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 appears structurally normal with trivial mitral
regurgitation. There is mild-moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2190-9-20**],
left ventricular systolic function is improved (septal motion is
now normal) and the estimated pulmonary artery systolic pressure
is higher.
.
CXR [**10-6**]: The endotracheal tube, upper mediastinal drain, left
subclavian catheter, and nasogastric tube are stable in
satisfactory position. The cardiomediastinal silhouette is
within normal limits. There has been slight improvement in
aeration of the right and left middle and upper lungs.
Underlying emphysematous changes are stable.
Brief Hospital Course:
A/P: 53 yo F with a questionable history of prior post-surgical
PE, COPD and bullous emphysemia admitted to [**Hospital3 **] on
[**2190-9-18**] with a septic bursitis of the right knee, transferred
with acute onset hypoxia, hypotension, and tachycardia.
.
# Hypoxic respiratory failure.
She was transferred from OSH with hypoxic respiratory failure
already intuabeted. A chest CT showed severe bullous emphysema
that was likely leading to poor oxygenation. Additionally,
there was concern for ARDS from systemic inflammation in the
setting of her septic bursitis leading to worsening oxygenation.
She was ventilated on lung protective strategies including
ARDSnet volume-control and APRV. She was treated with
Zosyn/Vanco to cover a potential community/hospital acquired PNA
although no objective evidence for this was found (multiple
negative endotracheal and BAL sputum cultures were negative).
She was treated with a course of steroids and inhaled
corticosteroids/B-agonists to treat any potential COPD
exacerbation. She was slowly weaned to pressure support
ventilation on [**9-22**] and her PEEP was slowly weaned down from
15-> 10 over several days. She was extubated on [**9-29**] but
persisted to have tachypnea and profound hypoxemia despite being
on a high flow mask. Given her persistent hypoxemia, she was
re-intubated on [**10-1**]. A CTA on [**10-1**] was performed to rule out
pulmonary emboli to rule out other causes for her profound
hypoxemia - this was negative. A TTE with bubble study was
obtained on [**9-30**] to rule out any anatomic shunting but was also
negative. It was felt that likely her poor baseline respiratory
function coupled with slowly resolving ARDS was likely the
etiology of her persistent hypoxemia. She was empirically
started on high dose IV steroids to treat potential etiologies
such as eosinophillic PNA or fibrotic ARDS without much
improvement in her respiratory status. Given her persistent
vent requirements, she had a tracheostomy placed on [**10-6**] for
eventual transfer to vent rehab for long term vent wean. Her
settings remained at PS 5/5 at 50% Fi02 on her day of discharge.
A trach collar trial was not yet attempted during her
hospitalization.
.
# Septic R knee bursitis.
Had a bursa tap at the OSH that grew MSSA with a knee
arthrocentesis that did not reveal any septic knee joint
involvement. She was initially on Vanco for empiric coverage
which was switched to Nafcillin 2g IV q6 on [**9-23**]. Given rising
WBC and persistent fevers, she was switched back to Vanco/Zosyn
on [**9-26**]. Ortho was consulted and performed a bursectomy in the
OR on [**9-27**] to complete remove the septic bursa. Her fever
curve eventually trended downward, and her WBC returned to
[**Location 213**]; she was transitioned back to Nafcillin on [**10-2**]. An
additional knee arthrocentesis in the OR again demonstarted
sterile joint space and no joint wash-out was performed. Her
stitches were removed on [**10-8**].
.
Her Nafcillin 2gm IV q6 should be continued for 6 weeks from her
bursetomy on [**2190-9-27**] (End date [**2190-11-12**]). A PICC line was
placed for long term antibiotics.
.
# Sedation: She was initially on Fentanyl/Versed gtt while
intubated. She was placed on a Fentanyl gtt and given valium to
help her slowly wean off her sedation and not precipitate
withdrawal. Please remove fentanyl patch on [**2190-10-12**].
.
# FEN: A PEG tube was placed on [**10-6**] for long term nutrition
needs given her persistent vent needs. Please continue Replete
full strength at 70ml/hr with 100mL free water flushes q6h.
.
# DMII: Pt was on humalog sc sliding scale while in patient.
Pt's FS was in 100s-200s mostly. Pt was discharged with
glipizide 2.5mg qday and metformin 500mg [**Hospital1 **] which pt was on at
home but re-started at a lower dose. These can be titrated up
as needed for glucose control in addition to sliding scale
insulin.
# Prophylaxis: Please continue Hep SQ tid and a PPI daily.
.
# Access: R PICC line inserted.
.
# Communication: Husband, [**Name (NI) **] [**Name (NI) **] (c) [**Telephone/Fax (1) 75107**]
.
# Code: Full.
.
# Dispo: To pulmonary vent rehab for long term weaning.
Medications on Admission:
Meds (prior to admission): Unknown, the patient's husband will
make a list of her medications.
.
(on transfer):
Neo gtt 40mcg
Dilaudid PRN
Dig 0.75mg
Heparin 1000U gtt
Kefzol day 1: [**2190-9-18**]
Vanco day 1: [**2190-9-18**]
Lasix 20mg IV x1 given on the day of transfer for concern of
volume overload
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
3. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: As per standard
sliding scale units Subcutaneous ASDIR (AS DIRECTED).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
6. Guaifenesin 600 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO BID (2 times a day).
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
8. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
10. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Hospital1 **]: Two (2) gram
Intravenous Q6H (every 6 hours): Continue until [**2190-11-12**].
11. Zolpidem 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime)
as needed.
12. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr [**Year (4 digits) **]: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
13. Metformin 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Septic bursitis c/b ARDS
Bullous emphysema
Hypoxemic Respiratory failure due to COPD/ARDS
Discharge Condition:
Stable to be discharged to a vent rehab
Discharge Instructions:
You are being transferred to [**Hospital **] Hospital for long term
ventilator weaning.
You will be administered medications as below.
Followup Instructions:
Please follow up with Interventional Pulmonology clinic for
assistance with trachesotomy revision or removal. Call ([**Telephone/Fax (1) 27079**] to scheduled follow up as needed.
|
[
"496",
"0389",
"51881",
"99592",
"42731"
] |
Admission Date: [**2182-9-9**] Discharge Date: [**2182-10-16**]
Service: MED
Allergies:
Captopril
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
[**Age over 90 **] yo Russain speaking M with history of CAD s/p CABG, COPD, CHF
(EF 30-35%) and recent MICU admission for PNA, sepsis requiring
intubation, now presenting with SOB, tachypnea, temperature to
102F with desaturation to 79% on room air. His saturation
improved to 97% with a non rebreather and he was then
transferred to the ED from NH. Per pt's son, [**Name (NI) **], the pt has
been more SOB and not tolerating po's over the past 2 days at
[**Hospital3 2558**]. He was recently admitted [**2182-6-24**] for aspiration
PNA and sepsis requiring intubation. He failed swallow study at
that time but was d/c'd to rehab reportedly tolerating po's. In
the ED, the pt was febrile to 102F and given lasix 20mg iv x 1
for slight CHF on CXR. ABG on 70% FM was 7.38/45/60 and BP was
borderline low. The patient was started on ceftriaxone, flagyl
and azithromycin. He was admitted to the unit for close
monitoring of blood pressure and pulmonary function.
Past Medical History:
CAD s/p CABG
CHF
recent MICU admx for PNA, sepsis
HTN
s/p CVA
hypothyroidism
anemia
s/p prostate surgery
h/o C.diff
h/o a.flutter
Social History:
Russian immigrant
60 p-y tobacco
occ EtOH
Physical Exam:
NAD, alert, oriented to person and hospital
mmm, no JVD, EOMI
heart RRR without m/r/g
pulm rales at bilateral bases. l>r
abdomen soft, nt/nd. No HSM
2+ankle edema, 1+dp pulses bilat, warm
EOMI, Pupils 4-->2mm bilat,sensation and strength intact,
dysarthric, eomi.
Pertinent Results:
[**2182-9-18**] 10:07 pm SPUTUM **FINAL REPORT [**2182-9-21**]**
GRAM STAIN (Final [**2182-9-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2182-9-21**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # 174-8437E [**2182-9-18**].
YEAST. SPARSE GROWTH.
[**2182-9-18**] 10:07 pm BLOOD CULTURE Site: A LINE **FINAL REPORT
[**2182-9-24**]**
AEROBIC BOTTLE (Final [**2182-9-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2182-9-22**]):
ENTEROCOCCUS FAECALIS
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ =>16 R =>16 R
LEVOFLOXACIN---------- =>8 R =>8 R
PENICILLIN------------ 16 R 16 R
VANCOMYCIN------------ <=1 S <=1 S
[**2182-9-15**] 5:31 am BLOOD CULTURE**FINAL REPORT [**2182-9-18**]**
AEROBIC BOTTLE (Final [**2182-9-18**]):KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 RANAEROBIC BOTTLE (Final [**2182-9-18**]):
KLEBSIELLA PNEUMONIAE.
Brief Hospital Course:
In the [**Hospital Unit Name 153**], the patient was treated with flagyl, azithro, and
ceftriaxone to cover both aspiration and nursing home acquired
pneumonia. He failed a trial of 5L nasal cannulae with
desaturation, but showed improvement on 40% FIO2 by facemask.
Chest PT was performed with emphasis to the site of the left
lower lobe pneumonia. He was supported with bronchodilators and
steroids with a plan to wean his steroids only if he required a
prolonged duration of therapy. A discussion was undertaken
about the benefit of NG tube placement with transition to PEG,
in order to limit future aspiration events. A discussion was
undertaken with the daughter and son, who agreed that this
procedure could be performed pending the patient's approval and
with the assurance of speech and swallow that the patient's
dysphagia would not improve with a temporary rest from
swallowing. The patient decided to take time to think about
whether or not to have the PEG placed, but agreed to placement
of an NG tube in the interim. He did have new EKG changes in
V5/V6 with tachycardia. This resolved after fluid resuscitation
and resoution of tachycardia. A CXR was not impressive for
signs of pulmonary edema. Fluids were otherwise kept even with
lasix as needed to prevent volume overload. The patient
appeared to have a mixed respiratory and metabolic acidosis with
no anion gap. He is perhaps unable to compensate with this
acute insult in light of his COPD and moderate renal
insufficiency.
The patient was transferred to the medicine floor [**9-18**] and later
that day developed acute respiratory distress with sat 90% on a
nonrebreather mask, respiratory acidosis, and hypotension with
BP90/50 likely due to repeat aspiration He was intubated and
returned to the ICU on the same day. He was bradycardic HR 48,
thrombocytopenic, and had digitalis toxicity. Digitalis was
permanently discontinued and thought to be the cause of the
bradycardia. Beta blockade was temporarily held for bradycardia.
The patient completed a 5 day course of stress dose steroids for
hypotension and klebsiella, enterobacter bacteremia. He received
dopamine for the hypotension and bradycardia. The patient did
well after extubation on [**9-23**] and he returned to the medicine
floor without hemodynamic instability or respiratory distress.
He was readmitted to the ICU for hypercarbic and hypoxic
respiratory failure due to aspiration, and also suffered severe
hypotension with suspected sepsis.
In ICU pt continued to be hypercarbic despite attempts at
multiple ventilator settings and O2 saturations hovered in the
high 80's. He continued to be hypotesive despite max dose
vasopressin and norepinephrine and required frequent normal
saline boluses. Pt developed acute on chronic renal failure and
became anasacic due to multiple fluid boluses resulting and
diffuse skin breakdown along with digit dry gangrene due to
vasopressors. A family meeting was called and it was decided
that the pt would be made CMO. The pt was given morphine as
needed to make respiration comfortable and he was removed from
the ventilator on [**10-15**] and pt expired the next morning.
Medications on Admission:
Regular insulin-sliding scale.
Aspirin 81 q.d.
Atorvastatin 10 mg q.h.s.
Folic acid 1 mg p.o. q.d.
Levothyroxine 75 mcg p.o. q.d.
Acetaminophen prn.
Dextromethorphan/guaifenesin 5 mL p.o. q.6h. if needed.
Solu-Medrol 50 mcg dose disk with one disk q.12h.
Inhaled fluticasone 110 mcg aerosol two puffs b.i.d.
Polyvinyl Alcohol drops 1-2 drops ophthalmic prn as
needed.
Liquid omeprazole.
Therapeutic multivitamin one cap p.o. q.d.Senna.
Docusate p.o. b.i.d.
Amiodarone 200 mg p.o. b.i.d.
Ipratropium inhalation q.6h. as needed.
Captopril now increased to 50 mg p.o. t.i.d. and
hold for systolic blood pressure less than 120.
Metoprolol 12.5 mg p.o. t.i.d.
Carbamide peroxide drops eyedrops 5-10 drops p.o.
b.i.d. for the next four days.
Furosemide 20 mg p.o. q.d., hold for systolic blood
pressure less than 110.
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic and hypercarbic respiratory failure
Discharge Condition:
Death
|
[
"5070",
"4280",
"2760"
] |
Admission Date: [**2126-6-17**] Discharge Date: [**2126-6-18**]
Service: CCU
CHIEF COMPLAINT: Sudden onset of shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female with a history of type 2 diabetes, 3-vessel coronary
artery disease, and a preserved ejection fraction of 60%, as
well as mild diastolic dysfunction who presents with the
above complaints as well as diaphoresis and nausea which
occurred suddenly while she was taking her morning
medications in her bathroom. At this time she also felt her
heart was increased. She called the Emergency Medical
Services who arrived and placed her on BiPAP with settings of
10 and 5, 1 inch of nitroglycerin paste, and gave her
morphine, oxygen, as well as 50 mg of Lasix with 300 cc of
urine output.
On arrival at the [**Hospital1 69**]
Emergency Room she received another 80 mg of Lasix, and her
BiPAP was weaned to 100% nonrebreather with saturations
greater than 99%. She was admitted to the Medical Intensive
Care Unit on the Coronary Care Unit service where she was
rapidly weaned to 4 liters of nasal cannula without
desaturation and maintained a stable respiratory rate in the
low 20s. At this time she denied any history of chest pain,
dietary indiscretion as far as salt intake, orthopnea or a
prior event similar to those which brought her to the
hospital. With her prior cardiac ischemia she has had only
nausea in the past. She has no history of paroxysmal
nocturnal dyspnea or cough, although she does report some
left lower extremity swelling which has been stable since
vascular surgery but is also reporting new onset right lower
extremity edema which she has not previously noticed. She
also orthopnea but uses two pillows at home for comfort.
PAST MEDICAL HISTORY:
1. Insulin-dependent type 2 diabetes mellitus times 20
years. Last hemoglobin A1c was 9.1.
2. Peripheral vascular disease including a right femoral to
peroneal bypass and transmetatarsal amputation in [**2123-12-20**] which was reportedly occluded in [**2124-8-18**].
She also has a left femoral to dorsalis pedis bypass which
was patent as of [**2124-8-18**].
3. History of mild chronic obstructive pulmonary disease.
She has no pulmonary function tests on record. The only
description of this diagnosis is that it is mild. She has no
tobacco history .
4. Recurrent lower extremity cellulitis.
5. Degenerative joint disease.
6. Hypertension.
7. Status post cholecystectomy.
8. Total abdominal hysterectomy.
9. Right hip fracture in [**2119**].
10. Left hip fracture in [**2123**].
11. Left humeral fracture in [**2121**].
12. C4-C5 spinal stenosis.
13. Coronary artery disease with 3-vessel disease previously
described as not amenable to coronary artery bypass graft.
Baseline electrocardiogram showed inferior and anterior
Q waves as well as ST elevation anteriorly. Cardiac
catheterization in [**2126-3-19**] performed for an isolated
troponin leak showed an ejection fraction of 60%, apical
akinesis, a left ventricular end-diastolic pressure of 14,
right coronary arteries showed diffuse disease, left coronary
arteries in this left dominant system showed an left anterior
descending artery lesion of 80% proximally, 60% mid left
anterior descending artery, and 90% distally. Left
circumflex showed a 50% lesion in the mid circumflex and a
70% lesion in the distal circumflex. There was diffuse
disease in first obtuse marginal and second obtuse marginal
with up to 70% lesion. The left posterior descending artery
was normal. She had mild diastolic dysfunction. An
echocardiogram performed in [**2126-3-19**] showed left atrial
enlargement. Dimensions were 5.6 cm X 3.9 cm. She had a
normal right atrium. She had symmetric mild left ventricular
hypertrophy. No wall motion abnormalities were described.
Delayed relaxation, trivial mitral regurgitation, and trivial
tricuspid regurgitation. As well, mild thickening of the AV
was noted; however, this was a suboptimal study.
SOCIAL HISTORY: The patient has never smoked. Has had
distant social alcohol use, none currently. Denied any other
substance use including intravenous drug abuse. She lives
with her 80-year-old sister.
FAMILY HISTORY: She has another sister with coronary artery
disease. Her father died of a myocardial infarction at 69.
Her mother died of coronary artery disease at age 67, and she
has another brother with coronary artery disease.
ALLERGIES: PENICILLIN gives her a rash, TETRACYCLINE gives
her gastrointestinal upset. She has another nonspecific
allergy reported to TERBUTALINE.
MEDICATIONS ON ADMISSION: Medications include
lisinopril 20 mg p.o. q.d., Imdur 30 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d., Tums 500 mg p.o.
q.d., multivitamin p.o. q.d., NPH insulin 17 units q.a.m. and
10 units q.p.m., atenolol 75 mg p.o. q.d. (this was increased
from 50 mg p.o. q.d. one week prior to admission).
REVIEW OF SYSTEMS: She denies symptoms of urinary tract
infections. She has been drinking seven to eight glasses of
water a day in an attempt to improve her health. She denies
abdominal pain. She does have nausea which is resolving.
She denies vomiting, diarrhea, and constipation. She reports
some arthritic leg pain. She denies rash.
PHYSICAL EXAMINATION ON ADMISSION: On physical examination,
she was saturating 97% on 3 liters and 89% on room air.
Pulse was 66, blood pressure was 143/55, temperature was 97
degrees, respiratory rate was 18 to 20. In general, she was
an obese elderly female in no acute distress. HEENT
examination showed no jugular venous distention. Mucous
membranes were moist. The patient was edentulous. Pupils
were sluggish but equal, round, and reactive to light.
Extraocular movements were intact. Cranial nerves II through
XII were intact. Cardiovascular examination was obscured by
her breath sounds but showed a regular rate and rhythm with
normal S1 and S2, and potentially a [**11-24**] murmur at her left
lower sternal border. Lung examination showed good air
movement but loud coarse breath sounds including expiratory
grumbles and wheezes and some inspiratory crackles, right
greater than left, at the bases which were decreased since
evaluation in the Emergency Room. Extremities showed a right
transmetatarsal amputation, several left toe amputations.
Surgical scars from her bypass procedures. No cyanosis or
clubbing. She had a good pulse in her left bypass graft but
none in her dorsalis pedis or posterior tibialis on either
side. She had prominent pitting edema to slightly above her
knees.
LABORATORY ON ADMISSION: White blood cell count was 11.6,
hemoglobin 15, hematocrit 45.8, platelets 237. Sodium 139,
potassium 3.8, chloride 102, bicarbonate 24, BUN 16,
creatinine 0.7, glucose 277. Calcium 8.8, magnesium 1.8,
phosphorous 4.9. PT 12.3, INR 1, PTT 23.5. Creatine kinase
was 58 on admission. Troponin returned at less than 0.3.
Urinalysis was positive for nitrites, negative for white
blood cells and showed few bacteria. Lipid profile obtained
in [**2126-3-19**] showed an LDL of 85, an HDL of 43, a
triglycerides of 60.
RADIOLOGY/IMAGING: Chest x-ray was obtained in the lordotic
position and was also rotated which showed an elevated left
hemidiaphragm secondary to a large amount of gastric air.
There was left costophrenic angle blunting. The right was
not included in the x-ray. She had a central alveolar
pattern in her lung fields, consistent with congestive heart
failure.
Electrocardiogram at baseline the patient has Q waves and ST
elevations in V2 through V3 as well as T wave flattening in
V5 through V6 and I. She also has Q waves in inferior leads
III and F as well as V1 and V4. On admission she was in
sinus tachycardia at 111, had a normal axis, and had ST
elevations in V1 through V4, had T wave inversions and
flattening in the same leads, left atrial enlargement,
possibly a right atrial abnormality, Q waves in II, III, F,
V1 through V5; 40 minutes later the patient was in a sinus
rhythm at 81, axis was 0, ST elevations had decreased in V1
through V3, and she had one premature ventricular
contraction.
IMPRESSION: Impression at that time was that this was a
76-year-old female with 3-vessel coronary artery disease,
diabetes, diastolic dysfunction with flash pulmonary edema
and rapid improvement with oxygenation and subjective
breathing while in the hospital.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: As far as her pump function, the patient
was continued on 1 inch of nitroglycerin paste. She was
given supplemental oxygen by nasal cannula. She was given
further Lasix 60 mg and 100 mg over the first night of her
admission as well as potassium repletion and diuresed
3 liters by discharge the following day. By afternoon the
next day, she was feeling entirely well, was breathing at her
baseline, saturating 95% to 96% on room air, and had no
complaints. She was taking a full diet. The day after
admission the team increased her lisinopril to 30 mg q.d. and
put her on standing Lasix 60 mg p.o. q.d. Her nitroglycerin
paste was switched to Imdur. The possibility of excessive
volume intake or dietary indiscretion in terms of sodium were
discussed with the patient. She was to decrease her fluid
intake to only when she is thirsty and to avoid high-salted
foods.
As far as her coronary artery disease, the patient ruled out
for myocardial infarction by enzymes; although, it was
impossible to rule an episode of ischemia which worsened her
diastolic dysfunction and precipitated this event. Her beta
blocker, ACE inhibitor, and aspirin were continued. In spite
of her acceptable lipid panel, no lipid lowering medications
were started. She was seen by Cardiothoracic Surgery the day
after admission for consideration of possible coronary artery
bypass graft. Surgery felt that she would be a acceptable,
but technically difficult, coronary artery bypass graft to
perform.
As far as her electrical issues, the patient was monitored on
telemetry and had no arrhythmias inhouse, but it was not
possible to exclude transient arrhythmia as a cause of her
flash pulmonary edema. At discharge, her plan for management
of her coronary artery disease was to include medical
management at this time, follow up with her primary care
physician (Dr. [**First Name (STitle) **], as well as consideration for
dobutamine echocardiogram or stress nuclear perfusion imaging
should the patient have recurrent episodes with consideration
of coronary artery bypass graft in the future if required.
2. ENDOCRINE: The patient's diabetes was managed with
q.i.d. fingersticks and regular insulin sliding-scale with
good control.
3. PULMONARY: The diagnosis of her chronic obstructive
pulmonary disease was discussed with Dr. [**First Name (STitle) **] who was
uncertain why this had appeared in records and was unaware of
any data that suggested this diagnosis. We therefore believe
that she had been misdiagnosed with chronic obstructive
pulmonary disease and was actually having an episode of heart
failure at the time this diagnosis was made. There were no
pulmonary function tests to support the diagnosis of chronic
obstructive pulmonary disease. The patient does not have a
history of tobacco use, and she is slightly old to be
presenting with alpha-1 antitrypsin disease.
4. INFECTIOUS DISEASE: Her urinalysis was repeated and was
entirely normal, and she was therefore not treated for the
nitrite-positive urinalysis on admission.
5. HEMATOLOGY: The day after admission, the patient was
noted to have a hematocrit of 33.4 which was greater than 10
points lower than her admission hematocrit of 45.8. The
patient was heme-negative in the Emergency Room, and on
repeat examination after this hematocrit was obtained. The
patient's prior hematocrits were reviewed and it was noted
that her admission hematocrit of 45.8 was markedly elevated
to her baseline which was in the middle 30s. A repeat
hematocrit the day after admission was slightly increased
from that morning value, and it was therefore felt that the
elevated value of 45.8 was spurious.
6. FLUIDS/ELECTROLYTES/NUTRITION: The patient had potassium
repletion in the hospital and was placed on a low-sodium,
low-fat, heart-healthy diabetic diet. She was to follow up
her potassium and diet with Dr. [**First Name (STitle) **] as an outpatient.
CONDITION AT DISCHARGE: Stable.
CODE STATUS: Full code.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 30 mg p.o. q.d. (increased from 20 mg).
2. Atenolol 75 mg p.o. q.d.
3. Lasix 60 mg p.o. q.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. NPH insulin 17 units q.a.m. and 10 units q.h.s.
6. Imdur 30 mg p.o. q.d.
7. Multivitamin p.o. q.d.
DISCHARGE FOLLOWUP: Followup was arranged with Dr.[**Name (NI) 39123**]
nurse [**First Name (Titles) 96208**] [**Last Name (Titles) **] on [**6-25**] and with Dr. [**First Name (STitle) **] shortly
thereafter.
DISCHARGE DIAGNOSES:
1. Flash pulmonary edema in the setting of normal systolic
function, diastolic dysfunction, and 3-vessel coronary artery
disease.
2. Insulin-dependent diabetes mellitus.
3. Peripheral vascular disease.
4. Recurrent lower extremity cellulitis.
5. Degenerative joint disease.
6. Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-6-19**] 10:48
T: [**2126-6-21**] 06:28
JOB#: [**Job Number 96209**]
|
[
"4280",
"496",
"41401",
"25000",
"4019"
] |
Admission Date: [**2107-7-20**] Discharge Date: [**2107-7-25**]
Date of Birth: [**2045-2-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 y/o F with a history of chronic progressive multiple
sclerosis, hypertension, anorexia nervosa, recently diagnosed
with Clostridium difficile diarrhea, represents due to a
worsening leukocytosis, anasarca, abdominal distension, and
profuse diarrhea. Per her husband she was started on
ciprofloxacin in mid- [**Month (only) 205**] and 4-5 days later started to have
profuse watery diarrhea for which her urologist, Dr. [**Last Name (STitle) **],
provided her with imodium. The next day ([**7-11**]), she was taken to
[**Hospital3 **] because of the diarrhea and dehydration. She was found
to have moderately low blood pressures. She was given fluids and
diagnosed with c.diff. The day after admission, she had a BP of
76/51 and was transferred to the ICU. Of note during her
hospitalization her weight went from 83 lbs to 132 lbs and she
became anasarcic. Her treatment consisted of IV flagyl and PO
vanco initially. Her IV flagyl was stopped upon discharge from
[**Hospital3 **]. Her plan was to complete 14 d course of PO vanco. At
rehab, she was started on dual therapy IV vanco and flagyl. She
always denied fevers, chills, nausea, vomitting. She would have
intermittent abdominal pain. On [**7-18**] She was discharged to [**Hospital1 13696**] rehab where she was started on TPN. At rehab she was noted
to have an increased WBC count from 15 (on discharge from [**Hospital **]) to 29. She also had an increasingly tender abdomen so she
was sent to [**Hospital1 18**] ER for further eval.
.
In the ED, initial vs were: T 100.1, P 80, BP 118/76, R 19, O2
sat 95% on 4L. She was persistently tachycardic in 110s-120s
while in the ED; did not decrease with IVFs. Patient was given
Flagyl IV 500 mg x1, Vanco 500 mg IV x1, zofran x1 and 1.5L NS
IVFs.
.
On the floor, she is feeling well. She noted shortness of breath
earlier in the day, but it has since resolved. She has no cough,
fevers, chills. No nausea, vomitting. She does not eat well,
although has been trying to drink ensure. She denies headaches,
dizziness.
Past Medical History:
Multiple sclerosis (diagnosed in [**2086**], chronic progressive for
20 y, wheel chair bound and has a paraplegia at baseline)
Depression
Anorexia nervosa
HTN
Osteoporosis
Social History:
Worked in CPA firm, no longer working but accompanied husband to
work, wheelchair bound; used to drink socially, no tobacco or
drug history; has 2 children with grandchildren
Family History:
Mother-colorectal ca
[**Name (NI) 100464**] hemorrhage
Physical Exam:
Vitals: T: 96.8, BP: 118/59, P: 109, R: 28, O2: 93% on 4L
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 breath sounds [**1-25**]
up lung fields on back, no crackles or wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present but
mildly hypoactive, no rebound tenderness or guarding, no
organomegaly
GU: foley
Rectal: poor tone, soft nonbleeding external hemorrhoid
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema wiht pink, blotchy rash bilaterally
Pertinent Results:
labs-
[**2107-7-20**] 02:30PM BLOOD WBC-25.5*# RBC-2.77*# Hgb-8.0*#
Hct-26.4*# MCV-95 MCH-28.7 MCHC-30.1* RDW-15.4 Plt Ct-490*
[**2107-7-25**] 04:54AM BLOOD WBC-21.4* RBC-3.26* Hgb-9.2* Hct-29.6*
MCV-91 MCH-28.1 MCHC-30.9* RDW-16.5* Plt Ct-280
[**2107-7-20**] 02:30PM BLOOD Neuts-84* Bands-4 Lymphs-7* Monos-3 Eos-1
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2107-7-20**] 02:30PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Spheroc-OCCASIONAL
[**2107-7-21**] 04:01AM BLOOD PT-11.4 PTT-24.9 INR(PT)-0.9
[**2107-7-20**] 02:30PM BLOOD Glucose-774* UreaN-17 Creat-0.5 Na-129*
K-5.5* Cl-91* HCO3-30 AnGap-14
[**2107-7-20**] 03:20PM BLOOD Glucose-132* UreaN-17 Creat-0.3* Na-135
K-3.9 Cl-100 HCO3-29 AnGap-10
[**2107-7-25**] 04:54AM BLOOD Glucose-106* UreaN-16 Creat-0.4 Na-138
K-4.4 Cl-103 HCO3-30 AnGap-9
[**2107-7-20**] 02:30PM BLOOD ALT-24 AST-23 AlkPhos-77
[**2107-7-22**] 06:36AM BLOOD ALT-27 AST-30 LD(LDH)-242 CK(CPK)-47
AlkPhos-102 TotBili-0.1
[**2107-7-20**] 10:50PM BLOOD calTIBC-150* Ferritn-147 TRF-115*
[**2107-7-25**] 04:54AM BLOOD Triglyc-123
[**2107-7-20**] 10:50PM BLOOD TSH-6.2*
[**2107-7-21**] 04:01AM BLOOD Free T4-0.94
[**2107-7-20**] 02:48PM BLOOD Lactate-1.4
[**2107-7-21**] 08:59PM BLOOD Lactate-0.8
[**2107-7-21**] 01:01AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
[**2107-7-21**] 01:01AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
[**2107-7-24**] 12:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2107-7-21**] 4:25 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2107-7-23**]**
FECAL CULTURE (Final [**2107-7-22**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2107-7-23**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-7-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CT Abd/pelvis [**7-20**] with contrast
IMPRESSION:
1. Abnormal hyperenhancement and wall thickening of the left
hemicolon,
consistent with patient's history of colitis. Large amount of
ascites. No
evidence of perforation.
2. Bilateral pleural effusions with compressive lower lobe
atelectasis.
Echo [**7-21**]
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Large left pleural effusion.
Left upper ext ultrasound
IMPRESSION: No evidence of DVT.
Brief Hospital Course:
62 y/o F with hx of MS, HTN, and anorexia who was recently
diagnosed with c.diff colitis and admittted with recurrent
diffuse watery diarrhea.
.
# C.diff Colitis: The patient has hx of c.diff colitis form
outside hospital. Upon admission, she continued to have
voluminous diarrhea output requiring rectal tube placement. The
patient was also intravascularly volume depleted secondary to
decreased PO intake and increased diarrhea output. She initially
had borderline hypotension and tachycardia to 120s, and received
IVF as well as PRBC transfustion to replete volume. The patient
was noted to have leukocyctosis, likely from inadequate
treatment of severe infection, which trened down to 21 at
discharge. CT scan was consistent with colitis, no dilation,
abscess or perforation. The patient was initially on IV flagyl
and PO vanco later changed to PO flagyl and PO vanco. She was
maintained on bowel rest in the MICU with TPN for nutrition
until diarrhea decreased, and now is briging with TPN back to a
regular diet. Her diarrhea stopped on [**2107-7-23**], and she will need
a 14 day course of these abx from this date (end date [**2107-8-6**])
and then a [**Doctor Last Name 2949**] of the vancomycin. Taper will be 125 mg
vancomycin PO BID for 7 days, followed by 125 mg PO daily for 7
days, followed by 125 mg every other day for 2 weeks.
.
.
# Anasarca: She initially developed anasarca secondary to
aggressive rehydration in the setting of hypoalbuminemia with
her initial c. diff infection. During this hospital course this
improved with Lasix 10mg IV x 2 during her stay. She has a poor
nutritional status which likely causes her anasarca. She was
continued on TPN as above. UA was negative for protein, to rule
out nephrotic syndrome. Echo was checked to rule out heart
failure, ef was normal.
.
# Anemia - patient has new anemia from baseline. Hct of about
25 on admission, up to 29 at discharge. Likely from slow blood
loss due to colitis. Was given 1 unit of RBCs during admission.
Hct then remained stable.
.
# Tachycardia / relative hypotension: as discussed above,
secondary to volume depletion from diarrhea. Not febrile,
lactate normal. Do not think she has septic shock. Improved to
low 100s at dishcarge.
.
# L arm swelling: L arm slightly more swollen than R arm, is the
same arm where PICC was placed. No erythema, intact pulses. US
of left arm showed no DVT.
.
#. lower extremity pain: The patient began complaining of
bilateral pain at back of thigh and knees on [**7-22**]. Due to high
risk for DVT in setting of immobility, bilateraly LENI's were
done and were negative for DVT. Pain improved with Tylenol and
repositioning.
.
# MS: stable, unchanging symptoms. Neuro consulted in the ED,
followed pt. She was continued on her Oxybutinin and Impramine
at home doses. Provigil was held due to tachycardia and should
be restarted as out pt when appropriate.
.
# HTN: SBPs stable in 100s, holding antihypertensives for now.
Valsartan and quinapril should be restarted as outpatient when
appropriate.
.
# Anorexia: long standing issue (for >20 years). Was restarted
on TPN prior to admission. Continued on TPN during her hospital
course. Changed to cycled TPN during nights only to encourge
appetite. Meals were supplemented with Ensure.
.
The patient was discharged to [**Hospital **] [**Hospital **] rehab on [**2107-7-25**].
Medications on Admission:
Alendronate-Vitamin D3 70 mg-2,800 units weekly
Ergocalciferol (Vitamin D2) 50,000 unit Capsule monthly
Econazole 1 % Cream [**Hospital1 **]
Imipramine 100 mg qHS
Modafinil 100 mg daily
Oxybutynin SR 5 mg Tab daily
Quinapril 40 mg daily
Valsartan 160 mg daily
Guar Gum [Benefiber] 1 g tab daily
One-A-Day Womens Formula daily
Potassium Chewable 20 mg tabs, 0.5 tabs daily
Nexium EC 40 mg daily
Phos-NaK 280mg-160mg-250mg packets, 1 pack daily
Mag-[**Doctor Last Name **] 200mg-200mg/5ml, 10ml q6hrs
Tums 500 mg tabs, 2 tabs [**Hospital1 **]
Florastor 250 mg [**Hospital1 **]
Ativan 0.5 mg PO q4hrs PRN
Tobramycin 0.3% Oph Soln 2 gtt each eye daily
Regular (Novolin) Insulin SC
SQ Hep tid
TPN
.
Vanco 250 mg IV q6hrs - started at [**Hospital1 1872**]
Flagyl 500 mg IV q8hr - started at [**Hospital1 1872**]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 11 days: Last day [**8-6**] at this dose, then taper as
directed.
3. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days: last day of course [**8-6**].
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Alendronate-Vitamin D3 70-2,800 mg-unit Tablet Sig: One (1)
Tablet PO once a week.
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
14. Benefiber (Guar Gum) 1 gram Tablet Sig: One (1) Tablet PO
once a day.
15. Tobramycin Sulfate 0.3 % Drops Sig: Two (2) drops Ophthalmic
once a day.
16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO twice a day.
18. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
20. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous PRN
line flush.
21. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous PRN
line flush.
22. Saline flush
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:
[**Hospital1 700**]
Discharge Diagnosis:
C. dif infection
anasarca
primary:
C. dif infection
.
secondary:
multiple sclerosis
anorexia nervosa
Discharge Condition:
The patient was discharged in good condition, afebrile, with
stable vital signs.
Discharge Instructions:
You were admitted to the hospital with diarrhea and were found
to have a recurrence of C dif infection. You were treated with
antibiotics and your symptoms should continue to improve.
You will need to continue these antibiotics for several weeks.
.
You also received supplemental nutrition through your IV. You
will continue to receive this at rehab, but you should start to
eat more on your own.
.
The following changes were made to your home medications:
--> You will take Flagyl and vancomycin as directed until [**8-6**].
You will then take decreasing doses of vancomycin as directed
for the next several weeks.
.
--> You will not take Provigil, quinapril or Valsartan unless
directed by physician.
.
Please seek medical attention if you experience fever, cough,
shortness of breath, abdominal pain, diarrhea, or any new
symptoms.
Followup Instructions:
You should follow-up with your primary care physician after you
leave [**Hospital **] [**Hospital **] rehab.
|
[
"4019",
"2859"
] |
Admission Date: [**2198-11-11**] Discharge Date: [**2198-11-16**]
Date of Birth: [**2170-4-19**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
28 year old male with DM1 complicated by nephropathy,
retinopathy, and severe gastroparesis requiring multiple
admissions and gastric pacer placement, who presented to the ED
from home complaining of nausea and vomiting for over 2 days.
The patient is uncomfortable and only limited history can be
obtained. He reported multiple bouts of emesis similar to his
usual flare of gastroparesis. Came to the ED after he failed po
reglan in addition to his other regimen at home. His emesis was
initially clear/yellow and then turned brown which he states is
not unusual for him. He denies any fevers, chills, abdominal
pain. His last BM was earlier today. No [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] red blood in
emesis. No BRBPR or melena. He denies any focal complains. His
last Glargine dose was yesterday [**2198-11-10**]. He took Humalog
today.
.
In the ED initial VS 99.7; 119; 164/93; 16; O2 sat 99%. He was
given 2 liters of NS, as well as dolasetron 12.5 mg IV,
promethazine 12.5 mg IV x2, and metoclopramide 10 mg IV x 2.
Past Medical History:
1) Type 1 Diabetes Mellitus: Diagnosed at age 2, complicated by
retinopathy (blind in left eye), neprhopathy (see below),
gastroparesis. Followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **].
2) Chronic renal insufficency: baseline Cr ~ 1.6-2; +
proteinuria
3) Gastroparesis: Since [**2194**]. Received Botox injection to the
pylorus in 3/[**2197**]. Had Gastric stimulator placed on [**2197-11-10**] by
Dr. [**Last Name (STitle) **]. Flare regimen includes reglan, Zelnorm,
phenergan, compazine, and anzemet. Pacer last interrogated
06/[**2198**].
4) History of hypoglycemic seizure
5) Hypertension
6) Migraines
7) Depression
8) Anemia
9) Gastritis/esophagitis
Social History:
Patient lives with his wife who is very dedicated to his care.
Denies tobacco, alcohol, and illicit drug use. He is currently
unemployed and on disability.
Family History:
Paternal grandfather with [**Name (NI) 59282**]
Mother and sister with thyroid disease
Physical Exam:
VS: T: 97 (axillary); BP 170/88; HR 118; RR 18; 100% on RA
GENERAL: Very uncomfortable appearing male, vomiting small
amounts of dark coffee ground material throughout the interview.
NECK: supple, no LAD
HEENT: PERRL, no scleral icterus, MM tachy
CV: regular, tachycardic, no murmurs/rubs/gallop appreciated.
PULM: CTA bilaterally
ABDOMEN: Hyperactive bowel sounds, soft, non-tender,
non-distended. Gastric pacer is palpable.
EXTR: No edema, warm.
NEURO: alert, answers questions appropriately
Exam abbreviated due to the patient's discomfort.
Pertinent Results:
[**2198-11-11**] 06:30PM BLOOD WBC-8.0 RBC-4.60 Hgb-12.0* Hct-35.8*
MCV-78* MCH-26.0* MCHC-33.4 RDW-12.7 Plt Ct-384
[**2198-11-12**] 07:59PM BLOOD WBC-13.9* RBC-3.45* Hgb-9.5* Hct-26.9*
MCV-78* MCH-27.4 MCHC-35.2* RDW-12.9 Plt Ct-315
[**2198-11-16**] 05:35AM BLOOD WBC-9.2 RBC-3.30* Hgb-9.0* Hct-25.6*
MCV-78* MCH-27.3 MCHC-35.2* RDW-12.7 Plt Ct-241
[**2198-11-11**] 06:30PM BLOOD Neuts-64.3 Lymphs-25.3 Monos-5.7 Eos-3.3
Baso-1.4
[**2198-11-12**] 05:40AM BLOOD Neuts-94* Bands-0 Lymphs-5* Monos-0 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2198-11-16**] 05:35AM BLOOD Neuts-56.5 Lymphs-28.9 Monos-10.8 Eos-3.4
Baso-0.3
[**2198-11-13**] 03:06AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2198-11-11**] 06:30PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1
[**2198-11-12**] 05:40AM BLOOD PT-12.2 PTT-17.8* INR(PT)-1.0
[**2198-11-14**] 06:36AM BLOOD PT-12.7 PTT-21.9* INR(PT)-1.1
[**2198-11-11**] 06:30PM BLOOD Glucose-150* UreaN-23* Creat-2.3* Na-139
K-4.0 Cl-99 HCO3-27 AnGap-17
[**2198-11-12**] 07:59PM BLOOD Glucose-309* UreaN-28* Creat-2.0* Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
[**2198-11-14**] 06:36AM BLOOD Glucose-103 UreaN-12 Creat-1.8* Na-141
K-4.1 Cl-109* HCO3-23 AnGap-13
[**2198-11-16**] 05:35AM BLOOD Glucose-133* UreaN-19 Creat-1.8* Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
[**2198-11-11**] 06:30PM BLOOD ALT-16 AST-17 AlkPhos-93 Amylase-104*
TotBili-0.3
[**2198-11-11**] 06:30PM BLOOD Lipase-21
[**2198-11-12**] 05:17PM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
[**2198-11-14**] 12:39AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8
[**2198-11-16**] 05:35AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1
[**2198-11-12**] 07:59PM BLOOD Acetone-SMALL
[**2198-11-12**] 08:11AM BLOOD Type-ART pO2-108* pCO2-33* pH-7.39
calTCO2-21 Base XS--3
[**2198-11-12**] 06:45PM BLOOD Type-ART pO2-48* pCO2-39 pH-7.40
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2198-11-12**] 07:23PM BLOOD Type-ART pO2-106* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2198-11-12**] 08:11AM BLOOD Lactate-1.6
[**2198-11-12**] 06:45PM BLOOD Lactate-3.9* K-3.9
[**2198-11-12**] 07:23PM BLOOD Lactate-3.1* K-4.0
[**2198-11-12**] 07:59PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2198-11-12**] 07:59PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-11-12**] 07:59PM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2198-11-13**] 03:07AM URINE Hours-RANDOM Creat-47 Na-94
[**2198-11-13**] 3:07 am URINE Site: NOT SPECIFIED
**FINAL REPORT [**2198-11-14**]**
URINE CULTURE (Final [**2198-11-14**]): NO GROWTH.
[**2198-11-12**] Blood cultures PENDING
[**2198-11-11**] ECG: Sinus tachycardia. Otherwise, tracing is within
normal limits.
[**2198-11-12**] Abd XRay: PORTABLE ABDOMEN: Single view of the abdomen
shows some stool and small amount of gas are seen in the rectum
and in the ascending colon. The remainder of the abdomen is
gasless. No loops of bowel are seen. A neuro stimulating device
over the thoracolumbar spine is again noted. Bony structures are
within normal limits.
IMPRESSION: No definite evidence of obstruction, however,
gasless abdomen makes evaluation of small bowel loops difficult.
[**2198-11-12**] CXR: The heart size is normal, and there are no
mediastinal or hilar abnormalities. The lungs are clear, and no
pleural abnormalities are evident on this single projection.
Gastric stimulator leads project over the upper abdomen,
unchanged.
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
28 yo M with DM1 and severe gastroparesis s/p gastric pacer
placement with recurrent admissions for gastroparesis flares
presents with nausea and vomiting, most likely secondary to
recurrent gastroparesis flare with suspicion of overlying
infection.
.
# Nausea and vomiting: Anion gap acidosis. Abdomen soft and
benign on exam. LFTs and lipase are WNL. EKG with sinus tach.
Gastroparesis flare is the most likely etiology as the patient
reports that his symptoms are similar to his usual symptoms with
gastroparesis flare. Small bowel obstruction is also in the
differential but given reassuring abdominal exam and history
will defer further imaging at this time.
.
Pt was kept NPO and given IVF. His home PO medicines were held.
He was given IV anzemet, compazine, reglan, and phenergan for
nausea. He was having coffee grounds emesis, which per pt is
usual for his episodes of gastroparesis, but emesis was
gastroccult negative. GI and [**Last Name (un) **] were made aware of pt. Pt
was given IV hydralazine for BP control and IV protonix for GI
ppx. Labs and HCT were followed to watch for DKA and bleeding.
Pt refused NG lavage and HCT was stable, pt had PIVx2 and active
type and crossmatch. Pt was kept on telemetry to follow HD
stability as he was tachycardic. Urine and blood cultures were
obtained as pt was febrile and had a leukocytosis. Pt was given
slightly less glargine than usual as he was NPO and covered with
SS humalog.
.
Pt had critical BS levels x3 fingersticks. Pt had FS at 4:30pm
which was >500 and pt was given 18units of humalog insulin. BS
was checked again at 5pm and BS was again >500. Labs were drawn
and 1L LR was given (pt has been getting 200cc/hr). BS at 5:15pm
was 561 on his chem panel. 8 units of regular insulin were given
IV at 5:45pm and at 6pm his BS was >500 on finger stick. At this
point the decision was made with the primary care team in
conjunction with the [**Last Name (un) **] attending, Dr. [**First Name (STitle) 3636**], for the pt to be
transferred to the ICU for an insulin drip in order to control
his blood glucose. The MICU resident was notified and an ICU bed
obtained. At 6:15pm the pt's BS was 445. Pt was then transferred
to the MICU.
.
****ICU Course****
Pt was maintained on insulin drip for improved glycemic control
until HD#5 when he was able to tolerate POs and again take his
lantus and humalog insulin injections. He was given aggressive
IVF hydration and anti-emetics on HD#5 and although he had a
small anion gap HD#2 it had resolved by HD#3 and never went into
DKA although there were small amounts of ketones in his blood at
the time of his transfer to the ICU. He was maintained on the
anti-emetic, PPI, IVF as before. He required hydralazine and
metoprolol IV to control his tachycardia and HTN until he was
able to take POs and restart his home meds. His acute on
chronic renal failure improved with fluid hydration to his
baseline around 1.7. Once he was tolerating POs and off the
insulin drip, he was transferred back to the floor. When the pt
was tolerating POs he was restarted on his home tegaserod. GI
recommended erythromycin as a prokinetic but the pt refused to
take it as it upset his stomach.
.
HD#5 pt was transferred to floor. He was able to tolerate a
diet and his blood sugars were controlled on his home regimen.
His HCT was stable at his baseline around 26. He was taking his
home PO medications to control his HTN. His WBC was normal
HD#6. No antibiotics were ever given as no source of infection
was ever determined and pt stated that he normally has a fever
and increased WBC during his episodes of gastroparesis.
.
10. Full code
Medications on Admission:
1. Metoclopramide 10 mg PO TID PRN nausea
2. Tegaserod Hydrogen Maleate 6 mg PO BID
3. Valsartan 80 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. Pantoprazole 40 mg Q12H
6. Insulin Glargine 25 Units SQ QHS
7. Ferrous Sulfate 325 PO BID
Discharge Medications:
1. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
7. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
8. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) UNITS
Subcutaneous at bedtime.
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-6 UNITS
Subcutaneous four times a day as needed for FSBG >150: Per
Sliding Scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Gastroparesis
Secondary Diagnosis:
1. Metabolic Acidosis- Starvation Ketosis
2. Volume Depletion
3. Diabetes type I
Discharge Condition:
stable. tolerating PO's. off IV pain control, anti-emetics
Discharge Instructions:
You were admitted for gastroparesis and treated with insulin and
intravenous fluids. If you have recurrent abodminal pain,
nausea, vomiting, fever >101, or other concerning symptoms
please see your primary care physician or present to the
emergency department for evaluation.
Followup Instructions:
Please call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] to make an
appointment with a new PCP [**Last Name (NamePattern4) **] [**2-9**] weeks. The clinic is located
in the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**] of [**Hospital1 771**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"2762",
"5859",
"V5867",
"4019",
"42789",
"2859",
"311"
] |
Admission Date: [**2184-2-7**] Discharge Date: [**2184-2-13**]
Date of Birth: [**2135-4-10**] Sex: M
Service: MEDICINE
Allergies:
Remicade / Lipitor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
dyspnea, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 year old man here with complaint of decreased po intake and
inability to get out of bed for 5 days. Pt was in his usual
state of health until 5 days earlier when he [**Last Name (un) 4996**] to have
generalized fatigue. The next day he began to experience a
decrease in appetite, nausea, decreased PO intake, subjective
fevers, chills and diarrhea: Pt normally has [**5-9**] BMs per day
from Crohns disease, however on this day his stools became more
watery and frequent. Pt frequently has blood streaked stools,
but has not noticed an increase in bloody stools, and denies
black tarry stools. Meanwhile his generalized fatigue was
worsening to the point that it was difficult for him to make it
out of bed and into the bathroom. By the day of admission pt had
continued low PO intake, and has notices decreased urine output.
The diarrhea had begun to resolve, and on the day of admission
pt had not had any bowel movements.
Pt reports that his wife was recently sick with the flu, however
her symptoms consisted mostly of nausea and vomitting.
In ED: Tmax 101.7, SBP in the 60s. MM dry, guiac trace positive.
Hct was 28.1 so a T/C obtained. CXR with question of LML, LLL
PNA, so a ct chest/abd obtained and showed LLL PNA and
nonspecific stranding around the kidneys. UA with trace Leuk,
Neg Nitrite, (WBC, RBC, and Bact Pending). Sepsis protocol
initiated. Pt given vanco, levo, flagyl. R SCL placed and 4 L
NS given, with pressures increasing to the 80s, so levophed
given for persistent hypotension and systolic pressures rose to
100s. Cortisol level ordered, and still pending. Utox
+opiates, but pt takes Vicodin.
Past Medical History:
- Crohn's disease
- obesity
- HTN
- inflammatory arthritis
- s/p cholecystectomy
PSYCHIATRIC HISTORY: Several prior inpatient hospitalizations
for depression at [**Hospital1 18**] and Bay Ridge, he says he has been at [**Hospital1 **]
3-4 times. Said he experienced visual and auditory
hallucinations ("not of this world") in [**2170**] for which he
received hospitalization here, but he never experienced them
again. His current psychiatrist is Dr. [**Last Name (STitle) **] whom he sees once
every 2 months, prior psychiatrist was Dr. [**Last Name (STitle) 1452**]. Has had 2
prior overdoses (he denies trying to kill self,) once in [**5-6**]
with valium, and once in [**9-6**] with klonopin. He denies other
suicide attempts, he denies any h/o homicidal or violent
behavior.
Social History:
Lives with family. No illicit drug use. Smoker.
Family History:
Non contributory.
Physical Exam:
VS: Temp:98.2 BP: 129/73 HR:96 RR:20 O2sat 98% 4L NC
GEN: obese gentleman, comfortable, NAD, slightly slurred speech
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: End exp wheeze throughout, rhonchorous BS at L Base
CV: Distant, RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3 nonfocal
RECTAL: guaiac positive (per ED)
Pertinent Results:
[**2184-2-12**] 05:02AM BLOOD WBC-5.7 RBC-2.75* Hgb-9.1* Hct-28.4*
MCV-103* MCH-33.2* MCHC-32.2 RDW-13.3 Plt Ct-467*
[**2184-2-7**] 02:20PM BLOOD WBC-19.6*# RBC-3.18* Hgb-11.1*#
Hct-32.0*# MCV-101* MCH-35.0* MCHC-34.8 RDW-13.4 Plt Ct-370#
[**2184-2-10**] 05:48AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL
[**2184-2-13**] 06:01AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137
K-4.1 Cl-105 HCO3-26 AnGap-10
[**2184-2-7**] 02:20PM BLOOD Glucose-143* UreaN-87* Creat-6.3*#
Na-120* K-4.0 Cl-86* HCO3-19* AnGap-19
[**2184-2-13**] 06:01AM BLOOD ALT-26 AST-23 AlkPhos-82 Amylase-381*
TotBili-0.4
[**2184-2-10**] 05:48AM BLOOD ALT-52* AST-87* LD(LDH)-204 AlkPhos-135*
Amylase-342* TotBili-0.6
[**2184-2-7**] 02:20PM BLOOD ALT-30 AST-69* CK(CPK)-218* AlkPhos-105
Amylase-50
[**2184-2-13**] 06:01AM BLOOD Lipase-577*
[**2184-2-12**] 05:02AM BLOOD Lipase-657*
[**2184-2-11**] 05:34AM BLOOD Lipase-640*
[**2184-2-10**] 05:48AM BLOOD Lipase-598*
[**2184-2-7**] 02:20PM BLOOD Lipase-45
[**2184-2-13**] 06:01AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8
[**2184-2-7**] 02:20PM BLOOD TotProt-6.6 Albumin-2.8* Globuln-3.8
Calcium-8.3* Phos-4.7* Mg-2.0
[**2184-2-8**] 05:34AM BLOOD calTIBC-131* VitB12-1503* Folate-12.6
Ferritn-GREATER TH TRF-101*
[**2184-2-7**] 02:20PM BLOOD Cortsol-54.8*
[**2184-2-8**] 05:34AM BLOOD Vanco-7.5*
[**2184-2-7**] 05:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-2-7**] 11:50PM BLOOD Type-MIX Temp-37.2 Rates-/28 O2 Flow-4
pO2-42* pCO2-40 pH-7.31* calTCO2-21 Base XS--5 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**]
[**2184-2-7**] 05:00PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2184-2-7**] 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-0.2 pH-6.5 Leuks-TR
[**2184-2-7**] 05:00PM URINE RBC-0-2 WBC-[**4-7**] Bacteri-FEW Yeast-NONE
Epi-0-2 TransE-0-2
[**2184-2-7**] 07:15PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2184-2-8**] 09:52AM URINE Streptococcus pneumoniae Antigen
Detection-Test
Blood culture - negative
C diff negative x3
Sputum culture - normal flora
US liver: IMPRESSION: Limited evaluation of the pancreas and
distal common bile duct due to overlying bowel gas. Normal
son[**Name (NI) 493**] appearance of the liver.
CT OF THE ABDOMEN: Extensive airspace opacity within the left
lower lobe has improved moderately since the prior exam. There
is no pleural effusion. The heart size is normal. The contrast
bolus is suboptimal, which may relate to the patient's body
habitus. There is evidence of prior ventral hernia repair with a
mesh. The liver, spleen, and adrenal glands are normal. The
gallbladder is surgically absent. Multiple subcentimeter
periportal lymph nodes are again noted. There is mild stranding
of the peripancreatic fat in the region of the celiac axis,
consistent with the patient's clinical picture of pancreatitis.
The pancreas enhances homogeneously. There is no evidence of
complication. No free fluid or abscess formation. The kidneys
enhance and excrete contrast symmetrically with mild stable
perinephric stranding. The intra-abdominal small and large bowel
loops are normal.
CT OF THE PELVIS: Air is seen within the bladder, likely related
to recent Foley catheterization. The sigmoid colon and rectum
are normal. No free fluid or pelvic lymphadenopathy.
No suspicious lytic or sclerotic lesions. Degenerative changes
are noted at L5-S1.
IMPRESSION:
1. Mild uncomplicated pancreatitis.
2. Improving left lower lobe pneumonia.
3. Unchanged subcentimeter periportal lymphadenopathy.
CXR: IMPRESSION:
1. Left-mid and lower lung opacity concerning for pneumonia.
Lateral view may be performed to further evaluate.
CT on admission (Torso)
IMPRESSION:
1. Multilobar left-sided consolidation consistent with
pneumonia. Follow up imaging after treatment and resolution of
symptoms recommended.
2. Several periportal lymph nodes which are not enlarged by CT
criteria, although more numerous than typically are seen.
3. Nonspecific stranding surrounding the kidneys. Please
correlate with urinalysis/culture.
Brief Hospital Course:
The patient was diagnosed with pneumoni and required O2 and
pressors for hypotension. After clinical stabilization in ICU,
he was transferred to floor. After initial broad spectrum
antibitics, he was tapered to levofloxacin. In terms of the
diarrhea, at discharge the patient reported his diarrhea was at
baseline. He was continued on flagyl at home dose and C diff was
negative. ARF resolved completely with fluids and thought to be
from hypovolemia. Similarly, hyponatremia resolved. Guiac
positive stool are likely from Crohns disease. A recent
colonoscopy was done that revealed colitis. He has a follow up
with Dr [**Last Name (STitle) 1940**] next week.
In the hospital, he was noted to have elevated lipase, US and CT
abd negative for gall stone or tumor. GI consulted and did not
recommend further testing, but to follow up with Dr [**Last Name (STitle) 1940**] for
further assessment. Interestingly, he had no abdominal pain,
nausea or vomiting and was eating a regular diet at the time of
pancreatitis.
Sugars were mildly high. Given h/o obesity he may have impaired
glucose tolerance. Also noted to be tachycardic on ambulation,
but asymptomatic. Further PCP follow up is recommended.
Medications on Admission:
CYMBALTA 60 mg--1 capsule(s) by mouth once a day
GABAPENTIN and tizanidine - patient stopped them as they made
him very drowsy.
HUMIRA 40 mg/0.8 mL--sq every other week
RISPERDAL 1MG--One by mouth at bedtime
VICODIN ES 7.5 mg-750 mg--1 tablet(s) by mouth four times a day
as needed for pain
ZESTRIL 40 mg--1 tablet(s) by mouth 1 po qd
HCTZ - patientstopped taking shortly after being prescribed by
PCP as he though thathis admitting symptoms were from HCTZ.
Metronidazole 250 mg QID - but patient takes [**Hospital1 **].
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
3. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Metronidazole
(flagyl) - continue to take as recommended by Dr [**Last Name (STitle) 1940**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Community acquired pneumonia/ respiratory failure
Acute pancreatitis
Delirium - resolved
Rectal bleeding / diarrhea likely from history of crohns disease
Acute renal failure - resolved
Possible impaired glucose tolerance
Tachycardia on ambulation
Discharge Condition:
stable
Discharge Instructions:
Your are being treated for a pneumonia with antibiotic:
levofloxacin for pneumonia. Take medicines as prescribed.
Keep your appointments as scheduled.
Return to the hospital if you have worsening diarrhea, abdominal
pain or any other symptoms of concern to you.
You should see Dr [**Last Name (STitle) 1940**] for further work up of the
pancreatitis and also about the further plan for humira.
your sugars were mildly high in the hospital. discuss with Dr
[**Last Name (STitle) **] about further monitoring to see if you have diabetes.
your heart rate was higher when you walked on the [**Hospital1 **]. Discuss
with Dr [**Last Name (STitle) **] about further heart testing before your surgery.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1144**]. Appointment on [**2184-2-17**] at 1415
hours.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2184-2-16**] 11:30
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2184-3-2**] 11:20
Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2184-3-4**]
10:30
|
[
"0389",
"486",
"5849",
"51881",
"2761",
"2762",
"99592",
"4019",
"311",
"3051",
"2859"
] |
Admission Date: [**2144-9-26**] Discharge Date: [**2144-11-4**]
Date of Birth: [**2070-4-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sudafed / Amoxicillin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2144-9-30**] Open repair thoracoabdominal aortic aneurysm
[**2144-10-12**] Reintubation, left chest tube insertion, and
bronchoscopy
[**2144-10-15**] Redo left thoracotomy and drainage of left empyema,
Right chest tube placement, Flexible bronchoscopy.
[**2144-10-19**] Bronchoscopy
[**2144-10-27**] An 8.0 Portex tracheostomy tube placement, 19-
French percutaneous endoscopic gastrostomy Ponsky tube
placement, flexible bronchoscopy.
History of Present Illness:
74 year old male with acute onset of chest pain radiating to
back while working on roof. History of poorly controlled
hypertension. Had CTA at OSH which found to have type B aortic
dissection with intramural hematoma.
Past Medical History:
Hypertension
Benign Prostatic Hypertrophy
Hernia Repair
s/p Appy
Gastric Esophageal reflux disease
Left shoulder bursitis
ETOH
Social History:
Lives with spouse
ETOH 1 drink/day
Tobacco: quit over 10 years ago
Family History:
NC
Physical Exam:
Admission
37.1, 80 SR, 20, 100/50
NAD, A/)x3
CV RRR
Pulm CTAB
Abd soft, NT, ND
Pulses +2 equal bilat, nl CR
Discharge
98.4, 75SR, 145/59, 20, 100%
General NAD, Alert and oriented conversing using passy muir
valve
Able to lift and hold UE, moves right LE on bed, no movement
left LE
Resp:CTAB
Cardiac RRR
Abd soft, NT, ND +Bs
Inc left thorocotomy with staples intact, no erythema, no
drainage, small necrotic area on posterior aspect.
Ext warm
Pertinent Results:
[**2144-11-3**] 12:45AM BLOOD WBC-9.6 RBC-2.91* Hgb-8.7* Hct-25.5*
MCV-87 MCH-29.7 MCHC-34.0 RDW-15.6* Plt Ct-205
[**2144-9-26**] 07:49PM BLOOD WBC-9.5 RBC-4.41* Hgb-13.0* Hct-35.5*
MCV-81* MCH-29.4 MCHC-36.6* RDW-14.5 Plt Ct-244
[**2144-10-31**] 02:15AM BLOOD Neuts-80.4* Lymphs-14.6* Monos-2.4
Eos-2.4 Baso-0.2
[**2144-9-26**] 07:49PM BLOOD Neuts-83.5* Lymphs-10.9* Monos-5.1
Eos-0.2 Baso-0.2
[**2144-10-12**] 10:36PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Stipple-1+
[**2144-11-3**] 12:45AM BLOOD Plt Ct-205
[**2144-11-3**] 12:45AM BLOOD PT-15.1* PTT-39.2* INR(PT)-1.4*
[**2144-9-26**] 07:49PM BLOOD Plt Ct-244
[**2144-9-26**] 07:49PM BLOOD PT-11.6 PTT-21.7* INR(PT)-1.0
[**2144-11-3**] 12:45AM BLOOD Glucose-139* UreaN-46* Creat-0.6 Na-144
K-4.0 Cl-104 HCO3-38* AnGap-6*
[**2144-9-26**] 07:49PM BLOOD Glucose-123* UreaN-20 Creat-0.7 Na-138
K-3.5 Cl-103 HCO3-26 AnGap-13
[**2144-10-12**] 10:36PM BLOOD ALT-36 AST-26 LD(LDH)-338* AlkPhos-50
TotBili-0.7
[**2144-10-2**] 02:24AM BLOOD ALT-48* AST-141* LD(LDH)-489* AlkPhos-50
Amylase-36 TotBili-2.7*
[**2144-11-3**] 12:45AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.4
[**2144-9-28**] 03:24AM BLOOD Calcium-7.4* Phos-1.4* Mg-1.5*
[**2144-10-4**] 03:09AM BLOOD VitB12-602 Folate-6.5
[**2144-10-4**] 03:09AM BLOOD Ammonia-30
[**2144-10-4**] 03:09AM BLOOD TSH-0.58
[**2144-11-3**] 12:45AM BLOOD Vanco-16.4
[**2144-9-29**] 06:44PM BLOOD Type-ART pO2-259* pCO2-42 pH-7.35
calTCO2-24 Base XS--2
Time Taken Not Noted Log-In Date/Time: [**2144-10-27**] 12:24 pm
PLEURAL FLUID
GRAM STAIN (Final [**2144-10-27**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2144-10-31**]):
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).
GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
STAPH AUREUS COAG +. RARE GROWTH.
[**Female First Name (un) **] (TORULOPSIS) GLABRATA. SPARSE GROWTH.
ID PERFORMED ON CORRESPONDING FUNGAL CULTURE.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2144-10-31**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.
[**2144-10-19**] 8:55 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2144-10-27**]**
GRAM STAIN (Final [**2144-10-19**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2144-10-27**]):
THIS IS A CORRECTED REPORT ([**2144-10-25**]).
OROPHARYNGEAL FLORA ABSENT.
BURKHOLDERIA (PSEUDOMONAS) CEPACIA. SPARSE GROWTH.
TIMENTIN >64 (MCG/ML) Resistant.
BURKHOLDERIA (PSEUDOMONAS) CEPACIA. SPARSE GROWTH. 2ND
[**Last Name (un) 68374**].
TIMENTIN >64 (MCG/ML) Resistant.
STAPH AUREUS COAG +. RARE GROWTH. PREVIOUSLY REPORTED
AS.
RARE GROWTH OROPHARYNGEAL FLORA ([**2144-10-21**]).
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BURKHOLDERIA (PSEUDOMONAS) CEPACIA
| BURKHOLDERIA
(PSEUDOMONAS) CEPACIA
| | STAPH AUREUS
COAG +
| | |
CEFTAZIDIME----------- =>16 R 16 I
CHLORAMPHENICOL------- 16 I 16 I
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- S S <=0.12 S
MEROPENEM------------- 2 S S
OXACILLIN------------- <=0.25 S
PENICILLIN------------ 0.25 R
TRIMETHOPRIM/SULFA---- S S
[**10-31**]
IMPRESSION: No DVT involving the left upper extremity. PICC line
is seen in the brachial vein
[**10-30**]
Portable upright frontal radiograph compared to [**2144-10-28**].
The left-sided chest tube has been removed. A left-sided PICC
and a tracheostomy tube remain in place. There is no significant
change in appearance of small bilateral pleural effusions, left
greater than right with associated atelectasis. There is no
pneumothorax.
IMPRESSION: Stable bilateral pleural effusions with associated
atelectasis. No pneumothorax.
[**10-23**]
TECHNIQUE AND FINDINGS: The patient was placed on the
angiography table and the left arm and axilla were prepped and
draped in standard sterile fashion. Under ultrasonographic
guidance, the left brachial vein was cannulated with a 21-gauge
needle following local administration of 1% lidocaine. Pre- and
post-cannulation ultrasound hard copy images were obtained. A
0.018-inch guide wire was placed through the needle into the
superior vena cava usig flouroscopic guidance. The needle was
exchanged for a 4 French micropuncture sheath. The PICC line was
trimmed to 46 cm. After the inner dilator was removed, the PICC
line was inserted with tip ending in the mid SVC. The wire was
removed and final fluoroscopic images were obtained. The dual
lumen PICC line hub was flushed, heplocked, and StatLocked.
There were no immediate post-procedure complications.
IMPRESSION:
Successful placement of a dual lumen PICC line via the left
brachial vein with tip in the mid SVC. The line is ready for
use.
[**10-5**] MR spine
IMPRESSION:
1. No evidence of epidural masses or hematoma.
2. No evidence of cord compression.
3. Increased signal intensity in the conus region which is
nonspecific and infarction cannot be excluded based on this
appearance.
4. Increased signal intensity within the mid-lower thoracic
spinal cord could be artifactual.
5. Mild disc bulge at L4-5 and left disc herniation at L5-S1
causing mild indentation on the thecal sac.
[**2144-9-30**] TEE
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: 0.35 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Aorta - Valve Level: 2.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *5.8 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 8 mm Hg
Mitral Valve - Peak Velocity: 2.0 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 260 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
Good (>20 cm/s)
LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the RAA.
Normal interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root. Focal calcifications in
aortic root. Normal
ascending aorta diameter. Focal calcifications in ascending
aorta. Normal
aortic arch diameter. Focal calcifications in aortic arch.
Markedly 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: Normal mitral valve leaflets. Mild mitral annular
calcification.
No MS. Mild (1+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
PRE-BYPASS: No spontaneous echo contrast is seen in the left
atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular
chamber size and free wall motion are normal. The aortic root is
mildly
dilated. There are focal calcifications in the aortic arch. The
descending
thoracic aorta is markedly dilated. There are complex (>4mm)
atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally
normal. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid
regurgitation is seen.
POST-BYPASS: Preserved biventricular function, LVEF >55%. Mitral
regurtiation
remains mild. Aortic insufficiency remains mild. There is a
prosthetic graft
insitu in the descending aorta from below the left subclavian
down as far
distal as can be visualized (about the level of the diaphragm).
Incidental
note is made of mobile echogenic material within the lumen of
the thoracic
graft about the level of an intercostal button. This material
may represent
clot, suture material, or tissue from the button; surgeons
notified.
Brief Hospital Course:
Admitted from OSH with Type aortic dissection for surgical
evaluation. He underwent preoperative work up including cardiac
evaluation. Blood pressure was closely closely controlled with
vasoactive drips in the ICU. On [**9-29**] he was due to respiratory
failure and bronched. [**9-30**] he went to the operating room for
thoraco-abdominal aorta replacement with 26 mm gelweave graft.
Please see operative report for further details. He was
transferred back to the ICU for hemodynamic monitoring. In the
first 24 hours he awoke, following commands, and moving upper
extremeties. He was able to slightly move right foot and no
movement left LE. He was treated with steroids, increased B/P,
and continued with lumbar drain. He was extubated on [**10-2**]. He
was alert but confused and still no improvement in LE. He
underwent MR of spine and head see reports. He had episodes of
intermittent Atrial fibrillation that he converted with
amiodarone and started on anticoagulation. He was started on
tube feeds for nutrition since he failed swallowing evaluation.
He remained extubated requiring frequent pulmonary toileting
with increased oxygen requirement and was reintubated on [**10-12**].
He also had chest tube placed at that time for left pleural
effusion, and bronchoscopy. Effusion was found to be
chylothorax and thoracic surgery was consulted. His tube feeds
were stopped due to chylothorax and he was started on TPN. On
[**10-14**] he was bronched and extubated but failed quickly requiring
reintubation. [**10-15**] ID was consulted due to + cultures (see lab
data) bacteremia treating with Vancomycin and Zosyn. He also
went to the operating room and underwent redo left thoracotomy
and drainage of left empyema, Right chest tube placement,
Flexible bronchoscopy. Please see operative report for further
details. He developed a rash, at which time Zosyn was
discontinued and he was started on Miropenem and the rash did
clear after a few days. He was restarted on tube feeds prior to
chest tube removal, no further [**Last Name (LF) 3564**], [**First Name3 (LF) **] chest tubes removed. He
continues on tube feeds for nutritional support via G tube. He
underwent trach and Gtube placement due to respiratory failure
on [**10-27**]. Please see operative report for further details. He
has continued to progress working with physical therapy and has
been able to tolerate trach collar during the day. He was ready
and discharged to rehab on POD 34.
Medications on Admission:
HCTZ 25, Atenolol 100mg', prilosec, methyldopa 250mg qam, 500mg
qpm, Kdur 10meq', ASA 81mg'
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Month/Day (1) **]: One (1) Gm
Intravenous Q 24H (Every 24 Hours): continue until [**2144-11-25**], then
should start Doxyclycline 100 mg daily for lifelong suppression.
2. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day/Year **]: Ten (10) ml PO BID
(2 times a day).
4. Insulin Regular Human 100 unit/mL Solution [**Month/Day/Year **]: sliding scale
Injection AC and HS: SQ.
5. Bisacodyl 10 mg Suppository [**Month/Day/Year **]: One (1) Suppository Rectal
QOD ().
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units SQ Injection TID (3 times a day).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two
(2) Puff Inhalation Q4H (every 4 hours).
9. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
12. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q4-6H (every 4 to
6 hours) as needed.
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
14. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: Five Hundred (500) mg PO
DAILY (Daily).
15. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: Five (5) ml PO DAILY
(Daily).
16. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
17. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
BID (2 times a day).
18. Lantus 100 unit/mL Solution [**Hospital1 **]: Twelve (12) units
Subcutaneous qam .
19. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
20. Potassium Chloride 20 mEq Packet [**Hospital1 **]: One (1) PO twice a
day: with lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Type B aortic dissection s/p repair
Chylothorax
Respiratory Failure
MSSA Bacteremia - tx vancomycin
MSSA Buetholderis Pneumonia -tx meropenem
Enterococcal Empyema - tx vancomycin
PMH:
BPH
GERD
left shoulder bursitis
s/p Appy
s/p hernia
Discharge Condition:
good
Discharge Instructions:
Please make all follow up appointments
Continue antibiotic treatment for life
Any questions please call
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] after discharge from rehab ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] in [**Hospital **] clinic upon discharge from rehab ([**Telephone/Fax (1) 10**], please call for appt. Please have Vanco trough,CBC
w/Diff, BUN/Cr, AST/ALT Qweek and fax results to [**Telephone/Fax (1) 1353**]
Attn Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**]
Dr [**Last Name (STitle) **] after discahrge from rehab ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**Last Name (STitle) **] after discahrge from rehab ([**Telephone/Fax (1) 2625**]) please
call for appointment
Completed by:[**2144-11-4**]
|
[
"42731",
"2760",
"5119",
"4019"
] |
Admission Date: [**2182-6-20**] Discharge Date: [**2182-7-17**]
Date of Birth: [**2117-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Somnolence & respiratory distress
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
History of Present Illness:
Patient is a 64 y/o F with a 92 pack-year smoking history,
presumed COPD, hypertension, hypothyroidism and obesity, who
presented to an outside hospital in [**Hospital1 6687**] with shock and
respiratory failure secondary to strep pneumoniae pneumonia and
is transferred to [**Hospital1 18**] for further management of her
respiratory failure.
Mrs. [**First Name (STitle) 2523**] initially presented to the [**Hospital **] hospital with
hypoxic/hypercarbic respiratory failure. She was intubated and
treated for shock (SBP as low as 80s). She was found to have R
sided PNA. On [**2182-6-20**], she was transferred to [**Hospital1 18**].
Past Medical History:
hypertension
hypothyroidism
obesity
Social History:
Lives in [**Location 7349**], though stays in [**Hospital1 6687**] during summers. Works as
art dealer. Long term smoker: 46yr x 2ppd. Married, two grown
kids
Family History:
NC
Physical Exam:
T 96.8 BP 140/70 (130-170/60-90) HR 94 (60-90s) RR 25 O2 sat 90%
6L (84-92% on 4L NC); Length of stay I/O -3.5L; 19hr -2.2L
Gen: Awake, [**Last Name (un) **],ox3, pleasant, NAD.
HEENT: PERRL, EOMI
CV: RRR, nl s1/s2, no m/r/g
Lungs: Decreased airflow, mild bibasilar crackles
Abd: Soft, obese, NT, ND, normoactive BS
Ext: 1+ pitting edema on b/l LE.
Skin: no rashes; marks on abd [**2-2**] hep SC shots
Pertinent Results:
Admission:
[**2182-6-20**] 06:00PM GLUCOSE-163* UREA N-33* CREAT-1.8* SODIUM-143
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-27 ANION GAP-13
[**2182-6-20**] 06:00PM AMYLASE-1011*
[**2182-6-20**] 06:00PM LIPASE-243*
[**2182-6-20**] 06:00PM CALCIUM-6.2* PHOSPHATE-5.0* MAGNESIUM-1.5*
[**2182-6-20**] 06:00PM TSH-1.0
[**2182-6-20**] 06:00PM WBC-26.2* RBC-4.62 HGB-15.2 HCT-49.2*
MCV-106* MCH-32.9* MCHC-31.0 RDW-14.6
[**2182-6-20**] 01:56PM LACTATE-6.2*
[**2182-6-20**] 01:50PM CK-MB-85* MB INDX-6.6* cTropnT-0.20*
[**2182-6-20**] 01:50PM ALT(SGPT)-411* AST(SGOT)-601* CK(CPK)-1289*
[**2182-7-9**] VBG 7.45/58/42
Discharge labs:
[**2182-7-16**] WBC 6.1 Hgb 10.9 Hct 33.2 MCV 97 Plt 157
[**2182-7-17**] Gluc 110 BUN 15 Crt 0.7 Na 141 K 3.9 Cl 101 CO2 29
[**2182-6-20**] EKG: Sinus tachycardia. Biatrial enlargement. Right axis
deviation. ST segment elevations in leads V3-V4 with tall peaked
precordial T waves and an increase in rate compared to the
previous tracing of [**2182-6-20**].
[**2182-6-20**] CT ABDOMEN: Absence of intravenous contrast limits
evaluation of the abdominal parenchymal organs and vasculature.
There is a small amount of ascites around the liver, and
throughout the abdomen. The liver itself is grossly
unremarkable. Small calcified gallstone is seen within the
gallbladder lumen. There is a mild amount of gallbladder wall
edema, likely secondary to ascites. Pancreas is edematous, and
there is a minimal amount of peripancreatic stranding. There is
no discrete fluid collection or abscess. The spleen is
unremarkable. The adrenal glands, kidneys, and ureters are
unremarkable. Stomach and intra-abdominal loops of bowel are
normal. There is no bowel obstruction. There is no free air or
abnormal intra-abdominal lymphadenopathy.
[**2182-6-20**] CT PELVIS: Pelvic loops of large and small bowel are
normal. Urinary bladder is decompressed with Foley catheter in
place. The uterus and adnexa are grossly unremarkable. There is
a small amount of free pelvic fluid. There is no abnormal pelvic
or inguinal lymphadenopathy. Bilateral femoral central venous
catheters are in place, tips in the external iliac veins. Minor
atherosclerotic changes are seen in the distal abdominal aorta.
There is no osseous lesion suspicious for malignancy. There is
mild
dextroconvex lumbar scoliosis, and associated degenerative
change.
IMPRESSION:
1. No focal lung consolidation. Small right, and trace left
pleural
effusions, and associated mild bibasilar atelectasis.
2. Several small, ill-defined areas of parenchymal nodularity,
largest in the right upper lobe is somewhat linear, 11 mm in
size. Given the background emphysematous change, six-month
followup is recommended to determine stability of these nodules.
3. Mild pancreatic edema and peripancreatic stranding compatible
with
pancreatitis. No peripancreatic fluid collection.
4. Small volume of ascites throughout the abdomen.
5. Cholelithiasis. Mild associated gallbladder wall thickening
is likely
secondary to ascites.
[**2182-6-22**] CTA CHEST W&W/O: There is no evidence of main, central,
or segmental pulmonary embolism. Main pulmonary artery measures
3.6 cm, a finding suggestive of underlying pulmonary arterial
hypertension. No significant hilar or mediastinal
lymphadenopathy is identified.
Patient is intubated. Central airways have a posterior
concavity, suggestion tracheomalacia.
Evaluation of the lung parenchyma does reveal increased patchy
areas of
consolidation within the right middle lobe. This is a
nonspecific finding,
but discoid morphology likely reflects atelectasis.
Mold-moderate emphysema is noted. Bilateral moderate pleural
effusions are seen, right greater than left. These are slightly
increased in size since the prior study. Areas of nodularity
again seen, the largest of which is again noted within the right
upper lobe. Six- month followup is again recommended to ensure
stability of these findings.
The visualized portions of the upper abdomen appear grossly
unremarkable,
noting small ascites. No suspicious lytic or blastic bony
lesions are seen.
IMPRESSION:
1. No evidence of pulmonary embolism. Suggestion of pulmonary
hypertension.
2. Increased pleural effusions.
3. Increased areas of discoid atelectasis in the right middle
lobe.
4. Pulmonary nodules again seen, recommend six-month followup to
ensure
stability.
5. Small ascites.
[**2182-7-8**] Transthoracic Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No intracardiac shunt is identified after
intravenous saline microbubbles at rest. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. 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. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved global
biventricular cavity sizes and global systolic function. No
intracardiac shunt identified.
[**2182-7-15**] Right and left lateral decubitus films:
There is no significant change in the left-sided effusion.
However, the right-sided pleural effusion is slightly decreased
in volume.
There are no other interval changes noted.
IMPRESSION: Stable left-sided pleural effusion with slight
decrease in volume of right-sided pleural effusion.
Brief Hospital Course:
This is a 64 yo F with HTN, hypothyroidism, obesity, presumed
COPD who presented to an OSH with respiratory failure in setting
of strep pneumo pneumonia and sepsis, and was transferred to
[**Hospital1 18**] for further evaluation and management.
# Septic Shock: Mrs. [**First Name (STitle) 2523**] was initially hypotensive to the 80s
and with evidence of end-organ damage: elevated LFTs, ARF and
cardiac enzymes. This resolved with aggressive IVF as well as
temporary treatment with pressors. She was treated for strep
pneumo pneumonia (sputum cx positive for the organism; bld cx
negative) with a 14 day course of levofloxacin, which was
completed on [**2182-7-3**].
# Hypoxic/Hypercarbic Respiratory Failure: Mrs. [**First Name (STitle) 2523**] presented
with both hypoxic and hypercarbic respiratory failure in setting
of strep pneumo pneumonia with sepsis. She required 14 days of
mechanical ventilation. She was extubated successfully on
[**2182-7-1**]. Following extubation the patient required BiPAP for a
period, and eventually only required BiPAP at night for
treatment of newly diagnosed obstructive sleep apnea.
Despite treatment of her pneumonia, Mrs. [**First Name (STitle) 2523**] had a persistent
oxygen requirement, initiall as high as 6-7L via NC. She
underwent CTA of chest, which was negative for PE, though did
show bilateral pleural effusions. Based on this, her hypoxia
was attributed primarily to volume overload from the aggressive
volume resuscitation when she presented with shock. However, it
was also thought that she had some component of COPD (emphysema
seen on chest CT) and possibly obesity hypoventilation syndrome
as well. With aggressive diuresis, her oxgyen requirement was
weaned to 2-3L via nasal cannula. Of note, the requires
continuous oxygen at present to keep her oxygen at a goal of
90-95%. As she diureses further, she may be able to be weaned
further off of oxygen. Prior to admission, she was not on
supplemental oxygen, though she may require low level at home,
depending on how she responds to continued diuresis at rehab.
# Volume Overload/Pleural Effusions: The patient was grossly
overloaded on transfer to the medical [**Hospital1 **] from the MICU,
following volume resuscitation. She required aggressive
diuresis and diuresed over 10Liter. She is being discharged on
60mg lasix PO daily--she was on 60mg twice daily for the few
days prior to discharge, but this was dose decreased as pt seems
to be nearing her dry wieght. She still has bilateral pleural
effusions, which are thought to be from her volume overload and
which are improving on CXR with diuresis. Because of this, the
effusions were not tapped during this hospital stay. She should
have a follow-up chest x-ray if her oxygen requirement increases
to assess the size of her pleural effusions. She should be on a
1.5L fluid restriction. It is suspected that her lasix dose may
be able to be further decreased as she gets closer to her dry
weight, though this will need to be monitored closely,
particularly via measurement of her creatinine (crt 1.7 on day
of discharge). At present, we are aiming for a fluid balance
(I/O goal) of approximately 500cc to 1liter negative daily. If
her creatinine increases, this goal should be adjusted.
# Presumed COPD: the patient has a 92 pack year history of
smoking. She smoked up until current admission. She has never
had a formal evaluation for COPD (ie, no PFTs in past).
However, given her smoking history and CT chest showing evidence
of emphysema, she was treated for a COPD exacerbation with
inhalers/nebulizers (see med list) and prednisone taper. She
should continue the inhalers started during the hospitalization
as an outpatient. She will need formal PFT evaluation as an
outpatient as well.
# Obstructive sleep apnea/Query obesity hypoventilation
syndrome: Mrs. [**First Name (STitle) 2523**] showed evidence of desaturating while
sleeping. She was seen by the pulmonary consult service and
sleep consult services. She was started on BiPAP at night at a
setting of [**12-11**] and 3L of 02 for presumed obstructive sleep
apnea. She has an appointment scheduled at the [**Hospital1 18**] outpatient
sleep clinic on [**8-6**] (see appointment list).
# Hypertension: Patient has a history of hypertension treated
with hydrochlorothiazide. Her HCTZ was held on admission
because of her hypotension. She was then started lisinopril as
she became hypertensive later in her hospital. Her SBP on
discharge was in the 100s-110s.
# Anemia/Guaiac + Stool: Her admission hematocrit was elevated
in the setting of dehyration--49. It dropped into the low 40s
with IVF. However, on [**2182-7-5**], her hematocrit dropped to 35.7.
She was guaiac was positive on [**7-4**] and [**7-5**]. She was
hemodynamically stable and did not require transfusion. Her
hematocrit has remained stable between 33-35 since that time.
Repeat guaiacs were negative. She will need outpatient
evaluation, including colonoscopy.
# Glucose intolerance: Mrs. [**First Name (STitle) 2523**] required insulin while on
prednisone (for her COPD exacerbation). HOwever, even off of
the steroids, she still had elevated fasting gluose levels >110.
She will need additional outpatient evaluation and treatment
for this.
# Pulmonary nodules: see CT report. Will need 6mo repeat Chest
CT.
# FEN: Pt has required regular potassium repletion while on
lasix. Please monitor her potassium and replete as necessary.
She had a K of 2.9 on [**7-6**], likely due to the combination of
contraction alkalosis
# NSTEMI: in setting of septic shock (likely not plaque
rupture). TTE w/ normal systolic function following
resuscitation. Should be started on aspirin as outpatient once
she undergoes eval of anemia.
# Hypothyroidism: She as continued on home synthroid regimen.
# ARF: Elevated Cr at presentation (2.6), which resolved with
IVF, suggesting pre-renal etiology in setting of sepsis. Normal
Crt on discharge.
# PPx: SC heparin
# Social - Full Code status, communication with son [**Name (NI) **]
[**Telephone/Fax (1) 78530**],son [**Name (NI) **] and husband [**Name (NI) 892**] [**Telephone/Fax (1) 78531**]
Medications on Admission:
HCTZ 50 mg daily
Atenolol 25 mg daily
Levoxyl 200 mcg daily
Prempro 0.45-1.5 mg daily
OTC allergy med chlorpheniramine
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-2**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: One
(1) Inhalation every six (6) hours.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): DVT Prophylaxis--not a home med.
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
60mg.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1
doses: 40meq/day (to be adjusted per serum potassium level).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Strep pneumoniae pneumonia
Septic shock
Respiratory failure
Pleural effusions
Guaiac postive stools
Obstructive sleep apnea
COPD/Emphysema
Pulmonary (lung) nodules
Glucose intolerance (pre-diabetes)
Obesity/Deconditioning
Hypertension
Secondary:
Hypothyroidism
Discharge Condition:
Good, 02 sat 91-96% on 2L NC, SBP 100-110s, HR 60-80s, weight
243lb
Discharge Instructions:
You were admitted with sepsis from pneumonia. During your
hospital stay you were newly diagnosed with the following:
1. Obstructive sleep apnea
2. COPD/Emphysema
3. Pulmonary (lung) nodules
4. Glucose intolerance (pre-diabetes)
5. Guaiac positive stool (small amount of blood in your stool)
You will need close follow-up for those issues.
- You will need to see a sleep specialist--see
appointments--regarding your sleep apnea. You should continue
to use your BiPAP machine as instructed.
- You were started on a number of new inhalers (see list) for
your presumed emphysema. You will need to undergo lung function
tests after discharge. This can be arranged by your PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] will need to have a CT scan of your chest within 6months
to follow-up the lung nodules found.
- You will need to have formal testing for diabetes wit your
PCP. [**Name10 (NameIs) **] should adhere to a low-sugar/low carbohydrate diet.
- You should have a colonoscopy within 6months to evaluate for
an episode of blood in your stool, as well as for routine colon
cancer screening.
You were started on a new blood pressure medication called
lisinopril, which is to take the place of hydrochlorothiazide.
You should continue your other medications.
Followup Instructions:
You have an appointment with the sleep specialist [**First Name8 (NamePattern2) **]
[**Name8 (MD) **], MD, on [**2182-8-6**] at 8:00am on the [**Hospital Ward Name 516**] of [**Hospital1 18**] on
the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Please call and
reschedule if you cannot make this appointment.
Phone:[**Telephone/Fax (1) 612**]
Please see your primary care doctor within 1-2 weeks of
discharge from rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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