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Admission Date: [**2108-10-22**] Discharge Date: [**2108-10-25**]
Date of Birth: [**2046-3-3**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: This is a 62-year-old gentleman,
status post coiling of left anterior choiroidal artery aneurysm
incidentally found on CT scan for work-up of headache which he
has had for 30 years since [**Country 3992**], and is to have elective
coiling by Dr. [**Last Name (STitle) 1132**] on [**2108-10-22**].
PAST MEDICAL HISTORY: Seizure disorder.
Constipation.
Status post cardiac ablation 1 month ago for chronic atrial
flutter. He is now off Coumadin.
Hypertension.
PAST SURGICAL HISTORY: Groin hernia repaired in [**Country 3992**].
Cardiac ablation, as above.
SOCIAL HISTORY: Smoked for 30 years, 1 pack per day, stopped
8 years ago. Drinks about 1 pint of beer a day, but had [**Last Name **]
problem being off alcohol in [**Hospital3 417**] Hospital for 2
weeks.
FAMILY HISTORY: No aneurysms.
ADMISSION MEDICATIONS:
1. Folic acid 1 mg po once daily.
2. Digoxin 125 mcg po once daily.
3. Diltiazem 240 mg once daily.
4. Colace.
5. Senna.
6. Toprol XL 150 mg po once daily.
7. Famotidine 20 mg po bid.
8. Spironolactone 25 mg po bid.
9. Aspirin.
HOSPITAL COURSE: The patient underwent diagnostic angiogram
and then coiling of a left Ant. Choroidal artery aneurysm without
incident.
Postoperatively, the patient was hypertensive and had to be
started on a nitroprusside drip to control pressures for a
goal range of less than 140. To stay within that range, we
then switched over to labetalol drip. Cardiology was
consulted and made recommendations on his medications. He
was to increase his Toprol XL to 200 mg po once daily.
Eventually, his spironolactone was maintained. His digoxin
was maintained. His diltiazem was stopped. He was also
started on captopril, starting at a small dose and increasing
to 12.5 mg once daily, and while monitoring his creatinine
which came in at a baseline of about 1.2, and is currently
0.9 and is doing well on current regimen.
He is going to be discharged to home, but he is going to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], fax number [**Telephone/Fax (1) 51220**],
phone number [**Telephone/Fax (1) 40236**], on [**11-6**] at 11:15. He is to
follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
He should monitor for the following: Fevers, chills, nausea,
vomiting, inability to tolerate food, drink, severe headache,
mental status changes, weakness. If any of these occur he is
to please contact his physician [**Name Initial (PRE) 2227**].
DISCHARGE CONDITION: Good.
MAJOR PROCEDURES: Status post coiling of anterior choroidal
artery aneurysm.
CHANGES TO MEDICATIONS:
1. Stop taking diltiazem.
2. Start captopril 12.5 mg po tid.
3. Change Toprol XL to 200 mg po once daily.
4. Continue his digoxin as directed previously.
5. Continue his spironolactone as directed previously.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 15649**]
MEDQUIST36
D: [**2108-10-25**] 11:19:20
T: [**2108-10-25**] 11:57:04
Job#: [**Job Number 51221**]
cc:[**Name8 (MD) 51222**]
|
[
"4240",
"4019"
] |
Admission Date: [**2165-4-19**] Discharge Date: [**2165-4-25**]
Date of Birth: [**2097-5-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Progressive memory loss
Major Surgical or Invasive Procedure:
Left Temporal Craniotomy
History of Present Illness:
This is a 67 year old gentleman who was brought into the
hospital by his family
after an MRI ordered by his PCP showed [**Name Initial (PRE) **] left temporal tumor.
Per family, the patient has been increasingly forgetful for the
past
few weeks. They have noticed that he is unable to recall his
grand [**Hospital1 **] names and is at times confused. They have also
noticed episodes of ataxia, but deny falls.
Past Medical History:
DM
Hyperlipemia
Carcinoid tumor
Social History:
Retired painter
Lives with his sister
Family History:
NC
Physical Exam:
T: 97.5 BP: 109 /43 HR:60-90 R 13-19 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to 3 EOMs Intact
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert
Orientation: Oriented to self only, and date, can not recall
home
address or birth date
Language: Speech fluent with good comprehension and repetition.
Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-15**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
EXAM ON DISCHARGE: neurologically intact with ever so slight
right pronation.
Pertinent Results:
MRI brain [**2165-4-19**]:
1. Large, irregularly rim-enhancing and centrally necrotic 4-cm
mass
occupying much of the left temporal lobe with extensive
vasogenic edema, mass effect and subfalcine herniation.
2. Evidence of subpial spread to involve the overlying
extra-axial space, as well as possible extension along the fiber
bundles of the [**Last Name (un) 46280**] portion of the anterior commissure,
crossing the midline.
3. Discrete 11-mm mass at the most medial aspect of that
temporal lobe,
representing a "satellite" lesion with visible thin contiguous
extension from the dominant mass.
COMMENT: The constellation of findings is quite concerning for
primary
high-grade glial neoplasm with direct spread into the
subarachnoid space,
extension to a "satellite nodule" and possibly along fiber
bundles into the contralateral hemisphere; this would be a quite
unusual appearance for
metastatic disease.
CXR [**2165-4-20**]:
No signs for acute cardiopulmonary process.
MRI Brain [**2165-4-20**]:
Pre-operative planning study demonstrates irregularly enhancing
lesion with rim enhancement in the left temporal region with a
satellite
nodule as discussed in detail previously on the MRI of [**2165-4-19**].
No change in appearance seen. There remains mass effect on the
left side of the brain stem and left lateral ventricle.
Brief Hospital Course:
Mr. [**Known lastname 11952**] was evaluated in the Emergency room and given his MRI
findings given 20mg of Decadron IV immediately along with 500mg
of Keppra for seizure propholaxis. He was admitted to the
Neurosurgery service and transferred to the surgical ICU for
monitoring and Neuro checks.
On [**4-20**] an MRI wand study was performed for operative planning
and the patient was transferred to the floor with a stable neuro
exam.
On [**4-22**] the patient was taken to the Operating room for a
craniotomy and tumor resection. Post operatively, patient was
able to follow commands and was oriented to himself. He was
moving all extremities. Post op CT and MRI were stable and he
was transferred to the floor. He has both expressive and
receptive aphasia which decadron is being used to help reduce
severity.
On [**4-24**], patient's exam was much improved. His aphasia was
improved with decadron, but still had some word finding
difficulty. He is alert and oriented to himself, hospital, and
month and is full strength in all extremities. He has a slight R
drift. Patient is awaiting final recommendations from PT/OT. A
brain tumor appointment has been made for him on [**2165-5-1**].
Medications on Admission:
Medications prior to admission:
DOXAZOSIN - 4 mg Tablet -
LATANOPROST [XALATAN] - 0.005 % Drops - 1 gtt ou at bedtime
METFORMIN - 500 mg Tablet - ii Tablet(s) by mouth twice a day
PIOGLITAZONE [ACTOS] - 45 mg Tablet daily
SIMVASTATIN - 20 mg Tablet daily
TIMOLOL MALEATE - 0.5 % Drops - 1 gtt right eye once a day
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/t/fever.
Disp:*30 Tablet(s)* Refills:*0*
8. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times
a day for 4 days: until sunday then you will take 3mg po tid
till tuesday. Then on wednesday you will take 2mg po tid until
further notice from Dr. [**Last Name (STitle) 724**] .
Disp:*120 Tablet(s)* Refills:*2*
9. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Left temporal tumor
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
-
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
VISUAL FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] [**2165-6-25**] 10:30am
Dr. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in Brain [**Hospital 341**] Clinic Phone:[**Telephone/Fax (1) 1844**] on
Wednesday [**2165-5-1**] @ 11am. His office is located at [**Hospital3 **]
on the [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] building on the [**Location (un) **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-5-7**] 1:00
Completed by:[**2165-4-25**]
|
[
"25000",
"2724"
] |
Admission Date: [**2142-4-3**] Discharge Date: [**2142-5-8**]
Service: SURGERY
Allergies:
Penicillins / Codeine / Clindamycin / Zestril / Ciprofloxacin /
Ivp Dye, Iodine Containing / Milk
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ischemic right foot.
Major Surgical or Invasive Procedure:
1. Abdominopelvic arteriogram and selective right lower
extremity arteriogram.
2. Right saphenofemoral artery to plantar bypass using left
greater saphenous vein, angioscopy.
3. a Exploration of bypass graft.
b Thrombectomy of bypass graft.
c Angioscopy vein graft.
d Patch angioplasty of graft using greater saphenous vein x4.
4. Ligation of the right lower extremity vein graft.
History of Present Illness:
This 87-year-old lady has previously had a right superficial
femoral angioplasty and stent. She has had recurrent ischemic
ulceration of her right
foot and is undergoing a diagnostic arteriogram.
Past Medical History:
1. Type 2 diabetes mellitus.
2. Total right hip replacement in [**2131**].
3. Total abdominal hysterectomy and bilateral salpingo-
oophorectomy.
4. Cholecystectomy.
5. Appendectomy.
6. DDD pacer status post Type II AV block.
7. Spinal stenosis.
8. Chronic lower back pain.
9. Hypothyroidism.
10. Orthostatic hypotension.
11. Recurrent Malignant External Otitis
12. Bell's Palsy
Social History:
She is a nonsmoker, and denies alcohol use. The patient
is a retired nurse [**First Name (Titles) 767**] [**Hospital1 69**].
Family History:
She has a family history pertinent for
diabetes mellitus, coronary artery disease
Physical Exam:
99.5 61 132/50 18 97%
No apparent distress, alert and oriented x3
Perrla, EOMI MMM, slight droop lt droop noted
RRR, S1 S2
Clear to auscultation
Soft abdomen, non-tender, non distended
Left DP palpable, Left PT biphasic, Right PT and BP monophasic
Erythema of right foot on dorsal surface extending to ankle
Ulceration of rt 4th digit
Pertinent Results:
[**2142-5-7**] 04:00AM BLOOD
WBC-8.9 RBC-3.05* Hgb-9.3* Hct-26.4* MCV-87 MCH-30.4 MCHC-35.0
RDW-14.3 Plt Ct-173
[**2142-5-7**] 04:00AM BLOOD
PT-18.5* PTT-37.2* INR(PT)-1.7*
[**2142-5-7**] 04:00AM BLOOD
Glucose-97 UreaN-24* Creat-1.1 Na-142 K-3.8 Cl-101 HCO3-34*
AnGap-1106/19/06
Calcium-8.5 Phos-3.0 Mg-1.8
[**2142-5-1**]
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE Hours-RANDOM UreaN-268 Creat-44 Na-73 K-34
URINE Osmolal-331
[**2142-5-6**] 7:00 pm STOOL CONSISTENCY: SOFT Source: Stool.
FINAL REPORT [**2142-5-7**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2142-5-7**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2142-5-1**]
Probable atrial sensed and ventricular paced rhythm with
occasional atrial
premature beats. Since the previous tracing of [**2142-4-25**]
ventricular premature beats are no longer seen.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 0 136 400/438.42 0 -83 -167
[**2142-4-26**] 1:15 PM
CHEST (PORTABLE AP)
HISTORY: Congestive heart failure.
UPRIGHT AP VIEW OF THE CHEST: Increasing moderate bilateral
pleural effusions, right greater than left are present.
Additionally, bibasilar opacities reflecting atelectasis
persists. Rounded opacity within the medial aspect of the right
base also may represent right middle lobe collapse. The cardiac
contours are obscured by the basilar atelectasis. The
mediastinal and hilar contours are unchanged, and there is no
evidence of pulmonary vascular engorgement. Calcifications of
the mitral annulus and aortic knob are unchanged. There is no
pneumothorax. Right-sided dual chamber pacemaker with leads
overlying the right atrium and right ventricle, unchanged. Right
internal jugular central venous catheter with tip overlying the
SVC is stable. Severe degenerative changes are present within
both shoulders.
IMPRESSION: Increasing moderate-sized bilateral pleural
effusions, right greater than left. Bibasilar atelectasis
persists. Possible right middle lobe collapse.
Cardiology Report ECHO Study Date of [**2142-4-13**]
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
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 - Ejection Fraction: 30% to 35% (nl >=55%)
Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Valve Area: *1.3 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
mild diastolic dysfunction with Vp velocity is 28cm/sec.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the LA. Mild spontaneous echo contrast in the
body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Depressed
LAA emptying velocity (<0.2m/s) All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast
in the body of the RA. A catheter or pacing wire is seen in the
RA and
extending into the RV. No spontaneous echo contrast in the RAA.
No ASD by 2D
or color Doppler. The IVC is normal in diameter with appropriate
phasic
respirator variation.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Normal LV cavity size. Moderately depressed LVEF. No LV
mass/thrombus.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior - hypo; mid anterior - hypo; basal anteroseptal
- hypo; mid anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque. Normal aortic root diameter. Simple
atheroma in aortic root. Simple atheroma in ascending aorta.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mild AS. Mild (1+)
AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. Moderate thickening of mitral valve
chordae. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
is seen in the body of the left atrium. Mild spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s).
No spontaneous echo contrast is seen in the body of the right
atrium. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed. No
masses or thrombi are seen in the left ventricle. R. 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. There are
simple atheroma in the aortic root. There are simple atheroma
in the ascending aorta. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. There is mild aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate thickening of the mitral valve
chordae. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
[**2142-4-7**] 7:01 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
TECHNIQUE: Routine noncontrast head CT was followed by MDCT
imaging of the head and neck following the administration of 90
cc of intravenous Optiray. Nonionic contrast was administered
per protocol. Coronal and sagittal reformatted images were
obtained.
NONCONTRAST HEAD CT: There is no intra- or extra-axial
hemorrhage, mass effect, or shift of normally midline
structures. There is no specific evidence of major vascular
territorial infarction. Patchy and confluent hypodensity in
bihemispheric subcortical and periventricular white matter,
representing chronic micro-ischemic change; the appearance is
not significantly changed from prior study dated [**2140-7-26**]. The
[**Doctor Last Name 352**]-white matter differentiation is otherwise preserved. The
surrounding soft tissue and osseous structures are unremarkable.
The imaged paranasal sinuses and mastoid air cells are
appropriately aerated.
CT ANGIOGRAM HEAD: The major vessels of the circle of [**Location (un) 431**] and
their major branches are patent. There is no hemodynamically
significant stenosis or aneurysmal. Within the limits of
coverage of this study, no sign of AV malformation is apparent.
There are moderate mural calcifications of the cavernous and
supraclinoid segments of both intracranial internal carotid
arteries.
CT ANGIOGRAM NECK: There is no evidence of significant stenosis
or ulceration, particularly with reference to the carotid
bifurcation bilaterally. The left jugular vein is asymmetrically
enhancing compared with the right. While this maybe related to
the phase of contrast injection, right internal jugular thrombus
cannot be excluded. There are large bilateral pleural effusions,
reaching the level of the right lung apex, and diffuse
atherosclerosis with dense mural calcifications along the aortic
arch.
IMPRESSION:
1. No intracranial hemorrhage or major vascular territorial
infarction.
2. Unremarkable CTA of the neck and circle of [**Location (un) 431**].
3. Asymmetric enhancement of the left internal jugular vein
compared with the right. While this may be related to the phase
of contrast injection, a right internal jugular thrombus cannot
be excluded.
4. Large bilateral pleural effusions.
5. Atherosclerosis.
Brief Hospital Course:
86 Female admitted with right 4th toe ischemia and was placed on
antibiotics for cellulitis. After resolution of the cellulitis
she underwent a right SFA->plantar BPG w/ left NRSVG ([**4-13**]) and
tolerated the procedure well and had a strongly palpable graft
pulse. Approximately one week later she underwent a toe
amputation by the podiatry service. She was noted to be
hypotensive to the 80s post-operatively after receiving a dose
of morphine and it was noted that her graft had lost its
palpable signal and was weakly dopplerable. She was emergently
taken back to the OR and underwent a graft thrombectomy and
patch angioplasties. She had a palpable graft post-operatively.
She was progressing well until [**4-27**] when she was noted to have a
small amount of serous fluid draining from her thigh (medial)
incision and some underlying induration and erythema. The wound
was opened on [**4-28**] and drained of seropurulent fluid. Culture
revealed E. Coli. She was treated with antibiotics accordingly
and the wound was packed with wet-to-dry dressings. A vac was
placed on [**4-30**]. later that evening she was noted to have brisk
bleeding from her thigh wound. She was taken immediately to the
OR where the bleeding vessel was ligated. She bled again in the
PACU, this time dropping her pressures. She went again to the
OR where the vein graft was noted to be macerated from the
infection and frankly bleeding. This was ligated and the wound
left open. She was transfused multiple units of blood and
2units of FFP. She recovered well with a notably cool right
lower leg. She was eventually diuresed and her hematocrit
remained stable. A vac was placed on her wound on [**5-4**]. She is
tolerating a regular diet, out of bed with assist, and continued
on IV antibiotics with a right IJ central line. She has
underlying CHF and reactive airway disease which have required
diuresis and nebulizer treatments but have remained stable. She
currently has RLE pain but is refusing an amputation at this
time. Her blood supply to her right lower leg is poor and her
leg should be protected from trauma and pressure ulceration.
Please follow up with Dr. [**Last Name (STitle) **] for any antibiotic
changes or major changes in her care.
Medications on Admission:
coumadin 2'/4'Sundays (for PAF),
lasix 20/10QOD,
lantus,
lisinopril 10',
quinine 25',
synthroid 75mcg',
colchicine 0.6',
asa 81'
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day.
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
INR goal 2.
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
16. Insulin
Insulin SC Fixed Dose Orders
Bedtime
lantus 20 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-55 mg/dL 4 oz. Juice and 15 gm crackers
56-160 mg/dL 0 Units
161-200 mg/dL 2 Units
201-240 mg/dL 4 Units
241-280 mg/dL 6 Units
281-320 mg/dL 8 Units
321-360 mg/dL 10 Units
361-400 mg/dL 12 Units
> 401 mg/dL Notify M.D.
17. Potassium Oral
18. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
20. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**11-20**]
Tablets PO Q6H (every 6 hours) as needed.
21. Ceftriaxone 1 gm IV Q24H
22. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for breakthru pain.
23. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ischemic ulceration of the right foot.
Acute occlusion of right superficial femoral artery to posterior
tibial bypass graft.
Hemorrhage from the right lower extremity vein graft.
Discharge Condition:
Stable
Discharge Instructions:
routine wound care checks / fevers / chills / discharge from
wound/ pain management.
Please keep right lower extremity clean, dry, moisturized.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2142-6-20**] 1:30.
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]. Schedule an
appointment for 2 weeks.
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2142-6-20**] 1:30.
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]. Schedule an
appointment in 2 weeks.
Completed by:[**2142-5-9**]
|
[
"4240",
"25000",
"V5861"
] |
Admission Date: [**2105-5-30**] Discharge Date: [**2105-6-6**]
Date of Birth: [**2037-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Neck and Shoulder Pain
Major Surgical or Invasive Procedure:
Septic joint washout
PICC line placement
L hallux ulcer debridement x2
History of Present Illness:
This is a 68 yo M with a past medical history of DM, HTN, who
presented to an OSH with neck pain on two different occasions
and on the third presentation, has altered mental status and
fevers, had an LP and was admitted. He was given CTX for
antibiosis. His course was subsequently complicated by a GPC
bacteremia, and worsening neck pain, and ?upper extremity
weakness, was then transferred to [**Hospital1 18**] for MRI of neck to rule
out epidural abscess. He was found on MRI to have no definite
signs of epidural abscess in the cervical or thoracic spine, but
was then found to have decreased L shoulder range of motion with
significant pain. Ortho was consulted, and tapped the joint,
which was consistent with septic arthritis, with [**Numeric Identifier 79644**] WBC. At
that time, he was taken to the OR for washout, which was
significant for large amount of pus, sent for cultures. He was
also noted to have an ulcer on his left foot which probed to
bone.
.
Labs were notable for a white count of 20K, mild elevations in
LFT's, mild hyponatremia and CRP>200, ESR 80. He is admitted to
the MICU post-operatively for further work up of his bacteremia,
and possible osteomyelitis. Now called out to the medicine floor
post-washout.
.
At this time, patient denies fevers, chills, shortness of
breath, chest pain, abdominal pain, diarrhea, dysuria,
hematochezia, melena, weakess or other symptoms. He is currently
denying shoulder pain after the surgery, but does not continued
neck soreness, though improved from prior.
Past Medical History:
HTN
DM2
History of hyperkalemia
Gout
Social History:
Married with 6 children. Lives with wife and two sons. [**Name (NI) **]
tobacco, illicits, etoh. Currently works as shuttle bus driver.
Family History:
non-contributory, son has significant diabetes with
complications
Physical Exam:
VS: T 98.4 142/80 82 18 94% on RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, mild conjuctival injection,
anicteric, OP clear, MM dry, Neck supple, no LAD, no carotid
bruits, small area of tenderness over cervical spine but
improved from prior per patient
CV: RRR, nl s1, s2, I/VI SM @ LLSB no r/g
PULM: CTAB, no w/r with good air movement throughout, scattered
rhonchi on the right base
ABD: soft, NT, ND, hypoactive BS, liver margin 2cm below costal
margin.
EXT: warm, dry, +1 distal pulses BL with trace edema of the
foot, per report 1x2cm ulcer on the bottom of the left great
toe, slightly bloody, no obvious pus (had been wrapped and
unwrapped throughout the day and patient deferred exam at this
time). L shoulder wrapped in sling, full radial pulse
NEURO: alert & oriented, CN II-XII intact, left should exam
limited due to immobility from surgery, otherwise, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis.
PSYCH: appropriate affect
Pertinent Results:
[**2105-5-30**] 01:15PM SED RATE-80*
[**2105-5-30**] 01:15PM PT-13.1 PTT-26.3 INR(PT)-1.1
[**2105-5-30**] 01:15PM PLT SMR-NORMAL PLT COUNT-248
[**2105-5-30**] 01:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2105-5-30**] 01:15PM NEUTS-94.5* BANDS-0 LYMPHS-3.3* MONOS-2.0
EOS-0.1 BASOS-0.1
[**2105-5-30**] 01:15PM WBC-19.7* RBC-4.66 HGB-13.5* HCT-38.4* MCV-83
MCH-29.0 MCHC-35.1* RDW-13.6
[**2105-5-30**] 01:15PM CRP-GREATER TH
[**2105-5-30**] 01:15PM CALCIUM-8.8 PHOSPHATE-2.3* MAGNESIUM-2.2
[**2105-5-30**] 01:15PM LIPASE-47
[**2105-5-30**] 01:15PM ALT(SGPT)-50* AST(SGOT)-63* LD(LDH)-340* ALK
PHOS-90 TOT BILI-0.7
[**2105-5-30**] 01:15PM estGFR-Using this
[**2105-5-30**] 01:15PM GLUCOSE-139* UREA N-39* CREAT-1.0 SODIUM-129*
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-25 ANION GAP-16
[**2105-5-30**] 01:21PM LACTATE-1.8
[**2105-5-30**] 04:59PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2105-5-30**] 04:59PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2105-5-30**] 04:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2105-5-30**] 07:02PM JOINT FLUID NUMBER-NONE
[**2105-5-30**] 07:02PM JOINT FLUID WBC-[**Numeric Identifier 79644**]* RBC-[**Numeric Identifier 890**]* POLYS-93*
LYMPHS-3 MONOS-4
.
ECHO:
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the aortic arch and descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. There is a 0.3cm by 0.3cm mobile
echodense structure (see cell 17) on the LVOT side of the aortic
valve that may be a small vegetation (orLambl's excrescence).
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Possible small aortic valve vegetation; no aortic
regurgitation. Mild mitral regurgitation.
.
MRI OF THE CERVICAL AND THORACIC SPINE.
CLINICAL INFORMATION: Patient with question of epidural abscess.
CERVICAL SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient
echo axial
images were obtained before gadolinium. T1 sagittal and axial
images were
obtained following gadolinium.
FINDINGS: There is no evidence of epidural abscess seen in the
cervical
region. No abnormal intraspinal enhancement is identified. At
the
craniocervical junction and C2-3, degenerative disease is
identified.
At C3-4 mild irregularity of the endplates is identified without
abnormal
signal within the disc or enhancement to indicate discitis.
Mild-to-moderate
left foraminal narrowing seen.
At C4-5, C5-6, and C6-7, mild disc bulging and posterior ridging
identified
without spinal stenosis. The spinal cord shows normal intrinsic
signal.
IMPRESSION:
1. No definite signs of epidural abscess, discitis, or
osteomyelitis.
2. Mild increased signal in the prevertebral soft tissues in the
cervical
region without distinct fluid collection. This could be due to
fluid within
the nasopharynx. If the patient has trauma, mild prevertebral
edema can also
have a similar appearance. Clinical correlation recommended.
3. Mild multilevel degenerative changes.
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the
thoracic spine were obtained before gadolinium. T1 sagittal and
axial images
were obtained following gadolinium.
FINDINGS: There is no evidence of discitis, osteomyelitis or
epidural abscess
seen in the thoracic region. No abnormal enhancement identified.
Mild
posterior ridging of the mid lower thoracic vertebral bodies
identified which
appears to be congenital in nature. Mild multilevel degenerative
changes are
seen. The spinal cord shows normal intrinsic signal without
extrinsic
compression.
IMPRESSION: Mild degenerative changes. No evidence of discitis,
osteomyelitis or epidural abscess in the thoracic region.
COMMENT: A small amount of fluid is seen in the atlanto-odontoid
and
atlantoaxial joint anteriorly which could be due to degenerative
in nature.
Brief Hospital Course:
A/P: 68 yo M with GPC bacteremia with septic arthritis of L
shoulder and electrolyte abnormalities.
.
# Group C Strep Bacteremia/Endocarditis: Initially with sepsis
physiology though was stable upon arrival to the medicine floor.
Was not hypotensive in MICU. Obvious cause is group C strep
bacteremia, likely source is L toe ulcer that is also growly
group C strep. Neck pain was concerning for abscess, but MRI
here did not show evidence of this, patient continued to refuse
any further neck imagining despite continued decreased ROM of
his neck. Given bacteremia, TTE was done which was negative,
however, TEE was performed showing evidence of an aortic valve
vegetation. Group C strep was found to be ceftriaxone sensitive
from the OSH. In addition, patient had shoulder washout on
admission to the hospital, cultures from that continued to be no
growth to date. Patient was treated with ceftriaxone, and sent
home for a total of 6 weeks of therapy (PICC line placed while
inhouse). He was hemodynamically stable throughout his
admission.
.
# L foot ulcer: Patient had non-healing ulcer, swab positive for
group C strep, and this likely represents the source of his
bacteremia. He was followed by podiatry and vascular surgery in
house. He had two bedside debridements by podiatry. He
additionally had non-invasive arterial studies that were normal
with good flow. He will be followed by Dr. [**Last Name (STitle) **] in podiatry as
an outpatient. His toe was treated with wet-to-dry dressing
with silvedine and post-op boot while inhouse.
.
# Septic Arthritis: Patient has been bacteremic with group C
strep, which is has likely seeded the L shoulder synovial space
via hematogenous spread. He is now s/p washout by ortho though
no growth from joint fluid. He has a history of gout, but an
acute gouty flare in this joint is uncommon without multiple
other joints being affected and the findings of pus on washout
is also inconsistent with gout. Also concern over persistent
neck pain and evolving abscess or seeding as above. He was
continued on ceftriaxone for a total of 6 weeks as above. He
refused any further head or neck imaging throughout his stay.
.
# Acute renal failure: Patient with creatinine bump from 0.8 to
1.2 overnight during admission. Baseline prior since admission
appears to be around 0.6-0.8. Patient maintained good UOP until
his last day of admission at which time he had urinary urgency
and hesitancy with a positive bladder scan. He did have
bilateral hydro on an OSH renal US, and a repeat renal US was
performed showing unchanged mild-to-moderate hydronephrosis. As
the patient had difficulty urinating, likley due to BPH, he was
sent home with a foley/leg bag with urology follow up as he
refused to stay any longer for further work up. UA, ucx and
urine eos were negative. Creatinine decreased to baseline prior
to discharge.
.
# Transaminitis: Found on admission, resolved without
intervention. Unclear etiology. Most concerning was that the
patient may be throwing septic emboli. Otherwise, etiologies
included congestion from sepsis, drug induced hepatitis
(although level of transaminitis is quite low), CBD pathology
(but TB is wnl). Most likely secondary to dehydration from
evolving sepsis on admission. Abd ultrasound done was c/w fatty
liver or other liver disease which cannot be excluded, though no
evidence of emboli.
.
# Hyponatremia: On admission. Resolved after hydration. Patient
likely was dehydrated given infection. Improvement in BUN as
well.
.
# HTN: Restarted low dose lisinopril on [**6-4**] given hypertension.
He was continued on 5mg daily on discharge.
.
# DM2: Holding metformin and glyburide, also on lantus at home
(20u QHS). Given low POs and post-surgical washout, was placed
on insulin ss initially. Lantus was restarted. Blood sugars
should be followed as an outpatient.
.
#CODE: FULL
.
#COMMUNICATION: patient
Medications on Admission:
Metformin
Glyburide
lisinopril
protonix
colace
ASA 81
Discharge Medications:
1. Ceftriaxone 2 gram Piggyback Sig: One (1) dose Intravenous
once a day for 5 weeks.
Disp:*5 weeks supply* Refills:*0*
2. PICC line care
PICC line care per NEHT protocol. Saline and heparin flushes.
3. Outpatient Lab Work
Please check weekly:
CBC, BMP, LFTs
Also, please check ESR, CRP one week prior to [**Month/Year (2) 648**] with
Infectious Disease physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please fax all results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 432**].
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily): to L foot ulcer with dressing change.
Disp:*1 tube* Refills:*2*
10. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Group C strep bacteremia
Aortic valve endocarditis
Septic arthritis of left shoulder
Hypertension
Type II DM, uncontrolled
Gout
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were admitted with bacteria in your blood. Your shoulder
had bacteria in it as well that was cleaned out by the
Orthopedic surgeons. You also were found to have bacteria on
your heart valve (endocarditis). For that, you will require 6
weeks total of IV antibiotics. This has been arranged for you.
You had a non-healing ulcer on your toe that is likely the
reason you had bacteria in your blood. Podiatry and Vascular
surgery teams evaluated you and debrided your toe. You will
follow up with both of these teams as an outpatient for further
evaluation and management of your wounds.
You have been unable to move your neck appropriately, though it
has been improving during your admission. Your initial imaging
did not show anything concerning, but this should be followed
very carefully by your outpatient doctors.
It is very important that you keep all of your follow up
apppointments. Please do not miss [**First Name (Titles) **] [**Last Name (Titles) 648**] with the
Infectious Disease doctor as they need to deteremine if you are
continuing to clear the bacteria in your blood.
If you develop chest pain, shortness of breath, weakness,
increased shoulder pain or inability to move your shoulder,
dizziness, vision changes, abdominal pain, or any other
concerning symptom, please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 10046**]d to the Emergency Room immediately.
Please take all medications as prescribed.
Followup Instructions:
Please keep the following appointments:
Vascular: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2105-7-16**] 2:45
Podiatry: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2105-6-10**] 11:40
You will have an [**Month/Day/Year 648**] with the infectious disease doctor,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2-4 weeks. Her office will call you to
arrange this [**Last Name (NamePattern1) 648**]. If you do not hear from them next
week, please call ([**Telephone/Fax (1) 4170**] to arrange this [**Telephone/Fax (1) 648**].
You should see your primary care doctor in [**11-19**] weeks. Please
call Dr. [**Last Name (STitle) 5263**] at [**Telephone/Fax (1) 7401**] to schedule this [**Telephone/Fax (1) 648**].
You will need to see a urologist to follow up regarding your
need for the foley catheter. You should keep it in place until
you see them. Please call ([**Telephone/Fax (1) 772**] to make an [**Telephone/Fax (1) 648**]
as soon as possible.
|
[
"2761",
"4019",
"2720"
] |
Admission Date: [**2182-5-1**] Discharge Date: [**2182-5-8**]
Date of Birth: [**2111-6-19**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
septic shock and respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70 year old man who was discharged after a 3 month
complicated hospitalization who presents with hypotension and
respiratory failure. His recent medical problems started after
he sustained a C7 vertebral fracture in [**12-21**]. He underwent a
ORIF of C6-7 with posterior fusion, laminectomy, and iliac crest
bone graft with wire placement in [**1-21**]. His course was
complicated by a CSF leak which was repaired, but then followed
by development of MRSA meningitis, cerebritis, sinusitis, and
mastoiditis, PE/DVT, NSTEMI, acute interstitial nephritis and
hypersensitivity desquamative dermatitis believed secondary to
vancomycin or rifampin, respiratory failure from pneumonia, ICU
neuropathy/myopathy, candidemia, and mental status changes.
.
He now presents following an episode of depressed mental status
and hypotension at [**Hospital1 **]. Fluid was given and EMS was called.
He had an ABG of 7.14/74/83 on unknown O2 settings and was found
to be satting 91% on NRB mask and have systolic pressures from
40-60, so he was intubated and transported to [**Hospital1 18**]. His
pressures stauyed in the 40-60's and he was started on levophed
and fluids. With his hypotension, lactate of 3.8 and WBC 28 with
17% bands, a code sepsis was called. He was given 4L more fluid
and a right IJ sepsis line was placed with CVP from [**5-23**]. Urine
and blood cultures were drawn. He was transferred to the MICU.
Past Medical History:
1. Diabetes Mellitus Type II Uncontrolled w/ Complications
2. Coronary Artery Disease s/p CABG x 3
3. Hypertension
4. Anxiety
5. Hypercholesterolemia
6. L3-L4 Surgery
7. BPH
8. Recent hospitalization notable for:
Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
CSF Leak - Wound infection s/p drainage and dural repair
[**2182-2-9**]
Incision and drainage and hardware exchange [**2181-2-12**]
MRSA Meningitis
MRSA Pneumonia
Left Heart Failure
Non-ST Elevation Myocardial Infarction
Left Occipital Stroke vs MRSA Cerebritis
RLE Deep Venous Thrombosis
Pulmonary Embolism
Non-Sustained Ventricular Tachycardia
Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin) Eosinophilia
Hypoxic Respiratory Failure
Septic vs. Anaphylactic Shock
Delirium
Cholestasis
RUE Paresis
Bilateral Lower Extremity Myopathy
Dysphagia
GI Bleed
Nosocomial LLL Pneumonia
Anemia - multifactorial: Illness, blood loss, CKD.
Sacral and Heel Ulcers
MRSA/VRE Colonization
Candidemia
decub ulcer
Hep C
RP bleed
Social History:
No smoking, etoh or IVDA. Was plumber. Lived with wife until
[**Name (NI) 404**], but was at [**Hospital3 **] since C spine fusion, then
[**Hospital1 18**], then [**Hospital1 **]
Family History:
NC
Physical Exam:
V: Tm 103.5 Tc 96 P70 BP 121/44 R12 100% CVP 6-8
Vent: AC 450x16 60% P5 PIP 21 Plat 16
Gen: intubated, sedated but appears comforatable
HEENT: Pupils reactive bilaterally. ETT in place.
Neck: no JVD
Resp: clear bilaterally no rhonchi
CV: RRR nl s1s2 + [**2-18**] WEM LUSB
Abd: Soft NTND G tube in place
Ext: warm, 1+ edema hands, no edema legs
Back: stage 2 sacral decub ~8 cm
Neuro: not following commands.
Pertinent Results:
[**2182-5-1**]
148 114 44 AGap=17
-------------< 216
4.5 22 1.8
Ca: 8.0 Mg: 1.6 P: 6.0 D
96
27.9 \ 7.7 / 461
/ 26.1\
N:80 Band:17 L:1 M:2 E:0 Bas:0
PT: 29.5 PTT: 51.6 INR: 3.1
[**2182-5-6**] 05:46AM BLOOD WBC-6.8 RBC-3.25* Hgb-9.2* Hct-28.8*
MCV-89 MCH-28.5 MCHC-32.1 RDW-18.0* Plt Ct-309
[**2182-5-5**] 06:00AM BLOOD Neuts-60.0 Bands-0 Lymphs-24.3 Monos-6.2
Eos-9.0* Baso-0.6
[**2182-5-6**] 05:46AM BLOOD Plt Ct-309
[**2182-5-6**] 05:46AM BLOOD Glucose-130* UreaN-31* Creat-1.3* Na-145
K-3.6 Cl-116* HCO3-21* AnGap-12
[**2182-5-2**] 09:43PM BLOOD CK(CPK)-42
[**2182-5-2**] 09:43PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2182-5-2**] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2182-5-2**] 07:57AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2182-5-2**] 04:57AM BLOOD Cortsol-23.2*
[**2182-5-2**] 07:57AM BLOOD Cortsol-31.2*
[**2182-5-2**] 08:30AM BLOOD Cortsol-33.5*
[**2182-5-3**] 04:12AM BLOOD Triglyc-168* HDL-27 CHOL/HD-3.6
LDLcalc-37
[**2182-5-5**] 05:58AM BLOOD Type-ART pO2-83* pCO2-35 pH-7.39
calHCO3-22 Base XS--2
[**2182-5-4**] 09:18AM BLOOD Lactate-1.1
[**2182-5-3**] 08:45PM BLOOD O2 Sat-80
MICRO
[**2182-5-4**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2182-5-4**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2182-5-4**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2182-5-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2182-5-2**] CATHETER TIP-IV WOUND CULTURE-FINAL {PSEUDOMONAS
AERUGINOSA} INPATIENT
WOUND CULTURE (Final [**2182-5-4**]):
PSEUDOMONAS AERUGINOSA. >15 colonies.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**2182-5-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**2182-5-1**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA,
2ND ISOLATE} INPATIENT
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
[**2182-5-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING EMERGENCY [**Hospital1 **]
[**2182-5-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
Cardiology Report ECHO Study Date of [**2182-5-3**]
Conclusions:
1. No atrial septal defect or patent foramen ovale is seen by
2D, color
Doppler or saline contrast with maneuvers.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened.
4. Compared with the prior study (images reviewed) of [**2182-4-18**],
there is no
significant change.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2182-5-2**] 1:50 PM
CONCLUSION: Negative right upper quadrant ultrasound.
CHEST (PORTABLE AP) [**2182-5-2**] 7:08 AM
IMPRESSION:
1. Slight improvement of a longstanding left retrocardiac
atelectasis (less likely pneumonia) and associated effusion.
2. New right IJ catheter without pneumothorax.
MR [**Name13 (STitle) **] W& W/O CONTRAST [**2182-5-4**] 3:50 AM
IMPRESSION: No evidence of new fluid collection seen or an area
of new enhancement identified. Focal increased signal seen
within the spinal cord at C7 level which could be secondary to
myelomalacia. No evidence of discitis or osteomyelitis.
Continued mild increased signal within the posterior soft
tissues at the laminectomy site could be due to inflammatory
changes without evidence of focal fluid collection.
Brief Hospital Course:
1) Septic shock with respiratory failure from pseudomonas line
infection - Pt was hypoxic and hypotensive on presentation and
intubated in the field. With elevated lactate, WBC, and
respiratory failure, this represented septic shock. The
potential sources were recurrence of meningitis/cervical fluid
abscess, UTI, C dif given antibiotic use, PICC line infection,
persistent candidemia, sacral decub inflammaion. He received 1
dose vancomycin in the ED and levo/flagyl, but on admission to
the MICU was changed to linezolid and cefepime to add
pseudomonas coverage. He was continued on voriconazole for
history of [**Female First Name (un) **] blood infection. His PICC line was pulled. He
got >10 liters of fluid and SVo2 was >90% despite fluids, so an
echo was done which showed no shunt. After 2 days, he was weaned
from levophedrine then extubated with improvement in SVO2 to the
80's. ID was consulted and recommended continuing linezolid and
cefepime, and obtaining MRI of the neck area which showed no
drainable fluid collection. His previous neck surgeon was
consulted and found no signs of infection in the neck area, so
the decision was jointly made not to perform LP. The next day,
cultures revealed pseudomonas sensitive to cefepime. He
continued to do well and was afebrile. He will be continued on
cefepime for 14 days total, and doxacycline indefinitely for
MRSA prophylaxis. He should have follow up with ID.
2) Sacral decub - wound care was consulted and noted that his
sacral decub ulcer had a black thick eschar on sacral decub 9x13
cm, increased from 2-3 cm on last discharge. Plastic surgery
felt not need for surgical interventions.
Copntinue care as directed.
3) EKG changes/demand ischemia - The patient was noted to have
new inferior flipped T waves on admission, and slightly elevated
troponins in the setting of systolic blood pressures to the
40's. This was felt to be demand ischemia, as he has a previous
history of CABG. HE should follow up with his cardiologist and
stress test or cath should be considered when his rehabilitation
is completed. He was continued on aspirin, and beta blocker and
captopril were restarted when blood pressure tolerated.
4) Vancomycin allergy with eosinophilia - The patient had a
history of severe desquamative reaction/AIN/hypotension and
fevers in recent hospitalization to vanco/rifampin. He received
a dose of vancomycin in ED and developed eosinophila, but no
evidence of rash or kidney failure. Urine eos were negative.
5) Acute renal failure - He had acute renal failure likely
secondary to sepsis, but FENA 3.67 so likely had some ATN in
addition to prerenal component. His creatinine improved with
hydration to baseline.
6) history of PE/DVT, on anticoagulation - He was reversed on
admission with 1 mg IV vitamin K in anticipation of possible LP,
but then started on heparin when INR was < 2. He was restarted
on coumadin 5 mg po qd on the evening of [**2182-5-6**]. Currently dose
2.5 mg/qhs. Goal 2-3mg
7) Hypernatremia: Increase Sodium on [**2182-4-7**]. Likely lack of
free water intake.
Currently getting 250 free water QID. Na trending down.
8) code status - His code status was extensively discussed with
his family on admission given his poor prognosis. He was
initially "do not shock, no CPR" but this was changed back to
full code after personal phone call from daugter morning of
[**5-2**].
Medications on Admission:
Acetaminophen 325 mg PO Q4-6H
Aspirin 325 mg PO DAILY
Nystatin 100,000 unit/g Cream Topical [**Hospital1 **]
Zinc Oxide-Cod Liver Oil 40 % Ointment [**Hospital1 **]
Mupirocin Calcium 2 % Cream Topical [**Hospital1 **]
Albuterol Sulfate 0.083 % Solution Q2H as needed.
Ipratropium Bromide 0.02 % Solution Inhalation Q6H (every 6
hours) as needed.
Sodium Chloride [**12-17**] Sprays Nasal TID (3 times a day).
Amlodipine 10 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Metoprolol Tartrate 100 mg PO TID
Folic Acid 1 mg PO DAILY
Epoetin Alfa 10,000 unit/mL QMOWEFR (Monday -Wednesday-Friday).
Doxycycline Hyclate 100 mg PO Q12H (every 12 hours).
Captopril 25 mg PO TID
Voriconazole 200 mg Intravenous Q12H through [**5-1**]
Insulin sliding scale
Heparin sliding scale
coumadin since [**4-26**]
linezolid started at [**Hospital1 **] [**5-1**]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): to be continued indefinitely for MRSA
prophylaxis.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): may titrate as tolerated to keep pulse around
60.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units SQ Injection QMOWEFR (Monday -Wednesday-Friday).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): may titrate to keep systolic blood pressure between 120
and 140.
14. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
adjust as needed, goal INR [**1-18**]. .
15. Insulin Regular Human Subcutaneous
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO ONCE (Once) for 1 doses.
17. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
19. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q12H
(every 12 hours) for 8 days: last day [**2182-5-15**]. Then please DC
PICC line.
20. free water
Please give 250 freww water QID through G tube.
Follow up sodium closely
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
pseudomonal line septic shock with urine and sputum colonization
respiratory failure
vancomycin allergy
acute renal failure
Discharge Condition:
Good
Discharge Instructions:
contineu your medications as prescribed
If you have hypotension, fevers, respiratory distress or other
concerns, please return to the ED.
Followup Instructions:
Please follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 65335**], 1
week after discharge from rehab.
Please follow up with your surgeon, Dr. [**Last Name (STitle) **], 1 week after
discharge from rehab.
Please follow up with your cardiologist in [**12-17**] months regarding
the need for stress testing.
|
[
"99592",
"51881",
"78552",
"5849",
"5990",
"2760",
"25000",
"4019",
"V4581"
] |
Admission Date: [**2166-10-4**] Discharge Date: [**2166-10-7**]
Date of Birth: [**2166-10-4**] Sex: M
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby boy [**Known lastname 23170**] is a 35 and
4/7ths week 2460 gram infant delivered to a 22-year-old G4,
P2 mom.
PRENATAL SCREENS: Blood type O positive, antibody negative,
negative, GBS positive. Mom does have a history significant
for seizure disorder treated with Topamax and history of IUGR
with previous pregnancies. Mom went into spontaneous labor
on [**10-3**]. Membranes ruptured approximately 11 hours prior to
delivery. There was no maternal temperature or fetal
tachycardia. Intrapartum antibiotics were started six hours
prior to delivery. Mom received one dose of Nubane one hour
epidural anesthesia. Mom progressed quickly from 8 cm to
delivery, two contractions by report. The Department of
Neonatology arrived at 3 minutes of age. The infant was pink
with good tone and strong cry. The infant as given stem and
bulb suction with brief blow-by oxygen. Apgars assigned; 8
and 8 and 1 and 5 minutes respectively. The patient was left
in Labor and Delivery for approximately one hour to bond with
the parents. We were then called by the Labor and Delivery
Staff for tachypnea and retractions.
Birth weight: 2460 grams. Temperature 97.6, heart rate 148,
blood pressure 67/28. Mean arterial blood pressure 40.
Respiratory rate: 80s. Oxygen saturation 93% on room air.
The patient was a nondysmorphic preterm infant with mild
respiratory distress. Skin was ruddy and smooth. Anterior
fontanelle soft, open, and flat with mild molding. Lips,
gums, palates were intact. There was bilateral red reflex
noted. Chest was symmetrical. Breath sounds were clear
bilaterally. There were mild-to-moderate retractions and
tachypnea. HEART: Heart was regular with a soft
intermittent murmur. The patient was pink and well perfused
with 2+ pulses in the upper and lower extremities. ABDOMEN:
Soft, no hepatosplenomegaly. Three-vessel cord with normal
bowel sounds. Also, the patient had normal male genitalia.
Testes were descended bilaterally. Anus was patent. Spine
was straight. Ossicles intact. No hip clicks. Slight
hypotonia consistent with age.
HOSPITAL COURSE: By systems.
RESPIRATORY: The patient was briefly on nasal cannula
oxygen, but by twenty-four hours, the patient was weaned to
room air where he currently remains in no distress.
CARDIOVASCULAR: The intermittent murmur that was heard on
admission resolved. Heart rate and blood pressures remained
within normal limits.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
initially started on IV fluids. When the respiratory
distress resolved, he was started on PO feeds. He is
currently taking an ounce to one and one half ounces every
three hours.
GASTROINTESTINAL: From a GI standpoint, he has had normal
meconium stools. He also has normal urine output.
HEMATOLOGY: Hematocrit was checked on day of life #1 and it
was 58. Although mom was GBS positive, she was pretreated
and there were no other sepsis risk factors. The patient was
observed and had no symptoms of sepsis.
SENSORY: Hearing screening has not yet been performed.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Transfer to newborn nursery.
Primary care pediatrician: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital 18017**] Health Center. Telephone #: [**Telephone/Fax (1) 45495**]. He has
been notified of the patient's delivery and NICU course.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2166-10-7**] 12:46
T: [**2166-10-7**] 13:02
JOB#: [**Job Number **]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2123-8-5**] Discharge Date: [**2123-8-14**]
Date of Birth: [**2056-2-28**] Sex: F
Service:
CHIEF COMPLAINT: Ms. [**Known lastname **] is a 67-year-old active
female who presents with chest pain upon exertion. She has
no chest pain at rest and her exertional chest pain usually
resides in five minutes. She underwent cardiac
catheterization which showed 70% left main disease and RCA
disease. Calcification in her ascending aorta was also noted
at this time. Coronary artery risk factors include
hypertension, hypercholesterolemia, diabetes mellitus and a
smoking history. Ms. [**Known lastname **] was evaluated by the medicine
service and was determined to be a candidate for coronary
artery bypass graft.
PAST MEDICAL HISTORY:
1. Anemia
2. Ovarian cancer
3. Hypertension
4. Hyperlipidemia
5. Noninsulin dependent diabetes mellitus
6. Carpal tunnel syndrome
7. Coronary artery disease
8. Emphysema
SOCIAL HISTORY: Former smoker, quit 10 years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin
2. Glyburide 2.5 mg qd
3. Zestril 40 mg [**Hospital1 **]
4. Norvasc 10 mg qd
5. Hydrochlorothiazide 25 mg qd
6. Lipitor 20 mg qd
7. Neurontin 900 mg tid
8. Niferex 150 mg qd
9. Multivitamin
10. Calcium
11. Beclomethasone inhaler
12. Timolol
13. Epogen 6000 units twice weekly
REVIEW OF SYSTEMS: Negative unless otherwise stated above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 125/39, heart rate 60,
respiratory rate 20. Patient is afebrile.
GENERAL: Alert and oriented x3.
NEUROLOGIC: Nonfocal.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light and accommodation. There are no carotid
bruits.
CARDIOVASCULAR: Regular rate and rhythm.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema.
HOSPITAL COURSE: Ms. [**Known lastname **] was taken to the Operating
Room on [**2123-8-9**] where a coronary artery bypass graft x3 was
performed. Grafts included a left internal mammary artery to
the LAD, saphenous vein graft to the PDA and saphenous vein
graft to OM. The operation was performed without
complication. She was then transferred to the Surgical
Intensive Care Unit where she was weaned off drips and
hemodynamically monitored. She was extubated and stabilized
on the evening of her operation. She was adequately fluid
resuscitated. Her chest tubes were discontinued on
postoperative day 1 and on the evening on postoperative day 1
she was evaluated and felt to be stable for transfer to the
floor.
Upon arrival on the floor, Ms. [**Known lastname **] did have one episode
of hypertension and she was A-paced to 90. On postoperative
day 2, the A-pacing was turned down to 60 and she was able to
maintain her pressures on her own. Metoprolol 12.5 mg [**Hospital1 **]
was started which her blood pressure tolerated. Ms.
[**Known lastname **] continued to do well and was ambulating well with
assistance.
On postoperative day 3, Ms. [**Known lastname 92384**] blood pressure
increased to the 160s systolic. Captopril 20 mg [**Hospital1 **] was
added which was successful in bringing her blood pressure
back down to the 120s, 130s systolic. Her pacer wires were
discontinued on postoperative day 4. She continued to work
well with physical therapy and was tolerating a po diet and
on postoperative day 5 she was stable to be transferred to a
rehabilitation facility.
PHYSICAL EXAM AT DISCHARGE:
VITAL SIGNS: T-max 99.2??????, T-current 97.3??????, pulse 68, blood
pressure 139/73, respirations 20, O2 saturation 94% on room
air.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. Her
incision was clean, dry and intact.
CHEST: Her chest tube sites were clean, dry and intact, as
well.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneous q 12 hours until
consistently ambulating
2. Lasix 20 mg po qd x7 days
3. KCL 20 milliequivalents po qd x7 days
4. Metoprolol 12.5 mg po tid
5. Docusate 100 mg po tid
6. Enteric coated aspirin 325 mg po qd
7. Glyburide 2.5 mg po qd
8. Iron polysaccharides 150 mg po qd
9. Atorvastatin 20 mg qd
10. Multivitamin 1 tablet qd
11. Beclomethasone spray 2 sprays per nostril [**Hospital1 **]
12. Timolol 0.25% 1 drop, right eye qd
13. Calcium gluconate 500 mg [**Hospital1 **]
14. Lisinopril 20 mg po bid
15. Epogen 6000 units intravenous or subcutaneous 2x per week
16. Dilaudid 2 to 4 mg po q 4 to 6 hours as needed for pain
17. Insulin sliding scale. Glucose 0 to 150 0 units of
regular insulin at breakfast, lunch, dinner and bedtime,
glucose 151 to 200 3 units breakfast, lunch, dinner, bedtime,
201 to 250 6 units breakfast, lunch, dinner, bedtime, 251 to
300 9 units breakfast, lunch, dinner, bedtime, 301 to 350 12
units breakfast, lunch, dinner, bedtime, 351 to 400 15 units
breakfast, lunch, dinner, bedtime, greater than 400 18 units
breakfast, lunch, dinner, bedtime and then also give juice
for glucose less than 60.
FOLLOW UP: Ms. [**Known lastname **] should follow up in clinic with Dr.
[**Last Name (STitle) **] in four weeks and follow up with Dr. [**Last Name (STitle) **] in three to
four weeks.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft x3
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor Last Name 92385**]
MEDQUIST36
D: [**2123-8-14**] 10:08
T: [**2123-8-14**] 10:33
JOB#: [**Job Number 92386**]
|
[
"41401",
"4019",
"2859",
"2724"
] |
Admission Date: [**2100-12-29**] Discharge Date: [**2101-1-7**]
Date of Birth: [**2019-7-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Subdural Hemorrhage, Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o white male with extenisve PMHX who was in his usual state
of health today when he had a witnessed fall by VNA at home.
Reported that pt was at coumadin clinic earlier today where INR
was 8.0. He was reaching for his walker at home when he fell
forward striking his head. He was sent to [**Hospital 1514**]
Hospital where he received 2 units of FFP, Vit K 5mg IM, Dilatin
and Mannitol 100mg. He deteriorated in their ER, was intubated
and had a second CT. The times of the CT's are not known to this
hospital although we do have the images. He was transferred
here after CT head revealed large SDH / Interhemispheric with
right left frontal contusion. Pt received proplex in this ER.
Past Medical History:
afib
PPM< DM
CABG
BPH
Aortic stenosis
Social History:
widowed
Family History:
unknown
Physical Exam:
Gen: WD/WN, barrel chest, intubated with cervical collar in
place
on propofol.
HEENT: NCAT, Pupils:reactive 2.5 to 2.0 mm bilaterally, EOM
unable to assess, no battles sign, no raccoon signs,
hemotympanum
not appreciated [**2-4**] cerumen impaction bilaterally.
Neck: collar in place.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2. loud murmur appreciated. ? type
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: sedated - sedation held for exam
Orientation: unable to assess [**2-4**] intubation
Cranial Nerves:
Pt unable to participate with exam
pupils as above, Positive corneals bialterally. no obvious
facial
droop.
NO gag or cough,
Motor: moves all extremeties/ localizes with LUE> RUE. W/D's x
4
to noxious
Toes downgoing bilaterally
Pertinent Results:
CT HEAD W/O CONTRAST [**2100-12-29**]
1. Large left frontal intraparenchymal hemorrhage effacing mass
effect described above.
2. Moderate right parafalcine subdural hematoma
CT HEAD W/O CONTRAST [**2100-12-30**] 11:35 AM
Stable appearance of left frontal and right parafalcine subdural
hemorrhages
Brief Hospital Course:
Subdural/Intraparenchymal hemorrhage: Patient admitted on [**12-29**].
Patient's INR was reversed in the ED, he was loaded with
dilantin and a CT Head was obtained. [**12-30**]: Repeat CT head was
obtained which showed a stable appearance of his Subdural bleed.
[**12-31**]: A follow-up CT head was obtained which was unchanged from
prior studies. [**1-2**]: The patient developed a fever, pan
cultures were sent which revealed E.Coli in the urine and Gram
Negative rods in the sputum antibiotics were started. [**1-3**]: The
patient continued to spike temps as high as 103. There was
discussion about possible trach and peg to be performed by the
trauma service, however, the family was contact[**Name (NI) **] and decided
that this was not what what they wanted. He was made comfort
measures and expired [**2101-1-7**].
Medications on Admission:
coumadin
pepcid
provachol
timoptic
beconase
nulev
neurontin
amoxicillin
flexaril
flomax
vicodin
Klonopin.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
S/P CLOSED HEAD INJURY - BIFRONTAL CONTUSIONS
Discharge Condition:
.
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2101-1-7**]
|
[
"42731",
"4241",
"5990",
"V5861",
"V4581"
] |
Admission Date: [**2182-6-12**] Discharge Date: [**2182-6-22**]
Date of Birth: [**2128-11-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
CT guided needle biopsy
Intubation
Arterial cannulation, a-line placement
Central line placement
History of Present Illness:
Pt is a 53 Y M with Hx of DM2, HTN who is transferred from
[**Hospital3 **] after being hospitalized from [**6-5**] - [**6-12**]
with bilateral pneumonia and concern for new malignancy. 2
weeks prior to admission to the OSH, he was experiencing
cold-like symptoms and received Azithromycin without relief.
This was switched to Levaquin, again without improvement. He
claimed that for these 2 weeks, he was basically bed-bound and
extremely tired. At the end of that time, he was coughing to
where "my face turned [**Doctor Last Name 352**]" and had some sputum production and
low-grade fevers. He received a CXR which showed bilateral PNA;
he was admitted to the [**Hospital1 2436**] ICU for hypoxic respiratory
failure and Pneumosepsis. On [**6-5**] he started Ceftriaxone,
Azithromycin, and IV steroids for supposed concurrent COPD
exacerbation. He also received 1 dose of Vancomycin. He could
not tolerate BiPAP and was given nasal O2. His respiratory
status stabalized and was transferred to the floor requiring 4L
of NC. He claims that during his hospital stay, he did not feel
that his breathing had improved. Urinary Legionella Ag and
strep Ag were negative as were MRSA screen and blood cultures
drawn on [**6-5**]. CTPA was negative for PE but did reveal
mediastinal and retroperitoneal adenopathy. CT of the abdomen
and pelvis a 6.3x4.8cm mass, "concern for a renal cell carcinoma
vs. lymphoma." The patient was agreeable for transfer to [**Hospital1 18**]
for work-up of this potential malignancy.
.
On arrival, he mentions orthopnea and LE edema which began
around the time he started his cold and has worsened. He also
mentions that the afternoon of transfer, he experienced 1 minute
of blurry vision where his daughter noted his left pupil was
bigger than the right but resolved spontaneously without any
associated headaches, nausea, confusion, or vomiting.
.
Review of Systems:
(+) Per HPI; 11 lb weight loss in 3 weeks
(-) Denies chills, night sweats. Denies loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
.
Past Medical History:
PMH:
Bilateral PNA
DM2 on Metformin
HTN
Hyponatremia
Atypical chest pain with a normal stress test in [**2179**]
Hyperlipidemia
Asthma as a child
OSA
Seasonal allergies
Social History:
Works in IT. Lives at home with daughter and wife. Denies
tobacco, etoh, illicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with CABG x4 in his 60s.
Physical Exam:
ADMISSION EXAM
VS: T 97.4 bp 144/90 HR 98 RR 18 SaO2 93% on 3L NC RR 18
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion, PERRLA at 3mm
NECK: Supple, cannot appreciate JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp slightly labored, Crackles at bases with expiratory
wheezes from bases to apices.
ABD: Soft, Obese, NT, ND, no HSM, cannot palpate kidney; bowel
sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, 1+ edema bilaterally, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention,no focal deficits, intact
sensation to light touch
PSYCH: appropriate
.
Pertinent Results:
[**2182-6-12**] 10:14PM GLUCOSE-130* UREA N-16 CREAT-0.5 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-28 ANION GAP-12
[**2182-6-12**] 10:14PM ALT(SGPT)-18 AST(SGOT)-14 LD(LDH)-188 ALK
PHOS-66 TOT BILI-0.3
[**2182-6-12**] 10:14PM TOT PROT-5.3* ALBUMIN-3.3* GLOBULIN-2.0
CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-1.6 URIC ACID-3.5
[**2182-6-12**] 10:14PM WBC-13.2*# RBC-4.84 HGB-13.9* HCT-39.6*
MCV-82 MCH-28.7 MCHC-35.2* RDW-13.4
[**2182-6-12**] 10:14PM NEUTS-81.8* LYMPHS-8.6* MONOS-8.4 EOS-1.1
BASOS-0.1
[**2182-6-12**] 10:14PM PLT COUNT-294
[**2182-6-12**] 10:14PM PT-13.3* PTT-25.8 INR(PT)-1.2*
[**2182-6-12**] 10:14PM FIBRINOGE-413*
[**2182-6-12**] 10:14PM RET AUT-1.4
[**2182-6-12**] 09:45PM URINE HOURS-RANDOM CREAT-42 SODIUM-33
POTASSIUM-13 CHLORIDE-21 TOT PROT-6 PROT/CREA-0.1
[**2182-6-12**] 10:14PM RET AUT-1.4
[**2182-6-12**] 09:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2182-6-12**] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
CXR from [**Hospital1 2436**]: bilateral PNA with pleural effusions.
Images not available for viewing
.
CT Chest [**5-15**]
FINDINGS: The thyroid gland is unremarkable. There is no
supraclavicular or
axillary lymphadenopathy. There is extensive mediastinal and
hilar
lymphadenopathy, similar in extent to the prior study from only
a few days
earlier. For example, right anterior mediastinal node measuring
1.5 x 1.5 cm,
previously measured 1.6 x 1.4 cm (4:11); 2.2 x 1.2 cm right
precarinal node
(4:20), previously measured 1.2 x 2.3 cm; more inferiorly, 2.5 x
1.9 cm node
(4:23), previously was 2.5 x 2.0 cm. Multiple nodes are seen in
the
prevascular station which also are similar in appearance to the
prior exam.
Right paraesophageal nodal conglomerate is unchanged and
measures 4.9 x 3.7
cm (4:33). Large right hilar nodal conglomerate, measures 4.9
cm in maximal
dimension (4:28) compared to 4.8 cm. Left hilar adenopathy
measures 4.1 cm
(4:29) compared to 4.3 cm. There is resultant compression of
the right main
stem bronchus (4:27) and bronchus intermedius as well as the
right lower lobe
bronchus. The heart has a rounded appearance with a small
pericardial
effusion. This concerning for pericardial constriction from
underlying
process involving the lungs and mediastinum.
LUNGS: In the right upper lobe there are multiple foci of
consolidation,
multiple nodules, ground-glass opacities and interlobular septal
thickening.
This pattern is also seen in the right lower lobe but is less
extensive. More
frank consolidation with air bronchograms are present in the
right middle lobe
and left lower lobe. Within the left upper lobe there are
innumerable
predominantly sub-centimeter discrete rounded nodules. There
are bilateral
pleural effusions greater on the right, similar in extent
compared to the
prior study. These findings are suggestive of primary lung
malignancy,
lymphoma, possible infection such as tuberculosis and less
likely vasculitis.
There is no pneumothorax.
This study is limited for evaluation of subdiaphragmatic
structures but
demonstrates extensive retroperitoneal lymphadenopathy, better
assessed on the
recent outside hospital scan with IV contrast, however, the
overall extent
appears unchanged. For example, right retroperitoneal node
measuring 1.7 x
2.8 cm (4:63), previously measured 1.4 x 2.7 cm on the prior
study; epigastric
node measuring 1.8 cm, is similar to the prior study (4:57);
left paraaortic
nodal conglomerate measures 3.2 x 2.3 cm compared to 3.2 x 2.1
cm on the prior
study.
OSSEOUS STRUCTURES: There are no suspicious bony lesions.
IMPRESSION:
1. Multifocal process within the lungs with frank consolidation
in the right
middle and left lower lobes, severe multifocal opacities with
nodules,
centrilobular septal thickening in the right upper lobe and less
extensive in
the right lower lobe with multiple nodules in the left upper
lobe. Extensive
mediastinal and hilar lymphadenopathy, unchanged from the prior
exam.
Possible etiologies include primary lung cancer, lymphoma,
infection such as
TB and less likely vasculitis.
2. Associated compression of the right main stem bronchus,
bronchus
intermedius and right lower lobe bronchus from lymphadenopathy.
3. Rounded appearance to the heart, with small pericardial
effusion
suggesting pericardial constriction from this underlying
process. Recommend
clinical monitoring.
4. Bilateral pleural effusions, worse on the right, unchanged
from the prior
exam.
5. Extensive retroperitoneal and paraaortic lymphadenopathy,
similar in
appearance to the prior study.
.
MR [**Name13 (STitle) 430**] [**6-13**]
FINDINGS: The study is limited by motion artifact.
There is no evidence of hemorrhage. There are areas of increased
FLAIR signal
corresponding to punctate foci of slow diffusion within the
bilateral parietal
lobes, the left frontal lobe, and the left temporal and
occipital lobes.
There is also a focus of slow diffusion within the left
cerebellar hemisphere.
There is no evidence of mass lesion or hemorrhage. There are no
definite
areas of abnormal enhancement.
The visualized paranasal sinuses, mastoids, and orbits are
unremarkable.
IMPRESSION:
Study is limited by motion artifact.
Multiple foci of slow diffusion in both cerebral hemispheres, as
well as in
the left cerebellar hemisphere, without enhancement. These are
compatible with
acute/subacute ischemia, likely from a central embolic source.
Consideration might be given to NBTE ("marantic endocarditis"),
in this
setting.
.
[**6-19**] TISSUE BIOPSY PATHOLOGY
Pleural fluid, cell block:
Consistent with metastatic poorly-differentiated carcinoma (see
note).
Note: Immunohistochemical stains reveal that the tumor cells
show patchy positivity for CK20, CK7 (focal), and P504S and are
negative for TTF-1, P63, and B72.3. [**Last Name (un) **]-31 shows focal dim
staining in rare tumor cells. Calretinin appears to stain tumor
cells (patchy) and mesothelial cells. WT-1 highlights
background mesothelial cells. The patient's prior pathology
specimen S12-33153P was also reviewed for comparison. The
morphologic and immunophenotypic findings are consistent with
poorly-differentiated carcinoma similar to that described in the
patient's para-aortic node specimen (S12-33153P). The
immunoprofile is not specific but may be compatible with renal
cell carcinoma; however, other sites cannot be entirely
excluded. Clinical correlation is required. Please also see
the corresponding cytology C12-[**Numeric Identifier 85415**].
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to [**Hospital1 18**] from [**Hospital3 **] after
being hospitalized from [**6-5**] - [**6-12**] with bilateral pneumonia and
concern for new malignancy. On [**6-5**] he started Ceftriaxone,
Azithromycin, and IV steroids for supposed concurrent COPD
exacerbation. Urinary Legionella Ag and strep Ag were negative
as were MRSA screen and blood cultures drawn on [**6-5**]. CTPA was
negative for PE but did reveal mediastinal and retroperitoneal
adenopathy. CT of the abdomen and pelvis a 6.3x4.8cm mass,
"concern for a renal cell carcinoma vs. lymphoma." He reported
that orthopnea and LE edema began around the time he started his
respiratory symptoms. He was transferred to [**Hospital1 18**] for further
care.
While in house, he had left para-aortic lymph node biopsy
[**2182-6-13**] which showed poorly differentiated carcinoma with clear
cell features. His oxygen demand was initially 3L on nasal
cannula with saturation in the 90's. This gradually worsened to
6L on NC to 6L NC plus shovel mask with saturation maintaining
90-95%. LENI's negative bilaterally in the lower extremities.
MRI brain was concerning for acute/subacute ischemia from
central embolic source with no vegetations on TTE. TEE was
recommended by neurology consult team however given his poor
current status this has been deferred. He is on IV heparin for
this with goal PTT of 50-70 to avoid bleeding. on [**2182-6-19**] CXR was
suggestive of superimposed pneumonia (vanc and zosyn were
started for nosocomial pneumonia on that day) in addition to
underlying pulmonary metastases and new mild pulmonary edema.
VS on the floor prior to MICU transfer were: Afebrile,
Saturating mid-high 80's to low 90's on nasal cannula and shovel
mask sitting in chair and looking exhausted with the head bowed
down. Per hospitalist, this was definitely different from what
he was on admission. BP was 103/65, HR 105, RR 30's.
On arrival to the MICU, patient's VS. T 97.7, HR 105, BP
90's/50's, RR 28, Sat 88% on NRB. He was put on face mask
ventilation but continued to have increased work of breathing
and worsening respiratory status. Repeat ABGs showed
respiratory acidosis and failure with pH 7.09-7.14 pCO2 55-60
PO2 56-82 and HCO3 19-21. Patient was intubated. Femoral line
and a-line were placed. Patient suspected to be in pneumosepsis,
and became hypotensive and required pressor support with
levophed and vasopressin. Continuing hypotension required
additional support with phenylephrine.
Given decompensation, family meeting was held at midnight on
[**6-22**]. Mr. [**Known lastname 85416**] wife decided DNR with no escalation of care. He
expired peacefully overnight.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]:PRN dyspnea
2. fenofibrate *NF* 200 Oral daily
can substitute forumlary med
3. Atorvastatin 80 mg PO HS
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Chlorthalidone 12.5 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Aspirin 81 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2182-6-24**]
|
[
"51881",
"486",
"5849",
"2762",
"5119",
"2761",
"496",
"4019",
"2724",
"32723",
"53081"
] |
Admission Date: [**2162-6-13**] Discharge Date: [**2162-6-22**]
Date of Birth: [**2122-7-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SOB, cough, LE edema
Major Surgical or Invasive Procedure:
right heart catheterization
arterial line placement
central line placement
History of Present Illness:
39 yo F w a pmh of depression, seasonal allergies, presents with
new cardiomyopathy with an EF of 15%. Over the past 3 months she
has had progressive DOE. She noted that her excercise tolerance
has steadily diminished over this time, she was initially able
to run on the treadmill for 4 mi 3-4x/week, now she cannot do
[**1-26**] mi without SOB. Approximately 3 weeks ago she began to
develop a cough and some wheezing, which she attributed to
seasonal allergies, claritin provided some relief. She traveled
to [**State 108**] were her cough worsened, she developed fevers to 102
and nausea/vomiting. She also noted trace LE edema. She
presented to her PCP who treated her for bronchitis with
azithromycin. This did not relieve her symptoms, her cough
worsened, she developed severe LE edema (3+). At her
cardiologist's office an echo revealed an EF of 30%. She was
started on Lasix 40 PO and Coreg 3.125mg [**Hospital1 **]. Her edema improved
markedly. A few days prior to admission the pt. presented to an
OSH with weakness, dizziness, diaphoresis. She was noted to be
hypotensive (86/72) and received fluid resuscutation. Per OSH
records she had a 8 and 10 beat run of VT. Her cardiac enzymes
were negative. She was transferred to [**Hospital1 18**] for further care.
REVIEW OF SYSTEMS:
+ orthopnea, + h/o SOB, +LE edema, poor appetite, denies weight
loss, chest pain, abdominal pain, changes in Bowel/bladder fxn,
rashes, joint pains. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
positive for dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, negative for palpitations, syncope or
presyncope.
Past Medical History:
depression, seasonal allergies
Social History:
no tobacco use, [**4-29**] glasses of wine per week, denies IVDA.
She is married with 2 children. She is a self employed attorney
Family History:
Father- alcoholic (expired), Mother- healthy
[**Name (NI) 12408**] hx. of endocarditis at 19yo, Sister- rheumatoid
arthritis diagnosed in her 20's
Physical Exam:
VS: T 99.3 BP 112/70 HR 105 RR 25 O2 93 RA weight 91.3 kg
Gen: well appearing, overweight female in NAD.
HEENT: MMM, NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 8 cm.
CV: RR, normal S1, S2. S3 present No m/r/g. No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. no wheezes, notable for
rales [**1-26**] way up the back bilaterally
Abd: Soft, NTND. No HSM or tenderness.
Ext: WWP, no edema
Skin: No stasis dermatitis, ulcers, scars.
.
Pulses:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
.
Pertinent Results:
EKG demonstrated: (not official read) sinus tach, left and right
atrial enlargment, TWI in v5, v6, TW flattening in v4, freq.
PVCs, low voltage in limb leads. with no significant change
compared with prior dated [**2162-6-12**]
TELEMETRY demonstrated:tachycardia, NSR, freq. PVCs
2D-ECHOCARDIOGRAM performed on [**6-13**] demonstrated: prelim read:
mild MR, TR. hypokinetic LV and RV, LA and RA enlargement. Small
pericardial effusion.
CXR: Cardiac silhouette is enlarged. Pulmonary vascularity is
within normal limits. Basilar atelectasis is present bilaterally
and there are questionable small pleural effusions. Followup
radiographs with improved inspiratory level may be helpful for
more complete assessment of the bases when the patient's
condition permits.
TTE: The left atrium is dilated. The right atrium is dilated.
Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated.
There is severe global left ventricular hypokinesis (EF 10%).
The right
ventricular cavity is moderately dilated, with moderate global
right
ventricular free wall hypokinesis. The number of aortic valve
leaflets cannot
be determined. No aortic regurgitation is seen. The mitral valve
appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction.
Moderate right ventricular systolic dysfunction.
CATH: PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right internal jugular vein, using a 7 French pulmonary wedge
pressure
catheter, advanced to the PCW position through an 8 French
introducing
sheath. Cardiac output was measured by the Fick method.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.05 m2
HEMOGLOBIN: 14 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 15/14/12
RIGHT VENTRICLE {s/ed} 43/16
PULMONARY ARTERY {s/d/m} 43/22/31
PULMONARY WEDGE {a/v/m} 26/23/16
AORTA {s/d/m} 108/66/79
**CARDIAC OUTPUT
HEART RATE {beats/min} 100
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 67
CARD. OP/IND FICK {l/mn/m2} 3.2/1.6
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1675
PULMONARY VASC. RESISTANCE 375
**% SATURATION DATA (NL)
SVC LOW 53
PA MAIN 60
AO 95
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour40 minutes.
Arterial time = 0 hour38 minutes.
Fluoro time = 1.6 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 0 ml,
Indications - Renal
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Resting hemodynamic monitoring demonstrates mildly elevated
biventricular filling pressure, moderate pulmonary hypertension,
and low
cardiac output.
FINAL DIAGNOSIS:
1. Severe ventricular dysfunction.
ABD ULTRASOUND: FINDINGS: The liver is mildly increased in size,
with normal echotexture without evidence of focal lesion. The
gallbladder is normal. There is no evidence of intra- or
extra-hepatic biliary ductal dilatation. The common duct
measures 6 mm. The pancreas is not well visualized. The aorta is
normal in caliber throughout. The right kidney measures 10.5 cm
and the left 10.4 cm. The renal parenchymal echogenicity and
thickness are normal without evidence of calculi or
hydronephrosis. The spleen is normal in size and echogenicity.
The portal vein is patent with antegrade flow.
IMPRESSION:
Mild hepatomegaly; otherwise, unremarkable abdominal ultrasound.
CAROTID U/S: FINDINGS: The bilateral common carotid artery,
internal carotid artery and external carotid artery are widely
patent and demonstrate normal arterial waveforms. The bilateral
vertebral arteries are antegrade in direction.
Peak systolic velocities of the right internal carotid artery is
78 cm/sec with a right ICA/CCA ratio of 0.78. No evidence of
intraluminal plaque.
Peak systolic velocity of the left internal carotid artery is
109 cm/sec, corresponding to a left ICA/CCA ratio of 1.4. No
evidence of intraluminal plaque.
IMPRESSION: Normal carotid ultrasound. No evidence of
hemodynamically significant stenosis.
ECHO ([**2162-6-15**]--2 DAYS LATER THAN PREVIOUS):
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is severe global left ventricular
hypokinesis.
Apical contraction is relative[**Name (NI) 72784**] preserved. No intraventricular
thrombus is
seen, but apical views are suboptimal. The right ventricular
cavity is mildly
dilated with mild global free wall hypokinesis. 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 pulmonary artery systolic
hypertension.
There is a small circumferential pericardial effusion.
Compared with the prior study (images reviewed) of [**2162-6-13**],
biventricular
systolic function is slightly improved, but left ventricular
function remains
severely depressed.
[**2162-6-13**] 10:35PM POTASSIUM-5.5*
[**2162-6-13**] 09:41PM GLUCOSE-92 UREA N-10 CREAT-0.8 SODIUM-137
POTASSIUM-6.1* CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
[**2162-6-13**] 09:41PM ALT(SGPT)-129* AST(SGOT)-60* CK(CPK)-68 ALK
PHOS-86 TOT BILI-0.6
[**2162-6-13**] 09:41PM CK-MB-NotDone cTropnT-0.02*
[**2162-6-13**] 09:41PM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-5.1*
MAGNESIUM-2.6 IRON-46
[**2162-6-13**] 09:41PM calTIBC-439 FERRITIN-39 TRF-338
[**2162-6-13**] 09:41PM TSH-2.5
[**2162-6-13**] 09:41PM [**Doctor First Name **]-POSITIVE TITER-1:160
[**2162-6-13**] 09:41PM RHEU FACT-10
[**2162-6-13**] 09:41PM WBC-10.4 RBC-4.71 HGB-14.0 HCT-42.2 MCV-90
MCH-29.8 MCHC-33.2 RDW-14.9
[**2162-6-13**] 09:41PM NEUTS-77.0* BANDS-0 LYMPHS-16.6* MONOS-3.8
EOS-1.7 BASOS-0.9
[**2162-6-13**] 09:41PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2162-6-13**] 09:41PM PLT SMR-HIGH PLT COUNT-514*
[**2162-6-13**] 09:41PM PT-13.7* INR(PT)-1.2*
Micro Data:
**FINAL REPORT [**2162-6-22**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2162-6-22**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
VIRAL CULTURE (Pending):
**FINAL REPORT [**2162-6-21**]**
WOUND CULTURE (Final [**2162-6-21**]): No significant growth.
[**2162-6-19**] 6:00 am SEROLOGY/BLOOD
**FINAL REPORT [**2162-6-21**]**
LYME SEROLOGY (Final [**2162-6-21**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
[**2-27**] weeks.
[**2162-6-19**] 12:10 am SPUTUM Site: EXPECTORATED
**FINAL REPORT [**2162-6-21**]**
GRAM STAIN (Final [**2162-6-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-6-21**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
[**2162-6-18**] 11:27 pm URINE Source: Catheter.
**FINAL REPORT [**2162-6-19**]**
Legionella Urinary Antigen (Final [**2162-6-19**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2162-6-15**] 4:39 am Blood (Toxo) Source: Line-Arterial.
**FINAL REPORT [**2162-6-15**]**
TOXOPLASMA IgG ANTIBODY (Final [**2162-6-15**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2162-6-15**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
The FDA is advising that the result from any one
toxoplasma IgM
commercial test kit should not be used as the sole
determinant of
recent toxoplasma infection when screening a pregnant
patient.
[**2162-6-15**] 4:39 am Blood (EBV) Source: Line-Arterial.
**FINAL REPORT [**2162-6-17**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2162-6-17**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2162-6-17**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2162-6-17**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop 6-8 weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
[**2162-6-15**] 4:39 am Blood (CMV AB) Source: Line-Arterial.
**FINAL REPORT [**2162-6-15**]**
CMV IgG ANTIBODY (Final [**2162-6-15**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
44 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2162-6-15**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**2-27**]
weeks.
Greatly elevated serum protein with IgG levels >[**2155**] mg/dl
may cause
interference with CMV IgM results.
[**2162-6-15**] 4:39 am SEROLOGY/BLOOD Source: Line-Arterial.
**FINAL REPORT [**2162-6-15**]**
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2162-6-15**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
[**2162-6-14**] 3:00 pm BLOOD CULTURE Source: Line-fem aline.
**FINAL REPORT [**2162-6-20**]**
AEROBIC BOTTLE (Final [**2162-6-19**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 7087**] [**Last Name (NamePattern1) 394**] @ 4PM ON [**2162-6-17**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ISOLATED FROM ONE SET ONLY.
ANAEROBIC BOTTLE (Final [**2162-6-20**]): NO GROWTH.
Brief Hospital Course:
Hospital course: The patient is a 39 yo F with new onset
cardiomyopathy with an EF of 15%, initially presented to an OSH
with hypotension, responded well to IVF. Tranferred to [**Hospital1 18**] for
further w/u and care. Initially req. milrinone for inotropic
support. Milrinone was stopped and pt. was hemodynamically
stable. Discharged on Digoxin and captopril. She also underwent
initial evaluation for heart transplantation. Her hospital
course was complicated by pneumonia.
1) Cardiomyopathy: Newly diagnosed dilated cardiomyopathy.
Initial echo on presentation showed an EF of 10%. A follow up
echo (on milrinone) was 20%. She has had recent symptoms
consistent with URI/bronchitis. Therefore, this is most probably
viral cardiomyopathy. Other etiologies of her cardiomyopathy
were explored. [**Doctor First Name **], Fe studies, HIV, thyroid labs are all
normal. she had no significant alcohol or CAD history. Also,
echo findings were not consistent with CAD. Initially, she was
started on an ACE inhibitor and diuresed with lasix. However,
she became progressively hypotensive and her exam was consistent
with cardiogenic shock. A PA catheter was placed, with initial
findings showing a CO of 3.2, CI 1.56, RA 15/14, RV 43/16, PCW
17, PA 43/22. She was started on milrinone in the cath lab and
continued on milrinone 0.375 on the floor. Her CO/CI improved to
4.9/2.3. Milrinone was weaned and captopril, carvedilol, and
lasix was started. Over the following 24 hrs her urine output
decreased, her CI worsened and her MV02 dropped to the 50's. She
was again restarted on milrinone gtt. Digoxin was started
(loading dose) and milrinone was again weaned off with
continuation of captopril. She remained hemodynamically stable
off of milrinone and did well on digoxin and captopril which was
transitioned to lisinopril. She was also started on a BB and
aldactone prior to discharge. Because of that, her digoxin level
was checked and returned at 0.7. This should be followed as her
amiodarone achieves therapeutic levels. Also, evaluation for
potential heart transplant was initiated as an inpatient, and
she is scheduled to follow up with [**Hospital1 336**] Transplant center as
well as [**Hospital 18**] [**Hospital 1902**] Clinic. She was discharged on long acting ACE
inhibitor and Toprol. She will need follow up labs sent in a
week or two to follow her renal function, potassium, and digoxin
level. In addition, workup for cardiomyopathy revealed a
positive [**Doctor First Name **]. Anti-[**Doctor Last Name 1968**] and Anti-dsDNA were sent and are
pending at this time. These will also need to be followed up.
.
2) Fever: The patient has had persisent fevers throughout her
stay with Temperatures up to 102. She was started on
ceftrioxone/azithro for a RLL PNA. She spiked to 102F despite
ceftriaxone/azithro and vancomycin for possible line infection.
Blood cx grew GPR, which is likely contamination. CXR shows RLL
consolidation and a possible layering effusion. Her sputum gram
stain was significant for 3+ GPCs. After initiation of
vancomycin her fever curve trended down. However, due to her
peristent low grade fevers, ID was consulted. Multiple
serologies and microbial studies were sent and were negative.
She was discharged on levofloxacin for total 14 day course for
community acquired PNA. ID also recommended sending Cdiff prior
to discharge, and it was negative. Other blood cultures and
viral cultures are pending at this time and will need to be
followed up by her PCP as well.
3) Rhythm: NSR, tachycadia. Her tachycardia was likely due to
compensatory mechanism for poor forward flow. She was started on
an ACE-I for afterload reduction. Beta blocker was initiated
towards discharge and switched to long-acting Toprol XL.
.
4 Ectopy: The patient had several runs of NSVT throughout her
stay. She was asymptomatic during this episodes. Amiodarone was
initiated. EP was consulted for possible pacemaker placement or
ICD, but she was too early in her DCM to be a candidate for ICD
placement.
.
5) Cardiac transplant workup: Due to the severity of the
patients cardiomyopathy and CHF, cardiac transplant workup was
intiated. [**Hospital1 336**] was contact[**Name (NI) **] and the heart failure service was
consulted. Hepatitis serologies were negative, HIV was negative,
PPD was negative, Iron studies were normal. Abdominal US showed
mild hepatomegaly. [**Hospital1 336**] aware, heart failure service aware, and
she will follow up with these services.
.
6) Cough: Dry, received robitussin with codeine, tes. perles.
.
7) FEN: cardiac, low salt diet, fluid restriction.
.
8) PPX: heparin sq, bowel regimen
.
9) Code: full code
Medications on Admission:
cymbalta
coreg 3.125mg [**Hospital1 **]
lasix 40 po qday
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO
Q6H (every 6 hours).
Disp:*1200 ML(s)* Refills:*0*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 weeks: Take 2 tabs daily for 2 weeks, then 1 tab daily
(please confirm this dose schedule with your primary
cardiologist).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
1. Cardiomyopathy
2. Congestive heart failure (EF 10%) due to cardiomyopathy
3. Pneumonia
4. Ventricular ectopies
.
Secondary diagnosis:
1. Depression
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You were admitted for cardiomyopathy with CHF. During your stay,
a work up was initiated for potential heart transplant. You were
also found to have a pneumonia for which you were treated with
antibiotics. You were started on several medications during this
hospitalization (see medication sheet). Please take these as
written unless directed otherwise by your primary care physician
or cardiologist. Please weigh yourself daily and check your
blood pressure periodically. Report any significant weight
gains (5-10lbs), or blood pressure changes to your cardiologist.
Please eat a low sodium diet (< 2g per day) and avoid
ibuprofen.
.
You have been diagnosed with a pneumonia. You should continue
the antibiotic levofloxacin for 7 days.
.
Please also continue to take all of your other medications as
prescribed.
.
You should be on birth control due to your heart condition,
please discuss options with your primary care physician.
.
Please attend your appointments as below.
.
If you experience shortness of breath, chest pain, leg swelling,
dizziness or other worrisome symptoms you should immediately
seek medical attention.
Followup Instructions:
Please follow up with your primary care physician (Dr.
[**Last Name (STitle) 3321**] [**Telephone/Fax (1) 17026**]) within 1 week after discharge from the
hospital. He/She should also follow up on all the serologies and
microbial studies that have been initiated in the hospital and
were still pending upon discharge.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (primary
cardiologist)--[**Telephone/Fax (1) 3183**] within 1 week as well.
.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13595**] from the [**Hospital 1902**] clinic at
[**Hospital1 18**] on [**2162-7-5**] at 1PM (phone [**Telephone/Fax (1) 13133**]: Please call
ahead to confirm).
In addition, please follow up with the advanced cardiomyopathy
clinic at [**Hospital 4415**] for further transplantation
evaluation (phone number [**Telephone/Fax (1) 72785**], [**Doctor First Name **]). They will call
you tomorrow about an appointment in 2 weeks, please call them
if you do not receive this phone call.
|
[
"4280",
"486",
"4168",
"311"
] |
Admission Date: [**2131-4-1**] Discharge Date: [**2131-4-12**]
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Malaise, weakness, bilateral arm pain and nausea
Major Surgical or Invasive Procedure:
Valvuloplasty
History of Present Illness:
Briefly, [**Known firstname **] [**Known lastname **] is an [**Age over 90 **] year old woman with history of CAD
s/p CABG, ischemic and valvular cardiomyopathy (EF 20-25%),
severe aortic stenosis ([**Location (un) 109**] 0.8cm2), recent admission for chest
pain s/p cath which showed 3 vessel native coronary artery
disease, patent SVG-OM, SVG-RCA, LIMA-LAD, severe aortic
stenosis, and severely elevated LV diastolic and systolic
pressures. Her EKG at the time showed small ST elevations in V1
and aVR, CE were negative. She returned to the hospital
complaining malaise and weakness, bilateral arm pain and nausea.
The patient developed chest pain again while in the ED, her EKG
showed concerning ST depression in the inferior lateral leads.
The cardiology fellow was called and she was started on heparin
drip with bolus and given a dose of morphine, now chest pain
free. Her troponins were negative. She was given a dose of
potassium for hypokalemia. She was admitted for further
management of Afib with RVR and hypotension.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Coronary artery disease
- Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2 (Symptomatic as of
[**2127**])
- Moderate mitral regurgitation
- Ischemic and valvular cardiomyopathy with an EF 20-25%
-CABG: 3V CABG in [**Location (un) 5622**] per patient report [**2107**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
3. OTHER PAST MEDICAL HISTORY:
- Breast cancer, grade 3 s/p mastectomy
- Right rotator cuff tendinopathy.
- Right biceps tendinitis
- Polymyalgia rheumatica
- Osteoporosis
- Right fourth trigger finger release
- Squamous cell carcinoma (left dorsal hand) s/p excision
- Hysterectomy
Social History:
Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter
nearby who is her emergency contact.
Occupation: Was a homemaker.
Functional Status: Very active, exercises 3x week, does
treadmill, aerobics and yoga.
Tobacco/EtOH/Illicit Drugs: Denies.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8cm. No bruits.
CARDIAC: normal S1, S2. 3/6 systolic crescendo-descrescendo
murmur at RUSB with radiation to the neck. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities. Khyphotic. Resp were
unlabored, no accessory muscle use. Bilateral crackles up to the
apices.
ABDOMEN: +BS, soft, NT, ND. No HSM. Abd aorta not enlarged by
palpation. No abdominal bruits.
EXTREMITIES: wwp, trace bilateral LE edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT
2+
Pertinent Results:
Labs on admission:
[**2131-4-1**] 12:10PM PLT SMR-NORMAL PLT COUNT-156
[**2131-4-1**] 12:10PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2131-4-1**] 12:10PM NEUTS-86* BANDS-0 LYMPHS-13* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-4-1**] 12:10PM WBC-4.0 RBC-3.94* HGB-10.7* HCT-31.6* MCV-80*
MCH-27.1 MCHC-33.7 RDW-17.8*
[**2131-4-1**] 12:10PM cTropnT-<0.01
[**2131-4-1**] 12:10PM estGFR-Using this
[**2131-4-1**] 12:10PM GLUCOSE-125* UREA N-25* CREAT-0.8 SODIUM-142
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2131-4-1**] 01:18PM PT-11.7 PTT-21.7* INR(PT)-1.0
[**2131-4-1**] 03:00PM URINE MUCOUS-RARE
[**2131-4-1**] 03:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2131-4-1**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR
[**2131-4-1**] 03:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2131-4-1**] 04:20PM cTropnT-0.02*
.
Labs at discharge:
[**2131-4-12**] 06:10AM BLOOD WBC-5.1 RBC-2.87* Hgb-7.7* Hct-24.0*
MCV-84 MCH-26.9* MCHC-32.1 RDW-17.3* Plt Ct-335
[**2131-4-12**] 06:10AM BLOOD Plt Ct-335
[**2131-4-12**] 06:10AM BLOOD PT-25.4* PTT-71.4* INR(PT)-2.4*
[**2131-4-12**] 06:10AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-31 AnGap-8
[**2131-4-12**] 06:10AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
.
Imaging:
- Portable TTE (Complete) ([**2131-4-2**] at 3:45:43 PM)
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 30 %) with global hypokinesis and regioanl
akinesis of the distal LV/apex and lateral walls. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric jet of moderate to severe (3+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2131-3-8**], the LVEF and RVEF hasve
decreased. If indicated, a dobutamine echo may better assess
true critical AS from a low-output state.
.
- Portable TEE (Complete) ([**2131-4-5**] at 10:30:00 AM)
IMPRESSION: Significant calcific aortic stenosis. Mild aortic
regurgitation. Moderate to severe mitral regurgitation. Complex
aortic atheroma. Depressed [**Hospital1 **]-ventricular function.
.
Portable TTE (Complete) ([**2131-4-11**] at 11:43:26 AM)
RESULT: Compared with the prior study (images reviewed) of
[**2131-4-2**], velocities across the aortic valve have decreased. LV
function is substantially better - ejection fraction appears
normal on the current study. Therefore, the degree of reduction
of aortic stenosis is probably greater than that suggested by
reduced velocities. The degree of mitral regurgitation has also
decreased and is now mild to moderate. Mild to moderate aortic
regurgitation is now seen.
.
Cardiac Catheterization ([**2131-3-9**])
FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease.
2. Patent SVG-OM, SVG-RCA, LIMA-LAD. 3. Severe aortic stenosis.
4. Severely elevated left ventricular diastolic and systolic
pressures.
.
ECG ([**2131-4-1**] 12:21:12 PM)
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with ST-T wave abnormalities. Intra-ventricular
conduction delay with left axis deviation is probably left
anterior fascicular block and additional intraventricular
conduction delay/possible right ventricular conduction delay.
Cannot exclude ischemia. Clinical correlation is suggested.
Since the previous tracing of [**2131-3-9**] there may be no
significant change but unstable baseline on previous tracing
makes comparison difficult.
.
ECG ([**2131-4-10**] 9:08:54 AM)
Sinus bradycardia. Left axis deviation. Non-specific
intraventricular
conduction delay. Left ventricular hypertrophy. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2131-4-3**]
the rate is slower and sinus rhythm is now clearly present.
TRACING #1
.
ECG ([**2131-4-11**] 9:35:38 AM)
Sinus rhythm. Left axis deviation. Non-specific intraventricular
conduction delay. Left ventricular hypertrophy. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2131-4-10**]
there is no significant change.
TRACING #2
.
CHEST (PA & LAT) ([**2131-4-1**] 2:04 PM)
Stable mild cardiomegaly. Tortuous aorta with calcifications.
Diffuse bilateral ground-glass opacities, minimally improved
since [**2131-3-7**] consistent with pulmonary edema. No
evidence of pleural effusion or pneumothorax. Retrocardiac
opacification likely represents atelectasis.
.
CT CHEST W/O CONTRAST ([**2131-4-4**] 5:42 PM)
IMPRESSION:
1. Multifocal mosaic attenuation with more focal consolidation
in the right upper lobe consistent with severe pulmonary edema,
given similar distribution of asymmetric edema previously.
2. Mild atherosclerotic calcification of the aortic root and
descending thoracic aorta without evidence of porcelain aorta in
this portion, calcification of the aortic arch, its branches and
descending thoracic aorta and coronary arteries is moderately
severe.
4. Severe calcification of the aortic valve consistent with
aortic stenosis.
5. Bilateral small pleural effusions.
6. Right upper pole exophytic renal lesion, probably represents
cyst but
merits ultrasound evaluation, if this has not been already
performed at
another institution.
.
CT BRAIN PERFUSION / CTA HEAD W&W/O C & RECO / CTA NECK W&W/OC &
RECON([**2131-4-10**] 12:28 PM)
IMPRESSION:
1. Short-segment, approximately 5 mm occlusion of a sylvian left
MCA branch, with robust distal reconstitution. The occluded
segment is hyperdense on precontrast images, consistent with a
thrombus or embolus. There is associated increased mean transit
time in the superior left MCA distribution without a matched
decrease in regional cerebral blood volume, suggesting ischemia
without evidence of a completed infarction. MRI would be more
sensitive for an acute infarction.
2. Chronic left superior parietal infarction in the left MCA
territory.
3. Mild cervical carotid atherosclerosis without a
hemodynamically
significant stenosis.
4. The left vertebral artery arises directly from the aortic
arch. Calcified plaque at its origin results in mild stenosis.
5. Marked interval improvement, though not complete resolution
of opacities at the imaged lung apices, compared to the [**2131-4-4**]
chest CT.
Brief Hospital Course:
89-year-old woman with severe AS, CAD s/p CABG, HTN, HL, and DM
Type 2 who presented with malaise, weakness, bilateral arm pain
and nausea with progressively worsening aortic stenosis.
.
# Severe Aortic Stenosis with Angina:
Initial concern that patient's presenting symptoms were
secondary to worsening AS ([**Location (un) 109**]: 0.9, gradient of 42, velocity of
3.2). She refused AVR during previous admission. Extensive
conversation regarding potential therapeutic interventions for
AS: AVR vs Corevalve vs ballon valvuloplasty. Patient considered
high risk from a surgical standpoint. Patient and family highly
interested in CoreValve, however patient excluded from trial due
to moderate to severe mitral regurgitation. Decision made to
proceed with valvuloplasty. Valvuloplasty successfully improved
aortic gradient as well as valve area however it was complicated
by CVA of left MCA territory, likely embolic in nature.
Fortunately, the next day, there were no neurologic deficits,
and initial dysarthria resolved without intervention.
.
# CORONARIES:
History of CAD s/p CABG [**39**] years ago. Cardic risk factors
include known CAD, HTN, HL, type 2 DM, advanced age, and
postmenopausal state. Recent cath in [**2131-2-23**] demonstrated
right-dominant system with 3 vessel native coronary artery
disease. (LMCA had 40% stenosis, LAD 80% stenosis before the
1st diagonal. The LCx was diffusely diseased. The RCA was
totally occluded). Venous conduit angiography demonstrated a
patent SVG-OM. The SVG-RCA had diffuse disease but supplied the
proximal RCA. On this admission patient presented with chest
pain and elevated biomarkers. She was medically treated for
NSTEMI.
.
# PUMP: History of ischemic cardiomyopathy. TTE on [**2131-4-2**]
moderately depressed left ventricular systolic function (LVEF=
30 %) with global hypokinesis and regioanl akinesis of the
distal LV/apex and lateral walls; no ventricular septal defect.
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. Her most recent TTE revealed new
diastolic dysfunction in addition to systolic dysfunction.
Patient was actively diuresis with IV lasix bolus with good
effect.
.
# RHYTHM: On admission patient in NSR. Interventricular
conduction delay present and at baseline. During hospitalization
noted to transition to atrial fibrillation, likely paroxysmal
atrial fibrillation. Episode of atrial fibrillation with rapid
ventricular rate prompted transfer to CCU as patient hypotensive
with worsening heart failure when reverted to Afib with RVR.
Patient was amiodarone loaded and maintained on amiodorane 400mg
PO BID for total of 10gm prior to transition to daily dosing.
Patient reverted to NSR with amio with rates well controlled on
beta-blocker. Patient was CHADS 3 and anti-coagulated with
argatrobran (in setting of ? HIT) initially. When serotonin
release assay returned negative, patient switched to coumadin.
Patient switched from metoprolol tartrate to carvedilol for rate
control given her congestive heart failure.
.
# Thrombocytopenia/HIT. Initially suspected due to heparin so
heparin was off. Thrombocytopenia resolved thereafter. Although
PF4 Ab was positive, serotonin assay returned negative.
Therefore, she is HIT negative. Argatroban was stopped. Her
platelet count normalized at the time of discharge.
.
# Group B Strep Bacteremia. A PICC was placed. ID recs noted
that in light of complex
aortic atheroma seen on TEE and heavy calcifications a prolonged
course may be warranted in the instance that the patient
developed an endovascular infection. She received ceftriaxone
daily for a four week course starting from day of valvuloplasty.
Last day is [**2131-5-9**].
.
# Left MCA ischemia
The patient experienced dysathria after valvuloplasty where
balloon burst mid-procedure. This was believed to be a stroke
secondary to a possible air embolism. CT/CTA performed (see
under results). She was put on 4-hourly neurological checks and
her SBP was held at goal of 120s-160s. Dysarthria resolved the
next day and she returned to baseline.
.
# Iron Deficiency Anemia: Pt was anemic on admission, iron
studies reveal iron deficiency anemia and due to her history of
colonic adenoma four years ago. In house she was maintained on
iron supplementations, stools were guaiac positive, however no
frank melena or BRBPR. Patient transfused to achieve HCT>23. She
was also started on PPI.
OUTPATIENT ISSUE:
-- Utility/Need for outpatient evaluation and repeat
colonoscopy.
.
# Diabetes: Her metformin was held during this admission and she
maintained on an insulin sliding scale. Metformin restarted on
discharge.
.
# HTN: Metoprolol was switched to coreg. Lisinopril was
restarted. Amlodipine was held at discharge as there is no
cardiac benefit, but can be restarted if she remains
hypertensive in the outpatient setting.
.
# Code Status: Full Code
# Emergency contact: [**Name (NI) 1439**] [**Name (NI) 27145**] (Health care proxy). Home:
[**Telephone/Fax (1) 27146**]; Cell: [**Telephone/Fax (1) 27147**]
Medications on Admission:
1. alendronate 70 mg Tablet PO once a week.
2. amlodipine 5 mg Tablet PO DAILY (Daily).
3. furosemide 40 mg Tablet PO once a day.
4. lisinopril 10 mg Tablet PO DAILY (Daily).
5. metformin 850 mg Tablet PO twice a day.
6. metoprolol tartrate 25 mg Tablet Tablet PO DAILY
7. metoprolol tartrate 50 mg Tablet Two (2) Tablet PO at
bedtime.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
9. trazodone 50 mg Tablet (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
13. Centrum Silver 500-250 mcg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
14. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
.
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start [**2131-4-12**].
Disp:*30 Tablet(s)* Refills:*2*
2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. multivitamin with iron-mineral Tablet Sig: One (1) Tablet
PO once a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. 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*
13. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 25 days: Day
1 of 4 week course of antibiotics was [**4-10**].
Disp:*25 gram* Refills:*0*
14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
NSTEMI
Atrial Fibrillation
Aortic Stenosis
Transient Ischemic Attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname **] it was pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] due to treatment of chest pain. You
were found to have a heart attack and you were medically
managed. While hospitalized you [**Doctor Last Name **] seen to enter an abnormal
rhythm known as atrial fibrillation. Unfortunately when you
entered this rhythm it was difficult for your heart to pump
blood forward and instead it pooled in your lungs. You were
transferred to the cardiac intensive care unit for close
monitoring and diuresis.
.
While hospitalized there was ample discussion surrounding the
management of your aortic stenosis. After careful deliberation
it was decided to proceed with valvuloplasty. The valvuloplasty
was successful in dilating your aortic stenosis however it was
complicated by mild stroke. The Neurology team saw you and
recommended close monitoring. Your symptoms, predominantly
slurred speech, resolved without intervention.
.
While hospitalized you were also found to have an infection in
your blood stream. You were started on IV antibiotics. A PICC
line was placed to facilitate further treatment as an
outpatient.
.
CHANGES TO YOUR MEDICATIONS:
- START Ceftriaxone 2gm daily through [**5-9**]
- STOP taking your amlodipine until you follow up with your
primary care doctor
- START taking pantoprazole to prevent bleeding from your
stomach
- START taking amiodarone for your atrial fibrillation
- START taking warfarin for your atrial fibrillation. Your goal
INR is [**12-28**] and will be checked at rehab.
- STOP taking metoprolol
- START taking carvedilol
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up at the appointments below:
Department: GERONTOLOGY
When: TUESDAY [**2131-4-17**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2131-4-30**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-5-9**] at 1 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
Department: INFECTIOUS DISEASE
When: TUESDAY [**2131-5-29**] at 2:30 PM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2131-4-13**]
|
[
"41071",
"4280",
"42731",
"2875",
"V4581",
"25000",
"2724",
"4019"
] |
Admission Date: [**2171-5-12**] Discharge Date: [**2171-5-15**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Influenza Virus Vaccine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Blue foot
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, Ms. [**Known lastname 284**] is an 87 year old woman with history of
dementia and recent admission for pneumonia who presents with a
blue foot. She had recently been discharged after a
hospitalization for pneumonia. She was discovered to have a
bilateral occlusive DVT presenting as ischemia (phlegmasia
cerulea dolens) as well as a UTI, hypernatremia, and elevated
white count. CTA of the abdomen showed a non-occlusive SMA
thrombus She was started on enoxaparin but was not considered a
surgical candidate given her poor functional status. On the day
prior to transfer, palliative care was consulted regarding end
of life options for the patient, and in a meeting between Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] of palliative care, the HCP for the patient
(information below), and a close friend of the patient, she was
made [**Name (NI) 3225**] (comfort measures only).
Past Medical History:
1. Alzheimer's dementia
2. hypertension
3. hyperlipidemia
Social History:
No tobacco, alcohol or illicits. Lives at [**Location 582**] in long term
care.
Family History:
unknown, estranged son. [**Name (NI) **] [**Name (NI) **] [**Name (NI) 2795**] is health care proxy
and very involved in her care.
Physical Exam:
VS: 96.3 ax, 128/60, 98, 18, 95% RA,
Gen: elderly, minimal speech, screams with movement, but NAD at
rest
HEENT: poor dentition, MM extremely dry, sclera anicteric, op
clear, neck supple
Heart: regular
Lungs: diminished at R base, exam limited by pt cooperation
Abd: soft, diffusely tender, no rebound/guarding, +BS, + stool
guaic
Ext: cyanotic, cool R forefoot, +edema. DP trace palp. L DP 1+.
b/l posterior calf tenderness
Skin -- sacral erythema
Pertinent Results:
[**2171-5-12**] 12:50PM PT-12.7 PTT-19.9* INR(PT)-1.1
[**2171-5-12**] 12:50PM PLT COUNT-299
[**2171-5-12**] 12:50PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL
[**2171-5-12**] 12:50PM NEUTS-89.6* BANDS-0 LYMPHS-7.5* MONOS-2.4
EOS-0.2 BASOS-0.3
[**2171-5-12**] 12:50PM WBC-20.1* RBC-3.83* HGB-11.4* HCT-36.1 MCV-94
MCH-29.8 MCHC-31.6 RDW-14.0
[**2171-5-12**] 02:50PM estGFR-Using this
[**2171-5-12**] 02:50PM GLUCOSE-117* UREA N-64* CREAT-1.8*
SODIUM-157* POTASSIUM-8.3* CHLORIDE-123* TOTAL CO2-24 ANION
GAP-18
[**2171-5-12**] 03:06PM LACTATE-3.3*
[**2171-5-12**] 04:15PM URINE RBC-[**3-20**]* WBC-[**12-5**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2171-5-12**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2171-5-12**] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2171-5-12**] 04:30PM LIPASE-44
[**2171-5-12**] 04:30PM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-97 TOT
BILI-0.2
[**2171-5-12**] 04:30PM GLUCOSE-110* UREA N-62* CREAT-1.7*
SODIUM-159* POTASSIUM-3.9 CHLORIDE-125* TOTAL CO2-22 ANION
GAP-16
[**2171-5-12**] 04:39PM K+-4.2
[**2171-5-12**] 09:31PM LACTATE-2.2*
.
[**2171-5-12**]: Occlusive right common femoral, superficial femoral,
and popliteal DVT. Occlusive-to-partially occlusive left greater
saphenous, common femoral, and superficial femoral DVT. Left
popliteal vein unable to be evaluated due to patient
incooperation. Of note, the concurrent CT excludes more central
venous thrombosis in the illiac vessels and IVC, through the
level of the right atrium.
.
CXR: 1. Interval development of moderate right pleural effusion.
The right middle and lower lobe consolidative changes have
improved. 2. No pneumoperitoneum is visualized.
.
AXR [**2171-5-12**]: 1. No supine evidence of free intraperitoneal air.
2. Non-obstructive bowel gas pattern is noted.
3. Possible rectal fecal impaction.
.
CT Abd/Pelv: 1. Non-occlusive non-calcified proximal SMA
atheroma resulting in less than 50% narrowing of the lumen. No
other findings to suggest acute mesenteric ischemia; however,
even with a normal CT this cannot be completely excluded.
Clinical correlation is advised. 2. Right common femoral DVT.
This can be further evaluated for extent with dedicated right
lower extremity ultrasound. 3. Right lower lobe pneumonia with
mild right lower lobe compression atelectasis and moderate to
simple right pleural effusion. 4. Multiple bilateral renal cysts
of which display a partial septal calcification on the right.
This is likely of no clinical significance given patient's age.
5. Ill-defined hypoattenuating peripheral right hepatic lesion
may represent a irregular area of parenchymal fibrosis,
persistent perfusion abnormality ([**Male First Name (un) **]) related to underlying
FNH or, less likely, atypical hemangioma.
Brief Hospital Course:
Ms. [**Known lastname 284**] is a 87yF with dementia, recent pneumonia, now
with phlegmasia cerulea dolens, abdominal pain. Prognosis
extremely poor, with ischemia/imminent infarction of right foot
+/- bowel (given abdominal exam and known non-occlusive SMA
thrombus). After a family meeting between the health care proxy
and the palliative care team, it was decided to pursue [**Known lastname 3225**]
status. The patient was transferred to an inpatient hospice
facility.
- HCP [**Name (NI) **] [**Last Name (NamePattern1) **] cell [**Telephone/Fax (1) 96363**] home [**Telephone/Fax (1) 96364**] work
[**Telephone/Fax (1) 96365**].
Medications on Admission:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Acetaminophen 325 - 650 mg PO Q6H PRN
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
Primary:
Phlegmasia cerulea dolens
Non-occlusive SMA thrombus
Secondary:
Alzheimer's dementia
Discharge Condition:
Stable, pain free
Discharge Instructions:
If you develop any pain, nausea, vomiting, or shortness of
breath, or any other concerning symptoms, please seek help from
your hospice provider.
Followup Instructions:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"5849",
"5119",
"2760",
"486",
"2762",
"4019",
"2720"
] |
Admission Date: [**2112-6-4**] Discharge Date: [**2112-6-6**]
Date of Birth: [**2047-8-13**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ceftriaxone / Ibuprofen
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
asthma exacerbation/anaphylaxis
Major Surgical or Invasive Procedure:
epinephrine pen administration
History of Present Illness:
64M with history of CAD s/p CABG and severe asthma who presented
from home with respiratory arrest. He had a recent admission at
an OSH two weeks ago where he underwent ASA desensitization
therapy. He developed wheezing at home today and took 30
prednisone but was then found lying in his back yard cyanotic.
EMS was called. On the scene they reported no air movement. They
were unablet to bag ventilate. He was given epinephrine and had
rapid improvement in symptoms. On arrival to the ED, he was
afebrile, BP 141/78 RR18 and 100% NRB. He was placed on
continuous nebs, given mthylprednisolone 125 IV x1 and magnesium
2g IV. CXR was negative as was troponin. On transfer to the
floor he is [**Age over 90 **]% on room air.
.
Currently feeling much better but anxious. He states that his
symptoms came on relatively suddenly and did not include any
itching/rash/angioedema/runny eyes/rhinorrhea as well as no
chest pain or nausea. He had gone outside because he thought he
might have to call 911 and did not want them to have to manage
opening a locked door. He has had two attacks like this since
his ASA densensitization but was able to take prednisone soon
enough for the prior attack to self-resolve. Prior to the asa
desensitization, his last severe attack requiring ED visit was
30 years ago.
.
His asthma developed at age 20 and is associated with nasal
polyposis and ASA sensitivity. In his 20s, he had frequent ED
visits (sometimes up to three times weekly), but only one
hospital admission and no intubations. He failed and actually
had a paradoxical reaction to inhaled steroids and has been
prednisone dependent for 10 years.
Past Medical History:
ASTHMA, ASA sensitive with nasal polypsis/eosinophilia, samter's
triad, pred dependent
MITRAL VALVE PROLAPSE
HYPERCHOLESTEROLEMIA
DIVERTICULOSIS
COLONIC POLYPS
GASTROPARESIS
OSTEOPENIA
CORONARY ARTERY DISEASE, s/p CABG [**2104**]
SLEEP APNEA
CATARACT - NUCLEAR SCLEROTIC SENILE
ESOPHAGEAL REFLUX
CANCER - PROSTATE s/p XRT
RADIATION PROCTITIS
Social History:
Smoking: Quit ([**2077-2-11**]) 1.5 ppd, 13.5 pack-years
Alcohol: minimal no drugs
Family History:
NC
Physical Exam:
On Admission:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: cta b/l throughout
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
On discharge:
Gen: alert and oriented, NAD
HEENT: PERRL, anicteric
CV: RRR, no m/r/g
Pulm: CTA bilat without wheezing
Abd: soft, NTND
Extrem: no edema, cyanosis or clubbing
Pertinent Results:
On Admission:
[**2112-6-4**] 05:15PM BLOOD WBC-10.9 RBC-4.60 Hgb-12.8* Hct-39.8*
MCV-87 MCH-27.8 MCHC-32.2 RDW-14.4 Plt Ct-285
[**2112-6-4**] 05:15PM BLOOD PT-12.6 PTT-19.2* INR(PT)-1.1
[**2112-6-4**] 05:15PM BLOOD UreaN-24* Creat-1.2 Na-140 K-5.4* Cl-101
HCO3-20* AnGap-24*
[**2112-6-4**] 05:15PM BLOOD Calcium-8.9 Phos-6.5* Mg-2.3
[**2112-6-4**] 05:26PM BLOOD Glucose-255* Lactate-5.2* Na-140 K-4.9
Cl-102
[**2112-6-4**] 05:26PM BLOOD Hgb-12.7* calcHCT-38 O2 Sat-94 COHgb-3
MetHgb-0
[**2112-6-4**] 05:26PM BLOOD freeCa-0.98*
.
ABG:
[**2112-6-4**] 05:26PM BLOOD pO2-135* pCO2-41 pH-7.30* calTCO2-21 Base
XS--5 Comment-GREEN TOP
.
Tox:
[**2112-6-4**] 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
Imaging:
CXR [**2112-6-4**]:
1. Cardiomegaly but no overt edema.
2. Probable small hiatal hernia.
On discharge:
[**2112-6-6**] 04:33AM BLOOD WBC-13.6*# RBC-4.46* Hgb-12.0* Hct-36.8*
MCV-83 MCH-26.9* MCHC-32.6 RDW-14.9 Plt Ct-319
[**2112-6-5**] 05:01AM BLOOD Neuts-93.4* Lymphs-2.9* Monos-2.3 Eos-0.3
Baso-1.2
[**2112-6-6**] 04:33AM BLOOD Plt Ct-319
[**2112-6-4**] 05:15PM BLOOD Fibrino-284
[**2112-6-6**] 04:33AM BLOOD Glucose-152* UreaN-28* Creat-0.9 Na-142
K-3.5 Cl-105 HCO3-25 AnGap-16
[**2112-6-6**] 04:33AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1
Brief Hospital Course:
64 y/o with h/o severe prednisone dependent asthma (adult onset
with ASA sensitivity, eosinophilia) s/p ASA densitization at [**Hospital1 112**]
two weeks ago with acute asthma attack.
.
# Asthma exacerbation/anaphylactic reaction: Per report, patient
cyanotic at home, which improved with epi pen in field, nebs and
prednisone. Patient admitted to the MICU for close monitoring.
Trigger felt likely to be aspirin, as asthma previously well
controlled prior to starting ASA following recent ASA
desensitization. There was no evidence of infection (lack of
fever or symptoms). Therefore, aspirin was held. Patient treated
with NEBs q4hr + prn, started on outpatient Montelukast and
Zyflo. Per discussion with allergy and pulmonary, Zyflo was
initiated due to the aspirin desensitization, and can be
stopped, as he will not continue these desensitizations. Patient
started on 60 mg prednisone and then experienced increased
SOB/decreased peak flow consequently started on Solmedrol 125mg
q8hr. He was then transitioned to prednisone 60mg PO daily and
was stable on this regimen for the following 18 hours. We also
held his B-blocker. Peak flow on the day of discharge from the
MICU was 417 and he was without wheeze.
.
The patient's allergist was contact[**Name (NI) **] who agreed with stopping
the aspirin. With regard to follow-up, patient and provider will
be in close communication, but formal appointment is not
required as there is no plan to continue aspirin
desensitization. Pulmonary was consulted, and outpatient
pulmonologist [**Hospital1 112**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] was the consult attending. With
multidisciplinary discussion, patient will be discharged on
prednisone 60 mg daily (with 2 week taper and to be managed by
Dr. [**Last Name (STitle) 9303**], discharged with epi pen for emergency use
(patient educated how to use), and he was continued on
outpatient montelukast. Zyflo was discontinued as his aspirin
desensitatization is discontinued. He is not on inhaled
corticosteroids due to paradoxical allergic reaction. Patient
instructed that as he missed dose is now re-sensitized to
Aspirin and can not re-start taking without risk of worsening
asthma/anaphylaxis. We restarted albuterol and ipratropium INH
PRN. He will discuss with his pulmonologist re long acting
inhaled steroid and long acting anticholinergic and will follow
up with him soon. He will continue to hold B-blocker until
breathing/PEF at baseline.
.
# GERD: Continued omeprazole
.
# Lactic acidosis: resolved. [**3-16**] cyanosis on presentation
.
# CAD s/p CABG: Held beta-blocker (bisoprolol) in setting of
bronchospasm - patient to re-start once at baseline. Continued
pravastatin. As aspirin stopped re-started plavix.
.
# HTN: Continued HCTZ
.
# Prostate ca s/p xrt: Held avodart (non-form)
Medications on Admission:
1. PREDNISONE 20 MG PO QAM
2. ACETYLSALICYLIC ACID 650 MG PO BID
3. CALCIUM CITRATE 950 MG PO DAILY
4. CHOLECALCIFEROL 5,000 UNITS PO DAILY
5. CLOPIDOGREL 75 MG PO DAILY
6. DIAZEPAM 5 MG PO TID
7. DUTASTERIDE 0.5 MG PO BID
8. HYDROCHLOROTHIAZIDE 25 MG PO DAILY
9. OMEPRAZOLE 40 MG PO DAILY
10. FORMOTEROL 1 INHALATION INH Q24H
11. XOPENEX 1.25 MG Q2H PRN Shortness of Breath,Wheezing
12. Bisoprolol (zebeta) 1.25/day
13. pravastatin 80
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety/insomnia.
3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium Citrate + Oral
8. Vitamin D Oral
9. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
10. Xopenex 1.25 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation q2hr as needed for shortness of breath or wheezing.
11. prednisone 10 mg Tablet Sig: 1-6 Tablets PO once a day:
Please take 6 tabs (60mg) daily for 3 days from [**Date range (1) 11757**], then
5 tabs (50mg) daily for 3 days from [**Date range (1) 40693**], then 4 tabs (40mg)
daily for 3 days from [**Date range (1) 58651**], then 3 tabs (30mg) daily from
[**Date range (1) 58652**], then 2 tabs (20mg) daily from [**Date range (1) 16935**], then 1 tab
(10mg) daily until advised to change.
Disp:*90 Tablet(s)* Refills:*1*
12. formoterol fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) INH Inhalation every twenty-four(24) hours.
13. bisoprolol fumarate 5 mg Tablet Sig: 0.25 Tablet PO twice a
day: Take only if breathing is stable as directed by your
cardiologist and pulmonologist. Hold for shortness or breath or
wheeze. .
14. ipratropium bromide 0.02 % Solution Sig: One (1) INH
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) PUFF Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
16. epinephrine 1 mg/mL (1:1,000) Solution Sig: One (1) INJ
Injection once a day as needed for Severe allergic reaction.
Disp:*2 Pens* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia/Respiratory distress
Acute Asthma
Aspirin hypersensitivity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for severe respiratory distress. You improved
with epinephrine, aggressive nebulizer therapy and prednisone.
You were closely monitored in the ICU prior to discharge and
improved significantly.
The cause of your respiratory distress was likely secondary to
your asthma and the trigger is unclear but may have been related
to aspirin therapy. YOUR ASPIRIN WAS DISCONTINUED. IT IS VERY
IMPORTANT THAT YOU DO NOT RESTART TAKING ASPIRIN ON YOUR OWN -
BECAUSE YOU MISSED A DOSE YOU ARE NO LONGER DESENSITIZED AND
RESTARTING PUTS YOU AT RISK FOR WORSENING ASTHMA/ANAPHYLAXIS.
We have made the following medication changes:
STOP: Aspirin - DO NOT RE-START UNLESS DIRECTED BY YOUR
ALLERGIST
CHANGE prednisone dosage: Please take 6 tabs (60mg) daily for 3
days from [**Date range (1) 11757**], then 5 tabs (50mg) daily for 3 days from
[**Date range (1) 40693**], then 4 tabs (40mg) daily for 3 days from [**Date range (1) 58651**], then
3 tabs (30mg) daily from [**Date range (1) 58652**], then 2 tabs (20mg) daily from
[**Date range (1) 16935**], then 1 tab (10mg) daily until advised to change by
your pulmonologist.
HOLD: Bisoprolol (Zebeta) - you can re-start taking once your
breathing is at your baseline and your peak flows are stable
CONTINUE Singulair: It is important to take Singulair as
directed by your lung doctor
START Epinephrine as needed. You have been given a script for
Epinephrine shot and instructed how to use it if needed.
START Plavix
Otherwise we made no changes to your medications.
.
IT IS IMPORTANT YOU FOLLOW UP WITH YOUR LUNG DOCTOR:
Please call your lung doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] to arrange close
follow-up. We have also sent him an email and spoke with him on
the phone. He will also try to contact you to ensure a close
follow up appointment.
Followup Instructions:
IT IS IMPORTANT YOU FOLLOW UP WITH YOUR LUNG DOCTOR:
Please call your lung doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**] to arrange close
follow-up. We have also sent him an email and spoke with him on
the phone. He will also try to contact you to ensure a close
follow up appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2112-6-6**]
|
[
"V4581",
"4240",
"2720",
"53081",
"4019"
] |
Admission Date: [**2178-7-6**] Discharge Date: [**2178-7-13**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Confusion, hypoxia, fever
Major Surgical or Invasive Procedure:
Intubation
Central line placement
A-line placement
Fecal disimpaction
History of Present Illness:
78 y/o male with Parkinson's, HTN, chronic lower back pain
secondary to spinal stenosis presents with one week of
obstipation, nausea/vomiting, anorexia, two days of increasing
confusion. According to the family, five days prior to
admission he began to be nauseated and vomited and over the next
few days was noted to be extremely constipated (non-compliant
with bowel regimen [**Name6 (MD) **] [**Name8 (MD) **] RN). He ate little and continued to
vomit occasionally. Three nights prior to admission he became
confused and this progressively worsened and he became weaker.
Two night prior to admission he was found to have a new oxygen
requirement and this increased over the next day, and he became
febrile.
In the ED, he was febrile to 102, hypotensive, tachypneic, and
confused and was intubated as his respiratory status continued
to decline. He was loaded with 6L IVF and was transiently on a
norepinephrine drip. Additionally in the ED he was noted to be
hyperkalemic with K+6.0 and peaked T-waves on ECG that resolved
with insulin +D50 and calcium gluconate Surgery was consulted
for possible small bowel obstruction. Evaluation revealed
severe fecal impaction, but no SBO. He was started empirically
on Vanco/Levofloxacin/Flagyl.
Past Medical History:
[**Last Name (un) 3562**] disease
Hypertension
Chronic lower back pain
Chronic renal insufficiency (baseline creat 1.2-1.5)
CAD
h/o melanoma s/p resection 20yrs ago
Gerd
BPH
Social History:
Lives at [**Hospital 100**] Rehab with his wife. A former International
Relations professor. independent in most ADLs
Family History:
son and daughter have renal cysts
Physical Exam:
t 102.1, bp 94/42, hr 64, rr 30, spo2 88%
100% on AC 550 x24 FiO2 1.0 PEEP 12
GEN: intubated, sedated
HEENT: PERRL, MM dry, ETT in place
Neck: supple, no JVD
CV: RRR, no mrg
Resp: coarse breath sounds throughout, bilateral rhonchi, no
crackles
Abd: distended, pain to deep palpation, decreased BS with
increased pitch
Ext: no edema
Neuro: PERRL, responds to voice, moves all extremities
Pertinent Results:
[**2178-7-6**] 08:15AM PLT SMR-NORMAL PLT COUNT-154
[**2178-7-6**] 08:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2178-7-6**] 08:15AM NEUTS-72* BANDS-18* LYMPHS-5* MONOS-3 EOS-0
BASOS-2 ATYPS-0 METAS-0 MYELOS-0
[**2178-7-6**] 08:15AM WBC-9.0 RBC-3.70* HGB-11.7* HCT-34.6* MCV-93#
MCH-31.5# MCHC-33.7 RDW-13.8
[**2178-7-6**] 08:15AM CK-MB-7
[**2178-7-6**] 08:15AM cTropnT-0.10*
[**2178-7-6**] 08:15AM ALT(SGPT)-3 AST(SGOT)-25 CK(CPK)-579* ALK
PHOS-96 AMYLASE-165* TOT BILI-0.5
[**2178-7-6**] 08:15AM GLUCOSE-193* UREA N-117* CREAT-6.7*#
SODIUM-129* POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-18
[**2178-7-6**] 08:29AM LACTATE-1.5
[**2178-7-6**] 08:45AM URINE RBC-[**2-7**]* WBC-0-2 BACTERIA-0 YEAST-RARE
EPI-0
[**2178-7-6**] 08:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2178-7-6**] 08:45AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2178-7-6**] 09:36AM K+-6.2*
[**2178-7-6**] 10:43AM LACTATE-1.8
[**2178-7-6**] 10:43AM TYPE-ART PO2-58* PCO2-42 PH-7.28* TOTAL
CO2-21 BASE XS-6
[**2178-7-6**] 12:00PM LACTATE-1.4 K+-5.0
.
Rads:
KUB [**7-6**]: IMPRESSION:
1) No definite evidence of obstruction.
2) Calcified renal cyst.
3) The upper abdomen including the hemidiaphragms were not
imaged. There is no free air seen in the portion of the abdomen
imaged.
.
CT Abd/Pelvis [**2178-7-6**]: IMPRESSION:
1) Dilated stool filled colon, particularly the rectosigmoid.
There is also apparent rectal wall thickening. The findings are
consistent with a fecal impaction.
2) Dense consolidation in both lower lobes which contain high
attenuation
material, suspicious for aspiration.
3) Extremely limited assessment of the abdomen due to
respiratory motion and beam hardening artifact from the
patient's arms.
4) Peripherally calcified cystic structure in the upper pole of
the right
kidney with Hounsfield units not consistent with a simple cyst.
This is
inadequately assessed without IV contrast. Further evaluation
with MRI could be considered. Two additional likely cysts in
the lower pole of the right kidney.
5) 7 mm non-obstructing right renal stone and tiny 1 mm
non-obstructing left renal stone.
.
Renal U/S: IMPRESSION:
1. No evidence of hydronephrosis on this limited exam.
.
CXR [**2178-7-12**] COMMENTS: Portable erect AP radiograph of the chest
is reviewed and compared with the previous study of [**2178-7-8**].
There is continued mild congestive heart failure with
cardiomegaly and small bilateral pleural effusion. There is
continued opacity in both lower lobes indicating aspiration
pneumonia. The patient has been extubated. The right jugular
IV catheter remains in place. The nasogastric tube terminates
in the gastric antrum. No pneumothorax is identified.
Brief Hospital Course:
78yo man with h/o CAD, HTN, Parkinson's Dz, chronic back pain
presented in sepsis, diagnosed with MRSA pneumonia and severe
fecal impaction. During his hospitalization the following
issues were addressed:
1. Sepsis: Sepsis was thought to be due to MRSA pneumonia vs
aspiration event in setting of partial small bowel obstruction
brought on by fecal impaction. He was treated with aggressive
iv fluids and required levophed initially to support blood
pressure. He was intubated for airway protection, and a right
subclavian central line was placed. Surgery service continued
to follow during the first few days of hospitalization but did
not feel he was obstructed causing his sepsis. He was treated
with Vancomycin for MRSA PNA ([**2178-7-13**] = day [**6-18**]). He also
completed a 7 day course of levofloxacin/metronidazole for
suspected GI source. Extubation was delayed due to copious
secretions; he was successfully extubated on [**2178-7-10**].
Additionally the patient failed the cortisol stimulation test
and was treated with hydrocortisone. This was discontinued on
day 5 as the patient was persistantly hypertensive at that time.
2. MRSA pneumonia: sputum grew MRSA. He was treated with
vancomycin and remained afebrile. Blood cultures were
nondiagnostic. He will complete this antibiotic course [**2178-7-20**].
Vancomycin was dosed according to level given his concurrent
renal failure. A trough shoudl be checked daily with goal
trough 15-20.
3. ARF: He presented with an acute renal failure on chronic
renal insufficiency. This was felt to be due to prerenal
etiology given his recent episodes of emesis and fever prior to
presentation. All nephrotoxic medications were held, and
creatine improved to near baseline with good urine output by the
time of discharge.
4. HTN: following extubation, the patient continued to be
hypertensive, requiring a nitroglycerin gtt for control. Oral
medications were titrated, and the gtt discontinued prior to
discharge. Goal SBP 140-150 was achieved on amlodipine 10mg
daily, Imdur 60mg daily, Metoprolol XL 50mg daily, and
Lisinopril 20mg daily. Lisinopril was restarted after
creatinine improved to baseline levels. Additionally,
hypertension improved with control of the patient's chronic
pain.
5. Hyperglycemia: patient was hyperglycemic in setting of
sepsis and with concurrent steroid use. He was treated with an
insulin gtt for tight glucose control. This was discontinued,
and he was placed on sliding scale prior to discharge. He was
not requiring supplemental insulin at the time of discharge.
6. Fecal impaction: The patient was severely impacted on
admission. He required repeated soap suds enemas and manual
disimpaction. He was discharged on a standing bowel regimen of
colace and senna consistent with his outpatient regimen. This
should be continued as long as he is on chronic narcotics.
7. Parkinson's disease: the patient's Sinemet was held on day
two for concern that it can cause ileus, leading to worsening
constipation and possible SBO. The dose was gradually titrated
back up in discussion with his outpatient neurologist. He was
on QID dosing at the time of discharge (home dose 6x/day).
8. FEN: While intubated he was on tubefeeds. Post-extubation
he had a bedside swallow exam which he passed. He was
tolerating a normal po diet at the time of discharge.
9. Health Maintenance: He was given pneumococcal vaccine.
9. Dispo: Patient was discharged to MACU. He is a full code.
Medications on Admission:
Atenolol 12.5mg daily
Sinamet 1 tab 6x/day
Neurontin 600mg daily
Zestril 40mg QAM, 10mg QPM
Zoloft 100mg daily
ASA 325mg daily
Colace 250mg daily
Finasteride 5mg daily
Imdur 15mg daily
Prevacid 30mg daily
Multivitamin daily
Nifedipine 60mg [**Hospital1 **]
Oxycodone SR 20mg [**Hospital1 **]
Senna 3tabs [**Hospital1 **]
Zocor 80mg daily
Tamsulosin 0.4mg daily
Tolterodine 4mg QHS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous
Q 24H (Every 24 Hours) for 7 days.
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Tolterodine Tartrate 4 mg Capsule, Sust. Release 24HR Sig:
One (1) Capsule, Sust. Release 24HR PO at bedtime.
16. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Aspiration pneumonia
Sepsis
Altered Mental Status
Fecal impaction
Acute renal failure
Secondary:
Parkinson's disease
Hypertension
Chronic lower back pain
Discharge Condition:
Improved, oriented, stable off oxygen, with improving renal
function
Discharge Instructions:
Please return to the ED for fevers, shortness of breath,
vomiting, or other concerning symptoms.
Because of your medications you routine take, it is imperative
that you remain on the laxatives and stool softeners you have
been prescribed, taking them every day.
Followup Instructions:
Please see your primary care doctor in the next week. Call to
make an appointment.
Please see your neurologist in the next two weeks, call to make
an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"0389",
"51881",
"5070",
"5849",
"78552",
"2762",
"2767",
"99592",
"4019"
] |
Admission Date: [**2198-3-17**] Discharge Date: [**2198-3-19**]
Date of Birth: [**2149-12-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2198-3-17**]:
2 overlapping Pixel stents to the proximal right coronary artery
History of Present Illness:
The patient is a 48 year old female with a history of rheumatoid
arthritis, hyperlipidemia, and tobacco who was transferred to
[**Hospital1 18**] with substernal chest pain that awoke the patient the
night prior to admission. She had never experienced chest pain
before but admits to feeling some jaw pain intermittently during
the past week which she thought was due to her rheumatoid
arthritis. The patient awoke with severe chest pain associated
with shortness of breath, no radiating pain or nausea/vomiting.
She presented to an outside hospital and was found to have ST
elevations in the inferior leads suggesting an acute inferior MI
and was transferred to [**Hospital1 18**] for cath which showed the
following:
COMMENTS:
1. Coronary angiography of this left dominant circulation
demonstrated
two vessel coronary artery disease. LMCA was very short and had
no
angiographically apparent disease. LAD had mild diffuse disease
throughout with 50-60% distal stenosis. LCX had minimal luminal
irregularities. RCA was a non-dominant vessel with proximal
total
occlusion.
2. Left ventriculography was not performed.
3. Limited resting hemodynamics demonstrated classic RV
infarction
physiology with elevated RA pressure (17 mmHg), prominent X and
Y
descents, and pseudoconstriction pattern in RV tracing. Left
sided
pressures were also elevated with mPCWP of 17 mmHg. Cardiac
output and
cardiac index were reduced at 3.8 L/min and 2.2 L/min/m2.
4. Distal aortogram demonstrated aortic graft just above the
iliac
bifurcation with reimplantation of left renal artery.
5. Successful PTCA/stenting of the proximal non-dominant RCA
with
overlapping 2.0x18 and 2.0x13mm Pixel stents covering the
ostium. Final
angiography revealed no residual stenosis, no dissection and
TIMI-3 flow
(see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Right ventricular infarction.
3. PVD.
4. PCI of the RCA.
Past Medical History:
Rheumatoid arthritis
Tobacco
Social History:
The patient admits to smoking tobacco. She denies alcohol or
illicit drug use.
Family History:
Noncontributory.
Pertinent Results:
[**2198-3-17**] 11:21PM GLUCOSE-98 UREA N-7 CREAT-0.4 SODIUM-141
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-28 ANION GAP-6*
[**2198-3-17**] 11:21PM CK(CPK)-271*
[**2198-3-17**] 11:21PM CK-MB-31* MB INDX-11.4* cTropnT-0.82*
[**2198-3-17**] 11:21PM CALCIUM-7.2* PHOSPHATE-2.1* MAGNESIUM-2.1
[**2198-3-17**] 11:21PM WBC-6.0 RBC-3.16* HGB-10.0* HCT-30.0* MCV-95
MCH-31.7 MCHC-33.4 RDW-14.8
[**2198-3-17**] 11:21PM PLT COUNT-206
[**2198-3-17**] 01:41PM POTASSIUM-3.9
[**2198-3-17**] 01:41PM CK(CPK)-490*
[**2198-3-17**] 01:41PM CK-MB-68* MB INDX-13.9*
[**2198-3-17**] 01:41PM PLT COUNT-283
[**2198-3-17**] 09:55AM COMMENTS-MIXED [**Last Name (un) **]
[**2198-3-17**] 09:55AM O2 SAT-69
[**2198-3-17**] 08:14AM GLUCOSE-106* UREA N-8 CREAT-0.5 SODIUM-139
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-25 ANION GAP-10
[**2198-3-17**] 08:14AM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.8
[**2198-3-17**] 08:14AM CRP-2.61*
[**2198-3-17**] 08:14AM WBC-6.9 RBC-3.68* HGB-11.7* HCT-33.7* MCV-92
MCH-31.7 MCHC-34.6 RDW-14.3
[**2198-3-17**] 08:14AM PLT COUNT-274
[**2198-3-17**] 08:14AM PT-12.6 INR(PT)-1.0
[**2198-3-17**] 05:15AM CK(CPK)-22*
[**2198-3-17**] 05:15AM CK-MB-NotDone cTropnT-<0.01
ECHO Study Date of [**2198-3-19**]
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion
abnormality cannot be fully excluded.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen.
6.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion
cannot be excluded.
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
C.CATH Study Date of [**2198-3-17**]
COMMENTS:
1. Coronary angiography of this left dominant circulation
demonstrated
two vessel coronary artery disease. LMCA was very short and had
no
angiographically apparent disease. LAD had mild diffuse disease
throughout with 50-60% distal stenosis. LCX had minimal luminal
irregularities. RCA was a non-dominant vessel with proximal
total
occlusion.
2. Left ventriculography was not performed.
3. Limited resting hemodynamics demonstrated classic RV
infarction
physiology with elevated RA pressure (17 mmHg), prominent X and
Y
descents, and pseudoconstriction pattern in RV tracing. Left
sided
pressures were also elevated with mPCWP of 17 mmHg. Cardiac
output and
cardiac index were reduced at 3.8 L/min and 2.2 L/min/m2.
4. Distal aortogram demonstrated aortic graft just above the
iliac
bifurcation with reimplantation of left renal artery.
5. Successful PTCA/stenting of the proximal non-dominant RCA
with
overlapping 2.0x18 and 2.0x13mm Pixel stents covering the
ostium. Final
angiography revealed no residual stenosis, no dissection and
TIMI-3 flow
(see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Right ventricular infarction.
3. PVD.
4. PCI of the RCA.
Brief Hospital Course:
The patient is a 48 year old female with no prior CAD,
hyperlipidemia, rheumatoid arthritis, and tobacco history who
presented with acute lone RV infarction, ST elevation inferior
MI.
1. CAD
- The patient's cath showed the following:
1. Coronary angiography of this left dominant circulation
demonstrated
two vessel coronary artery disease. LMCA was very short and had
no
angiographically apparent disease. LAD had mild diffuse disease
throughout with 50-60% distal stenosis. LCX had minimal luminal
irregularities. RCA was a non-dominant vessel with proximal
total
occlusion.
2. Left ventriculography was not performed.
3. Limited resting hemodynamics demonstrated classic RV
infarction
physiology with elevated RA pressure (17 mmHg), prominent X and
Y
descents, and pseudoconstriction pattern in RV tracing. Left
sided
pressures were also elevated with mPCWP of 17 mmHg. Cardiac
output and
cardiac index were reduced at 3.8 L/min and 2.2 L/min/m2.
4. Distal aortogram demonstrated aortic graft just above the
iliac
bifurcation with reimplantation of left renal artery.
5. Successful PTCA/stenting of the proximal non-dominant RCA
with
overlapping 2.0x18 and 2.0x13mm Pixel stents covering the
ostium. Final
angiography revealed no residual stenosis, no dissection and
TIMI-3 flow
(see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Right ventricular infarction.
3. PVD.
4. PCI of the RCA.
- The patient was pain free after 2 overlapping bare metal
stents were placed to the right coronary artery. She was
continued on Plavix 75 mg, atorvastatin 80 mg, and lopressor
12.5 mg [**Hospital1 **] in addition to aspirin 325 mg.
- Her peak CK was 68 with a post-procedure troponin of 0.82.
- She decided to follow up with a cardiologist in her local area
after consulting with her primary care physician.
[**Name Initial (NameIs) **] The patient's CRP was 2.61 in the setting of RA and she had a
TG of 248 with an HDL of 27 and LDL of 67.
2. ? CHF
- The patient underwent an echo on [**2198-3-19**] which showed an EF of
60% with a suboptimal study, normal RV function and trivial MR.
- The patient did not exhibit any signs of volume overload
during her hospitalization.
3. Rheumatoid arthritis
- The patient stated that she does not take prednisone daily
while at home, only as needed for her arthritic pain. She was
asked to continue the use of this medication only as directed by
her rheumatologist.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lone right ventricular infarction
ST elevation inferior myocardial infarction
Discharge Condition:
Stable.
Discharge Instructions:
Please call 911 or return to the ER if you experience any
recurrent chest pain.
You MUST take Plavix every day for the at least the next month.
Failure to do so may result in another heart attack or even
death.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7401**] Appointment should
be in [**7-15**] days. At this time, you should decide on a
cardiologist with whom to follow in 4 weeks after you leave the
hospital.
|
[
"41401"
] |
Admission Date: [**2116-3-11**] Discharge Date: [**2116-3-17**]
Date of Birth: [**2054-3-15**] Sex: F
Service: MEDICINE
Allergies:
Thorazine / Penicillins
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
61 y.o. woman with pmh COPD, found by VNA in her home today to
be short of breath and somnolent. In ED Vitals were 97.6, 88,
108/38, 15 84% RA, 100% on NRB. She was wheezy and not moving
air. WBC 11.9 with Neutrophils 80%. Her ABG was 7.26/68/67/32.
Placed on BiPAP, new ABG 7.19/76/73/30. CXR showed new lingular
infiltrate. Got a dose of nebs, solumedrol 125mg IV, Levaquin
X1. Vitals prior to transfer 110/60, 80's, 95%, FiO2 40%. BiPAP
settings Pressure support 14, PEEP 6.
.
On arrival to ICU, the patient is awake, but does not remember
any events of the day. She is denying chest pain, abdominal
pain, but is reporting shortness of breath.
Past Medical History:
* COPD - patient denies h/o intubation, CO2s 60s
* Schizoaffective disorder, bipolar
* Chronic low back pain, followed at pain clinic
* duodenal polyp, adenoma on bx [**9-/2114**]
* esophageal stricture s/p dilatation
* h/o urinary retention
* h/o ovarian cysts
* s/p ccy
.
Social History:
Lives alone, long history of smoking ~1ppd since age 14. States
today she currently smokes 2ppd. Denies EtoH or ilict drug use.
Lives in senior housing. Has brother who lives nearby, is
involved and is HCP. Retired typist.
Family History:
Twin brother died of MI at 49 yo
Physical Exam:
Vitals: 97.1 109/54 88 18 95%2L-->88% 2L c exertion
Pain: denies
Access: PIV
Gen: mod distress at rest, coughing, audible wheezing, mild
accessory muscle use, able to speak full sentences
HEENT: mmm
CV: RRR, no m appreciated
Resp: bilateral wheezing, prolonged expiration, scattered
rhonchi, decent air movement
Abd; soft, obese, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: strange affect, pleasant/cooperative.
.
Pertinent Results:
WBC 11.9->8.9
hgb 11s baseline
Chem panel unremarkable. BUN 9, creat 0.6\
Bicarb 35
Phos 0.5-->2.9
.
ABG [**3-12**]: 7.31/63/62 (baseline)
.
.
Imaging/results:
CXR [**2116-3-11**]: Probable lingular infiltrate. Radiographic followup
is recommended to clearance.
.
CXR [**2116-3-13**] In comparison with the study of [**3-11**], there is
increasing opacification at the left base silhouetting the
hemidiaphragm and consistent with a lower lung pneumonia.
Probable left pleural effusion and possible right effusion as
well.
CXR [**2116-3-15**]: Improving left retrocardiac consolidation and
improving small
left pleural effusion.
.
EKG: [**2116-3-11**]: NSR, rate 75, normal axis, No LVH, no ischemic
changes.
.
Brief Hospital Course:
61 y.o. woman with pmh COPD, found by VNA in her home on [**2116-3-11**]
with shortness of breath and somnolence. She was admitted to
[**Hospital1 18**] in [**Month (only) **] for SOB with PNA and then discharged to a rehab.
She improved remarkably at the rehab and was discharged from
there on [**2116-3-2**]. She was off oxygen supplementation and had
stopped smoking during her rehab stay. Upon returning home she
started smoking again. On the day of admission, she was unable
to get up from bed due to severe weakness and SOB. She was also
noted to be confused by her VNA with her O2 sats in mid 70's/RA.
On admission, had hypercapneic respiratory failure and was
admitted to MICU. CXR also with LLL PNA. Was started on IV
steroids, broad Abx, nebs. Tolerated brief BiPAP, but kept
pulling off. Her antibiotics were subsequently tapered to
levofloxacin alone on [**3-12**]. Transfered to Gen Med on [**3-13**]. While
on Gen Med, continued to be in COPD exacerbation and was treated
with duonebs q4, prednisone 40mg, levaquin. Repeat CXR showed
improved infiltrates and her Abx were stopped after a 7-day
course. Given frequency of exacerbations, decision made for slow
prednisone taper over 2weeks. The importance of smoking
cessation was repeatedly emphasized to her, and she acknowledged
understanding. Chantix was offered but she preferred to use
nicotine patches. Home O2 was arranged for her and increased VNA
services. When she is appropriately improved, she will be
referred to outpatient pulmonary rehab.
Medications on Admission:
Albuterol Inhaler 1-2 Puffs Q2H as needed
Chlordiazepoxide 10 mg PO BID
Mellarrill 200 mg PO BID
Topiramate 100 mg PO QAM
Topiramate 150mg PO QPM
Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **]
Prilosec 20mg PO daily
Albuterol Nebulization Q4H as needed for shortness of breath
Atrovent 2 puffs [**Hospital1 **]
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Topiramate 50 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
5. Thioridazine 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
Inhalation twice a day.
10. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day: when off atrovent nebs.
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
Disp:*1 month supply* Refills:*2*
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4 () as needed for shortness of breath or wheezing.
Disp:*1 month supply* Refills:*2*
14. Home O2
2-3 L/min continuous
O2 saturation 88% on RA [**2116-3-17**]
15. Nebulizer machine
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take three tablets (30mg total) daily for three days,
then two tablets (20mg total) daily for three days, then one
tablet (10mg) daily for three days, then stop.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
COPD exacerbation/hypercapneic resp failure
LLL pneumonia
Schizoaffective disorder
Tobacco abuse
Discharge Condition:
stable
Discharge Instructions:
You were admitted for another COPD exacerbation. You also have a
pneumonia and completed one week of antibiotics for this with
improvement in your symptoms and chest x-ray. Continue taking
steroids as directed.
It is VERY important that you stop smoking. You need oxygen at
home and it is extremely dangerous for you to smoke at home with
oxygen in the house.
If you have worsening shortness of breath, lightheadedness,
chest pain, fevers, chills, or any other concerning symptoms,
call your doctor.
Followup Instructions:
You have an appointment with your primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] on Thursday [**3-26**] at 1:15pm. Call his office
at [**Telephone/Fax (1) 2205**] with any questions.
Please ask Dr. [**Last Name (STitle) 2903**] to refer you to Pulmonary clinic (lung
doctors)
Please keep your appointment or make one with Dr. [**First Name (STitle) **] in
psychiatry.
|
[
"486",
"51881",
"2761",
"3051"
] |
Admission Date: [**2111-1-19**] Discharge Date: [**2111-1-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Right IJ catheter
History of Present Illness:
85 yr old male with hx of AAA s/p endovascular repair in [**11-29**]
presents from [**Hospital 100**] Rehab with increasing WBC count (to 25.2),
fever to 102 and bulging R groin with clear fluid seeping. Pt is
a poor historian [**2-26**] dementia but denied chest pain, sob, n/v/d.
Three hours after arrival in the [**Name (NI) **], pt noted to be more
lethargic with labored breathing and SBP had dropped from the
100s to the 80s/40s. Pt was intubated for airway protection and
started on a dopamine drip. BP improved to 120s/50s. He was sent
for head CT which showed a lacunar infarct. CT chest/abd
negative for abscess, UA positive for infection and pt was
admitted to the SICU.
.
In the SICU, pt was started on vanc/levo/flagyl. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was
done and showed an inappropriate response (10.6 --> 19.0) so pt
received three days of stress dose steroids. Cardiology was
consulted given the hx of pericardial effusion on prior CT. An
echo showed that the pericardial effusion was stable in size
without evidence of tamponade. Pt was extubated on HD#3 as his
mental status improved and he has been maintaining his sats on
50% face mask. The dopamine was weaned off on HD#4 and BP has
been stable in the 120s/60s. ID was consulted on [**1-22**] given
that pt was growing MRSA in his urine. Speech and swallow was
consulted after pt was seen coughing after sips of water which
he failed so an NGT remains in place.
Past Medical History:
1. Parkinson's Disease
2. Hypertension
3. DM
4. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear
5. Scoliosis/Kyphosis
6. Stable pericardial effusion, last echo [**10-28**] at [**Location (un) **]
(followed by Kanam)
7. Secondary pulm HTN likely [**2-26**] OSA
8. h/o AAA s/p Aortic stent graft repair of abdominal aortic
aneurysm with a Zenith device in [**11-29**]
Social History:
Lives with wife prior to Rehab. Quit tobacco many years ago, but
smoked [**2-27**] cigarettes/day x 10 years. Veteran. Retired; used to
worked in advertising. No ETOH
Family History:
NC
Physical Exam:
Exam on transfer from SICU:
tmax/c 98.4, BP 126/56 (110-120/50-70), HR 69 (60-80), R 28, O2
99% on 50%FM; I/O 1.3/1.2 today, 2.4/2.1 yesterday (+9.8L po
Gen: NAD, AO x 3,
HEENT: MM dry, EOMI, no scleralm icterus
Neck: JVD to mid ear
CV: RRR, 2/6 systolic murmur heard best at LLSB
Chest: diffuse rhonchi, decreased breath sounds at left base
Abd: decreased bowel sounds, soft, nontender
Groin: 3cm erythematous swelling, nontender, draining serous
fluid
Ext: resting tremor in left arm, 2+ edema in right arm; [**2-27**]+
edema in lower ext to sacrum
Neuro: CN 2-12 intact, strength 4-/5 in upper and lower ext
though left weaker than the right; sensation intact
Pertinent Results:
Studies:
Abd CT [**1-19**]:
1. Interval development of simple-fluid containing collection
within the right inguinal region, and interval increase in size
of two left inguinal fluid collections. There is no evidence of
rim enhancement, surrounding inflammatory fat stranding, or
extravasation of contrast into these simple containing fluid
collections.
2. Stable appearance of aortic endovascular graft without
evidence of endoleak. Stable appearance of infrarenal abdominal
aortic aneurysm.
3. Moderate sized bilateral pleural effusions with bibasilar
collapse/consolidation.
.
Head CT [**1-19**]:
No intracranial hemorrhage or mass effect. Chronic microvascular
angiopathy. Left basal ganglia lacunar infarction.
.
Echo [**1-20**]:
- Overall left ventricular systolic function is normal
(LVEF>55%).
- Right ventricular systolic function appears depressed.
- Mild (1+) mitral regurgitation is seen.
- Moderate to severe [3+] tricuspid regurgitation is seen.
- There is moderate pulmonary artery systolic hypertension.
- Significant pulmonic regurgitation is seen.
- There is a moderate to large sized pericardial effusion. The
effusion appears circumferential. No right ventricular diastolic
collapse is seen. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
.
RUE LENI [**1-23**]:
No evidence of deep venous thrombosis in the imaged vessels
.
Micro:
Urine Cx [**1-19**]: MRSA, enterococcus
Urine Cx [**1-19**]: MRSA, enterococcus
Right Groin Swab: MRSA
Rectal Swab for VRE: positive
Blood cx: pending
Stool for c diff: negative
Brief Hospital Course:
85M with hx of Parkinson's disease, AAA s/p repair in [**11-29**]
admitted on [**1-19**] from [**Hospital 100**] Rehab with fever and leukocytosis
and subsequently became hypotensive and unresponsive in ED with
intubation for airway protection likely [**2-26**] MRSA UTI
.
1. Sepsis: In the SICU, patient was started on
vancomycin/levofloxacin/flagyl. A cortisol stimulation test was
done and showed an inappropriate response (10.6 --> 19.0) so
patient received three days of stress dose steroids. Urine grew
out MRSA and pt was continued on Vancomycin. ID was consulted
and recommended completing a 10-day course. The dopamine was
weaned off on HD#4 and BP remained stable in the 120s/60s.
.
2. Respiratory failure/Pneumonia: Patient was intubated in the
ED for labored breathing in the setting of sepsis. He was
extubated on HD#3 as his mental status improved and he has been
maintaining his sats on 50% face mask. Due to a persistent
elevated WBC and MRSA in urine, ID was consulted. A possible
pneumonia was seen on CXR, likely ventilator-associated so
patient was continued on Levofloxacin/Flagyl for 10 day course.
.
3. Leukocytosis: WBC trending down. Likely elevated in setting
of pneumonia and urinary tract infection and also high dose
steroids. C diff was negative
.
4. Acute on chronic Renal Failure: Baseline creatinine of
1.4-1.5 during last admission. Acute renal failure this
admission is likely secondary to acute tubular necrosis during
hypotension in ED. Creatinine trended down to baseline with
gentle hydration.
.
5. Volume overload: EF normal and with normal E/A ratio so no
clear evidence for heart failure. Patient is 9L over hospital
stay. Patient has been gently diurese after ICU stay and is
almost euvolemic on discharge.
.
5. AAA s/p repair: no evidence of infection of graft, vascular
was involved throughout hospital stay
.
6. Parkinsons: continue sinemet, mirapex
.
7. New lacunar infarct:Neurology consult was obtained while
patient was inpatient. It was probably due to small vessel
disease from long standing diabetes. It is not likely related to
his dysphagia. His swallowing problem was probably from
deconditioning and post intubation. His Parkinson disease was
also thought to be stable. Aspirin was started as stroke
prevention. Blood pressure should be controlled at around 130/80
8. HTN: continue Toprol
.
9. DM: Fingerstick well controlled on insulin sliding scale
.
10. Anemia: Baseline hct appears to be 30
.
11. FEN: On thickend nectar liquid and ground solid(aspirate on
thin liquid). Should have repeat speech and swallow in [**2-27**] weeks
to reasssess.
.
12. Prophylaxis: Sc heparin, PPI, bowel regimen
.
13. Access: right internal jugular, should pull this out after
finishing antibiotic. This should not be left longer than that
as it can act as a source of infection.
.
14. Code: full
Medications on Admission:
Meds at home:
* nebs prn
* Toprol XL 100mg qd
* Amiodarone 200mg qd
* Carbidopa/Levodopa 25/100mg tid
* Protonix
* Mirapex 0.5mg tid
* Senna
* Aranesp 25mcg q14 days
* Heparin SQ [**Hospital1 **]
* Lidoderm patch to left shoulder
* MVI
.
Meds on transfer from ICU:
1. Carbidopa-Levodopa (25-100) 1 TAB PO TID
2. Metronidazole 500 mg IV Q8H
3. Metoprolol 2.5 mg IV Q6H
4. Heparin 5000 UNIT SC TID
5. Mirapex *NF* 0.5 mg Oral TID
6. Insulin SC
7. Pantoprazole 40 mg IV Q24H
8. Levofloxacin 250 mg IV Q48H
9. Lorazepam 0.5-1 mg IV Q4H:PRN agitation
10. Vancomycin HCl 1000 mg IV Q48H
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Pramipexole 0.25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed.
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days. Tablet(s)
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous every eight (8) hours for 4
days.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
MRSA urosepsis
urinary tract infection
lacunar infarct
Secondary:
Parkinson's disease
hypertension
diabetes
scoliosis
Discharge Condition:
stable
Discharge Instructions:
please return to the hospital or call your doctor if you have
chest pain, shortness of breath, increased sputum production,
abdominal pain, dizziness or if there are any concerns at all
Followup Instructions:
Please call [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 3070**] to make an appointment
within 2 weeks of discharge
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 5088**]( your
neurologist) to make an appointment soon
Completed by:[**2111-1-29**]
|
[
"0389",
"486",
"40391",
"99592",
"51881",
"5845",
"5859",
"2762",
"5990",
"25000",
"2859",
"53081"
] |
Admission Date: [**2129-5-16**] Discharge Date: [**2129-6-3**]
Date of Birth: [**2052-12-16**] Sex: F
Service: MEDICINE
Allergies:
Diflucan
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
mental status changes, fever and poor po intake at home
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Mrs. [**Known lastname 9480**] is a 76 yo AA female with PMH significant for IgD
multiple myeloma diagnosed [**3-/2129**] (presented with a creatinine
of 6.8 and a calcium of 12.5), s/p plasmapheresis x 5 and pulse
steroids, also h/o parafalcine intracranial hemorrhage/seizure
who is now presents with a 4 day hsitory of generalized
weakness, fatigue, and poor po intake at home. The patient is a
poor historian and history is obtained primarily from her
husband.
Per patient's family, she had an appointment and was seen in
Heme/[**Hospital **] clinic on [**2129-5-12**]. She was in her usual state of health
until [**2129-5-13**] when she started complaining of diffuse pain not
localizing to any particular place in her body. No nausea,
vomiting, chest pain or SOB. No cough. Over the next few days
she has become progressively more confused from already poor
baseline. Family reports minimal po intake. Patient has had no
BM over the last 2-3 days. In the ED patient febrile 101.5, HR
80, BP 117/74. She was given Tylenol 650 mg daily and treated
with Kayexalate for hyperkalemia (K 5.8, Cr 3.4 up from 2.9 on
[**3-14**]). The [**Last Name (un) **]
ROS negative for melena, hematochezia, urinary complaints.
Patient at baseline has significant problems with short term
memory, ambulates with a walker. Per PCP and her family, this is
a singnificant change in her mental status and baseline.
Past Medical History:
1. IgD multiple myeloma, dignosed [**3-/2129**] when the patient
presented with actue renal failure Cr 6.8 and hypercalcemia
2. Colon CA Duke's C2 s/p resection in [**2111**]; normal C-scope in
[**2125**] except for diverticulosis
3. Thalassemia trait, microcytic anemia
4. HTN
5. Gout
6. Seizure [**2129-4-3**] [**3-2**] right parafalcine parietal hemorrhage.
Etiology for bleed was not clear as location is atypical for HTN
bleeding. There was concern for intracranial mass and the
patient was scheduled for outpatient f/u with neurosurg [**5-16**].
Has been in rehab at [**Hospital1 41724**] hospital until a few weeks prior
to this admission.
7. Polycystic kidney disease and polycystic liver disease
8. Enhancing nodule, 5 mm, within the cyst, upper pole of left
kidney
Social History:
She is married for the last 14 years. Lives with her husband.
She has two living daughters, though she had one daughter who
died because of a CNS aneurysm. Her daughter had polycystic
kidney disease. Mrs. [**Known lastname 9480**] does not smoke tobacco or alcohol
and has never done so significantly in her life. She is a
retired [**Location (un) 86**] public school administrator. She retired in [**2122**].
Family History:
Daughter had CNS aneurysm
Diabetes
Lung CA
Physical Exam:
VITAL SIGNS: 99.4, 142/80, 96, 20, 95% RA
GENERAL: chronically ill appearing female, alert, oriented to
self, place, but not date. Able to choose correct year from
three choices.
HEENT: NC, AT, sclera non-icteric, PERRL, OP clear, no lesions
NECK: Supple, with no JVD, lymphadenopathy or thyromegaly.
PULMONARY: Clear to auscultation bilaterally.
HEART: RRR, nl S1S2, no m/g/r
GI: decreased BS, soft, NT, mildly distended, marked
hepatomegaly
EXTREMITIES: 3+ lower extremity edema.
Neuro/Psych: oriented to self and place only, but selects [**2129**]
from 3 choices, poor attention, + perserverence, able to answer
some questions appropriately but at times does not make sense,
looses train of thought
Pertinent Results:
[**2129-5-16**] 07:50AM WBC-9.9 RBC-4.32 HGB-11.5* HCT-37.0 MCV-86
MCH-26.7* MCHC-31.1 RDW-16.2*
[**2129-5-16**] 07:50AM PLT COUNT-422
[**2129-5-15**] 09:54PM LACTATE-2.1*
[**2129-5-15**] 09:22PM GLUCOSE-125* UREA N-55* CREAT-3.4* SODIUM-142
POTASSIUM-5.8* CHLORIDE-110* TOTAL CO2-19* ANION GAP-19
[**2129-5-15**] 09:22PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-310* ALK
PHOS-194* AMYLASE-66 TOT BILI-0.6
[**2129-5-15**] 09:22PM LIPASE-33
[**2129-5-15**] 09:22PM NEUTS-90.7* BANDS-0 LYMPHS-7.0* MONOS-2.2
EOS-0 BASOS-0
IgD level [**5-12**] pending (60 on [**2129-4-18**])
Urinalysis:
[**2129-5-16**] 06:04AM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015
[**2129-5-16**] 06:04AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2129-5-16**] 06:04AM URINE RBC-36* WBC-38* BACTERIA-NONE YEAST-MANY
EPI-0
NCHCT [**5-16**]: Resolving hemorrhage with area of decreased
attneuation in the right medial parietal lobe. No areas of acute
hemorrhage. No evidence of acute territorial infarction or
hydrocephalus. Unchanged left parafalcine meningioma at cranial
vertex.
KUB (supine) [**5-16**]: No evidence of stool impaction. Soft tissue
masses occupying the upper abdomen displacing bowel inferiorly,
unchanged from previous study.
CXR [**5-16**]: No evidence of pneumonia.
MRI abd [**2129-3-29**]:
1. A 5 mm enhancing nodule within the 7 cm upper pole left renal
cyst, concerning for an intracystic neoplasm.
2. Numerous complex nonenhancing cystic liver lesions and
biliary ductal
dilatation in the left lobe, most likely secondary to
compressive effects of these cysts.
3. Bilateral adrenal adenomas.
4. Small ascites, bibasilar pleural effusions and compressive
atelectasis.
5. Vertebral body changes, which may be consistent with multiple
myeloma.
Brief Hospital Course:
1. C diff colitis. As part of work up for fever, the patient had
CXR on admission w/o infiltrate. WBC WNL. Urine culture did not
grow anything. The patient was empirically on Levaquin very
briefly for presumed UTI but it was discontinued when cultures
showed no growth. The patient then developed diarrhea and her
stool culture return positive for c diff toxin and she was
started on Flagyl po. She had no hisotry of recent outpatient
antibiotic use. She defervesced on Flagyl. Her abdominal exam
remained benign. CT abd/pelvis showed findings thickening of
bowel wall in the transverse, descending, sigmoid, and mildly in
the rectum that are most suggestive of colitis. The patient
diarrhea improved.
2. Multiple myeloma with leptomeningeal involvement. The patient
was noted to have urinary retention, progressive leg weakness
and decreased rectal tone. Leg weakness progressed to the point
that the patient was unable to move her legs or get out of bed.
She had MRI of the lumbar spine to evaluate for cauda equina
which revealed a nodule at L3 that enhanced with gadolinium. LP
was pursued and revealed CSF protein markedly elevated at 166,
glc normal. CSF Tube 1: WBC 58, 4P, 82L, 5M, 9% other; RBC 20.
Cytospin results returned as atypical plasmacytoid cells and
blood; suspicious for involvement by myeloma. The Radiation
Oncology and Neuro Oncology teams were consulted. The patient
also had brain, as well as T- and C- spine MRIs to evaluate for
extend of disease. The patient started radiation treatment on
[**2129-5-27**]. and was thought to be a candidate for intrathecal MTX
and ARA-C until her clinical status began to decline (see
below).
3. Mental status changes. The etiology for the patient's mental
status changes were presumed to be likely multifactorial due to
infection with c diff, dehydration, constipation. Ammonium level
was normal. Because of h/o seizures secondary to intracranial
bleed in [**2129-3-29**], EEG was pursued per suggestion of Neuro
Oncologist and revelaed increased stage II sleep concerning for
early encephalopathy.
Decadron was slowly tapered from 4 mg po daily on admission and
she was continued on Keppra. Then, on [**5-30**] patient became
minimally responsive with bp drop to low 80's sbp with transient
response to fluids. She was transfered to MICU for pressores as
patient was full code. On admission to ICU, etiology of altered
mental status and hypotension was attributed to hypovolemia +/-
?infection in addition to leptomeningeal spread of her disease.
She was placed in stress dose steroids (althoiugh her am
cortisol was 34 and adrenal insifficency was unlikley), levo/
flagly and placed on levophed. Patient found to be growing
pseudomonas in her urine. Patient expressed her desire to be
comfortable and for no agressive measure to be taken.
Eventually family meeting was held and decision to make her dnr/
dni and the CMO pending arrival of her brother from out of town.
She was then transfered back to the floor for comfort care.
3. Hyperkalemia. Likely due to worsened renal fx and
constipation. Improved.
4. Acute on chronic renal failure (Cr 2.9 on [**2129-5-12**] and 3.4 on
admission). likely combination of prerenal from poor po intake
and from nephropathy secondary to MM. The patient was originally
treated with gentle hydration.
5. Anemia. Procrit per Heme/Onc.
6. HTN. The patient has been hypotensive during this admissino.
Norvasc, Metoprolol were held. She was given IVF for BP support
and eventually was transfered to the unit (see section under
altered mental status).
7. Renal lesion seen on MRI [**2129-3-29**] concerning for malignancy
8. Metabolic acidosis - likely secondary to diarrhea, tubular
disease and inability to reabsorb bicarb, large amounts of NS
given for hydration. Metabolic disturbances were corrected with
bicarb as needed.
9. Hypernatermia. Na was as high as 150. This was presumed to be
due to free water deficit from decreased po intake. Serum Na was
slowly corrected with hypotonic IV fluids.
Medications on Admission:
Norvasc 7.5 mg [**2-2**] po daily
Dexamethasone 4 mg po daily
Prevacid 30 mg po daily
KCl 20 MEq daily
Bactrim [**1-30**] tab M, W, F
Bicitra 10 ml [**Hospital1 **]
Keppra 500 mg [**Hospital1 **]
Lopressor 100 mg [**Hospital1 **]
Nystatin 5 ml tid
Epogen 40,000 every two weeks
Fluconazole daily
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*15 Patch 72HR(s)* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: [**6-7**] mg PO Q1-2H
() as needed: titrate to comfort.
Disp:*500 mg* Refills:*1*
3. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed.
Disp:*100 Tablet(s)* Refills:*1*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: use while patient is on narcotics.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Multiple Myeloma
Discharge Condition:
Stable
Discharge Instructions:
Please let you caretaker know if you are in increasing pain or
discomfort
Followup Instructions:
Goal of care is comfort
Completed by:[**2129-6-3**]
|
[
"5990",
"5849",
"4019",
"2859"
] |
Admission Date: [**2175-11-14**] Discharge Date: [**2175-11-29**]
Date of Birth: [**2098-11-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
[**2175-11-14**] Mitral Valve Replacement (25mm St. [**Male First Name (un) 923**] Mechanical) via
right thoracotomy
Closed right thoracostomy [**2175-11-20**]
History of Present Illness:
This is a 76 year old female with history of rheumatic heart
disease. She is s/p aortic valve replacement in [**2167**]. Recent
echocardiogram revealed moderate to severe mitral regurgitation.
Recent cardiac catheterization showed normal coronaries. She
presented for redo-operation with mitral valve replacement on
[**2175-11-6**] she was brought to the Operating Room. After
intubation, she had an OG tube placed which suctioned out
approximately 30cc of coffee-ground fluid. There was concern for
GI bleed and since surgery was elective, it was cancelled.
GI was immediately consulted for an upper endoscopy. The patient
was transferred to the CVICU, remained intubated and underwent
an esophagogastroendoscopy by the GI service shortly thereafter.
This showed gastritis with Barrett's esophagus. This was treated
with proton pump inhibitors and she was discharged.She now
presents as a same day admit for surgery.
Past Medical History:
Rheumatic Valvular Disease
Barrett's Esophagus
Hypertension
Hyperlipidemia
Chronic atrial fibrillation
Neuropathy of Lower Extremities
Hemorrhoids
Arthritis
s/p aortic valve replacement(bioprosthetic) [**2167**] by Dr. [**Last Name (STitle) 38279**]
at [**Hospital3 2358**]
Hysterectomy
Bilateral Cataracts
Social History:
Last Dental Exam: Several weeks ago, cleaning performed
Lives with: husband
[**Name (NI) **]: [**Name2 (NI) 84422**]
Tobacco: denies
ETOH: rare
Family History:
Father died of heart failure at age 61
Physical Exam:
Admission:
Pulse: 79 Resp: 16 O2 sat:
B/P Right: 168/87 Left: 127/85
General: Elderly female in no acute distress
Skin: Dry [x] intact [x] - well healed sternotomy and abd
incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur - mixed systolic and
diastolic murmurs, soft
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema trace
bilaterally
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2175-11-14**] 07:30AM HGB-11.8* HCT-34.1*
[**2175-11-14**] 12:50PM GLUCOSE-102 LACTATE-1.2 NA+-141 K+-3.6
CL--103
[**2175-11-14**] 06:41PM FIBRINOGE-235
[**2175-11-14**] 06:41PM PT-15.9* PTT-29.8 INR(PT)-1.4*
[**2175-11-14**] 06:41PM PLT COUNT-164
[**2175-11-14**] 06:44PM GLUCOSE-187* LACTATE-3.1* NA+-139 K+-3.1*
CL--105
[**2175-11-14**] 08:13PM estGFR-Using this
[**2175-11-14**] 08:13PM UREA N-14 CREAT-0.5 CHLORIDE-114* TOTAL
CO2-21*
[**2175-11-29**] 06:05AM BLOOD WBC-13.7* RBC-3.01* Hgb-8.9* Hct-27.8*
MCV-92 MCH-29.6 MCHC-32.0 RDW-17.5* Plt Ct-372
[**2175-11-28**] 06:01AM BLOOD WBC-19.1* RBC-2.84* Hgb-8.5* Hct-26.1*
MCV-92 MCH-30.0 MCHC-32.7 RDW-18.0* Plt Ct-383
[**2175-11-29**] 06:05AM BLOOD Plt Ct-372
[**2175-11-29**] 06:05AM BLOOD PT-31.5* INR(PT)-3.2*
[**2175-11-28**] 06:01AM BLOOD PT-28.7* INR(PT)-2.8*
[**2175-11-28**] 06:01AM BLOOD UreaN-20 Creat-0.7 K-3.9
[**2175-11-25**] 04:19AM BLOOD Glucose-118* UreaN-21* Creat-0.6 Na-139
K-3.6 Cl-100 HCO3-31 AnGap-12
Radiology Report CHEST (PA & LAT) Study Date of [**2175-11-27**] 10:14
AM
Final Report
REASON FOR EXAMINATION: Followup of the patient after mitral
valve
replacement with elevated white blood cells.
PA and lateral upright chest radiographs were compared to
[**2175-11-25**].
The right PICC line tip is at the level of mid SVC. The replaced
aortic and mitral valves are in unchanged position. The right
pleural effusion which is partially loculated with adjacent area
of atelectasis did not change in the interim. There are no areas
of consolidation worrisome for newly developed infectious
process. No pneumothorax is demonstrated.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
TEE (Complete) Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Stroke Volume: 62 ml/beat
Left Ventricle - Cardiac Output: 3.80 L/min
Left Ventricle - Cardiac Index: *1.98 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *1.3 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-13**] T): 2.0 cm2
TR Gradient (+ RA = PASP): *46 to 50 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
AORTIC VALVE: AVR leaflets move normally. Thickened AVR
leaflets. Cannot exclude AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Partial mitral leaflet flail. Mild valvular MS (MVA 1.5-2.0cm2).
Moderate to severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Severely thickened/deformed tricuspid valve leaflets. No TS.
Moderate to severe [3+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre Bypass: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
aortic valve prosthesis leaflets appear to move normally. The
prosthetic aortic valve leaflets are thickened. The study is
inadequate to exclude significant aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is partial mitral leaflet flail.
There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The tricuspid
valve leaflets are severely thickened/deformed. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion. RV function mildly depressed at baseline, improved on
milrinone infusion.
Post Bypass: Patient is in atrial fibrillation (baseline rhythm)
on Milrinone and Phenylepherine infusions. Preseved
biventricular function. LVEF >55%. A mechanical mitral valve
prosthesis is in situ with peak gradient 8, mean 4 mm Hg normal
washing jets and a small, stable, perivalvular leak. Aortic
prosthesis is unchanged from baseline. Aortic contours intact.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD,
Brief Hospital Course:
[**First Name8 (NamePattern2) **] [**Known lastname 84423**] was a same day admit and underwent a Mitral Valve
Replacement via right thoracotomy on [**11-14**]. Please see operative
note for surgical details. Following surgery she was transferred
to the CVICU for invasive monitoring on Milrinone, Epinephrine
and Neosynephrine She was tacchycardic to the 140s with good
cardiac function. Despite weaning off the Epinephrine and small
doses of beta blockers, her heart rate remained rapid and her BP
was lower with the fast rate. The Milrinone was then weaned and
stopped with the heart rate falling into the 110-120 range.
Amiodarone and beta blockers did not slow her ventricular
response adequtely and eventually Digoxin was given with a drop
in the rate to below 100. She remained stable. She was
extubated during this time without incident.
She became hypertensive postoperatively and required a
nitroglycerin drip. She had pauses after digoxin loading and a
heart rate in the 50's. Digoxin was stopped, EP was consulted
and Lopressor was held until her heart rate improved. Lopressor
was added back and eventually converted to Atenolol with
reasonable heart rate control in the 80-90s. Chest tubes were
removed per cardiac surgery protocol.
Ms. [**Known lastname 84423**] was started on anticoagulation for chronic atrial
fibrillation and the mechanical mitral valve. She was started on
Coumadin and then a Heparin drip on postoperative day 3 at
midnight. She was therapeutic on Heparin and Coumadin. On
postoperative day 6 she developed guaiac positive stools. A
chest xay was done which showed a right hemothorax. A chest
tube was placed which drained 1.9 L dark red fluid. She was
hemodynamically stable throughout this. She was transfused with
2 units of packed red blood cells and serial hematocrits were
done. Hematocrit remained stable at 26. CXR showed improvement
of the effusion with a moderate lateral residual component on
[**11-21**]. Coumadin was restarted with INR 2.2. She was
transferred to the floor in stable condition.
Once on the floor her activity level was advanced. A PICC line
was placed on [**11-22**] and the triple lumen catheter was removed
from the jugular vein. A CXR demonstarted some improvement in
the aeration of the right lung but a persisitent loculated
effusion. The CT was removed per Dr. [**Last Name (STitle) **]. She continued to
make slow improvement while awaiting her INR to become
therapeudic. During this period she
was noted to have an elevated white blood cell count, she was
pan cultured and all cultures returned negative. Her right groin
cannulation site had slight erythema and she was begun on Keflex
with a resultant downward trend of her white cell count. On POD
15 she was discharged home with visiting nurses. INR levels and
Coumadin dose adjustments to be followed by Dr [**First Name (STitle) 24344**]
Medications on Admission:
Atorvastatin 10 mg daily
Furosemide 80 mg daily
Gabapentin 300 mg AM,600mg 1600,600my 2200
Isosorbide Dinitrate 30 mg daily
Colchicine 0.6 mg DAILY
Losartan 25 mg daily
Pantoprazole 40 mg [**Hospital1 **]
Metoprolol Tartrate 50 mg [**Hospital1 **]
Ciprofloxacin 500 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day:
take 80mg [**Hospital1 **] x10 days then 80mg QD.
Disp:*60 Tablet(s)* Refills:*1*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
12. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
take 6mg on [**11-29**] and [**11-30**] then as directed by Dr [**First Name (STitle) 24344**].
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Mitral Regurgitation
s/p Mitral valve replacement
Rheumatic Valvular Disease
Hypertension
Hyperlipidemia
Chronic atrial fibrillation
Neuropathy of Lower Extremities
Hemorrhoids
Arthritis
s/p 21mm AVR (bioprosthetic) [**2167**] by Dr. [**Last Name (STitle) 38279**] at [**Hospital3 **]
s/p Hysterectomy
Bilateral Cataracts
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever of greater then 100.5
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
Shower daily. Wash wound with soap and water. No lotions, creams
or pwoders to incision until it has healed.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month from date of surgery and taking
narcotics.
Please call with any questions or concerns.
take all medications as directed
Followup Instructions:
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks-nurses to schedule prior to
discharge
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) **] in [**1-13**] weeks ([**Telephone/Fax (1) 31529**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24344**] in [**2-14**] weeks [**Telephone/Fax (1) 77061**]
Please call providers for all appointments
Completed by:[**2175-11-29**]
|
[
"2762",
"4019",
"42731",
"V5861",
"2724",
"42789",
"2875"
] |
Admission Date: [**2150-2-22**] Discharge Date: [**2150-2-26**]
Date of Birth: [**2068-6-26**] Sex: M
Service: SURGERY
Allergies:
Flurazepam
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
lower back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81M retired internist w/ PMH of diverticulitis, afib on coumadin
c/o lower back pain x 3 wks.
Lower back pain described as constant, band-like, not relieved
by
anything. Pt denied abdominal pain. In addition, he had
persistent diarrhea x 1 wk (2-3x/day) - non-bloody. Mild
confusion noted by daughter during that week. Denies f/c/n/v.
Denies sick contact.
Of note, pt accidentally took extra coumadin yesterday (4mg
instead of usual 2mg). Noted epistaxis today but was able to
stop
it. Denies hematuria.
Past Medical History:
ischemic cardiomyopathy
afib w/ complete heartblock
s/p single chamber ICD [**3-19**]
s/p CABG, MVR (porcine) '80s
CVA '80s
sacral decubitius
depression
diverticulitis (no OR)
s/p subtotal gastrectomy, splenectomy for bleeding DU '70s
Social History:
former smoker, quit 30 yrs ago (<1ppd x 20 yrs)
former ETOH, quit 10 yrs ago
denies IVDU
retired internist at [**Hospital1 1559**]
Family History:
noncontributory
Physical Exam:
At Discharge:
Vitals: 97.8, 66, 108/60, 24, 99% on RA
GEN: NAD, A/Ox3
CV: RRR
RESP: CTAB
ABD: soft, NT/ND, +BS, +flatus, Loose stools
Sacral-two small pin-point stage 2 ulcers-duoderm gel &allovyne
dressing
Skin: emaciated, macular rash across back and back or LE's.
Extrem: no c/c/e
Pertinent Results:
CT PELVIS W/O CONTRAST Study Date of [**2150-2-21**] 11:16 PM
IMPRESSION:
1. Acute sigmoid diverticulitis. A small air collection along
the inferior
aspect of the sigmoid colon and dome of the bldder may represent
a large
diverticulum or a contained perforation. No drainable fluid
collection is
seen.
2. Noncontrast evaluation of the aorta demonstrated mild
atherosclerotic
changes without aneurysm.
3. Mild T12 compression deformity, of unknown chronicity.
.
[**2150-2-21**] 08:40PM BLOOD PT-150* PTT-64.3* INR(PT)-22.3*
[**2150-2-22**] 03:41AM BLOOD PT-150* PTT-70.5* INR(PT)-27.4*
[**2150-2-22**] 02:52PM BLOOD PT-20.8* PTT-35.1* INR(PT)-2.0*
[**2150-2-24**] 07:40AM BLOOD PT-16.9* PTT-31.8 INR(PT)-1.5*
[**2150-2-21**] 08:40PM BLOOD Glucose-108* UreaN-32* Creat-1.8* Na-140
K-3.2* Cl-100 HCO3-25 AnGap-18
[**2150-2-22**] 03:41AM BLOOD Glucose-103 UreaN-27* Creat-1.4* Na-139
K-2.7* Cl-103 HCO3-22 AnGap-17
[**2150-2-22**] 02:52PM BLOOD Glucose-111* UreaN-21* Creat-1.1 Na-142
K-3.6 Cl-105 HCO3-25 AnGap-16
[**2150-2-24**] 07:40AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-138
K-3.5 Cl-106 HCO3-27 AnGap-9
[**2150-2-21**] 08:40PM BLOOD ALT-10 AST-22 AlkPhos-144* TotBili-0.4
[**2150-2-21**] 08:40PM BLOOD Lipase-32
[**2150-2-21**] 08:40PM BLOOD Albumin-3.4 Calcium-9.9 Phos-2.3* Mg-2.4
[**2150-2-22**] 03:41AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
[**2150-2-23**] 08:00AM BLOOD Calcium-9.2 Phos-1.8* Mg-2.1
[**2150-2-24**] 07:40AM BLOOD Calcium-8.4 Phos-1.3* Mg-1.9
[**2150-2-21**] 08:40PM BLOOD Digoxin-1.7
[**2150-2-24**] 07:40AM BLOOD Digoxin-1.6
[**2150-2-21**] 08:40PM BLOOD WBC-16.2* RBC-4.00* Hgb-11.6* Hct-35.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-16.0* Plt Ct-462*
[**2150-2-22**] 03:41AM BLOOD WBC-23.1* RBC-3.62* Hgb-10.6* Hct-31.5*
MCV-87 MCH-29.3 MCHC-33.6 RDW-16.0* Plt Ct-427
[**2150-2-23**] 02:57AM BLOOD WBC-12.8* RBC-3.51* Hgb-10.7* Hct-31.2*
MCV-89 MCH-30.4 MCHC-34.2 RDW-16.2* Plt Ct-383
[**2150-2-24**] 07:40AM BLOOD WBC-14.7* RBC-3.37* Hgb-9.7* Hct-29.9*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.3* Plt Ct-343
Brief Hospital Course:
[**Date range (1) 82049**]-Mr. [**Known lastname **] presented to [**Hospital1 18**] with complaints of back
pain. He was found to have a tender abdomen upon exam. He
underwent CT scan and was noted to have diverticulitis. In
addition, his INR was elevated to 22.3 at admission due to
accidentally ingestion of addtiontal Coumadin per patient. Due
to INR level, dehydration related to diarrhea at home as
evidence by increased creatinine to 1.8, the patient was
admitted to General surgery service for possible surgical
management of diverticulitis. The patient was transferred to
SICU from ED due to profound dehydrated status, and semi-acute
appearance. He was resusciated with IV fluid. Given Vitamin K
and Frozen plasma to reverse INR. His clinical appearance
improved with hydration, and abdomen appeared less tender.
Patient's Cardiologist was consulted due to his extensive
cardiac history. He remained stable, surgical intervention was
not imminently required. Patient was transferred to Stone 5 for
continued monitoring.
.
[**2-24**]-Due to extensive Psychsocial issues following services
consulted: Speech/Swallow to rule out aspiration, Physical
Therapy to assess safety for discharge. Geriatrics due to
medication errors and multiple concerns posed by patient's
daughter whom he lives with including lack of appetite, mis
management of medications, safety at home, and changes in
cognitive status, voice, speech. Social Work consulted to offer
resources/supports. Cardiology continues to follow patient.
Coumadin discontinued. Patient started on baby aspirin.
.
[**2-25**]-Screened for REHAB to continue physical therapy, assessment
of nutritional status/hydration, aspiration precautions, and
assessment of post-Rehab disposition. In addition, patient will
require follow-up with geriatrics, ENT for voice evaluation, and
further evaluation of back pain. Dr. [**Last Name (STitle) **] should be
contact[**Name (NI) **] primarily regarding any concerns regarding this
patient's ongoing care. The patient should continue with
Cipro/Flagyl for total of 2 weeks to treat diverticulitis.
Contact Dr. [**Last Name (STitle) **] with concerns regarding abdominal pain,
etc.
Medications on Admission:
coumadin 2mg daily
lasix 20mg daily
digoxin 0.125 daily
avapro 150mg daily
ambien 10mg daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever or pain for 10 days: Do not
exceed 4000mg in 24hrs .
Discharge Disposition:
Extended Care
Facility:
Aberjona
Discharge Diagnosis:
Primary:
Hypercoagulopathy
Acute Renal Failure due to dehydration and diarrhea
Acute diverticulitis
Sacral decubitus ulcer
Malnutrition
.
Secondary:
Decreased in cognition-possible early dementia
ischemic cardiomyopathy (EF unknown)
afib w/ complete heartblock s/p single chamber ICD [**3-19**]
CAD s/p CABG and MVR (porcine) in [**2121**]
CVA [**2121**]
depression
diverticulitis (non-operative)
s/p subtotal gastrectomy and splenectomy for bleeding DU in
[**2111**]
Discharge Condition:
Stable
Tolerating low residue regular, pureed diet with thick liquids.
Back pain well controlled with oral medication
Discharge Instructions:
REHAB Instruction:
Please call or return to the ER for any of the
following:
* New chest pain, pressure, squeezing or tightness.
* New or worsening cough or wheezing.
* vomiting and cannot keep in fluids or your medications.
* dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* 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.
* Continue to ambulate several times per day.
.
Nutrition:
-Continue soft dysphagia diet. Continue assessing patient's
swallowing, adjust diet as tolerated. Continue aspiration
precautions.
.
Medications:
-Continue PO Flagyl and Cipro for another 13 days to treat
diverticulitis.
.
Coagulation management:
-Dr. [**Last Name (STitle) **] has discontinued the Coumadin. The patient was
started on a baby aspirin during this admission. Please continue
this medication as prescribed.
.
Out-patient follow-up:
-Patient requires follow-up with Geriatrics, Nutrition, ENT, &
Back pain.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in [**2-17**]
weeks or as needed.
2. Follow-up with your Cardiologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],([**Telephone/Fax (1) 3942**] in [**1-16**] week.
3. Follow-up with Gerontologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 719**] in [**1-16**] week.
***Please arrange for out-patient Nutrition management, and ENT
consultation for evaluation of speech/voice changes.
.
Previous appointments:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-7-6**] 12:40
Completed by:[**2150-2-25**]
|
[
"5849",
"42731",
"V5861",
"V4581"
] |
Admission Date: [**2107-3-7**] Discharge Date: [**2107-3-22**]
Date of Birth: [**2047-5-25**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**Known lastname 668**]
Chief Complaint:
esrd
Major Surgical or Invasive Procedure:
living non-related renal transplant [**2107-3-8**]
History of Present Illness:
59 y.o. female with ESRD who dialysis M-W-F using Left arm loop
graft presents for LURT. She is on coumadin which she stopped on
[**3-5**]. Last dialyzed today to her dry weight of 124 kg.
Past Medical History:
ESRD (diabetic nephropathy) on HD for the last 9 months
DM2 x 30yrs with subsequent nephropathy, retinopathy, neuropathy
HTN
CAD s/p 3v CABG in [**10/2103**]
Hyperlipidemia
PVD with several toe amputations; s/p bilateral leg
revascularization in [**2098**]
Remote hx of skin cancers on back and face
Social History:
Smokes 1 ppd x 30 yrs, denies heavy EtOH, denies drugs incl
IVDU. On disability
Family History:
Father died of bulbar palsy, mother died of MI.
Physical Exam:
99 90 127/63 24 95% wt 124kg
NAD, lying in bed
oral mucosa pink/moist, dentition okay, no pharyngeal reness or
exudate
lungs CTA, bilaterally
Cards-+femoral pulses
Card-RRR, no m/r/g noted. 2+ pedal and radial pulses
abd-soft, non-tender, obese. +BS
ext-1+ LE edema bilaterally. +bruit/thrill in Left arm AVG loop
skin-warm&dry
Pertinent Results:
[**2107-3-7**] 03:20PM PT-18.1* PTT-30.9 INR(PT)-1.7*
[**2107-3-7**] 03:20PM PLT COUNT-217
[**2107-3-7**] 03:20PM WBC-6.0 RBC-4.03* HGB-13.0 HCT-39.4 MCV-98
MCH-32.4* MCHC-33.1 RDW-15.7*
[**2107-3-7**] 03:20PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-2.4*#
MAGNESIUM-1.5*
[**2107-3-7**] 03:20PM ALT(SGPT)-16 AST(SGOT)-17
[**2107-3-7**] 03:20PM estGFR-Using this
[**2107-3-7**] 03:20PM UREA N-19 CREAT-3.1* SODIUM-141 POTASSIUM-3.8
CHLORIDE-96 TOTAL CO2-35* ANION GAP-14
[**2107-3-7**] 09:15PM PTT-45.0*
Brief Hospital Course:
She was admitted the night prior for IV heparin given h/o of
CABG/leg bypass for which she was on coumadin. She was also
dialyzed the day of admission. Heparin was stopped preop. She
underwent living unrelated renal transplant on [**2107-3-8**] by Dr.
[**Known lastname **] [**Last Name (NamePattern1) **]. Intraop after arterial anastomosis, "The kidney
filled up with blood but remained somewhat dusky and
bluish-appearing." IV fluid bolus was given to improve BP and
Neo-Synephrine was given, but this didnot make any substantial
improvement. TheBookwalter retractors were adjusted and "this
appeared to take some compression off the right-sided iliac
artery and dramatically improved flow to the kidney which then
pinked-up immediately." Cardiac, she was transferred to the ICU
post-op because she was having hypotension in the recovery room
which she was started on levophed. She was then weaned off of
levophed by the AM of POD 1 and did not require pressors for the
rest of her hospitalization. On POD 3 she was started on
lopressor low dose due to her cardiac history and she was
re-started on her aspirin. Renally she had low urine output and
early impaired graft function. On POD 4 she had a renal
ultrasound that showed loss of diastolic flow consistent with
ATN. On POD 8 she had a kidney biopsy done. The pathology was
not finalized at time of discharge.
GI: She tolerated a regular diet but by POD 7 she still had not
had a bowel movement and she even started to have some bilious
emesis. She was started on an aggressive bowel regimen with
gastrograffin enemas, and go-lytley. She finally had several
bowel movements on POD 12 when she was given lactulose. When
she was straining her bowels she had some leakage of blood from
her wound. At CT scan was done revealing a fluid collection in
the left flank inseparable from the small bowel. Subcutaneous
hematoma anteriorly in the pelvis with intact underneath fascia.
There was no bowel obstruction.
She was discharged home in stable condition with persistent
difficulty moving her bowels. Vital signs were stable.
Creatinine had decreased to 4.5. Urine output for 24 hours was
400cc.
Medications on Admission:
coumadin 5 QD: Last dose 3/31, Lyrica 75', Phos-Lo 667 2 tabs q
meals, Lisinopril 40', Effexor XR 150', Renal Cap', Protonix
40', Toprol 50', Lipitor 20', Ambien 10'hs, Aspirin 81', colace
100', Insulin N 4units breakfast/dinner, Novolog SS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain medication. stop if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD ().
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 * Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Take in AM.
Disp:*30 Tablet(s)* Refills:*0*
14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO twice a day.
16. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day: Take at lunchtime.
Disp:*2 bottles* Refills:*2*
17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous four times a day: Please follow Printed
sliding scale.
Disp:*2 bottles* Refills:*2*
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
esrd
delayed graft function
depression
Discharge Condition:
good
Discharge Instructions:
Please call transplant office if fevers, chills, nausea,
vomiting, inability to take medications, incision
red/bleeding/draining, decreased urine ouptut, shortness of
breath or increased edema
Labs every Monday and Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, albumin, urinalysis, and trough prograf
level. fax to [**Telephone/Fax (1) 697**]
No driving while taking pain medications. [**Month (only) 116**] shower, pat
incision dry.
No heavy lifting (nothing >10lbs.)
Measure and record JP drain output. Bring record to clinic with
you
Followup Instructions:
[**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-3-24**] 10:40
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-3-28**] 1:00
Provider: [**Known lastname **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-4-4**] 2:00
Completed by:[**2107-3-22**]
|
[
"40391"
] |
Admission Date: [**2200-3-7**] Discharge Date: [**2200-3-21**]
Date of Birth: [**2120-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Recurrent SOB and Cough.
Major Surgical or Invasive Procedure:
1) Intubation and Mechanical Ventilation.
2) Cardiac Catheterization.
History of Present Illness:
80M recently emigrated from [**Country 3992**] admitted here [**Date range (1) 39348**] for
dyspnea, productive cough, and profuse sweats. Dx with
multi-lobar community acquired PNA, treated with levofloxacin.
Pt returned 3 days after discharge on [**3-7**] with [**Month/Year (2) 9140**]
productive cough, SOB, anorexia. No fever/chills/chest pain. Per
son, patient also with increased frequency of urination, but no
dysuria, hematuria. No sick contacts.
Patient's recent hospitalization from [**Date range (1) 39348**] complicated by
mild CHF, Zoster on his right buttock, and acute gout of the
right knee. He was also placed in isolation and had 3 successive
negative smears for AFB due to concern for MTB infection (CT
showed apical scarring and evidence of granulomatous disease).
AFB cultures were still pending at the time of his discharge,
but his PPD had been negative.
ED Course: Upon admission on [**3-7**] patient was found to be
signficantly hypoxic (80% RA) and was intubated in the ED. He
was also hyponatremic to 119 which was thought [**1-29**] pulmonary
SIADH from infection, and was corrected with 3% hypertonic
saline.
Past Medical History:
Possible Prior Pulm TB, Severe AI, HTN, CHF (EF 35-40% in
[**11-30**]), "Other Heart Condition" (Dx in [**Country 3992**] and cured with
Chinese Herbs), "Stomach Problem", Gout, Asbestosis, Recent
Hyponatremia (Likely Via Pulm SIADH).
Social History:
Born in [**Country 3992**]. Never smoked. Previous heavy ETOH use. No
drugs. Retired belt maker.
Family History:
Non-contributory.
Physical Exam:
T100 BP200/140--> 150/63 HR112-->90 RR35 O2sat 80% RA (100%,
intubated)
GEN - intubated and sedated
HEENT - Pupils 2mm bilat, minimally reactive. Frothy secretions
at mouth., ETT in place
RESP - Coarse breath sounds at left/mid lung. Decreased breath
sounds at base. No wheezes.
CV - RR. III/VI diastolic murmur at USB.
ABD - Soft/NT/ND. bowel sounds present
EXT - 1+ pitting edema LE bilaterally, hands/feet are cool/dry
skin- patches of redness (from "coining") over shoulders and
upper chest
Pertinent Results:
[**2200-3-7**]
WBC-9.3 HGB-12.3* HCT-37.6* MCV-89 PLT COUNT-775*
NEUTS-71.4* LYMPHS-21.8 MONOS-6.1 EOS-0.3 BASOS-0.5
SODIUM-118* POTASSIUM-4.4 CHLORIDE-84* TOTAL CO2-24 UREA N-8
CREAT-0.8 GLUCOSE-141* ANION GAP-10
CALCIUM-7.7* MAGNESIUM-1.9 PHOSPHATE-2.6*
CK(CPK)-291* CK-MB-8 cTropnT-0.01
AMYLASE-58
LACTATE-3.2*
PH-7.14* PCO2-75* PO2-454* CO2-27 BASE XS--5 AC 350/25/5/1.0
PH-7.36 PCO2-43 PO2-147* CO2-25 BASE XS--1 AC 440/25/5/0.6
URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
Sputum Cx [**2199-3-3**]: 3+ GPC in pairs and clusters, 2+ GNR
[**2200-3-1**] HIV negative
EKG: ST @113, LVH, ?ST depression/TWI in inferior leads.
CXR: (prelim) multifocal infiltrates
CTA: (prelim) No PE. Mild [**Month/Day/Year 9140**] of right lower lobe
opacities. Left lower lobe opacities are stable.
Brief Hospital Course:
Mr [**Known lastname 59697**], who recently returned from [**Country 3992**] and had a recent
[**Hospital1 18**] admission (treated for CAP) was initially readmitted this
hospital with impending respiratory failure and multifocal
pneumonia by chest imaging. He was intubated, started on
mechanical ventilation (MV), and admitted to the ICU. He was
again treated for infectious pneumonia with broad-spectrum
antibiotics and was eventually weaned off mechanical ventilation
and then did well on room air.
1) Hosp-Acquired PNA (HAP): As above, the patient had a
pneumonia (and required mechanical ventilation on admission)
which was treated as HAP as above: Vancomycin and Zosyn. He had
four successive negative AFB sputum samples on his previous
admission, but the time of this admission, the cultures had
grown out AFB (which were eventually isolated as MAC, and not
TB). Thus, given his chronic lung disease, the MAC was believed
to be only a colonizer of his lungs and not contributing the
acute process. Nevertheless, before AFB organism identification
returned, he was empirically treated for tuberculosis with
mutli-drug therapy. Although preliminary lab data indicated MAC,
the final results would not return for several months. Thus, he
was discharged on multi-drug therapy for empiric TB treatment.
Of note, given his recent travel to [**Country 3992**] and the new history
of direct chicken exposure, there was an initial concern for
Avian influenza. After speaking with the ID team, this concern
was later put to rest. Upon extubation, the patient required
low-level supplemental oxygen and eventually was stable on room
air.
2. Aortic Regurgitation/HTN: The patient had known severe AR and
a depressed EF. Per his family, he did not want to know the
extent of his heart disease, despite the possibilty of
benefiting form AVR. He was continued on afterload reduction and
BP control with Lisinopril, Amlodipine, and Metoprolol. Of note,
the patient had new anterior ST elevations while in the ICU, on
MV. He was urgently taken to for cardiac catherization and had
multiple sets of negative cardia enzymes. Cardiac cath showed
clean coronary arteries and confirmed his noted heart findings
(re: AI) as on ECHO.
5. Anemia: His HCT was stable in the low 30's. He had a few
episodes of heme-positive stool during this hospital stay and
reported chronic loose stools. Outpatient colonoscopy was
recommended. The etiology of the anemia was likely acombination
of iron deficiecny (iron was 12), inflammatory anemia and
possible chronic low-level hemolysis given severe AI. He was
started on Folic Acid empirically.
6. Hyponatremia: The patient had low serum sodium on his
previous admission, which was consistent with pulmonary SIADH.
Again, on admission he had low serum sodium (119). This improved
with fluid restriction and the treatment of his pneumonia.
Medications on Admission:
Amlodipine 5mg qd
Lisinopril 40mg qd
Ranitidine 150mg [**Hospital1 **]
Levaquin 500mg qd (1 day left)
Valacyclovir 1g tid (1 day left)
Ibuprofen 600mg q6h
Robitussin prn
Chinese herbal medicine
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*2 inh* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*0*
9. Ethambutol HCl 400 mg Tablet Sig: 2.5 Tablets PO once a day:
Please take 1000 mg PO DAILY.
Disp:*75 Tablet(s)* Refills:*0*
10. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Pyrazinamide 500 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Pyridoxine HCl 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
13. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*0*
14. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1) Hospital-Acquired Pneumonia.
Secondary Diagnosis:
2) Likely Mycobacterial (MAC) Lung Colonization.
3) Severe Aortic Regurgitation.
4) Congestive Heart Failure.
5) Hypertension.
Discharge Condition:
Fair/Stable.
Discharge Instructions:
1) Please call your doctor or return to the emergency room if
you have any shortness of breath, fevers, chills, trouble
breathing, sweats, or any other concerning symptoms.
2) Please take your medications as instructed.
3) You likely have a chronic infection of the lung from an
organism called MAC. This infection is similar to tuberculosis,
but it is not the same. At this time, you do not need to be
treated for MAC. As an outpatient, you will be seen by
infectious disease doctor and a pulmonary (lung) doctor, who
will evaluate this lung infection.
4) There is a small chance that you have tuberculosis in your
lungs now. We will know the answer to this in the next three to
four weeks, once the final sputum culture results are available.
Because there is a chance you have tuberculosis, you will
continue to take the anti-tuberculosis medications (Ethambutol,
Isonniazid, Pyrazinamide, Pyridoxine, and Rifampin) for the next
three to four weeks. They can be stopped once we can rule out
tuberculosis definitively. Your new infectious disease doctor
(Dr. [**Last Name (STitle) 17444**] will guide you at your next visit.
5) Regardless of the results of the pending sputum studies, your
family members are not at risk for becoming infected with your
current disease. They do not need wear a mask around you. Since
your immediate family members had recent normal chest x-rays and
PPDs prior to arriving to the United States (nine months ago),
it is not necessesary to repeat these now. If they have further
questions, they should speak to their doctors.
Followup Instructions:
1) Please see your primary doctor (SMALL,[**Doctor Last Name **] [**Telephone/Fax (1) 59698**])
on Tuesday, [**3-25**] at 1:45PM at [**Street Address(2) 59699**] in
[**Last Name (un) 813**], MA. Your SMA10 (electrolytes and kidney function tests),
urinalysis along with your CBC (blood counts) should be checked
during that visit. Dr. [**Last Name (STitle) 4460**] will also decide what medication to
use for your gout. She may change your colchicine to
allopurinol. She was also evaluate your need for continuing
Terazosin. You may be able to discontinue this medication once
you see her.
2) Please see the Pulmonary doctors [**First Name (Titles) **] [**Last Name (Titles) 18**] ([**Telephone/Fax (1) 612**]) for
an evaluation of your lung disease and possible MAC infection
for the following appointment:
[**4-21**] at 1030 AM with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 58318**] on the [**Hospital1 18**] [**Hospital Ward Name 5074**] on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building, in the
Pulmonary (Lung) Clinic.
3) Please see your new infectious disease doctor [**First Name (Titles) **] [**Last Name (Titles) 18**] for
the
following appointment:
Please see Dr [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 59700**], MD. Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-4-10**] 11:004)
3) Here is a list of your other appointments:
Provider [**Month/Day/Year **] Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2200-4-7**] 10:00
Provider [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2200-4-14**] 10:40.
|
[
"51881",
"4280",
"4241",
"4019",
"2859"
] |
Admission Date: [**2156-3-5**] Discharge Date: [**2156-3-8**]
Date of Birth: [**2081-5-9**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 y/o woman who writes with her right hand but does most other
things with her left presented today from [**Hospital3 **] s/p
tPA for right MCA syndrome. She was in her normal state of
health ( which according to her daughter is active, lives alone,
has no issues) until about 11:15 am when she was found on the
ground. The last time she was seen in her normal condition was
about 1 hour prior. She was alert, oriented, with an agnosia to
her florid left sided weakness. At OSH she was noted to have
virtually no movement of the left side with eye deviation to the
right. TPA was given after a CT scan showed hyperdense right MCA
(distal) and no bleed. After the tPA she was note dto be
obtunded, eyes closed and not responding. There are various
reports on this where someone noted that this happened
spontaneously and by EMS report here in the ED at [**Hospital1 **] they states
that she was given IV Ativan and then became
lethargic. These events however are not mentioned in the notes
that accompany her. Here in the ED she was very lethargic with
eyes closed, could not hold open her lids and was very
dysarthric. She had no acute complaints when I asked her.
Past Medical History:
HTN
HLD
AF discovered 2 weeks prior to admission and not anticoagulated
Had recent aspiration of a pancreatic cyst
TIA in [**2134**] (had left CEA in [**2134**])
R carotid reported to be 75% narrow.
Social History:
Denies tobacco, etoh, other drugs. Lives on her own. She is
active likes to go ball room dancing.
Family History:
Multiple family members in [**Name (NI) 4754**] with strokes. Daughter
mentioned grandmother, and various aunts and uncles of the
patient.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.6 P:70 R: 16 BP: 140/70 SaO2:96% 2L
General: lethargic, NAD.
HEENT: NC/AT, MMM.
Neck: Supple
Pulmonary: Lungs CTA bilaterally frontal fields
Cardiac: RRR
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: cherry angiomas.
Neurologic:
-Mental Status: Lethargic, cant keep her eyes open. Able to tell
me her name, her handedness, the date accurately. She is very
dysarthric, minimal speech output given lethargy. No paraphasic
errors noted. She has a right gaze deviation that I cant
overcome. She is not neglecting the left side.
-Cranial Nerves:
I: Olfaction not tested.
II: pupils pinpoint, reactive.
III, IV, VI: Left gaze dev.
V: not tested.
VII: left facial droop.
VIII: hearing decreased b/l.
IX, X: not tested.
[**Doctor First Name 81**]: not tested.
XII: not tested.
(not tested)* lethargic and will be tested later.
-Motor:
Left side: Arm antigravity with antigravity movement of the
biceps and triceps. Her IP is 2+ to 3-. She is able to flex and
extend at the knee with her heel on the bed. TA was 3. Right
side: Full at the upper and lower extremity. Lethargic and some
limitation to testing based on effort.
-DTRs: 2 at the biceps triceps. Right knee is 3+ and left knee
2. none at the ankles. Plantar response was extensor
bilaterally.
-Coordination:not tested.
-Gait: not tested .
.
.
Discharge Physical Exam:
AOx3 recalls [**3-13**] words, no visual or sensory inattention and
performs line bisection normally. Slight left NLF flattening and
no oethr cranial nerve deficits. Left pronator drift with left
arm>leg weakness and 4+/5 in shoulder abdiction and extensors
and [**5-15**] in flexors in arm and IP 4+/5 and otehrwise [**5-15**] in left
leg. Left extensor plantar with withdrawal on right. No sensory
deficits. No ataxia.
Pertinent Results:
Laboratory invetsigations:
[**2156-3-5**] 06:14PM BLOOD WBC-8.0 RBC-4.91 Hgb-14.8 Hct-43.4 MCV-88
MCH-30.2 MCHC-34.2 RDW-13.1 Plt Ct-206
[**2156-3-5**] 06:14PM BLOOD Neuts-80* Bands-0 Lymphs-18 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-3-5**] 06:14PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Ellipto-OCCASIONAL
[**2156-3-6**] 02:05AM BLOOD PT-11.3 PTT-22.9* INR(PT)-1.0
[**2156-3-5**] 06:14PM BLOOD Glucose-104* UreaN-9 Creat-1.0 Na-140
K-4.1 Cl-105 HCO3-20* AnGap-19
[**2156-3-6**] 02:05AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 Cholest-190
.
Other pertinent labs:
[**2156-3-7**] 06:05AM BLOOD ALT-23 AST-28 AlkPhos-124* TotBili-0.7
[**2156-3-5**] 07:55PM BLOOD cTropnT-<0.01
[**2156-3-6**] 02:05AM BLOOD %HbA1c-6.1* eAG-128*
[**2156-3-6**] 02:05AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 Cholest-190
[**2156-3-6**] 02:05AM BLOOD Triglyc-78 HDL-48 CHOL/HD-4.0 LDLcalc-126
[**2156-3-6**] 02:05AM BLOOD TSH-2.7
[**2156-3-7**] 06:05AM BLOOD Digoxin-1.9
[**2156-3-5**] 06:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge labs:
[**2156-3-8**] 05:35AM BLOOD WBC-11.1* RBC-5.21 Hgb-15.2 Hct-42.1
MCV-81* MCH-29.1 MCHC-36.1* RDW-13.3 Plt Ct-242
[**2156-3-8**] 10:55AM BLOOD PT-11.5 PTT-70.8* INR(PT)-1.1
[**2156-3-8**] 05:35AM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-133
K-4.1 Cl-97 HCO3-26 AnGap-14
[**2156-3-8**] 05:35AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
.
.
Urine:
[**2156-3-5**] 05:42PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.023
[**2156-3-5**] 05:42PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2156-3-5**] 05:42PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2156-3-5**] 05:42PM URINE Mucous-RARE
[**2156-3-8**] 09:43AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2156-3-8**] 09:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
[**2156-3-5**] 05:42PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Microbiology:
[**2156-3-8**] URINE URINE CULTURE-PENDING
.
.
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2156-3-5**] 4:39 PM
NON-CONTRAST HEAD CT: Evaluation for hemorrhage is somewhat
limited due to
recent contrast bolus four hours prior, though no definite
hemorrhage is
identified. There is no shift of the usually midline structures.
Suprasellar
and basal cisterns are widely patent. No mass or mass effect is
evident.
There is subtle loss of [**Doctor Last Name 352**]-white matter differentiation in the
right insular
ribbon, findings concerning for right MCA territory infarction.
MRI with
diffusion is recommended for increased sensitivity for
detection. The
ventricles and sulci are normal in size and configuration. There
is no scalp
hematoma or acute skull fracture. The visualized paranasal
sinuses and
mastoid air cells are well aerated.
IMPRESSION:
1. No definite hemorrhage, though limited due to recent contrast
bolus at
outside hospital.
2. Subtle loss of [**Doctor Last Name 352**]-white matter differentiation in the right
insular
ribbon concerning for evolving subacute infarction in the right
MCA territory.
.
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST [**2156-3-6**] 10:18 AM
FINDINGS:
MRI OF THE HEAD.
Restricted diffusion is identified in the vascular territory of
the right MCA,
with no evidence of hemorrhagic transformation. Additionally,
multiple foci
of restricted diffusion are also visualized on the left cerebral
hemisphere
and right temporo-occipital region. The ventricles and sulci are
unchanged
and appear slightly prominent, likely age related and
involutional in nature.
On FLAIR, few foci of high signal intensity are noted in the
subcortical white
matter, which are nonspecific and may reflect chronic
microvascular ischemic
disease. In the left frontal convexity, small focus of
restricted diffusion
is also identified (image #20, series #5).
The orbits, the paranasal sinuses and the mastoid air cells are
unremarkable.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid
arteries, there
are flow-stenotic lesions at M2/M3 segment on the right and also
decreased
flow on the distal branches of the left middle cerebral artery,
likely
consistent with atherosclerotic disease. The basilar artery
appears patent
with dominance of the left vertebral artery, the right vertebral
artery is not
visualized, probably is hypoplastic.
IMPRESSION: Subacute ischemic event is identified on the right
middle artery
vascular territory, involving the insula and also scattered foci
of restricted
diffusion in both cerebral hemispheres consistent with
thromboembolic ischemic
event as described above.
The MRA of the head demonstrates flow-stenotic lesions at the
middle cerebral
artery bifurcations involving the M2/M3 segments, no aneurysms
are identified.
Probably the right vertebral artery is hypoplastic.
.
CHEST (PORTABLE AP) Study Date of [**2156-3-6**] 10:39 AM
Compared with several minutes earlier on the same day, the
coiled tube has
been removed. An NG tube is now present, tip extending beneath
diaphragm,
overlying the stomach. Patchy opacity at both lung bases with
suspected small bilateral effusions are unchanged. No
pneumothorax detected.
.
CHEST (PA & LAT) Study Date of [**2156-3-8**] 9:41 AM
FRONTAL AND LATERAL CHEST RADIOGRAPHS: A nasogastric tube
terminates within the stomach. Since the [**2156-3-6**]
examination there has been improved aeration at the lung bases.
No new superimposed consolidation or opacity is seen. There is a
persistent small left pleural effusion. The heart size is
normal. The hilar and mediastinal contours are within normal
limits. There is no pneumothorax.
IMPRESSION: No new consolidation or opacity since [**2156-3-6**].
Improved bibasilar aeration.
.
.
Cardiology:
TTE (Complete) Done [**2156-3-8**] at 4:00:44 PM FINAL
Conclusions
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). 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) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Brief Hospital Course:
74 year old woman with multiple vascular risk factors including
recently diagnosed atrial fibrillation (not anticoagulated),
right carotid stenosis and prior left CEA was transferred from
OSH post tPA (6-7 hours post event) for possible intervention
following acute onset of left-sided weakness and dysarthria.
Patient had received lorazepam at the OSH which accounted for
considerable drowsiness. Patient did not receive intervention
and was observed in the ICU for post tPA monitoring. Patient had
episodes of AF with RVR and was initially treated with digoxin
and PRN IV metoprolol and latterly with a reduced dose of po
metoprolol given borderline BPs. She was started on IV heparin
and warfarin. She passed S&S and placed on a regular diet. TTE
showed no atrial or ventricular clot with preserved global and
regional biventricular systolic function. She was assessed by PT
and OT and deemed to benefit from rehab and was therefore
transferred to rehab on [**2156-3-8**] on warfarin with an IV heparin
bridge. She has neurology follow-up.
.
.
# Neurology:
On admission, the patient was drowsy and lethargic but alert and
oriented felt likely secondary to lorazepam. She was dysarthric
without evidence of aphasia and had a right gaze deviation
without apparent neglect. She had a left facial droop and left
hemiparesis without sensory disturbance.
CT-head showed subtle loss of [**Doctor Last Name 352**]-white matter differentiation
in the right insular
ribbon concerning for evolving subacute infarction in the right
MCA territory without evidence of hemorrhage post tPA. MRI
showed subacute right MCA infarct involving the insula in
addition to multiple foci of restricted diffusion in the left
cerebral hemisphere and right temporo-occipital region
consistent with embolic infarcts. MRA revealed right M2/M3
segment stenosis on the right and decreased
flow in the distal branches of the left MCA felt likely
consistent with atherosclerotic disease.
Given the above, the decison was made not to intervene based on
her improved motor function, the location of the clot in the
distal MCA portion, and documented (75%) stenosis of the right
carotid, which would have made intervention both risky and
difficult. She was therefore admitted to the ICU for observation
post tPA on [**2156-3-5**].
The likely cause of her embolic infarcts is non-anticoagulated
AF.
Stroke risk factors were assessed and patient was monitored on
telemetry and this revealed persistent AF with episodes of RVR.
HbA1c was 6.1% and FLP revealed Cholesterol 190 TGCs 78 HDL 48
LDL 126. Serum and urine tox screens were normal. CEs were
negative and TSH was 2.7. Pravastatin was therefore increased to
80mg daily. Aspirin was stopped. Patient was maintained on a
HISS to maintain normoglycemia and fingersticks were
unremarkable.
Echo showed no left atrial mass or thrombus with normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function EF >60%.
Anti-hypertensives were held to allow autoregulation and she was
initially treated with IV digoxin for AF with RVR. She was then
treated with PRN IV metoprolol and transferred to the floor on
[**2156-3-6**]. Patient was started on IV heparin 24 hours after tPA
and was started on warfarin on [**2156-3-6**]. She was restarted on
low dose metoprolol 25mg tid on [**2156-3-8**] and her BP was closely
monitored.
There was initial concern regarding her swallowing and an NG
tube was initially placed in the ICU. On further assessment on
[**2156-3-8**] by S&S, she was passed for regular diet.
Patient continued to improve neurologically and had no evidence
of neglect and on discharge had mild left hemiparesis. Patient
was assessed by PT and OT and deemed to benefit from rehab and
was therefore transferred to rehab on [**2156-3-8**] on warfarin with
an IV heparin bridge. She has neurology follow-up.
.
# Cardiology:
Patient was monitored on telemetry and ECG showed SR with LBBB
with AF noted on telemetry. Patient had episodes of AF with RVR
in the setting of stopping her metoprolol, lisinopril and
amlodipine to allow autoregulation of BP and improve perfusion.
Given embolic strokes she was started on IV heparin as a bridge
to warfarin especially concerning her recent biopsy. Aspirin was
stopped. Digoxin was initially started in the ICU out of
concerns regarding BP compromise from other agents. Digoxin
level was 1.9 and digoxin was ultimately stopped on transfer to
the floor. Patient had continued AF episodes with asymptomatic
RVR into the 120s-140s although BP was borderline in 100s/110s
and was treated with PRN IV metoprolol and on the day of
discharge transitioned to low dose metoprolol 25mg tid whichshe
tolerated well with BPs maintained in 120s. Patient was
evaluated with a TTE which showed no left atrial mass or
thrombus with normal biventricular cavity sizes with preserved
global and regional biventricular systolic function EF >60%. She
was transferred to rehab on metoprolol 25mg tid and we have held
lisinopril and amlodipine. Pravstatin was increased as above to
80mg daily. She was discharged on an IV heparin infusion with a
goal PTT 50-70 given her recent stroke. PTT should be checked
every 6 hours, and heparin can be stopped once INR is
therapeutic (2.0-3.0) for 24 hours.
Medications on Admission:
Aspirin 81mg qd
metoprolol 100mg [**Hospital1 **]
Amlodipine 5mg qd
Lisinopril 40mg daily
Pravastatin 40mg daily
omeprazole
Iron
vit D
Discharge Medications:
1. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. iron 325 mg (65 mg iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
4. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six [**Age over 90 1230**]y (650) units Intravenous
Infusion: Continue until INR is therapeutic for 24 hours. Goal
PTT 50-70 given recent stroke.
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Outpatient Lab Work
Daily INR and PTTs every 6 hours while on heparin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary diagnosis:
1) Right middle cerebral artery infarct s/p tPA with aetiology
likely secondary to embolism from atrial fibrillation
2) Atrial fibrillation with episodes of rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic:
AOx3 recalls [**3-13**] words, no visual or sensory inattention and
performs line bisection normally. Slight left NLF flattening and
no oethr cranial nerve deficits. Left pronator drift with left
arm>leg weakness and 4+/5 in shoulder abdiction and extensors
and [**5-15**] in flexors in arm and IP 4+/5 and otherwise [**5-15**] in left
leg. Left extensor plantar with withdrawal on right. No sensory
deficits. No ataxia.
Discharge Instructions:
Dear Mrs. [**Known lastname 92430**],
You were admitted to the [**Hospital1 18**] inpatient neurology stroke
service as a transfer for a stroke in the right side of your
brain. While you were here we obtained an MRI which confirmed
your stroke and on blood vessel imaging showed a blockage of one
of the arteries on the right side of your brain, consistent with
the stroke you had been treated for at [**Hospital3 **].
You were very drowsy on arrival here felt likley due to the
lorazepam that you had received. We treated your stroke with a
clot-busting medication called tPA and for this you were
initially admitted to the ICU for observation. You were stable
and transferred to the floor.
You did well on the floor and due to low blood pressure we have
held your amlodipine (Norvasc) and lisinopril and reduced your
metoprolol for the time being. You did have episodes of high
heart rate as we had reduced your metoprolol. You had an
echocardiogram which showed no evidence ofa clot in your heart
and this showed that your heart was pumping well.
The likely cause of your stroke was your irregular heart rate
called atrial fibrillation which causes clots to form in the
heart and then can go to the brain and cause a stroke. For this,
we have started you on a medication called heparin which is
given intravenously in addition to warfarin. The heparin will be
stopped when the warfarin level (INR) is at the correct
therapeutic range. You will need frequent blood tests at rehab
to monitor your INR and you will need to continue warfarin as an
outpatient lifelong.
There were initial concerns regarding your swallowing and you
were assessed by the speech and swallow specialists and they
felt you could have a normal diet. You were assessd by PT and
you strength has improved since your initial presentation and at
this time you are ready to go to rehab to continue your recovery
on [**2156-3-8**].
.
The following changes were made to your medications:
We STARTED Warfarin 5mg daily to thin your blood and reduce your
risk of further stroke given your atrial fibrillation
We STARTED heparin IV which you shoudl continue until your
warfarin level (INR) is in the correct range
We INCREASED pravastatin to 80 mg daily
We DECREASED metoprolol to 25mg three times daily
We STOPPED aspirin
We HELD lisinopril and amlodipine given low blood pressure
.
Please continue your other medications as previously prescribed.
Followup Instructions:
Please see your PCP on discharge from rehab.
.
We have arranged the following neurology follow-up:
Department: NEUROLOGY
When: FRIDAY [**2156-5-7**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"42731",
"4019",
"2724"
] |
Admission Date: [**2129-5-16**] Discharge Date: [**2129-5-22**]
Date of Birth: [**2084-4-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
presumed seizure, new brain mass
Major Surgical or Invasive Procedure:
[**2129-5-20**]: Bifrontal Craniotomy for sella meningioma, partial
frontal lobectomy
History of Present Illness:
Patient is a 45M who presented to Hospital on [**5-16**] after general
body aching, and unexplained bruising and loss of time. He
describes that at 3am on [**5-16**] he awoke feeling soar all over his
body went to the bathroom and noticed he had a large left black
eye. He went down to the cellar and noticed fresh blood on the
floor. At the time he woke up patient noticed he had also had,
at some point, loss of bowel and bladder function which he did
not recall. Upon questioning patient is very unsure about the
events of the day on [**5-15**]. He recalls going to a car show and
coming home to watch TV, he can not recall what he had for
dinner, what he was watching on TV or when or how he made it to
bed.
Past Medical History:
None
Social History:
Landscaper, lives with wife, has a 20year old son. 1.5 pack
smoking hx for 30 years.
Family History:
Prostate cancer
Physical Exam:
Exam on Admission:
T:98.9 BP:160 / 106 HR:84 R 18 O2Sats 96 RA
Gen: WD/WN, comfortable, NAD. large left orbital ecchymosis and
edema.
HEENT: Pupils: 4 to 3 mm bilaterally EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR
Abd: Soft, NT,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-23**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-25**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on Discharge:
neurologically intact with L orbital ecchymosis and well healing
incision
Pertinent Results:
Labs on Admission:
[**2129-5-16**] 04:05PM BLOOD WBC-16.4* RBC-5.52 Hgb-17.1 Hct-47.9
MCV-87 MCH-30.9 MCHC-35.6* RDW-13.6 Plt Ct-208
[**2129-5-16**] 04:05PM BLOOD Neuts-76.8* Lymphs-17.2* Monos-4.6
Eos-0.3 Baso-1.0
[**2129-5-16**] 04:05PM BLOOD PT-12.6 PTT-28.4 INR(PT)-1.1
[**2129-5-16**] 04:05PM BLOOD Glucose-92 UreaN-17 Creat-1.3* Na-142
K-4.0 Cl-105 HCO3-25 AnGap-16
[**2129-5-16**] 04:05PM BLOOD CK(CPK)-1164*
[**2129-5-16**] 04:05PM BLOOD cTropnT-<0.01
[**2129-5-16**] 04:05PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.3
[**2129-5-16**] 04:44PM BLOOD Lactate-1.8
Labs on Discharge:
XXXXXXXXXXXXXXXXXXX
------------------
IMAGING:
-----------------
CT/CTA OF HEAD [**5-16**]:
4.8x4.3x4.5cm rounded hyperdense slightly enhancing right
frontal mass causing mass effect on right and left frontal
lobes with grey matter hypodesity in the right frontal lobe
likey edema. appears stable in size since CT performed at OSH at
12:18PM on [**5-16**]. right and left ACA's displaced by this mass,
but flow remains within. otherwise COW vessels appear normal.
large feeding vessle (400B:15) may arise from right opthalmic
artery. no herniation. mass may arise from skull base, but no
significant bony remodeling. no hemorrhage. soft tissue
thickening and stranding around right preseptal orbital tissue.
final read pending 3d reformats.
MRI HEAD [**5-17**]:
midline structures and surrounding vasogenic edema. There are
a few punctate foci of susceptibility artifact within the mass
likely
consistent with calcification or hemorrhage. The A2 segments of
both anterior cerebral arteries are displaced to the left by the
mass. The right A1 segement is diplaced posteriorly and to the
left. No additional enhancing lesions are identified. There is
no significant restricted diffusion to suggest acute ischemia.
There is no hydrocephalus. The intracranial arterial flow voids
are patent. There is mucosal thickening
involving multiple bilateral ethmoid air cells, the sphenoid
sinuses and the left frontal sinus. There is fluid within the
mastoid air cells, bilaterally.
IMPRESSION:
1. Probable meningioma of the planum sphenoidale or olfactory
groove with
mass effect on both frontal lobes and slight leftward shift of
the normally midline structures. Patent but displaced A2 sements
and right A1 segment. No acute hemorrhage or infarction.
2. Sinus and mastoid disease as described above, the activity of
which is to be determined clinically.
MRI Head [**5-20**](post-op):
FINDINGS: Since the previous MRI examination, there has been
resection of the large mass in the inferior frontal lobe region
representing an olfactory groove meningioma. No residual nodular
enhancement is seen. Blood products are seen at the surgical
margin. There is air within the surgical cavity as well as blood
products. Fluid fills predominantly in the area. There is
surrounding edema seen as on the previous MRI examination. There
is no hydrocephalus or new midline shift. Soft tissue changes
are seen in both mastoid air cells, which could be related to
intubation.
IMPRESSION: Status post resection of the brain mass with
expected
post-surgical changes. Blood products, fluid and air are seen in
the surgical cavity as well as scalp edema and fluid level. No
hydrocephalus or midline shift seen. No new areas of brain
parenchymal hemorrhage distal from the surgical site noted.
Brief Hospital Course:
Patient is a 45M admitted to [**Hospital1 18**] following transfer from OSH
with a newly diagnosed frontal midline mass. He was started on
Keppra in our emergency department for what was thought to be
seizures prior to presentation. He was admitted to the
neurosurgery service, step-down status for further work up. On
[**5-16**], he underwent CTA of the Head and MRI of the head. He did
need to have additionally radiographic evaluation of his orbits
prior to MRI due to unknown foreign body. Because of the
vascular supply to the lesion, on [**5-18**] her underwent an
angiogram to attempt to embolize the supply. Due to the
proximity of the tumor supply to opthalmic artery supply-it was
decided to forego embolization because of the risk to his
vision. On [**5-19**] MRI WAND study was obtained and he was taken to
the OR for surgical resection of said mass. Post-operatively, he
was taken to the ICU for continued close monitoring. On [**5-20**], he
was doing quite well, and determined to be appropriate to
transfer to the NSURG floor.
While on the floor, his neurological exam continued to improve,
and his pain was well controlled. he was out of bed and walking
the hallways with PT, who determined he was cleared for
discharge to home.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotic.
Disp:*60 Capsule(s)* Refills:*0*
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): take while on decadron.
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
6. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO three
times a day for 10 days: take 3mg tid for 2 d then 3mg [**Hospital1 **] for 2
days then 2mg [**Hospital1 **] for 2 days then 1mg [**Hospital1 **] for 2 days then dc.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Brain Mass **Meningioma(pre-lim)
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Keppra(Levetiracetam), for
anti-seizure medicine, take it as prescribed and you will not
require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**7-30**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-27**] at
11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a
multi-disciplinary appointment. Their phone number is
[**Telephone/Fax (1) 1844**]. You will need to call them prior to your
appointment to update your insurance coverage.
??????You will not need an MRI of the brain as this was done prior to
your discharge.
**You will also require Visual Field Testing prior to you Brain
tumor clinic follow up. Please call ([**Telephone/Fax (1) 5120**] to schedule
this. They are also located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**] 5.
Completed by:[**2129-5-22**]
|
[
"3051"
] |
Admission Date: [**2181-10-26**] Discharge Date: [**2181-11-10**]
Date of Birth: [**2112-3-18**] Sex: F
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
weakness, GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
thoracentesis
chest tube placement
blood transfusion
History of Present Illness:
69yoF with metastatic NSC lung ca to lumbosacral spine p/w from
OSH with GIB. Patient had been admitted there one week prior
with weakness/lethargy/ nausea/anorexia and constipation. Per
patient, she received increased bowel regimen starting 1 day
prior to transfer and since that time has been having BRBPR
every 10-15 minutes afterwards. Upon calling the hospital, we
are informed that her Hct has dropped from 30-34 yesterday to
23.4 today prior to transfer. She received one unit PRBC at 6pm
immediately prior to transfer and was started on a PPI gtt and
octreotide gtt. She had NG lavage at OSH which was reportedly
negative. Has never had EGD/[**Last Name (un) **] in past.
.
Currently, pt denies abdominal pain. No n/v. No fevers. C/o
chronic back pain currently, requesting ativan and pain
medication.
.
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. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
.
Past Medical History:
-Inflammatory arthritis involving hands
-COPD
-s/p appendectomy
-s/p tonsillectomy
-Nonsmall cell lung ca - s/p radiation to spine, currently on
carboplatin and pemetrexed(last dose 2 weeks ago)
Social History:
works in cafeteria at [**Hospital3 10310**]. Has son and 3 daughters
(1 daughter at bedside). Lives with son [**Name (NI) **], who is primary
caregiver and HCP.
- Tobacco: 1ppd x 55yrs
- Alcohol: denies
- Illicits: denies
Family History:
denies any significant family history
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS, occ wheeze throughout
CV: Tachycardic rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: tender external hemorrhoid, bright red blood in diaper.
pt refusing internal rectal exam for me, though surgery did exam
and per report no rectal masses
GU: foley in place, good UOP
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam:
Frail, older than stated age
Afebrile, BP 124/64 HR 113, RR 18 96%3L
more alert, still a little cloudy.
OP dry.
Lungs diminished bilaterally, no wheezes.
CV tachycardic, no murmurs appreciated
Abdomen soft, NT, ND. No bladder tenderness.
Ext without edema. Oriented to place, time, person. asks me
"who did I marry that day" - recalling the events, and her
confusion.
Foley out.
Pertinent Results:
ADMISSION LABS:
[**2181-10-26**] 09:24PM BLOOD WBC-4.5 RBC-3.21* Hgb-9.5* Hct-28.3*
MCV-88 MCH-29.7 MCHC-33.6 RDW-16.2* Plt Ct-150
[**2181-10-26**] 09:24PM BLOOD PT-14.0* PTT-29.1 INR(PT)-1.2*
[**2181-10-26**] 09:24PM BLOOD Glucose-74 UreaN-7 Creat-0.3* Na-138
K-3.3 Cl-101 HCO3-24 AnGap-16
[**2181-10-26**] 09:24PM BLOOD ALT-21 AST-35 LD(LDH)-627* CK(CPK)-161
AlkPhos-182* TotBili-0.7
[**2181-10-26**] 09:24PM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-10-27**] 03:02AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-10-26**] 09:24PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.9 Mg-1.9
[**2181-10-26**] 10:21PM BLOOD Type-[**Last Name (un) **] pO2-25* pCO2-44 pH-7.36
calTCO2-26 Base XS--1
[**2181-10-26**] 10:21PM BLOOD Lactate-1.5
.
IMAGING:
CXR: NG tube tip is either in the distal stomach or proximal
duodenum.
There is residual contrast in the collecting system of the
visualized portion of the right kidney and there is also oral
contrast within the colon. The mediastinum is slightly
prominent, possibly due to supine technique. There is right
lower lobe infiltrate.
.
CTA:
1. No evidence of active bleeding in the small bowel.
Gastrointestinal
bleeding in the large bowel is unable to be assessed on this
examination
secondary to recent oral contrast administration from CT
examination performed at an outside hospital.
2. Diffuse osseous metastatic disease, some of which demonstrate
a soft
tissue component. Pathologic fracture involving the right medial
acetabulum. The largest metastatic lesions at L2, and the
posterior elements of L3 are at risk of pathologic fracture.
3. Calcified gallbladder wall likely an early porcelain
gallbladder.
4. Moderate simple right pleural effusion.
5. 7-mm left adrenal nodule likely myelipoma or adenoma.
6. Proctitis.
.
Subsequent Results:
.
[**2181-10-27**] 09:34AM BLOOD WBC-5.8 RBC-3.88* Hgb-11.4* Hct-32.6*
MCV-84 MCH-29.2 MCHC-34.8 RDW-17.6* Plt Ct-151
[**2181-11-2**] 07:10AM BLOOD WBC-8.8 RBC-3.27* Hgb-9.7* Hct-28.5*
MCV-87 MCH-29.6 MCHC-34.0 RDW-16.9* Plt Ct-168
[**2181-11-2**] 07:10AM BLOOD Glucose-123* UreaN-9 Creat-0.3* Na-134
K-4.0 Cl-95* HCO3-29 AnGap-14
[**2181-11-2**] 07:10AM BLOOD LD(LDH)-1649*
[**2181-10-26**] 09:24PM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-10-27**] 03:02AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-10-30**] 10:19AM BLOOD cTropnT-<0.01
[**2181-11-2**] 07:10AM BLOOD TotProt-4.3* Albumin-2.0* Globuln-2.3
Calcium-8.2* Phos-3.7 Mg-1.8
[**2181-10-30**] 10:19AM BLOOD TSH-3.2
[**2181-11-2**] 11:47AM PLEURAL TotProt-1.6 LD(LDH)-652 Albumin-0.9
.
Colonoscopy ([**10-29**]):
Findings:
Flat Lesions - A single small angioectasia with stigmata of
recent bleeding was seen in the 60 cm. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully.
Protruding Lesions - A single sessile 5 mm non-bleeding polyp of
benign appearance was found at ~18 cm. A single sessile 5 mm
non-bleeding polyp of benign appearance was found in the rectum.
Excavated Lesions - A few non-bleeding diverticula with small
openings were seen in the distal sigmoid colon. A single
non-bleeding diverticulum was seen in the cecum.
Impression:
Polyp at ~18 cm
Polyp in the rectum
Diverticulosis of the distal sigmoid colon
Diverticulum in the cecum
Angioectasia in the 60 cm (thermal therapy)
Otherwise normal colonoscopy to terminal ileum
Recommendations: Patient should have a repeat flex sig with
polpyectomies and visualization of the rectum as an outpatient.
Clips were not used for AVM given likelihood that patient will
need MRI for ongoing treatment and care of her lung malignancy.
.
CTA Chest ([**10-30**]):
IMPRESSION:
1. No pulmonary embolism.
2. Large right upper lobe mass with probable lymphangitic spread
and
mediastinal invasion and compression of the right upper lobe
pulmonary
arterial and obliteration of a right upper lobe bronchus.
Extensive
mediastinal, subcarinal, and contralateral hilar
lymphadenopathy. Extensive bony metastatic disease involving a
left anterior third rib, numerous vertebral bodies, and the
sternum.
3. Increased size of a large right pleural effusion. Small left
pleural
effusion with atelectasis. Possible early aspiration has
occurred in the left lower lobe with bronchial wall thickening
that appears similar to the CT study performed two days prior.
4. Incidental note of an aberrant right subclavian artery.
.
CXR ([**11-1**]):
IMPRESSION: AP chest compared to [**10-26**]:
Large right hydropneumothorax is new since [**10-26**], including
substantial volume of right pleural fluid. Interstitial edema
has developed in the left lung, probably due to redirection of
pulmonary perfusion. Focal opacity in the perihilar left upper
lung could be pneumonia or aspiration. Followup advised. Heart
size is normal. Relatively mild leftward mediastinal shift
suggests central adenopathy anchoring the mediastinum.
.
CXR ([**11-1**]):
IMPRESSION: AP chest compared to 7:01 p.m.:
Moderate-sized right hydropneumothorax is still substantial,
only mildly
smaller following the insertion of a small-bore catheter in the
right upper hemithorax. Interstitial edema persists because
there right lung is
substantially atelectatic, accounting for new small left pleural
effusion.
Mediastinal widening reflects extensive adenopathy. The heart is
non-enlarged but pericardial effusion is not excluded.
.
Pleural Fluid Cytology ([**11-2**]): Atypical.
Rare groups of atypical epithelial cells.
Heme slides were reviewed.
Note: Recommend resubmission the entire fluid to cytology
for cellblock preparation and further evaluation, if fluid
reaccumulates.
.
Most recent CXR:
[**11-6**]
As compared to the previous radiograph, the distribution and the
extent of the left pleural effusion are unchanged. On the right,
a small new pleural effusion could have developed. The
pre-existing air collection in the right soft tissues has
decreased and is in part not included on the image. Unchanged,
however, are the increases of interstitial density, likely to
reflect interstitial fluid overload. Unchanged inhomogeneous
bone density, reflecting known lytic changes.
.
Discharge labs:
[**2181-11-7**] 06:00AM BLOOD WBC-8.6 RBC-2.92* Hgb-8.5* Hct-25.4*
MCV-87 MCH-29.1 MCHC-33.4 RDW-17.0* Plt Ct-100*
[**2181-11-7**] 06:00AM BLOOD Glucose-84 UreaN-7 Creat-0.2* Na-137
K-3.4 Cl-94* HCO3-32 AnGap-14
Outstanding tests: None
Brief Hospital Course:
69yoF with metastatic lung cancer, who presented with an acute
lower GI bleed, found to have a bleeding AVM, with course
complicated by pleural effusion, with thoracentesis resulting in
pneumothorax, as well as severe malignant pain syndrome, now on
methadone and oxycodone.
ACTIVE ISSUES:
.
# GI bleed, with acute blood loss anemia: Pt with BRBPR
concerning LGIB. Per report, NG lavage at OSH was negative,
given 1 unit PRBC, started on octreotide and Protonix drips and
transferred to [**Hospital1 18**]. NG lavage was repeated on admission and
was negative, pt was transfused 2 additional units of PRBC with
appropriate response. An angiogram was unsuccessful in
localizing a bleed, as PO contrast from a prior study at the OSH
obscured the study. GI and surgery were consulted: surgery
rec'd GI to scope and GI rec'd scope in AM. After remaining with
stable Hct and blood pressure in the ICU, the pt was transferred
to the medical floor. She then completed a bowel prep and
underwent a colonoscopy on [**10-29**], which showed a single AVM with
evidence of recent bleed, which was cauterized. Of note, no
clips were placed, in anticipation of possible future MRI that
pt's cancer management may require. She was also noted to have
2 sessile polyps, which were not removed, and will require
outpatient flex-sig's for polypectomies at a later date.
.
# Pleural Effusion: The patient was noted to have a large right
pleural effusion on CTA of the chest, performed to evaluate
tachycardia. Given the size of the effusion, rate of
accumulation and her oxygen requirement, Interventional Pulm was
consulted to perform a thoracentesis. Although her outpatient
imaging studies had already previously shown the effusion, and
was presumed to be a malignant effusion, no prior diagnostic
thoracentesis had been performed. A bedside thoracentesis was
attempted by IP on [**11-1**], however, the patient developed a
moderate sized pneumothorax and an anterior chest tube was
placed at the bedside, with follow-up CXR showing good
resolution of both the effusion and pneumothorax. Pleural fluid
analysis revealed an elevated LDH consistent with an exudate.
Chest tube was removed on [**11-3**] with no signs of reaccumulation
of effusion and only small amt of pneumothorax. Pleural fluid
cytology is pending at this time and showed atypical cells, but
not malignant cells. However, this does not exclude a malignant
cause for the effusion.
.
# Metastatic lung ca, with malignant pain syndrome: pt is s/p
radiation and chemotherapy x 2 sessions. Initially was
continued on her home pain regimen for her bone pain of
methadone 5mg TID. Palliative care was consulted, with attempt
to increase her methadone, but she developed an acute
encephalopathy with higher doses of methadone, 5 mg po bid and
10 mg po qhs. She also has prn Oxycodone for breakthrough pain.
She was noted to have a pathologic fracture of her right
acetabulum. This was known prior to her admission, and
confirmed with her outpatient oncologist. Orthopedics here
recommened that her activity be partial weight bearing as
tolerated, and that she ambulate with a walker or cane at all
times. Her outpatient Oncologist, Dr. [**Last Name (STitle) 31966**] was contact[**Name (NI) **] on
multiple occasions, but her functional status has declined
significantly and her ability to tolerate further chemotherapy
will need to be assessed after her strength improves.
.
# sinus tachycardia: initially thought to be [**1-31**] volume loss in
the setting of GIB, but it was not responsive to fluids or PRBC
overnight and has been persistently tachycardic during
admission. Had 3 negative troponins to rule out active cardiac
ischemia, and also had normal TSH. Pain adequately managed, and
receiving Ativan for anxiety as needed. CTA showed no evidence
of PE. Called outpatient PCP and Oncologist offices, pt's
baseline HR at previous office visits for the past year have
ranged in the low 100's to 110's. Sinus tachycardia is likely
pt's underlying baseline due to underlying malignancy or her
COPD.
.
# Oral thrush: pt was noted to have some oral thrush on exam on
[**11-2**] and started on Nystatin. She found this intolerable due to
nausea and was switched to oral clotrimazole with good effect.
.
# Acute cystitis: Pt was found to have acute cystitis on [**11-3**]
and started on a course of levofloxacin to be completed on
[**11-10**]. Levofloxacin used over cipro given equivalent E coli
coverage but better coverage of respiratory infections in this
vulnerable pt with ? infiltrate. Plan will be to complete 10
days of abx for complicated UTI.
.
# Urinary retention: On [**11-3**] soon after UTI diagnosis an attempt
was made to DC foley but the patient developed urinary retention
and foley replaced. Repeat voiding trial on [**11-9**] which she
again failed.
.
# Nausea: She continues with nausea, likely multifactorial,
that is improved with compazine and zofran. KUB on [**2181-11-8**]
showed no obstruction or ileus. She will require continued
symptomatic management for nausea.
CHRONIC ISSUES:
# COPD: continued flovent, albuterol and ipratropium nebs as
needed
.
Goals of care:
She was seen by palliative care, and there were extensive
discussions with her family, including her son, [**Name (NI) **],
regarding goals of care. She will be transitioned to
rehabilitation with a goal of strengthening, and focus on
palliation of symptoms. She remains a full code, per her son's
request, and is not fully aware of the extent of her disease,
again per family request. Hospice may need to be considered in
the near future
Outstanding Transitional Issues:
1. may need outpt flex-sig for polypectomies, assuming improved
clinical recovery.
Medications on Admission:
Medications on transfer:
methadone 5mg PO TID
octreotide gtt
protonix gtt
lorazepam 0.5mg TID
tylenol prn
percocet prn
compazine prn
ambien prn
zofran prn
Discharge Medications:
1. methadone 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*15 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
12. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 3 days.
13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
14. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehab
Discharge Diagnosis:
Lower GI bleed - AVM
Right pleural effusion
Chronic diagnoses:
COPD
metastatic NSCLC
pathologic fracture
sinus tachycardia
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 transferred from [**Hospital3 10310**] Hospital to [**Hospital1 18**] ICU
with bloody stools. During this hospitalization, you were
transfused red blood cells and underwent a colonoscopy for your
GI bleed. A source of bleed was identified, and the bleeding
was stopped by cautery. Some polyps were seen, and these will
need to be removed at a later date. You were also noted to have
lots of fluid around your right lung, so you underwent a
drainage of the fluid, which was complicated by partial collapse
of the right lung, so a chest tube had to be placed. You were
evaluated by the Physical Therapists, and given your
deconditioning and weakness, we think you will benefit from a
stay at a rehab facility. You continue to have some nausea and
some pain, but you are otherwise stable. You do have to have a
catheter in your bladder due to your inability to urinate. You
need to get stronger before you can try any more chemotherapy,
and Dr. [**Last Name (STitle) **] agrees with this. You will also need to work
just on being more comfortable.
.
Medication changes:
1. Decadron 4 mg for 3 more days
2. Compazine around the clock.
Followup Instructions:
DR. [**Last Name (STitle) **] WILL CALL YOUR NURSING HOME ON MONDAY IF YOU DO NOT
NEED TO COME TO THIS APPOINTMENTS.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2181-11-15**] at 3:00 PM
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: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2181-11-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"2875",
"2851",
"42789",
"496"
] |
Admission Date: [**2119-11-9**] Discharge Date: [**2119-11-14**]
Date of Birth: [**2037-3-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5134**]
Chief Complaint:
S/p fall, found down, rapid atrial fibrillation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82F w hx HTN, atrial fibrillation, s/p partial thyroidectomy,
remote seizure disorder, who presented to ED last night. She had
fallen 4 days prior, mechanical fall from toilet, no loss of
consciousness; pt lives alone but did not use her lifeline
because she was concerned that EMS would not be able to open her
locked bathroom door. She was apparently able to phone her
neighbors 2 days ago, but remained on the floor at home until
yesterday when she called EMS. She denied overall weakness but
did state that her legs would not support her. Though she does
have a remote history of seizures, she denied any seizure
activity, tongue-biting, bladder/bowel incontinence, or loss of
consciousness during this episode. She notes that she had just
been leaning forwards on the toilet and lost her balance. She
did miss [**First Name (Titles) **] [**Last Name (Titles) 4982**] for at least 2 days while on the
bathroom floor and had very limited po intake.
.
In the ED, patient was noted to be in Afib with RVR to 180s,
refractory to boluses of IV metoprolol and diltiazem, but
responded to diltiazem drip, for which she was admitted to the
medical ICU. CT head was negative, and CXR had cardiomegaly. In
the MICU, diltiazem drip was weaned off overnight. She was
placed on diltiazem 60mg QID and metoprolol tartrate 50mg TID
(home doses: diltiazem XR 240mg daily and metoprolol tartrate
100mg [**Hospital1 **]). She was also noted to have a urinary tract
infection, for which she was given a dose of ceftriaxone in the
ED then switched to ciprofloxacin this morning. She did have a
supratherapeutic INR on presentation, was given a dose of po
vitamin K 5mg in the ED.
.
Prior to transfer to floor, vitals as follows:
T 98.2 HR 90 (irregularly irregular) BP 142/69 RR 22 O2 Sat 93%
RA
.
Review of sytems:
(+) 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:
-Atrial fibrillation
-Hypertension
-Remote seizure disorder (per patient, last seizure > 30 years
ago)
-S/p partial thyroidectomy, now with hypothyroidism
Social History:
Lives at home alone in an apartment in [**Location (un) **]. Occasional
half-glass of etoh. No tobacco or illicits.
Family History:
No heart disease, cancer, or other seizure history
Physical Exam:
VS: Temp:96.9 BP: 150/115 HR:103 (afib) RR:18 O2sat92% RA
GEN: pleasant, comfortable, NAD, sweaty
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, JVP to 8 cm at 30
degrees elevation, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardic, irregularly irregular, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or HSM
EXT: no c/c/e. + ecchymosis over left knee. 2+ DP/PT/radial
pulses bilaterally.
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps
RECTAL: deferred
Pertinent Results:
Labs on Admission:
[**2119-11-9**] 02:35PM URINE HOURS-RANDOM
[**2119-11-9**] 02:35PM URINE GR HOLD-HOLD
[**2119-11-9**] 02:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.021
[**2119-11-9**] 02:35PM URINE BLOOD-LG NITRITE-POS PROTEIN-150
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2119-11-9**] 02:35PM URINE RBC-[**3-31**]* WBC-[**12-16**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2119-11-9**] 12:30PM PT-51.3* PTT-39.6* INR(PT)-5.6*
[**2119-11-9**] 12:15PM GLUCOSE-95 UREA N-51* CREAT-1.2* SODIUM-138
POTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-29 ANION GAP-18
[**2119-11-9**] 12:15PM estGFR-Using this
[**2119-11-9**] 12:15PM CK(CPK)-2098*
[**2119-11-9**] 12:15PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2119-11-9**] 12:15PM WBC-8.7# RBC-4.98# HGB-14.9 HCT-44.2 MCV-89#
MCH-29.8 MCHC-33.6 RDW-15.1
[**2119-11-9**] 12:15PM NEUTS-84.9* LYMPHS-7.6* MONOS-6.3 EOS-0.8
BASOS-0.5
[**2119-11-9**] 12:15PM PLT COUNT-362
Labs on Discharge:
[**2119-11-14**] 05:10AM BLOOD WBC-5.4 RBC-3.83* Hgb-11.4* Hct-33.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.5 Plt Ct-320
[**2119-11-14**] 05:10AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-137
K-3.9 Cl-99 HCO3-30 AnGap-12
Imaging:
ECG Study Date of [**2119-11-9**] 12:07:06 PM
Atrial fibrillation with rapid ventricular response. Consider
left ventricular hypertrophy with repolarization abnormality. No
previous tracing available for comparison.
ECG Study Date of [**2119-11-9**] 3:05:52 PM
Atrial fibrillation. Since the previous tracing the rate has
decreased.
QRS voltage has increased and is probably more apparent.
Clinical correlation is suggested.
CT HEAD W/O CONTRAST Study Date of [**2119-11-9**] 12:26 PM
IMPRESSION
1. No evidence of acute intracranial injury.
2. Nonspecific hypodense bony lesions in the frontal bone.
Correlation with
history of malignancy and comparison with prior CTs if available
is
recommended.
CT C-SPINE W/O CONTRAST Study Date of [**2119-11-9**] 12:29 PM
IMPRESSION:
1. No evidence of acute injury to the cervical spine.
2. Enlarged left thyroid gland, likely multinodular goiter, but
clinical
correlation recommended.
3. Fibrotic changes in bilateral lung apices, most likely
related to prior
granulomatous disease.
CHEST (SINGLE VIEW) Study Date of [**2119-11-9**] 3:51 PM
IMPRESSION: Retrocardiac atelectasis or pneumonia. Cardiomegaly.
Enlarged left thyroid gland.
Brief Hospital Course:
82 y/o F with hypertension, atrial fibrillation, remote seizure
disorder and thyroidectomy, past episodes of self-neglect,
presenting to ED after several days of immobilization [**2-28**] fall
at home.
.
#. Atrial fibrillation: Likely [**2-28**] withdrawal of dual rate
control with diltiazem and metoprolol in addition to significant
dehydration while the patient was on the floor of her home. The
patient was transferred to the ICU for rate control with a
diltiazem drip, to which she responded. Ultimately was able to
control rate on the drip, with hemodynamic stablitiy (mildly
elevated blood pressures). Was transferred to the floor on a PO
regimen of diltiazem and metoprolol similar to her home regimen.
On telemetry, patient was noted to have atrial fibrillation,
mostly in 50s-60s, with occasional asymptomatic bradycardia to
40s. The patient did not have any further episodes of Afib with
RVR on the floor. She was hemodynamically stable, and was
discharged on her home dose of diltiazem and 50 mg of metoprolol
[**Hospital1 **], as opposed to 100 mg [**Hospital1 **], given her asymptomatic
bradycardia.
#. Social: This is the second time patient has been immobilized
on ground for several days after falling, without seeking
medical care. Per EMS report, patient's house very messy.
Daughter markedly concerned for mother's ability to care for
herself. Elder care services was notified and prefer to evaluate
patient in home setting. It was decided upon discharge that the
patient would return to her home with her daughter, for further
evaluation by elder care services.
#. Hypertension: On ACE-i, [**Last Name (un) **], thiazide, beta blocker,
hydralazine at home. Mildly hypertensive on arrival, in setting
of not taking [**Last Name (un) 4982**] for several days. Upon discharge, the
patient was restarted on all of home [**Last Name (un) 4982**] except for the
hydralazine.
#. Nonspecific hypodense bony lesions: In hospital, we were
unable to correlate with a history of malignancy. Patient will
benefit from a comparison to prior CTs as an outpatient. Of
note, per [**2118-6-23**] [**Hospital6 2561**] Radiology, at that
time there was no evidence of intracranial traumatic injury,
remote ischemic injury and nonspecific white matter change,
cervical spondylosis without evidence of fracture or
dislocation, and enlarged left thyroid mass status post right
thyroidectomy. Follow-up as an outpatient is recommended.
#. Remote seizure disorder: Per patient, no seizure activity
for past several decades. No reported epileptiform symptoms,
although patient's insight to her own medical issues is in
doubt, given the events of the past week.
#. Supratherapeutic INR: Per patient, last INR check 1-2 weeks
ago was elevated at 3.5. Warfarin dosing of 6 mg daily was not
changed at that time, but the patient was instructed to eat
spinach daily. While in the hosptial, the patient's INR trended
downwards to 1.7; the patient was ultimately discharged on her
home dose of warfarin, and instructed to follow-up have her INR
drawn in two days and faxed to her PCP's office who manages her
warfarin dosing.
#. Renal insufficiency: Baseline Creatinine generally 0.8-1.0.
Patient had a mildly elevated BUN/Cr on admission to 51/1.2, in
setting of elevated CK and poor PO intake. Elevated
BUN/creatinine ratio consistent with perfusion-related injury.
THe patient received IVF in the ED, PO intake was encouraged,
and in the hospital the patient's ACE, [**Last Name (un) **], and HCTZ were held
until her [**Last Name (un) **] resolved with hydration
#. Elevated CK: Likely [**2-28**] being down on ground for several
days. Elevated EK resolved with hydration, and did not cause
significant renal impairment.
#. S/p thyroidectomy/hypothyroidism: Per patient, had part of
thyroid removed 1-2 years ago. On home levothyroxine, though not
documented in OMR. TSH 1.4 in [**Month (only) 958**], as measured at [**Hospital3 2568**].
On recheck here, TSH was noted to be 2.8.
#. UTI: Grossly positive u/a without culture sent. Ceftriaxone
x1 in ED. No fevers or SIRS physiology on arrival. Past urine
cultures at [**Hospital3 2568**] have grown E coli sensitive to everything
except tetracycline. Urine [**11-9**] growing Klebsiella, S to
everything tested except nitrofurantion. PO Cipro was started
for a total 3 day course for uncomplicated UTI (Day 1 [**2119-11-11**]
to end on [**2119-11-13**]).
#. Ketonuria: Normoglycemic and no history of diabetes. Suspect
starvation ketosis.
Comm: Daughter [**Name (NI) **] [**Name (NI) 12424**] (HCP: Cell: [**Telephone/Fax (1) 26655**], Home:
[**Telephone/Fax (1) 26656**]). Friend [**Name (NI) 1439**] [**Name (NI) **] [**Telephone/Fax (1) 26657**]
Code: Full
[**Telephone/Fax (1) **] on Admission:
-Warfarin 6 mg PO Daily
-Klor-con 10 mEq PO daily
-Dilt-XR 240 mg PO Daily
-HCTZ 25 mg PO daily
-Calcium citrate/Vit D3 (?dose PO daily)
-Hydralazine 35 mg PO TID
-Benicar 40 mg PO Daily
-Lisinopril 80 mg PO daily vs 40 mg PO BID
-Metoprolol tartrate 100 mg PO BID
-Levothyroxine 112 mcg daily
Discharge [**Telephone/Fax (1) **]:
1. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
2. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day.
3. DILT-XR 240 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. calcium citrate-vitamin D3 200 mg(calcium) -250 unit Tablet
Sig: One (1) Tablet PO once a day.
6. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
8. levothyroxine 112 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
- Atrial fibrillation with rapid ventricular rate
Secondary Diagnoses:
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 12424**], you were admitted to the hospital after you were
found on the floor of your bathroom, unable to get up. At that
time, you had a very high fast rate, likely from the fact that
you hadn't been taking your [**Known lastname 4982**] to help slow down your
heart. You were admitted to our hospital to further manage your
heart rate. Your physicians and family were concerned about your
fall, as this has happened before, and recommended that you have
somebody nearby to assist you at all times.
When you leave the hospital:
1. STOP taking Hydralazine 35 mg by mouth three times a day
2. DECREASE your dose of Metoprolol to 50 mg twice a day
(previously you had been taking 100 mg twice a day)
Your primary care physician can make changes to these
[**Known lastname 4982**] as needed.
We did not make any other changes to your [**Known lastname 4982**], so please
continue to take them as your normally do.
On your CT scan of your head, we noted that there was a small
area of the skull that was slightly less dense than the rest of
your skull. Please have your primary care doctor evaluate this
further.
Followup Instructions:
Please be sure to keep all of your followup appointments as
listed below.
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26658**]
When: Tuesday [**2119-11-21**] at 10:30 AM
Location: PHYSICIAN ASSOCIATES AT [**Hospital3 **]
Address: [**Hospital3 26659**] [**Apartment Address(1) 26660**], [**Hospital1 **],[**Numeric Identifier 26661**]
Phone: [**Telephone/Fax (1) 26662**]
|
[
"42731",
"5849",
"5990",
"4019",
"2449",
"2859"
] |
Admission Date: [**2182-7-14**] Discharge Date: [**2182-7-25**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Mental Status changes status post fall
Major Surgical or Invasive Procedure:
IR guided PEG placement
History of Present Illness:
Pt is a 89yo man w a PMH of Alzheimer's who presents s/p
unwitnessed fall with +LOC, unresponsiveon EMT arival, evaluated
at OSH where a head CT showed SAH, decision was made to transfer
the patient to [**Hospital1 18**], Hemodynamically stable throughout transfer
and in the ED at [**Hospital1 18**]
Past Medical History:
Alzheimers Disease
HTN
Hypercholesterolemia
depression
BPH
s/p TURP
Hard of Hearing
Bilateral cataracts
Social History:
EtOH neg
Tob neg
Physical Exam:
On admission:
VS: 97.4 90 176/75 18 97% RA
Gen: slightly aggitated
HEENT: c-collar on, R forehead laceration, PERRL,EOMI
Chest: CTAB
CVS:RRR
Abd: soft, NT/ND
Ext: multiple ecchymosis, no edema,pulses +2 throughout
Neuro: alert,unable to follow commands, MAE
Pertinent Results:
[**2182-7-14**] CT HEAD WITHOUT IV CONTRAST: A focal area of increased
density is seen within the right temporoparietal sulci,
consistent with a focus of subarachnoid hemorrhage. No other
foci of subarachnoid hemorrhage are seen. No subdural or
intraparenchymal hemorrhages identified. The ventricles and
sulci are prominent, consistent with age-related atrophic
change. There is decreased attenuation in the periventricular
white matter, consistent with changes relating to chronic small
vessel ischemic infarct. There is extensive calcification of the
carotid arteries bilaterally. The basilar artery appears
tortuous. The soft tissue and osseous structures are within
normal limits.
IMPRESSION: Subarachnoid hemorrhage in the right temporoparietal
region.
Speech and Swallow eval [**2182-7-22**]
SUMMARY / IMPRESSION:
The pt did not appear aware of food in his mouth and is not
responding to feeding utensils or food in his mouth. He is not
safe to try to feed and PEG placement is recommended as an
alternate route for nutrition/hydration/medication.
RECOMMENDATIONS:
1.Pt should remain strictly NPO with PEG placement recommended
for nutrition/hydration/meds
2.Pt should receive rigorous oral care
[**2182-7-21**] 07:20AM BLOOD WBC-7.3 RBC-3.93* Hgb-12.1* Hct-35.1*
MCV-89 MCH-30.8 MCHC-34.4 RDW-13.6 Plt Ct-380
[**2182-7-14**] 01:06AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.4* Hct-32.8*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.3 Plt Ct-352
[**2182-7-21**] 07:20AM BLOOD Glucose-94 UreaN-26* Creat-0.8 Na-141
K-4.1 Cl-105 HCO3-25 AnGap-15
[**2182-7-14**] 01:06AM BLOOD Glucose-102 UreaN-17 Creat-1.2 Na-127*
K-4.5 Cl-94* HCO3-23 AnGap-15
[**2182-7-14**] 01:06AM BLOOD CK(CPK)-110
[**2182-7-14**] 01:06AM BLOOD CK-MB-4 cTropnT-0.01
[**2182-7-21**] 07:20AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4
[**2182-7-14**] 01:23PM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.1 Mg-1.7
[**2182-7-16**] 04:06AM BLOOD TSH-2.3
[**2182-7-14**] 03:20AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2182-7-14**] 03:20AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0-2
Brief Hospital Course:
Pt was a trauma transfer from an OSH where he was found to have
a Right tempoparietal SAH, on presentation he did not follow
commands but otherwise had a non-focal neuro exam. Neurology
and Neurosurgery were consulted regarding the patients MS change
and management of his SAH, respectively. Neurology suggested
and EEG which was read as inconsistent with seizure activity,
making this an unlikely contributor to his MS change.
Neurosurgery evaluated the SAH with serial head CTs which showed
stable SAH and used Dilantin for prophylaxis. After running
several test to further evaluate his dementia, the consensus
among teams was that his changes in mental status were due to
his SAH on top of his underlying dementia, the patient's mental
status failed to improve and a speech and swallow eval revealed
that he was unable to protect his airway with POs. The decision
was then made to insert a PEG and tube feeds were started. On
discharge the patient was afebrile, hemodynamically stable, and
alert, but was still unable to follow commands and was at best
oriented to self only.
Medications on Admission:
Zestril
Flomax
Aricept
Liptior
Lexapro
Namenda
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: 10ml PO BID (2
times a day).
10. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for pain/fever.
11. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED): 0-70 mg/dL [**1-6**] amp D50;
71-120 mg/dL 0 Units;
121-160 mg/dL 3 Units;
161-200 mg/dL 6 Units;
201-240 mg/dL 9 Units;
241-280 mg/dL 12 Units;
281-320 mg/dL 15 Units;
321-360 mg/dL 18 Units
.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]-northshore
Discharge Diagnosis:
Left parietal Subarachnoid Hemmorhage
Dementia
Discharge Condition:
Stable
Discharge Instructions:
Take medications as perscribed, follow up as indicated. Return
to the Emergency Department if you develop high fevers (>101.5),
severe headache, Nausea, Vomiting, or other concerns.
Followup Instructions:
Follow up with:
Neurology: call ([**Telephone/Fax (1) 2528**] for an appointment in [**4-10**] weeks
regarding the patient's dementia
Neurosurgery: call ([**Telephone/Fax (1) 88**] for an appointment in 6 weeks,
with Dr. [**Last Name (STitle) **] regarding the patient's intercranial bleed
Trauma clinic: regarding removing the cervical collar call ([**Telephone/Fax (1) 4336**] for an appointment in 2 weeks or next available
appointment
Your primary care doctor as needed
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"5990",
"2761",
"4019",
"2720"
] |
Admission Date: [**2161-2-13**] Discharge Date: [**2161-3-5**]
Date of Birth: [**2119-3-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 41 year old
right-handed male CD4 count of 80, viral load of 150 in
[**2160-11-4**] with a past medical history significant for
thoracic spine muscle injury presenting with rapid onset
progressive sensory and motor deficit. The patient notes the
injury to his back in the area between the scapula about
three years prior and has had pain muscle pain in the
vicinity since. He woke up with this type of pain eight days
ago with mild relief of symptoms of Tylenol. The pain has
been worsening over the last couple of days. Initially the
patient describes a band-like compression around his torso
area, this type of band has increased to a point where two
days prior he woke up at 4 in the morning with abdominal
muscle feeling extremely tense. The patient was seen in the
Emergency Room one day prior and was discharged with muscle
spasm therapy. The patient notes that since yesterday
afternoon he has had total numbness from the toes, initially
moving upwards in the last 24 hours. During the course of
the day today he has had onset of weakness in the lower
extremities.
DR.[**Last Name (STitle) 95373**],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2161-3-5**] 14:52
T: [**2161-3-5**] 16:20
JOB#: [**Job Number 41650**]
|
[
"4280",
"3051"
] |
Admission Date: [**2104-6-23**] Discharge Date: [**2104-7-6**]
Service: CME
HISTORY OF PRESENT ILLNESS: This is an 83-year-old male with
a complex cardiac past medical history notable for CAD status
post CABG in [**2094**] and MI in [**2103**] with ventricular
fibrillation arrest, CHF with EF about 30 percent, PAF, CRF,
followed in the [**Hospital 1902**] Clinic by Dr. [**First Name (STitle) 2031**] with chronic
decompensated CHF poorly responsive to outpatient diuresis
and recently worsening CRF, now admitted with approximately a
three-day history of worsening dyspnea on exertion. Also
lower extremity edema, but denies PND/orthopnea/chest pain.
Noticed increased face and leg swelling for as long as 15
days and mild dyspnea on exertion. Usual exercise tolerance
is approximately 100 meters; now he is only able to walk 50
meters. Denies nausea/vomiting/abdominal pain/back pain.
Reports weight is approximately 140 pounds, only 1 to 2 pound
weight gain over his normal dry weight. Otherwise, he feels
well. No recent illnesses, fevers, or chills.
PAST MEDICAL HISTORY: CAD status post MI in [**2103**]. Status
post CABG in [**2094**] (LIMA-LAD, SVG to PDA, SVG to OM). Status
post MVR in [**2094**] (St. [**Male First Name (un) 923**]).
CHF with an EF of 30 percent to 40 percent from
echocardiogram in [**2102**] and 1 plus AR.
PAF on Coumadin.
Chronic renal insufficiency. Baseline creatinine 2s, most
recently 3.4 on [**2104-6-12**].
Hypertension.
Hypercholesterolemia.
TIA.
GERD.
Ventricular fibrillation arrest in [**2103**].
Hypothyroidism.
Right renal mass.
Anemia.
MEDICATIONS:
1. Hydralazine 25 mg p.o. t.i.d.
2. Imdur 60 mg q.d.
3. Lasix 40 mg q.d.
4. Amiodarone 200 mg q.d.
5. Lovastatin 20 mg q.d.
6. Toprol XL 100 mg q.d.
7. Synthroid 75 mcg q.d.
8. Coumadin 1 mg alternating with 0.5 mg q.d.
9. Protonix 40 mg q.d.
10. Temazepam h.s.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a
nonsmoker and nondrinker. He was previously a general
surgeon in [**Country 532**].
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission, temperature 92.3 degrees
p.o., 93.5 degrees axillary, on repeat 94.8 degrees axillary;
blood pressure 130/80, heart rate 50, respirations 16;
saturation 87 percent on room air, 98 percent on 2 liters.
Pleasant, elderly male lying at 30 degrees in no acute
distress, speaking in three-quarter sentences. HEENT:
Mucous membranes moist. JVD to angle of jaw 30 degrees. No
bruits. Cardiovascular: Regular rate and rhythm. S1,
mechanical S2. No S3 or S4. Lungs: Few crackles left base
greater than right base. Faint lower field expiratory
wheezes. Abdomen: Bowel sounds present, soft, nontender,
and nondistended. No masses. Liver edge 2 to 3 cm below
costal margin. No splenomegaly. Extremities: Chronic
stasis changes; 1 to 2 plus pitting, symmetric edema to knees
bilaterally.
LABORATORY DATA: Laboratory values significant for a
hematocrit of 31.3, a creatinine of 3.6, and an INR of 3.5.
HOSPITAL COURSE: Congestive heart failure. The patient was
admitted and immediately started on Natrecor. The patient
tolerated it well and it was able to be increased over the
next few days. Lasix was held given elevated creatinine. On
[**2104-6-25**], dopamine was added at low dose to help better
diurese the patient. This was continued and the patient
diuresed 1 to 2 kg over the next few days. The patient was
continued on his beta-blocker and he was also continued on
hydralazine for afterload reduction. He was not on an ACE
given his creatinine insufficiency. While the patient had an
intermittent stay in the CCU for rapid atrial tachycardia, on
discharge from the CCU, he was continued on Natrecor with
Lasix boluses and was able to be diuresed further and on
discharge was felt to be at his baseline in terms of dry
weight with improved JVD, though never completely improved
(thought to be secondary to patient's tricuspid
regurgitation).
Rhythm. The patient had a history of paroxysmal atrial
fibrillation, but was in regular sinus rhythm through the
early part of his admission. He was continued on amiodarone.
Coumadin was given for an INR goal of 2.5 to 3.5, though he
was supratherapeutic on admission and it was initially held.
On [**2104-6-29**], the patient was found by the ninth floor to be
in rapid atrial tachycardia with a heart rate of 120s,
initially thought to be atrial fibrillation. The patient
also had a 6/10 chest pain, which was nonradiating and was
reported to be different from his anginal pain. The
patient's blood pressure was 90/60. His dopamine and
Natrecor were held and Lopressor was given at this time. His
blood pressure decreased to systolic 80s and high 70s.
Because of the hypotension and rapid atrial rate, which
continued even after the Lopressor, the patient was
transferred to the CCU. In the CCU, patient was reloaded on
amiodarone although he initially was controlled with an
esmolol gtt and a Neo-Synephrine gtt. These were quickly
weaned off. Etiology of the patient's hypotension was
thought to be rate related, also from possible sepsis as the
patient was found to have a UTI. On discharge from the CCU,
the patient's heart rate was 86 on the amiodarone as well as
metoprolol.
Coronary artery disease. The patient was without chest pain
until his transfer to the CCU when he did experience chest
pain, which was nonradiating with any minimal exertion. The
patient was controlled with a nitroglycerin drip in the CCU.
On transfer, this was able to be weaned off and the chest
pain was thought to be related to the patient's fast rate.
In addition, the patient is known to have severe three-vessel
disease, but it was decided that medical management would be
the best way for treating the patient's known coronary artery
disease given his many comorbidities. The patient agreed to
this plan as well. After transfer to the floor, the patient
was able to be switched to Imdur for his anginal pain and
really was without further pain on the floor. He was also
continued on aspirin and Lipitor and a beta-blocker.
Valvular. The patient has a known St. Jude's valve as well
as severe TR. His INR was maintained at 2.5 to 3.5, though
he was supratherapeutic at one time.
ID. The patient was found to have a urinary tract infection
in the CCU, which was probably related to instrumentation.
The urinary tract infection grew Citrobacter and
Enterobacter. This was sensitive to Levaquin, and he was
continued for a 14-day course. The patient's Foley catheter
was discharged.
Renal. The patient's creatinine hovered around the 3s during
his entire admission. On discharge, when patient was more
euvolemic it was down to 3.0, which was the best it had been
during his hospital course. This will be followed closely by
the [**Hospital 1902**] Clinic on discharge. All of his medications were
renal dosed during his hospital course. The patient has a
known renal cell carcinoma that is seen on CAT scan. Again,
because of the patient's comorbidities, no surgical or
chemotherapeutic interventions have been planned, and this
will be a watch-and-wait carcinoma. The patient is aware of
this problem and agrees with the plan.
Heme. The patient's INR was supratherapeutic during much of
his admission. The patient required two units of blood on
[**2104-7-3**] for a slowly dropping hematocrit, though the patient
remained guaiac negative. He was noted, on [**2104-7-3**], to have
some abdominal tenderness and a hard mass in his abdomen. A
CT without contrast showed a rectus sheath hematoma and this
was thought to be the site of the patient's blood loss. The
area was monitored and the patient's hematocrit remained
stable for the rest of his hospital course and on discharge
was 31.7, which was his baseline. The patient was discharged
on a lower dose of Coumadin than he had been on previously.
The patient was restarted on Epogen, which he had been on as
an outpatient for his anemia. He will be continuing this as
an outpatient.
Access. On the floor, the patient had peripheral IV access,
but in the CCU, the patient required a right EJ to IJ line.
This was done without complications and was discontinued on
[**2104-7-4**] with some bleeding, which was controlled with
pressure.
Hypothyroid. The patient was continued on his Synthroid dose
as usual.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES: Congestive heart failure.
Mitral valve repair.
Coronary artery disease.
Paroxysmal atrial fibrillation.
Urinary tract infection.
Rectus sheath hematoma.
DISCHARGE FOLLOWUP: Dr. [**First Name (STitle) 2031**] in two weeks.
Dr. [**Last Name (STitle) **], PCP, [**Name10 (NameIs) **] one week.
VNA for INR checks.
DISCHARGE MEDICATIONS:
1. Synthroid 75 mcg 1 p.o. q.d.
2. Pantoprazole 40 mg 1 p.o. q.d.
3. Aspirin 325 mg 1 p.o. q.d.
4. Epogen 3,000 units subcutaneous Monday, Wednesday, and
Friday.
5. Amiodarone 200 mg 1 p.o. b.i.d.
6. Lasix 40 mg 1 p.o. b.i.d.
7. Levaquin 250 mg 1 p.o. q.48 h. x7 days.
8. Lovastatin 20 mg 1 p.o. q.d.
9. Imdur 30 mg 1 p.o. q.d.
10. Metoprolol 25 mg 1 p.o. b.i.d.
11. Coumadin 1 mg every Monday, Wednesday and Friday.
12. Coumadin 0.5 mg every Tuesday, Thursday, Saturday,
and Sunday.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], [**MD Number(1) 93747**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2104-8-21**] 11:25:09
T: [**2104-8-21**] 14:43:41
Job#: [**Job Number **]
|
[
"4280",
"42731",
"5990",
"40391",
"2720",
"V5861",
"2449"
] |
Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-27**]
Date of Birth: [**2075-8-31**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Adhesive Tape / Vancomycin
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
74 yo F with h/o GI AVMs but none on scope 1 year ago, on
warfarin for mechanical mitral valve. Showed up at [**Hospital 191**] clinic
and had an episode of coffee ground emesis there. Denies fever,
chills, chest pain.
.
In the ED, initial vs were: 97.4 70 130/35 100. Patient reported
as having pallor and appearing fatigued at presentation. NG
lavage initially with scant coffee grounds and cleared on second
500 mL lavage. HCT at 23.4 in ED down from 33 on [**2150-6-15**].
Patient was crossmatched for six units. No vitamin K or FFP
given in the ED. Receiving first unit of PRBC at time of signout
to floor. Vitals at time of signout to ICU were T afebrile, HR
76, BP 136/76, RR 16, O2Sat 100% RA. GI reportedly aware of
patient and planning to scope in AM unless becomes unstable.
.
Upon arrival, patient appears fatigued, pale. Her husband
describes that she was recently admitted for acute decompensated
right sided heart failure and was aggressively diuresed. She was
discharged to home and about 24 hours later began to have
worsening nausea and began to vomit. She vomited for several
days without evidence of coffee grounds or hematemesis, and
reduced PO intake. She eventually came in to [**Company 191**] for further
evaluation where she vomited and was found to have coffee
grounds in her emesis and was sent to the ED. The only recent
medication changes were that her spironolactone was increased
from 25mg to 100mg, and that she was told to stop taking her
diovan. She has had no sick contacts or travel. She admits to
chills but no fevers. No diarrhea or abdominal pain, no dysuria
or shortness of breath.
.
Review of systems:
(+) Per HPI
(-) Denies fever, 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. Rheumatic mitral valve disease s/p valvuloplasty in 01/90,
s/p St-Judes MVR in 03/[**2144**]. s/p multiple cardiac
catheterizations with clean coronaries.
2. H/o LGIB thought to be secondary to AVM's
3. Atrial fibrillation.
4. S/P VVI placement for symptomatic bradycardia in [**2120**], now
s/p two replacements with last replacement in [**2143**]
5. DM type 2
6. History of CHF
7. Hypercholesterolemia
8. History of hepatic congestion of unclear etiology with
multiple abdominal ultrasounds over last few years, as well as
history of hemangiomas improved after MVR
9. Depression
10. Breast mass with negative work-up.
11. Vitamin B12 deficiency anemia.
Social History:
- Tobacco: none
- Alcohol:none
- Illicits:none
She is married with 3 children, lives with her husband in
[**Name (NI) 4047**]. No history of EtOH or tobacco use. Originally from
[**Country 5881**]. Worked running a pizza shop on mass ave but now not
able to work due to CHF.
Family History:
Mother with diabetes, lived to 92
Physical Exam:
Vitals: T: BP: 139/38 P: 70 R: 18 O2: 99% 2L
General: Fatigued, somewhat somnolent but arousable
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles.
CV: Regular rate and rhythm, III/VI holosystolic murmur heard
best at LLSB with mechanical S1.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. Significant hepatomegaly with
liver edge palpated to 4 finger-breadths below the costal
margin.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Cardiology Report ECG Study Date of [**2150-6-19**] 2:09:36 PM
Ventricular paced rhythm. Compared to the previous tracing of
[**2150-6-18**] there is no change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 0 176 462/477 0 -74 109
Radiology Report CHEST (PRE-OP AP ONLY) PORT Study Date of
[**2150-6-22**] 12:25 AM
SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: Severe
multichamber
cardiomegaly, pulmonary vascular engorgement and right basal
septal thickening persist. The patient is status post mitral
valve replacement. There are multiple median sternotomy wires in
unchanged position. The left chest wall pacemaker is in
unchanged position. There is no large pleural effusion,
consolidation or pneumothorax.
IMPRESSION: Persistent severe cardiomegaly. Probably no acute
decompensation.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2150-6-23**]
2:30 PM
FINDINGS: The hepatic veins and their confluence are markedly
distended,
consistent with provided history of heart failure. The hepatic
echotexture is normal, without evidence of a focal lesion. The
main portal vein is patent with hepatopetal flow, with
pulsatility again reflective of right heart failure. Small
gallstones are present within the gallbladder, without secondary
findings for cholecystitis. There is no intra- or extra-hepatic
biliary ductal dilatation with the CBD measuring 2 mm. The
spleen is normal in size measuring 11 cm. No ascites is evident.
The pancreas is normal in echotexture, without evidence for
peripancreatic or fluid collection. No pancreatic ductal
dilatation or calcifications are evident.
IMPRESSION:
1. No peripancreatic fluid identified.
2. Markedly distended hepatic veins and pulsatility of the
portal vein,
compatible with provided history of tricuspid regurgitation.
3. Cholelithiasis.
CT ABD W&W/O C Study Date of [**2150-6-25**] 11:09 AM
FINDINGS:
In the liver, segment IV hypodense lesion measuring less than 1
cm is again identified, too small to characterize, but unchanged
from prior study.
IMPRESSION:
1. No CT evidence of acute pancreatitis or complications
thereof, including no peripancreatic stranding, peripancreatic
fluid collections, vascular compromise, or evidence of
pancreatic necrosis.
2. Findings reflecting known congestive failure, including
marked dilation of the IVC and hepatic veins, contrast reflux
into the venous system on arterial phase imaging, heterogeneous
hepatic parenchymal perfusion, and periportal edema/gallbladder
wall edema secondary to third spacing.
3. Multiple bilateral low-attenuation renal lesions, previously
characterized as cysts by ultrasound.
[**2150-6-19**] 02:00PM BLOOD WBC-10.8 RBC-3.10*# Hgb-7.8*# Hct-23.4*#
MCV-76* MCH-25.3* MCHC-33.5 RDW-16.4* Plt Ct-306
[**2150-6-27**] 05:55AM BLOOD WBC-9.9 RBC-3.36* Hgb-9.1* Hct-28.4*
MCV-85 MCH-27.2 MCHC-32.2 RDW-17.1* Plt Ct-220
[**2150-6-19**] 02:00PM BLOOD Neuts-90.7* Lymphs-5.5* Monos-3.2 Eos-0.2
Baso-0.4
[**2150-6-19**] 02:00PM BLOOD PT-51.9* PTT-30.0 INR(PT)-5.7*
[**2150-6-22**] 12:40PM BLOOD PT-29.6* INR(PT)-2.9*
[**2150-6-25**] 05:45AM BLOOD PT-20.3* PTT-33.6 INR(PT)-1.9*
[**2150-6-27**] 05:55AM BLOOD PT-22.3* INR(PT)-2.1*
[**2150-6-19**] 02:00PM BLOOD Glucose-282* UreaN-174* Creat-1.7*
Na-125* K-3.8 Cl-77* HCO3-28 AnGap-24*
[**2150-6-20**] 09:33AM BLOOD UreaN-130* Creat-1.3* Na-139 K-3.2*
Cl-93* HCO3-36* AnGap-13
[**2150-6-21**] 03:45AM BLOOD Glucose-129* UreaN-70* Creat-1.0 Na-140
K-3.4 Cl-101 HCO3-34* AnGap-8
[**2150-6-27**] 05:55AM BLOOD Glucose-180* UreaN-20 Creat-0.9 Na-136
K-4.3 Cl-98 HCO3-32 AnGap-10
[**2150-6-19**] 02:00PM BLOOD ALT-13 AST-22 CK(CPK)-23* AlkPhos-119*
TotBili-0.6
[**2150-6-22**] 06:00AM BLOOD ALT-18 AST-29 LD(LDH)-220 CK(CPK)-20*
AlkPhos-89 TotBili-0.8
[**2150-6-27**] 05:55AM BLOOD ALT-14 AST-20 AlkPhos-110*
[**2150-6-19**] 02:00PM BLOOD Lipase-138*
[**2150-6-22**] 06:00AM BLOOD Lipase-146*
[**2150-6-19**] 02:00PM BLOOD cTropnT-0.03*
[**2150-6-22**] 06:00AM BLOOD CK-MB-2 cTropnT-0.03*
[**2150-6-27**] 05:55AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.3
[**2150-6-24**] 05:40AM BLOOD calTIBC-391 VitB12-442 Ferritn-76 TRF-301
[**2150-6-23**] 05:40AM BLOOD Triglyc-85
[**2150-6-21**] 03:45AM BLOOD Digoxin-1.6
Brief Hospital Course:
74 yo F with history of right sided CHF admitted with UGIB found
to have acute renal failure in the setting of aggressive
diuresis, presenting with GI bleed.
#. Upper GI Bleed-
The patient was admitted to the MICU after having coffee ground
emesis at [**Company 191**]. She was placed on a protonix drip and received 2
units of pRBCs and 2 units of FFP while in the ED prior to
admission to the MICU. Due to her mechanical valve, her
supratherapeutic INR was not reversed with vitamin K. She
underwent an EGD on MICU day 2 which showed evidence of erosive
gastritis. She had no further bleeding after the EGD and was
called out to the floor, with her diet being advanced to clears.
She has a known history of AVMs in her small bowel and colon,
which could have contributed to GI bleed, but bleeding was felt
to be secondary to gastritis. Patient's Hct trended downwards
slowly on floor, and she was transfused 1u pRBCs, after which
her Hct was stable for several days. Aspirin was held and may
be restarted by primary care physician in the future if felt to
be safe.
# Anticoagulation s/p Mechanical Mitral Valve and Paroxysmal
Afib
Upon discharge, INR was subtherapeutic for mechanical mitral
valve, felt to be secondary to poor absorption of warfarin when
taken with sucralfate, which was discontinued upon discharge.
She was initially on enoxaparin bridge until noted to have slow
Hct drop on floor; enoxaparin bridge was stopped because of GI
bleed risk -- risk for stroke in a few days felt to be less than
risk of GI bleed. INR should be rechecked on Monday at followup
appointment.
#. Acute Renal Failure -
Her creatinine was rising upon discharge from her last admission
after aggressive diuresis and symptoms of nausea and vomiting
very likely related to marked uremia with BUN of 174 on
admission. BUN/creatinine ratio and urine electrolytes were in
keeping with a pre-renal cause. Patient was noted to be
auto-diuresing in MICU, which may have been post-ATN diuresis.
Patient did take low dose valsartan for 1-2days post discharge
when creatinine was elevated after aggressive diuresis; this may
have exacerbated an ATN. Patient has also had poor po intake for
several days, likely worsening prerenal state at home prior to
presentation, worsening uremia. On the floor, kidney function
was stable at baseline 0.9, and patient was re-started on po
diuretic regimen.
#. Right sided heart failure -
Managed by Dr. [**First Name (STitle) 2031**] at [**Hospital2 **] [**Hospital3 **]'s with recent admission
for decompensation. She was intravascularly volume deplete from
aggressive diuresis and UGIB. Diuresis was held during her ICU
stay and she was given gentle IV fluids. Upon transfer to
floor, a po diuretic regimen was started after a few of days of
monitoring GI bleed and question pancreatitis. She was
discharged on spironolactone 25mg and furosemide 120mg daily.
She was restarted on low dose valsartan, which she was on
previous to the last hospitalization, for cardioprotection.
#. Pancreatitis -
Patient was noted to have epigastric pain radiating to the back
with eating, initially attributed to her gastritis, though she
likely had some component of pancreatitis. Her lipase was
elevated to 140s, and she complained of pain and nausea. She
tolerated a diet of clears for a few days, and diuresis was held
initially. Abdominal ultrasound and pancreatic protocol CT did
not show any signs of gallstone pancreatitis, peripancreatic
fluid or pseudocyst.
#. Cholelithiasis -
Patient was noted to have gallstones on abdominal ultrasound.
She intermittently complained of right sided scapular pain which
may be secondary to her cholelithiasis. She did complain of
some right side abdominal discomfort radiating to the back with
eating fatty foods. Ultrasound showed no evidence of
cholecystitis. Patient may benefit from general surgery
evaluation as an outpatient.
#. Iron Deficiency Anemia -
Patient has chronic iron deficiency anemia, for which she takes
iron supplements. She does have known AVMs and newly discovered
erosive gastritis with no signs of ulcers on EGD. B12 and
folate are not low.
Medications on Admission:
Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
Calcium Carbonate
Ferrous Sulfate 325 mg [**Hospital1 **]
Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
Omeprazole 20 mg Capsule daily
Warfarin 5 mg Tablet
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Spironolactone 100 mg Tablet daily
Furosemide 80mg [**Hospital1 **]
Discharge Medications:
1. 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*
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
3. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Calcium Carbonate-Vitamin D3 600 mg(1,500mg) -400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:
PRN.
Disp:*60 Capsule(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Upper GI Bleed
Secondary Diagnoses:
Iron Deficiency Anemia
Chronic Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 93554**],
You were admitted to the hospital because you had vomited up
some dark blood which was concerning. Your blood counts
dropped, so you were given blood transfusions. You had an upper
endoscopy while in the ICU; with the small camera, they were
able to look inside your stomach and the beginning part of your
small intestine and saw that you have bad gastritis, which means
that your stomach lining is very inflamed. They did not see any
ulcers.
While you were here, you kidney function appeared to become
normal. You have a little bit of extra fluid but it is stable.
Please weigh yourself every morning, call your doctor if weight
goes up more than 3 lbs. Please remember to avoid as much
sodium/salt in your food and drink as possible.
While you were in the hospital, we also found that your pancreas
was a little inflamed for a little while, but it improved. Your
gall bladder has some stones, but it is not clear whether this
is causing your right sided back pain or not. When you see Dr.
[**Last Name (STitle) **] in [**Month (only) 205**], you may discuss this issue with him and whether
or not you should go to General Surgery clinic to be evaluated
or not.
The following changes have been made to your medications:
- Please INCREASE your furosemide back to your old dose of 120mg
daily
- Please DECREASE your spironolactone dose back to your old dose
of 25mg daily
- Please RESTART your valsartan (Diovan) 40mg daily
- Please START pantoprazole 40mg TWICE daily to reduce your
stomach acid
- Please STOP your aspirin 81mg for now because it can irritate
your stomach further
- Please start calcium carbonate with Vitamin D3 TWICE daily
- you may take Tylenol Extra Strength (500mg) for pain at home--
Please do not take more than 4 of these pills per day (2 grams
total)
- You may take Docusate (Colace) stool softeners TWICE daily to
help soften your stool and make it easier for you to pass bowel
movements
Your visiting nurse should check your blood pressure when she
visits your home to make sure it is not too low and to make sure
you are not having symptoms of lightheadedness or dizziness.
You will also need to have your INR (coumadin level) checked on
Monday at your primary care appointment at [**Hospital **].
Please also remember to check your blood sugars every morning
and two hours after finishing lunch. Please do not drink juice
as this will raise your blood sugar.
Followup Instructions:
Please be sure to keep all of your followup appointments as
listed below.
Department: [**Hospital3 249**]
When: MONDAY [**2150-6-29**] at 11:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
--> At this first visit, please have your INR (coumadin level)
checked.
Department: GASTROENTEROLOGY
When: MONDAY [**2150-7-6**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2150-7-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], 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
Department: [**Hospital3 249**]
When: TUESDAY [**2150-7-28**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2150-8-11**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"5845",
"4280",
"2720",
"25000",
"42789",
"V5861",
"42731"
] |
Admission Date: [**2142-11-5**] Discharge Date: [**2142-11-16**]
Service: Neurosurgery
ADMISSION DIAGNOSIS: Subdural hematoma.
CHIEF COMPLAINT: History of falling down.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old white
female with a history of hypertension, transient ischemic
attacks, multiple falls, and a history of idiopathic
thrombocytopenic purpura; who according to her son had fallen
at least three times in the last two weeks prior to
admission.
On the morning of admission, a [**Hospital6 407**]
nurse found the patient on the ground, called 911, and the
patient was sent to the [**Hospital6 2561**]. The patient
seemed to have slurred speech at that time and therefore
received CT scan and found to have a subdural hematoma and
was subsequently transferred to the [**Hospital1 190**].
PAST MEDICAL HISTORY: (Past medical history includes)
1. History of transient ischemic attack.
2. History of hypertension.
3. Chronic obstructive pulmonary disease.
4. Multi-infarct dementia.
5. History of abdominal aortic aneurysm 6 cm in size.
6. History of diverticulitis.
7. History of idiopathic thrombocytopenic purpura.
8. History of several falls and a fracture of the left femur
and right ankle in the past, and a hip repair to the left in
the past.
MEDICATIONS ON ADMISSION: Medications include aspirin,
Norvasc, Zoloft.
ALLERGIES: There were no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination the patient was afebrile with a blood pressure
of 141/68, heart rate 81, respiratory rate 25, and oxygen
saturation of 99% on 3 liters nasal cannula. She was awake
and oriented to hospital but thought it was [**2101-11-3**].
Her speech was slurred but somewhat fluent, and she followed
commands. The pupils were 3 mm bilaterally and reactive to
2 mm bilaterally. Extraocular movements showed a question of
an upward gaze limitation. Visual fields were grossly intact
to confrontation. Face was symmetric. Palate and tongue
were midline, and shoulder shrug was symmetric. Motor
examination showed a slight right-sided drift, and reflexes
were hyperreflexic on the right with the right toe going up.
The remainder of the physical examination including the ears,
nose, throat, heart, lungs, and abdomen was essentially
unremarkable.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories showed a white blood cell count of 9, hematocrit
of 29.1, platelet count of 499. Chem-7 revealed sodium
of 134, potassium 4.2, chloride 98, bicarbonate 27.3, blood
urea nitrogen 9, creatinine 0.5, and blood glucose was 89.
Coagulations revealed PT was 13.4, PTT was 23.7, and INR
of 1.1. Creatine kinase and troponin were negative on
admission.
HOSPITAL COURSE: Due to the clinical findings, the patient
was admitted to the Surgical Intensive Care Unit and seen by
Dr. [**Last Name (STitle) 6910**] as the attending who felt the patient would
require evacuation of the subdural hematoma.
The patient was therefore taken to the operating room on
[**2142-11-6**] where under general endotracheal anesthesia
the patient underwent a front bur-hole irrigation of subdural
space with evacuation of hematoma and insertion of red rubber
catheter for drainage. The patient tolerated the procedure
well and returned to the Neurologic Intensive Care Unit in
stable condition.
Postoperatively, was noted to be awake and alert but
inattentive and not following commands. There was no speech
output and she was globally aphasic. She was moving all
extremities strongly. A repeat CT scan showed some
improvement in the subdural hematoma, but the catheter was
deep within the hematoma and was therefore pulled back
approximately 1.5 cm, and review of the CT scan by
Dr. [**Last Name (STitle) 6910**] indicated residual subdural collection, and
therefore electively the patient was taken back to the
operating room due to the clinical examination findings of
aphasia, and she underwent a revision of bur holes in the
frontal and parietal area with evacuation of subdural
hematoma and reinsertion of a subdural drain. The patient
tolerated this procedure well and was again returned to the
Neurologic Intensive Care Unit in stable condition. Again,
she was awake and alert but somewhat inattentive following
the procedure. She was noted to be moving all extremities,
left greater than right and had a mild right hemiparesis and
also continued to be aphasic. Furthermore, the patient was
noted to not be following any commands after the second
surgery.
A subsequent repeat CT scan showed adequate drainage of the
subdural hematoma and the subdural drain was removed. The
patient was seen in consultation by the Physiotherapy
Service, and Occupational Therapy Service, and the Nutrition
Service. She was also subsequently transferred from the
Neurosurgical Intensive Care Unit to the neurosurgery
hospital floor, and her condition remained stable until
[**11-16**] when early in the morning she was found to be
pulseless and in cardiopulmonary arrest.
A code was called. The patient was reintubated. A advanced
cardiac life support algorithm for asystole was applied by
the code team, but the patient showed no response, and all
efforts were ceased, and the patient was declared deceased at
7:10 a.m. on [**2142-11-16**].
CONDITION AT DISCHARGE: Deceased.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2143-1-3**] 11:40
T: [**2143-1-5**] 05:21
JOB#: [**Job Number **]
|
[
"496",
"4019"
] |
Admission Date: [**2191-2-10**] Discharge Date: [**2191-2-13**]
Date of Birth: [**2121-10-27**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Balloon angioplasty of distal LAD
History of Present Illness:
69 y/o M h/o severe COPD on 2-4L home O2, CAD (most recent cath
[**2190-8-9**] showed no obstructive dz), admitted for CP. States was
at home, laying in bed watching TV when developed L sided CP
radiating to L arm. Assoc w/ SOB, diaphoresis. Took SL NTG at
home without relief.
.
Taken to [**Hospital 1474**] Hospital by EMS. ECG showed 1-2mm STE v3-v5.
He was started on NTG gtt for BP 200/105 and heparin. He
received ASA 325, Plavix 300, and aggrestat and was medflighted
to [**Hospital1 18**].
.
Also received Solumedrol 125mg, ceftriazone and azithromycin for
COPD flare.
.
Cath showed 90% thrombotic distal LAD, 80% LCx, 90% PDA. There
was diffuse coronary vasospasm that improved w/ 200mg IC TNG.
POBA w/ good result. RHC showed PCWP 39, RA 27, RV 45/18, PA
54/37, Received 40 IV lasix in lab.
.
ROS: significant for stable 2 pillow orthopnea, + PND, + DOE.
His grown children assist with ADLs.
.
Past Medical History:
Hypercholesterolemia
HTN
COPD (chronic 2L O2)
angina
GERD
esophageal strictures
BPH
h/o colonic polyps
S/P Appy
S/P Remote right ankle surgery
S/P Left Hand surgery after traumatic injury
Social History:
Widowed, 3 children; Prev tobacco (~2 packs/week), quit ~ 5
years ago; Denies EtOH, denies illicits.
Family History:
+ CAD
Physical Exam:
VS - BP 122/75, HR 105-115, RR 17, O2 96% 2L O2
gen - in bed, comfortable, NAD
HEENT - OP clr, MMM, JVP difficult to assess as pt supine
CV - RRR, distant
chest - CTAB anteriorly
abd - soft, NT, no g/r
ext - no edema, 2+ bilat DP pulses
Pertinent Results:
Labs on admit:
WBC 8.4, Hct 42.4, MCV 84, Plt 400
(DIFF: Neuts-93.6* Bands-0 Lymphs-5.9* Monos-0.5* Eos-0.1
Baso-0)
PT 13.2*, PTT 31.8, INR(PT) 1.2*
Na 135, K 5.1, Cl 99, HCO3 26, BUN 24, Cr 0.9, Glu 159
ALT 23, AST 14, AlkPh 86, TBili 0.3
Ca 8.8, Ph 4.4, Mg 1.9, Chol 197, TG 46, HDL 51, CHOL/HDL 3.9,
LDL 137*
HbA1c 6.3
ABG: 7.27/290/61
ABG: 7.37/84/46
.
Cardiac enzymes:
[**2191-2-10**] 05:25AM BLOOD CK(CPK)-99 CK-MB-NotDone cTropnT-0.09*
[**2191-2-10**] 11:15AM BLOOD CK(CPK)-156 CK-MB-8 cTropnT-0.09*
[**2191-2-10**] 05:55PM BLOOD CK(CPK)-214* CK-MB-7 cTropnT-0.08*
[**2191-2-11**] 06:15AM BLOOD CK(CPK)-178* CK-MB-6 cTropnT-0.08*
.
Labs on discharge:
[**2191-2-13**] 05:35AM BLOOD WBC-10.0 RBC-4.42* Hgb-12.6* Hct-37.0*
MCV-84 MCH-28.4 MCHC-33.9 RDW-13.5 Plt Ct-376
[**2191-2-13**] 05:35AM BLOOD Glucose-100 UreaN-25* Creat-0.9 Na-138
K-4.1 Cl-99 HCO3-32 AnGap-11
[**2191-2-13**] 05:35AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0
.
Imaging:
[**2191-2-10**] CXR - Hyperinflation reflects severe emphysema. Heart is
normal in size, and there is no pulmonary edema. Tiny left
pleural effusion may be present. No pneumothorax.
.
[**2191-2-11**] Cardiac cath -
1. Selective coronary angiography of this right dominant vessel
revealed
3 vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting lesions. The LAD had mild proximal
disease and a
90% thrombotic lesion in distal vessel?first septal branch (twin
LAD
system). The LCX was a small vessel and had an 80% distal
stenosis. The
RCA was a dominant vessel with mild proximal disease. The PDA
had a 90%
stenosis. The ramus intermedius was a small vessel with mild
diffuse
disease.
2. Resting hemodynamics revealed severely elevated left and
right sided
filling pressures, moderate pulmonary hypertension, and low
cardiac
index of 1.6 L/min/m2.
3. Left ventriculography was deferred.
4. After IC administration of nitroglycerin, flow through the
ramus
intermedius and the LCX improved dramatically suggesting a
componenet of
vasoconstriction.
5. Successful POBA of the distal LAD with a 2.0x15mm balloon
with
excellent results (see PTCA comments).
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severely elevated right and left sided filling pressures.
3. Moderate pulmonary hypertension.
4. Low cardiac index .
5. Acute Anterior MI.
.
[**2191-2-10**] EKG - Sinus tachycardia with Left axis deviation and late
transition. Since previous tracing, no significant change
Intervals Axes
Rate PR QRS QT/QTc P QRS T
107 164 90 346/408.85 77 -48 91
.
[**2191-2-11**] ECHO - The left atrium is normal in size. 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%). 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 ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Brief Hospital Course:
69 yo M w/ PMH of COPD, CAD, HTN and hypercholesterolemia, who
was admitted for STEMI and was found to have coronary vasospasm
and elevated filling pressures on cardiac catheterization.
.
# Ischemia: Mr. [**Known lastname **] had an ST elevation MI and went to the
cath lab for POBA to LAD. The most notable finding on his
catheterization was that his coronaries appeared to be diffusely
spastic and could be dilated with the administration of IV
nitro. His cardiac enzymes peaked at CK of 214, CK MB of 8, and
trop of 0.08 on [**2-10**]. He was continued on aggrestat, since he had
been started on it at the OSH, for a total of 18 hours
post-cath. He was on a nitro gtt on arrival to the CCU, but was
able to be weaned to PO meds shortly thereafter. He was started
on aspirin, plavix, and atorvastatin for his acute coronary
syndrome, an ACE-inhibitor for aid in cardiac remodeling, and
diltiazem and isosorbide mononitrate for relief of coronary
vasospasm. Given his pulmonary disease, no beta-blocker was
given. He tolerated these medications well, with no side
effects.
.
# Pump: Mr. [**Known lastname **] had markedly elevated filling pressures by
R heart catheterization and received IV lasix during the
procedure. However, he had an ECHO on [**2191-2-10**] which showed a
normal EF of 60%. He appeared euvolemic on exam with minimal
diuresis on PO lasix, so it was felt that his respiratory
symptoms and dyspnea were most likely due to his underlying
pulmonary disease. Prior to discharge, Mr. [**Known lastname **] had an
episode of hypotension after getting his PO lasix dose. He was
given additional PO fluids and his BP responded well, so his PO
lasix was discontinued since it was felt that he was euvolemic,
perhaps even hypovolemic, and his ECHO appeared to have a
preserved EF (though likely has diastolic dysfunction). He was
advised to follow-up with his cardiologist, Dr. [**Last Name (STitle) **], who can
decide if he needs to be restarted on lasix.
.
# Rhythm: Mr. [**Known lastname **] was monitored on telemetry and remained
in NSR through the majority of his stay.
.
# COPD: At the OSH, he was given IV steroids, ceftriaxone and
azithromycin for a COPD flare. However, on admission to the CCU,
he had no evidence of a COPD exacerbation (no wheezing, his O2
sats were stable on his home O2 requirement, and had no
dyspnea), so he was not continued on steroids or antibiotics. He
was continued on his home COPD regimen (inhaled steroids, long
acting anticholinergic, and albuterol). Once his cardiac enzymes
had peaked and he was transferred to the stepdown unit, he was
able to ambulate w/ PT and maintain stable oxygen saturations.
He was discharged home with home PT to help improve his
functional status.
.
# FEN: He was put on a low sodium, heart healthy diet. He was
not given any additional IVF after his post-cath hydration. His
electrolytes were checked daily and were repleted to keep his K
>4 and Mg >2.
.
# PPX: He received SC heparin for DVT ppx, protonix for GI ppx,
and colace/senna for a bowel regimen.
.
# Dispo: He was discharged home with services (PT and VNA). He
will follow-up with his PCP and with Dr. [**Last Name (STitle) **] within 2-4 weeks.
Medications on Admission:
Dilt 360 QD
Spiriva
Imdur 180 QD
Buspirone 10 TID
Guaifenesin 600 QID
citalopram 20 QD
Lactase
Pantoprazole 40 [**Hospital1 **]
Ativan 0.5 [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day). Tablet(s)
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
ST elevation MI s/p balloon angioplasty to distal LAD
.
Secondary diagnosis:
COPD
Hypercholesterolemia
HTN
GERD
Esophageal strictures
BPH
Discharge Condition:
Good. Afebrile, BP 92-139/50-81, HR 101, RR 20, sats 97% on 2L
O2.
Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: fever, chills, chest pain,
shortness of breath, jaw or arm pain, nausea, vomiting, leg
pain, leg swelling, numbness or tingling in your legs, or any
other worrisome symptoms.
2. Please continue taking all your medications as prescribed.
3. Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **], in [**2-12**]
weeks. He will help determine if you are eligible for cardiac
rehab and should be able to help you find services in your area.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 17996**] and Dr. [**Last Name (STitle) **] in [**2-12**]
weeks for follow-up after your hospitalization. You have been
started on several new medications so your creatinine and your
potassium levels should be monitored.
2. Please follow up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. You likely need
to have a stress test before you can begin cardiac rehab and he
will help facilitate that for you.
|
[
"496",
"4280",
"41401",
"4168",
"2720",
"4019",
"53081"
] |
Admission Date: [**2120-10-17**] Discharge Date: [**2120-11-14**]
Date of Birth: [**2120-10-17**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was born on
[**2120-10-17**], to a 25 year old gravida 3, para 2 to 3
mom with prenatal screens 0 positive, antibody screen
negative, hepatitis B surface antigen negative, RPR
nonreactive, Rubella immune, Group B Streptococcus negative.
Hew as born at 40 2/7 weeks by normal spontaneous vaginal
delivery. Rupture of membranes 2 1/2 hours prior to
delivery, no fever or prolonged rupture of membranes. His
Apgars were 7 and 9.
He was noted to have an abnormally shaped right ear as well
as a cleft palate on his initial physical examination.
Neonatal Intensive Care Unit was consulted and he was
transferred to our service for further evaluation.
PHYSICAL EXAMINATION: His initial physical examination
yielded a birth weight of 2100 gm, 10th percentile, a head
circumference 33 cm in the 25th to 50th percentile, and a
length of 47 cm, 20th percentile. His head and neck
examination were notable for a C-shaped defect of his hard
and soft palate, a broad nasal bridge, right ear that is low
set, posteriorly rotated and immature cartilage. Chest
examination with normal breath sounds. Cardiovascular
examination with regular rate and rhythm, normal femoral
pulses and no murmur. Benign abdominal examination. Normal
male genitalia with bilaterally descended testes. Neurologic
examination with decreased arousability but symmetric
movements and normal axial tone and a weak suck.
HOSPITAL COURSE:
Respiratory - He has been on room air but through the first
week of his life had occasional periods requiring blow by
oxygen or nasal cannula secondary to desaturations. His
desaturations were most often associated with need for oral
suctioning as secretions and saliva are pooling secondary to
his soft palate defect as well as his inability to coordinate
his swallowing. He has had no desaturations or apnea beyond
this first week of life.
Cardiovascular - He was noted to have a murmur on day of life
No. 5. This was evaluated and an echocardiogram was
performed with a noncritical coarctation noted and his ductus
arteriosus was closed at that time. We have followed this
very closely with right upper extremity and right lower
extremity blood pressures and he has had no periods where the
gradient has been significant. Cardiology is following
closely along with us and he is specifically followed by Dr.
[**Last Name (STitle) 56919**], the cardiology fellow.
On [**2120-11-15**] a repeat echocardiogram was performed as a
preoperative study for a planned G-tube placement scheduled
for Monday, [**11-18**]. The ECHO revealed a severe
coarctation of the aorta with gradients between 55-75 mmHg and
persistent antegrade diastolic flow. The abdominal aortic
flow pattern is nearly continuous low velocity flow. Plan is
to transfer infant to the cardiac unit at [**Hospital3 1810**]
(P6) for cardiovascular repair.
Fluids, electrolytes and nutrition - After consultation with
Plastic Surgery, Baby [**Name (NI) **] [**Known lastname **] was fed with [**First Name8 (NamePattern2) **] [**Last Name (un) 38296**]
nipple, and he has been unable to take adequate volume,
therefore has been gavaged fed. He has had some times of
abdominal distention and emesis but abdominal films have
never revealed anything but mild dilatation of bowel. His
feedings over the last 24 hours have been all gavage feedings
with Similac 24 calorie, we reduced his feed volume to 120
cc/kg/day and increased his calories in the hopes of
minimizing emesis. He has had normal urine output. His
growth has been poor secondary to initial feeding
difficulties as well as periods of NPO and septicemia. His
weight as of this interim summary is 2610 gm.
Due to critical coarctation, the infant was made NPO, started
on standard IV fluids (D10w with 2meqNa/100cc and
1meqKCL/100cc) at 120 cc/k/day.
Gastrointestinal - As mentioned above, he has had episodes of
emesis and abdominal distention. During the third week of
his life he had a gram positive septicemia and was NPO around
that time. When feedings were restarted he had significant
abdominal distention and emesis. An upper gastrointestinal
study was performed at that time and was normal. He has been
receiving gavage feeds over one and a half hours to minimize
any reflux and he was started on reflux medication on
[**11-13**]. He is on Reglan and Ranitidine.
He had a bilirubin of 13.1 on day of life No. 5. He was on
double phototherapy. His bilirubin came down to 8.9 on day
of life No. 7 and his phototherapy had been discontinued over
24 hours at that time.
Hematology - [**Known lastname 122**] had an admission hematocrit of 69 percent
and had desaturations over the first two days of life, so he
received a partial exchange transfusion to reduce his
hematocrit and his repeat hematocrit after that was 63
percent. His most recent hematocrit is 42.4 on [**11-11**].
Infectious disease - He had an initial complete blood count
with a white count of 15.8, platelets 134,000 with 76
neutrophils and 22 lymphocytes. He had a blood culture sent
but was never started on antibiotics after birth. His blood
culture was negative.
He had an episode of decreased perfusion, tone and overall
pallor on [**11-7**]. At that time, complete blood count,
blood culture were sent and he was started on Vancomycin and
Gentamicin. His blood culture grew gram positive cocci in
chains which was later identified as Streptococcus viridans.
He completed a seven day course of antibiotics which was
tailored to Ampicillin once sensitivities had returned. He
had a repeat blood culture the day after antibiotics had been
started that was negative. He had a lumbar puncture that was
performed and was negative prior to his antibiotics being
discontinued on [**11-13**].
Today, [**2120-11-15**] there were concerns about increased
lethargy and decreased activity. Although, this may be due to
severe coarctation the possibility of sepsis and recurrance of
strep viridans sepsis was raised. A repeat blood cx was sent
and the infant was restarted on ampicillin and gentamicin.
Immunology - Secondary to his septicemia and possible
DiGeorge syndrome, we consulted Immunology during the third
week of his life. They recommended sending T cell subsets
and three of his T cell counts were moderately depressed.
Immunology felt that it was not necessary for him to be on
prophylactic antibiotics but that it be investigated further
by T cell mitogen studies that can be performed when he is
transferred over to [**Hospital3 1810**] for his G-tube
placement.
Immunology should be reconsulted at that time. His T cell
results are as follows: He had a total white blood cell
count at that time of 10.6, absolute lymphocytes were 2120,
CD3 count 1726, CD8 count 567, CD4 count 1156.
Genetics - Genetics was consulted on his initial
presentation and we sent karyotype and Fish 22 which were
both normal. They later recommended signature chip testing
which was also negative. These results were reported to the
attending, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] as of [**11-13**]. He also
had a send out laboratory data to a laboratory at [**Last Name (un) 56920**]
[**State 2690**] to test for 10P13 deletion and this test is still
pending. He will follow up with [**Hospital **] Clinic within two
weeks to one month after his discharge from the hospital.
Neurology - Neurology was consulted secondary to Baby [**Name (NI) **]
[**Known lastname **]'s abnormal tone as well as feeding behavior. He had an
magnetic resonance imaging of his head during the first week
of his life which was notable for a thin dysplastic corpus
callosum and absent septum cavum pellucidum and a dysmorphic
brain stem. The neurologist will follow him in Neonatal
[**Hospital 878**] Clinic as well after his discharge.
Surgical:
To P6 for repair of coarctation.
General Surgery has been consulted secondary to
his poor feeding and originally has placed him on the schedule
to have a gastrostomy tube the week of [**11-18**].
He was seen initially by Plastic Surgery who would like to
repair his palate when he is bigger. They should be
contact[**Name (NI) **] upon his arrival to [**Hospital3 1810**] of [**Location (un) 86**]
to inform them of his gastrostomy tube and to whether or not
he should continue oral feedings.
Sensory - Audiology, he has not had a hearing screening yet.
Ophthalmology, he had an ophthalmology examination which
showed telecanthus but was otherwise normal.
Immunizations - He did receive hepatitis B vaccine on day of
life No. 1. He has a state newborn screen that is pending.
MEDICATIONS:
1. Zantac 6mg po q8, started [**11-13**], now on hold.
2. Reglan 0.1 mg po q8, started [**11-13**], now on hold.
3. Ampicillin 410 mg IV q12, started [**2120-11-15**].
4. Gentamicin 11 mg IV q24, started [**2120-11-15**].
DISCHARGE DIAGNOSIS:
1. Cleft palate and other dysmorphology as described above,
syndrome unidentified, possible DiGeorge.
2. Coartation of the aorta.
3. Strep viridans bacteremia, s/p 7 days of antibiotics
(ended [**2120-11-12**]). Current concern for repeat sepsis episode,
restarted amp/gent on [**2120-11-15**].
4. Discoordinated feedings, was to get G-tube on Monday,
[**11-18**].
5. Gastroesophageal reflux.
6. Failure to thrive.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Reviewed and signed by [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern1) 56887**]
MEDQUIST36
D: [**2120-11-14**] 18:06:58
T: [**2120-11-14**] 20:06:33
Job#: [**Job Number 56921**]
|
[
"53081"
] |
Admission Date: [**2105-12-12**] Discharge Date: [**2105-12-25**]
Service: MEDICINE
Allergies:
Penicillins / Iodine-Iodine Containing
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
Mechanical Intubation
Upper Endoscopy
[**Last Name (un) 1372**]-jejunal tube placement
History of Present Illness:
This is an 86 year old female with [**Last Name (un) 499**] cancer and carcinoid
lung cancer recently resected (5 years ago, in remission), known
MAC not being treated, and esophageal motility issues. Admitted
to [**Hospital1 **] [**Location (un) 620**] [**12-8**] c/o dysphasia for several days and found to
have aspiration pneumonia and food impaction.
Per family she had 3 days of diarrhea which was very runny but
not bloody. Nurse thought she had had a virus and gave her
immodium and her diarrhea stopped. Niece spoke with her on
Monday and she said that she was having difficulty swallowing
both solids and liquids -- not even a teaspoon of water without
it coming back up. On Tues she called her PCP who told her to go
to the hospital and get hydrated, as she had not had anything to
drink (that she kept down) for 3 days. She presented to [**Hospital1 **]
[**Location (un) 620**] where they gave her 3L NS and admitted her for [**Last Name (un) **].
Niece visited her Wednesday morning, she was down for an
endoscopy which showed a lot of residual food in her esophagus,
including multiple pills. They pushed it through (took 20
minutes). Also noticed an esophageal web, perfectly benign, but
would try to open it with a balloon the next day. Also did a
barium swallow test on Wednesday which was not definitive in
terms of difficulty swallowing. They decided they wanted a
motility test (not done at [**Hospital1 **] [**Location (un) 620**]). Thursday went down for
second endoscopy to open up web by which point she had spiked a
fever so they postponed the procedure. CXR showed a PNA. Assumed
that she had aspirated and started treatment for aspiration PNA.
Friday morning she was hypoxic to the point of needing a face
mask but needed to breath very hard. Friday night they felt they
needed to intubate her given her difficulty breathing. Intubated
about 1AM Fri-Sat overnight. CT scan this morning showed that
her PNA was worse.
CT scan showed bilateral infiltrates felt to be consistent with
aspiration PNA. An EGD did not show any significant obstruction
but some food particles were partially removed. She initially
did well but then on [**12-11**] she deteriorated and went into
respiratory distress. She remained hypoxic on 100% face mask.
After discussion with the family she was intubated.
Repeat chest CT showed worsening of bilateral multifocal
infiltrates felt most likely consistent with recurrent
aspiration with possible ARDS vs CHF. P/F ratio 58%/100%. No
history of CHF. Probably mostly aspiration PNA. Already on
levoquin and flagyl but added vancomycin.
Had also had some [**Last Name (un) **], had gotten some fluids but not that much.
CT scan which ruled out any mediastinitis. She remained
hemodynamically stable overnight with stable blood gases.
Vancomycin was added on top of Levaquin and Flagyl which she was
already on.
The family feels that because most of her doctors are in [**Name5 (PTitle) 86**]
they would like her transferred. She is being transferred for
further management of respiratory failure, multifocal pneumonia,
and aspiration pneumonia and pneumonitis on this patient.
Upon transfer from [**Hospital1 **] [**Location (un) 620**] VSS and as below. She was
intubated on A/C TV 400 FiO2 0.4. She was hemodynamically stable
not on pressors. Access was only peripherals but they were
trying to get a PICC prior to transfer. No need for CVL.
.
Upon arrival in the [**Hospital Unit Name 153**] she is sedated, intubated, and appears
in NAD.
Past Medical History:
MAC, untreated
lung carcinoid
[**Hospital Unit Name 499**] cancer
Atrial Fibrillation s/p pacemaker placement, stable
HTN, stable
Hypercholesterolemia, stable
Osteoporosis
Status post right hemicolectomy
Status post appendectomy
Status post TAH BSO
.
ONCOLOGIC HISTORY:
[**2099**]: found to have iron deficiency anemia and elevated CEA.
Colonoscopy demonstrated a large cecal mass.
[**2101-1-7**] hemicolectomy with Dr. [**Last Name (STitle) 1924**]; lesion was T3N0M0 and has
been followed clinically since this time
[**2105-3-3**] colonoscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] showed no abnormalities;
next colonoscopy recommended in [**2109**]. Preoperative CXR showed
abnormality noted in the LUL.
[**2101-3-25**]: VATS with left upper lobectomy; pathology demonstrated a
3.3 x 2.0 x 2.0 cm well differentiated bronchial carcinoid
tumor. Followed clinically by Dr. [**Last Name (STitle) **] since this
resection.
[**2104-4-3**] routine scheduled CT chest demonstrated a new
endobronchial nodule at the bifurcation of the right upper lobe
bronchus suspicious for endobronchial recurrence of the
carcinoid. It also demonstrated multiple new masses,
consolidations and nodules that might represent either multiple
metastatic lung disease or be a combination of metastasis with
pulmonary infection. She underwent bronchoscopy/BAL/RUL
endobronchial lesion biopsy and cryoablation of the
endobronchial tumor with Dr. [**Last Name (STitle) **]. Pathology of the
endobronchial lesion demonstrated bronchial carcinoid tumor,
similar to the previously resected LUL mass. All BAL fluid and
the CT-guided parenchymal tissue biopsy grew mycobacterium avium
complex.
[**2104-4-24**] octreotide scan revealed two areas of increased tracer
uptake in the right middle and lower lobes corresponding to
masses on the noncontrast enhanced chest CT and consistent with
metastatic disease.
.
Social History:
Has been an opera singer and is a retired school teacher for
special needs children. Lives in [**Hospital3 **] and is very
functional physically and socially. She exercises on a
treadmill. HCP is her niece [**Name (NI) 25415**] [**Name (NI) 35861**] [**Telephone/Fax (1) 47924**]. Never
smoked and min EtOH in past.
Family History:
Sister with leukemia and 2nd sister with [**Name2 (NI) 499**] CA in her 30's
Physical Exam:
On Admission:
Vitals: T: 100.7 BP: 130/62 HR: 74 RR: 25 O2Sat: 93%
GEN: elderly woman intubated NAD
HEENT: PERRL, sclera anicteric, MMM
NECK: No JVD
COR: RRR, II/VI SEM, normal S1 S2, radial pulses +1
PULM: faint expiratory wheeze, otherwise clear
ABD: Soft, mildly distended, +BS, no HSM, no masses appreciated
EXT: no edema or cyanosis
NEURO: sedated
Discharge:
VS: T 98.0, P: 75 (66-76), BP: 128/P (108-128/P'[**78**]), RR: 16
(16-20), 95% on RA
GEN: elderly, well appearing female, NC in place
CV: RRR, normal S1, S2, [**12-27**] soft SEM
PULM: CTAB
ABD: soft, BS+, nt, nd
EXT: no edema
GU: foley in place
Neuro: CN II-XII intact, 5/5 strength upper and lower
extremities
Pertinent Results:
Admission Labs:
[**2105-12-12**] 05:50PM WBC-12.1* RBC-3.85* HGB-11.0* HCT-33.6*
MCV-87 MCH-28.7 MCHC-32.9 RDW-14.5
[**2105-12-12**] 05:50PM PLT COUNT-224
[**2105-12-12**] 05:50PM NEUTS-87.8* LYMPHS-7.7* MONOS-4.0 EOS-0.2
BASOS-0.3
[**2105-12-12**] 05:50PM PT-16.4* PTT-33.4 INR(PT)-1.5*
[**2105-12-12**] 05:50PM GLUCOSE-93 UREA N-18 CREAT-1.1 SODIUM-143
POTASSIUM-2.9* CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2105-12-12**] 05:50PM ALBUMIN-3.3* CALCIUM-8.3* PHOSPHATE-1.3*#
MAGNESIUM-2.0
[**2105-12-12**] 06:09PM LACTATE-1.1
[**2105-12-12**] 06:09PM TYPE-ART RATES-14/ TIDAL VOL-450 PEEP-5 O2-60
PO2-87 PCO2-29* PH-7.47* TOTAL CO2-22 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
[**2105-12-12**] 11:08PM TYPE-ART RATES-14/ TIDAL VOL-450 PEEP-10
O2-40 PO2-97 PCO2-37 PH-7.40 TOTAL CO2-24 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
[**2105-12-12**] 05:50PM proBNP-[**Numeric Identifier 15993**]*
[**2105-12-12**] 05:50PM VANCO-30.7*
.
Discharge labs:
[**2105-12-25**] 06:00AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.5* Hct-25.3*
MCV-89 MCH-29.9 MCHC-33.6 RDW-16.0* Plt Ct-636*
[**2105-12-24**] 06:21AM BLOOD WBC-8.4 RBC-2.92* Hgb-8.5* Hct-25.9*
MCV-89 MCH-29.0 MCHC-32.7 RDW-15.7* Plt Ct-621*
[**2105-12-21**] 06:16AM BLOOD WBC-10.9 RBC-2.75* Hgb-8.2* Hct-23.6*
MCV-86 MCH-29.8 MCHC-34.7 RDW-14.7 Plt Ct-491*
[**2105-12-20**] 04:14AM BLOOD WBC-11.7* RBC-3.02* Hgb-8.8* Hct-26.7*
MCV-88 MCH-29.1 MCHC-32.9 RDW-14.4 Plt Ct-467*
[**2105-12-25**] 06:00AM BLOOD Glucose-89 UreaN-29* Creat-1.1 Na-139
K-3.8 Cl-98 HCO3-32 AnGap-13
[**2105-12-25**] 06:00AM BLOOD Iron-38
[**2105-12-24**] 06:21AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.3
[**2105-12-25**] 06:00AM BLOOD calTIBC-178* Ferritn-264* TRF-137*
.
Micro:
Urine cx: NGTD
.
Legionella Urinary Antigen (Final [**2105-12-16**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Blood cx: NGTD
.
[**2105-12-16**] 9:36 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2105-12-18**]**
GRAM STAIN (Final [**2105-12-16**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2105-12-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
[**2105-12-14**] 1:56 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2105-12-16**]**
GRAM STAIN (Final [**2105-12-14**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2105-12-16**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
[**2105-12-13**] 3:50 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2105-12-15**]**
GRAM STAIN (Final [**2105-12-13**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2105-12-15**]):
RARE GROWTH Commensal Respiratory Flora.
.
WOUND CULTURE (Final [**2105-12-19**]): No significant growth.
.
MRSA SCREEN (Final [**2105-12-15**]): No MRSA isolated
Imaging:
CXR: [**12-12**]
FINDINGS: The patient has been transferred from an outside
hospital. The tip of an endotracheal tube projects 4 cm above
the carina. Bilateral perihilar opacities, likely to reflect
pneumonia. Additional left basal and retrocardiac atelectasis.
The presence of small pleural effusion cannot be excluded. The
report from the outside hospital mentions that the patient has
undergone CT and bilateral pneumonia was confirmed.
.
TTE [**12-15**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
There is no ventricular septal defect. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2101-3-16**],
the degree of TR and pulmonary hypertension detected have
increased. The LV systolic function is less vigorous. The degree
of MR is probably similar or slightly less.
.
UE LENIS [**2105-12-16**]
FINDINGS: A PICC line extends through the left arm via the
basilic vein,
which has a relatively lateral position and is situated near
paired brachial veins. Occlusive thrombus is noted throughout
the basilic and axillary veins with substantial clot also
visualized within the left subclavian vein, although not
occlusive at the latter site. One of two brachial veins is also
probably clotted, noting lack of compressibility and
visualization of color flow.
IMPRESSION: Deep vein thrombosis along the course of the
left-sided PICC
line
FINDINGS: DOUBLE CONTRAST UPPER GI: [**2105-12-21**]
Barium passes freely to the stomach. There are ineffective
primary peristaltic contraction and partially effective
secondary peristaltic contractions. There are ineffective
tertiary contractions causing retrograde flow of contrast seen
throughout the esophagus. There are no filling defects detected
suggestive of an esophageal web. An NG tube can be seen
throughout the length of the esophagus passing through the
gastroesophageal junction into the stomach. A 13-mm barium
tablet
was given and passed freely through the level just superior to
the
gastroesophageal junction. The patient was given three glasses
of water and the tablet remained superior to the GE junction.
IMPRESSION:
1. No esophageal web identified. Poor esophageal motility with
partially
effective secondary peristaltic contractions and tertiary
contractions seen throughout the esophagus. There is no evidence
of narrowing or stricture within the esophagus.
VIDEO SWALLOW: [**2105-12-23**]
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There is no gross
aspiration or penetration. For full details, please refer to
speech and swallow division note in OMR.
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Brief Hospital Course:
This is an 86 year-old woman with a history of stage II [**Month/Day/Year 499**]
cancer and bronchial carcinoid tumor transferred to [**Hospital1 18**] MICU
from [**Location (un) 620**] intubated for aspiration pneumonia in the setting
of new onset dysphagia, course complicated by UE DVT in setting
of picc line with work-up revealing esophageal dysmotility
without esophageal structural abnormality.
# Respiratory Failure: Likely secondary to aspiration PNA in
setting of dysphagia with possible contribution of CHF and ARDS.
CXR showed bilateral patchy infiltrates and P/F ratio < 200
consistent with ARDS. Patient was treated for 10 days with
vancomycin, cefepime and flagyl for hospital
acquired/aspirations pneumonia; end date [**12-21**]. Patient was
intermittently diuresised to optimize respiratory status and
ultimately extubated on [**12-18**]. Post-extubation patient did well,
saturating >92% on 3L on day of transfer to medical floor.
# Dysphagia: original cause of admission to [**Location (un) 620**], evidence of
esophageal dysmotility on endoscope. [**Last Name (un) 1372**]-jejunal tube was
placed for tube feeds due to risk of aspiration. Patient had
repeat barium swallow which showed probable dysmotility but no
stricture or esophageal webs. Patient's diet was advanced to
full liquids on [**2105-12-24**]. She tolerated this diet well and was
advanced to a regular diet and her NJ tube was pulled on [**2105-12-25**].
She was discharged with outpatient follow-up with Dr. [**Last Name (STitle) 23804**] at
[**Hospital1 18**] [**Location (un) 620**].
#Acute Urinary Retention: Patient developed acute urinary
retention on [**2105-12-24**]. She had limited urine output and a bladder
scan showed 1 L and a straight cath was place which drained 1.1
L. She was again straight catheterized on [**2105-12-24**] in the
afternoon. On the morning of [**2105-12-25**] she was still having minimal
urine output with large residuals on bladder scan (880 cc). A
foley was placed for bladder decompression. She should keep the
foley in from [**Date range (1) 47925**] and have a voiding trial on [**2105-12-28**].
# Congestive Heart Failure: On admission BNP 10,856. TTE
demonstrated low-normal systolic function EF: 50-55%, mildly
dilated right ventricular cavity with borderline normal free
wall function, mild (1+) aortic regurgitation, mild (1+) mitral
regurgitation, moderate [2+] tricuspid regurgitation, moderate
pulmonary artery systolic hypertension, no pericardial effusion.
On day of transfer patient diuresised with 60mg PO Lasix with
plan to transition to home dose of 40mg on [**12-21**].
# AF s/p Pacer: bipolar pacemaker in place. CHADS 3 (CHF, HTN,
Age). Difficult rate control while intubated intermittently
requiring a dilt gtt. Transitioned to PO diltizam with prn IV
metoprolol once NGT placed. Rates controlled prior to transfer.
On discharge, she was back on her home regimen of metoprolol 150
mg po daily and diltiazem 240 mg po daily.
# Catheter induced upper extremity DVT. Intermittent fevers and
swelling of left upper extremity prompted upper extremity
ultrasound which demonstrated occlusive thrombus throughout the
basilic and axillary veins with substantial clot also
visualized within the left subclavian vein, although not
occlusive at the latter site. Patient started on Lovenox with
likely bridge to dibigatran for probable lifelong
anticoagulation in setting of atrial fibrillation.
#Anemia: Patient has baseline hematocrit around 32. It decreased
in this admission to approximately 25-26 and remained stable at
this level. Her iron studies were consistent with anemia of
chronic disease.
# [**Month/Day (4) **] Cancer: in remission
# Lung Carcinoid: in remission
# History of MAC: Per family 1.5 year history of MAC. Not on
steroids or otherwise immunosuppressed at baseline.
Pulmonologist = Dr. [**Last Name (STitle) 47926**] and Dr. [**Last Name (STitle) **] is also involved
in her care.
# Code: FULL CODE
Medications on Admission:
DILTIAZEM HCL 240 mg SR daily
ERGOCALCIFEROL 50,000 unit Capsule - 1 Cap MONTHLY
ESCITALOPRAM 10 mg Tablet daily
FUROSEMIDE 40 mg Tablet daily
LORAZEPAM 0.5 mg Tablet - [**11-24**] Tab in am [**11-22**] tab at bedtime
METOPROLOL SUCCINATE 150 mg SR daily
OMEPRAZOLE 20 mg Capsule EC daily
TOLTERODINE 4 mg Capsule SR 1 Capdaily
ASPIRIN 325 mg
SENNA 8.6 mg [**11-22**] Tab
MULTIVITAMIN
Discharge Medications:
1. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for anxiety.
6. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. multivitamin Capsule Sig: One (1) Capsule PO once a day.
9. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lovenox 80 mg/0.8 mL Syringe Sig: 0.7 ml Subcutaneous twice
a day for 1 weeks: STOP when INR > 2.0 for 2 days.
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust dose as needed for INR goal between [**12-24**].
13. Outpatient Lab Work
Please check daily INR until INR at goal between [**12-24**] for 2
consecutive days. Then check INR weekly along with weekly CBC.
Please adjust coumadin dose as needed.
14. Voiding Trial
Please keep foley in place until the morning of Monday, [**2105-12-28**]
then remove for 6 hour voiding trial.
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Ativan 0.5 mg Tablet Sig: [**11-24**] Tablet PO qAM.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Esophageal Dysmotility
Aspiration Pneumonia
Left Upper Extremity Deep Vein Thrombosis
Atrial Fibrillation with Rapid Ventricular Response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for difficulty swallowing, which
was most likely caused by a problem with the muscles in your
esophagus. You did not have any blockages or narrowing of your
esophagus. You will follow up with a gastroenterologist, Dr.
[**Last Name (STitle) 23804**].
You were also found to have pneumonia. You required a temporary
breathing tube and mechanical ventilator. You were treated with
a course of antibiotics and improved.
While in the intensive care unit, your heart went into a rapid
irregular rhythm and you were re-started on your home
medications to control your heart rate without any further
episodes of rapid heart rate.
In addition, you had a clot in your upper arm in the setting of
a catheter placement (PICC line) and you were treated with
lovenox, a blood thinner, to prevent the clot from growing
larger or breaking off and traveling to your heart, brain, or
lungs. Lovenox will be transitioned to Coumadin, a by-mouth
blood thinner, in the rehab facility.
You had some difficulty urinating prior to discharge, and a
foley catheter was placed to give your bladder time to relax
from being distended with urine. You should have the foley
catheter removed within 2-3 days. If you are still unable to
urinate without the catheter at that time, you should follow up
with your primary care physician regarding your difficulty
urinating.
Changes to your medications:
ADDED Lovenox injections twice a day- take until INR >2.0 for 2
days
ADDED Coumadin start at 2.5 mg by mouth once a day. This dose
may be adjusted for goal INR of [**12-24**].
DECREASED Aspirin from 325mg daily to 81mg daily.
STOPPED (Detrol) TOLTERODINE
Followup Instructions:
Please keep the following appointments:
Name: [**Last Name (LF) **],[**Name (NI) **] MD
Address: [**Location (un) **], [**Location (un) 620**], MA
Phone: [**Telephone/Fax (1) 3259**]
When: Thursday, [**1-14**], 2:30PM
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2106-1-19**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2106-1-19**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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: CARDIAC SERVICES
When: THURSDAY [**2106-2-18**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"51881",
"5070",
"5849",
"4280",
"42731",
"40390",
"5859",
"2720",
"V5861"
] |
Admission Date: [**2183-9-24**] Discharge Date: [**2183-9-25**]
Date of Birth: [**2106-10-7**] Sex: F
Service: CCU
CHIEF COMPLAINT: Hypotension and distal left anterior
descending perforation.
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname 33815**] is a 76 year old
female with a history of hypertension who was stung by an
insect Monday morning that resulted several hours later in
hives, tongue swelling, and diffuse skin erythema. She
presented to [**Hospital6 5016**] in [**Location (un) 7661**] where she was
treated with Solu-Medrol, Benadryl, and intravenous fluids.
Her vital signs were normal and stable. By report, the
patient was noted to have a [**Street Address(2) 17989**] depression in her
electrocardiogram in the Emergency Room, although the
electrocardiogram is not available and there is no further
information on these depressions. Subsequently, the patient
had an exercise treadmill test at the outside hospital. By
her account, she exercised five to six minutes, but stopped
after being told that her electrocardiogram showed ischemic
changes.
The patient had two negative sets of cardiac enzymes at the
outside hospital and was transferred to [**Hospital1 190**] for a cardiac catheterization for positive
stress test. At the cardiac catheterization, the patient had
a 90% mid left anterior descending lesion, stepped down to a
small vessel after D2 which was stented with a HEPACOAT
stent. Hemodynamics in the catheterization laboratory showed
pulmonary capillary wedge pressure of 13. The left
ventricular gram showed an ejection fraction of 58%.
The cardiac catheterization was complicated by a possible
intramuscular perforation of a distal left anterior
descending without evidence of tamponade physiology by
echocardiogram. She also had a hematoma at the right groin
site and a vagal episode when the sheath was pulled,
resulting in hypotension which responded to atropine and
intravenous fluids. She was subsequently brought up to the
Cardiac Care Unit for hemodynamic monitoring overnight.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diverticulitis, status post partial colectomy.
3. Arthritis.
4. Status post hysterectomy for fibroids.
5. Status post stress test and cardiac catheterization 10
years ago without intervention.
MEDICATIONS ON TRANSFER:
1. Prednisone tapers.
2. Toprol XL 100 mg by mouth once daily.
3. Solu-Medrol 60 mg intravenous q12.
4. Benadryl 25 mg intravenous q6 hours.
5. Aspirin 162 mg by mouth once daily.
6. Pepcid 20 mg intravenous q12.
7. Pravachol 40 mg by mouth qhs.
HOME MEDICATIONS:
1. Toprol XL 50 mg by mouth once daily.
2. Pravachol 20 mg by mouth once daily.
3. Aspirin 325 mg by mouth once daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her husband. She denied any
tobacco, alcohol, or drug use.
FAMILY HISTORY: Notable for diabetes mellitus, coronary
artery disease, peripheral vascular disease.
REVIEW OF SYSTEMS: Negative except for post-prandial
discomfort in her epigastrium that was relieved with
belching.
PHYSICAL EXAMINATION: On arrival to the Cardiac Care Unit,
the patient was afebrile; temperature 98.0; blood pressure
114/52; pulse 62 and regular; oxygen saturation rate 96% on
room air. General: She was a pleasant elderly female,
awake, alert and oriented times three, no acute distress.
Head, eyes, ears, nose and throat: Normocephalic,
atraumatic, pupils are equal, round, and reactive to light,
oropharynx clear and moist, anicteric. Neck: Supple, no
jugular venous distention, carotids were 2 plus bilaterally,
no bruits. Cardiovascular: Regular rate and rhythm, normal
S1 S2, bilateral heart sounds clear, no rub, no heave, no
gallop, soft 2/6 systolic murmur at the left upper sternal
border that slightly radiated to the axilla. Lungs: Clear
to auscultation bilaterally. Abdomen: Two well-healed scars
inferiorly, soft, non-tender, non-distended, normal bowel
sounds, no hepatosplenomegaly, no bruits. Extremities: No
cyanosis, clubbing or edema, her right groin site was clean,
dry, and intact with a pressure dressing, left groin at 1
plus femoral pulse without a bruit, her dorsalis pedis pulses
were 2 plus bilaterally, her posterior tibial pulses were 1
plus bilaterally. Neurological: The patient was moving all
extremities symmetrically.
LABORATORY DATA AND STUDIES: Electrocardiogram here showed
normal sinus rhythm at 55, normal axis, normal interval with
no hypertrophy, questionable Q and aVL biphasic T-waves in V1
and V4 that were new compared to the last electrocardiogram
at the outside hospital. The day of discharge, the patient's
white blood cell count was 4.8; hematocrit 34.5; platelets
98; PT 32.8; PTT 24.3; INR 1.3; Chem 7 was unremarkable
except for a BUN 26; CK 37; calc/mag/phos normal;
echocardiogram from [**9-25**], the day of discharge,
initial read showed no pericardial effusion; further
hemodynamics from the catheterization laboratory showed
cardiac output of 4.3 and a cardiac index of 2.25.
HOSPITAL COURSE:
1. Cardiac. A) Ischemia. The patient is status post a left
anterior descending stent, no further signs of ischemia. She
was treated with Plavix which she will continue for nine
months, aspirin, beta blocker, and Pravachol. She was not
treated with Integrilin or Heparin after the perforation of
the coronary artery. She had negative cardiac enzymes. B)
Pump. The patient has normal ejection fraction by left
ventricular gram, status post perforation of the distal left
anterior descending but there is no evidence of pericardial
effusion or tamponade physiology. Her Heparin and Integrilin
were held. She was continued on her Plavix and aspirin.
There were two echocardiograms done, neither of which showed
effusion. Her hematocrit was stable. C) Rhythm. Normal
sinus rhythm and no active issues.
2. Allergic reaction to a bee sting. The patient had been
on several days of Solu-Medrol which was discontinued here.
It was felt that the brief period of time she was treated
warranted a steroid taper.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post stent to left
anterior descending with very distal perforation of the left
anterior descending.
2. Hypertension.
3. Possible perforation of distal left anterior descending
without pericardial effusion.
DISCHARGE MEDICATIONS:
1. Toprol XL 50 mg by mouth once daily.
2. Plavix 75 mg by mouth once daily times 9 months.
3. Aspirin 325 mg by mouth once daily.
4. Pravachol 20 mg by mouth once daily.
The patient is to be considered for an ace inhibitor as an
outpatient.
FOLLOW-UP PLANS: The patient is to follow-up with her
cardiologist in [**Location (un) 7661**], Dr. [**Last Name (STitle) 7659**], within two weeks of
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2183-9-25**] 10:53
T: [**2183-9-28**] 16:40
JOB#: [**Job Number 50557**]
|
[
"41401",
"2720",
"4019"
] |
Admission Date: [**2118-5-21**] Discharge Date: [**2118-5-28**]
Date of Birth: [**2118-5-21**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 15473**] is a 35-week
gestation infant born with a birth weight of 2465 grams,
delivered to a 29-year-old gravida 1, para 0 (to 1) mother.
She was delivered prematurely because of preterm labor. The
mother had been treated with terbutaline and bed rest;
however, labor persisted and delivery was by cesarean section
because of a nonreassuring fetal heart monitor tracing. The
delivery was uncomplicated. Apgar scores were 8 at one
minute and 8 at five minutes. The baby had initial mild
grunting and increased work of breathing; however, this
resolved shortly after birth.
PHYSICAL EXAMINATION ON PRESENTATION: Her physical
examination on admission revealed she presented as an
appropriate for gestational age 35-week gestation infant.
The skin was pink and clear with no petechiae. Anterior
fontanel was soft and flat. Examination of the eyes revealed
normal red reflexes bilaterally. The palate was noted to be
intact. The lungs were clear bilaterally after initially
having some grunting. No respiratory distress was noted
following this initial transition. Cardiovascular
examination revealed no murmurs. Normal first heart sounds
and second heart sounds. Femoral pulses were 2+. Abdominal
examination was unremarkable with no organomegaly. Genital
examination revealed normal female external genitalia. The
anus was patent and normally placed. Her hip examination was
stable. Neurologic examination was within normal limits with
symmetric movement of all extremities and a normal Moro
reflex. Her weight, as noted, was 2465 grams, her length was
44.5 cm, and head circumference was 32 cm.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: As noted, she had transient
respiratory distress which resolved shortly after birth and
was on room air the remainder of her hospitalization with
respiratory rates in the 30s to 40s. She had no apnea of
prematurity. She did have occasional episodes of
desaturations with oral feeding initially. This was felt to
be related to immaturity and some mild dyscoordination. This
resolved prior to discharge.
2. CARDIOVASCULAR SYSTEM: She had no cardiac murmur noted,
and she had a normal cardiovascular examination throughout
the admission.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: She was started on
feedings on day one of life and transitioned from a
combination of Enfamil 20 and breast milk to all breast milk
by the time of discharge. She was noted to nurse and bottle
feed well.
The weight on the day of discharge was 2285 grams, and she
was taking ad lib by breast feeding at that time.
4. GASTROINTESTINAL ISSUES: The baby had physiologic
hyperbilirubinemia of prematurity. Her peak bilirubin was
12.8 on day of life five. She was treated with phototherapy
transiently. Her bilirubin fell to 9.6 on the day of
discharge ([**5-28**]), and this was a rebound bilirubin.
5. HEMATOLOGIC ISSUES: She had a complete blood count done
after birth. White blood cell count was 19,700 (with 47
polys and 1 band), hematocrit was 39.7%, and platelet count
was 323,000. Blood cultures were no growth at 48 hours, and
she was not treated with antibiotics.
6. NEUROLOGIC ISSUES: The baby had a normal neurologic
examination throughout the admission, and no studies were
indicated.
7. SENSORY ISSUES: The baby had a hearing screen with
automated auditory brain stem responses and passed in both
ears. She also had a car seat screening, and car seat
testing was passed on the day prior to discharge.
8. OPHTHALMOLOGIC ISSUES: A formal ophthalmologic
examination was not indicated in this 35-week gestation [**Doctor Last Name 360**].
9. PSYCHOSOCIAL ISSUES: A [**Hospital1 188**] Social Work was involved with the family. The contact
number was [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharged to home with her parents.
PRIMARY PEDIATRICIAN: Name of primary pediatrician is Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47899**] with [**Hospital **] Pediatrics (telephone number
1-[**Telephone/Fax (1) 37304**]; fax number 1-[**0-0-**]).
CARE RECOMMENDATIONS:
1. Feedings: Feedings at discharge were ad lib breast
feeding.
2. Medications: She was discharged home on no medications.
Supplemental iron should be initiated if mother continues to
exclusively breast feed.
STATE NEWBORN SCREEN: State newborn screening was sent to
the State Laboratory, and the results were pending.
IMMUNIZATIONS RECEIVED: She received a hepatitis B vaccine
on [**2118-5-25**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation.
(2) Born between 32 and 35 weeks gestation with plans for day
care during respiratory syncytial virus season, with a smoker
in the household, or with preschool siblings; and/or (3) With
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. A follow-up appointment with their primary pediatrician
was scheduled for [**2118-5-31**].
2. Referral to [**Hospital6 407**] was made.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Hyperbilirubinemia.
3. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern4) 41252**]
MEDQUIST36
D: [**2118-5-31**] 14:53
T: [**2118-5-31**] 15:33
JOB#: [**Job Number 47900**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2201-12-31**] Discharge Date: [**2202-1-3**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Fever, hypotension
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
[**1-2**] PICC line placement
[**1-3**] PICC line replacement
History of Present Illness:
Mr. [**Known lastname 8182**] is a 65-year-old gentleman with a complicated PMH
including CVA (nonverbal and does not move arms/legs at
baseline), afib on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG [**3-/2200**]), multiple prior episodes of
UTI/urosepsis with drug-resistant organisms, C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presents now with fever to 101, leukocytosis to
27.7, one episode of vomiting earlier today, and question of
aspiration. He was given a dose of tylenol in his nursing home
prior to transfer. He was brought to ED by ambulance from his
nursing home.
.
In the ED, initial vitals were 97.6 67 101/64 18 99% 2L.
Patient reported left chest pain as he is able to nod yes or no.
Labs notable for WBC 23.7 with 87% N. UA showed mod leuk, tr
bld, neg nitr, 7 RBC, 101 WBC, mod bacteria, no epis. EKG was
sinus at 69, LAD, RBBB, c/w prior per report. CXR revealed
infiltrates concerning for pneumonia. He received broad
spectrum antibiotics including levaquin, vancomycin 1 gram, and
cefepime 2 grams. He was initially assigned a floor bed, but
his BP dropped to mid 80's systolic. A 18G was placed on the
right with a 20G on the left. He was bolused with IVF for a
total of 3L. Was admitted for treatment of PNA and UTI. Most
recent vitals prior to transfer were 64 101/64.
.
Of note, patient has had several recent admissions, including
admission to [**Hospital Unit Name 153**] in [**2202-11-17**]/11 with urosepsis treated with
vancomycin and meropenem, and Medicine [**Date range (1) 80455**] with
UTI/sepsis treated with ceftriaxone and a right cold foot felt
to be secondary to vasospasm, that did not require [**Date range (1) **]
intervention. Patient received pain control, was seen by
Vascular surgery, and had return of palpable pulses during the
admission.
.
Upon arrival to the MICU, his vital signs were T 36.1, p 72, bp
116/67, r 11, 94% trach mask. On interview, he acknowledged that
he was in some discomfort but indicated that it was not in his
chest, abdomen, extremities, or genital area. Interview was
limited by his inability to respond beyond nodding yes/no, and
he was only responsive to very simple questions.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) -
Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**]
(outside facility, [**12/2198**] here)
Social History:
Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
GENERAL: well-appearing in NAD, comfortable, appropriate
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD, no carotid bruits
LUNGS: CTAB, no wheezing/rales/rhonchi, good air movement,
respirations unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: normoactive bowel sounds, soft, NT, ND, no
organomegaly, no guarding or rebound tenderness
EXTREMITIES: warm, well-perfused, no edema, 2+ peripheral pulses
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-24**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
On discharge:
VSS, HR in mid 50s, pressures 110-120/60s
Complains of right leg pain when asked, but pulses strong and no
open lesions. Otherwise as above.
Pertinent Results:
Admission Labs:
[**2201-12-31**] 06:10PM LACTATE-1.0 K+-4.7
[**2201-12-31**] 06:00PM GLUCOSE-140* UREA N-33* CREAT-0.7 SODIUM-145
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-30 ANION GAP-15
[**2201-12-31**] 06:00PM estGFR-Using this
[**2201-12-31**] 06:00PM WBC-23.7*# RBC-5.62 HGB-12.5* HCT-40.2
MCV-72* MCH-22.3* MCHC-31.2 RDW-16.1*
[**2201-12-31**] 06:00PM NEUTS-87.0* LYMPHS-8.9* MONOS-3.1 EOS-0.8
BASOS-0.2
[**2201-12-31**] 06:00PM PLT COUNT-212
[**2201-12-31**] 06:00PM PT-17.1* PTT-32.6 INR(PT)-1.6*
[**2201-12-31**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2201-12-31**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2201-12-31**] 06:00PM URINE HYALINE-4*
[**2201-12-31**] 06:00PM URINE HYALINE-4*
.
Other relevant labs:
[**2202-1-1**] 03:33AM BLOOD WBC-12.1* RBC-4.32* Hgb-9.8* Hct-31.4*
MCV-73* MCH-22.7* MCHC-31.1 RDW-16.2* Plt Ct-181
[**2202-1-2**] 07:55AM BLOOD WBC-7.9 RBC-4.38* Hgb-9.6* Hct-32.8*
MCV-75* MCH-22.0* MCHC-29.4* RDW-16.3* Plt Ct-167
[**2202-1-2**] 07:55AM BLOOD PT-19.3* PTT-31.2 INR(PT)-1.8*
[**2202-1-2**] 07:55AM BLOOD Vanco-18.3
[**2202-1-2**] 05:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2202-1-2**] 05:00PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2202-1-2**] 05:00PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
CXR [**2201-12-31**]:
New bibasilar opacities, with low lung volumes. Considerations
include pneumonia in the appropriate clinical setting, but
atelectasis or even aspiration could be considered depending on
clinical circumstances.
.
[**1-3**] CXR:
FINDINGS: Tip of right PICC terminates in the lower superior
vena cava. The tip of the catheter is about 3.3 cm below the
level of the radiodense
guidewire, which terminates in the mid superior vena cava.
Tracheostomy tube remains in standard position. Stable
cardiomegaly, and improving pleural effusion and left basilar
atelectasis.
.
MICROBIO:
[**12-31**] Blood cult1ure x 2: Negative to date
[**12-31**] Urine: URINE CULTURE (Final [**2202-1-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**12-31**] and [**1-1**] Sputum: GRAM STAIN (Final [**2202-1-1**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
Unable to definitively determine the presence or absence
of commensal
respiratory flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**12-31**] Legionella: Negative
Studies pending at Discharge:
[**1-2**] Urine Cx
Brief Hospital Course:
65-year-old gentleman, nonverbal status post a prior stroke with
residual paraplegia status post trach/PEG, atrial fibrillation
on warfarin, history of chronic aspiration and multiple
pneumonias, urinary tract infections and sepsis with
drug-resistant organisms admitted with pneumonia, sepsis, and
possible urinary tract infection
.
#Septic Shock/Pneumonia/Urinary tract infection:
Patient was initially admitted to the MICU with fluid responsive
hypotension. He had a dirty UA and chest X-ray consistent with
pneumonia. He was empirically treated with Vancomycin and
Cefepime with improvement in his hypotension and leukocytosis
(initially 27 but normal on discharge). A PICC line was placed
to complete an 8 day course of Vancomycin/Cefepime for health
care associated pneumonia which was felt to cover urinary
pathogens as well. Sputum grew Proteus. Although urine culture
was pending at time of discharge, the overall clinical
improvement suggested that any urinary pathogens would be
sensitive to Vancomycin and Cefepime. Urine culture however
should be followed at rehab. Given chronic Foley catheter if
urine culture is positive would consider treating for two weeks
with antibiotics to cover urinary sources and Foley should be
changed at next Urology appointment.
..
#Diabetes mellitus: Continued on home glargine and ISS
.
# Depression: Continued on Duloxetine and Mirtazapine
.
# Atrial fibrillation: Continued on Warfarin. INRs were mildly
subtherapeutic at 1.8
.
# Pain, probably neuropathic: Pt complained of right leg pain.
Pulses were strong and there was no wound. Pt continued on
Fentanyl, Morphine, Tylenol, Gabapentin, and Cymbalta.
.
# Hypothyroidism: Continued Levothyroxine
.
# Sacral decubitus ulcer: Healing. Would continued wound care
with frequent repositionings and dressings daily as needed.
.
.
Code status: DNR/DNI.
.
TRANSITIONAL:
1) Complete antibiotics-Last day: [**1-8**] if urine culture
negative, [**1-14**] if urine culture positive.
2) Follow up with urology for consideration of suprapubic
catheter placement given recurrent urinary tract infections and
sepsis
3) Follow up sensitivities for proteus positive sputum culture
and enteroccocus urinary tract infection with adjustment of
antibiotic course as dictated by urine culture
Medications on Admission:
MEDICATIONS (per [**2201-12-9**] d/c summary):
1. fentanyl 75 mcg/hr Patch 72 hr [**Month/Day/Year **]: One Patch 72 hr
Transdermal Q72H (every 72 hours).
2. mirtazapine 15 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO HS (at
bedtime).
3. insulin glargine 100 unit/mL Solution [**Month/Day/Year **]: Thirty Two (32)
units Subcutaneous at bedtime.
4. insulin sliding scale, continue insulin sliding scale as
prior to admission
5. senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipattion.
6. Cymbalta 30 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One
capsule, Delayed Release(E.C.) PO once a day: g/j tube.
7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Month/Day/Year **]: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
8. baclofen 10 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO QID (4 times a
day).
9. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO HS (at
bedtime).
10. levothyroxine 25 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY.
11. coumadin 4mg coumadin daily
12. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every 8
hours.
13. ascorbic acid 500 mg/5 mL Syrup [**Month/Day/Year **]: One (1) PO BID
14. therapeutic multivitamin Liquid [**Month/Day/Year **]: One (1) Tablet PO DAILY
15. zinc sulfate 220 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
18. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
19. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
20. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
21. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Last Name (STitle) **]:
One (1) Intravenous Q24H (every 24 hours) for 7 days.
22. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) mg PO Q6H (every
6 hours) as needed for pain.
23. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
Discharge Medications:
1. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Two (32)
units Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale Subcutaneous
QACHS: Continue insulin sliding scale.
4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Last Name (STitle) **]: One (1) inh Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
7. baclofen 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO QID (4 times a
day).
8. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
9. levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. warfarin 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
11. gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q8H (every
8 hours).
12. ascorbic acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) mL PO twice a
day.
13. cefepime 1 gram Recon Soln [**Last Name (STitle) **]: One (1) gram Injection Q12H
(every 12 hours): Completed after [**1-8**].
14. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1) gram
Intravenous Q 12H (Every 12 Hours): Finished after [**1-8**].
15. multivitamin Liquid [**Month/Year (2) **]: One (1) dose PO once a day.
16. zinc sulfate 220 (50) mg Capsule [**Month/Year (2) **]: One (1) Capsule PO
once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen. .
18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
19. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
mL PO once a day as needed for constipation.
20. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal at bedtime
as needed for constipation.
21. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
22. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 10mg PO Q6H (every 6
hours) as needed for pain.
23. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
24. fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Primary: Sepsis from UTI and possibly Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive, non-verbal, but
able to answer questions with nods and shakes and follows
commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 8182**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for sepsis that was found to be most likely from your
urine and possibly from your lungs. You were given fluids and
IV antibiotics which improved your infection. A PICC line was
placed so that you may take these antibiotics at your extended
care facility.
You should follow up with urology regarding evaluation for
suprapubic catheter placement as this may decrease your episodes
of urinary tract infection and sepsis.
Changes to your medications:
STARTED Vancomycin
STARTED Cefepime
STOPPED Ceftriaxone
Followup Instructions:
The following appointments were made for you:
Department: [**Hospital1 **] SPECIALTIES
When: WEDNESDAY [**2202-1-6**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 706**] CARE UNIT
When: WEDNESDAY [**2202-1-27**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) 706**]
When: WEDNESDAY [**2202-1-27**] at 10:00 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2202-1-4**]
|
[
"0389",
"78552",
"486",
"5849",
"5990",
"99592",
"V5867",
"2449",
"4019",
"42731",
"V5861",
"2724",
"2859",
"311"
] |
Admission Date: [**2109-11-1**] Discharge Date: [**2109-11-2**]
Date of Birth: [**2034-8-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Bilious Ascites
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
75 yo M with unknown PMH presents from OSH s/p prolonged
hospitalization [**1-7**] complicated lap chole. Pt presented to
[**Hospital 59749**] Hospital on [**10-16**] with RUQ pain radiating to back and
increased amylase (200's), lipase (4801), and LFT's. RUQ US
demonstrated GB thickening, stones, and + [**Doctor Last Name **]. Pt dx with
gallstone pancreatitis and taken for lap chole on [**2109-10-18**].
Found to have necrotic GB with thick wall.
Post-op course complicated by hypoxia and was unable to
extubate. Thought to be fluid overload or pranreatitis related
ards. Held on AC settings then switched to SIMV over the past
3-5 days.
The patient also developed rapid afib. He was initially
controlled on lopressor and dilt then converted to an amiodarone
drip. Ruled out for MI x 2. No EKG changes other than LBBB and
afib.
He had low grade fevers throughout the hospital stay since
his operation. [**10-26**] his temp increased to 101.6 with a left
shift. (most recently 23,000 88N 3L). Also had an increased bili
(TB 2.2 with DB 1.1). CT scan of abd/pel ([**10-26**]) demonstrated no
abcesses, mult cysts in liver, new ascites, and new L
pneumothorax. L chest tube placed and abx changed to
vanc/zosyn/flagyl. He cont to have fevers and was eventually
tapped on [**10-1**] producing 3 L of bilious ascites. (fluid
analysis = RBC 2300 WBC 55 N49, Bili 20, (-) gram stain) Sent
to [**Hospital1 18**] [**Hospital Unit Name 153**] for urgent ERCP to fix likely biliary leak.
Past Medical History:
No PMH provided from outside hospital, pt is intubated and can
not reach family, friends and can not reach PCP [**Name Initial (PRE) 4**] [**2109-11-4**]
(PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6359**])
Thought to have prior MI in [**2084**]'s,
Social History:
? former smoker, retired carpenter
PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 23281**]
Family History:
Unknown.
Physical Exam:
-VS: T: 100.6 BP: 150/90 HR: 100 RR: 24
-Gen: sedated, responding to some commands
-HEENT: mild sceral icterus; PERRL, EOMI, dry mm
-Neck: JVP 8cm
-Chest: [**Month (only) **]. BS at bases bilaterally, + rhonchi
-CV: tachycardia, RR, no murmurs, rubs, gallops
-Abd: distended, + shifting dullness with fluid wave, mild
response to palpation of RUQ
-Ext: warm, 1+ DP
-Neuro: responds to some verbal stimuli and moves all four
extremities spontaneously
Pertinent Results:
Pertinent labs/studies on transfer:
-CT abd/pelv ([**10-26**]): ascites, liver cysts, LUL PTX
-WBC 23.2 (85N/1band/4L) HCT 31 plt 1191; BUN 73/Cr 1.8; INR
1.4,
-TB 2.1 DB 1.1 AlkPhos 322 [**Doctor First Name **]/lip 26/29
-Micro: 1 bottle Blood Cx + Group B Strep [**10-16**], otw NGTD
(sputum, urine, serial blood cx)
.
[**2109-11-1**] 08:18PM WBC-21.6* RBC-3.68* HGB-9.8* HCT-31.0* MCV-84
MCH-26.6* MCHC-31.6 RDW-20.4*
[**2109-11-1**] 08:18PM NEUTS-89* BANDS-1 LYMPHS-6* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3*
[**2109-11-1**] 08:18PM ALBUMIN-2.7* CALCIUM-7.7* PHOSPHATE-5.9*
MAGNESIUM-2.5
[**2109-11-1**] 08:18PM LIPASE-29
[**2109-11-1**] 08:18PM ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-218
CK(CPK)-96 ALK PHOS-346* AMYLASE-20 TOT BILI-2.5* DIR BILI-1.5*
INDIR BIL-1.0
[**2109-11-1**] 08:18PM GLUCOSE-240* UREA N-82* CREAT-2.0* SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2109-11-1**] 08:31PM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025
[**2109-11-1**] 08:31PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-TR
[**2109-11-1**] 08:31PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2109-11-1**] 08:31PM URINE MUCOUS-RARE
[**2109-11-1**] 08:31PM LACTATE-2.8* K+-4.1
[**2109-11-1**] 08:31PM TYPE-ART TEMP-37.0 TIDAL VOL-600 PEEP-12
O2-40 PO2-86 PCO2-40 PH-7.37 TOTAL CO2-24 BASE XS--1
INTUBATED-INTUBATED
.
.
[**2109-11-2**] ERCP:
-Esophagus: limited exam of the esophagus was nml
-Stomach: limited exam of the stomach was nml
-Duodenum: limited exam of the duodenum was nml
-Major Papilla: Normal major papilla
-Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification. The procedure was not difficult. Cannulation of
the pancreatic duct was successful and superficial with a
sphincteroetome using a free-hand technique. Contrast medium
was injected resulting in partial opacification. The procedure
was not difficult.
-Biliary Tree: Extravasation of contrast at the level of the
cystic duct was noted - consistent with cystic bile duct leak.
-Pancreas: opacified portion of the pancreatic duct in the head
was normal
-Procedure: a 9cm x 10Fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the CBD.
-Recommendation: Repeat ERCP in 1 month for stent
removal/change, continue IV abx, consider drainage of the
biliary asciates if large amount is present on CT scan. Follow
up with Dr. [**Last Name (STitle) 5166**].
.
Brief Hospital Course:
A/P: 75 yo M with unknown [**Hospital **] transferred from OSH after
complicated course s/p lap chole [**10-18**], with fevers, bilious
ascites and vent-dependent resp failure, here for ERCP.
1. Sepsis:
A). Source: Pt was transferred to [**Hospital1 18**] intubated, on
vancomycin, zosyn and flagyl for anaerobic, GN,
enterococcus/resistant GP/pseudomonal coverage. Pt underwent
successful ERCP on the morning of [**11-2**]. The ERCP demonstrated
a bile leak in the CBD and a Cotton [**Doctor Last Name **] biliary stent was
successfully placed in the CBD. GI follow up recommended
removal/exchange of the stent in 1 month, continuation of the IV
antibiotcis and to consider drainage of ascites if large amount
is present on CT scan.
B). ID/Fevers: The source of the persistent fevers is most
likely intra-abdominal secondary to the large bile leak from the
CBD. Recommend, follow up of blood cultures, sputum gram stain
and culture, UA and urine culture, and to consider a CT of the
abdomen/pelvis several days post ERCP. Recommend continuing
coverage with the above antibiotics until further speciation and
sensitivities return. Consider large volume paracentesis if
significant amount of ascites is present on abd CT.
C). Hemodynamics: Pt was hypotensive since arrival. We held
the metoprolol and have supported blood pressure with NS boluses
and neosynephrine as needed. Neosynephrine was titrated off
successfully and pt maintained MAP >60 without complications
after the ERCP.
D). Respiratory Failure: unclear etiology, thought to be ARDS
(or acute lung injury). CXR with bilateral infiltrates and pt
does not have a known diagnosis of CHF. FiO2/PaO2 ratio at time
of admission to [**Hospital1 18**] was in the range of 200s suggesting acute
lung injury. Possibly COPD vs PNA vs aspiration. Pt did appear
tachypnic and uncomfortable on arrival to [**Hospital Unit Name 153**]. We have
maintained pt on TV 600 x RR 14, PEEP 12, FiO2 0.4 with propofol
for sedation. Propofol was weaned down and replaced with
midazolam as propafol appeared to decrease blooed pressure
excessively. Pt is currently ventilating and oxygenating well
on current settings. Recommend weaning pt off ventilator as
tolerated and weaning down sedation (midazolam and fentanyl)
concomitantly.
.
2. CV: Pt has been in and out of AFib since admission. However
pt was continued on the amiodarone gtt and has not gone into
rapid ventricular response since arrival. Recommend starting pt
on heparin gtt and coumadin for atrial fibrillation once pt is
over acute situation. Pt also has a h/o prior MI, we will
continue with ASA, but hold the metoprolol as above. Once
hemodynamics have stabilized can re-start metoprolol.
.
3. F/E/N: On arrival to [**Name (NI) 50345**], pt had a possible pre-renal
azotemia [**1-7**] asictes/sepsis with UNa < 10, BUN/Cr (80/2.0). Pt
was hydrated with NS, goal directed to CVP, oxygenation.
Recommend starting TF/TPN after ERCP and to replete lytes
aggressively. Recommend controlling FS <125. Pt was admitted
on FS QID, however sliding scale proved to be inadequate for
tight glucose control and an insulin gtt was started and is
continued to date. [**Month (only) 116**] continue with insulin gtt if FS prove
difficult to control.
.
4. Code: Full (no records otherwise, needs to be re-addressed
when pt MS improves)
.
5. Comm.: PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6359**] in [**Location (un) 3786**] ([**Telephone/Fax (1) 59750**]),
unavailable until [**11-4**].
Medications on Admission:
MEDS on transfer from OSH (outpt meds unknown):
1. ASA 325 once daily
2. Vancomycin 1g q24
3. Zosyn 3.25 q 6
4. Flagyl 500 TID
5. Amiodarone 0.5mg/min
6. Dilaudid PRN
7. Ativan PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection TITRATE TO (titrate to desired clinical effect (please
specify)).
8. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic TID (3 times a day) as needed.
9. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Midazolam HCl 5 mg/mL Solution Sig: [**12-7**] Injection TITRATE
TO (titrate to desired clinical effect (please specify)).
11. Amiodarone HCl 0.5 mg/min IV INFUSION
12. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours).
13. Vancomycin HCl 1000 mg IV Q24H
14. Metronidazole 500 mg IV Q8H
15. Fentanyl Citrate 25-100 mcg IV Q2H:PRN
16. Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bile Leak
Discharge Condition:
Stable
Discharge Instructions:
Please continue current antibiotic regimen.
Please follow up with your physicians at [**Hospital 8**] Hospital.
Followup Instructions:
Repeat ERCP in 1 month for stent removal/change.
Continue IV antibiotics.
Consider drainage of the biliary ascites if large amount is
present on abdominal CT scan.
Follow up with Dr. [**Last Name (STitle) 5166**] of [**Hospital1 18**].
Completed by:[**2109-11-2**]
|
[
"51881",
"42731"
] |
Admission Date: [**2172-12-11**] Discharge Date: [**2172-12-21**]
Date of Birth: [**2110-10-7**] Sex: F
Service: NEUROLOGY
Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
Weakness, diarrhoea, poor oral intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. [**Known lastname **] is 62 year old woan with myasthenia [**Last Name (un) 2902**], ho
of compression spinal fractures after steroid use for MG who
presents to neurology for diarrhea, dehydration and weakness
after not taking prescribed narcotics x 1 week. Patient was
prescribed oxycodone and oxycontin to treat back pain from
compression fractures which developed after steroid use. She
reported having good control of her back pain this week and
decided not to refill oxycodone/oxycontin rx. This week she felt
chills, "out of sorts", and developed abdominal cramps and
watery
diarrhea. Her diarrhea was nonbloody,watery and occured [**6-13**]
times
per day. No vomiting and no fevers. She was unable to take po
this week eating small amounts of rice and clear fluids. She
started feeling increasingly generalized weakness by the end of
the week and came to ED for evaluation via EMS.
Past Medical History:
PMHx:
1. Myasthenia [**Last Name (un) **]- followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG.
3. hypercholesterolemia
4. ho migraines
5. seasonal allergies
6. HTN
Social History:
Patient is single and lives alone. Limited social supports.
She is currently on disability. She used to work as a histology
tech a [**Hospital1 18**]. She denies ETOH/tobacco.
Family History:
Mother and father died of coronary artery disease in their 60s.
Sister died at age 5 of insulin dependent diabetes mellitus.
Physical Exam:
O: Tm: 98.7 Tc: 99.3 BP:147 / 62 HR: 62-69
RR: 16 O2Sat.:97% NIFs >60 I/Os:NR
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, mild T in all quads, D, +NABS. No rebound or
guarding. No HSM.
Extrem: Warm and well-perfused. Mild edema bilat
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Registration intact.
Recall: [**4-10**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. No apraxia,
no
neglect. [**Location (un) **] intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation. Optic
disc margins sharp.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Able to sustain upward gaze for 30 sec. Repeat EOMI
showed lag of left medial gaze. No diplopia or ptosis.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-12**] throughout. mild right pronator
drift. Neck flex/ext nml. Right arm changes [**6-12**] deltoid and 4-/5
after 50 arm flaps.
[**Doctor First Name **] Tri Bic WE WF FE FF
R 5- 5 5 5 5 5 5
L 5 5 5 5 5 5 5
IP HipAd HipAb Quads Hamstrings DF PF [**Last Name (un) 938**] TE TF
R 5 5 5 5 5 5 5 5 5 5
L 4 5 5 5- 5 5 5 5 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac 2+ throughout
Grasp reflex absent. Toes downgoing bilaterally.
Coordination: intention tremor in left UE. Nml finger taps and
no
FNT.
Gait: Shuffling gait with 5 steps before patient complains of
weakness
Pertinent Results:
[**2172-12-11**] WBC-11.1* RBC-4.19* Hgb-14.2 Hct-40.3 MCV-96 MCH-34.0*
MCHC-35.3* RDW-13.0 Plt Ct-156
[**2172-12-11**] Neuts-71.4* Lymphs-20.3 Monos-6.9 Eos-1.2 Baso-0.3
[**2172-12-11**] Plt Ct-156
[**2172-12-11**] Glucose-84 UreaN-21* Creat-0.7 Na-142 K-2.7* Cl-107
HCO3-27 AnGap-11
[**2172-12-13**] Calcium-8.8 Phos-3.0 Mg-2.1
[**2172-12-19**] calTIBC-270 VitB12-270 Folate-12.3 Ferritn-368* TRF-208
[**2172-12-13**] TSH-2.0
[**2172-12-15**] IgA-281
[**2172-12-16**] ART pO2-68* pCO2-50* pH-7.41 calTCO2-33* BaseXS-5
Echo:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) 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 moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the report of the prior study (images unavailable for review) of
[**2169-5-5**], no change.
CTA chest:
1. No evidence of pulmonary embolism.
2. Linear opacities in both lower lobes which may represent
scarring or residua of prior infection
CXR: No acute cardiopulmonary process.
ECG: Sinus rhythm. Short P-R interval. Non-diagnostic Q waves in
leads II, III, aVF. Early R wave progression. Since the previous
tracing of [**2169-3-8**] T wave abnormalities are probably more marked
but baseline artifact precludes some compoarison in the lateral
precordial leads.
Brief Hospital Course:
62 yo woman with ho of myasthenia [**Last Name (un) 2902**], HTN, spinal
compression fractures treated with narcotics, presented with
symptoms of narcotic withdrawal including chills, diarrhea,
dehydration and hypokalemia with possible exacerbation of
myasthenia [**Last Name (un) 2902**]. History of previous narcotic withdrawal after
discontinuation of narcotics. Right proximal UE weakness and
left LE proximal weakness. Mild lid lag with adduction of left
eye after 30 sec upward gaze, no diplopia or ptosis. Unable to
ambulate more than 5 steps without assistance and feeling very
fatigued. Admitted for investigations and treatment.
Progress:
Neurology: Neurological examination was closely monitored as
symptoms of narcotic withdrawal resolved. With increasing
symptoms of shortness of breath, and exclusion of other
cardiorespirtory causes, there was concern for exaccerbation of
MG. The patient was managed for several days in the ICU then
returned to the step down unit. She continued on her usual dose
of mestinon. The team consulted with Dr [**Last Name (STitle) **] regarding other
treatments. The patient was treated with 5 days of IVIG which
was well tolerated. Cellcept (mycophenolate) was also commenced
on [**2172-12-18**]. Strength was full with minimal fatiguability at
time of discharge.
.
Respiratory:
Increasing shortness of breath was associated with carbon
dioxide retention (arterial CO2 50). Investigations included CTA
on [**12-14**], which was negative for PE. There was no evidence
of heart failure or pneumonia on CXR. The pulmonary team were
consulted and followed during the admission. The patient was
supported with BiPAP ([**9-12**]) under close observation in the ICU
for several days prior to transfer back to [**Hospital1 **]. Oxygen via
nasal cannualae was required during the stay and weaned prior to
discharge. VSS and NIFs were monitored throughout and stable on
discharge. Respiratory technicians were involved in establishing
BiPAP and providing patient education. The patient felt
comfortable and back to baseline at discharge. Outpatient PFTs,
pulmonary follow up and sleep study have been arranged.
.
CVS: Home doses of antihypertensives were maintained and blood
pressure was stable.
.
Haematology: The hemoglobin was low normal and hematocrit just
below normal. Risk factors for anaemia screened for in order to
address treatable causes which may be contributing to shortness
of breath. Iron studies showed elevated ferritin. Other
parameters normal as were B12 and folate.
.
Musculoskeletal:
The patient was restarted on her usual pain medication. She
expressed an interest in reducing doses wherever possible. We
continued on standing doses and reduced prn doses of oxycodone.
Further decreases could be made in standing doses slowly if pain
remains well controlled. This should be done slowly. We stressed
the importance of not stopping medication suddenly.
ID: Urinalysis was positive and patient commenced on Bactrim.
Culture was mixed. Repeat culture was again negative prior to
commencement of cellcept.
.
FEN: Patient was rehydrated and electrolytes repleted and
monitored as diarrhoea resolved.
.
The patient was seen by PT and OT and cleared for discharge
home.
Medications on Admission:
Medications prior to admission:
1. Mestinon 30 mg TID
2. Oxycontin 40 mg po qam and 20 mg po qPM
3. Oxycodone 10 mg tid prn pain
4. Lipitor 20 mg po qday
5. Inderal 40 mg po BID
6. Evista
All:NKDA
Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO QAM (once a day (in the
morning)).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
3. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QPM (once a day (in the
evening)).
Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
6. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) 2902**]
Chronic back pain due to compression fractures post steroid use
Narcotic withdrawal
Discharge Condition:
Stable. Back pain controlled, power full and breathing at
baseline with establishment of BiPAP.
Discharge Instructions:
Take medications as prescribed. Ensure supply of medications to
avoid withdrawal symptoms in the future. Follow up as arranged
(see below). Seek medical advice for any symptoms of worsening
weakness or shortness of breath or other concerns.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2172-12-28**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2173-1-4**] 1:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] [**Month (only) 1096**]
visit-date to be advised.
Sleep Study: [**2172-12-23**] 8.30pm [**Hospital3 **] Hospital [**Hospital Ward Name 5074**] Sleep Lab, [**Hospital Ward Name 2104**] Bldg [**Location (un) **]
Pulmonary Function Tests: [**2172-12-28**] 9.30am [**Hospital3 **]
Hospital [**Hospital Ward Name 23**] [**Location (un) 551**] Pulm function Lab/Rehab Services
|
[
"2762",
"4019",
"2720"
] |
Admission Date: [**2164-2-17**] Discharge Date: [**2164-2-20**]
Date of Birth: [**2104-3-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Neosporin / Codeine /
Animal Hair/Dander
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain, Syncope
Major Surgical or Invasive Procedure:
Coronary angioplasty
Bare metal stent placement to LAD x 2
History of Present Illness:
59 year old man with hyperlipidemia was working out on his
treadmill the morning of admission when he developed a feeling
of "indigestion" associated with L arm tingling. He then
developed bilateral arm tingling, lightheadedness, and felt
generally unwell. 911 was called. EMS arrived at 11:41AM and at
11:43 the patient became unresponsive. He was found to be in
coarse VFIB, shocked 200 J x 1 to sinus tachycardia with
multiple PVC's. Given 90mg IV lidocaine and drip started at 2.
Upon arrival to [**Hospital1 46**] ER, patient was pain free with intact
mental status. Vitals 108/62, HR 60's SR without ectopy, sats
100% on 100% NRB. Labs at OSH significant for CPK 144, Trop .05,
K 3.6, Cr 1.4, INR normal, Hct 41, Plt 149. He then developed
recurrent chest pain. EKG with hyperdynamic T's across the
precordium. IV lido stopped; given Aspirin 324mg, Plavix 600 mg,
SL Nitro x2, Heparin gtt, Reglan 10 mg, Morphine 2 mg IV. CXR
WNL. He was transported to [**Hospital1 18**] for cath. ng for transport,
patient with 2/10 chest tightness, .
Upon arrival to [**Hospital1 18**] he was taken directly to the cath lab
where he was found to have 95% LAD lesion. BMS placed. He was
transferred to the CCU
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
Of note, he started an exercise regimen in [**9-23**], currently walks
1 hour daily on the treadmill and performs calisthenics. He has
lost 27 lbs with this regimen in the past 4 months.
Past Medical History:
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, -Hypertension
Cardiac History: NONE
Other PMH
Hyperlipidemia
Mild asthma
Cervical spine fusion
Hip surgery (?ruptured quad tendon)
3rd degree burns to b/l LE ([**Country 3992**]) s/p mult skin grafts
eye operations x 2 as a child
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He is retired, used
to work for the government. He exercises for 1 hour daily,
walking on the treadmill and doing calisthenics.
Family History:
His father had an MI at age 52, and later died of lung Ca.
Mother had a pituitary tumor (?benign), lung ca and DM. He has 2
older sisters who are A+W.
Physical Exam:
VS: T 97.1, BP 117/70, HR 77, RR 14, O2 100% on RA
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous membranes
dry.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Soft SEM at LUSB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi on anterior exam.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Sheath in place in R groin. No
bruit.
Skin: Extensive scarring over b/l LE. Abrasion over L achilles
tendon.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
2+PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
2+PT
Pertinent Results:
CARDIAC CATH performed on [**2164-2-17**] demonstrated:
LM: WNL
LCx: OM1 40%
LAD: 95% lesion extending beyond D1-> BMS placed. 50% lesion
more proximal.
RCA: 30% proximal.
----------------
ADMISSION LABS
----------------
9.5 \ ____ / 149
/ 36.6 \
139 | 106 | 14
---------------< 113
3.7 | 23 | 0.9
====================
CARDIAC CATH
===================
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated
single vessel disease. The LMCA had no significant disease. The
LAD had
a 95% thrombotic lesion extending beyond the D1 and a 50%
eccentric
lesion more proximally. The LCX system had a 40% OM1 lesion and
the RCA
had a 30% proximal lesion.
2. Resting hemodynamics revealed a SBP of 105mmHg and a DBP of
64mmHg.
3. Successful PCI/stent to the proximal LAD with 2 Vision bare
metal
stents (3.0x23mm distal and 3.5x12mm proximal with overlap).
Normal flow
down vessel and no residual stenosis at end of procedure.
FINAL DIAGNOSIS:
1. Thrombotic lesion in proximal LAD
2. Successful PTCA/stent to proximal LAD with 2 bare metal
stents.
==================
CARDIAC ECHO (TTE)
==================
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %) secondary to mild hypokinesis of the
anterior septum, anterior free wall, and apex. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: anteroapical hypokinesis with relatively
well-preserved overall left ventricular ejection fraction
Brief Hospital Course:
59 male with hyperlipidemia and +FH presented with STEMI/VF
arrest, now s/p BMS to LAD.
.
# CAD/Ischemia: Upon presentation, the patient was found to have
STEMI due to LAD lesion. The patient underwent successful PTCA
with BMSx2 to the LAD with good TIMI flow and with resolution of
symptoms. Patient will be discharged with scheduled follow up
and with a medical regimen consisting of ASA 325mg, plavix 75mg,
lipitor 80mg, metoprolol 12.5mg twice daily and lisinopril 2.5mg
daily. The patient did not tolerate higher doses of beta-blocker
and ACEi due to some hypotension. He was also given a
prescription for sublingual nitroglycerin for use as necessary
for chest pain. The patient was given prescriptions for blood
draws to be completed at his PCP's office for electrolyte check
(including K and BUN/Cr) [**Date Range 13835**] 1 week after discharge
and another blood draw to be completed 8 weeks after discharge
for monitoring of LFT's and cholesterol panel.
.
# VF arrest: Arrhythmia appears to be Secondary to STEMI.
Patient was immediately cardioverted with restoration of sinus
rhythm. Patient has maintained normal sinus rhythm on telemetry
and has not exhibited appreciable neurocognitive deficits.
.
# Systolic Function: Per TTE obtained this admission, minimally
diminished ejection fraction, likely secondary to stunned
myocardium. Would consider repeat echo and stress test as
outpatient.
.
# Shoulder pain: Patient suffers from chronic pain and had good
symptom control with tyelenol and oxycodone as needed.
.
#Asthma: We continued home dose of singulair and administered
nebulizer treatments as necessary.
.
# GERD. The patient had complaints of GERD type symptoms and was
started on a PPI.
.
# Code: The patient was FULL code throughout this admission.
Medications on Admission:
Zocor 10
Singulair
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please have blood drawn at your follow-up appointment with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 13835**] 1 week: Chemistry panel
(including K and BUN/Cr).
9. Outpatient Lab Work
Please have blood drawn at follow-up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 13835**] 8 weeks: LFT's and cholesterol panel.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual Q5minutes as needed for chest pain: Place one pill
under the tongue every 5 minutes for chest pain. Call an
ambulance if your pain is not relieved after 3 pills.
Disp:*20 Tablet* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Discharge Condition:
Stable, afebrile, chest pain free, ambulating without
assistance.
Discharge Instructions:
You were admitted to the hospital because of a heart attack. You
had 2 stents placed in a blocked artery around your heart.
Please take all medications as scheduled and keep all doctors
[**Name5 (PTitle) 4314**]. You must continue to take aspirin 325mg daily and
clopidogrel (also called plavix) 75mg daily without
interruption. If you are told to discontinue or hold these 2
medications by another physician contact your cardiologist
before doing so. Additional new medications for your heart
include atorvastatin (also called lipitor) 80mg daily,
lisinopril (also called zestril) 2.5mg daily and metoprolol
12.5mg twice daily. You may take a dissolving nitroglycerin pill
as prescribed as necessary for chest pain. You are also being
given a prescription for pantoprazole 40mg daily for
reflux/indigestion. Please discontinue the simvastatin (also
called zocor) you were taking prior admission.
Due to new medications, you must have blood drawn by your
primary care doctor in 1 week for chemistry monitoring,
including K (potassium) and BUN/Cr. You must also have blood
drawn by your primary care doctor in 8 weeks for monitoring of
liver function tests and a cholesterol panel.
If you experience new chest pain, shortness of breath, nausea,
vomiting or any other symptom that concerns you, please seek
medical attention.
Followup Instructions:
Dr. [**Last Name (STitle) 1617**], [**2164-3-1**] 3:15PM.
You must be seen by the cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]
([**Telephone/Fax (1) **]), 2 weeks after discharge. You should be contact[**Name (NI) **]
by his office for the date and time of this appointment. If you
do not hear from his office in the next 2 days, please call the
number provided to schedule this appointment.
|
[
"49390",
"53081",
"41401",
"2724"
] |
Admission Date: [**2136-12-21**] Discharge Date: [**2136-12-23**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old man
who presents with shortness of breath. He was recently
admitted to [**Hospital1 **] with chest pain on
[**2136-12-15**]. Patient ruled in for a myocardial infarction with
peak CK of over [**2135**]. Cardiac catheterization was done which
showed three-vessel disease with an ejection fraction around
30%. Decision was made to manage the patient medically. He
was also made DNR/DNI. He was discharged to rehab on
[**2136-12-18**].
Patient was sent back to the Emergency Department today
because of difficulty breathing. Patient was only able to
provide limited history, but states he is still short of
breath and is having cough. He denies chest pain.
PAST MEDICAL HISTORY: Hypertension, depression, three-vessel
coronary artery disease with an ejection fraction of 30%.
MEDICATIONS ON ADMISSION: Aspirin, Lopressor, captopril,
Lipitor, Protonix, Colace, Serzone, and Tylenol.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Patient has a father with coronary artery
disease.
PHYSICAL EXAMINATION AT TIME OF ADMISSION: Vital signs:
96.6, pulse 100, blood pressure 100/50, respiratory rate 40,
and sating 98% on 100% nonrebreather. Generally he was in
respiratory distress on 100% nonrebreather. HEENT: Pupils
are equal, round, and reactive to light. OP with dry mucous
membranes. Neck: Positive jugular venous distention. CVP
estimated around 10. Respirations: Diffuse rhonchi most
prominent in the right lower posterior lung fields. Coronary
examination: regular, rate, and rhythm, no murmurs, rubs, or
gallops. Abdomen was soft and nontender with positive bowel
sounds, mild diffuse tenderness. Extremities: He had trace
edema. Neurologic: He was alert and oriented times three.
LABORATORIES ON ADMISSION:
He had a white count of 19.0, hematocrit of 32.0, platelets
407,000. Sodium 134, potassium 6.2, chloride 100, bicarb 18,
BUN 63, creatinine 2.8.
His electrocardiogram showed a left bundle branch block.
Chest x-ray with a bilateral infiltrates right greater than
left and bilateral pleural effusions.
ASSESSMENT AND PLAN:
This is an 80-year-old man recently admitted with large
myocardial infarction and now presenting with shortness of
breath and increased respiratory rate. Chest x-ray
suggestive of pneumonia and possible congestive heart
failure.
1. Pulmonary. Plan to treat pneumonia with ceftriaxone and
azithromycin in this critically ill patient. Also plan to
continue oxygen, culture sputum, make him NPO. Pulmonary
edema may also be playing a role, but will hold on Lasix
given his hypotension.
2. Cardiovascular. Three-vessel coronary artery disease
holding his po medications. Will consider restarting aspirin
overall amount for myocardial infarction.
3. Renal. Creatinine increased. Check urine, electrolytes,
and Foley.
4. ID. Blood cultures times two. Urine cultures. Sputum
cultures. Ceftriaxone and azithromycin for pneumonia as
above.
5. Gastrointestinal. NPO.
6. Code status. DNR/DNI.
7. Communication. Discussed with son and told him the next
12-24 hours are critical.
HISTORY OF HOSPITAL COURSE:
The patient began to have evidence of a further myocardial
infarction with CK of 278 and a troponin of over 50. Patient
was made comfort measures only. He is not a candidate for an
invasive intervention. The patient continued to do poorly
and died at 1 pm on [**2136-12-23**] after extensive discussions with
the family. It was decided to discontinue oxygen.
CONDITION ON DISCHARGE:
Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36903**], M.D. [**MD Number(1) 36904**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1201**], M.D.
MEDQUIST36
D: [**2136-12-23**] 13:19
T: [**2136-12-27**] 06:06
JOB#: [**Job Number 32157**]
|
[
"486",
"4280",
"5849",
"51881",
"4019"
] |
Admission Date: [**2136-11-23**] Discharge Date: [**2136-12-1**]
Date of Birth: [**2069-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 year old man with h/o hypertension, permanent
pacemaker, IDDM, CHF with EF 10%, and ESRD on HD who was
transferred to the CCU for management of hypotension. He
presented to OSH from his NH on [**2136-11-20**] with complaints of
bilateral leg swelling, calf pain, and heel cellulitis, and was
transferred to [**Hospital1 18**] earlier today for revascularization of his
LLE.
.
At the OSH, ulcers were noted to the left fourth and fifth
toe-web area with purulent drainage, with diminished pulses.
Ultrasound was without evidence of DVT. Dopplers showed a high
grade plaque with abnormal wave forms in the left [**Hospital1 1793**], little
flow in the [**Hospital1 1793**]. No flow seen in any of the three run off
vessels. The patient was noted to have MRSA in nares, proteus in
wound, and c diff + stool. He was started on vancomycin, flagyl
and ertapenem. He was then transfered to [**Hospital1 18**] for
catheterization for revascularization. In the catheterization
lab, he was found to have total occlusion of L [**Hospital1 1793**] and is s/p
PTAx2 of [**Name (NI) 1793**], PTA to anterior tibialis/tibialis posterior. He
received [**2129**] units of heparin and 300 mg of plavix.
.
On the floor his SBP was <75 for approx 30 minutes. He had an
ACT>230, despite protamine bolus. After additional protamine,
his ACT went to 215 and his sheath was removed.
.
Of note, per the [**Hospital Unit Name 196**] team's discussion with his daughter,
[**Name (NI) **], he has been in [**Name (NI) 6930**] [**Hospital1 1501**] for 14 months. He has been
increasingly debilitated. In [**Month (only) 216**] he had a loculated pleural
effusion (?empyema) requiring drain. Since then he has had
dysphagia and inability to ambulate. Review of systems was
otherwise unable to be obtained due to patient's poor baseline
mental status.
.
Cardiac review of systems is notable for absence of chest pain.
Otherwise unable to obtain further ROS.
.
Past Medical History:
Hypertension
Hyperlipidemia
ESRD on hemodialysis x 4 years (M/W/F), has R SCL HD catheter
IDDM, not on insulin at rehab
depression
anemia
esophageal reflux
MRSA
Cdiff
CAD s/p "6+" MIs, no CABG, per report EF of 10% has ?PPM in
place
s/p CVA [**2128**] - residual L sided weakness
.
Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
Pacemaker/ICD placed- unsure of date placed
Social History:
Social history is significant for the absence of current tobacco
use. Per daughter he used to smoke cigars. There is no history
of alcohol abuse.
Physical Exam:
VS: T 97.8, BP 72/37, HR 73, RR 14, O2 97% on 1LNC
Gen: elderly, chronically ill appearing male in NAD, resp or
otherwise. Lying flat. Oriented x1. alert, responds to
questions, albeit inappropriately
HEENT: Conjunctiva were pink
Neck: Supple; difficult to determine JVP as patient was in
supine position.
CV: RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. bilateral
coarse BS with decreased BS anteriorly on the right. Bilateral
crackles ausculated. no wheezes.
Abd: soft, NTND normal BS.
Ext: No edema. No femoral bruits. left foot with dark 5-6 cm
long eschar over plantar surface. dusky appearance to 4th/5th
toes on right. Anterior ankle ulcer with good granulation
tissue- no evidence of pus. Dry, black 2 cm round right heel
ulcer.
Right foot, cool to touch. dry ulcers noted- well scabbed and no
sign of active infection.
Pulses:
Right: Carotid 2+; Femoral with sheath in place; DP/PT not
dopplerable
Left: Carotid 2+ ; Femoral 1+; DP/PT dopplerable
Pertinent Results:
EKG demonstrated regular rate, 66, demand pacing with right axis
deviation. No prior for comparison.
.
PERIPHERAL CATH: Cath showed patent bilateal renal artery stents
with poor flow, RLE patent to CFA, LLE patent to CFA, high grade
subtotal [**Year (4 digits) 1793**], high grade popliteal/TPT, 100%ant
tib/peroneal/post tib with poor flow seen at mid/calf/foot.
Intervention: Successful PTA of [**Year (4 digits) 1793**] x2, successful PTA of the
ant tib/tpt with straight continuous flow restored to foot via
dorsalis pedis.
.
2D-ECHOCARDIOGRAM: no ECHO report here; reportedly EF 10%; will
attempt to obtain previous ECHO reports
.
[**2136-11-23**] CXR: my right sided pleural effusion extending to apex;
.
From OSH:
[**11-23**] wbc 7.0, hct 37.9 plt 94*** *(139 on admit); K 3.7, bun
17, creat 3.8 (no INR drawn). Blood sugar this morning was 84.
yesterday was 69. Alb 1.6, Prealb 8.0.
Brief Hospital Course:
67 M CHF with EF 10%, biV pacer, and PVD; also ESRD on MWF HD
transferred for ischemic foot. Initially transferred to [**Hospital1 **] where he received a few days of abx. On [**11-23**] came to
[**Hospital1 18**], on cath showed total occlusion of L [**Hospital1 1793**] and s/p PTAx2 of
[**Name (NI) 1793**], PTA to anterior tibialis/tibialis posterior. Transferred
to CCU with persistent hypotension, thought to be likely
secondry to sepsis. He was continued on vancomycin, flagyl and
meropenem and started on dopamine drip. Vascular surgery was
consulted for ischemic foot but because of his sepsis, surgical
intervention was not recommended. On [**11-29**], CVVHD started. On
[**11-30**], he was made CMO by his family and on [**12-1**], he expired.
Medications on Admission:
Bactroban to both nares
Celexa 20mg
Coreg 3.125mg qd
Ecotrin 81mg daily
Flagyl 250mg po bid
Heparin with dialysis
Invasz 500mg every 24 hours
Lipitor 40mg
Lovenox 30mg daily (last given yesterday morning)
Nexium 40mg
Trazodone 25mg HS PRN
Vicodin Q4 prn
MOM
Vancomycin with HD
Tylenol
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Not applicable
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2136-12-24**]
|
[
"0389",
"99592",
"40391",
"2724",
"25000",
"41401",
"V5867"
] |
Admission Date: [**2136-4-17**] Discharge Date: [**2136-4-20**]
Date of Birth: [**2059-7-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, stent placement
History of Present Illness:
76 yo M hx HTN, hyperlipidemia p/w suddent onset SSCP this am
while drinking coffee, 10/10 intensity, assoc with diaphoresis,
blurry vision, lightheadedness and mild nausea. Pt took SL NTG
x2 with mild improvement. A friend took him home and he called
EMS, arrived approx 15 min after onset of chest pain. Given
325mg asa by ems.
On arrival ST elevations noted in II, III, aVF. In ED, code
STEMI activated, pt loaded with plavix, given heparin and
integrillin and taken to cath lab. He was found to have TO of
RCA, which opened with initial injection, BMS was placed. Also
noted to have 60-70% OM lesion.
Of note pt active, develops dyspnea with walking up a [**Doctor Last Name **]
associated with mild chest discomfort, resolves with rest. He
also has occasional chest discomfort after eating, attributes to
indigestion. No prior history of symptoms similar to todays
presentation.
.
ROS: Prior to today, pt had been feeling well, no recent
f/c/n/v/abdominal pain. No melena/hematochezia, no difficulty
urinating or obstructive symptoms since prostate CA treatment.
No hx PE or other blood clots, no orthopnea/PND/leg edema.
Past Medical History:
Hypertension
Hypercholesterolemia
Prostate CA s/p brachytherapy 6 yrs ago and lupron
s/p CCY 15 yrs ago
hx kidney stones
Social History:
Pt is retired from restaurant business, lives at home with wife.
+ tobacco hx, quit about 40 yrs ago after smoking x15 yrs
2-3ppd. Denies etoh or recreational drugs.
Family History:
Family hx with sister having MI at 70, brother with CVA in his
80s.
Physical Exam:
VS: T 96.0, BP 111/54, HR 69, RR 13, O2 sat 100% on 2L NC
Gen: [**Last Name (un) 664**] elderly male, well developed, NAD
HEENT: anicteric, OP clear
Neck: JVP 12cm
CV: RRR nl s1, s2 no m/r/g
Pulm: clear anteriorly without wheezes
Abd: soft, mild tenderness RLQ and suprapubic, no guarding or
rebound, no HSM
Ext: R groin with mod hematoma, no bruit, full pulses
bilaterally in DP/PT.
Neuro: non-focal
Pertinent Results:
Cardiac cath ([**2136-4-17**]): TO proximal RCA, opened with initial
injection. BMS stent to culprit RCA. OM1 with 60-70%.
COMMENTS:
1. Coronary angiography in this right-dominat system revealed
2-vessel
CAD.
--the LMCA had no angiographically apparent disease.
--the LAD had no angiographically apparent disease.
--the LCX had a 60-70% stenosis in an upper pole OM1.
--the RCA was totally occluded proximally, which opened with the
initial
injection; there were no collaterals.
2. Resting hemodynamics revealed high-normal right-sided
filling
pressures with RVEDP 12 mmHg; PA systolic pressures were normal
with
PASP 24 mmHg. The PCWP was normal with mean PCWP 12 mmHg.
Systemic
arterial systolic hypertension was mild with SBP 141 mmHg. The
cardiac
output was preserved, with cardiac index 3.0 L/min/m2.
3. Successful thrombectomy. ptca and stenting of the proximal
RCA and with a 3.5x18mm vision stent which was post dilated to
3.75mm.
Final angipography revealed 0% residual stenosis, no
angiographically
apparent dissection and timi 3 flow. The patient left the lab
free of
angina and in stable condition.
FINAL DIAGNOSIS:
1. Acute inferoposterior STEMI.
2. Two-vessel coronary artery disease.
3. Successful BMS of culprit RCA.
.
EKG: sinus brady at 52, nl axis, PR prolonged at 270msec. ST
elevations 2mm II, III, aVF, q wave in III. Reciprocal ST
depressions anteriorly. ST elevations resolved on
post-procedure EKG.
.
Hemodynamics: RA 13/14/13
RV 30/12
PA 24/9/13
PCWP 18/14/12
CO/CI 5.62/2.95
.
ECHO [**2136-4-19**]
EF 45-50%. 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 to mid inferior and infero-lateral
akinesis. No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
ADMISSION LABS
[**2136-4-17**] 10:20AM BLOOD WBC-7.4 RBC-3.96* Hgb-12.5* Hct-35.7*
MCV-90 MCH-31.7 MCHC-35.1* RDW-13.1 Plt Ct-161
[**2136-4-17**] 10:20AM BLOOD Plt Ct-161
[**2136-4-17**] 12:10PM BLOOD PT-13.8* INR(PT)-1.2*
[**2136-4-17**] 10:20AM BLOOD Glucose-130* UreaN-16 Creat-0.8 Na-139
K-4.3 Cl-107 HCO3-25 AnGap-11
[**2136-4-17**] 10:20AM BLOOD ALT-17 AST-19 CK(CPK)-74 AlkPhos-39
Amylase-68 TotBili-0.4
[**2136-4-17**] 10:20AM BLOOD CK-MB-5 cTropnT-0.01
DISCHARGE LABS
[**2136-4-20**] 08:00AM BLOOD WBC-11.8* RBC-3.01* Hgb-9.4* Hct-27.4*
MCV-91 MCH-31.3 MCHC-34.5 RDW-13.5 Plt Ct-199
[**2136-4-17**] 10:20AM BLOOD Neuts-75.9* Lymphs-18.1 Monos-4.8 Eos-0.9
Baso-0.3
[**2136-4-20**] 08:00AM BLOOD Plt Ct-199
[**2136-4-20**] 08:00AM BLOOD PT-12.5 PTT-45.5* INR(PT)-1.1
[**2136-4-20**] 08:00AM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-28 AnGap-13
[**2136-4-20**] 08:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
CARDIAC ENZYMES/HBA1C
[**2136-4-18**] CK 33* MB 7.3* Trop T 1.94*
SLIGHTLY HEMOLYZED
[**2136-4-17**] CK 52* MB 7.5* Trop T 2.78
HBA1C 5.8
Brief Hospital Course:
This is a 76 year old man with history of HTN, dyslipidemia who
presented with chest pain, found to have an STEMI, taken for
cardiac cath and BMS was placed to his RCA.
1. STEMI - Patient presented quickly to the hospital after an
episode of chest pain. He was found to have ST elevations in his
inferior leads with reciprocal changes consistent with acute
IMI, and found to have RCA lesion s/p BMS placement during
cardiac catheterization on [**2136-4-17**]. He was transferred to the CCU
for observation post procedure. He received integrillin gtt
after his procedure and was started on plavix after the
procedure. His enzymes peaked at 7pm after procedure with CK 52,
Trop T of 2.78. His ST changes were resolved on EKGs post
procedure. ECHO post procedure showed EF 45-50%, mild
inf/lateral akinesis. Post procedure EKG showing resolution of
ST elevations, no indication of stent rethrombosis or recurrent
MI. He had a small mild right groin hematoma post procedure
which remained stable with resolving ecchymosis upon discharge.
His pulses remained good. He was stable and transferred to the
medical floor. He was optimized on his medical regimen. He was
started on plavix 75mg PO daily, increased to 325mg PO daily
aspirin, lipitor 80mg PO daily. He was titrated up on his
metoprolol to 37.5mg PO TID and his BP remained SBP 100-110s
with HR in 60s. He will follow up with his cardiologist, Dr.
[**Last Name (STitle) **], where he can be started on an ACE inhibitor as his BP
allows.
2. Hematuria - The patient had urinary obstruction on
presentation likely 2/2 blood clots which resolved with CBI in
the CCU. Pt has hx of prostate CA s/p brachytherapy and lupron.
CBI was stopped after patient started making clear urine.
However, he had new hematuria likely secondary to trauma from
foley on [**2136-4-18**]. Urology was consulted and patient was restarted
on CBI with clear urine on [**2136-4-19**]. His foley was discontinued on
morning of admission and patient was able to void on own without
hematuria or pain by discharge.
3. Anemia - Patient with decreased Hct from 30.4 -> 27s with
nadir with Hct of 25. Likely blood loss from R groin hematoma,
with no indications of tense hematoma, active bleed, or GIB.
Patient also with some blood loss from hematuria. His Hct
remained stable at discharge at 27.4. He was started on niferex
150mg PO daily on discharge.
Medications on Admission:
Atenolol 25mg daily
Lipitor 10mg daily
ASA 81mg
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
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 DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*0*
6. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis
ST elevation myocardial infarction
Secondary diagnosis
Mild right groin hematoma
Anemia
Hematuria
Discharge Condition:
Stable, right groin ecchymoses stable
Discharge Instructions:
You were admitted to the hospital when you developed chest pain,
were found to have an acute heart attack and taken for cardiac
catheterization where a stent was placed in one of your heart
vessels. You were stable after your procedure and your heart
medications were optimized. You were also started on iron
supplementation for anemia.
Your new medication regimen is follows. It is important for you
to take all these medications daily as directed:
1. plavix 75mg daily
2. lipitor 80mg daily
3. aspirin 325mg daily
4. metoprolol 37.5mg twice a day
5. niferex 150mg daily
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], at your
scheduled appointment.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], your cardiology at your
scheduled appointment.
Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**], is aware of your
hospital stay and instructed you to first see Dr. [**Last Name (STitle) **] and you
can call to make an appointment with Dr. [**Last Name (STitle) 311**] afterwards. His
number: [**Telephone/Fax (1) 1713**]
|
[
"41071",
"2851",
"41401",
"4019",
"2724"
] |
Admission Date: [**2172-12-18**] Discharge Date: [**2173-1-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
Altered mental status, admitted to MICU for hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o woman with pmh of anemia, PUD, presents to the ED with
several days of poor po intake, somnolence, and altered mental
status. per ED notes and patient's family in USO until
approximately 1 week ago, when family members noticed she was
more withdrawn, not recognizing people, and needing encouragment
to take PO. Reports low urine output. Family denies fevers,
changes in bowel function, or nausea/vomitting. Other ROS unable
to be obtained as patient unresponsive.
Past Medical History:
-anemia, on iron supplementation
-peptic ulcer disase, history of perforated gastric ulcer four
years PTA with repair (?[**Location (un) **] patch placement)
Social History:
The pt. is originally from [**Country 2045**]. Pt. lives with her niece who
is her health care proxy. [**Name (NI) **] history of tobacco, alcohol or
illicit drug use.
No recent history of travel. She had been fully functional in
all of her ADLs per her niece.
Family History:
Noncontributory.
Physical Exam:
Vitals- T 98.0, BP 118/72, HR 76, RR 22, O2sat 96% RA
General- elderly woman lying in bed, responding to name,
initially not responding to questions, but began to respond
after asking repeatedly, following minor commands
HEENT- NCAT, sclerae muddy but anicteric, moist MM, patient not
opening mouth to command
Neck- no JVD seen
Pulm- + crackles 2/3 up R, + crackles at L base
CV- RRR, 2/6 SEM at [**Doctor Last Name **]/LLSB
Abd- + BS, mildly distended but soft, patient not guarding or
grimacing to deep palpation
Extrem- trace ankle edema b/l, no response to calf palpation, no
palpable cords
Neuro- somnolent but arousable to name, oriented to name and
"hospital", following simple commands, moving 4 extremities but
not cooperative with neuro exam
.
Brief Hospital Course:
Pt. was hypotensive (50's over 30's), hypothermic (96.0) and so
was admitted to [**Hospital Unit Name 153**].
In the [**Hospital Unit Name 153**], a right IJ was placed emergently and aggressive
fluid resusitation was begun. Dopamine was also started
peripherally while central line was placed. Her BP responded
well and she was changed to levophed after central line placed.
Broad spectrum antibiotics were started. She was weaned from
pressors the following day and continued to have good oxygen
saturations and BP. She in fact becamse hypertensive and her
metoprolol was restarted with good effect. Her mental status
recovered somewhat in that she opened her eyes to voice,
occasionally interacted with staff, and was able to speak a few
words. Per her family she did not yet appear at her MS [**Hospital Unit Name 5348**].
She failed a speech and swallow and it was recomended that she
be NPO and placed on NGT feeds. She was transfered to the floor
hemodynamically stable, tolerating her tube feeds, and sating
97-100% on 1-2L NC.
.
On transfer to the floor, her course was as follows:
# fever:
Patient was initially afebrile, completed vancomycin and
ceftriaxone for 14 days for pneumonia and was stable off
antibiotics. However, she began spiking fever on [**1-2**]. Repeat
urinalysis on [**1-2**] was c/w UTI. Her CXR still show right sided
consolidation but patient did not have sputum production. She
also had clinical evidence of aspiration per nursing staff.
Given that lung and urine was her potential infectious source,
she was started on vanco/zosyn [**1-3**], flagyl [**1-4**] and added
fluconazole [**1-4**] for yeast in urine. Fever seem get better with
addition of fluconazole. vanco/zosyn/flagyl were d/c'd that week
given improvement in respiratory symptoms and fever.
Fluconazole was given to compelete a 10 day course. Blood and
urine cultures remained negative except for >100K yeast in
urine.
Pt remained afebrile for the rest of her hospital course.
# acute renal failure
[**Month/Year (2) **] Cr was 0.8-0.9; creatinine began to rise on [**12-27**] and
continued to rise progressively to a peak of 3.7 on [**1-5**]. Renal
U/S was negative for any obstruction. Renal was consulted, felt
that ATN seemed most likely etiology in the setting of prior
hypotension. IVF were given initially, but then were limited by
pt's respiratory status. By [**1-6**], Cr began to decline and pt
began to diurese without any pharmacologic help. By time of
discharge, patients creatinine had nearly returned to [**Month/Year (2) 5348**]
and was continuing to improve.
# Pulmonary edema:
Patient was hydrated with IVF for acute renal failure as above
and shortly thereafter began to have worsening respiratory
distress. On exam, she had significant rales and some pulmonary
edema. She had been ruled out for MI by enzymes on [**12-21**] and
there were no obvious complain of chest pain. She was gently
diuresed with IV lasix and showed rapid improvement in
respiratory status, with improved oxygenation and decreased work
of breathing. For the remainder of her hospital stay, IVF were
more limited and patient continued to improve.
.
# Altered MS/agitation:
Pt's mental status worsened transiently in setting of renal
failure and worsening pulmonary edema, then began to improve
again as these issues resolved. By the time of discharge,
patient was more alert, able to answer some questions and follow
simple commands.
# Anemia:
Per PCP, [**Name10 (NameIs) 5348**] Hct is 30-33. Pt's hct had continued to drift
slowly downward and ultimately required transfusion of 1unit
PRBC on [**12-27**]. Hct responded appropriately, but continued to
drift slowly downwards, and patient ultimately required a second
transfusion on [**1-8**]. No clear etiology on CT abdomen, but
patient had some brown guaic-positive stools on [**1-8**],
[**1-11**]. Likely has slow GI bleed causing her anemia. Had been on
PPI, but given poor PO intake, new finding of heme-positive
stools, IV PPI was started on [**1-9**]. Overall, patient was
stable, and did not seem to have symptoms or physiologic
distress [**2-12**] anemia.
Will need to be intermittently followed by Dr. [**First Name (STitle) **].
.
# nutrition
Patient initially had NGT but pulled it out numerous times. Had
failed speech and swallow. Family has said that they want to
avoid PEG, NG, would like to continue to feed her orally and
they understand the risk of aspiration(nectar thickened soft
food). Pt. given some PPN on floor to improve nutritional status
and bridge pt to PO's while waiting for her mental status to
improve. By time of discharge, pt was taking some PO's but not
adequately to ensure good hydration, so was discharged with IVF
to rehab per Dr.[**Name (NI) 61245**] request.
.
# communication.
[**First Name9 (NamePattern2) **] [**Last Name (un) **] [**Telephone/Fax (1) 61246**] or [**Telephone/Fax (1) 61247**]. Staff had
contact[**Name (NI) **] and communicated with her family on multiple
occassion. They agree with plan of some IV hydration, continued
PO's despite some aspiration risk, no enteral feeding tube.
Patient will remain DNR/DNI.
Medications on Admission:
ASA 81 mg daily
Metoprolol 25 mg [**Hospital1 **]
Iron 325 mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed
for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID PRN
as needed for constipation.
Disp:*30 * Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer tx
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs nebulizer tx* Refills:*0*
4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*qs ML(s)* Refills:*2*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh
Inhalation every six (6) hours.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): [**Month (only) 116**] change to PO PPI when
taking PO's.
Disp:*30 Recon Soln(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
9. IV fluids
Please give D5W at 50ml/hr through peripheral IV
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Pneumonia
Altered mental status
Urinary tract infection
Acute renal failure
Pulmonary edema
Discharge Condition:
Good. Respiratory status improved, pt's mental status gradually
improving. Renal function improving.
Discharge Instructions:
Return to the hospital or call Dr [**First Name (STitle) **] immediately for:
-Worsening shortness of breath or more trouble breathing
-Poor urine output
-Worsening mental status
-Fevers >102 degrees
-Any other concerning symptoms
Followup Instructions:
Please call Dr.[**Name (NI) 61245**] office this week to arrange a follow-up
appointment.
Completed by:[**2173-1-13**]
|
[
"0389",
"486",
"5990",
"4280",
"5845",
"2762",
"2760",
"42731",
"78552",
"99592",
"4019"
] |
Admission Date: [**2119-8-5**] Discharge Date: [**2119-8-17**]
Date of Birth: [**2047-12-23**] Sex: M
Service: CA/TH [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient was admitted on
[**2119-8-5**] to the Medicine service for left sided chest pain,
shortness of breath, and lightheadedness. The patient was a
73 -year-old male with no cardiac history and no known risk
factors, with a recent history of worsening left sided chest
pain times three days. Before admission the patient had
several bouts of nonexertional chest pain and shortness of
breath which resolved slowly. On the day of admission, he
experienced more intense chest pain, roughly 8 out of 10,
accompanied with shortness of breath, lightheadedness,
dizziness, and diaphoresis.
The patient presented to the Emergency Department and was
given sublingual nitroglycerin which decreased the pain to 1
out of 10. The electrocardiogram showed T-wave flattening in
III and AVF, but no other ST changes. A chest x-ray showed
no evidence of acute cardiomyopathy. In the Emergency
Department, the patient was also given aspirin, morphine
times two doses, and one inch of nitroglycerin paste. The
patient was also started with a heparin 5,000 unit bolus and
then an 800 unit power drip.
PAST MEDICAL HISTORY:
1. Nephrolithiasis.
2. Status post appendectomy, remote.
3. Negative diabetes, hypertension, cancer, or
hypercholesterolemia.
ADMITTING MEDICATIONS: Include multi-vitamin one po q day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.6 F, blood pressure
134/71, pulse 80, respiratory rate 17, and O2 saturation 97%
on room air. General: he is a Russian speaking male with no
acute distress. Head, eyes, ears, nose and throat was pupils
were equal, round, and reactive to light, negative scleral
icterus. Neck was supple, negative lymphadenopathy, and a
jugular venous pulse of roughly 8.0 cm. Lungs were clear to
auscultation bilaterally, no wheezing, mild left sided
crackles at the bases.
Cardiovascular was regular rate and rhythm, S1, S2, negative
S3 and S4, positive grade III-IV systolic murmur heard best
at the apex and radiating to the carotids bilaterally.
Abdomen was soft, nontender, nondistended, positive bowel
sounds. Extremities were warm, negative femoral bruits, +2
popliteal, dorsalis pedis, and posterior tibial pulses
bilaterally. Neurologic was cranial nerves II through XII
intact grossly, normal motor and strength, no focal deficits.
ADMISSION LABORATORY DATA: Included a white blood cell count
of 7.5, hematocrit of 38.8, platelets of 243,000. Sodium
140, potassium 4.0, chloride 104, CO2 29, BUN 1.7, creatinine
0.6, and glucose 102. Urinalysis showed moderate blood,
otherwise negative. Urinary cultures were pending at the
time. PTT 26.2, INR 1.1.
Chest x-ray: negative acute cardiopulmonary process,
questionable old granulomatous process. Electrocardiogram
was normal sinus rhythm in the 50s with left ventricular
hypertrophy, T-wave flattening in III and AVF.
HOSPITAL COURSE: On [**2119-8-5**], the patient was monitored and
cared for by Medicine. On [**2119-8-9**], the patient had a
catheterization which showed negative significant stenosis in
the right coronary artery, left coronary artery, and left
anterior descending. Normal right sided pressures, elevated
left sided pressures, and ejection fraction of 62%. Negative
mitral regurgitation, but severe aortic stenosis.
Cardiothoracic Surgery was consulted on [**2119-8-9**] and the
patient was scheduled for an aortic valve replacement +/-
coronary artery bypass graft.
On [**2119-8-11**], the patient was brought to the Operating Room
with a diagnosis of severe aortic stenosis and coronary
artery disease. The patient had an aortic valve replacement
/ coronary artery bypass graft with a right saphenous vein
graft to the first obtuse marginal artery.
On postoperative day one, the patient did well, but continued
to have significant drainage out of the chest tube with
roughly 640 cc over 24 hours. On [**2119-8-12**], the patient was
transferred out of the Cardiothoracic Intensive Care Unit to
the floor. On [**2119-8-13**], the patient continued to do well and
had his chest tube removed. The patient continued to
progress and ambulated at a level 2. On postoperative day
three, the patient was transfused one unit of packed red
blood cells with a pretransfusion hematocrit of 21.2. The
patient continued to ambulate well and had a PT level between
a 3 and a 4.
On [**2119-8-16**], the patient's PT level was still between a 3 and
a 4 and a decision to screen for rehabilitation was made.
Later in the day, the patient showed marked improvement with
physical therapy and was once again scheduled for a possible
discharge with [**Hospital6 407**]. On [**2119-8-17**], the
patient continued to do well and was discharged home.
Discharge physical examination included preoperative weight
of 70.5, discharge weight 70.2, maximum temperature 98.6 F,
pulse 80, blood pressure 127/75, respiratory rate 20, O2
saturation 93% on room air. The patient was alert and
oriented. Incision was clean and dry. Respiratory rate was
clear to auscultation bilaterally. Cardiovascular was
regular rate and rhythm, S1, S2, sternum was stable. Abdomen
was soft, nontender, nondistended. Extremities: warm, well
profused, negative left lower extremity swelling.
COMPLICATIONS: None.
DISCHARGE MEDICATIONS: Metoprolol 12.5 mg [**Hospital1 **], aspirin 81 mg
q day, Motrin 400 mg q six hours prn.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home with [**Hospital6 407**].
FOLLOW-UP: Follow-up will be with Dr. [**Last Name (STitle) 70**] in three to
four weeks.
DR. [**Last Name (STitle) **]
Dictated By:[**Last Name (NamePattern1) 33068**]
MEDQUIST36
D: [**2119-8-17**] 21:53
T: [**2119-8-17**] 23:07
JOB#: [**Job Number **]
|
[
"4241",
"41401"
] |
Admission Date: [**2194-1-25**] Discharge Date: [**2194-1-25**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman with a history of hypertension and alcohol use
transferred from an outside hospital on [**2194-1-25**]
secondary to hyperbilirubinemia, newly diagnosed pancreatic
head mass, a CBD occlusion, hepatic abscess with blood
cultures positive for E. coli, [**Female First Name (un) 564**] glabrata,
Lactobacillus. The patient subsequently had a common bile
duct drain placed at the outside hospital. The patient was
subsequently treated with ampicillin, gentamicin, Flagyl,
AmBisome and was followed by Infectious Disease. The patient
was intubated for subsequent ARDS on [**2194-2-1**] and
subsequently had an ERCP with bronchial brushings revealing
atypical cells consistent with adenocarcinoma, CA99 of
36,000. The patient was subsequently transferred to [**Hospital1 18**] on
[**2194-1-26**] and taken to the ICU on [**2193-2-1**]
after hypoxic respiratory failure. The patient was
subsequently extubated, transferred to the Medicine Floor.
Blood cultures and urine cultures were negative since then.
Per ID consult, the patient's antibiotic regimen was changed
to Unasyn, vancomycin, and Voriconazole. Over the past eight
days, the patient's T bilirubin and alkaline phosphatase have
slowly risen which was thought secondary to worsening biliary
obstruction. Plans had been made for another palliative
stent. The patient subsequently developed increased
diarrhea. Clostridium difficile was negative times three,
thought secondary to pancreatic insufficiency.
The patient was started on Pancrease as well as TPN with
improving p.o. intake subsequently. Today, the covering
Medicine Team was called at bedside secondary to decreased
mental status and hypotension with blood pressure down to
70/40, tachycardia 158. The patient had a fingerstick blood
glucose at that time of 10. The patient was given 2 amps of
D50 with blood glucose returning to about 170 and resolution
of mental status change. The patient had a right femoral
line placed, given 3 liters of normal saline, and the blood
pressure improved to 90/50. Peripheral dopamine was started.
EKG revealed normal sinus rhythm at 158, rate-related ST
depressions in the lateral walls, CKs and troponins were
negative. CBC, further blood cultures, Chem-7 was taken.
The chest x-ray revealed mild volume overload. ABG revealed
the following numbers: 7.36, 29, 210, on a nonrebreather.
The patient was transferred to the ICU given the hypotension
requiring pressors, mental status change, and profound
hypoglycemia most likely secondary to hepatic failure due to
hepatic abscesses.
PAST MEDICAL HISTORY: Metastatic pancreatic cancer per
bronchial brushings, CA99, and imaging studies.
Hypertension.
Alcohol abuse.
Chronic pancreatitis.
MEDICATIONS ON TRANSFER TO THE ICU:
1. Celexa 20 mg p.o. q.d.
2. Protonix 40 IV q. 24 hours.
3. Heparin 5,000 units subcutaneously q. eight hours.
4. Vancomycin 1 gram IV q. 12 hours.
5. Lorazepam 0.5 to 2 mg q. 2 to 4 hours p.r.n.
6. Morphine IR p.o. q. eight hours p.r.n.
7. Regular insulin sliding scale.
8. Unasyn 3 grams IV q. six hours.
9. Pancrease t.i.d.
10. TPN.
11. Voriconazole 100 p.o. q. 12 hours.
PHYSICAL EXAMINATION: Vital signs: Upon admission,
temperature 100.4, temperature maximum 100.4, 64/20, 114, 97
percent on room air on Levophed. General: The patient was
alert and oriented times three. HEENT: The sclerae were
icteric. The mucous membranes were very dry. Heart: Normal
S1 and S2. No murmurs, rubs, or gallops. Lungs: Clear to
auscultation anteriorly. Abdomen: Positive bowel sounds.
Soft, tender in epigastrium, an epigastric mass is palpable.
No rebound or guarding. Extremities: No clubbing, cyanosis,
or edema. Very cachectic.
LABORATORY DATA: White count 12.5, hematocrit 26.5,
platelets 284,000. Sodium 139, potassium 3.8, chloride 97,
bicarbonate 17, down from 29 earlier today, BUN 14,
creatinine 1.0, glucose 78. PT 13.6, PTT 49.6, INR 1.2. The
differential on the white count revealed 35 percent
neutrophils, 58 percent bands, 3 percent lymphocytes, 10
percent monocytes. ALT 69, AST 148, LDH 415, alkaline
phosphatase 2,123. T bilirubin 8.0, calcium 7.3, phosphorus
4.2, magnesium 2.3. ABGs 7.36, 29, 210, on 100 percent
nonrebreather.
EKG revealed normal sinus rhythm at 158, rate-related ST
depressions in V4-V6.
Chest x-ray revealed mild volume overload. No pleural
effusions.
Blood cultures and urine cultures revealed no growth to date.
Stool cultures times three for C. difficile were negative.
HOSPITAL COURSE: The patient was admitted to the Fenard ICU
for severe sepsis with profound bandemia, profound
hypoglycemia, and acidosis. The cause of the patient's
severe sepsis was most assuredly her numerous hepatic
abscesses and the metastatic cancer that she had most likely
involving biliary obstruction. The patient was started on
sepsis protocol, aggressive IV fluid hydration was given to
the patient. The patient received approximately 10 liters of
IV fluid in the next 24 hours. The patient was also
continued on Levophed and Vasopressin. The case was
discussed with the ERCP fellow, attending, and ICU attending.
A CT of the abdomen was thought safest and highest yield at
that time. CT of the abdomen revealed unchanged nodules
throughout the liver which were thought once again to be
secondary to hepatic abscesses. The GI fellow and attending
felt that emergent ERCP would not change the patient's
prognosis and it was held off.
The plan was to do ERCP early the next morning. The patient
was continued on the antibiotic regimen that they had been on
for the time being. Unasyn was also added. The ID fellow
was consulted and followed along during the next 24 hours.
Since there were no huge abscesses on CT, there was no
benefit for Interventional Radiology placing a drain to drain
abscesses. Per the ICU attending, Zygress was held off
secondary to high INR and what appeared to be fulminant liver
failure. Blood cultures and urine cultures were taken.
As far as the patient's profound hypoglycemia, it was most
likely due to liver failure secondary to her metastatic
pancreatic disease as well as her hepatic abscesses. The
patient was placed on an insulin drip with tight glucose
control and despite a D10 drip, the patient's blood sugar
continued to dip down as low as the 20s with episodic mental
status change. Further cause of the patient's profound
hypoglycemia was thought secondary to severe sepsis and this
was being treated. As far as the patient's acidosis, the
patient was given bicarbonate ampules throughout the night
and was subsequently started on a bicarbonate drip. The
patient subsequently went into acute renal failure. There
was thought to be a postobstructive component to the renal
failure but most likely the patient was in ATN secondary to
profound hypotension. Nephrotoxins were avoided and Mucomyst
was given prior to dye loads.
The patient underwent an ERCP the next morning which revealed
ischemic gut. The patient was deemed not a candidate for
surgery. The patient's lactate remained approximately 8.5
despite 10 liters of IV fluids and a bicarbonate drip. It
was thought at that time by concensu's decision that the
patient should be made comfortable. The family agreed with
this decision. The propofol drip was increased. Pressors
were discontinued. The patient succumbed painlessly to her
profound sepsis. The family agreed to a follow-up autopsy
which will be done.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 48405**]
MEDQUIST36
D: [**2194-5-30**] 16:33:24
T: [**2194-5-30**] 17:16:31
Job#: [**Job Number **]
|
[
"51881",
"5845"
] |
Admission Date: [**2131-12-22**] Discharge Date: [**2131-12-25**]
Date of Birth: [**2092-11-27**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male pedestrian struck after a convenience store robbery by
an automobile. He had a GCS of 3 at the scene. He was sent
to [**Hospital1 69**] after noted to have a
large subarachnoid hemorrhage at an outside hospital. He was
immediately intubated at the scene and received Tetanus and
Kefzol at the outside hospital.
PAST MEDICAL HISTORY: Unknown.
PAST SURGICAL HISTORY: Unknown.
MEDICATIONS AT HOME: Unknown.
ALLERGIES: Unknown.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Temperature on admission was 97.4,
heart rate 80, blood pressure 119/65, oxygen saturation 100
percent on his vent. In general, the patient had a GCS of 3.
Head, eyes, ears, nose and throat - The face is stable. The
patient was intubated. He had a repaired laceration on the
right temporal parietal region of his head. His pupils were
three and two millimeters and sluggishly reactive. Trachea
was midline. Chest was clear to auscultation bilaterally.
The heart was regular rate and rhythm. The abdomen showed a
right inguinal laceration. His abdomen was soft and
nondistended. Pelvis was stable. The patient had decreased
rectal tone and he was guaiac negative. His back showed
abrasions in the sacral and lumbar areas but no deformities.
Extremities - Right leg was bandaged and reportedly had an
open fracture.
Films performed on admission included chest x-ray which
showed a right clavicle fracture and a left pneumothorax.
Pelvic x-ray was negative. Head CT showed extensive
tentorial subarachnoid hemorrhage with edema. Neck CT was
negative from the outside hospital. Chest CT showed a left
pneumothorax, sternal fracture and right clavicular fracture.
CT of his face showed a right mandibular, left mandibular
condyle and left zygomatic arch as well as left zygomatic
temporal junction fracture and also a nasal fracture. CT of
the abdomen from the outside hospital was negative. Right
tibia fibula film was performed and that showed a fracture.
HOSPITAL COURSE: The patient was immediately admitted to be
placed in the Intensive Care Unit. A left chest tube was
placed to decompress his pneumothorax. This eventually had
to be replaced as the tube was kinked and was not
decompressing his pneumothorax. Neurosurgery was involved
for treatment of his subarachnoid and it was deemed necessary
to place an interventricular drain as his head CT indicated
that there was high likelihood of herniation otherwise
particularly on a repeat head CT the morning after his
admission. Oromaxillofacial surgery was also involved
secondary to his facial injuries but indicated that they
would wait until the patient was stabilized before attempting
any sort of surgical correction. Orthopedics was also
consulted with regards to his severe fibular fracture. They
also declined correction until such time the patient was
stabilized. The thoracic surgery team was also consulted
regarding the sternal fracture and question of
pneumopericardium which they evaluated and indicated that
there was no pneumopericardium and the sternal fracture was
stable from a surgical point of view. Over the course of the
next 24 hours as stated, repeat head CT showed increased
intracranial swelling and the interventricular drain was
placed for decompression. The patient was also given
Mannitol to decrease intracranial pressures. He received
approximately two doses and due to increased serum osmolarity
and hypernatremia, this treatment was no longer available to
decrease intracranial pressure. Over the course of the next
24 hours, the patient's intracranial pressure continued to
rise and a family meeting was convened at which time surgery
and in particular craniotomy versus medical management versus
making the patient comfort measures only was presented. The
family declined surgery indicating that they did not wish
that a craniotomy be performed and that they would discuss
that night medical management versus making the patient
comfort measures only. The following morning the patient's
family arrived and decided to allow the patient to be comfort
measures only and allow his organs to be donated for
transplantation. It is now [**2131-12-25**], and the patient was
declared dead by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59718**]. The patient was taken to
the operating room by the transplant surgery staff and organ
procurement was performed on a delayed cardiac.
DISCHARGE DIAGNOSES: Subarachnoid hemorrhage, intracerebral
edema.
Right tibia fibular fracture.
Sternal fracture.
Right clavicular fracture.
Right mandible, left mandibular condyle, left zygomatic arch,
left zygomatic temporal junction and nasal fractures.
Left pneumothorax.
Coma.
Hypernatremia.
Hypokalemia.
Diabetes insipidus.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2131-12-25**] 16:47:28
T: [**2131-12-25**] 20:05:40
Job#: [**Job Number 59719**]
|
[
"2760"
] |
Admission Date: [**2167-5-16**] Discharge Date:[**2167-5-26**]
Service: CSU
ADMISSION DIAGNOSES:
1. Aortic stenosis.
2. Congestive heart failure.
3. Coronary artery disease.
4. Atrial fibrillation.
5. Gastroesophageal reflux disease.
6. Uterine cancer.
7. Status post cholecystectomy.
8. Status post total abdominal hysterectomy.
9. Status post excision of cataracts.
10. Status post right and left hip replacements.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement with
a #21 pericardial CE Magna valve.
2. Pleural effusions.
3. Atrial fibrillation.
4. Coronary artery disease with coronary angiogram
demonstrating a 50% lesion in a small left anterior
descending artery.
Remainder of discharge diagnoses as above in the admission
diagnoses.
ADMISSION HISTORY AND PHYSICAL: [**First Name8 (NamePattern2) **] [**Known lastname 8040**] is an 83 year
old woman with a history of heart disease and congestive
heart failure who had been hospitalized multiple times for
exacerbations of her CHF, which were managed medically with
diuresis. She was found to have aortic stenosis, with a valve
area of 0.7 cm, and it was felt that a surgical repair of
this would greatly improve her symptoms. She also had a
coronary angiogram which showed a small 50% lesion off her
left anterior descending, but otherwise no significant
disease. She was admitted on [**2167-5-16**] for preoperative
evaluation and elective repair of aortic valve, with possible
bypass grafting. But, as noted, with the lesion demonstrated
on previous catheterization, it was felt that coronary artery
bypass grafting was not indicated at this time.
On admission examination, the patient's weight was 63.0 kg.
She was afebrile and otherwise hemodynamically normal, with a
pulse of 60 in sinus rhythm, blood pressure 120/48. She was
satting 96 percent on room air. She was otherwise alert. She
had clear breath sounds. She had a systolic ejection murmur
which was felt to be IV/VI. Her abdomen was soft and she had
2+ bilateral pedal edema.
Her preoperative white blood cell count was 6.4, with
hematocrit of 31, platelet count 284. Her BUN and creatinine
were 19 and 1.1. Her urinalysis did not evidence any
infection.
HOSPITAL COURSE: The patient was admitted, as noted, on
[**5-16**] for a preoperative workup. Subsequently, on [**2167-5-19**], after her culture data had all evidenced no infection
and her carotid ultrasounds had shown no significant carotid
stenosis, she underwent an aortic valve replacement with a 21
mm CE Magna pericardial valve. There were no intraoperative
complications, and the patient tolerated the procedure well.
She was taken intubated from the operating room to the
cardiac surgery recovery unit, where she remained
hemodynamically stable overnight. By postoperative day two,
she was extubated and was otherwise with stable hemodynamics
and oxygenation. At this time, the patient's chest tube and
central venous access were removed. She did revert to atrial
fibrillation on postoperative day two, at which time she was
started on amiodarone, as per the patient's
electrophysiologist, Dr. [**Last Name (STitle) 284**]. We were initially going
to begin heparinization, but as the patient's platelet count
had been trending down into the seventies to eighties, it was
felt that it would be prudent to initially send off an HIT
panel prior to starting heparin. Heparin was discontinued at
this time. She never had any sort of bleeding problems.
The patient was transferred to the general floor on
postoperative day 3, where she continued to do well and was
maintained on oral amiodarone 400 mg twice a day, along with
Lopressor and diuresis with Lasix. Coumadin was started as
per cardiology consultation. The remainder of the patient's
hospitalization was essentially unremarkable, with continued
beta blockade and amiodarone, with coumadinization and
diuresis. As the patient never had any significant episodes
of congestive heart failure during her hospitalization from
her atrial fibrillation, she was given the option of trying
with transesophageal echocardiography and cardioversion prior
to discharge from her electrophysiologist versus
anticoagulation and discharge on amiodarone, with possible
cardioversion as an outpatient if she did not spontaneously
convert. She preferred the latter option.
It is felt by [**5-25**] (postoperative day 6) that this
patient was afebrile, otherwise hemodynamically normal, with
a pulse in the 90's (atrial fibrillation) but a blood
pressure with a systolic in the 110's and saturating 96% on
room air, that she could be discharged to rehab in stable
condition. Her discharge weight was only 1.5 kg above her
admission weight and, as noted, she was continuing diuresis.
She was therefore discharged to rehab on postoperative day 6
in fair condition on the following medications:
Colace 100 mg p.o. twice daily when taking narcotics.
Potassium chloride 20 mEq p.o. b.i.d.
Lansoprazole 30 mg p.o. once daily.
Aspirin 81 mg p.o. once daily.
Coumadin 1 mg p.o. at bedtime.
Lipitor 20 mg p.o. once daily.
Detrol 4 mg p.o. once daily.
Lopressor 25 mg p.o. b.i.d.
Amiodarone 400 mg p.o. once daily.
Lasix 20 mg p.o. b.i.d.
Vicodin 5/500 one tab every 6 hours as needed for pain.
The patient would need to follow up with Dr. [**Last Name (STitle) **]. [**Last Name (Prefixes) **]
in 4 weeks. She was to follow up with Dr. [**Last Name (STitle) 284**], her
electrophysiologist, in the next 2-3 weeks for adjustment of
her Coumadin dosing, possible outpatient elective
cardioversion. She is also to follow up with her primary care
doctor, Dr. [**Last Name (STitle) 3707**], for followup for her Coumadin and for
general medical assessment within the next week. The patient
was to eat a cardiac/heart healthy, low sodium diet. She has
strict sternal precautions and is to avoid weightbearing with
her arms or chest.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2167-5-25**] 10:03:48
T: [**2167-5-25**] 10:45:45
Job#: [**Job Number 99624**]
|
[
"4241",
"42731",
"4280",
"41401",
"53081"
] |
Admission Date: [**2168-6-16**] Discharge Date: [**2168-7-12**]
Date of Birth: [**2121-1-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Endotracheal intubation ([**Date range (1) 112325**])
[**6-23**] tracheostomy
[**6-23**] PEG
TEE ([**6-21**], [**6-30**])
Paracentesis [**6-30**]
History of Present Illness:
47F w/ unknown PMHx found by EMS conscious but nonverbal,
sitting on doorstep. Initially noted to be in narrow-complex
tachycardia 220 w/ no radial pulses. She was given adenosine 6,
12 and slowed to sinus tach at 140 w/occasional PACs. Appeared
hypovolemic per EMS.
Upon arrival in [**Last Name (LF) **], [**First Name3 (LF) **] "old" tampon was removed from her vagina
by RN staff. After 2L of fluid her Mental status improved. She
complained of pain "everywhere". She reported that she takes
amitryptiline at baseline and uses heroin but otherwise did not
provide any history.
In the ED, initial VS were:
T 97.9 HR 158 BP 82/49 RR 35 Sa 100% on 3L.
VBG in ED (10:00AM) 7.37/33/49/20
Her BP went as low as 80s in the ED, remained at 90 despite a
total of 5.5L NS. She given vanc/ceftriaxone/flagyl. MS
decreased again, was tachypneic to 45 and was therefore
intubated. A central line was placed and levophed was started.
Urine tox was positive for opiates and benzodiazepines.
On arrival to the MICU, patient's VS were:
T 102.7 HR 149 BP 138/113 RR 36 Sa 98% on Ventilator at 40% FiO2
Vent: Assist/Rate 20/450mL/PEEP 5/FiO2 40%. Breathing at
30s-40.
Past Medical History:
Hep. C not treated, being followed at [**Hospital1 2177**]
Asthma
Emphysema
Vit. D deficiency
Chronic HA
Social History:
Currently separated from wife for 3 weeks prior to admission
because of patient's polysubstance abuse. Pt actively using
heroine, MJ, BZ, ?cocaine. approximately 35 pack year smoking
hx. Two sons (24, 16). Two grandchildren
Family History:
Father deceased lung Ca
brother deceased ALL
Uncle deceased [**Name2 (NI) **] Ca + COPD
son bladder Ca
Physical Exam:
Exam at [**Hospital Unit Name 153**] admission:
General: Overweight female intubated and sedated on midazolam
and fentanyl infusion, completely unresponsive to examination
maneuvers, appears to be in 30s or 40s.
HEENT: Sclera slightly icteric, conjunctivae pale. No
ecchymoses, no LAD. Pupils constricted.
Neck: Supple, no LAD. JVP not elevated.
CV: Sinus rhythm, irregular. Hyperkinetic with palpable sternal
heave. S1 + S2, no murmurs, rubs, gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
Abdomen: No scars, wounds, or ecchymoses. Tense, cannot
adequately assess organomegaly. Bowel sounds absent.
GU: Foley
Ext: Hands and feet cool and pale with 1+ pulses bilaterally.
No clubbing, cyanosis, or edema. Numerous macular ecchymoses on
palms and soles, consistent with [**Last Name (un) 1003**] lesions. Splinter
hemorrhage of R 3rd digit. Dark ecchymotic macules in cubital
fossae.
Neuro: Unresponsive to exam maneuvers.
DISCHARGE EXAM
VS: 98.7, 124, 112/78, 19, 100% on 35% trach mask
Gen: NAD, Alert, nods/shakes head to yes/no questions
CV: RRR, S1+S2, [**2-23**] HSM loudest at apex
Pulm: clear on anterior auscultation. No increased work of
breathing.
Abd: Soft, distended, no TTP. +BS.
Extr: Hands bandaged+splinted. PICC site non-tender,
non-erythematous. Feet with stable dry gangrene.
Pertinent Results:
Admission Labs:
[**2168-6-16**] 09:55AM WBC-8.6 RBC-4.73 HGB-14.7 HCT-43.5 MCV-92
MCH-31.0 MCHC-33.7 RDW-12.5
[**2168-6-16**] 09:55AM PLT COUNT-51*
[**2168-6-16**] 09:55AM PT-21.4* PTT-32.0 INR(PT)-2.0*
[**2168-6-16**] 09:55AM FIBRINOGE-371
[**2168-6-16**] 09:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-6-16**] 09:55AM ALBUMIN-2.7*
[**2168-6-16**] 09:55AM LIPASE-8
[**2168-6-16**] 09:55AM ALT(SGPT)-25 AST(SGOT)-44* LD(LDH)-288*
CK(CPK)-243* ALK PHOS-83 TOT BILI-2.4*
[**2168-6-16**] 09:55AM UREA N-28* CREAT-1.5*
[**2168-6-16**] 10:00AM freeCa-1.02*
[**2168-6-16**] 10:00AM GLUCOSE-147* LACTATE-5.0* NA+-132* K+-3.4
CL--103 TCO2-18*
[**2168-6-16**] 10:00AM TYPE-[**Last Name (un) **] PO2-49* PCO2-33* PH-7.37 TOTAL
CO2-20* BASE XS--4
[**2168-6-16**] 10:20AM URINE WBCCLUMP-RARE MUCOUS-RARE
[**2168-6-16**] 10:20AM URINE AMORPH-RARE
[**2168-6-16**] 10:20AM URINE HYALINE-9*
[**2168-6-16**] 10:20AM URINE RBC-7* WBC-47* BACTERIA-MANY YEAST-NONE
EPI-<1 TRANS EPI-1
[**2168-6-16**] 10:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.5 LEUK-LG
[**2168-6-16**] 10:20AM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2168-6-16**] 10:20AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2168-6-16**] 10:20AM URINE UCG-NEGATIVE OSMOLAL-394
[**2168-6-16**] 10:20AM URINE HOURS-RANDOM UREA N-256 CREAT-30
SODIUM-70 POTASSIUM-49 CHLORIDE-86
[**2168-6-16**] 12:18PM TYPE-ART PO2-362* PCO2-46* PH-7.19* TOTAL
CO2-18* BASE XS--10
[**2168-6-16**] 05:46PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-POSITIVE
[**2168-6-16**] 05:46PM HCV Ab-POSITIVE*
DISCHARGE LABS
[**2168-7-12**] 04:31AM BLOOD WBC-10.8 RBC-2.53* Hgb-8.1* Hct-25.0*
MCV-99* MCH-31.9 MCHC-32.2 RDW-21.4* Plt Ct-233
[**2168-7-4**] 04:50AM BLOOD Neuts-82.3* Lymphs-10.8* Monos-3.5
Eos-3.2 Baso-0.3
[**2168-7-9**] 05:11AM BLOOD PT-15.5* PTT-39.7* INR(PT)-1.5*
[**2168-7-12**] 04:31AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-138
K-3.3 Cl-103 HCO3-25 AnGap-13
[**2168-7-7**] 03:34AM BLOOD ALT-22 AST-38 AlkPhos-81 TotBili-1.3
[**2168-7-12**] 04:31AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6
PERTINENT LABS
[**2168-6-17**] 06:03AM BLOOD FDP-80-160*
[**2168-7-3**] 07:04AM BLOOD Ret Aut-5.3*
[**2168-6-17**] 02:01PM BLOOD ESR-35*
[**2168-6-25**] 04:12AM BLOOD Lipase-186*
[**2168-6-16**] 05:46PM BLOOD CK-MB-8 cTropnT-0.21*
[**2168-6-17**] 01:35AM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.31*
[**2168-6-17**] 06:03AM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.41*
[**2168-6-17**] 09:52PM BLOOD CK-MB-5 cTropnT-0.29*
[**2168-7-3**] 03:40AM BLOOD calTIBC-150* Hapto-<5* Ferritn-487*
TRF-115*
[**2168-6-22**] 02:36PM BLOOD Osmolal-325*
[**2168-6-18**] 05:40AM BLOOD Cortsol-51.8*
[**2168-6-16**] 09:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-6-16**] 05:46PM BLOOD HCV Ab-POSITIVE*
[**2168-6-16**] 05:46PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
Imaging
[**7-11**] Video swallow
IMPRESSION: No evidence of aspiration or penetration. For full
details,
please see speech pathology report in webOMR.
CXR (5 done):--Mild pulmonary vascular congestion.
--In comparison with the earlier study of this date, there has
been placement of an endotracheal tube with its tip
approximately 2.5 cm above the carina. Nasogastric tube extends
well into the stomach, beyond the lower margin of the image.
--In comparison with the earlier study of this date, there has
been
placement of a right IJ catheter that extends to about the level
of the
cavoatrial junction. No evidence of pneumothorax.
--[**6-19**]: IMPRESSION: Orogastric tube ends in the distal stomach.
ET tube in standard placement. Previous vascular engorgement
and mild pulmonary edema has cleared in the upper lungs, but
consolidation in the lower lungs, particularly the right has
worsened, though this could be atelectasis, is more concerning
for extensive pneumonia.
--[**6-21**]: FINDINGS: As compared to the previous radiograph, the
pre-existing
parenchymal opacities at the right lung base and in the left
perihilar area have substantially decreased in extent and
severity. As a consequence, the lung parenchyma is more
transparent and lucent than before. The image shows no evidence
of newly appeared parenchymal opacities. The size of the
cardiac silhouette is constant and normal. No pulmonary edema.
The monitoring and support devices are in unchanged position.
--[**7-1**]: There are new bilateral alveolar consolidations that
could be compatible with multifocal pneumonia.
--[**7-3**]: Unchanged tracheostomy tube, unchanged left PICC line.
No evidence of pneumothorax.
--[**7-10**]: Decreasing effusions with persistent consolidation on
the right
and volume loss in the left lower lobe.
CT Head [**6-16**]: Ill-defined non-territorial hypodensities in left
cerebellum and right vertex concerning for infarction, possibly
embolic or venous in etiology. Infection cannot be excluded.
Equivocal hyperdensities within Preliminary Reportbilateral
sulci may represent blood products. MR with and without contrast
is recommended for further evaluation.
CT Head [**6-18**]: IMPRESSION: Persistent hypodensities in bilateral
cerebellar hemispheres and right vertex, concerning for
infarcts, however, other underlying conditions, cannot be
completely excluded, correlation with MRI of the brain with and
without contrast is recommended. No evidence for new acute
intracranial hemorrhage.
MR [**Name13 (STitle) 430**] [**6-20**]: IMPRESSION: 1. Numerous, diffuse acute infarcts
without mass effect or hydrocephalus. The findings are
compatible with septic embolic infarcts, some of which have
microhemorrhages. In the setting of septic emboli, there is a
substantial risk this patient may have a mycotic aneurysm, which
may be a further contraindication to anticoagulation. We do not
see a mycotic aneurysm on this study, but these are frequently
distal and the infarcts are distal. If clinically indicated, an
MRA of the more distal vessels could be performed (from the
vertex to the supraclinoid ICA) to evaluate for a more distal
mycotic aneurysm.
TEE [**6-17**]: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic valve
and there does not appear to be involvement of the intervalvular
fibrous area or the aortic root. No aortic regurgitation is
seen. There is a large vegetation on the mitral valve,
predominantly on the posterior leaflet, that measure 2.4x1.4cm,
with leaflet abscess suggested (and possibly posterior annulus
early abscess). There is a significant mobile elements to the
vegetation. At least moderate (2+) mitral regurgitation is seen,
though this may be underquantified due to the large vegetation.
No masses or vegetations are seen on the tricuspid or pulmonic
valve.
IMPRESSION: Large mitral valve vegetation measuring 2.4x1.4cm
with leaflet abscess and at least moderate mitral regurgitation.
No other valvular or root involvement.
TEE [**6-30**]: The left atrium is dilated. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. There are filamentous strands on the aortic leaflets
consistent with Lambl's excresences (normal variant). No aortic
valve abscess is seen. No aortic regurgitation is seen. There is
a moderate-sized (1.3 cm x 0.9 cm) vegetation on the posterior
leaflet of the mitral valve. There is an abscess cavity seen
adjacent to the mitral valve along the posterior annulus.
Moderate (2+) mitral regurgitation is seen.
IMPRESSION: Moderate sized mitral valve vegetation measuring 1.3
cm x 0.9 cm with leaflet abscess, likely mitral annular
(posterior) abscess and moderate mitral regurgitation. No other
valvular or root involvement
Compared with the prior study (images reviewed) of [**2168-6-21**], the
vegetation is significantly smaller than prior study when it
measured 2.4x1.4cm. The posterior annulus abscess appears
similar.
RUQ U/S [**6-21**]: IMPRESSION: Tumefactive sludge and stones without
the gallbladder without specific findings to suggest
cholecystitis. Trace ascites.
CT Chest/Abd/Pelvis [**6-29**]: IMPRESSION: 1. Small bilateral
pleural effusions with compressive atelectasis. 2. Large
abdominal ascites. 3. Nodular liver contour suggestive of
cirrhosis. 4. Large volume splenic infarct and bilateral renal
infarcts, compatible with history of endocarditis and septic
emboli. 5. Anasarca.
Brief Hospital Course:
47F with PMH of hep. C cirrhosis, IVDU, who was found down
possibly in the setting of heroin use, now intubated and in
septic shock with etiology concerning for endocarditis.
#Refractory Septic shock: [**1-21**] MSSA bacteremia from endocarditis:
Upon ED admission she was hypotensive to 80s, refractory to
fluid resuscitation; during her first 24hrs in the hospital she
required levo/vasopressin/neo to maintain MAP>60. Neo was d/c'd
after the first day, and vasopressin several days later. She
was continued on levo infusion until [**6-24**], and did not require
pressors for the duration of her ICU admission.
# MSSA endocarditis - TTE and TEE ([**6-17**], [**6-21**], [**6-30**]) revealed
large mitral valve vegetation with abscess. No progression was
observed during the hospitalization. Patient was initially
covered on vanc/zosyn, subsequently narrowed to nafcillin after
cultures grew MSSA. All blood cx after [**6-16**] were sterile. CT
surgery deferred mitral valve replacment surgery initially as
patient was too hemodynamically unstable. Once stabilized,
surgery was deferred because of lack of progression of
endocarditis as evidenced by TEE, her fever defervesced, and
blood cx were sterile. The patient was seen by ID, and will
received a 6-week course of nafcillin starting on [**2168-6-17**].
# Respiratory Failure: Patient was initially intubated on AC,
later weaned to CPAP/PSV and then to T-mask. Bedside
tracheostomy was performed [**6-23**] due to prolonged ventilator use
and poor progress towards extubation. Initially tachypneic to
40s, subsequently to 20s-30s; thought to be a combination of
primary central cause plus respiratory compensation for
metabolic acidosis. Passe-Muir valve was fitted [**6-30**] in order to
allow patient to speak. While she had pneumonia, she required
ventilator support as she became tachypnic. Once her pneumonia
resolved, she was able to be weaned from ventilator support and
tolerated trach mask well.
# Pneumonia - Patient had change in amount and character of
secretions, became febrile, tachypnic, and CXR concerning for
multi-focal pna. Sputum cx growing GNR speciated as Klebsiella
Pneumonia. She was treated with cefepime, once sensitivities
were obtained she was changed to levofloxacin, completing an 8
day course. She required ventilator support during her
pneumonia. Clinically she improved and was able to tolerate
trach mask without need for ventilator.
# AMS/head CT abnormalities: Lesions on head CT may represent
septic emboli, possibly contributing to AMS. Additionally, the
patient was hyperthermic to 107 while in septic shock, which
most likely contributes to her altered mental status. Brain MR
was performed without contrast due to [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **]; contrast is
necessary to identify mycotic aneurysms. EEG performed revealed
mostly (slow) delta activity, triphasic waves, and no
epileptiform discharges suggesting diffuse cerebral dysfunction.
Since the patient has biopsy proven cirrhosis, hepatic
encephalopathy was thought to be a component of her AMS as
triphasic waves seen on EEG. However, her AMS did not clear
after being treated with lactulose, making hepatic
encephalopathy unlikely. Once pt improved clinically and she was
able to be weaned from ventilator, she was able to communicate
with physicians/nurses with use of her passe-muir valve. She was
alert and oriented.
# Hand/foot necrosis: Patient was admitted with [**Last Name (un) 1003**] lesions
to hands and feet; after the first 24hrs in [**Hospital Unit Name 153**] areas of
necrosis and "dry gangrene" were seen that subsequently covered
multiple fingers and distal 50% of both feet. The most likely
etiology is septic emboli in addition to the need for extensive
pressor use while she was in septic shock. Vascular surgery was
consulted and recommended debridement of feet in [**12-22**] months.
Hand surgery was consulted and recommended maintaining hands in
splints/dressings with betadine and allowing fingers to
auto-amputate.
# SBP: Patient developed new ascites with increasing abdominal
distention after one week and ascites was confirmed on CT [**6-29**].
Paracentesis of peritoneal fluid on [**7-1**] revealed >400 PMN's
with SAAG>2 with FATP <2.5 (suggesting hepatic source for the
ascites), but no organisms on Gram stain, but consistent with
SBP. She was started on CTX and albumin was administered.
Peritoneal fluid cx demonstrated yeast, and she was started on
micafungin. Given the most likely source of yeast is
intra-abdominal, flagyl was added as she is at increased risk
for anaerobic infection also. Pt completed 8 day course of
micafungin for [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**] and glabrata.
# [**Last Name (un) **]: Cr peaked at 3.1 (baseline unknown), later down to 1.1
two weeks after admission. Fena was initially 2.5%; thought due
to ATN from prolonged hypotension.
# Mixed anion/non anion gap acidosis: Her metabolic
derangements initially included (i) primary anion gap acidosis
(AG=13 but with Ca=6.3, thus ULN for AG is 8.6); (ii) primary
respiratory alkalosis (pCO2=26 vs. 30.5 predicted by winter's
formula); (iii) primary non-anion-gap acidosis (HCO3 down by
24-15=9 vs. AG increased by 13-8.6 = 4.4). Likely etiology for
non-gap acidosis is dilutional effect of boluses.
# Hepatitis C cirrhosis: Records were obtained from [**Hospital1 2177**] where
she receives her care indicating that she was diagnosed with
biopsy proven hep. c cirrhosis and has never received interferon
therapy. Upon admission AST 45 with direct Bili 2.7; her
transaminases and bilirubin subsequently normalized.
# Coagulopathy/thrombocytopenia: Pt had thrombocytopenia (as low
as Plt 12) with coag factor deficiency (INR as high as 2.4).
Likely secondary to infection, possibly also liver disease.
Peripheral smear found no schistocytes making TTP unlikely.
Platelets and INR subsequently returned to [**Location 213**]-range two
weeks after admission.
#Pancreatitis - lipase to 186 on [**6-25**] in the setting of
increased abdominal pain on exam. Adominal ultrasounds were
unremarkable. She received morphine for pain and tube feeds
were held for two days, after which symptoms resolved.
#UTI - completed 7 day course of cipro for complicated UTI.
Transitional Issues:
--------------------
-continue Nafcillin for 6 week course until [**2168-7-29**]
-will recommend oxycodone 5 mg prn for pain control for now,
expect to discontinue after resolution of acute illness
-As per ID, weekly Chem 7, CBC, and LFTs with results faxed to
[**Hospital **] clinic
-hand necrosis - follow up with hand surgeon should be arranged
-foot necrosis - follow up with orthopedic
-should recheck TEE in mid-[**Month (only) 216**] (~[**8-1**])
-pt known IVDU tolerance currently is not known and concern for
opiate dependence to develop
-Nutrition calorie count as may not need TPN
Medications on Admission:
Advair
Singulair
Proventil
Amitriptyline
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
Pt must obtain weekly:
CBC with diff
Chem 7
LFTs
ESR
CBC
These results should be faxed weekly to Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Hospital **]
clinic at [**Telephone/Fax (1) 1419**]
2. Albuterol Inhaler [**1-23**] PUFF IH Q4H:PRN wheeze
3. Acetaminophen 650 mg PO Q6H pain
Do not exceed 4g in one day
4. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
5. Docusate Sodium (Liquid) 100 mg PO BID
Hold for loose stools.
6. Heparin 5000 UNIT SC TID
7. Nafcillin 2 g IV Q4H endocarditis
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain in feet
9. Quetiapine Fumarate 25 mg PO HS:PRN agitation, insomnia
10. Senna 1 TAB PO BID:PRN constipation
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
MSSA endocarditis
Respiratory Failure
Pneumonia
Acute tubular necrosis
Pancreatitis
Hand/foot necrosis
Fungal peritonitis
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of bed with assist
Discharge Instructions:
Dear Ms. [**Known lastname 112326**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted after being found unconscious.
You required intubation and eventual tracheostomy. You were
found to have an infection growing on your heart valves and this
infection spread to other parts of your body affecting many
organs. While you were admitted you were also treated for a
pneumonia, damage to your kidneys, a urinary tract infection and
a yeast infection in your belly.
Because you were so seriously ill, a number of changes were made
to your medications, including a need to complete at least 6
weeks of antibiotics for your heart infection.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2168-7-19**] at 9:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2168-7-19**] at 10:00 AM
With: HAND CLINIC [**Telephone/Fax (1) 3009**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2168-7-25**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2168-7-26**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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: CARDIAC SURGERY
When: THURSDAY [**2168-8-4**] at 1:30 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
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"51881",
"78552",
"5845",
"5990",
"2762",
"99592",
"42731",
"2875",
"49390",
"3051"
] |
Admission Date: [**2164-8-30**] Discharge Date: [**2164-9-1**]
Date of Birth: [**2098-5-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Atrial fibrillation with rapid ventricular response and
hypotension; ?gram positive bacteremia; transfer from outside
hospital.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 40612**] is a 66-year old male with a history of hypertension,
paroxysmal atrial fibrillation who presents from an OSH with
unstable angina. Says that two days prior to admission to
outside hospital, he awoke from sleep with chills and shivering.
He woke up and took Motrin which improved his chills. The
following morning, he went out for an hour long walk without any
dyspnea on exertion. On night prior to admission to OSH, he
again woke from sleep with chills and subjective coldness. This
time he also had SOB. He called an ambulance and was admitted
to [**Hospital6 63271**].
.
At OSH, his vitals were T 102.4, HR 90, RR 24, BP 99/59, O2 sat
92% RA. He was noted to have pna on CXR. EKG showed AF but no
ischemic changes. He was also noted to have an 18 beat run of
VT in the ED that spontaneously converted. He denied chest
pain, palpitations, lightheadedness or dizziness.
.
He was admitted to the ICU. Cardiac enzymes were drawn and
found to peak at 4.26 with CK 345 (downtrending to 3.12 and 288
at time of transfer). His BNP was 46. Also notable was a
bandemia to 17% on a WBC of 3.9. He received lopressor 5 mg for
atrial fibrillation with rates to 160s. A blood culture showed
GPCs in [**12-30**] blood cultures with speciation still pending at time
of transfer. TTE was done that showed EF 20%, down from >55%
two years ago. At OSH, he was seen by a cardiologist, Dr. [**Last Name (STitle) **]
[**Name (STitle) 13224**] [**Doctor Last Name **], who recommended that he be transferred to [**Hospital1 18**]
where he receives his primary care. At time of transfer, his
cardiovascular meds included carvedilol 3.125 mg [**Hospital1 **], coumadin,
lisinopril 10mg, spironolactone 25 mg, digoxin 0.125 mg and
Lasix 80 mg [**Hospital1 **].
.
On admission to [**Hospital1 18**], he was asymptomatic. He denied fevers,
chills, cough, sputum production, chest pain, palps or
lightheadedness. Said that he has no h/o anginal type symptoms,
that he walks about 3 miles per day without difficulty prior to
this episode.
Past Medical History:
1. Hypertension.
2. Paroxysmal atrial fibrillation status-post DC cardioversion
in [**2162-7-27**]; asymptomatic episodes on [**Doctor Last Name **] of Hearts
monitor from [**2163-2-1**].
3. Obesity.
4. Possible sleep apnea (does not use CPAP therapy).
5. Bilateral hip replacement.
..
CARDIAC HISTORY:
CABG: None
Percutaneous coronary intervention: None
Pacemaker/ICD placed: None
..
CARDIAC RISK FACTORS:
+ Smoking quit 30 yrs ago, <10 pk-yrs total
- Hypercholesterolemia
+ Hypertension
- Diabetes
- Family history of premature cardiac death or MI
Social History:
He is married and lives in [**Location (un) 3844**]. He has 8 children and
is a retired truck driver. He has a significant 30-pack-year
tobacco history but quit many years ago. Similarly he has a
remote history of significant alcohol use but has not had a
drink in many years.
Family History:
His father had diabetes and died of stroke at 65. Mother died
with [**Name (NI) 2481**] in her 80s. No family history of sudden
cardiac death, cardiomyopathy, or premature coronary artery
disease.
Physical Exam:
VITALS: T 97.1, BP 123/74, HR 135 irregular, RR 16, 96% RA
GENERAL: AAOx3, NAD, talking complete sentences, sitting
upright in bed breathing normally
HEENT: EOMI, PERRLA
NECK: Supple, non-tender
HEART: Distant and irregular heart sounds. No obvious murmurs.
LUNGS: CTA b/l. No focal changes in breath sounds. No wheezes
or crackles at bases.
[**Last Name (un) **]: Soft, non-tender, no masses. Normal bowel sounds.
LEGS: No pitting edema.
SKIN: Very tan ?hyperpigmentation?
Pertinent Results:
LAB RESULTS:
.
[**2164-8-30**] 03:06PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2164-8-30**] 03:06PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2164-8-30**] 03:06PM URINE RBC-0-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2164-8-30**] 02:37PM GLUCOSE-119* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
[**2164-8-30**] 02:37PM estGFR-Using this
[**2164-8-30**] 02:37PM ALT(SGPT)-19 AST(SGOT)-27 LD(LDH)-210
CK(CPK)-222* ALK PHOS-44 TOT BILI-0.5
[**2164-8-30**] 02:37PM CK-MB-7 cTropnT-0.25*
[**2164-8-30**] 02:37PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-2.6*
MAGNESIUM-1.9 CHOLEST-164
[**2164-8-30**] 02:37PM TRIGLYCER-134 HDL CHOL-28 CHOL/HDL-5.9
LDL(CALC)-109 LDL([**Last Name (un) **])-98
[**2164-8-30**] 02:37PM DIGOXIN-0.7*
[**2164-8-30**] 02:37PM WBC-3.7* RBC-3.78* HGB-11.3* HCT-33.6* MCV-89
MCH-29.8 MCHC-33.6 RDW-13.4
[**2164-8-30**] 02:37PM NEUTS-67.1 LYMPHS-25.7 MONOS-6.5 EOS-0.3
BASOS-0.4
[**2164-8-30**] 02:37PM PLT COUNT-238
[**2164-8-30**] 02:37PM PT-26.8* PTT-37.4* INR(PT)-2.7*
..
MICROBIOLOGY:
BLOOD CULTURES: negative x3
URINE CULTURE: negative
..
STUDIES:
.
CXR: FINDINGS: The lungs are clear without consolidation or
effusion. The hilar and cardiomediastinal contours are
unremarkable. The visualized osseous and soft tissue structures
are normal.
IMPRESSION: There is no radiological evidence of pneumonia.
.
EKG: Atrial fibrillation with HR 130s. No ST-T changes or TWI.
.
TELEMETRY: As above, irregularly irregular, rate in 130s.
.
2D-ECHOCARDIOGRAM ([**8-1**]):
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). 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
a trivial/physiologic pericardial effusion.
..
2D- ECHOCARDIOGRAM ([**2164-8-29**]): PER OUTSIDE HOSPITAL RECORD
LV dilitation with diffusely hypokinetic left ventricle with EF
20%, biatrial enlargement, mild to moderate MR.
..
TRANS-THORACIC ECHO ([**2164-8-31**]):
The atria are moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
global left ventricular hypokinesis (consistent with
tachycardia, toxic, metabolic process, etc.; LVEF = 45-50%).
Precise LV systolic function quantification is difficult because
of tachycardia. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a trivial pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with mild global
systolic dysfunction. Dilated right ventricle with mild global
systolic dysfunction.
Compared with the prior study (images reviewed) of [**2162-8-11**],
tachycardia and mild LV dysfunction are new. The other findings
are similar.
Brief Hospital Course:
In summary, this is a 66-year old man with a history of
hypertension and paroxysmal atrial fibrillation who presents
from OSH with elevated troponins in setting of AF with RVR,
fevers, and question of gram positive cocci bacteremia.
.
# CAD/ISCHEMIA: At admission his cardiac risk factors included
remote smoking history, hypertension, and age. He had no
history of diabetes, no CAD history, and no history of
anginal-type symptoms during his 3-mile/day walks. There was no
significant family history of premature CAD and no Q-waves on
EKG to indicate a prior myocardial infarction. His elevated
troponins at OSH were believed due to demand ischemia in the
setting of prolonged tachycardia and febrile illness. They were
downtrending at the time of transfer to [**Hospital1 18**]. On admission his
troponin-T peaked at 0.28 and CPK peaked at 243. He was
without chest pain, palpitations, lightheadedness, or dizziness
throughout the hospitalization. He complained only of mild
fatigue that was subacute over the days leading up to admission.
.
We continued his aspirin and BB. We checked a lipid panel,
which returned normal, and opted not to begin statin therapy.
He was discharged on his outpatient cardiovascular regimen,
which included a BB, ACEI, ASA, Lasix, and spironolactone.
.
# PUMP: Per OSH records, recent EF was 20%, down from >55% two
years ago. We were unsure of the accuracy of the recent
measurement, given the absence of significant CHF symptoms or
cause for such a dramatic decrease in ejection fraction. Iron
studies were checked to r/o hemochromatosis and TSH came back
normal to r/u hypo or hyperthyroidism; EKG, as above, did not
show any pathologic q-waves or ST-deviations and thus was not
suggestive of active or past coronary artery disease. Our
repeat TTE showed an LVEF of 50-55% with only mild progression,
if any, of LV dysfunction. Given this new information, we
decided to stop his digoxin as there was no clear indication for
its use. As above, his BB, ACEI, Lasix, and spironolactone were
continued.
.
# RHYTHM: He presented in atrial fibrillation with a rapid
ventricular response of 130s. Upon admission to the CCU, we
tried to slow his rate with 5 mg pushes of IV metoprolol.
However, after 20 mg of Lopressor his rate came down to the
110s, but he remained in atrial fibrillation.
.
He was started on carvedilol at a dose of 25 mg [**Hospital1 **] to replace
his outpatient regimen of diltazem 240 mg one daily. His
warfarin was continued at his outpatient dose. Serial INRs were
checked.
.
On HD 2 we decided to electrically cardiovert him. Prior to
cardioversion, we confirmed that he had been anticoagulated at
therapeutic levels for at least three weeks. He was given
propofol for sedation and cardioverted on [**8-31**]. After
cardioversion he remained in NSR with SBPs to the 100-110s. He
was monitored on telemetry for 24 hours and discharged on
carvedilol for rate control and his outpatient coumadin dose for
embolic stroke prevention. He is followed in cardiology clinic
by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
.
# HTN: At admission he was hypotensive with SBP in the 90-100s.
In an effort to maximize his BB therapy, we initially held his
outpatient antiHTNive regimen which included ACEI,
spironolactone, and Lasix. After cardioversion, as his blood
pressure tolerated, we added back his outpatient
antihypertensives.
.
# FEVERS / ?PNA / ?GPC BACTEREMIA: Per OSH records, he had Tm
102.4 upon arrival at ED on [**8-29**]. His initial CXR showed
possible pneumonia and labs showed 17% bands on normal white
count. [**12-30**] blood cultures grew out GPC, speciation not yet
known at time of transfer. He was started on empiric vancomycin
to cover GPC. CXR, blood and urine cultures all returned
negative. When he remained afebrile and the speciation from OSH
showed coag-negative staph, vancomycin was discontinued. We
continued his levofloxacin for a full 7-day course for
presumptive treatment of CAP. This was a diagnosis made at the
OSH.
Medications on Admission:
1. Diltiazem 240 mg once a day.
2. Digitek 0.125 mg once a day.
3. Lasix 80 mg twice a day.
4. Lisinopril 10 mg a day.
5. Spironolactone 25 mg a day.
6. Coumadin 2 mg daily
7. ASA 81 mg daily
8. Tramadol 100 mg daily prn
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO MWFRISUN ().
7. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO QTUTHSA
(TU,TH,SA).
8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Community acquired pneumonia
Atrial fibrillation with rapid ventricular response status post
cardioversion
.
Secondary:
Hypertension
Discharge Condition:
Afebrile, asymptomatic and hemodynamically stable.
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
experiencing fever and an abnormal rhythm called atrial
fibrillation. You had a procedure called cardioversion to
convert your rhythm to normal sinus rhythm. You may have had a
Pneumonia which caused your fever. You were treated with seven
day course of levofloxacin which you need to complete as out
patient.
.
Please take the medications as written below. Your medications
were discussed with your out patient cardiologist. Your digoxin
and diltiazem were discontinued. You are started on Carvedilol.
Please discuss restarting you lasix with your primary care
doctor.
.
Please keep all of your follow up appointment.
.
If you develop chest pain, shortness of breath, recurrent fevers
or any other concerning symptoms, please call your primary care
doctor or go to the nearest Emergency Department.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters per day.
Followup Instructions:
Please follow up with your primary care doctor within one week
of discharge.
.
Cardiology follow up:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2164-9-26**] 1:40
Completed by:[**2164-9-3**]
|
[
"42731",
"486",
"4019"
] |
Admission Date: [**2145-11-24**] Discharge Date: [**2145-12-1**]
Date of Birth: [**2145-11-24**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 47356**] [**Known lastname **] delivered
at 34 5/7 weeks gestation, weighing 2550 gm and was admitted
to the Intensive Care Nursery from Labor and Delivery for
management of respiratory distress.
Mother is a 27 year old gravida 1, para 0, now 1 mother with
estimated date of delivery [**2144-12-25**]. Prenatal
screens included blood type A positive, antibody screen
negative, Rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, and Group B Streptococcus unknown.
The pregnancy was uncomplicated until a question of premature
rupture of membranes with onset of contractions around 45
hours prior to delivery. Labor was augmented with Pitocin.
There was on maternal fever. The mother received intrapartum
antibiotics for unknown Group B Streptococcus status and
prematurity about 43 hours prior to delivery. The infant
emerged with cry, was dried, bulb suctioned and given free
flow oxygen. Apgar scores were 7 and 8 at 1 and 5 minutes
respectively. The infant began grunting, flaring and
retracting in the Delivery Room and required free flow oxygen
to remain pink.
PHYSICAL EXAMINATION: Physical examination on admission
revealed weight 2550 gm (50th percentile), length 50 cm (90th
percentile), head circumference 33 cm (75th percentile).
Examination was remarkable for a preterm infant with mild to
moderate respiratory distress, anterior fontanelle soft,
normal facies, intact palate, mild to moderate retractions
with fair air entry, Grade II/VI systolic murmur at the lower
left sternal border. Femoral pulses present. Abdomen was
flat, soft, nondistended without hepatosplenomegaly. Normal
external genitalia. Stable hips. Fair perfusion, normal
tone and activity.
HOSPITAL COURSE: 1. Respiratory - Required intubation and
assisted ventilation with two doses of Surfactant for
respiratory distress syndrome. Maximum ventilator support,
pressures 25/5, rate 30, 50% oxygen. Was extubated to CPAP
on day of life #1. Remained on CPAP until day of life #4.
Required supplemental oxygen via nasal cannula after CPAP
until day of life #5. Weaned to room air on day of life #6
([**2145-11-30**]). He has remained in room air since with
oxygen saturations in the high 90s, comfortable work of
breathing. Respiratory rate in the 40s to 50s. No apnea.
Cardiovascular, received a normal saline bolus on admission
for a low mean blood pressure, has remained hemodynamically
stable throughout the remainder of the hospitalization. A
soft murmur audible on admission is not heard at discharge.
Recent blood pressure is 66/41 with a mean of 50.
2. Fluids, electrolytes and nutrition - Was NPO on admission
and was maintained on intravenous fluid of D10/W. Enteral
feeds were started on day of life #2 and advanced to full
feeds on day of life #4 without problems. At discharge is
feeding every 4 hours, ad lib amount with Enfamil 20 or
expressed breastmilk. Has breastfed several times. Weight
at discharge is 2335 gm which is a weight gain of 25 gm from
the previous day.
3. Gastrointestinal - Received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin, total 14, direct .4,
bilirubin off phototherapy at the time of discharge, total
9.7, direct .3.
4. Hematology - Hematocrit on admission 51.5%, infant's
blood type is A positive, direct Coomb's is negative.
5. Infectious disease - Received 48 hours of Ampicillin and
Gentamicin and sepsis was ruled out. Complete blood count on
admission showed a white count of 17.3 with 38 polys, 1 band,
319,000 platelets. Blood culture was negative.
6. Neurology - Examination is age-appropriate. Sensory,
hearing screening was performed with automated auditory brain
stem response, infant passed both ears.
CONDITION ON DISCHARGE: Stable one week old, now 36 1/2
weeks corrected age, premature infant.
DISCHARGE DISPOSITION: Discharge home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47357**], Phone [**Telephone/Fax (1) 38162**].
CARE/RECOMMENDATIONS:
1. Feeds - Ad lib demand breast or bottle feeding, follow
weight gain.
2. Medications - None.
3. Carseat position screening - Passed carseat test.
4. State newborn screen status - State newborn screen sent
at day of life #3 and is pending.
5. Immunizations received - Received hepatitis B
immunization on [**2145-12-1**].
6. Follow up appointments scheduled/recommended - Mother to
make an appointment with pediatrician for Friday, [**2145-12-3**].
DISCHARGE DIAGNOSIS:
1. Appropriate for gestational age 35 4/7 weeks preterm
female.
2. Respiratory distress syndrome, resolved.
3. Sepsis, ruled out.
4. Indirect hyperbilirubinemia, resolving.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 36096**]
MEDQUIST36
D: [**2145-12-1**] 14:27
T: [**2145-12-1**] 15:25
JOB#: [**Job Number 47358**]
|
[
"V053",
"V290"
] |
Admission Date: [**2119-12-14**] Discharge Date: [**2119-12-22**]
Date of Birth: [**2052-7-16**] Sex: M
Service: GOLD SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old man
who had undergone a pylorus sparing Whipple procedure on
[**2117-12-11**] for intraductal papillary mucinous tumor of
the pancrease. The patient presented to the Emergency
Department on [**2119-12-14**] complaining of three weeks of
intermittent nausea and vomiting and abdominal pain. The
patient reports that the abdominal pain and nausea and
vomiting became most severe the night prior to admission with
three episodes of vomiting including some bilious fluid. The
patient reports that his pain is located in the right upper
quadrant and is described as being severe without any
radiation and it is described in quality as being colicky and
intermittent in nature. The pain was so severe that the
patient could not sleep. The patient denies having fevers at
home, however, he reported having chills while having his
episodes of pain. The patient also reports that his bowel
movements have become pale colored, but denies having any
changes in frequency. He did not report changes in flatus or
urinary symptoms, but did report that his urine had become
dark recently. The patient also reports having pruritus and
has recently started taking Atarax.
PAST MEDICAL HISTORY:
1. Intraductal papillary mucinous tumor of the pancrease and
chronic pancreatitis.
2. History of diabetes.
PAST SURGICAL HISTORY:
1. Pylorus sparing Whipple procedure in [**2117-12-11**].
2. Incisional hernia repair status post Whipple procedure
[**2119-1-24**].
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Atarax.
2. Pancrease enzymes.
3. Insulin regimen including NPH doses at breakfast, dinner
and bedtime and a regular insulin sliding scale.
4. Reglan.
5. Percocet.
6. Colace.
7. Pletal.
8. Aciphex.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
temperature of 96.9. Heart rate 80. Blood pressure 121/64.
Respiratory rate 18. Sating 95% on room air. The patient
was alert and oriented times three, jaundice in appearance.
The patient had icteric sclera. The neck was supple. There
was no JVD. Cardiovascular examination was regular rate and
rhythm. S1 and S2. No murmurs were heard. Respirations
clear to auscultation bilaterally. Abdominal examination
showed a well healed incision from the Whipple procedure with
bowel sounds soft, nondistended, but mildly tender in the
right upper quadrant. Extremities were warm and without any
edema.
LABORATORIES ON ADMISSION: White blood cell count 17.1 with
neutrophil of 77%, lymphocytes of 18%, hematocrit 41.9 and
platelets 469. PT 12. PTT 23.8 with an INR of 1.0.
Chemistries sodium 141, potassium 3.9, chloride 103, CO2 27,
BUN 11 and creatinine 0.7 and glucose of 167. AST 49, ALT
48, alkaline phosphatase 338 with a total bilirubin of 6.7,
amylase 19, lipase 7. The patient had a recent CAT scan
dated [**2119-12-11**], which did not show any recurrence of
the IPMT.
HOSPITAL COURSE: Given the patient's significant past
medical history and his surgical history of having gone a
Whipple procedure and the patient's current state of biliary
obstruction and symptoms of chills the patient was suspected
of having obstructive jaundice and cholangitis. The patient
was made NPO and was put on intravenous fluids and was
started on Amp, Levo and Flagyl empirically. The patient was
sent for an ERCP urgently, however, the patient's biliary
anastomosis could not be reached by the endoscope therefore
endoscopic retrograde cholangiopancreatography could not be
performed. Because the patient's bilary obstruction could
not be relieved the patient was sent to the interventional
radiology for percutaneous transhepatic biliary drainage and
the patient underwent procedures successfully without any
complications. Upon admission the patient was found to have
occasional fever spikes to 101 on hospital day one and two.
The patient was pan cultured. Blood cultures ultimately did
not grow out any bacteria, however, the bile cultures drawn
from the PTC2s grew out pan sensitive E-coli and pan
sensitive Enterococcus and the bowel cultures specimens sent
on hospital day two also grew out pan sensitive E-Coli and
pan sensitive Klebsiella oxytoca.
The patient was still having a fever on hospital day two and
because his total bilirubin level had increased from 6.7 to
7.8 the patient was resent to the interventional radiology
for check of the catheter. This was done without any
complications. Although the patient still had a continuous
structure of the common bile duct at the biliary anastomosis
contrast flowed freely into the small bowel without any
difficulty, therefore the catheter was working properly and
the patient was continued on intravenous antibiotics and
Ampicillin, Levaquin and Flagyl. The patient's total
bilirubin and his liver function tests were followed daily
and the patient's total bilirubin peaked at a level of 9.3 on
hospital day three and four with temperature spikes to
temperature max of 103.7 on hospital day four. The patient
was carefully observed and continued on his intravenous
antibiotics. The patient's total bilirubin gradually
decreased with the PTC2 draining dark bilious drainage and
the patient subsequently was doing well on intravenous
antibiotics. On discharge the patient had been afebrile for
48 hours with total bilirubin trending down to a level of 6.0
from a peak of 9.3. The patient's liver function tests
levels were within normal limits. The patient was tolerating
a regular diet without any difficulty and without nausea and
vomiting. The patient's abdominal pain decreased
significantly after the PTC and drainage with only mild
tenderness at the incision site of the PTC2. This pain was
initially treated with po Percocet, but because the patient
became somnolent the patient was switched over to Tylenol #3
with good effect. On hospital day eight the patient was
switched over to po Levaquin after confirming the
sensitivities on the E-Coli enterococcus and the Klebsiella
that grew out from the bile culture on admission the patient
was discharged home on [**2119-12-22**] on hospital day nine
to finish his po antibiotics course at home.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. History of pancreatic intraductal papillary mucinous
tumor status post Whipple procedure on [**2118-1-6**] found to have
cholangitis due to anastomotic stricture with E-Coli,
Klebsiella oxytoca and Enterococcus.
2. Diabetes mellitus.
DISCHARGE MEDICATIONS: The patient is to continue all of his
preoperative medications as listed above. The patient is
also to complete a fourteen day course of Levaquin 500 mg po
q.d. for twelve more days. The patient is also prescribed
Tylenol with codeine 300/30 mg one to two tables po q 4 hours
prn pain and Colace 100 mg po b.i.d. prn constipation.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 468**] in
his office on [**2120-1-1**] and is to undergo a 2
cholangiogram on the morning of the 22nd to check for
presence of biliary obstruction.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2119-12-24**] 08:53
T: [**2119-12-25**] 06:21
JOB#: [**Job Number 13961**]
|
[
"4280",
"25000"
] |
Admission Date: [**2195-3-25**] Discharge Date: [**2195-4-1**]
Date of Birth: [**2122-8-8**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
woman with a history of coronary artery disease who reported
increasing shortness of breath and chest discomfort times
several months, refused a stress test, which was ultimately
done on the morning of admission and was positive for
ischemic changes. She was then sent to the cardiac
catheterization laboratory, which showed three vessel disease
and was ultimately referred for coronary artery bypass
grafting. As stated, the catheterization showed proximal
right coronary artery with 100 percent lesion, the mid left
anterior descending coronary artery with a 90 percent lesion,
the first diagonal with an 80 percent lesion and obtuse
marginal one with a 90 percent lesion with an ejection
fraction of 52 percent.
PAST MEDICAL HISTORY: Diabetes mellitus.
Hypertension.
Hypercholesterolemia.
PAST SURGICAL HISTORY: Appendectomy.
Bilateral hernia repairs.
ALLERGIES: The patient states an allergy to Lisinopril which
causes a cough.
MEDICATIONS ON ADMISSION:
1. Diovan 80 mg daily.
2. Glyburide 5 mg daily.
3. Methocarbamol 750 as needed.
4. Atenolol 25 mg daily.
5. Oxycodone as needed.
6. Hydrochlorothiazide 12.5 mg daily.
7. Lipitor 10 mg daily.
8. Ritalin daily, no dose provided.
SOCIAL HISTORY: The patient is [**Name8 (MD) **] RN who continues to work
as a Hospice nurse. She lives in [**Location 32651**] with a roommate.
She has a remote tobacco history, quit two years ago after 45
years of smoking. No alcohol use.
FAMILY HISTORY: Significant for brother with coronary artery
disease who had a coronary artery bypass graft at 65 years of
age.
PHYSICAL EXAMINATION: Height five feet five inches, weight
190 pounds. Vital signs revealed temperature 99.5, heart
rate 70, blood pressure 130/50, respiratory rate 20, oxygen
saturation 95 percent in room air. In general, sitting
comfortably in bed in no acute distress. Neurologically, she
is alert and oriented times three, moves all extremities,
nonfocal examination. Respiratory clear to auscultation
bilaterally. Cardiovascular regular rate and rhythm, S1 and
S2, no murmurs, rubs or gallops. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with trace edema, positive for
varicosities. Pulses - radial one plus bilaterally, dorsalis
pedis and posterior tibial both one plus bilaterally.
LABORATORY DATA: At catheterization, white blood cell count
8.0, hematocrit 39.8, platelet count 295,000. Sodium 138,
potassium 4.3, chloride 99, CO2 30, blood urea nitrogen 25,
creatinine 0.7, glucose 142. Prothrombin time 13.0, partial
thromboplastin time 25.0, INR 1.1. Liver function tests are
within normal range.
HOSPITAL COURSE: On [**2195-3-26**], the patient was brought to
the operating room where she underwent coronary artery bypass
grafting times four. Please see the operative note for full
details. In summary, the patient had a coronary artery
bypass graft times four with left internal mammary artery to
the left anterior descending coronary artery, saphenous vein
graft to the right coronary artery, saphenous vein graft to
the obtuse marginal and to the diagonal sequentially. Her
bypass time was 68 minutes with a cross clamp time of 43
minutes. She was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At the time of transfer,
the patient was in sinus rhythm at 70 beats per minute with a
mean arterial pressure of 81 and CVP of 13. She had Neo-
Synephrine at 0.5 mcg/kg/minute, Propofol 20 mcg/kg/minute
and insulin at two units per hour. The patient did well in
the immediate postoperative period. Her anesthesia was
reversed. She was weaned from the ventilator and
successfully extubated. She remained hemodynamically stable
throughout the operative day and was able to be weaned off
all vasoactive intravenous medications overnight and on
postoperative day number one, she remained hemodynamically
stable. Her Swan-Ganz catheter was removed. She was begun
on diuretics as well as beta blockade and transferred to the
floor for continuing postoperative care and cardiac
rehabilitation. On postoperative day number two, the patient
continued to do well. Her Foley catheter, chest tubes, and
temporary pacing wires were removed. Her activity level was
increased with the assistance of the nursing staff as well as
physical therapy. The remainder of the [**Hospital 228**] hospital
course was uneventful. Her activity level was advanced on a
daily basis. Her medications were adjusted and, on
postoperative day number six, it was decided the patient was
stable and ready to be discharged to home with visiting
nurses. At the time of this dictation, the patient's
physical examination is as follows: Temperature 98.9, heart
rate 97, sinus rhythm, blood pressure 156/68, respiratory
rate 20, oxygen saturation 92 percent in room air. The
patient's weight at discharge is 92 kilograms and
preoperatively was 82 kilograms. On physical examination,
neurologically she is alert and oriented times three, moves
all extremities, follow commands, nonfocal examination.
Pulmonary is clear to auscultation bilaterally. Cardiac
regular rate and rhythm, S1 and S2. The sternum is stable.
The incision was with Steri-Strips, open to air, clean and
dry without drainage or erythema. The abdomen is soft,
nontender, nondistended, normoactive bowel sounds.
Extremities are warm and well perfused with one to two plus
edema. Bilateral endoscopic vein grafting, incision sites
with Steri-Strips open to air, clean and dry, right thigh
with a large ecchymotic area.
CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Potassium Chloride 20 mEq twice a day times two weeks and
then daily times two weeks.
2. Colace 100 mg twice a day.
3. Aspirin 81 mg daily.
4. Atorvastatin 10 mg daily.
5. Glyburide 5 mg daily.
6. Percocet 5/325 one to two tablets q4-6hours as needed.
7. Ibuprofen 600 mg q6hours.
8. Ferrous Gluconate 300 mg daily times one month.
9. Ascorbic Acid 500 mg twice a day times one month.
10. Lasix 40 mg twice a day times two weeks and then
daily times two weeks.
11. Metoprolol 75 mg twice a day.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting times four with left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to right coronary artery and
saphenous vein graft to obtuse marginal and diagonal
sequentially.
Hypertension.
Diabetes mellitus.
Hypercholesterolemia.
Status post appendectomy.
Status post hernia repair.
FOLLOW UP: The patient is to have follow-up in the [**Hospital 409**]
Clinic in two weeks, follow-up with Dr. [**Last Name (STitle) **] in two to
three weeks, follow-up with Dr. [**Last Name (STitle) 4001**] in three to four
weeks, and follow-up with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2195-4-1**] 16:22:27
T: [**2195-4-1**] 18:17:48
Job#: [**Job Number 98469**]
|
[
"41401",
"9971",
"42731",
"4019",
"25000",
"2720"
] |
Admission Date: [**2103-10-8**] Discharge Date: [**2103-10-29**]
Date of Birth: [**2042-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer, Tracheoesophageal fistula
Major Surgical or Invasive Procedure:
Rouex-N-Y gastrojejunostomy, esophageal conduit, jejunostomy,
small bowel resection, thoraco-abdominal incision with
anastomosis
PICC line
SVC filter
Intubation
Arterial line
Right IJ venous catheter
Left subclavian venous catheter
History of Present Illness:
Dr. [**Known lastname 31624**] is a 61-year-old M, now 12 years after trimodality
therapy for esophageal cancer. He was recently diagnosed with a
fistula from the carina of the trachea to the gastric conduit,
presumably based on the foreign body of the lesser curvature
staple line eroding into the airway. Biopsies of both the
bronchial and gastric side of this had not shown any malignancy,
nor was there any mass lesion visible by CT scan. His Y-stent is
effectively controlling and
preventing ongoing biliary soilage of the lower lobe at this
time. He remains nutritionally behind, and given the irradiated
field, a feeding jejunostomy was placed on [**2103-7-2**] for his
nutritional gains and to divert the pancreatic and biliary
drainage, which tends to reflux into the gastric conduit, to
allow unrestricted healing of this site.
Patient returns on this admission for further surgical repair of
his tracheoesophageal fistula repair.
Past Medical History:
Past Medical History: Esophageal Cancer, bowel obstruction, TEF,
Left vocal cord paralysis, Depression s/p ECT (following [**2091**]
surgery), Anxiety
.
Past Surgical History: Esophagectomy at [**Hospital1 112**] in [**2091**] complicated
by stricture and tracheal esophageal fistula s/p dilation x2 and
Y-stent for the TEF on [**6-24**], exploratory laparotomy/LOA/biliary
diversion with G and J Tube placement [**2103-7-9**], Repair of TE
fistula w/intercostal flap [**8-20**], Roux-n-Y gastrojejunostomy
(esophageal conduit) with intra-thoracic anastomosis, small
bowel
resection, J-tube on [**10-8**]
Social History:
General Surgeon, lives w/ wife and 2 small children ages 5 and
7.
non-smoker
Family History:
non-contributory
Physical Exam:
Admission Physical Exam
Vitals: 96.7 77 126/74 16 97% Rm Air
Gen: No acute distress
Cardio: RRR, no RMG
Pulm: CTA, lower BS to right bases
Abd: soft, NT/ND, active BS, j-tube in place (TF at goal)
Ext: No C,C,E
Pertinent Results:
[**2103-10-8**] 11:04PM BLOOD WBC-8.6 RBC-3.36* Hgb-9.9* Hct-28.3*
MCV-84 MCH-29.5 MCHC-35.0# RDW-16.3* Plt Ct-242#
[**2103-10-9**] 04:36AM BLOOD WBC-11.5* RBC-3.52* Hgb-9.9* Hct-30.4*
MCV-87 MCH-28.1 MCHC-32.5 RDW-15.6* Plt Ct-248
[**2103-10-12**] 07:35AM BLOOD WBC-8.5 RBC-2.29* Hgb-6.6* Hct-20.1*
MCV-88 MCH-28.7 MCHC-32.8 RDW-16.1* Plt Ct-249
[**2103-10-14**] 07:00AM BLOOD WBC-10.1 RBC
-3.12* Hgb-9.3* Hct-27.6* MCV-88 MCH-29.7 MCHC-33.6 RDW-15.4 Plt
Ct-317
[**2103-10-17**] 05:26AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.8* Hct-29.8*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.4 Plt Ct-440
[**2103-10-18**] 05:31AM BLOOD WBC-12.2* RBC-3.04* Hgb-8.9* Hct-27.2*
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.3 Plt Ct-568*
[**2103-10-22**] 05:58AM BLOOD WBC-12.2* RBC-3.12* Hgb-8.8* Hct-27.9*
MCV-89 MCH-28.4 MCHC-31.7 RDW-15.0 Plt Ct-815*
[**2103-10-23**] 05:25AM BLOOD WBC-12.3* RBC-3.00* Hgb-8.8* Hct-26.4*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.8* Plt Ct-885*
[**2103-10-23**] 11:53AM BLOOD WBC-13.3* RBC-2.94* Hgb-8.4* Hct-25.9*
MCV-88 MCH-28.8 MCHC-32.6 RDW-15.0 Plt Ct-923*
[**2103-10-24**] 04:01AM BLOOD WBC-10.4 RBC-3.26* Hgb-9.6* Hct-28.0*
MCV-86 MCH-29.5 MCHC-34.4 RDW-15.3 Plt Ct-629*
[**2103-10-25**] 01:27AM BLOOD WBC-11.3* RBC-3.36* Hgb-10.0* Hct-28.8*
MCV-86 MCH-29.9 MCHC-34.8 RDW-15.4 Plt Ct-554*
[**2103-10-27**] 04:58AM BLOOD WBC-7.6 RBC-3.70* Hgb-10.6* Hct-31.9*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.2 Plt Ct-568*
[**2103-10-21**] 04:41PM BLOOD PT-15.8* PTT-26.9 INR(PT)-1.4*
[**2103-10-21**] 10:51PM BLOOD PT-15.2* PTT-31.4 INR(PT)-1.3*
[**2103-10-22**] 05:58AM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3*
[**2103-10-23**] 11:53AM BLOOD PT-16.5* PTT-59.1* INR(PT)-1.5*
[**2103-10-24**] 04:01AM BLOOD PT-15.0* PTT-29.7 INR(PT)-1.3*
[**2103-10-26**] 03:31AM BLOOD PT-14.3* PTT-28.6 INR(PT)-1.2*
[**2103-10-8**] 11:04PM BLOOD Glucose-128* UreaN-19 Creat-0.8 Na-138
K-4.7 Cl-107 HCO3-24 AnGap-12
[**2103-10-17**] 06:27PM BLOOD Glucose-173* UreaN-11 Creat-0.8 Na-136
K-4.2 Cl-104 HCO3-26 AnGap-10
[**2103-10-27**] 04:58AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-138
K-4.0 Cl-104 HCO3-27 AnGap-11
[**2103-10-19**] 05:02AM BLOOD calTIBC-243* Ferritn-211 TRF-187*
[**2103-10-19**] 05:02AM BLOOD Triglyc-139
Upper GI SBFT [**2103-10-19**]:
Status post esophagectomy, with Roux-en-Y gastrojejunostomy
anastomosis. No evidence of leak or obstruction at the GJ
anastomosis, although contrast is slow flowing through the
anastomosis, consistent with postoperative edema. Although
incompletely assessed, contrast has likely traversed through the
JJ anastomosis.
CTA [**2103-10-21**]
1. Interval development of bilateral segmental and subsegmental
pulmonary
emboli.
2. Decreasing size of posterior mediastinal collection in
comparison to prior study.
3. Persistent bilateral pleural effusions. Continued airspace
disease at
right lung base. Development of ground-glass attenuation in
bilateral lung
fields, which can be consistent with worsening infection or
infarcts.
LE US
No evidence of acute DVT involving the right or left lower
extremities.
UP US
Partially occlusive thrombus of the right axillary vein. These
findings were discussed in person with the medical resident
caring for the
patient.
CXR
Large round opacity in left lower lung, in part due to loculated
intrafissural fluid, but also raising the possibility for either
a rounded
pneumonia or evolving lung abscess
Brief Hospital Course:
Patient was taken to the OR by Dr. [**Last Name (STitle) **] for Roux-n-Y
gastrojejunostomy (esophageal conduit) with intra-thoracic
anastamosis, small bowel resection, and J-tube for repair of his
tracheoesophageal fistula on [**2103-10-8**]. Epidural placed and split
with PCA to provide additional pain control. He was transferred
to the thoracic surgical floors for further postoperative
recovery.
[**Date range (3) 78800**]: Patient followed a normal postoperative course.
He ambulated without any difficulty with assistance. He was kept
NPO with tube feeds at goal via J-tube. Patient transfused 2
units pRBC for Hct of 20. Post-transufion Hct showed adequate
response with Hct of 31. The plan was for upper GI study one
week after his surgery to assess anastomosis before starting his
diet.
[**2103-10-14**]: Patient was febrile to 101.9. Vancomycin and Zosyn
started for empiric coverage. Patient also developed atrial
fibrillation with HR > 170's. He was not able to convert with
lopressor and became hypotensive despite multiple fluid boluses.
Cardiac enzyme panel were negative. Electrolytes checked and
were repleted. Transferred to the intensive care unit for
symptomatic atrial fibrillation. Amiodarone started and he
converted to sinus that evening. HIs epidural was removed by APS
for possible bacteremia. He kept on PCA for pain control.
[**2103-10-15**]: Patient with tachypnea secondary to his abdominal
distention. Oxygen saturations were > 93% and blood gases showed
normal gas exchange. Pulmonary toilet with nebulizer to help
with his respiratory status. Patient complained of a "reflux"
that is not GERD-like but exacerbated when he lays flat. With
his constipation and ileus, full bowel regimen with laxatives
started. Golytely started at 40ml/hr via his J-tube to encourage
bowel movements. Patient remained NSR.
[**2103-10-16**] -[**2103-10-18**]: Right picc line provided for additional venous
access while patient remained on amiodarone drip. PIV removed
for phlebilits most likely [**2-17**] amiodarone drug reaction. He
remained NSR. Golytely continued to be fed via J-tube. Patient
able to pass flatus and stool. He was kept on antibiotics for a
incisional wound cellulitus that was indurated, tender and
erythematous.
[**Date range (1) 78801**]: Patient with improving dyspnea. Regular BM.
Subjectively feels improved overall. Barium swallow showed no
leak and tube feeds (Replete with fiber) was restarted. His
chest tube was also removed. Patient started on sips and
advanced to clears for comfort. Tube feeds advanced to goal.
Began diuresis which slightly improved his dyspnea. He remained
at 4L oxygen via NC, RR at 32. Serial cxr continued to show
bibasilar atelectasis.
[**2103-10-22**]: With continued and worsening dyspnea, CT scan of chest
showed bilateral pulmonary embolism. Heparin drip started, PTT
goal of 60-80. No heparin bolus was given and PTT checked every
6 hrs to adjust heparin drip.
[**2103-10-23**]: Patient transferred to ICU for ~ 500ml of bloody
emesis. Heparin drip stopped. He remained hemodynamically
stable. Hct at 26. NGT was placed for decompression. Planned for
elective intubation, EGD and bronchoscopy. EGD showing clots at
esophageal conduit. Bronchoscopy showed mild blood in LLL
bronchus. No areas of active bleeding found. Protonix also
started. Patient transfused 2u pRBC. With pulmonary emboli and
upper GI bleed, vascular surgery consulted to place IVC filter.
LENI were negative for any DVT.
[**2103-10-24**]: SVC filter placed by vascular surgery without
complications.Please see dictated note for more detail. Patient
remained intubated and taken back to ICU after surgery. RIJ wire
removed (proximity to SVC filter) and left subclavian central
venous line placed. Patient was weaned from ventilator for
extubation. US of upper extremity showed partially occlusive
thrombus of the right axillary vein. Additional unit of blood
given to keep Hct > 30.
[**Date range (1) 78802**]: Patient extubated and returned to general
surgical floor. NG removed and tube feeds restarted with goal of
90ml/hr. His diet advaced to clears and fulls. Continued to have
bowel movements. Patient weaned from oxygen use and with normal
oxygenations even with ambulation. Less abdominal distention as
he tolerated diet without nausea or vomiting. He is being
discharged home with tubefeeds on [**2103-10-29**].
Medications on Admission:
Ativan 0.25-0.5mg PO PRN, Roxicet PRN at meal
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*500 ML(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: Take from date of discharge until [**11-3**].
Disp:*22 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 weeks: Take from [**2103-11-4**] until [**2103-11-17**].
Disp:*14 Tablet(s)* Refills:*0*
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for anxiety/insomnia.
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Cancer
tracheoesophageal fistula
Left vocal cord paralysis
Depression
Anxiety disorder
Pulmonary embolism
Upper GI bleed
respiratory failure requiring intubation
atrial fibrillation
Discharge Condition:
Stable
On tube feeds and tolerating regular diet
Meeting discharge criteria
Discharge Instructions:
General:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* 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.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week
Follow up with PCP [**Last Name (NamePattern4) **] [**1-17**] weeks
|
[
"51881",
"42731"
] |
Admission Date: [**2181-5-29**] Discharge Date: [**2181-6-5**]
Date of Birth: [**2111-1-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 70-year-old white male
with known coronary artery disease, status post myocardial
infarction times three and status post percutaneous
transluminal coronary angioplasty and stent in [**2179**]. He also
has a history of non-insulin-dependent diabetes mellitus,
hypertension, and hyperlipidemia. He presented to [**Hospital6 3622**] on [**5-25**] with intermittent chest pain and
increased lower extremity edema.
The patient ran out of Lasix two weeks prior to admission and
had progressively worsening dyspnea on exertion with chest
pressure. At [**Hospital6 33**], he was diuresed with
Lasix, and his electrocardiogram revealed congestive heart
failure. He had lateral ST depressions.
He underwent cardiac catheterization which revealed 3-vessel
coronary artery disease, and a reduced an ejection fraction,
with an occluded stent. He had a normal left main. He ruled
out for a myocardial infarction and presented to [**Hospital1 346**] for coronary artery bypass graft.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Status post myocardial infarction times three.
2. History of colon cancer; status post colectomy in [**2176**]
with colostomy takedown.
3. History of non-insulin-dependent diabetes mellitus.
4. History of gastroesophageal reflux disease.
5. History of hyperlipidemia.
6. History of hypertension.
7. History of diverticulosis.
8. Status post appendectomy.
9. Status post percutaneous transluminal coronary
angioplasty and stent in [**2179**].
10. Status post right shoulder rotator cuff repair.
MEDICATIONS ON ADMISSION:
1. Glipizide 10 mg p.o. once per day.
2. Glucophage 850 mg p.o. twice per day.
3. Zestril 40 mg p.o. once per day.
4. Isosorbide 60 mg p.o. once per day.
5. Lipitor 20 mg p.o. once per day.
6. Norvasc 10 mg p.o. once per day.
7. Atenolol 25 mg p.o. once per day.
8. Glucotrol 5 mg p.o. three times per day.
9. Iron.
10. Multivitamin one tablet p.o. every day.
11. Avandia 4 mg p.o. once per day.
12. Aspirin 81 mg p.o. once per day.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
quit smoking in [**2169**] and does not drink alcohol.
REVIEW OF SYSTEMS: His review of systems was unremarkable.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, he was well-developed and well-nourished white
male in no apparent distress. Vital signs were stable.
Afebrile. Head, eyes, ears, nose, and throat examination
revealed normocephalic and atraumatic. Extraocular movements
were intact. The oropharynx was benign. The neck was supple
with full range of motion. No lymphadenopathy or
thyromegaly. Carotids were 2+ and equal bilaterally without
bruits. The lungs had bibasilar rales. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. No murmurs, rubs, or
gallops. The abdomen was obese and soft with a large
reducible ventral hernia. The abdomen was nontender with
positive bowel sounds. Extremities had bilateral trace pedal
edema. The pulses were 2+ and equal bilaterally throughout.
Neurologic examination was nonfocal.
PERTINENT LABORATORY VALUES ON DISCHARGE: His laboratories
on discharge revealed hematocrit was 28.4, white blood cell
count was 12,700, and platelets were 355. Sodium was 139,
potassium was 4, chloride was 101, bicarbonate was 28, blood
urea nitrogen was 26, creatinine was 1.2, and blood glucose
was 167.
HOSPITAL COURSE: On [**5-30**], he underwent a coronary artery
bypass graft times four with a left internal mammary artery
to the left anterior descending artery and reversed saphenous
vein graft to obtuse marginal, first diagonal, and the
posterior descending artery. Cross-clamp times was 71
minutes. Total bypass times was 83 minutes.
He was transferred to the Cardiothoracic Surgery Recovery
Unit on Neo-Synephrine and propofol in stable condition. He
had a stable postoperative night and was extubated. He was
transfused one unit of packed red blood cells.
On postoperative day one, he had some bradycardia and was
atrioventricularly paced. He also had decreased urine output
requiring increasing Lasix doses and eventually required
dopamine and responded to this very well. He had the chest
tubes discontinued on postoperative day two. His dopamine
was weaned off, and he had diuresis on his own.
He continued to progress and was transferred to the floor.
On postoperative day five, he had his wires discontinued that
day.
DISCHARGE DISPOSITION: On postoperative day six, he was
discharged to rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg p.o. three times per day.
2. Glipizide 5 mg p.o. four times per day.
3. Glucophage 850 mg p.o. twice per day.
4. Avandia 4 mg p.o. once per day.
5. Pravachol 20 mg p.o. once per day.
6. Multivitamin one tablet p.o. every day.
7. Prilosec 20 mg p.o. once per day.
8. Lasix 20 mg p.o. twice per day (times one week) then
decrease to 10 mg p.o. once per day.
9. Potassium chloride 20 mEq p.o. twice per day (times one
week) then discontinue.
10. Lopressor 25 mg p.o. twice per day.
11. Zestril 20 mg p.o. once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be
followed by Dr. [**Last Name (STitle) **] in one to two weeks and by Dr. [**Last Name (STitle) **] in
four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2181-6-5**] 12:59
T: [**2181-6-5**] 13:37
JOB#: [**Job Number **]
|
[
"41401",
"4280",
"25000",
"53081",
"4019",
"2720",
"412",
"V4582"
] |
Admission Date: [**2100-11-7**] Discharge Date: [**2100-11-23**]
Date of Birth: [**2028-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr /
Lipitor / Zetia
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
non-healing chest wound
Major Surgical or Invasive Procedure:
left thoracotomy/removal pacer leads [**2100-11-15**]
History of Present Illness:
72 yo male s/p original abdominal pacer placement in [**2053**] for
myocarditis. This failed due to infection and hemothorax.
Subsequently a pacer was placed in the left chest which was
complicated and difficult. Has had multiple surgeries including
16 generator changes. Developed a mass in the left chest which
proved to be a retained sponge from a prior surgery. This was
removed surgically in [**12-22**] along with a new generator change.
This incision developed a MRSA infection and did not heal.
Referred for surgery to remove hardware.
Past Medical History:
Myocarditis s/p pacemaker
CHF, most recent echo showing normal LV function. Last report
shows EF 40-45%
CAD, s/p prior stenting (LAD and OM)
hypertension
hyperlipidemia
atrial flutter/fib on coumadin
hepatitis C
mass on left chest wall - negative needle biospy
B renal cysts
erectile dysfunction
Bipolar disorder
[**Last Name (un) **]. arthritis of spine
Social History:
Social history is significant for the absence of current tobacco
use.Smoked pipe for 2 years. There is no history of alcohol
abuse. He lives alone in basement apartment in [**State **] with
some local friends, but no family nearby. He has a brother, Dr.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 96500**] (Urologist) in LA who is involved in his life.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
69", 186# T:98.3, 106/58,P:60, RR:20,100% O2SAT on R/A
General: A&Ox3, NAD
HEENT: WNL
CVS:irreg.irreg, v-paced
Lungs:decreased bases
Abd: benign
Extr:venous stasis changes, 1+edema
left thoracotomy wound vac intact/staples intact
Pertinent Results:
Conclusions
[**2100-11-23**] 09:09AM BLOOD WBC-4.9 RBC-2.70* Hgb-9.0* Hct-27.2*
MCV-101* MCH-33.3* MCHC-33.1 RDW-15.8* Plt Ct-117*
[**2100-11-8**] 12:53AM BLOOD WBC-6.8 RBC-3.21* Hgb-10.4* Hct-30.5*
MCV-95 MCH-32.5* MCHC-34.1 RDW-14.9 Plt Ct-103*
[**2100-11-23**] 09:09AM BLOOD PT-23.6* INR(PT)-2.3*
[**2100-11-8**] 05:50AM BLOOD PT-17.6* PTT-36.7* INR(PT)-1.6*
[**2100-11-22**] 05:01AM BLOOD Glucose-89 UreaN-42* Creat-1.8* Na-135
K-4.0 Cl-106 HCO3-24 AnGap-9
[**2100-11-8**] 12:53AM BLOOD Glucose-119* UreaN-23* Creat-1.3* Na-135
K-3.8 Cl-104 HCO3-25 AnGap-10
[**2100-11-19**] 06:13AM BLOOD ALT-68* AST-75* LD(LDH)-313* AlkPhos-90
TotBili-1.2
[**2100-11-8**] 12:53AM BLOOD calTIBC-295 VitB12-1401* Folate-GREATER
TH Ferritn-207 TRF-227
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Last Name (LF) **], [**Known firstname 900**] [**Hospital1 18**] [**Numeric Identifier 96501**] (Complete)
Done [**2100-11-15**] at 1:28:24 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2028-2-28**]
Age (years): 72 M Hgt (in): 69
BP (mm Hg): 123/69 Wgt (lb): 180
HR (bpm): 60 BSA (m2): 1.98 m2
Indication: evaluate for endocarditis, intraoperative management
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2100-11-15**] at 13:28 Interpret MD: [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15426**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Left Atrium - Volume: *52 ml < 32 ml
Left Atrium - LA Volume/BSA: *26 ml/m2 < 22 ml/m2
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.5 cm
Left Ventricle - Fractional Shortening: *0.15 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Complex (>4mm) atheroma in the ascending aorta. Normal
aortic arch diameter. Complex (>4mm) atheroma in the aortic
arch. Normal descending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets. Mild to moderate ([**12-16**]+) AR. Eccentric AR
jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
1. The left atrium is moderately dilated.
2. No atrial septal defect or PFO is seen by 2D or color
Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are complex (>4mm) atheroma in the ascending aorta, the
aortic arch and descending thoracic aorta.
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. The aortic valve leaflets are mildly
thickened. Mild to moderate ([**12-16**]+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric originating from the
base of the right and left coronary leaflets. No aortic
vegetations seen..
7. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. No mitral vegetations seen.
8. Moderate [2+] tricuspid regurgitation is seen. No tricuspid
vegetations seen.
9. There is no pericardial effusion.
10. A circumflex artery aneurysm is noted
11. Dr. [**Last Name (STitle) 914**] was notified in person of the results during the
surgery.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician
Brief Hospital Course:
The patient is a 71 year old male with a history of multiple
revisions of pace-maker, coronary artery disease, chronic
systolic congestive heart failure-?acute on chronic systolic
CHF, and bipolar disorder who presents from [**State **] for
evaluation of non-healing wound and likely pacemaker revision.
Non-healing wound, pacemaker: Patient with first pacer placed
[**2054**] cardiomyopathy secondary to myocarditis. This was an
abdominal pacemaker and his course was complicated by infection;
patient reportedly has a fistula. Since that time, he has had
multiple revisions, with one hematoma. He reports that he has
had continued drainage and bleeding from his chest wall
abnormality that is concerning for persistent infection (either
abscess, infected new or old wires that are in place) in setting
of sinus tract. He has had no fevers, chills, or other features
to suggest systemic disease. He had been on Levofloxacin for
treatment for approximately ten days prior to admission, however
he was started on Vancomycin upon admission. His wound culture
subsequently grew MRSA. An ECHO was obtained which showed no
vegetation.
Cardiac surgery evaluated the patient for hardware removal and
this was done by Dr. [**Last Name (STitle) 914**] on [**11-15**]. Extubated that
evening.Please refer to operative report for further details.
POD #1EP interrogated pacer. Mr.[**Name14 (STitle) 96500**] had postoperative
confusion. Narcotics were discontinued. No focal defecit.Id
following with antibiotic reccommendations->Vanco x 14 days,
start date [**11-16**];trough level maintained 15-20. He was restarted
on Coumadin for chronic AFib. INR goal 2.0. Transiently
postoperative he was placed on Tube Feeds to improve nutritional
intake. Speech and swallow was consulted. Supervised feedings
were instituted. POD#7 Mini vac dressing was applied to left
thoracotomy leteral wound. Staples remain in place, to be
discontinued at wound clinic scheduled with Dr[**Last Name (STitle) 5305**] office
at 1 week following discharge to rehab [**2100-12-1**]. Postoperative
delerium continues to improve. On POD#8 Mr.[**Name14 (STitle) 96500**] continued to
progress and he was discharged to rehab. All follow up
appointments were advised.
Medications on Admission:
ASA 81 mg daily
Calcium plus D 600 mg TID
digoxin 0.25 mg daily
folic acid 400 mcg daily
iron 325 mg daily
lasix 40 mg daily
levofloxacin
lithobid 600 mg HS
lopressor 25 mg [**Hospital1 **]
MVI daily
NTG prn
warfarin 5 mg daily (LD [**11-4**])
vit. C 500 mg daily
Vit. E 200 units daily
Vancomycin ( started at admission)
Discharge Medications:
1. Aspirin 81 mg [**Month/Year (2) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Month/Year (2) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Calcium Carbonate 500 mg [**Month/Year (2) 8426**], Chewable Sig: One (1)
[**Month/Year (2) 8426**], Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit [**Month/Year (2) 8426**] Sig: One (1)
[**Month/Year (2) 8426**] PO DAILY (Daily).
5. Folic Acid 1 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) [**Month/Year (2) 8426**] Sig: One (1)
[**Month/Year (2) 8426**] PO DAILY (Daily).
7. Ascorbic Acid 500 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2
times a day).
8. Multivitamin [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY (Daily).
9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Lithium Carbonate 300 mg [**Month/Year (2) 8426**] Sustained Release Sig: Two
(2) [**Month/Year (2) 8426**] Sustained Release PO QHS (once a day (at bedtime)).
11. Tramadol 50 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO Q6H (every 6
hours) as needed.
12. Simvastatin 10 mg [**Month/Year (2) 8426**] Sig: Two (2) [**Month/Year (2) 8426**] PO DAILY
(Daily).
13. Furosemide 40 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY
(Daily).
14. Ranitidine HCl 150 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID
(2 times a day).
16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
17. Warfarin 1 mg [**Month/Year (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 8426**] PO Once Daily
at 4 PM.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Bisacodyl 5 mg [**Last Name (Titles) 8426**], Delayed Release (E.C.) Sig: Two (2)
[**Last Name (Titles) 8426**], Delayed Release (E.C.) PO BID (2 times a day) as needed.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
21. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
22. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 7 days.
23. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
pacer lead site infection
s/p left thoracotomy/removal of pacer leads
hypertension
myocarditis/cardiomyopathy
congestive heart failure/EF 40-45%
A fib/flutter
hepatitis C
bil. renal cysts
coronary artery disease s/p LAD and OM stents
left chest wall hematoma [**2091**]
removal of chest wall foreign body/pacer generator change [**12-22**]
prior pacer [**2053**] ( removed)/subsequent 16 generator changes
bipolar disorder
erectile dysfunction
hyperlipidemia
[**Last Name (un) **]. arthritis of spine
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
call for fever greater than 100.5, redness or drainage
no driving for at least 2-3 weeks AND until off all narcotics
shower daily and pat incision dry
no lotions, creams or powders on any incision
Followup Instructions:
see Dr. [**Last Name (STitle) 96502**] in [**12-16**] weeks
see Dr. [**Last Name (STitle) 1911**] in [**1-17**] weeks
see Dr. [**Last Name (STitle) 914**] at Clinic for wound check/staple removal on
[**2100-12-1**] at 1:30pm.#[**Telephone/Fax (1) 170**]
Completed by:[**2100-11-23**]
|
[
"4280",
"42731",
"41401",
"40390",
"5859",
"2859",
"2724",
"53081",
"V5861",
"V4582"
] |
Admission Date: [**2115-2-25**] Discharge Date: [**2115-3-3**]
Date of Birth: [**2069-12-2**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Latex
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
transferred for further managment of probable hepatorenal
syndrome
Major Surgical or Invasive Procedure:
nasogastric tube placed
History of Present Illness:
This is a 46 year old female with a past medical history of
pancreatitis and alcoholic liver disease who presented to [**Location (un) 21541**] Hospital on [**2115-2-18**] with a complaint of abdominal pain. The
patient reports that her pain had gradually been getting worse
over the three weeks prior to her presentation. It is described
as a diffuse ache, worse on the right side of the abdomen. No
change with eating, no associated sxs.
At the time of her admission, the pt was found to have acute
hepatitis and was thought to be mildly encephalopathic. Her ALT
was 25, AST 189, AP 233 and ammonia 134. Her INR was 2.0 and
remained roughly stable throughout her stay. The leading
diagnostic consideration was alcoholic hepatitis; the patient
denied APAP consumption and there was little evidence to support
another etiology (though it is unclear whether she has had an
infectious work-up). She was treated with lactulose. She was
also found to have an elevated WBC count of 20; it does not
appear that she was febrile at that time. She was treated
intermittently with Levaquin and vancomycin for a suspected skin
infection on her back; her WBC count fell to 13.7 and her skin
improved.
The pt was also found to be in renal failure, with an initial
SCr of 3, which then rose. The renal service was consulted; ddx
was felt to include a pre-renal, ATN or HRS. The pt was treated
aggressively with fluids and followed over several days without
any significant improvement, making HRS appear more likely to
the physicians there. She was thus started on midodrine,
octerotide and albumin.
On the day before transfer, three days since last CBC, her WBC
was re-checked and found to have risen to 22.7. The patient was
also noted to have low-grade temps. A CXR and repeat urine cx
were performed. The CXR was read as showing bilateral pneumonia,
although the feeling of the transferring physician was that this
was inconsistent with the patient's clinical picture. Cefepime
was started.
Of note, the patient had undergone paracentesis twice in the OSH
ED prior to her presentation on this admission. Two weeks prior
to the outside admission she had a 6L para without albumin. By
report, her SCr was at her baseline, 0.6, as recently as
[**2115-2-1**].
On ROS, the patient admits she had noted her eyes were yellow
several weeks ago. She denies any fevers or chills. No nausea or
vomiting; some abd pain as outlined above. Minimal,
non-productive cough. No loose, dark or red stools. No urinary
sxs. No MSK or neuro complaints.
Past Medical History:
pancreatitis in [**2108**]
EtOH abuse; reportedly has not beeing drinking since [**12-24**]
anxiety
depression
known ascities x 5 months
HPV
anorexia/bulemia
s/p c-section
Social History:
The patient smokes [**1-18**] ppd. She recently worked as a bartender
but is not doing this currently. She was drinking heavily, as
recently as 2 months ago. She has since cut back significantly,
but was drinking intermittently up to her OSH admission.
Family History:
One uncle with HTN and renal disease on HD. Otherwise NC.
Physical Exam:
VS: 97.8 81 20 94/52 98% RA
GEN: Middle-aged female in NAD. Awake, but fatigued. Oriented
x3.
HEENT: EOMI, PERRL, positive conjunctivael icterus, OP moist and
without lesion
NECK: Supple, no JVD.
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, mildly distended. TTP over the RUQ, but no R/G. Mild
hepatomegaly, liver span ~14 cm.
EXT: No C/C. Mild edema.
NEURO: A&O but with some lapses in attention. + asterixis. CN
[**2-28**] intact. Motor strength intact in all extremities. Sensation
intact grossly.
SKIN: Jaundiced. Several small, healing lessions across upper
back, largest 8mm in diameter.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2115-2-25**] 10:01PM BLOOD WBC-17.2* RBC-2.31* Hgb-8.8* Hct-25.2*
MCV-109* MCH-38.1* MCHC-34.9 RDW-13.8 Plt Ct-300
[**2115-2-25**] 10:01PM BLOOD Neuts-83.9* Lymphs-9.0* Monos-5.2 Eos-1.7
Baso-0.2
COAGS:
[**2115-2-25**] 10:01PM BLOOD PT-23.9* PTT-50.1* INR(PT)-2.3*
CHEMISTRIES:
[**2115-2-25**] 10:01PM BLOOD Glucose-106* UreaN-45* Creat-3.8* Na-140
K-3.4 Cl-113* HCO3-12* AnGap-18
LIVER ENZYMES:
[**2115-2-25**] 10:01PM BLOOD ALT-24 AST-97* LD(LDH)-253* AlkPhos-160*
TotBili-28.8*
---------
IMAGING STUDIES:
CXR [**2115-2-25**]: IMPRESSION: Bilateral diffuse reticular nodular
opacity consistent with pneumonia.
ABD U/S [**2115-2-26**]: IMPRESSION:
1. Cirrhotic liver, marked hepatomegaly, and severe portal
hypertension.
Bidirectional portal venous flow directed into the patent
umbilical vein.
2. Moderate ascites. Due to marked hepatomegaly, the presence of
an ostomy
in the right lower quadrant, and the distribution of peritoneal
fluid, a safe
spot for bedside paracentesis was not identified.
Ultrasound-guided
paracentesis can be performed.
3. Normal kidneys without hydronephrosis.
4. Small gallstones without acute cholecystitis.
Brief Hospital Course:
This was a 45 year old female with known alcoholic liver disease
transferred from OSH and determined to have acute on chronic
alcoholic liver disease, as well as, hepatorenal syndrome and
pneumonia.
# Acute on chronic alcoholic hepatitis: Patient was not a
candidate for transplant given her last reported alcohol was in
[**12-24**]. She was treated with intravenous steroids up until she
developed respiratory distress and was made CMO by her family in
the ICU. Patient's acute hepatitis was further complicated by
her hepatorenal syndrome and likely pneumonia.
# Respiratory Distress: Patient was transferred from the liver
floor to the MICU when she was found to be in respiratory
distress. Prior to developing respiratory distress patient was
already severely encephalopathic. ABG demonstrated worsening
acute metabolic acidosis. Diuresis was attempted in given
suspicion for pulmonary edema without good effect. MICU team
discussed patient's poor prognosis with family who agreed it was
best to make her comfort measures only.
# Hepatorenal Syndrome: Acute renal failure consistent with HRS.
Patient was treated with albumin, mitodrine and octreotide.
Treatment was stopped when patient made CMO.
# Encephalopathy: Patient's encephalopathy worsened quickly from
time of admission to hospital day 2. Encephalopathy worsened by
the fact that she refused both oral and PR lactulose and would
not tolerate an NG tube.
# Pneumonia: Patient found to have a bilateral pneumonia. White
blood cell count 17.2 on admission. She was treated with
Meropenem which was stopped when she was made CMO.
After being made CMO the patient was transferred to the liver
service. She remained on a morphine drip titrated to comfort.
The patient passed away on [**2115-3-3**] from respiratory failure as
an immediate cause of death and acute on chronic alcoholic
hepatitis as her primary cause of death. Patient's family was at
bedside when she passed.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Midodrine 10 mg PO TID
Octreotide Acetate 100 mcg SC Q8H
Albumin 25% (12.5g / 50mL) 62.5 g IV DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Rifaximin 400 mg PO TID
Lactulose 30 mL PO QID
MethylPREDNISolone Sodium Succ 40 mg IV Q24H
Sodium Bicarbonate 1300 mg PO BID
Meropenem 500 mg IV Q12H *Awaiting ID Approval*
sevelamer HYDROCHLORIDE 800 mg PO TID W/MEALS
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Acute on Chronic Alcoholic Hepatitis, Hepatorenal
Syndrome, Respiratory Arrest
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2115-3-4**]
|
[
"486",
"51881",
"2762",
"311"
] |
Admission Date: [**2198-1-9**] Discharge Date: [**2198-1-13**]
Date of Birth: [**2127-1-20**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This gentleman was admitted to
the Cardiology Service for cardiac catheterization
preparation for aortic valve replacement which was scheduled
for [**1-10**]. This gentleman had a past medical history
of aortic stenosis which he had a diagnosis for three years
prior. His most recent echocardiogram on [**2197-7-18**] showed
mild left ventricular hypertrophy with an ejection fraction
of 55%, mild left atrial enlargement, and critical aortic
stenosis with a mean gradient of 87 mmHg, a peak of 136 mmHg,
and a calculated valve area of 0.4 cm2. In addition, it also
showed 1+ aortic insufficiency and 1+ mitral regurgitation.
The patient had refused surgery in the past and finally
agreed to have treatment. He denied any history of chest
pain, shortness of breath, palpitations, dizziness or
lightheadedness. His height is 5 feet 10 inches, weight of
170 pounds.
PAST MEDICAL HISTORY: Past medical history also includes
hypertension, hypercholesterolemia, and a current smoking
history of three to four cigarettes per day.
MEDICATIONS ON ADMISSION: At the time of admission for his
catheterization he was on aspirin 325 mg p.o. q.d.,
atenolol 50 mg p.o. q.d., and amiloride 5/50 mg p.o. q.d.
ALLERGIES: He had no known drug allergies.
LABORATORY DATA ON PRESENTATION: His laboratories from
[**12-27**] showed a white blood cell count of 7.1,
hematocrit 43, platelet count of 164,000. Sodium 141,
potassium 3.9, chloride 102, bicarbonate 28, blood urea
nitrogen 19, creatinine 1.2, with a blood sugar of 115.
HOSPITAL COURSE: On [**1-9**] he had his cardiac
catheterization which showed an aortic valve area of 0.7 cm2
and a gradient of 68 mmHg. His left main was normal. His
left anterior descending artery was normal. His first
diagonal had 20% proximal lesion. His circumflex, obtuse
marginal, and ramus intermedius were okay, and his dominant
right coronary artery was also okay. He had a normal
ejection fraction, and the plan was to have his aortic valve
replacement.
In the morning, he was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] who saw him
in no apparent distress. His lungs were clear bilaterally.
His heart was regular in rate and rhythm. His extremities
had no cyanosis, clubbing or edema, and he consented him for
surgery on [**1-9**].
On [**1-10**], he underwent aortic valve replacement by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with 21-mm pericardial valve. He was
transferred to the Cardiothoracic Intensive Care Unit in
stable condition on a Neo-Synephrine drip and a propofol
drip. He was also seen by Case Management on [**1-10**];
and on postoperative day one, he was seen by Physical
Therapy. He was extubated and stable overnight from his
operation with a temperature maximum of 100.8. His blood
pressure was 123/48, and he was satting 96% on 4 liters. His
white count was 10.5, with a hematocrit of 20.2, and a
platelet count of 82,000. His blood urea nitrogen was 16
with a creatinine of 0.8. He was awake and alert. His
sternum was stable. His lungs were clear bilaterally. His
chest tubes were in place, and his extremities were warm.
His belly was soft and nontender. He was started with some
Lasix diuresis and transfused 2 units of packed red blood
cells for his hematocrit. His calcium and potassium were
repleted as necessary, and his Neo-Synephrine was weaned
down, and on the first postoperative morning, he was at
0.75 mcg/kg per minute.
On postoperative day two, his potassium had been repleted.
His temperature maximum was 100.1. He was hemodynamically
stable with a heart rate of 70, and blood pressure of 146/66.
He was satting 98% on 2 liters. He was up in the cardiac
chair and was comfortable. His heart was regular in rate and
rhythm. His lungs were clear bilaterally. His sternum had
no drainage. He had no edema. His Foley and wires remained
in place. He had some serosanguineous drainage but no air
leak from his chest tubes. He was started on an ACE
inhibitor. His Foley was discontinued, and he continued with
Physical Therapy. He was also seen by Case Management.
On [**1-13**], the patient did a level V and wanted to be
discharged. His pacing wires were discontinued. His chest
tubes had been discontinued the day prior. He was instructed
to have followup with Cardiology in 7 to 10 days and to
follow up with Cardiothoracic Surgery in 30 days, and to have
some [**First Name (Titles) 407**] [**Last Name (Titles) **] checks which would be
scheduled for the following Monday, as well as a
cardiopulmonary assessment.
On the day of discharge, his lungs were clear bilaterally.
His heart was regular in rate and rhythm. He did have a
small sternal click, but no murmur. He had no peripheral
edema and had a relatively uncomplicated postoperative
cardiac course.
MEDICATIONS ON DISCHARGE: (Discharge medications were as
follows)
1. K-Dur 20 mEq p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Percocet one to two tablets p.o. q.4-6h. p.r.n.
5. Protonix 40 mg p.o. q.d.
6. Oxazepam 15 mg p.o. q.h.s. as needed.
7. Aspirin 325 mg p.o. q.d. \
8. Lopressor 12.5 mg p.o. b.i.d.
9. Captopril 6.25 mg p.o. t.i.d.
DISCHARGE FOLLOWUP: Again, he was given follow-up
instructions to see Dr. [**Last Name (STitle) 70**] as well as his cardiologist
and would be followed by the [**First Name (Titles) 407**]
[**Last Name (Titles) 26476**].
DISCHARGE STATUS: Was discharged to home on [**2198-1-13**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2198-3-20**] 09:33
T: [**2198-3-22**] 12:17
JOB#: [**Job Number 36971**]
|
[
"4241",
"4019",
"2720",
"3051"
] |
Admission Date: [**2133-10-3**] Discharge Date: [**2133-12-2**]
Date of Birth: [**2068-1-29**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male admitted to [**Hospital6 256**] on
[**10-3**] from [**Hospital3 4419**] with shortness of
breath. The patient apparently had vomited while eating at
the rehabilitation center and was felt to have an aspiration
Levofloxacin and Clindamycin with a white blood cell count of
16.9 on admission. The patient was also noted to have ST
depressions laterally and subsequently ruled in for a
non-Q-wave myocardial infarction.
The patient was initially managed medically and given concern
for infection (aspiration pneumonia). On [**10-12**], the
have sustained another non-Q-wave myocardial infarction. The
patient was intubated. An intra-aortic balloon pump was
placed, and the patient was transferred to the CCU.
The patient has known coronary artery disease (three-vessel
disease) and underwent a two-vessel coronary artery bypass
grafting on [**2133-10-13**]. The patient was extubated on
[**2133-10-15**]. The patient was treated with Levofloxacin
and Vancomycin for ten days given the history of aspiration
pneumonia and MRSA positive sputum. The patient had
bilateral pleural effusions postoperative and had chest tubes
placed bilaterally. The pleural fluid was not evaluated.
CT Surgery course was notable for postoperative atrial
fibrillation on postoperative day #10 and treated with
Amiodarone. PEG was placed by IR on [**10-23**]. The patient
was felt to be volume overloaded postoperatively and was
treated with Lasix 80 mg IV b.i.d. and Diuril 250 mg IV
b.i.d.
The patient responded well to this regimen. The patient
later suffered right lung collapse when the chest tube was
placed water seal. The lung did not reexpand when chest tube
was placed to suction. The patient had the right chest tube,
and a second was placed with reexpansion of right lung. The
patient then underwent bronchoscopy on [**11-3**] which
revealed copious secretions. No mass or mucous plug was
visualized.
On [**11-4**], the patient was transferred to the SICU
Service. The patient was noted to have elevation in BUN and
creatinine (95/2.5). FENA was less than 1, and urine osmosis
was elevated. The patient was felt to have prerenal
azotemia. The patient received intravenous fluids, and
diuretics were held until [**11-12**]. The patient gradually
became more tachypneic with increasing oxygen requirement
initially on approximately 70% FIO2 shovel mask with
respiration rate in the 30s. Over the next few days, the
patient had been placed on BIPAP with improvement on
oxygenation and has also been on 100% non-rebreather.
On [**11-7**], the patient had underwent a right Doxycycline
pleurodesis with no repeated lung collapse. On [**11-8**],
the sputum grew Staphylococcus aureus, and the patient was
restarted on Vancomycin. On [**2133-11-12**], the patient
was transferred to the MICU Service from the SICU Service for
further management of his respiratory distress.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery
disease with OM stent in [**2127**] and a two-vessel coronary
artery bypass grafting on [**10-13**]. 3. Insulin-dependent
diabetes mellitus. 4. Prostate cancer. 5. Chronic renal
insufficiency. 6. Multiple lacunar infarcts. 7.
Hypercholesterolemia. 8. Gait disorder. 9. Right-sided
weakness.
MEDICATIONS ON TRANSFER: Vancomycin, NPH Insulin 12 U subcue
b.i.d., regular Insulin sliding scale, Epogen 10,000 U subcue
q.Wednesday, ASA 81 mg q.d., Zoloft 25 mg q.d., Lipitor 20 mg
q.h.s., Lopressor 50 mg t.i.d., Amiodarone 400 mg q.d.,
Hydralazine 25 mg q.6, Clonidine patch 0.2 mg, free water
bolus at 250 cc b.i.d., Zantac 150 mg q.d., Iron Sulfate 325
mg t.i.d., Zinc 220 mg q.d., Vitamin C 500 mg q.d.,
........... 10 drops b.i.d., Nepro 35 cc/hr, ProMod 35 cc/hr.
SOCIAL HISTORY: The patient is married. He smoked one pack
per day times 30 years and quit ten years ago. His primary
care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) 3510**].
PHYSICAL EXAMINATION: Vital signs: On admission to the MICU
temperature was 97.5?????? with a T-max of 98.6??????, blood pressure
118/43 to 140/53, heart rate 60-70, respirations 30, 100%
oxygen non-rebreather, oxygen saturation 95%, 24-hour I&Os at
4380 in, 1300 out. HEENT: Pupils 2 mm constricted to light.
Sclera anicteric. Neck: Supple. No lymphadenopathy. JVP
9-10 cm (5 cm above the sternal notch). Chest: Diffuse
rhonchi. No crackles or wheezing. Sternum healing well.
Cardiovascular: Regular, rate and rhythm. Normal S1 and S2.
No murmurs, rubs or gallops. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: Warm.
Pedal edema 1+. Skin breakdown over the right shin. Sacral
ulcer, healing. Neurological: Opens eyes to verbal stimuli.
Not communicative.
LABORATORY DATA: Electrocardiogram showed normal sinus
rhythm at 70 beats per minute with normal axis, normal
intervals, and T-wave inversions in V5 and V6 with a Q-wave
in leads III. Chest x-ray showed congestive heart failure
with left lower lobe collapse and pleural effusions
bilaterally. Echocardiogram on [**10-23**] showed a left
atrium of 4.1 cm and an ejection fraction of 45-55%.
WBC was 16.5, hemoglobin 8.1, hematocrit 24.8, platelet count
240; sodium 141, potassium 5.9, chloride 112, bicarb 22, BUN
103, creatinine 2.7, glucose 113, phosphate 24, magnesium
2.4; arterial blood gases on 100% non-rebreather showed a
7.35/37/70; sputum on [**11-7**] and 25 showed MRSA
positive.
HOSPITAL COURSE: The patient is a 65-year-old man with a
complicated hospital course. The patient was admitted with
likely aspiration pneumonia, non-Q-wave myocardial infarction
and underwent coronary artery bypass grafting and initially
did well. The patient was diuresed regular, but over the
last few days before admission to the MICU, had an elevation
in BUN and creatinine. The patient was felt to be volume
depleted and was treated with intravenous fluids and
withholding diuretics.
The patient then gradually had a worsened respiratory status
with increasing oxygen requirement and decreased
responsiveness. Chest x-ray had revealed the vascular
congestion which supported fluid overload. The patient also
had copious secretions on bronchoscopy on [**11-7**] with a
history of recurrent aspiration, left lower lobe collapse and
consolidation, as well as elevated WBC which supported
possible incompletely treated aspiration pneumonia. Physical
exam at the time of MICU admission was not impressive for
overload. JVP was not elevated. There was no peripheral
edema, and chest exam was not impressive for wet crackles.
The patient's respiratory decline was gradually progressive
and not acute.
While in the MICU, the patient was placed on BIPAP. The
patient had poor tidal volumes and increased respiration rate
and had continued copious secretions. The patient was
eventually intubated on [**11-13**]. The patient then had a
bronchoscopy which removed a significant amount of
secretions, as well as revealed white plaques in the trachea
which was deemed to be likely candidal infection. The
patient was then started on Fluconazole and completed a 7-day
course.
He also completed an 8-day course of Flagyl, as well as
Ceftriaxone for presumed aspiration pneumonia. In addition,
he completed a 14-day course of Vancomycin for MRSA positive
sputum.
From a cardiovascular standpoint, the patient has coronary
artery disease status post two-vessel coronary artery bypass
grafting during this admission. The patient while in the
hospital was continued on Aspirin, Lopressor, and loaded on
Amiodarone given postoperative atrial fibrillation.
On [**11-16**] a chest CT was obtained which revealed
bilateral loculations, left greater than right, with collapse
of left lung and bilateral pleural effusions, as well as a
left upper lobe consolidation and fluid in the anterior
pericardium with some air extending up into the mediastinum.
A left thoracentesis was performed, and pleural fluid labs
were only significant for transudative fluid. Cultures from
the pleural fluid were negative. A right thoracentesis was
deferred due to difficulty to access the loculated area in
the right apex of the lung. CT Surgery decided to hold off
on any surgical intervention of the pleural fluid, effusions
and loculations.
On [**11-23**], a Swan was placed to help determine fluid
status and cardiac output. The patient was found to have
normal cardiac output, cardiac index, stroke volume, as well
as SVR. It was determined that the patient was not
intravascular dry, and the etiology of his elevated BUN, and
creatinine was unclear until an MRA of his kidneys were
obtained which revealed bilateral renal artery stenosis.
The MRA which was done on [**11-28**] showed high-grade
stenosis of the right renal artery and moderate stenosis of
the left renal artery, as well as sclerosis of the aorta and
iliacs.
The Renal Team was consulted, and the best option was for
intervention by stenting across the ostial lesions of both
the right and left renal artery. The stenting procedure will
be deferred until infection is completely ruled out.
On [**11-27**], a tracheostomy was placed. During the
hospital stay, the patient has been oxygenating and
ventilating well on pressure support; however, the patient
has continued to have thick tan secretions requiring
suctioning approximately every three hours. This suggested a
continuing pulmonary infection, most likely due to a
bronchitis; however, the patient has been afebrile, and the
white count has been stable from [**10-16**] to 15. All
antibiotics were discontinued on [**11-24**].
The patient's long vent dependence has been attributed to
deconditioning, as well as respiratory muscle weakness, as
well as likely temporary diaphragmatic dysfunction due to
status post coronary artery bypass grafting and phrenic nerve
involvement. The patient was screened for pulmonary
rehabilitation facilities and was accepted to [**Hospital3 33538**].
From a gastrointestinal standpoint, the patient's hematocrit
has slowly declined during the hospital stay and has required
approximately 1 U every three days. The work-up had been
deferred until the patient was deemed more stable. The
patient has a history of colon polyps, and likely the
decrease in hematocrit is due to a lower GI bleed not likely
to be acute. GI was consulted, and EGD will be performed
prior to the patient's discharge. The remainder of his GI
work-up will be done after transfer. The patient's
hematocrit has been maintained equal to or greater than 30
given his history of coronary artery disease.
While in the hospital, the patient was maintained on tube
feeds which eventually reached goal at 25 cc/hr with Impact
with Fiber. One other electrolyte issue with the patient was
that he has been hypernatremic which has since then resolved
after D5W intravenous fluids, as well as free water boluses
p.r.n.
The patient has had a sacral ulcer which has been followed by
Skin Care, as well as Plastic Surgery. The ulcer has been
treated with wet-to-dry bandages and has been healing well.
As per Plastic Surgery, debridement was not deemed necessary
at this time.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post two-vessel coronary
artery bypass grafting.
2. Pneumonia/bronchitis.
3. Bilateral renal artery stenosis.
4. Likely lower gastrointestinal bleed.
5. Hypertension.
6. Insulin-dependent diabetes mellitus.
7. Chronic renal insufficiency.
8. Hypercholesterolemia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2133-12-1**] 15:49
T: [**2133-12-1**] 15:47
JOB#: [**Job Number **]
|
[
"5070",
"41071",
"41401",
"42731",
"5119",
"4280",
"5180"
] |
Admission Date: [**2136-4-26**] Discharge Date: [**2136-5-2**]
Date of Birth: [**2064-11-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
Cardiac Cathterization [**2136-4-26**]
CABGx3(LIMA->LAD, SVG->OM, PDA) [**2136-4-27**]
History of Present Illness:
71 year-old man, patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21127**], Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **],
with a recent MI and prior RCA PTCA referred for cardiac
catheterization.
Mr. [**Known lastname **] was vacationing in [**Location (un) 22931**] this past [**Month (only) 116**],
when
he developed acute chest pain while at rest. He went to a local
ER where he was found to be having an acute inferior MI. He was
treated with TNK and subsequently developed (new) rapid afib.
He
was rate controlled with beta blockers and spontaneously
converted back to NSR. His peak CK was 1877 with an MB of 300.
A
post MI stress test was done on [**2136-4-16**]. He exercised 12 minutes
38 seconds of a modified [**Doctor First Name **] protocol, 95% PHR. He had no
chest
pain or SOB. No EKG changes.
Since his recent MI he has been feeling well without any
complaints of chest discomfort or shortness of breath.
Past Medical History:
Hyperlipidemia
Hypertension
Diabetes Mellitus
Past Myocardial Infarction
S/P Left carotid endarterectomy
Diverticulosis
Social History:
Patient is married with one daughter. [**Name (NI) **] is a retired college
music professor. His wife is a physician.
Family History:
One brother had an MI at age 54. Father with some heart disease,
dying at age 70. Another brother died from heart disease at age
79.
Physical Exam:
Ht: 69" Wt: 179 lbs
BP: 132/48 HR 78
GEN: well developed, well nourished in no acute distress
HEART: RRR, normal S1-S2, no murmur
LUNGS: CLear
ABD: Soft, nontender, nondistended, normal active bowel sounds
EXT: No edema, 2+ pulses, no varicosities.
Pertinent Results:
[**2136-4-26**] 12:40PM GLUCOSE-141* UREA N-19 CREAT-0.7 SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2136-4-26**] 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2136-4-26**] 02:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2136-4-26**] 12:40PM WBC-3.8* RBC-4.07* HGB-13.5* HCT-39.1* MCV-96
MCH-33.1* MCHC-34.4 RDW-12.4
[**2136-5-1**] 06:05AM BLOOD WBC-9.5 RBC-2.94* Hgb-9.5* Hct-27.1*
MCV-92 MCH-32.5* MCHC-35.2* RDW-12.6 Plt Ct-205
[**2136-5-2**] 06:20AM BLOOD Glucose-160* UreaN-23* Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-28 AnGap-15
[**2136-5-1**] 06:05AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.4
[**2136-4-26**] CXR
No acute cardiopulmonary abnormality
[**2136-4-29**] CXR
The patient is status post CABG and median sternotomy. The
patient has been extubated, and the Swan-Ganz catheter has been
removed. The right jugular Cordis sheath is terminating in the
superior vena cava. The left chest tube and mediastinal drain
remain in place. There is a tiny left apical pneumothorax (5%).
There is continued cardiomegaly without evidence of congestive
heart failure. Patchy atelectasis is seen in the left lung base.
[**2136-4-26**] Cardiac Catheterization
1. Selective coronary angiography revealed a right dominant
system
with three vessel coronary artery disease. The LMCA had 70%
ostial and
60% distal lesions. The LAD had a 70% proximal eccentric
stenosis that
becomes intramyocardial. The LCX had no angiographically
apparent flow
limiting stenoses. The RCA had 80% ostial and proximal disease
with a
dissection cap and moderate mid vessel disease.
2. Limited resting hemodynamics demonstrated moderately elevated
left
sided pressures (LVEDP 20 mmHg) with no gradient upon movement
of the
catheter from the ventricle back to the aorta.
3. Left ventriculography showed inferior akinesis (EF 45%) with
moderate mitral regurgitation
[**2136-4-26**] ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function appears mildly
depressed. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**11-20**]+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
[**2136-4-26**] Carotid Ultrasound
Findings as stated above which indicate 40% to 59% right ICA
stenosis, no significant left ICA stenosis.
[**2136-5-1**] EKG
Sinus rhythm
Left bundle branch block
The inferolateral ST-T wave changes may be in part primary and
Cannot exclude in part ischemia
Since previous tracing of [**2136-4-28**], no significant change
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2136-4-26**] for a cardiac catheterization. This revealed a
70% stenosed left main coronary artery, a 70% stenosed left
anterior descending artery, an 80% stenosed right coronary
artery and a mildly reduced ejection fraction of 45%. Due to the
severity of his disease, the cardiac surgical service was
consulted and Mr. [**Known lastname **] was worked-up in the usual
preoperative manner including a carotid ultrasound which showed
a 40% to 59% right internal carotid artery stenosis an no
significant left internal carotid artery stenosis. An
echocardiogram was performed that showed an ejection fraction of
40-45%, [**11-20**]+ mitral regurgitation and trivial tricuspid
regurgitation. On [**2136-4-27**], Mr. [**Known lastname **] was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively, he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. He was then transferred to the cardiac
surgical step down unit for further recovery. He was gently
diuresed towards his preoperative weight. Beta blockade was
titrated for optimal heart rate and blood pressure control. His
chest drains and epicardial pacing wires were removed per
protocol. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Mr.
[**Known lastname **] had some paroxysmal atrial fibrillation for which his
beta blockade was increased. Mr. [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
five. He will follow-up with Dr. [**Last Name (STitle) 70**], his cardiologist and
his primary care physician as an outpatient.
Medications on Admission:
Zebeta 2.5mg every morning
Plendil 10mg twice a day
Folic acid 1mg twice a day
Diovan 80mg once daily
Aspirin 325mg daily
Metformin 500mg, two tablets twice a day (held as of [**2136-4-25**])
Actos 45mg every morning
Prandin 1mg twice a day
Lipitor 10mg every evening
NTP 0.4mg/hour during the day
Vitamin Supplements
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO daily ().
Disp:*15 Tablet(s)* Refills:*2*
10. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Repaglinide 1 mg Tablet Sig: One (1) Tablet PO BIDWM (2
times a day (with meals)).
Disp:*60 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
CAD
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Do not use creams, lotions, or powders on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Completed by:[**2136-5-3**]
|
[
"41401",
"4240",
"4019",
"2724",
"25000"
] |
Admission Date: [**2187-9-19**] Discharge Date: [**2187-9-20**]
Date of Birth: [**2123-6-13**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
tongue swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 64 YOM with a PMH of hypertension who presented
to the ED with tongue swelling and muffled voice which began 45
minutes after he woke up. He is not having difficulty manageing
his secretions though he has increased saliva. This similar
presentation happened once before and no cause was ever found
for the angioedema (went to [**Doctor Last Name **] in [**Location (un) 3844**]). The
patientis not on an ace inhibitor and he denies taking any new
medications. His only medications are terazosin (been on this
for 6 months), baby aspirin (years), and fish oil. He has eaten
no new foods and has no family history of swelling. Denies
insect bites. Has no pets. Works in construction.
In the ED, VS were: 97.6 102 196/135 18 96%. Exam was notable
for an "impressively swollen" tongue. Labs showed WBC 5.1 (4.2%
Eos), otherwise chem 7 WNL. He was given 125 mg solumedrol, 20
mg famotidine, 50 mg benadryl, and Zofran for nausea. He was
admitted to the ICU for observation for possible intubation.
Vital signs prior to transfer were: HR 80 151/95 97% on RA.
On the floor, pt appeared comfortable and was breathing
normally. Voice was muffled, but no stridor. He denied
complaint and ROS was negative for fever, chills, headache,
sinus tenderness, rhinorrhea or congestion, cough, shortness of
breath, wheezing, chest pain, chest pressure, palpitations,
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits, dysuria, frequency, or urgency. Denies
rashes or skin changes.
Past Medical History:
Hypertension
fractured right ankle and ribs during construction accident (no
surgeries)
Social History:
Married to [**First Name4 (NamePattern1) **] [**Known lastname **], has 3 children. Lives in [**Location **].
Works in construction. Drinks 2 glasses wine a night, denies
tobacco or other drug use.
Family History:
No history of angioedema
Physical Exam:
Admission Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, tongue enlarged more on the left
side than right, submandibular swelling, mild parotid fullness,
no drooling, no lip swelling, no stridor
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
.
Discharge Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, no appreciable tongue swelling
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Admission Labs:
[**2187-9-19**] 06:40AM BLOOD WBC-5.1 RBC-4.74 Hgb-15.5 Hct-43.6 MCV-92
MCH-32.6* MCHC-35.4* RDW-14.3 Plt Ct-146*
[**2187-9-19**] 06:40AM BLOOD Neuts-64.9 Lymphs-24.2 Monos-6.1 Eos-4.2*
Baso-0.6
[**2187-9-19**] 06:40AM BLOOD Glucose-133* UreaN-18 Creat-0.9 Na-138
K-5.6* Cl-102 HCO3-26 AnGap-16
.
Markers:
[**2187-9-19**] 08:58AM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-PND
.
CHEST (PA & LAT) Study Date of [**2187-9-19**]
IMPRESSION:
1. Nonvisualization of the subglottic airways. In a patient with
the clinical history of angioedema, this may represent
subglottic edema, but upper airway is better assessed by soft
tissue neck radiographs, cross-sectional imaging or direct
visualization.
2. Apparent widening of the mediastinum. In the absence of prior
radiographs for comparison, consider chest CT to differentiate
prominent mediastinal fat and vessels from lymph node
enlargement or mass.
3. Focal right lower lobe opacity which may represent aspiration
or early pneumonia.
4. Multiple healed and some subacute rib fractures involving the
lateral aspect of the mid thoracic right ribs.
.
CT chest [**2187-9-19**]:
1.Central airway till subsegmental level is patent. There is no
focal lung
lesion/consolidation.
2.Bilateral minimal dependent lung atelectasis.
3.Cholelithiasis without cholecystitis.
4.Multiple old rib fractures on right side.
.
CT neck [**2187-9-19**]
1. No obstructing lesion compressing the airway.
2. Abundant mediastinal lipomatosis likely accounts for the
radiographic
finding of "mediastinal widening."
3. No mass, lymphadenopathy, or other soft tissue abnormality.
.
Echo [**2187-9-20**]
The left atrium is mildly dilated. 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 ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. The pulmonic valve
leaflets are thickened. There is stenosis of the main pulmonary
artery. There is no pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
The right ventricular wall may be hypertrophied. There is
turbulent flow with an increased gradient of approximately 16mm
Hg seen through the pulmonary outflow tract - this is probably
because of a mild narrowing of the main pulmonary artery just
distal to the pulmonic valve.
.
Discharge labs:
[**2187-9-20**] 04:22AM BLOOD WBC-7.7# RBC-4.35* Hgb-14.4 Hct-41.2
MCV-95 MCH-33.0* MCHC-34.9 RDW-14.0 Plt Ct-152
[**2187-9-20**] 04:22AM BLOOD PT-12.4 PTT-21.4* INR(PT)-1.0
[**2187-9-20**] 04:22AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-142
K-4.1 Cl-105 HCO3-31 AnGap-10
[**2187-9-20**] 04:22AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 YOM with a history of hypertension, on
terazosin, who presented to the ED with his second episode of
tongue swelling. He was admitted to the ICU for observation in
case he needed intubation.
.
# Tongue swelling: Unclear etiology as pt not on ACEI or any
new medications. Differential diagnosis includes allergic
reaction to unknown environmental exposure (insects, food,
animal saliva- shellfish ingestion day prior to admission),
acquired C1 esterase deficiency (which usually occurs in this
age group), medications, or idiopathic angioedema. He has not
taken any medications usually implicated with this presentation
(NSAIDS, ACEI, CCB, estrogens), however terazosin is listed as a
<1% incidence of facial swelling. He does not have a peripheral
eosinophilia. C1 esterase level was sent, but pending at the
time of discharge. His terazosin was stopped and when taking PO
he was changed to a different PO BP medication (as below). He
was treated with a pulse of 40mg of steroids x5 days as well as
famotidine and benadryl. Upon discharge, he will need further
work-up with an allergist close to home investigate the cause of
his angioedema. He has been advised to avoid shellfish until
formal allergy testing is done.
.
# Mediastinal fullness: Concern for mass or other lesion of left
hilum on admission CXR. CT was done and did not should any mass
or enlarged lymph nodes, but a narrowing of the PA was noted.
This finding was confirmed with echo, but not found to be
hemodynamically significant.
.
# Hypertension: He was normotensive in the hospital with
occasional hypertensive readings. He was on terazosin, which was
held in setting of angioedema (see above). Started on HCTZ
12.5mg daily for hypertension. Pressures were in the 130s on the
day of discharge.
.
Full Code
Medications on Admission:
terazosin for HTN
81 mg Aspirin
fish oil
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Angioedema
.
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
.
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] because of tongue swelling. You were admitted to the ICU
for close monitoring in case you developed difficulty breathing.
.
Over the course of the day, the swelling improved, and you were
able to tolerate eating and drinking. We did not find a clear
reason for the swelling of your tongue. We strongly recommend
seeing an allergy specialist at home after your discharge. Until
you have allergy testing you should NOT eat clams, lobster, or
other shellfish. We changed your blood pressure medicine.
.
You had a small abnormaility on your chest xray, so we did a CT
scan and echocardiogram to evaluate. You have a narrowing of the
pulmonary artery which brings blood from the heart to the lungs.
This is not causing any issues, and there is nothing to do for
this problem. Please call you doctor if you develop leg
swelling, distention of your belly, or shortness of breath.
.
We made the following changes to your medications:
- STOP terazosin
- START Hydrochlorothiazide 12.5mg by mouth daily
- START prednisone 40mg for 3 more days.
.
Please follow-up with your PCP and an allergy specialist.
Followup Instructions:
Please follow-up with your primary care physician (Dr. [**Last Name (STitle) 410**],
[**Telephone/Fax (1) 91416**]) within 1 week and establish care with an allergy
specialist.
.
There is a test (called the C1-esterase inhibitor) pending at
the time of your discharge. Your PCP should follow up on this
result.
|
[
"2767",
"4019"
] |
Admission Date: [**2109-12-16**] Discharge Date: [**2109-12-28**]
Date of Birth: [**2057-3-3**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old male
with liver cirrhosis secondary to hepatitis C and alcohol
abuse. He presented to [**Hospital1 69**]
on [**2109-12-16**] for a living related liver transplant
from his son, [**Name (NI) 44475**] [**Name (NI) 44476**]. The complications and risks of
procedure were discussed in full with the patient prior to
the surgery.
PAST MEDICAL HISTORY:
1. Chronic hepatitis C cirrhosis.
2. Heavy alcohol use.
3. Herpes.
4. Status post tonsillectomy.
5. Status post thyroid cyst resection.
6. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Prevacid 30 mg p.o. b.i.d.
2. Famvir 25 mg p.o. b.i.d.
3. Aldactone 50 mg p.o. q.d.
4. Nadolol 20 mg p.o. q.d.
5. Glucosamine one tablet p.o. q.d.
6. Multivitamin.
7. Escitalopram 10 mg p.o. q.d.
8. Migraine medication prn.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.0, blood pressure
127/68, pulse 66, respiratory rate 16, and satting 97% on
room air. The patient is generally icteric in no acute
distress. There are numerous spider nevi present. Head,
eyes, ears, nose, and throat: Normocephalic, atraumatic.
External ocular movements intact. Neck is without
lymphadenopathy or thyromegaly. There is no JVD. Chest was
clear to auscultation. Heart sounds were regular, rate, and
rhythm. His abdomen was soft, nontender. There is no
hepatosplenomegaly appreciated. His extremities: Pulses
were 2+ bilaterally, no bruits were appreciated. There is no
clubbing, cyanosis, or edema noted.
LABORATORIES ON ADMISSION: WBC was 5.3, hematocrit 42.0,
platelets 75. INR was 1.7. PT was 16.2. Sodium was 138,
potassium 4.3, chloride 103, bicarb 30, BUN 6, creatinine
0.7, glucose 91. His AST is 91, ALT 58, alkaline phosphatase
127, total bilirubin is 3.6. Albumin was 3.0.
BRIEF SUMMARY OF HOSPITAL COURSE: Patient is a 52-year-old
gentleman with liver cirrhosis secondary to chronic hepatitis
C and long history of alcohol use, who presented to [**Hospital1 1444**] on [**2109-12-16**] for
living related liver transplant from his son.
The patient was preoped in the usual standard fashion.
Procedure went without any complications. The estimated
blood loss from the procedure was around 2200 cc. The
patient did receive a variety of intraoperative fluids
including blood products.
The patient was taken to the ICU for close monitoring
postoperatively. A postoperative day one Duplex ultrasound
of the liver revealed a patent artery and vein. He again
received variable blood products including red blood cells
for a hematocrit as low as 27.4 and six packs of platelets x3
for a platelet count of 85 as well as a FFP for an elevated
INR.
In the ICU, the patient was diuresed and weaned to
extubation. He was on a variety of antihypertensives. He
received a short course of perioperative Unasyn. In
addition, there was a short period of time where he was on an
insulin drip as well as a hydrogen chloride drip for a bicarb
of 36. These were eventually stopped. Patient was extubated
on postoperative day four.
Another Duplex ultrasound was repeated, which was normal.
Arterial and venous wave forms were normal. There was no
biliary ductal dilatation. The liver function tests
continued to trend downward.
On postoperative day five, the patient was transferred to the
floor. Around that period, the patient had a very brief
episode of some mild confusion. This eventually resolved.
For immunosuppressant medication, the patient received during
the hospital course a total of two doses of Simulect. He was
started on cyclosporin on postoperative day one. He
additionally was on a short Solu-Medrol taper and eventually
was placed on p.o. prednisone.
His diet was slowly advanced, which he has tolerated. A
postoperative T tube study was done on postoperative day 10,
which showed a size discrepancy, a question of a stenosis at
the common bile duct at the biliary anastomosis. It was
thought to continue with the T tube open to gravity. JP had
been discontinued at this point. A future ERCP will
eventually be discussed with the patient in clinic. It was
thought that the patient was stable for discharge on
postoperative day 12 with follow-up appointments with Dr.
[**Last Name (STitle) **] at the [**Hospital 1326**] Clinic.
CONDITION ON DISCHARGE: Home with VNA services.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Cyclosporin 350 mg p.o. b.i.d.
2. CellCept 1 gram p.o. b.i.d.
3. Prednisone 20 mg p.o. q.d.
4. Valcyte 450 mg p.o. b.i.d.
5. Fluconazole 400 mg p.o. q.d.
6. Bactrim DS one tablet p.o. q.d.
7. Alprazolam 0.5 mg p.o. q.h.s.
8. Citalopram 20 mg p.o. q.d.
9. Clonidine 0.3 mg p.o. b.i.d.
10. Hydralazine 25 mg p.o. t.i.d.
11. Insulin-sliding scale.
12. Pantoprazole 40 mg p.o. q.d.
13. Colace 100 mg p.o. b.i.d.
14. Silvadene 1% cream applied t.i.d. to the arm and abdomen
where the patient experienced some tape burns.
15. Percocet 1-2 tablets p.o. q.4-6h. prn pain.
DISCHARGE INSTRUCTIONS: Patient additionally is to have
triweekly laboratories which include CBC, Chem-10, coags
including PT, PTT, and INR, liver function tests, amylase,
lipase, albumin. He is additionally to have cyclosporin
levels drawn before the a.m. cyclosporin dose. Patient is to
have VNA services for laboratories, nursing, for wound care,
for T tube management and teaching, and to assist with
medications and compliance as well as insulin administration
and blood sugar checking.
FOLLOW-UP PLANS: Patient is to followup with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the Transplant Center, telephone number [**Telephone/Fax (1) 673**]
on [**1-4**] at 2 p.m. He additionally, is to followup
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2110-1-6**] at 12:40 p.m.
SERVICES: He is to be discharged with VNA services as
described.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 12276**]
Dictated By:[**Last Name (NamePattern1) 28937**]
MEDQUIST36
D: [**2109-12-27**] 20:57
T: [**2109-12-31**] 08:48
JOB#: [**Job Number 44477**]
|
[
"4019"
] |
Admission Date: [**2122-10-1**] Discharge Date: [**2122-10-6**]
Service: CCU
IDENTIFICATION/CHIEF COMPLAINT: The patient is a 78-year-old
male with a history of coronary artery disease and is status
post coronary artery bypass graft times two with a porcine
mitral valve replacement and congestive heart failure, with
an ejection fraction of less than 20%.
HISTORY OF PRESENT ILLNESS: The patient had been in his
usual state of health at home until two weeks prior to
admission. At that time, the patient began noticing
increased shortness of breath and dyspnea on exertion.
Typically, he was able to walk half a mile without any
problems. [**Name (NI) **] also states that he had a 3-pound weight gain
over that period of time. During the week prior to admission
the patient had his Lasix dose doubled to 40 mg once a day.
He had some laboratory work drawn on [**Hospital3 4298**] which
showed an increase of his creatinine to 3 from a baseline
of 2.3 to 2.5. The patient was subsequently seen in the
Congestive Heart Failure Clinic by Dr. [**Last Name (STitle) **] where he was
noted to be in worse condition compared to his previous
office visit in [**2122-7-26**]. The patient has also had
previous admissions for congestive heart failure requiring
milrinone to aid in his diuresis. His most recent admission
was in [**2122-3-26**].
PAST MEDICAL HISTORY:
1. Coronary artery disease; the patient is status post
coronary artery bypass graft in [**2102**] and a redo coronary
artery bypass graft in [**2121-3-26**]. The patient has also
undergone a cardiac catheterization and stenting of his vein
graft to his left anterior descending artery in [**2122-1-26**].
2. [**State 531**] Heart Association class III congestive heart
failure. The patient was found on echocardiogram to have an
ejection fraction of less than 20%.
3. Mitral valve replacement with a porcine mitral valve.
4. DDD pacemaker for complete heart block following his redo
coronary artery bypass graft.
5. Hypercholesterolemia.
6. History of atrial fibrillation, post redo coronary artery
bypass graft that was initially treated with Coumadin but
subsequently discontinued secondary to hemoptysis in [**2121-7-26**].
7. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION:
1. Amiodarone 100 mg p.o. q.d.
2. Carvedilol 3.125 mg p.o. b.i.d.
3. Losartan 25 mg p.o. q.d.
4. Digoxin 0.125 mg on Monday and Thursday.
5. Erythropoietin 10,000 units every week on Wednesday.
6. Lipitor 10 mg p.o. every Monday, Wednesday and Friday.
7. Lasix 40 mg p.o. q.d.
8. Prilosec 20 mg p.o. q.d.
9. Vitamin E.
10. Flonase.
ALLERGIES: PENICILLIN, DOXYCYCLINE.
SOCIAL HISTORY: The patient is a retired architect and
denies a smoking or alcohol history.
PHYSICAL EXAMINATION ON ADMISSION: The patient was in mild
respiratory distress. His temperature on admission was 97,
blood pressure 103/45, heart rate was 76 and regular, and a
respiratory rate of 20. On head and neck examination, the
patient's mucous membranes were moist, and his oropharynx was
clear. His pupils were equal and reactive to light. On
cardiovascular examination, the patient's jugular venous
pressure was noted to be at 14 cm above the sternal angle.
He had a normal S1 and S2, and he had an audible S3 and S4.
He also had a 2/6 systolic murmur at his left sternal border
radiating to his right second intercostal space and to his
apex. On respiratory examination, the patient had a few
scattered inspiratory crackles at the bases. His abdominal
examination showed him to have bowel sounds present with no
abdominal distention or pain on palpation. His liver was
palpable 4 cm below the costal margin. On musculoskeletal
examination, the patient was noted to have a slight amount of
edema in his ankles at 1+.
RADIOLOGY/IMAGING: The patient's electrocardiogram showed
him to be AV-paced at a rate of 70.
LABORATORY DATA ON ADMISSION: The patient's Chem-7 revealed
a sodium of 129, potassium of 5.2, chloride 92,
bicarbonate 26, BUN 65, and creatinine of 2.5; in comparison
to [**9-15**], where his BUN was 58 and creatinine was 2.5.
His complete blood count showed a white blood cell count
of 3.2, hematocrit of 34.8, and platelet count of 84. His
PT was 14.5, PTT of 29.2, and INR of 1.4. His urinalysis was
negative.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit and was initiated on a milrinone infusion with a
50-mcg/kg bolus, followed by a 0.28-mg/kg/min. infusion. He
was also given an intravenous dose of Lasix 40 mg. The
patient remained on his baseline medications and continued
with the milrinone until the day before discharge. He was
completely stable during his hospital course.
He was transferred to the floor on [**2122-10-5**]. His
milrinone infusion was continued for a total duration of four
days. During that time, the patient's net total body fluid
balance was minus approximately 4 liters. The patient was
restarted on his p.o. Lasix dose on [**10-5**] and was
diuresing well following the discontinuation of his milrinone
infusion. Symptomatically, the patient was improved and felt
less short of breath. He was able to go for short walks
without any difficulty.
The patient was discharged to home on [**10-6**]. He was
given a dose of Epogen 10,000 units subcutaneous times one to
save him an additional trip to get Epogen tomorrow. He also
had his iron preparation changed to an elixir to see if the
patient would have better tolerance of the iron.
CONDITION AT DISCHARGE: The patient was in stable condition.
DISCHARGE STATUS: Discharged to home.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Amiodarone 100 mg p.o. q.d.
3. Carvedilol 6.125 mg p.o. q.d.
4. Digoxin 0.125 mg on Monday and Thursday.
5. Prevacid 20 mg p.o. q.d.
6. Cozaar 25 mg p.o. q.d.
7. Lipitor 10 mg p.o. every Monday, Wednesday and Friday.
8. Lasix 20 mg p.o. b.i.d.
9. Vitamin E 400 units p.o. q.d.
10. Multivitamins 1 tablet p.o. q.d.
11. Ferrous fumarate 100 mg p.o. b.i.d. elixir.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with Dr. [**Last Name (STitle) 7626**] and also had an appointment arranged to
be seen in the Congestive Heart Failure Clinic.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2122-10-6**] 13:26
T: [**2122-10-6**] 12:35
JOB#: [**Job Number **]
|
[
"4280",
"41401",
"V4581"
] |
Admission Date: [**2115-4-16**] Discharge Date: [**2115-4-24**]
Date of Birth: [**2040-9-12**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
man, with a long history of chronic obstructive pulmonary
disease and a former smoking history. In the Fall of [**2113**],
he developed evidence of pneumonia in the right upper lobe,
treated with antibiotics. His symptoms resolved, but the
lesion in the right upper lobe persisted. CT scans suggested
malignancy, and operation was advised.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease with previous coronary bypass.
A preoperative PET scan was consistent with malignant process
without signs of metastasis.
HOSPITAL COURSE: On the day of admission, I performed a
bronchoscopy followed by a right upper lobectomy and
mediastinal lymph node dissection. Operation went well. The
patient was extubated in the operating room. He had a small,
persistent air leak, but his chest tubes were able to be
removed on the fourth postoperative day. He completed
rehabilitation and was discharged on the fifth postoperative
day on his usual medications and pain medication. Follow-up
in the Thoracic Oncology Center was arranged.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern4) 36759**]
MEDQUIST36
D: [**2115-8-2**] 12:05
T: [**2115-8-5**] 15:07
JOB#: [**Job Number 101146**]
|
[
"42731",
"5180",
"V4581"
] |
Admission Date: [**2173-4-19**] Discharge Date: [**2173-4-25**]
Date of Birth: [**2117-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
known coronary artery disease s/p PTCA [**2160**] with acute acute
onset of chest pain, shortness of breath. Cardiac
catheterization -60% distal left main, 90% osteal LAD, 70%
osteal Cx,, significant RCA disease, EF 50%.
Major Surgical or Invasive Procedure:
coronary artery bypass graft x5 (LIMA-LAD, SVG-Ramus, SVG-PDA,
SVG-PLV, SVG-OM) [**2173-4-21**]
History of Present Illness:
Patient with known
Past Medical History:
hyperlipidemia
hypertension
coronary artery disease, s/p PTCA [**2160**]
Social History:
warehouse worker or Stop and Shop
lives with wife
Family History:
positive for MI/CAD
Physical Exam:
general; well appearing, robust male in nAD
HEENT: unremarkable. carotids +2 bilat
chest: clear to asculatation bilat
Cor: RRR S1, S2
abd: soft, NT, +BS,
extrem: pulses +2 bilat groin and feet
neuro; intact
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 80941**] (Complete)
Done [**2173-4-21**] at 11:23:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2117-8-7**]
Age (years): 55 M Hgt (in): 70
BP (mm Hg): 117/65 Wgt (lb): 225
HR (bpm): 74 BSA (m2): 2.20 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 440.0, 413.9
Test Information
Date/Time: [**2173-4-21**] at 11:23 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW06-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size
and regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) 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. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
6. Trivial mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm.
1. Biventricular function is unchanged.
2. Aortic contours appear intact post decannulation
3. Other findings are unchanged
Dr. [**First Name (STitle) **] was notified in person of the results
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2173-4-21**] 15:07
[**2173-4-19**] 07:40PM GLUCOSE-107* UREA N-18 CREAT-1.0 SODIUM-140
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12
[**2173-4-19**] 07:40PM WBC-9.3 RBC-4.57* HGB-14.4 HCT-41.0 MCV-90
MCH-31.6 MCHC-35.2* RDW-12.8
Brief Hospital Course:
Mr. [**Known lastname **] was admitted prior to surgery for IV heparinization.
He remained chest pain free and was taken to the OR on [**4-21**] for
CABG X5. See oprative note for details.
On POD#1 he was extubated, his chest tubes were removed and he
was started on lopressor and diuresis.He was aslo transferred
from the ICU to the floor. he progressed well post-operatively.
he was evaulated by physical therapy and cleared for discharge
to home. On POD#3 his temporary pacing wires were removed. he
was discharged to home on POD#4.
Medications on Admission:
Toprol XL 25,Imdur, Norvasc, ASA 325,Zocor 20
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*65 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
coronary artery disease
hypertension
hyperlipidemia
PTCA [**2160**]
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Name (STitle) **] in 3 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] (cardiologist and primary care)in [**2-23**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2173-4-25**]
|
[
"41401",
"V4582",
"4019",
"2724",
"3051"
] |
Admission Date: [**2126-9-19**] Discharge Date: [**2126-10-25**]
Date of Birth: [**2073-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine / Penicillins / Metformin / Heparin Agents
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Right Wrist ORIF
Right elbow external fixation
Tracheostomy Change
Percutaneous gastrostomy tube placement
History of Present Illness:
53 yo m with hx of severe COPD, s/p trach, who presented today
to the ER after a fall at his nursing home. He had a mechanical
fall by slipping on an object on the floor. He fell on his right
wrist resulting in severe pain and wrist deformity. He was give
oxycodone 20mg at the NH and morphine 10mg PO by EMS enroute.
.
On presentation to the ER his VS were 98.6 122 129/93 22 100% 4
liters. He is on a baseline 2-3 liters oxgyen, with 92-94% sats
at the rehab. CXR showed no acute change. On wrist xray he was
found to have a radius and ulnar fracture. He was given an
additional diluaudid 1mg x 3. Then he was too sleepy and was
given 0.2 of narcan. Ortho reduced his wrist and placed a splint
on it with plans for a likely operation. With the reduction he
was given an additional dialudid 0.25 reduction. He remained
tahcy to 120s to 130s with sinus tach on EKG. He was found to
have pin point pulpils and again was given 0.2 narcan. Then his
SOB worsen, with sats in 80s. ABG checked 7.15/129/ 50 (unclear
if veinous). Respriatory was called and changed his trach to 6.0
cuff and vent was started with CMV 400 x 24, FIO2 100, PEEP 5.
At tranfer to the MICU his HR was 125, BP was 131/87, and sats
of 94-95%.
Past Medical History:
COPD with trach on O2 and prednisone, tracheomalacia, h/o
tracheal stenosis
Type II DM
diastolic CHF
mild pulmonary HTN
osteoporosis s/p Mid-thoracic vertebral body fracture
h/o nephrolithiasis
h/o MRSA nasal swab, MRSA sputum Cx
Hepatitis B
h/o gastric and duodenal ulcers
chronic LBP - pt reports compression fractures from osteoporosis
Social History:
Mr. [**Name13 (STitle) 14302**] lives in the [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home. He quit
using heroin about eight years ago, but has an approximately 20
year history. He quit drinking more than seven years ago. He
quit smoking approximately one to two years ago and has a 60
pack year history. He smoked two packs per day for many years.
He tested HIV negative in the past. He used to work as a dog
groomer. He did work in construction in the past, but does not
know of any asbestos exposure. He denies TB exposure.
Family History:
Non-contributory.
Physical Exam:
Vitals: T:99 BP: 113/91 P: 120 R: 21 O2: 98%
General: somluent, complaining of severe pain in wrist when
awake
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, no LAD
Lungs: rhonchi bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild distention, non-tender, bowel sounds present
Ext: warm, well perfused, 2+ pulses, erythema on lower
extremities, 1+ edema to knees, venous statsis changes
Pertinent Results:
Initial labs:
[**2126-9-19**] 03:30PM BLOOD WBC-11.8* RBC-4.57* Hgb-11.5* Hct-38.7*
MCV-85 MCH-25.2* MCHC-29.7* RDW-14.9 Plt Ct-329
[**2126-10-21**] 04:36AM BLOOD WBC-10.9 RBC-3.25* Hgb-8.3* Hct-27.2*
MCV-84 MCH-25.5* MCHC-30.5* RDW-15.0 Plt Ct-525*
[**2126-9-19**] 03:30PM BLOOD PT-11.3 PTT-25.9 INR(PT)-0.9
[**2126-10-21**] 04:36AM BLOOD PT-12.9 PTT-28.4 INR(PT)-1.1
[**2126-10-21**] 04:36AM BLOOD Plt Ct-525*
[**2126-9-19**] 03:30PM BLOOD Glucose-236* UreaN-16 Creat-0.8 Na-140
K-4.6 Cl-93* HCO3-41* AnGap-11
[**2126-9-20**] 03:25AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-144
K-4.2 Cl-97 HCO3-44* AnGap-7*
[**2126-10-21**] 04:36AM BLOOD Glucose-133* UreaN-10 Creat-0.5 Na-143
K-4.4 Cl-103 HCO3-32 AnGap-12
[**2126-9-23**] 04:02AM BLOOD ALT-33 AST-50* AlkPhos-35* TotBili-0.2
[**2126-9-20**] 06:27AM BLOOD CK-MB-11* MB Indx-6.3* cTropnT-0.05*
[**2126-9-24**] 06:45PM BLOOD CK-MB-8 cTropnT-0.03*
[**2126-10-3**] 02:39AM BLOOD proBNP-41
[**2126-9-20**] 03:25AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8
[**2126-9-20**] 06:27AM BLOOD Calcium-8.1* Mg-1.7
[**2126-10-21**] 04:36AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
[**2126-9-19**] 09:43PM BLOOD Type-ART pO2-50* pCO2-129* pH-7.15*
calTCO2-48* Base XS-10 Intubat-NOT INTUBA
[**2126-9-19**] 11:58PM BLOOD Type-ART pO2-105 pCO2-87* pH-7.29*
calTCO2-44* Base XS-11
[**2126-10-9**] 01:48AM BLOOD Type-ART FiO2-40 pO2-49* pCO2-75* pH-7.42
calTCO2-50* Base XS-19 -ASSIST/CON Intubat-INTUBATED Comment-PS
= 8
[**2126-10-9**] 06:23AM BLOOD Type-ART pO2-68* pCO2-70* pH-7.44
calTCO2-49* Base XS-18
[**2126-10-15**] 06:34PM BLOOD Type-ART pO2-66* pCO2-63* pH-7.44
calTCO2-44* Base XS-15
[**2126-9-20**] 04:07AM BLOOD Lactate-7.0*
[**2126-9-20**] 04:18AM BLOOD Lactate-5.6* Na-141 K-4.2
[**2126-9-20**] 09:44AM BLOOD Lactate-2.0
[**2126-9-20**] 06:02PM BLOOD Lactate-1.7
[**2126-9-20**] 10:29PM BLOOD Lactate-1.2
[**2126-10-5**] 01:07PM BLOOD Glucose-146* Lactate-0.7 Na-143 K-4.9
Cl-86*
[**2126-10-3**] 06:24PM BLOOD LEVETIRACETAM (KEPPRA)-Test
[**2126-10-12**] 05:05PM BLOOD B-GLUCAN-Test
[**2126-10-12**] 05:05PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
[**2126-9-27**] 03:00PM URINE RBC-[**6-19**]* WBC-0 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2126-10-12**] 09:45AM URINE CaOxalX-OCC
[**2126-10-11**] 12:45PM URINE CaOxalX-MOD
[**2126-9-27**] 11:28AM URINE Hours-RANDOM UreaN-446 Creat-54 Na-101
K-31 Cl-97
Discharge labs:
8.1
13.5 >-----< 447
25.8
.
143 100 7
-------------------< 99
4.1 40 0.5
.
MICRO:
[**2126-9-20**] 4:04 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2126-9-24**]**
GRAM STAIN (Final [**2126-9-20**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2126-9-24**]):
~5000/ML OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM------------- 4 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
[**2126-9-29**] 1:33 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2126-9-30**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-9-30**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2053**] @ 3:56A [**2126-9-30**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2126-9-27**] 3:00 pm BLOOD CULTURE Source: Line-A-line.
**FINAL REPORT [**2126-10-3**]**
Blood Culture, Routine (Final [**2126-10-3**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
PSEUDOMONAS AERUGINOSA.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], #[**Numeric Identifier 26242**] [**2126-9-30**]
11:00AM.
FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. 2ND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 2 S 2 S
MEROPENEM------------- 4 S 8 I
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
[**2126-10-16**] 5:26 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2126-10-16**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2126-10-18**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 110911**]
[**2126-10-12**].
POTASSIUM HYDROXIDE PREPARATION (Final [**2126-10-17**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2126-10-17**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2126-10-22**] 2:42 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2126-10-22**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). HEAVY GROWTH.
[**2126-10-22**] 2:42 pm URINE Source: Catheter.
**FINAL REPORT [**2126-10-25**]**
URINE CULTURE (Final [**2126-10-25**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
RADIOLOGY:
[**10-23**] CXR:
FINDINGS: Lung volumes remain low. Increased opacification
within the left
lower chest is likely subsegmental atelectasis. The lateral
aspect of the
right chest is excluded from this examination, however, moderate
right pleural effusion and right base segmental atelectasis
appear unchanged, and a small left pleural effusion is
unchanged. A tracheostomy tube is in the standard position. A
left PICC line terminates at the junction of the brachiocephalic
veins. There is no pneumothorax. The heart size is normal.
IMPRESSION: Interval increase in subsegmental left lower lobe
atelectasis.
Stable bilateral pleural effusions and right basilar
atelectasis.
[**10-22**] Elbow xray:
FINDINGS: In comparison with the study of [**10-21**], external
fixation device
remains in place. The alignment of structures around the elbow
appears to be quite well maintained.
[**10-21**] CT head:
NON-CONTRAST HEAD CT: Imaging was repeated using helical mode
due to patient motion. No evidence of acute intracranial
hemorrhage, edema, mass, mass effect, hydrocephalus, or large
vascular territory infarction is seen. Vascular calcifications
are noted particularly in the right carotid siphon. On a couple
of images only, the basilar artery (6:12) and the left vertebral
artery (6:9) appears dense, similar in appearance to [**2126-9-20**];
with this vessel seen to enhance normally on subsequent MRI.
There is also increased attneuation in the prepontine cistern on
this image, likely artifactual. Thus this probably represents
artifact rather than thrombosis.
The soft tissues, orbits and skull appear intact. A left
nasogastric tube is in place. There is partial opacification of
ethmoid air cells as well as mucosal thickening within the
sphenoid and maxillary sinuses. Partial
opacification of the mastoid air cells was also previously
present.
IMPRESSIONS: No acute traumatic injury seen. Slightly dense
appearanc eof
the Basilar artery focally, is likely artifactual. Attention can
be paid to this on f/u study.
[**10-18**] EEG:
SPIKE DETECTION PROGRAMS: There were 1,000 entries in these
files.
These contained movement and electrode artifact. There were no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were four entries in these
files.
These showed movement and electrode artifact. There were no
electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were three entries in these files.
The
first pushbutton was pressed by a nurse due to paroxysmal
bilateral
elevation of the arms. There is no obvious change in the EEG
from
interictal background activity.
The next pushbutton is pressed for abrupt elevation of the
right arm on video. There is no visualization of the left arm on
this
part of the video monitoring. Likewise, there is no change in
EEG from
background interictal activity.
The last pushbutton is pressed for unclear reasons and the
patient is not visualized on video; however, there again is no
obvious
change in EEG from interictal background activity.
AUTOMATED TIME SAMPLES: There were 82 entries in these files.
There
was a low voltage and mixed theta/delta frequency slowing of the
background. There was no focal slowing or epileptiform
discharges.
SLEEP: No morphologies in sleep were seen during this study.
CARDIAC MONITOR: Showed normal sinus rhythm in a single EKG
channel.
IMPRESSION: This is an abnormal video EEG due to low voltage and
slowing of the background activity. There were no epileptiform
discharges or electrographic seizures. This telemetry captured
three
pushbutton activations, two involving sudden elevation of the
arm(s)
without obvious EEG correlate. These findings are consistent
with a
moderate to severe encephalopathy secondary to anoxic injury. On
video,
abrupt episode of bilateral arm elevation with sustained
elevation for a
couple of seconds suggests frontal seizure activity that may not
be
detected on current study. Clinical correlation is recommended.
Compared to EEG from prior 24 hours, this study is unchanged.
CTA chest:
FINDINGS: Quality of vascular opacification allows to exclude
acute pulmonary embolism in the central pulmonary arteries and
several well-perfused right lower lobar segmental pulmonary
arteries. The left lower lobar and segmental pulmonary arteries
show lesser perfusion due to the presence of atelectasis and
small pleural effusion. An apparent filling defect on image 30
on series #3 is most likely caused by partial volume averaging,
resulting from increased lymphatic tissue. The pulmonary
arteries are borderline in size. In addition to left lower lobar
atelectasis and effusions, there is atelectasis in the right
lower lobe. Small pleural effusion on the left is new and
atelectasis has minimally increased. Dependent atelectasis
adjacent to the left fissure is also seen, increased from the
prior. Otherwise, there is no change from
the prior study, with indwelling tracheostomy tube, prominent by
number but not enlarged by size, mediastinal and bilateral hilar
lymph nodes. Again seen is centrilobular and paraseptal
emphysema with upper lobe predominance. Coronary artery
calcifications involve left anterior descending, left main and
right coronary arteries.
This study is not optimized for subdiaphragmatic evaluation,
except to note nasogastric tube, coursing in the stomach, with
the tip not in the field of view.
Note is again made of infrarenal IVC filter.
There is a tiny calcification in the mid pole of the left
kidney, which may represent a vascular calcification versus
non-obstructing calculus.
Stable degree of significant kyphotic angulation is noted at at
T8-9 level.
IMPRESSION:
1. No evidence of PE in the central and some segmental pulmonary
arteries.
2. Development of small left pleural effusions, and mild
increase in
bibasilar consolidations, right lower lobe consistent with
atelectasis and
more heterogeneous appearance of the left lower lobe, but likely
also due to atelectasis.
Brief Hospital Course:
The patient initially presented to [**Hospital1 18**] after a fall at his
nursing home, during which he sustained fractures to his right
wrist (radius and ulna) and elbow. He was in a significant
amount of pain for which he was medicated with hydromorphone. He
had tachycardia that was progressive to the 120s and had
progressive shortness of breath. He was admitted to the medical
ICU where he went into cardiac arrest, thought to be driven by
hypoxia. His medical course has been notable for prolonged
tracheostomy dependence, ventilator associated pseudomonal
pneumonia and pseudomonal bacteremia, seizures, and prolonged
altered mental status and agitation.
# Cardiac Arrest (Pulseless Electrical Activity)
Mr. [**Known lastname 110907**] was started on the arctic sun cooling protocol and
had continuous EEG monitoring during a time which seizure
activity was suspected. After undergoing a tracheostomy change
for an MRI-compatible trach, he had a head MRI/MRA which showed
no evidence of anoxic brain injury. However, his mental status
has been labile and has improved on lower narcotic doses and
sedation.
# Hypercarbic Respiratory Failure: This was felt to be a
combination of VAP and COPD exacerbation as described below. He
is trach-dependent.
# Chronic Obstructive Lung Disease: He was started on IV
steroids and quickly tapered to prednisone 10 mg daily. He is
on steroids chronically.
# Ventilator Associated Pneumonia: He was treated with a 14 day
course of meropenam/tobramycin, ended [**10-13**]. Last bronchoscopy
on [**10-16**] still had sputum culture growing pseudomona, felt to be
colonization at this point. He was also noted to have positive
B-glucan but negative galactomanna. BAL grew yeast, bcxs were
negative for fungus. He was not treated for fungal pneumonia.
He had repeat fevers on [**10-22**] and was started on a 8 day course
of cefepime and gent for presumed recurrent pseudomonas VAP.
Sputum cultures show heavy GNR growth, speciation adn
sensitivities pending.
# UTI: Patient was found to have MDR. He needs 1 week course
of nitrofurotoin starting [**10-25**].
# Altered Mental Status: This was felted to be due to anoxic
brain injury from PEA arrest and ICU delirium worsened by
narcotics. His mental status improved with decreasing dose of
narcotic regimen. He was also started on clonidine for
agitation, which is now being tapered off. By discharge, he was
able to communicate (via mouthing words) appropriately.
# Seizure: Neurology was consulted and felt that the patient
had clinical seizures although his EEG did not show any
epileptiform activity. He was started on Keppra.
# C. difficle colitis: Patient was treated with po vancomycin,
projected end date to be 1 week past last dose of antibiotics.
# Right Wrist/Elbow Fracture: Patient underwent ex-fix and PRIF
on R elbow and wrist on [**10-7**] by Orthopedics. His pain was
controlled with fentanyl patch and oxycodone for breakthrough
pain. He was started on calcium and vitamin D and was
recommended to start a bisphosphonate as an outpatient.
# Fungal rash on back: He is on antifungal creams as well as
fluconzole to complete 14 day oral course.
# Diabetes: He was continued on his home ISS.
# Iron deficiency anemia: Pt was continued on iron supplements.
# Nutrition: PEG was placed on [**10-22**]. Patient is on tube
feeds.
Medications on Admission:
Tums 500mg TID
Iron 325mg Qday
Celexa 20mg Qday
Bactrim DS MWF
SSI
Combivent 2 puffs Q4H PRN
Mylanta 30ml Q6H PRN
Mag Citrate Qweekly PRN constipation
Lactulose 30ml Q6H PRN
Miralax MWF
Tyelnol 650mg Q6H PRN
Arovent Q4H PRN
Duoneb 2 puffs PRN
Senokot [**Hospital1 **] PRN
Oxycodone 10mg Q6H PRN
Oxygen 2liters NC
Lotrisone cream [**Hospital1 **]
Miconazole Nitrate powder [**Hospital1 **] to groin
Prednisone 15mg alternating with 20mg Qday
ASA 325mg
Colace 100mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Vancomycin completed coures on [**9-18**]
Lasix 40mg [**Hospital1 **]
KCL 20meq [**Hospital1 **]
Mirapex 0.25mg HS
Cipro 500mg [**Hospital1 **] for 7 days, completed [**2126-9-17**]
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: 0-12 units
Subcutaneous ASDIR (AS DIRECTED): Pls see sliding scale.
2. Gentamicin 40 mg/mL Solution [**Month/Day/Year **]: Four [**Age over 90 1230**]y (450) mg
Injection Q24H (every 24 hours) for 4 days: Until [**2126-10-29**].
3. Nitrofurantoin (Macrocryst25%) 100 mg Capsule [**Month/Day/Year **]: One (1)
Capsule PO BID (2 times a day) for 7 days.
4. Cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) gram Intravenous
twice a day for 4 days: Until [**2126-10-29**].
5. Fluconazole 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
6. Fentanyl 25 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: One (1) PO every 6-8 hours
as needed for pain.
8. Fondaparinux 2.5 mg/0.5 mL Syringe [**Month/Day/Year **]: One (1) Subcutaneous
DAILY (Daily).
9. Vancomycin 125 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
10. Prednisone 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Age over 90 **]: 4-8 Puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
15. Miconazole Nitrate 2 % Powder [**Age over 90 **]: One (1) Appl Topical TID
(3 times a day) as needed for groin rash.
16. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Age over 90 **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eye.
17. Colace 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg PO twice
a day.
18. Senna 8.8 mg/5 mL Syrup [**Age over 90 **]: One (1) Tablet PO BID (2 times
a day).
19. Lactulose 10 gram/15 mL Syrup [**Age over 90 **]: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
20. Polyethylene Glycol 3350 17 gram/dose Powder [**Age over 90 **]: One (1)
PO DAILY (Daily) as needed for constipation.
21. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Age over 90 **]: 2.5
Tablets PO DAILY (Daily).
22. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension
[**Age over 90 **]: Five Hundred (500) mg PO TID (3 times a day).
23. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Age over 90 **]: Three
Hundred (300) mg PO DAILY (Daily).
24. Aspirin 325 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
25. Cortisone 1 % Cream [**Age over 90 **]: One (1) Appl Topical [**Hospital1 **] (2 times a
day) as needed for rash on face.
26. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 1000 (1000) mg PO q8
hr.
27. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mouth care.
28. Terbinafine 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
29. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl
Topical TID (3 times a day).
30. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day): Please titrate off over 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Right radial and ulnar fracture
Pulseless electrical activity arrest
Respiratory failure
Anoxic brain injury
Secondary:
Ventilator associated pneumonia
Chronic obstructive pulmonary disease exacerbation
C. difficile colitis
Urinary tract infection
Diabetes mellitus type 2
Fungal rash
Delirium
Discharge Condition:
Stable oxygenation on PS, afebrile x 48 hours
Discharge Instructions:
You were admitted for a wrist fracture of the right arm, which
has been fixed by Orthopedics. During your hospitalization,
your heart stopped (PEA arrest) and you have recovered from
this. Your respiratory status worsened from a combination of
your COPD and pneumonia. Both have been treated and you have
improved. You are being discharged to [**Hospital 100**] Rehab MACU.
Followup Instructions:
Please follow up with orthopedics 1 week after discharge from
MACU with Dr. [**Last Name (STitle) 1005**]. His clinic number is [**Telephone/Fax (1) 1228**].
Please follow up with your pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] 2 weeks
after your discharge from MACU. His clinic number is ([**Telephone/Fax (1) 514**].
Please also follow up with Neurology regarding your seizure
activity. The clinic number is ([**Telephone/Fax (1) 58666**].
|
[
"5990",
"5180",
"25000",
"4280",
"4168"
] |
Admission Date: [**2137-11-8**] Discharge Date: [**2137-11-12**]
Date of Birth: [**2094-9-10**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Endoscopy with clipping and injection of duodenal bulb ulcer
History of Present Illness:
43Fwith a history of hypertension and peritoneal TB s/p
treatment who presented with bloody diarrhea after 4 days of
brown diarrhea. She began having diarrhea 4 days prior to
admission. On the day prior to admission she began passing
bloody stool with each bowel movement, approximately 4-5 times
during the course of the day. The blood was bright red and there
are some clots mixed in by report. She denies any abdominal
pain, chest pain, chest pressure, palpitations, or DOE.
Otherwise she has not complaints. She denies taking any aspirin
or NSAIDs.
.
In the ED, initial VS were: pain 0, T 96, HR 114, BP 157/90, R
16, 100% on RA. Rectal exam was notable for bright red blood,
anoscopy only showed a skin tag. Gastroenterology was notified
and she was started on a PPI IV BID. The patient received 3L NS.
Vitals on transfer were BP 144/93, HR 105, RR 30. On the medical
floor, she was transfused two units of pRBC for a HCT of 25.8
with a goal HCT of 30. However, her post transfusion HCT was
23.8. She then had a large BM with BRB, but flushed it down the
toilet. A repeat HCT was 24.3. An OG lavage was attempted, but
she vomited bright red blood. She was started on a pantoprazole
drip in place of PPI IV BID. Given her ongoing BRBPR,
hematemasis, and unchanged HCT despite 2 units pRBCs she was
transfered to the MICU for urgent EGD and colonoscopy. Of note,
review of records revealed a known R colonic vascular ectasia in
[**2132**]. She also has a history of miliary TB with peritoniteal
involvement.
.
Review of systems:
(+) Per HPI
(-) Denies fever. Denies headache, lightheadedness or dizziness.
Denies sinus tenderness, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness. Denied
vomiting, constipation or abdominal pain. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- Peritoneal TB, s/p treatment with RIPE and B6 under direct
observation therapy, completed in ?[**2135**]
- Hypertension on lisinopril + HCTZ
- Hemorrhoids
- s/p tubal ligation
- s/p surgery for "intestinal blockage" - sounds like bowel
obstruction that complicated her last pregnancy.
Social History:
Ms. [**Known lastname **] lives in [**Location 3786**] with her husband and 4 children. She was
born in [**Country 84632**], [**Country 480**] but immigrated to the US in [**2115**]. She
works as a CNA. No recent travel. She denies any tobacco, rare
alcohol, no IVDA.
Family History:
Mother died at 55 of an accident, father died at 65. One sister,
one brother, four children without illness.
Physical Exam:
General: Tachypneic, shivering under multiple sheets. Alert,
oriented, mild distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: well-healed midline incision, decreased bowel sounds,
soft, non-tender, non-distended, no organomegaly
Ext: Cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact.
Pertinent Results:
Admission labs:
[**2137-11-8**] 05:43PM BLOOD WBC-12.3*# RBC-2.66*# Hgb-8.9* Hct-25.8*
MCV-97# MCH-33.5*# MCHC-34.6 RDW-15.5 Plt Ct-244
[**2137-11-9**] 04:45AM BLOOD WBC-12.1* RBC-2.68* Hgb-8.3* Hct-24.3*
MCV-91 MCH-31.0 MCHC-34.2 RDW-17.2* Plt Ct-164
[**2137-11-8**] 05:43PM BLOOD Neuts-76.8* Lymphs-17.1* Monos-5.1
Eos-0.4 Baso-0.5
[**2137-11-8**] 05:43PM BLOOD PT-16.5* PTT-31.5 INR(PT)-1.5*
[**2137-11-9**] 04:45AM BLOOD PT-17.0* PTT-32.9 INR(PT)-1.5*
[**2137-11-11**] 04:00AM BLOOD Fibrino-282
[**2137-11-8**] 05:43PM BLOOD Ret Man-4.6*
[**2137-11-8**] 05:43PM BLOOD Glucose-140* UreaN-15 Creat-0.6 Na-133
K-3.3 Cl-96 HCO3-22 AnGap-18
[**2137-11-8**] 05:43PM BLOOD ALT-27 AST-115* TotBili-1.5
[**2137-11-9**] 04:45AM BLOOD LD(LDH)-177 CK(CPK)-159*
[**2137-11-10**] 04:09AM BLOOD ALT-22 AST-135* LD(LDH)-369* AlkPhos-72
TotBili-1.3
[**2137-11-8**] 05:43PM BLOOD Lipase-57
[**2137-11-8**] 05:43PM BLOOD Calcium-9.3 Phos-2.9 Mg-1.7 Iron-114
[**2137-11-10**] 04:09AM BLOOD Albumin-2.7* Calcium-7.7* Phos-3.0 Mg-2.1
[**2137-11-8**] 05:43PM BLOOD calTIBC-289 Ferritn-165* TRF-222
[**2137-11-9**] 04:45AM BLOOD VitB12-828 Folate-8.6
[**2137-11-12**] 06:58AM BLOOD Free T4-1.0
[**2137-11-12**] 06:58AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-PND
IgM HAV-NEGATIVE
[**2137-11-12**] 11:12AM BLOOD Smooth-NEGATIVE
[**2137-11-12**] 11:12AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80
[**2137-11-11**] 04:45PM BLOOD CA125-29
[**2137-11-12**] 06:58AM BLOOD HCV Ab-NEGATIVE
[**2137-11-8**] 05:54PM BLOOD Hgb-9.5* calcHCT-29
[**2137-11-9**] 11:28AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2137-11-9**] 11:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2137-11-10**] 08:40PM URINE RBC-0-2 WBC-[**10-11**]* Bacteri-MANY
Yeast-NONE Epi-21-50
Discharge labs:
[**2137-11-11**] 04:45PM BLOOD Hct-26.5*
[**2137-11-12**] 06:58AM BLOOD Hct-26.0*
[**2137-11-11**] 04:00AM BLOOD WBC-6.7 RBC-2.77* Hgb-9.1* Hct-25.5*
MCV-92 MCH-32.7* MCHC-35.5* RDW-17.6* Plt Ct-160
[**2137-11-12**] 06:58AM BLOOD PT-16.0* PTT-33.8 INR(PT)-1.4*
[**2137-11-12**] 06:58AM BLOOD K-3.2* HCO3-21*
[**2137-11-11**] 04:00AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-138
K-3.4 Cl-108 HCO3-19* AnGap-14
[**2137-11-12**] 06:58AM BLOOD ALT-20 AST-103* LD(LDH)-183 AlkPhos-89
TotBili-1.2
[**2137-11-11**] 04:00AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.9
[**2137-11-9**] 11:28 am URINE Source: Catheter.
**FINAL REPORT [**2137-11-10**]**
URINE CULTURE (Final [**2137-11-10**]):
GRAM POSITIVE BACTERIA. ~1000/ML.
ORGANISM. ~1000/ML.
BCx negative x1
Time Taken Not Noted Log-In Date/Time: [**2137-11-9**] 5:47 pm
SEROLOGY/BLOOD
**FINAL REPORT [**2137-11-11**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2137-11-11**]):
EQUIVOCAL BY EIA.
(Reference Range-Negative).
[**11-8**] EKG
Sinus tachycardia. Otherwise, no other significant diagnostic
abnormality.
No previous tracing available for comparison.
[**11-8**] CXR
FINDINGS: Frontal and lateral views of the chest are obtained.
There is
persistent elevation of the right hemidiaphragm. Previously seen
diffuse
miliary nodules are not well appreciated on the current study,
either due to
resolution or due to differences in technique, as CT is more
sensitive. No
focal consolidation or pleural effusion is seen. Cardiac and
mediastinal
silhouettes are unremarkable.
IMPRESSION:
1. Persistent elevation of the right hemidiaphragm. No focal
consolidation
seen.
2. Previously seen diffuse miliary pulmonary opacities not well
appreciated
on the current study, which may be due to resolution or
differences in
technique, as CT is more sensitive.
[**11-9**] investigation of transfusion rxn
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname **] experienced a
temperature increase of 2.6 degrees F in the 90 minutes
following a
leukoreduced compatible red blood cell transfusion. She had no
further
fevers during her hospital stay. The differential diagnosis
includes
acute hemolytic transfusion reaction (AHTR), septic reaction,
febrile
nonhemolytic transfusion reaction (FNHTR) and unrelated to
transfusion.
Lab evaluation showed no evidence of hemolysis. A septic
reaction is
unlikely given RBCs are stored at refrigerated temperatures,
resolution
of fever without treatment and no additional symptoms such as
hypotension. FNHTR is a possibility although leukoreduction
signficantly
reduces the incidence of these reactions. As such, other
non-transfusion
related causes of fever should be ruled out. No change in
transfusion
practice is recommended at this time.
[**11-11**] CT chest/abd/pelvis
CT OF THE CHEST WITH IV AND P.O.CONTRAST: The airway is patent
to the
segmental level bilaterally. There is bilateral minimal linear
atelectasis.
Focal pleural thickening is noted (2:26). There is no focal
consolidation,
pleural effusion, or pneumothorax. Heart and pericardium appear
unremarkable.
There is no mediastinal, hilar, or axillary lymphadenopathy.
CT OF ABDOMEN WITH IV AND P.O. CONTRAST: Again noted, there is
an 8 mm
rounded, hypoenhancing lesion at the dome of the liver,
unchanged when
compared to prior study, most likely represents a benign cyst.
The liver
otherwise enhance homogeneously without evidence of intra- or
extra-hepatic
biliary dilatation. Hepatic and portal veins are patent.
Gallbladder,
spleen, pancreas, adrenal glands, stomach, small bowel appear
unremarkable.
Contained extraluminal foci of air are noted (2:54, 2:55 and
2:56) surrounding
the duodenal bulb, most likely related to status post procedure
of duodenal
ulcer clipping. There is no evidence of contrast extravasation.
Intraperitoneal hypoattenuating fluid is noted anteriorly and
superiorly to
the stomach(2:59), without concomitant wall enhancement to
suggest active
infection reaction, these findings most likely suggest retention
cyst or
lymphocele. The kidneys enhance and excrete contrast
symmetrically. There is
a 9 x 14 mm hypoattenuating lesion in the upper pole, most
likely represent
simple cyst, unchanged. There is no stone or hydronephrosis.
There is no
intra-abdominal lymphadenopathy.
CT OF THE PELVIS WITH IV AND P.O. CONTRAST: The bladder, distal
ureters,
adnexa, rectum, and sigmoid colon appear unremarkable. Known
submucosal
fibroid is less well seen, measuring approximately 3.1 x 3.2 cm
and is
heterogeneous in attenuation. The patient is status post
bilateral tubal
ligation. There is no pelvic lymphadenopathy. There is no free
air or free
fluid.
OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions are
seen.
IMPRESSION:
1. Extraluminal air surrounding the duodenal bulb, most likely
related to
recent surgical procedure. There is no contrast extravasation.
2. Intraperitoneal fluid collection adjacent to the anterior
wall of the
stomach without wall enhancement to suggest active infectious
process. These
findings most likely suggest retention cyst of lymphocele.
3. Small focus of pleural thickening without focal lung
consolidation.
Brief Hospital Course:
43yoF with h/o miliary/peritoneal TB s/p RIPE/B6 Tx for 1yr
under direct observation therapy admitted with bloody diarrhea
and hematemesis during admission, s/p endoscopy with duodenal
bulb ulcer visualized which was injected and clamped, seen to
have small amt of free air after procedure, and incidentally
found 10cm perihepatic fluid collection.
1. UGIB: Originally with bloody diarrhea, and while OG lavage
was attempted pt had hematemesis and taken more urgently to
endoscopy. Duodenal ulcer was found, injected and clamped and
Hct stabilized through rest of admission, stable on discharge.
Is s/p 4U PRBC's through admission. Was never hemodynamically
unstable, diet was advanced without complications. Pt had
equivocal Hpylori serology, started on Amoxicillin,
Clarithromycin, and PPI x2 wks, given high pretest probability.
Appt made to f/u with GI.
2. Free air in abdomen: small amt of air seen on CT abdomen
around area of proceduralized duodenum. Abd benign by PE, no
extraluminal extravasation, no hemodynamic compromise. GI felt
this not clinically significant and stable to watch, may have
been caused by clipping during EGD. To be f/u'd in GI.
3. Fluid collection: Seen on CT torso, 10cm perihepatic,
anterior to stomach. Concerning in the setting of known miliary
TB with peritoneal involvement, however pt without fevers,
elevated WBC count, extensive ROS for pulmonary and
extra-pulmonary TB sxs completely negative, and abdominal exam
benign; therefore not felt likely to be peritoneal TB. Not
clinically significant and GI recommended endoscopic u/s as an
outpt.
4. Transaminitis: Unclear etiology of isolated elevated ALT and
INR, which did not respond to 3 days of Vitamin K. Abd u/s
without evidence of cirrhosis or other acute pathology, only
showing fluid collection as above. Pt asymptomatic and no
sequalae of liver disease on physical exam. Negative serology
for Hep A and Hep C. HepBsAg negative, HepBsAb positive
indicative of immunity from exposure or vaccination (HepBcAb
still pending). Smooth muscle Ab negative and [**Doctor First Name **] positive in
low titer, diffuse pattern. As pt was stable, appt was made to
f/u with Hepatology for further assessment.
5. HTN: Home HCTZ and Lisinopril was held in setting of GIB, and
pressures were stable and normal through admission. Held on
discharge, to be followed up as outpt.
6. h/o ovarian Tb - Given a history of ovarian involvement by
peritoneal TB, we obtained a repeat CA-125, which was normal.
Medications on Admission:
- Lisinopril/hydrochlorothiazide, 20 mg/25 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper GI bleed from duodenal bulb ulcer, s/p endoscopy,
clipping, and injection
2. Left perihepatic fluid collection of unknown etiology
3. Small amount of free air in abdomen after endoscopy
4. Elevations in liver enzyme AST and in INR of unknown
significance
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**] with bloody diarrhea and found to
have an ulcer in your duodenum that was bleeding. You underwent
an endoscopic procedure to fix the bleed. Your blood level was
monitored and was steady, indicating that you were not having
further bleeding. While you were here, you were also noted to
have a fluid collection near your liver and some elevations in
your liver enzymes. Because this is not acutely affecting you,
this will be worked up as an outpatient with the appointments
listed below.
The following changes were made to your medication list:
1. START Amoxicillin, Clarithromycin, and Pantoprazole, as
listed below. This is a regimen to clear a possible stomach
infection that may have caused the bleeding. You will need to
take this twice a day for two weeks.
2. HOLD Hydrochlorothiazide-Lisinopril. This blood pressure med
was held while you were having active bleeding. You should
reassess this with your primary care doctor.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name (STitle) 17832**] [**Name (STitle) 16365**]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2137-11-25**] 2:00pm
Location: [**Street Address(2) 59699**], [**Location (un) 577**]
Phone number: [**Telephone/Fax (1) 17826**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**]
Specialty: Gastroenterology
Date/ Time: [**2137-11-20**] 3:30pm
Location: [**Location (un) 830**] [**Hospital Unit Name 1825**] [**Location (un) **]
Phone number: [**Telephone/Fax (1) 463**]
Appointment #3
MD: Dr. [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**]
Specialty: Gastroenterology-Liver Center
Date/ Time: [**2137-11-28**] 1:20pm
Location: [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) 858**]
Phone number: [**Telephone/Fax (1) 2422**]
Completed by:[**2137-11-16**]
|
[
"2851",
"4019"
] |
Admission Date: [**2165-9-9**] Discharge Date: [**2165-9-11**]
Date of Birth: [**2113-11-15**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterization with bare metal stent to the mid left
anterior descending artery
History of Present Illness:
Patient is a 51 year-old male with a past medical history of
NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to
the LAD, depression presenting with acute onset chest pain
beginning at around 8 AM as his car was getting towed and he was
running. He describes the pain as pressure-like beginning
substernally, radiating to the back and right side of the chest,
initially an [**6-26**], associated with SOB and some nausea. Of
note, he had not taken his aspirin this morning. The pain went
down slightly after this event, and he went to his psychiatry
appointment at [**Hospital1 **]. While at the appointment, the pressure was
present at roughly [**5-26**]. The appointment ended, and he was
walking to the car when the pressure, SOB, and nausea became so
severe that he could not walk. He thus presented to the ED.
.
On arrival to the ED, initial vitals were 96.3 73 142/91 16
100%. Initial ECG showed NSR, no ST changes compared with
prior. Patient received aspirin and NG, and the pain came down
to [**2-24**], became more comfortable. A half an hour, patient was
sleeping, but upon awakening reported worsening 7/10 chest pain,
not relieved with 3 x NG. A repeat ECG showed NSR, new RBBB,
right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S
wave in V4/V5, 1-2 mm STE in v3/v4. Code STEMI called, patient
started on a heparin gtt, given Plavix 600 mg, started on an
integrillin gtt, and taken to the cath lab. In the cath lab,
cath showed aneurysm formation within the DES to the LAD, with
stents widely patent except for a 70-80% stenosis in the mid
LAD. This lesion was ballooned and a BMS (Integrity) placed. He
arrived to the CCU pain free and comfortable.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. He is normally very
active, walking 30-40 min several days a week, walking flights
of stairs without issue.
.
Of note, after his NSTEMI, he was started on metoprolol and
lisinopril. The lisinopril was discontinued after symptoms of
lightheadedness, and metoprolol discontinued in [**2162**] after he
had fatigue and lightheadedness. He has had intolerance to
lipitor, zetia in the past secondary to vague symptoms
(abdominal pain, fatigue).
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD, PTCA to Ramus
in [**2161**]
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
.
1. Status post penile surgery.
2. Perioral vitiligo.
3. Erectile dysfunction.
4. CAD: Acute MI [**9-16**], s/p stenting to LAD and PTCA to ramus
5. Depression
Social History:
Lives at home with wife. [**Name (NI) **] 4 children. Manages a [**Doctor Last Name 9381**] gas
station. He denies tobacco, ETOH, or drug use.
Family History:
No history of premature cardiac disease in family. Otherwise
noncontibutory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
Tm: 36.6 ??????C (97.9 ??????F), Tc: 36.6 ??????C (97.9 ??????F) HR: 77 (73 - 102)
bpm BP: 125/77(90) {112/69(82) - 131/80(91)} mmHg RR: 25 (19 -
25) insp/min
SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal, No(t) Widely split ),
No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
.
DISCHARGE PHYSICAL EXAM:
.
Tm: 36.8 ??????C (98.2 ??????F), Tc: 36.8 ??????C (98.2 ??????F)HR: 78 (73 - 102)
bpm
BP: 102/61(65) {94/51(58) - 131/113(117)} mmHgRR: 19 (19 - 25)
insp/min
SpO2: 97%
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: RRR, nl S1/S2, no m/r/g S4, no elevated JVP
Peripheral Vascular: 2+ peripheral pulses in UE??????s and LE??????s
Respiratory / Chest: CTAB, no rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No significant LE edema
Skin: Not assessed
Neurologic: CN??????s III-XII intact, [**3-21**] motor in BUE and BLE??????s, no
gross sensory deficits
Pertinent Results:
ADMISSION LABS:
.
[**2165-9-9**] 10:20AM BLOOD WBC-10.2 RBC-5.15 Hgb-16.1 Hct-45.2
MCV-88 MCH-31.2 MCHC-35.5* RDW-12.5 Plt Ct-278
[**2165-9-9**] 10:20AM BLOOD Neuts-73.5* Lymphs-18.7 Monos-5.3 Eos-1.9
Baso-0.5
[**2165-9-9**] 10:20AM BLOOD Plt Ct-278
[**2165-9-9**] 06:15PM BLOOD Plt Ct-308
[**2165-9-9**] 10:20AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-138
K-3.6 Cl-102 HCO3-25 AnGap-15
[**2165-9-9**] 10:20AM BLOOD Lipase-61*
[**2165-9-9**] 10:20AM BLOOD CK-MB-4
[**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01
[**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64*
[**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66*
.
PERTINENT LABS:
.
[**2165-9-10**] 04:25AM BLOOD CK(CPK)-423*
[**2165-9-9**] 10:20AM BLOOD Lipase-61*
[**2165-9-9**] 10:20AM BLOOD CK-MB-4
[**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01
[**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64*
[**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66*
[**2165-9-10**] 04:25AM BLOOD %HbA1c-5.4 eAG-108
[**2165-9-10**] 04:25AM BLOOD Triglyc-150* HDL-38 CHOL/HD-3.6
LDLcalc-67 LDLmeas-79
.
DISCHARGE LABS:
.
[**2165-9-11**] 06:00AM BLOOD WBC-9.1 RBC-4.98 Hgb-15.2 Hct-44.5 MCV-90
MCH-30.5 MCHC-34.1 RDW-12.4 Plt Ct-298
[**2165-9-11**] 06:00AM BLOOD Plt Ct-298
[**2165-9-11**] 06:00AM BLOOD PT-11.8 PTT-27.9 INR(PT)-1.0
[**2165-9-11**] 06:00AM BLOOD Glucose-105* UreaN-11 Creat-0.8 Na-136
K-4.1 Cl-103 HCO3-25 AnGap-12
[**2165-9-11**] 06:00AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
.
MICRO/PATH:
.
MRSA Screening: PENDING
.
IMAGING/STUDIES:
.
Cardiac Cath [**2165-9-9**]:
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of ISRS proximal LAD with BMS.
3. Successful RRA TR band.
.
ECG [**2165-9-6**]:
Sinus rhythm. Resolution of anterior ST segment elevation.
Morphology of this tracing is identical to that seen on tracing
#1. Right bundle-branch block is no longer seen.
.
TTE [**2165-9-10**]: LVEF 60%
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). However, the midventricular segment of the anterior
and lateral walls appears hypokinetic. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. There is
mild bileaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2162-9-17**], the findings are similar.
Brief Hospital Course:
51 year-old male with a past medical history of NSTEMI in [**2161**]
s/p POBA to the culprit occluded ramus and DES to the LAD,
hyperlipidemia, depression presenting with acute onset chest
pain this morning, symptoms indicative of unstable angina, new
RBBB, J point elevations on ECG, now s/p BMS to mid LAD lesion.
.
ACTIVE DIAGNOES:
.
# NSTEMI S/P BMS to LAD: Pt presented same day with acute
severe anginal chest pain, ECG showed NSR, new RBBB, right asix
deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S wave in
V4/V5, 1-2 mm STE in v3/v4. Code STEMI was called, patient
started on ASA 325mg, heparin drip, loading dose of Plavix,
started on an integrillin drip, and taken to the cath lab. Cath
showed aneurysm formation within the DES to the LAD, with stents
widely patent except for a 70-80% stenosis in the mid LAD. This
lesion was ballooned and a BMS (Integrity) placed to mid LAD.
His pain rapidly improved and follow-up EKG's showed resolution
of his RBBB and normal sinus rhythm. TTE showed LVEF of 60% but
the midventricular segment of the anterior and lateral walls
appear hypokinetic. He was discharged on 325 aspirin daily, 75mg
plavix, 25 metoprolol tartrate [**Hospital1 **], and re-started on his prior
home crestor with follow-up arranged with his outpt PCP and
cardiologist. He was instructed to to stop his niacin and
ibuprofen.
.
CHRONIC DIAGNOSES:
.
# HLD: Stable. Total Chol 135, Trigs 150, HDL 38, LDL 79. He was
re-started on his home crestor 5mg PO 3 days weekly. He did not
previously tolerate atorvaststain (developed weakness and
abdominal pain) and has had trouble with other statins
previously.
.
# Depression: Stable. Continued on his home citalopram.
.
TRANSITIONAL ISSUES:
.
1)Pt has new BMS to mid LAD, on plavix and ASA 325mg. Follow-up
set up with his home cardiologist who will manage his cardiac
meds.
2)Pt has history of poor medication compliance especially with
statin drugs. His LDL was 79 here, would likely benefit from
aggressive lowering to <70. He is on the largest dose of crestor
that we think he will presently tolerate. Would attempt to
uptitrate as an outpatient.
Medications on Admission:
- Citalopram 20 mg
- Ibuprofen 400 TID PRN
- Niacin [Niaspan Extended-Release] 500 mg PO BID
- NG .4 SL PRN
- Crestor 5 mg once a day
- Tacrolimus [Protopic] 0.1 % Ointment apply to affected areas
[**Hospital1 **]
- Aspirin 81 mg
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO three times a
week.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST Elevation myocardial infarction
Dyslipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 93439**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
having a heart attack. You had a catheterization of your heart,
and you were found to have a blockage in your left anterior
descending artery that was cleared and a bare metal stent was
placed. You will need to take plavix and aspirin every day for
at least one month and likely for much longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you that it
is OK. You should continue to take your other medicines as noted
below. Please follow physical therapy instructions for activity
for the next few weeks.
.
We made the following changes to your medicines:
1. STOP taking Ibuprofen, take tylenol as needed for pain
instead
2. Increase aspirin to 325 mg daily
3. START taking clopidogrel (Plavix) to keep the stent from
clotting off and causing another heart attack. Only Dr. [**Last Name (STitle) **]
will tell you when it is OK to stop this medicine
4. START taking metoprolol twice daily to help your heart
recover from the heart attack.
5. Continue Crestor at 5 mg daily to lower your cholesterol.
Please try to take every day if you can.
6. STOP taking niacin per Dr. [**Last Name (STitle) **]
Followup Instructions:
Department: PSYCHIATRY
When: MONDAY [**2165-10-21**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2165-9-13**] at 3:00 PM
With: [**Doctor First Name 26**] KOPLOW, LICSW [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2165-11-7**] at 9:10 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2165-9-16**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2165-9-25**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2165-9-11**]
|
[
"41401",
"412",
"V4582",
"2724"
] |
Admission Date: [**2168-4-12**] Discharge Date: [**2168-4-19**]
Date of Birth: [**2083-10-6**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Codeine
Attending:[**Attending Info 65513**]
Chief Complaint:
Ovarian CA
Major Surgical or Invasive Procedure:
Exploratory laparotomy, bilateral salpingoophorectomy,
omentectomy, tumor debulking
History of Present Illness:
Ms. [**Known lastname 47164**] is an 84 year old with HTN, HL, DM, and AF who was
referred to see Dr. [**Last Name (STitle) 5797**] on [**2168-4-12**] after an evaluation for
constipation found large, bilateral cystic pelvic masses that
appeared to arise from her ovary. Imaging showed evidence of
metastatic abdominal/pelvic disease and she had markedly
elevated CA-125. Paracentesis was performed on consult day,
cytology was nondiagnostic, there was no evidence of malignant
cells identified. CT scan of the chest did not show any evidence
of intrathoracic metastatic disease but disease was noted in the
upper abdomen.
Past Medical History:
-Recent diagnosis of peritoneal vs. ovarian Ca
-hypothyroidism
-hypercholesterolemia
-history of a duodenal ulcer
-diabetes,
-osteopenia
-hypertension
-chronic renal disease
-atrial fibrillation (on Coumadin prior to decision for surgery)
-hysterectomy years ago for nonmalignant disease
Social History:
Lives in senior housing with her husband, no smoking or EtOH
Family History:
Per notes daughters with breast Ca. Brother with [**Name2 (NI) 499**] cancer.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical Exam on admission to [**Hospital Unit Name 153**]
T 99.2 ??????F, HR: 91, BP: 105/44, RR:14, SpO2: 95% on 4L
NAD
RRR
CTAB
Abd soft, appropriately TTP, no rebound or guarding
Incision with dressing clean/dry/intact
LT NT/+boots
On discharge:
VS: T96.5 BP 149/85 (range 122/68-149/85) HR 97 (range 73-110)
RR 20 O2sat 98% on RA
NAD
Irregularly irregular rate and rhythym, normal S1 and S2, grade
II/VI holosystolic murmur (present per OMR since [**2166**])
CTAB with mildly decreased breath sounds at the bases
Abdomen soft, appropriately tender to palpation, no rebound or
guarding +BS
Incision with staples, clean, dry, intact, no areas of drainage
No staining of peripad
LE mildly tender (baseline), [**12-13**]+ edema bilaterally
DP pulses 2+
Pertinent Results:
[**2168-4-12**] 05:03PM BLOOD WBC-19.8*# RBC-3.49* Hgb-9.6* Hct-29.2*
MCV-84 MCH-27.5 MCHC-32.8 RDW-14.8 Plt Ct-337
[**2168-4-13**] 03:22AM BLOOD WBC-14.4* RBC-2.89* Hgb-8.0* Hct-24.7*
MCV-85 MCH-27.8 MCHC-32.5 RDW-14.7 Plt Ct-287
[**2168-4-12**] 05:03PM BLOOD Plt Smr-NORMAL Plt Ct-337
[**2168-4-13**] 03:22AM BLOOD PT-17.2* PTT-40.3* INR(PT)-1.5*
[**2168-4-13**] 03:22AM BLOOD Plt Ct-287
[**2168-4-13**] 10:37AM BLOOD Plt Ct-299
[**2168-4-12**] 05:03PM BLOOD Glucose-152* UreaN-33* Creat-1.0 Na-139
K-4.3 Cl-114* HCO3-20* AnGap-9
[**2168-4-13**] 03:22AM BLOOD Glucose-95 UreaN-29* Creat-1.2* Na-139
K-4.1 Cl-111* HCO3-22 AnGap-10
[**2168-4-12**] 05:03PM BLOOD Calcium-6.9* Phos-4.0 Mg-1.3*
[**2168-4-13**] 03:22AM BLOOD Mg-2.1
[**2168-4-12**] 11:34AM BLOOD Type-ART Rates-/10 Tidal V-480 pO2-174*
pCO2-34* pH-7.41 calTCO2-22 Base XS--1 Intubat-INTUBATED
Vent-CONTROLLED
[**2168-4-12**] 01:03PM BLOOD Type-ART Tidal V-480 pO2-207* pCO2-34*
pH-7.42 calTCO2-23 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2168-4-12**] 02:31PM BLOOD Type-ART Tidal V-470 PEEP-2 FiO2-61 O2
Flow-1 pO2-236* pCO2-38 pH-7.36 calTCO2-22 Base XS--3
Intubat-INTUBATED Vent-CONTROLLED
[**2168-4-12**] 05:18PM BLOOD Type-ART pO2-176* pCO2-40 pH-7.28*
calTCO2-20* Base XS--7 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2168-4-12**] 11:34AM BLOOD Glucose-245* Lactate-1.4 Na-132* K-3.4*
Cl-101
[**2168-4-12**] 01:03PM BLOOD Glucose-201* Lactate-1.8 Na-133* K-3.6
Cl-104
[**2168-4-12**] 02:31PM BLOOD Glucose-179* Lactate-1.5 Na-134* K-3.9
Cl-104
[**2168-4-12**] 05:18PM BLOOD Glucose-143* Lactate-2.1* Na-135 K-3.9
Cl-115*
[**2168-4-13**] 10:46AM BLOOD Lactate-1.2
[**2168-4-12**] 11:34AM BLOOD Hgb-9.3* calcHCT-28 O2 Sat-98
[**2168-4-12**] 01:03PM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-98
[**2168-4-12**] 02:31PM BLOOD Hgb-12.7 calcHCT-38 O2 Sat-98
[**2168-4-12**] 05:18PM BLOOD Hgb-9.2* calcHCT-28 O2 Sat-98
[**2168-4-12**] 11:34AM BLOOD freeCa-1.11*
[**2168-4-12**] 01:03PM BLOOD freeCa-1.07*
[**2168-4-12**] 02:31PM BLOOD freeCa-1.24
[**2168-4-12**] 05:18PM BLOOD freeCa-1.09*
Radiology:
KUB [**2168-4-15**]: FINDINGS: Surgical staples are seen along the
midline. There is a diffuse haze to the abdomen, which could
reflect ascites. No dilated loops of small bowel are seen. Air
is seen in the rectum. No free intraperitoneal air seen. There
are scattered air-fluid levels.
IMPRESSION:
1. No evidence of obstruction.
2. Ascites.
EKG [**2168-4-12**]:
Atrial flutter with ventricular premature beat. Low limb and
lateral precordial lead QRS voltage. Delayed R wave progression
with late precordial QRS transition. Modest low amplitude T wave
changes. Findings are non-specific. Since the previous tracing
of [**2167-4-5**] atrial flutter has replaced sinus rhythm, ventricular
ectopy is present and limb lead QRS voltage is lower.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 0 94 394/451 0 1 75
Pathology Report:
SPECIMEN SUBMITTED: OMENTAL BIOPSY, RIGHT FALLOPIAN TUBE AND
OVARY, Tumor From Hepatic Flexure, OMENTUM, LEFT FALLOPIAN TUBE
AND OVARY, UMBILICAL TUMOR.
Procedure date Tissue received Report Date Diagnosed by
[**2168-4-12**] [**2168-4-12**] [**2168-4-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 14739**]/lo??????
DIAGNOSIS:
I. Omentum, biopsy (A-B):Involvement by serous borderline
tumor, see synoptic report.
II. Fallopian tube and ovary, right (C-H): Serous borderline
tumor with desmoplastic invasive implants on the fallopian and
ovarian surfaces.
III. Abdomen, hepatic flexure soft tissue (I-L): Desmoplastic
noninvasive implants of serous borderline tumor.
IV. Omentum (M-P):Invasive implant of serous borderline tumor.
V. Fallopian tube and ovary, left (Q-U): Serous borderline
tumor with desmoplastic implant or ovarian surface. Fallopian
tube not identified.
VI. Umbilicus (V-Y): Desmoplastic invasive implant of serous
borderline tumor.
[**2168-4-19**] 06:30
COMPLETE BLOOD COUNT
White Blood Cells 9.7 4.0 - 11.0 K/uL
Red Blood Cells 4.21 4.2 - 5.4 m/uL
Hemoglobin 12.1 12.0 - 16.0 g/dL
Hematocrit 37.7 36 - 48 %
MCV 90 82 - 98 fL
MCH 28.8 27 - 32 pg
MCHC 32.2 31 - 35 %
RDW 15.6* 10.5 - 15.5 %
Platelet Count 481* 150 - 440 K/uL
[**2168-4-17**] 06:25
COMPLETE BLOOD COUNT
White Blood Cells 9.0 4.0 - 11.0 K/uL
Red Blood Cells 3.89* 4.2 - 5.4 m/uL
Hemoglobin 11.3* 12.0 - 16.0 g/dL
Hematocrit 34.0* 36 - 48 %
MCV 88 82 - 98 fL
MCH 29.1 27 - 32 pg
MCHC 33.3 31 - 35 %
RDW 15.3 10.5 - 15.5 %
DIFFERENTIAL
Neutrophils 66.3 50 - 70 %
Lymphocytes 19.7 18 - 42 %
Monocytes 7.0 2 - 11 %
Eosinophils 6.3* 0 - 4 %
Basophils 0.7 0 - 2 %
Platelet Count 396 150 - 440 K/uL
[**2168-4-15**] 03:30
COMPLETE BLOOD COUNT
White Blood Cells 14.2* 4.0 - 11.0 K/uL
Red Blood Cells 2.89* 4.2 - 5.4 m/uL
Hemoglobin 8.2* 12.0 - 16.0 g/dL
Hematocrit 25.6* 36 - 48 %
MCV 89 82 - 98 fL
MCH 28.3 27 - 32 pg
MCHC 32.0 31 - 35 %
RDW 15.0 10.5 - 15.5 %
DIFFERENTIAL
Neutrophils 82.2* 50 - 70 %
Lymphocytes 10.1* 18 - 42 %
Monocytes 5.5 2 - 11 %
Eosinophils 1.7 0 - 4 %
Basophils 0.4 0 - 2 %
Platelet Count [**Telephone/Fax (3) 86652**] K/uL
[**2168-4-19**] 06:30
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 28.4* 10.4 - 13.4 sec
PTT 37.3* 22.0 - 35.0 sec
INR(PT) 2.7* 0.9 - 1.1
[**2168-4-15**] 03:30
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 16.4* 10.4 - 13.4 sec
PTT 33.8 22.0 - 35.0 sec
INR(PT) 1.4* 0.9 - 1.1
[**2168-4-18**] 06:25
RENAL & GLUCOSE
Glucose 103* 70 - 100 mg/dL
Urea Nitrogen 14 6 - 20 mg/dL
Creatinine 0.9 0.4 - 1.1 mg/dL
Sodium 141 133 - 145 mEq/L
Potassium 4.5 3.3 - 5.1 mEq/L
Chloride 107 96 - 108 mEq/L
Bicarbonate 24 22 - 32 mEq/L
Anion Gap 15 8 - 20 mEq/L
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
Phosphate 3.3 2.7 - 4.5 mg/dL
Magnesium 1.8 1.6 - 2.6 mg/dL
[**2168-4-14**] 17:38
RENAL & GLUCOSE
Glucose 216* 70 - 100 mg/dL
Urea Nitrogen 33* 6 - 20 mg/dL
Creatinine 1.3* 0.4 - 1.1 mg/dL
Sodium 135 133 - 145 mEq/L
Potassium 4.1 3.3 - 5.1 mEq/L
Chloride 105 96 - 108 mEq/L
Bicarbonate 20* 22 - 32 mEq/L
Anion Gap 14 8 - 20 mEq/L
Calcium, Total 7.4* 8.4 - 10.3 mg/dL
Phosphate 2.9 2.7 - 4.5 mg/dL
Magnesium 2.0 1.6 - 2.6 mg/dL
[**2168-4-14**] 5:00 pm URINE Source: Catheter.
**FINAL REPORT [**2168-4-15**]**
URINE CULTURE (Final [**2168-4-15**]): NO GROWTH.
Brief Hospital Course:
On [**4-12**], the patient had bilateral salpingo-oophorectomy, tumor
debulking, and omentectomy. 3L of ascites were drained at
surgery and EBL was 500 ml. She was transfused 1 unit PRBCs
intraop. Please see operative reporte in OMR for further
details. Overall she tolerated the procedure well with no
immediate complications observed, though her post-op course was
notable for brief ICU monitoring for fluid shifts. On [**2168-4-14**]
patient able to maintain good urine output and was transferred
to the gyn floor.
On the floor, her problems were managed as follows:
# Post-op: She was able to ambulate with walker assist by
discharge after being seen by PT. Her pain was well controlled
with oral pain medications. Her catheter was discontinued and
she was able to void easily. She had good return of bowel
function by discharge and her diet was advanced appropriately.
# Atrial flutter/fibrillation: Pt has a history of AFib with
RVR. Anticoagulants were held after procedure but she continued
on nodal agents with good rate control. Her diltiazem was
initially started at 30mg four times daily, and by the time of
discharge was increased to 60mg four times daily. Coumadin was
restarted on [**4-17**] with a Lovenox bridge; on the day of discharge
her INR was noted to be 2.7 on 2.5mg Coumadin daily.
# HTN/HPL: She was restarted on her home HCTZ. She also was
restarted on home statin.
# Diabetes mellitus: Her home regimen was NPH 30am and 10QHS
with Humalog 5 at breakfast, 2 lunch, 2 at dinner. Post-op she
was started on an insulin sliding scale with goal to keep values
<175. Once her diet was advanced to sips, she was restarted on
her home NPH doses. These were gradually decreased as her
glucose control was excellent, and she was discharged on only
NPH 24units in the morning with a humalog sliding scale for
meals.
# CKD: Her Cr during this hospitalization was noted to be better
than previous baseline values. She did initially have low urine
output that resolved after fluid boluses. She was given Lasix
twice after blood transfusions.
# Urinary urgency: Her home oxybutinin was held, and could be
restarted as an outpatient if this problem re-presents itself.
# Anemia: She was ultimately transfused 3 units PRBCs with good
response and her Hct on discharge was 37.7%.
# Hypothyroidism: She was continued on her home doses of
levoxyl.
She was ultimately discharged to rehab in good condition on
POD#7.
Medications on Admission:
-Insulin Regular Human 5 units w/breakfast, 2 units w/lunch & 2
units with dinner
-NPH insulin: 30 units QAM and 10 units QPM
-Diltiazem HCl 240 mg daily
-Pravastatin 40 mg every evening
-Hydrochlorothiazide 32.5 mg daily
-Levothyroxine 100 mcg DAILY
-Oxybutynin Chloride 2.5 mg PO BID
-Ranitidine 150 MG TAB at bedtime daily
-Vitamin D 1,000 UNIT daily
-MVI daily
-Fluticasone Proprionate 110 mc 2 puffs inhaled [**Hospital1 **]
(has been holding ASA and coumadin)
.
Meds on Transfer to ICU:
-HYDROmorphone 0.125-0.25 mg SC Q4H:PRN pain
-Insulin SC
-Levothyroxine Sodium 100 mcg PO/NG DAILY
-Diltiazem 60 mg PO/NG QID
-Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
-Pantoprazole 40 mg IV Q24H
-Heparin 5000 UNIT SC TID Order date: [**4-12**] @ 1700
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia.
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule PO
DAILY (Daily).
7. diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day): Hold for systolic BP < 100 or diastolic BP <60 or
HR < 60.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous with meals: per printed sliding scale.
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Four (24) units Subcutaneous every morning.
12. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
13. multivitamin Capsule Sig: One (1) Capsule PO once a day.
14. Outpatient Lab Work
Please check INR weekly to monitor coumadin therapy
15. enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous [**Hospital1 **] (2 times a day).
16. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You underwent surgery for masses on your ovaries suspicious for
cancer. Overall, your postoperative course was uncomplicated. We
are sending you to a rehab facility for continued management of
your other medical problems to assist in the healing process.
Your staples should be removed in the rehab facility.
Call your doctor for:
* fever > 101
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from your incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* No strenuous activity, no heavy lifting of objects >10lbs for
6 weeks.
* Nothing in the vagina (no tampons, no douching, no sex), for
3 months
* You may eat a regular diet.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
Followup Instructions:
You have a post-op appointment with Dr. [**Last Name (STitle) 5797**] in the [**Hospital Ward Name 23**]
Center [**Location (un) **] clinic:
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2168-5-2**] 10:00
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
Completed by:[**2168-4-19**]
|
[
"2449",
"2724",
"V5867",
"40390",
"5859",
"42731"
] |
Admission Date: [**2157-9-4**] Discharge Date: [**2157-9-7**]
Date of Birth: [**2122-9-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34 yo female with history of alcohol abuse, Hepatitis C
infection, who presents to [**Hospital1 18**] ED for assistance with alcohol
detox and symptoms of withdrawal. She has been drinking 1L of
vodka daily. She had her last drink at 7pm last night. She now
feels mildly nauseated, anxious and shaky. No hallucinations,
recent seizures, or loss of consciousness. But she does report a
history of several falls, known b/l clavicle fractures. She does
not recall the circumstances surrounding the falls and reports
being intoxicated at those times. She has had many admission for
EtOH withdrawal ([**Hospital1 2177**] and [**Hospital 1263**] Hospital). She reports
convulsions from these - but unclear whether severe tremor or
actual seizure. She presents today because she was feeling
poorly overall - pain from fractures as well as L hip and L knee
pain and she would like rehab.
.
In the ED she received a banana bag, 2mg IV ativan and a total
of 30mg of IV diazepam.
Past Medical History:
- Alcohol abuse
- Hepatitis C
- h/o pancreatitis
Social History:
- Tobacco: 1 ppd
- etOH: 1L vodka daily
- Illicits: marijuana (told nursing), remote hx of IDVA
Family History:
No family history of alcohol abuse
Physical Exam:
GEN: Apparently anxious and tremulous
VS: 98.2 116 140/93 19 97% on RA CIWA 18
HEENT: MMM, no OP lesions, JVP 7cm, neck is supple, no cervical,
supraclavicular, or axillary LAD , tenderness over b/l clavicles
L chest with eschar and minimal surrounding erythema approx
1.5cm.
CV: tachycardia, regular, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic
liver disease
LIMBS: Bruising over L hip, tenderness at the site though full
ROM, No LE edema, +tremor at rest and with intention, no
clubbing
SKIN: No rashes, superficial facial laceration - eyebrow
NEURO: Nonfocal, alert and oriented x 3, conversive, able to
answer questions and follow commands, fully awake throughout
interview. Moving all extremities purposefully
Pertinent Results:
Labs on Admission:
[**2157-9-4**] 08:05PM UREA N-6 CREAT-0.5 SODIUM-137 POTASSIUM-3.0*
CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
[**2157-9-4**] 08:05PM CALCIUM-7.6* PHOSPHATE-2.1* MAGNESIUM-1.5*
[**2157-9-4**] 10:50AM URINE HOURS-RANDOM
[**2157-9-4**] 10:50AM URINE UCG-NEGATIVE
[**2157-9-4**] 10:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2157-9-4**] 10:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2157-9-4**] 10:50AM URINE BLOOD-TR NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2157-9-4**] 10:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0
[**2157-9-4**] 10:12AM GLUCOSE-111* UREA N-7 CREAT-0.5 SODIUM-142
POTASSIUM-2.9* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2157-9-4**] 10:12AM estGFR-Using this
[**2157-9-4**] 10:12AM ALT(SGPT)-28 AST(SGOT)-56* LD(LDH)-440* ALK
PHOS-78 TOT BILI-0.6
[**2157-9-4**] 10:12AM LIPASE-61*
[**2157-9-4**] 10:12AM ALBUMIN-4.0 CALCIUM-8.1* PHOSPHATE-2.5*
MAGNESIUM-1.4*
[**2157-9-4**] 10:12AM ASA-NEG ETHANOL-150* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-9-4**] 10:12AM WBC-5.9 RBC-3.80* HGB-11.8* HCT-35.1* MCV-92
MCH-30.9 MCHC-33.5 RDW-14.8
[**2157-9-4**] 10:12AM NEUTS-76.6* LYMPHS-16.8* MONOS-3.3 EOS-2.7
BASOS-0.6
[**2157-9-4**] 10:12AM PLT COUNT-182
.
UA:
Moderate blood, sperm, 3 WBC, few bacteria. Nitrite negative.
Tr leukocytes. No culture sent.
.
Labs on Transfer:
[**2157-9-5**] 03:34AM BLOOD WBC-6.7 RBC-3.64* Hgb-11.9* Hct-33.8*
MCV-93 MCH-32.8* MCHC-35.4* RDW-14.7 Plt Ct-140*
[**2157-9-5**] 04:11AM BLOOD PT-10.9 PTT-39.3* INR(PT)-0.9
[**2157-9-5**] 03:34AM BLOOD Glucose-105* UreaN-6 Creat-0.5 Na-135
K-3.8 Cl-99 HCO3-27 AnGap-13
[**2157-9-5**] 03:34AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
.
Imaging:
[**9-4**] CXR: IMPRESSION: No acute displaced rib fractures. Please
refer to the concurrent
dedicated radiograph for clavicular fracture evaluation.
.
[**9-4**] Clavic XR: 1. Subacute bilateral distal clavicular
fractures with early callus formation.
2. Asymmetric foreshortening of the right clavicle as described
above.
.
[**9-4**] CT-HEAD w/o contrast: IMPRESSION: No acute intracranial
process.
.
Microbiology:
[**2157-9-4**] 10:50 am URINE Site: CATHETER
**FINAL REPORT [**2157-9-7**]**
URINE CULTURE (Final [**2157-9-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >100,000
ORGANISMS/ML..
.
Discharge labs:
[**2157-9-6**] 09:10AM BLOOD WBC-5.5 RBC-3.60* Hgb-11.4* Hct-33.6*
MCV-93 MCH-31.5 MCHC-33.7 RDW-13.9 Plt Ct-147*
[**2157-9-7**] 06:40AM BLOOD Glucose-113* UreaN-15 Creat-0.6 Na-137
K-3.6 Cl-101 HCO3-31 AnGap-9
[**2157-9-7**] 06:40AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.9
Brief Hospital Course:
34 yo woman with hx of alcohol abuse and hepatitis C infection
who presents with alcohol withdrawal.
.
# Alcohol withdrawal: She was initially admitted to the ICU with
a subjective history of "convulsions" concerning for a history
of seizures. Remained stable overnight HD1 into HD2 on Diazepam
PO q1hr for CIWA > 10. Trazodone was held. Social work was
consulted. Banana bag was given, lytes aggressively repleted.
She was transferred to the floor and remained on the CIWA
protocol. She was slowly detoxed. She was seen by social work
and offered information on inpatient detox facilities. She
however opted to arrange, through her father, admission to a
detox unit to continue her detoxification and efforts to remaine
sober.
.
# Hepatitis C infection, chronic: No evidence of current liver
dysfunction. LFTs were essentially unremarkable with slightly
elevated AST and Lipase; LDH was 440.
.
# Clavicular fracture, with severe pain: She was admitted after
several falls, in the setting of alcohol intoxication. Imaging
showed old bilateral clavicular fractures and rib fracture. She
ambulated without difficulty and without assist devices. She
did require significant oral pain medications for comfort, and
was discharged with a small supply of oral hydromorphone for
pain. Outpatient orthopedic referral was recommended if pain is
persistent.
.
# Urinary tract infection: She complained of dysuria and poorly
smelling urine after foley was removed. Urinalysis was
equivocal. She was treated with 3 days of ciprofloxacin.
.
Follow up: PCP/ortho, after detox.
Outstanding tests: None.
Medications on Admission:
- Trazodone 150mg po qhs
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*60 Tablet(s)* Refills:*0*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
6. Trazodone 150 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Clavicular fractures
Hepatitis C, chronic
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol withdrawal, and were sent to the
ICU for monitoring. You are still having some symptoms of
withdrawal, but the valium we have given you in the hospital
should slowly leave your system and protect you from worsening
withdrawal symptoms. You should try to find a detox facility.
You asked us not to send you directly to a detoxification
facility.
.
Medication changes:
Take Dilaudid (hydromorphone) 2 mg tabs [**1-15**] every 4 hours for
pain for the next week. See your PCP for other pain medications
after that
Take ciprofloxacin for a UTI for 3 days.
Followup Instructions:
Follow up with your PCP after you leave rehabilitation.
Follow up with an orthopedic surgeon if you continue to have
collar bone pain.
|
[
"5990",
"3051",
"2875"
] |
Admission Date: [**2194-8-19**] Discharge Date: [**2194-8-21**]
Date of Birth: [**2128-4-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Motrin / Latex / IV Dye, Iodine Containing / trees
and grass
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
upper endoscopy with banding of esophageal banding
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 18741**] is a 66-year-old female with a history of
cirrhosis likely due to nonalcoholic steatohepatitis complicated
by hypertensive gastropathy, esophageal varices, and hepatic
encephalopathy who has a PMH sig for reflux, epilepsy, polio
(wheelchair bound), hypertension, hyperlipidemia, post-traumatic
stress disorder, and a questionable history of ITP, who
presented to the ED with melena x 2 days. She has been having
daily regular BMs that are tarry black, no hematochezia. She has
had intermittant nausea but no emesis, and no decrease in
appetite. She has been having epistaxis for the last 3 days as
well, can not quantify amount. She denies fevers, but gets
chills frequently. She also occasionally notes abdominal
cramping in the morning but has no pain currently. She also
denies dizziness, cough, CP, increased lethargy or confusion.
.
Of note, the patient was hospitalized recently on [**2194-7-4**]
with melena and was found to have 3 cords of nonbleeding grade 2
varices, which were banded. She then underwent a repeat
endoscopy on [**2194-7-15**] revealing abnormal mucosa in two areas
compatible with esophageal band ulceration as well as portal
hypertensive gastropathy but no esophageal or gastric varices
were noted. The patient was started on Carafate and omeprazole.
She recently followed up in clinic with Dr. [**Last Name (STitle) 497**] on [**2194-7-24**] and
her nadolol was decreased down from 40 mg down to 20 mg due to
hypotension and bradycardia.
.
In the ED: VS 97.2 106/47 57 18 99% RA. NG lavage showed bright
red blood, no coffee grounds, that cleared with 200 cc of NS.
She had an 18 G IV placed and was started on octreotide and
protonix gtt. Hct was 32 (at baseline, but down from previous
Hct 37 a month ago). CXR for NGT placement showed haziness over
the left base, poor inspiratory film.
.
ROS was positive for recent HA and a hx of seizures. She is
followed by Dr. [**First Name (STitle) 437**] and was recently changed from zonisamide
to Keppra, now uptitrated to 1000mg [**Hospital1 **]. ROS also positive for
urinary frequency last week without dysuria, and she denies this
currently.
.
On the floor, patient appeared comfortable but drowsy. She
denied pain or other complaint.
Past Medical History:
ITP-extent of evaluation unclear
[**Name2 (NI) 87200**] bleeding s/p D&C
GERD
EPILEPSY
POLIO, wheel chair bound
HTN
HLD
PTSD
Asthma
Social History:
Pt lives at home with her husband. Does not have any children.
Is wheelchair bound.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No hx of liver disease
Grandmother with Myasthenia [**Name (NI) **]
Mother with Breast Ca
Physical Exam:
Admission Exam:
Vitals: T: 98.6 BP: 115/54 P: 60 R: 18 O2:97%
General: Alert, oriented x 3 but speaking very slowly, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: + BS, obese, vertical low abdominal scar, soft,
non-tender, non-distended, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: hyper and hypopigmnted areas on back, chest, arm, dorsum
of foot
Neuro: CN II-XII intact, [**5-15**] upper extremity strength, [**5-15**] RLE
strength, [**4-15**] LLE strength, sensation intact.
Pertinent Results:
Admission labs:
[**2194-8-19**] 12:12PM BLOOD WBC-4.7 RBC-3.45* Hgb-11.0* Hct-32.1*
MCV-93 MCH-31.9 MCHC-34.3 RDW-16.1* Plt Ct-73*
[**2194-8-19**] 12:12PM BLOOD Neuts-79* Bands-1 Lymphs-15* Monos-3
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2194-8-19**] 12:12PM BLOOD PT-16.3* PTT-31.2 INR(PT)-1.4*
[**2194-8-19**] 12:12PM BLOOD Glucose-117* UreaN-17 Creat-0.6 Na-142
K-4.0 Cl-112* HCO3-21* AnGap-13
.
CXR [**2194-8-19**]
FINDINGS: Portable chest radiograph demonstrates interval
placement of a
nasogastric tube, which can be followed to the level of distal
esophagus.
However, the nasogastric tube tip nor side port cannot be
clearly seen. Heart size is slightly enlarged, but this may be
exaggerated by AP portable technique and bilateral low lung
volumes. No focal opacification identified. The left
costophrenic angle excluded from view. New right pleural
effusion evident.
IMPRESSION: Nasogastric tube followed to level of distal
esophagus and then cannot be clearly seen - consider repeat to
assess position of tip.
.
Brief Hospital Course:
Ms. [**Known lastname 18741**] is a 66 YOF with NASH cirrhosis and recent variceal
bleed s/p banding who presented with melena for three days in
the setting of epistaxis and was found to have variceals with
possible bleeding that are s/p banding
.
# Upper GI bleed: Likely variceal bleed. Patient underwent
urgent EGD in the ICU. 1 cords of grade II varices were seen in
the lower third of the esophagus and there was a red whale spot
suggestive of recent bleeding. Portal gastropathy was also
present. There was also blood in the stomach body but this was
likely related to scope trauma. The varix was banded and the
patient remained hemodynamically stable with stable Hct.
Octreotide was continued overnight the night of admission, and
then stopped prior to patient leaving MICU. Pt able to tolerate
po the day after banding, so PPI changed to po. She tolerated
clears and was advanced to soft solids prior to leaving MICU.
Hct remained stable. Patient was discharged with plan for
repeat EGD and colonoscopy as an outpatient. She was discharged
to complete 5 day course of Bactrim for SBP prophylaxis.
# NASH cirrhosis: Mild asterixis on admission exam, but oriented
and denies confusion. Re-started nadolol, rifaximin, lactulose
when taking po.
# Epilepsy: Pt recently transitioned from zonisamide to Keppra.
Given IV keppra while NPO and changed back home PO in the
morning. Discharged on PO Keppra.
Medications on Admission:
ALBUTEROL SULFATE
FLUTICASONE
pantoprazole 40 PO Q day
zofran ODT 4 mg 1 tab Q8 PRN nausea
LATANOPROST [XALATAN] - 0.005 %Drops - 1 drop by eye daily
LEVETIRACETAM - 1000mg [**Hospital1 **]
NADOLOL - 20 mg Q day
OMEPRAZOLE - 40 mg Q day
PREGABALIN [LYRICA] - 300 mg Capsule HS
RIFAXIMIN [XIFAXAN] - 550 mg [**Hospital1 **] - not refilled since [**Month (only) **]
SIMVASTATIN - 20 mg Q day - not filled since [**Month (only) 116**]
LACTULOSE - 10 gram/15 mL Solution - 30 ml(s)TID - not refilled
since [**Month (only) 116**]
PRAMIPEXOLE - 1.5 mg Tablet HS
SUCRALFATE - 1 gram/10 mL Suspension - 10 ml QID
OXYCODONE - 5 mg [**Hospital1 **] PRN - last filled [**Month (only) **]
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pregabalin 75 mg Capsule Sig: Four (4) Capsule PO QHS (once a
day (at bedtime)).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
11. pramipexole 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Life Care at Home of [**State 350**]
Discharge Diagnosis:
Bleeding esophageal varix
Melena
Discharge Condition:
Condition: Stable.
Mental status: Alert, oriented x3
Ambulatory status: walks with walker
Discharge Instructions:
Hello Ms. [**Known lastname 18741**],
You were admitted to the Medical Intensive Care Unit after two
days of black stool. An endoscopic study found a lower
esophageal blood vessel that had been bleeding, and this was
banded. While you were in the ICU, and after you were moved to
the regular medicine floor, your blood count remained stable.
The following changes were made to your medications:
1. Added Bactrim to protect from developing an infection.
Please take for the next 4 days.
2. Increased your pantoprazole to twice daily.
3. Stopped zonisamide.
Followup Instructions:
You have the following appointment scheduled.
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**]
Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2194-8-28**] 12:40PM
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2194-10-3**] 8:20AM
For your endoscopy and colonoscopy on [**10-14**]:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS
Date/Time:[**2194-10-14**] 9:00
|
[
"4019",
"2724",
"53081"
] |
Admission Date: [**2180-12-7**] Discharge Date: [**2180-12-16**]
Date of Birth: [**2134-10-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 46 year old woman with a hx of DM who presents
from [**Hospital3 3583**] with a STEMI. She reports awaking at 6am
with 9/10 chest pain across her chest, radiating to the left arm
and jaw. She went to work today and left at 2pm due to the pain.
She presented to [**Hospital3 3583**] at 4pm and ECG showed ST
elevations and q waves in V1-V3. She was given aspirin,
metoprolol, plavix 600mg x1, heparin gtt, nitro gtt, integrilin
gtt. She was transferred to the [**Hospital1 18**] cath lab where cardiac
cath showed acute thrombus of the proximal LAD. This was treated
with thrombectomy and BMS x 1. She was revascularized at 6:30am.
.
On arrival to the floor, she rates the pain as [**12-27**]. She denies
shortness of breath, nausea or vomiting. She states that she did
have some pain yesterday associated with vomiting but this
resolved on its own after about an hour. She has never had this
kind of pain before.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
Diabetes Mellitus
Social History:
-Tobacco history: smokes 10 cigarettes per day x 15 years
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Mother and father both had diabetes.
Physical Exam:
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 104 (104 - 105) bpm
BP: 97/71(76) {94/65(72) - 108/74(79)} mmHg
RR: 19 (14 - 19) insp/min
SpO2: 99%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 72.2 kg (admission): 72.2 kg
Height: 65 Inch
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL, XANTHOMA on Left eyelid
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Cardiac catheterization [**2180-12-7**]: 1. Selective coronary
angiography in this right dominant system demonstrated one
vessel disease. The LMCA had no angigoraphically apparent
disease. The LAD had a total occlusion in the proximal portion
of the vessel after the D1 which had a very hig take off point.
The LAD was filled with thrombus up to the first septal branch.
The Cx had no angiographically apparent disease. The RCA had no
angigraphically apparent disease.
2. Limited resting hemodynamics revealed elevated left sided
Echocardiogram [**2180-12-8**]: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed (LVEF= 20 %) secondary to
extensive apical akinesis/dyskinesis, anteroseptal akinesis, and
anterior and inferior free wall hypokinesis. A left ventricular
apical mass/thrombus cannot be excluded. Right ventricular
chamber size is normal. with focal hypokinesis of the apical
free wall. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
CXR [**2180-12-8**]: Normal lung volumes. Mild cardiomegaly without
obvious
overhydration. Minimal atelectasis at the left lung base.
Minimal Kerley B
lines seen in the right hemithorax, likely to reflect
interstitial fluid
overload. No focal parenchymal opacity suggesting pneumonia.
Normal
appearance of the mediastinum and the hilar structures.
ABD US
IMPRESSION:
1. No biliary abnormalities. CBD measures 4 mm.
1. 2.7-cm right hepatic lesion, likely hemangioma.
2. Gallbladder sludge without acute cholecystitis.
3. Right pleural effusion.
[**2180-12-7**] 10:04PM BLOOD CK-MB-94* MB Indx-7.6* cTropnT-7.63*
[**2180-12-8**] 04:10AM BLOOD CK-MB-58* MB Indx-5.6 cTropnT-4.65*
[**2180-12-7**] 10:04PM BLOOD ALT-74* AST-181* LD(LDH)-1190*
CK(CPK)-1233* AlkPhos-96 TotBili-0.5
[**2180-12-8**] 04:10AM BLOOD ALT-67* AST-158* LD(LDH)-1170*
CK(CPK)-1031* AlkPhos-87 TotBili-0.6
[**2180-12-9**] 05:51AM BLOOD ALT-77* AST-90* LD(LDH)-846* AlkPhos-205*
TotBili-0.5
[**2180-12-10**] 06:41AM BLOOD ALT-60* AST-42* LD(LDH)-625* AlkPhos-203*
TotBili-0.4
[**2180-12-7**] 10:04PM BLOOD %HbA1c-11.2*
[**2180-12-7**] 10:04PM BLOOD Triglyc-161* HDL-36 CHOL/HD-3.7
LDLcalc-66
[**2180-12-7**] 10:04PM BLOOD Calcium-8.5 Phos-2.7 Mg-1.5* Cholest-134
[**2180-12-10**] 06:41AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.6 Iron-25*
Brief Hospital Course:
SUMMARY
Ms. [**Known lastname **] is a 46 year old woman with a history of DM who
presents with chest pain and STEMI c/b post-STEMI pericarditis.
She presented 2-3 days after onset of MI, received a BMS and had
a course complicated by pericarditis and LV akinesis. She had
very poorly controlled DM and was kept for insulin teaching and
coumadin bridging.
BY PROBLEM
A. STEMI s/p BMS to LAD complicated by:
Systolic Heart Failure (EF 25%)
Pericarditis
LV Akinesis
Sinus Tachycardia
An LAD thrombus was removed and BMS placed. likely [**12-20**]
days after the onset of her MI. ECHO shows extensive HK, AK in
anteroseptal, inferior and apex. EF 20%. She was in sinus
tachycardia as a result of the infarction. Patient had
persistent chest pain relieved best with nsaids x 1 and
colchicine thereafter, she also had diffuse STE indicating
pericarditis. This pericarditis later caused a true fever
(negative cultures, cxr). Ms. [**Known lastname **] eventually did well without
cochicine. She was discharged on ASA, Plavix, Simvastatin 80mg,
Lisinopril and Toprol. She was discharged on coumadin with INR
checks for LV akinesis. She was discharged on low dose
furosemide for fluid maintenance. She was given extensive CHF
and DM teaching via portugese interpreter.
B. Diabetes Mellitus, Type 2. Poorly Controlled with
complications
Her HgA1c was 11.2. She had vision difficulties and
difficult to control blood sugars. Started on insulin and
received intensive teaching. [**Last Name (un) **] consult followed. She was
discharged on a regimen of 70/30 [**Hospital1 **] crafted by [**Last Name (un) **]
C. Elevated LFT??????s:
Ms. [**Known lastname **] had elevated AST/ALT on admission. As these fell,
her alk phos rose. Her bilirubin was consistently normal. A RUQ
ultrasound nl. All other w/u negative (hepatitis serologies,
AMA, [**Doctor First Name **]). The main posibilties are two. She either had a drug
reaction that led to a mixed insult with hepatocellular injury
up front and biliary injury thereafter or she was transiently
hypotensive causing hepatocellular injury vis-a-vis low hepatic
arterial pressure which would explain the predominant elevation
of alkaline phosphatase (biliary injury). All levels resolved by
discharge.
TO BE FOLLOWED
1) INR on coumadin
2) Glucose control on insulin
Medications on Admission:
Glimepiride 8mg PO BID
Metformin 1000mg PO BID
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check INR on Monday [**2180-12-18**] and call results to [**Hospital 18**]
[**Hospital **] clinic at [**Telephone/Fax (1) 2173**]
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Thirty (30) units Subcutaneous before breakfast: Give 15
units before dinner.
Disp:*1 BOTTLE* Refills:*2*
10. Insulin Syringe-Needle U-100 1 mL 27 x [**3-24**] Syringe Sig: One
(1) syringe Miscellaneous twice a day.
Disp:*1 box* Refills:*2*
11. Lancets Misc Sig: One (1) lancet Miscellaneous with
fingersticks.
Disp:*1 box* Refills:*2*
12. One Touch Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] with
fingersticks.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute Systolic congestive Heart Failure, EF 25%
Diabetes Mellitus Type 2
Pericarditis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a large heart attack and your heart is now weak. You
will need to be careful that you avoid salt in your diet and
monitor yourself for fluid retention. Symptoms of fluid
retention are swelling in your legs, trouble breathing, fatigue
or dry cough. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if
weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
You have been started on Insulin to help keep your blood sugars
low. You will need to check your blood sugar twice daily before
your insulin doses. We have given you instructions on what to do
if your blood sugar is too high or too low. Please follow the
diabetic diet that was given to you. You are on many new
medicines to help your heart recover from the heart attack and
to help your heart pump better. You are also on Warfarin and
your INR needs to be checked on Monday [**2180-12-18**].
Medicine changes:
1. Stop taking all of your medicines at home
2. START taking Inuslin
a. Use your long acting insulin (70/30) twice daily, as
directed, at breakfast and bedtime.
3. START taking Warfarin (Coumadin) to prevent blood clots in
your heart. Call Dr. [**Last Name (STitle) **] if you notice dark bowel
movements, your vomit blood or a cut does not stop bleeding. It
is normal to have easy bruising, bleeding gums and mild
nosebleeds on this medicine.
4. START Metoprolol, a beta blocker to help your heart pump
better.
5. START Aspirin 325mg daily to prevent the stent from clotting
off.
6. START Clopidogrel (Plavix) to prevent the stent from clotting
off. Do not stop taking Plavix or aspirin for at least one month
unless Dr. [**First Name (STitle) 437**] tells you to. Stopping these medicines could
cause another heart attack.
7. START taking Lisinopril to help your heart pump better.
8. START taking Fursemide (lasix) to prevent excess fluid from
accumulating.
.
Check your blood sugar using a glucometer before breakfast and
before dinner. Record these readings and bring them to every
doctor's appt.
.
Partners [**Name (NI) 269**] will draw your coumadin level on Monday [**12-18**] and
call the results to [**Hospital1 **].
.
You will be called on monday to arrange your services.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 62**] Date/time: [**2181-1-8**] 1:30PM
.
Primary care:
Dr. [**Last Name (STitle) 86814**] [**Name (STitle) **] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1538**] Phone:
[**Telephone/Fax (1) 250**] Date/Time: Tuesday [**12-26**] 1:45pm. [**Location (un) **], Atrium Suite, [**Hospital Ward Name 23**] clinical Center. [**Hospital Ward Name 516**],
[**Hospital1 18**]. The clinic will contact you regarding ongoing
appointments for blood sugar checks.
.
Partners [**Name (NI) 269**] will draw your Coumadin level on [**2180-12-18**].
.
Completed by:[**2180-12-16**]
|
[
"3051",
"25000",
"4280"
] |
Admission Date: [**2120-11-19**] Discharge Date: [**2120-12-6**]
Date of Birth: [**2040-2-23**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Difficulty ambulating
Major Surgical or Invasive Procedure:
PEG placement [**12-4**].
History of Present Illness:
80 yo F w/ hx of CAD s/p MI, HTN, HLD, and hypothyroidism, had
been at home on Sunday when per report, her legs gave out and
she slowly slid into a chair. There was no report of head or
body trauma. Since then she has been lethargic and largely
bed-bound, with decreased PO intake. She has apparently been
unable to ambulate to the bathroom as the husband reports having
had to clean her soiled clothing in bed. All along her husband
believed this reperesented an orthopedic problem as she had knee
surgery in the past. He attempted to get an office appointment
Mon for her without success. Today when he finally got through,
he was instructed to take her to the ER. When he brought her to
[**Hospital **] Hospital, a head CT revealed a right frontal
hemorrhage; she received 1 g Dilantin, 1 unit of platelets and 2
units of FFP and she was transferred to [**Hospital1 18**].
Past Medical History:
CAD s/p MI and proximal LAD taxus stent
HTN
HLD
hypothyroidism
left knee sx
Social History:
Lives at home with husband
Family History:
Noncontributory
Physical Exam:
T- 101.8F BP- 119/57 HR- 67 RR- 14 O2Sat 100% on 2L NC
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: no carotid bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema, good peripheral pulses bilaterally
Neurologic examination:
Mental status: Sleeping, refuses to open eyes, but will follow
some basic commands including showing tongue or showing 2
fingers. After repeated questioning, ultimately able to state
age and [**Location 27224**], but never states name, date or current
location.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. mild L-NLF flattening. (+) corneal reflex.
Hearing grossly intact. Palate elevates symmetrically. Tongue
protrudes midline.
Motor: Normal bulk bilaterally. Tone increased in the LUE, and
to a
lesser extent LLE. No observed myoclonus or tremor. Moves RUE
spontaneously against gravity. Wiggles ankles B/L spontaneously
right better than left. Withdraws IP's anti gravity to pain, but
will not keep legs up when held for her. Minimal movement of the
LUE, even to bed pressure, but will provide some resistance to
gravity when arm dropped.
Sensation: withdraws RUE and B/L LE to bed pressure. Does not
withdraw LUE.
Reflexes: +2 and symmetric in the UE throughout. 0's at the
patellae and
Achilles B/L. Toes upgoing bilaterally
Coordination and gait: unable to assess
Pertinent Results:
MRI [**2120-11-20**]
Large right frontal lobe intraparenchymal hemorrhage with
associated
vasogenic edema and mass effect demonstrates expected time
evolutional
changes. No evidence of an associated mass. No pattern on
gradient echo
sequences suggestive of amyloid angiopathy. The likely etiology
of this
intraparenchymal hemorrhage includes hypertension, underlying
vascular
malformations such as an arterial vascular malformation, or
coagulopathies.
11/ 17/ 08: CT CNS, CTA
1. Unchanged right frontal lobar hemorrhage with surrounding
edema. Unchanged
bilateral subarachnoid and intraventricular hemorrhage. Stable
ventricular
dilatation.
2. No evidence of a vascular malformation associated with the
right frontal
hematoma. However, a small malformation may be compressed by the
hematoma.
After the blood products resolve, MRI with gadolinium is
recommended to
exclude an underlying mass. MRA or CTA may be performed at that
time to
reassess for a small vascular malformation.
3. Probable 2 mm calcified aneurysm in the cavernous left
internal carotid
artery.
Brief Hospital Course:
-Likely amyloid angiopathy
-Head CT (OSH, per report): 5 cm area of hemorrhage in the right
frontal lobe with surrounding edema, blood in the lateral
ventricles, 4 mm of midline shift, subarachnoid blood, blood at
the right falx. She was given Dilantin 1 gm IV and transferred
to [**Hospital1 18**]
-Given 1 U plt and 2 U FFP, initially admitted to NeuroICU
-Neurosurgery consulted: no acute surgery needed
-CT Head:
1) Large right frontal lobe intraparenchymal hemorrhage with
surrounding edema, exerting mass effect on the right lateral
ventricle and associated shift of midline structures, 4 mm to
the left.
2) Small amount of subarachnoid hemorrhage and intraventricular
hemorrhage.
3) Right temporal and occipital [**Doctor Last Name 534**] are larger than on the
left, which may signify developing hydrocephalus.
-f/u Repeat Head CT
-MRI head:
1. Large right frontal lobe intraparenchymal hemorrhage with
associated vasogenic edema and mass effect demonstrates expected
time evolutional changes. No evidence of an associated mass. No
pattern on gradient echo sequences suggestive of amyloid
angiopathy. The likely etiology of this intraparenchymal
hemorrhage includes hypertension, underlying vascular
malformations such as an arterial vascular malformation, or
coagulopathies.
-CXR: No acute cardiopulmonary abnormality.
-Cont. telemetry
-HgA1c 5.9%, FLP Chol 158, TG 68, HDL 71, LDL 73, CEs CK
1576-1391-1190, CKMB 20-15-11, TropT <0.01 x3, TSH 10
-Holding home ASA and Plavix
-Cont. Dilantin 100 mg IV q8hr x 1week, f/u daily level
-Keep SBP <160, Cont. Lisinopril 20 mg daily, HCTZ 12.5 mg
daily, Amlodipine 2.5 mg daily, Atorvastatin 80 mg daily
-Cont. Levothyroxine 88 mcg daily
-Cont. Memantine 10 mg daily
-Heart healthy diet, IVF NS at 70 cc/hr
-fever to 101.8F while in ICU. WBC count WNL, but with left
shift.
Fever could be secondary to bleed itself. UA moderate blood and
CXR negative, no obvious source. F/U BCx. Would hold Abx for
now.
-Na down to 129, serum osm 274, urine osm 689, FeNa 1.8%; may
have SIADH
-PPx: Pneumoboots, Tylenol prn
-f/u S&S recs: NPO, NGT placed
-f/u nutrition recs for TFs
-f/u PT/OT recs
-Contacts: PMD [**First Name8 (NamePattern2) 7325**] [**Last Name (un) **]: [**Telephone/Fax (1) 7328**]. Son [**Name (NI) **]
[**Telephone/Fax (1) 80217**] (c), [**Telephone/Fax (1) 80218**] (w)
This 80 F was admitted with a spontaneous right frontal IPH. She
was initially admitted to the ICU where her bleed size was found
to be stable over days. She had an MRI which did not show
evidence of mircobleeds. A CTA was done which did not elucidate
a vascular source for her bleed. There was some involvement of
blood in her ventricles however there was only minimal evidence
of hydrocephalus that remained stable over time. Once
transferred to the floor, her course was complicated by relative
hyponatremia to ~127 that improved after her HCTZ was
discontinued. She also developed a UTI with both enterococcus
and E.coli which was treated with a week course of vancomycin
and ceftriaxone respectively. She also developed some soft
stools, and C.Diff Ag was negative x (). This was thought in
part to be due to her tube feeds which were adjusted
accordingly. She received a PEG tube on [**2120-12-4**].
Medications on Admission:
Lipitor 80 mg PO Qday
Namenda 10 mg PO Qday
Synthroid 88 mcg PO Qday
Norvasc 2.5 mg PO Qday
HCTZ 12.5 mg PO Qday
Plavix 75 mg PO Qday
ASA 325 mg PO Qday
Lisinopril 20 mg PO Qday
Potassium PO Qday
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO Qday ().
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 6 days: last dose 11/28.
10. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) g Intravenous Q24H (every 24 hours) for 7 days: last
dose 11/29.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
right frontal IPH
Discharge Condition:
stable LUE and LLE paresis. Stable eyelid apraxia. Minimally
responsive to touch or voice. Rare vocalizations yes/no.
Discharge Instructions:
You were admitted with a right frontal bleed in your brain. This
was thought to be secondary to brittle vessels in your brain,
possibly along with high blood pressure. Long term you will need
to make sure your blood pressure is well controlled. You
received a PEG tube for feeding. This is potetially reversible
if you are able to swallow more appropriately in the future.
Please return to the ER if you experience any sudden weakness,
headache, somnolence, or anything else that concerns you
seriously.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2120-1-22**] at 1:00 pm in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"2761",
"5990",
"41401",
"4019",
"2724",
"2449",
"412"
] |
Admission Date: [**2197-9-27**] Discharge Date: [**2197-9-30**]
Date of Birth: [**2152-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
45 y/o man with alleged hx of seizure disorder and polysubstance
abuse presents after being found unresponsive by family. Per
report from EMS, his family heard a thump and found him on the
floor laying still without tonic/clonic movements, no tongue
biting or bowel/bladder incontinence and had a bruise on his
head. They called EMS immediately who boarded and collared the
patient, reported a normal glucose and ECG showing normal sinus
rhythm, and gave narcan without improvement in mental status.
Upon arrival to the ED, he was unresponsive with a GCS of 8. He
had small movements of his upper extremities, but no movement of
his lower extremities and he did not withdraw to pain. Pupils
were 4mm and not reactive in the bright trauma room. He had
significant respiratory secretions with normal oxygen
saturations and was soon after intubated for airway protection.
.
Induction for intubation included 100mg lidocaine, 20mg
etomodate, 120mg succinylcholine. 7.0 ET tube was placed
without immediate complication and he was sedated with propofol.
CT head and C-spine were completed which did not show acute
intracranial hemorrhage or fracture respectively. Utox showed +
benzos, and serum tox, including ethanol, was negative. ECG
showed narrow complex normal sinus rhythm. He was given
maintenance fluids @75cc/hr.
Past Medical History:
Past psychiatric history:
- multiple dual diagnosis hospitalizations, including several at
[**Hospital1 18**] in late 90's. Pt is vague about when most recent hosp was.
- several suicide attempts, including Tegretol OD in [**2178**] and
cutting wrists in [**2171**]
- current psychiatrist is Dr. [**First Name (STitle) **] at [**Hospital1 1680**] JP
- denies h/o violence
Past Medical History:
- Scrotum and testicle injury in [**2171**], s/p orchiectomy and
multiple subsequent surgeries, which resulted in chronic pain.
Social History:
Substance use history:
- Xanax from illicit sources.
- EtOH: long h/o abuse/dependence since late teens
- Marijuana: h/o chronic use, which pt says he has "cut down
on," most recent use "a few days ago"
- Cocaine: past abuse, none in several years
- Opiates: pt denies but OMR indicates misuse of prescription
opiates for pain in past
- Denies h/o IVDU
Family History:
Father- recovering alcoholic
Physical Exam:
ADMISSION EXAM
Vitals: T:94.4 BP: 91/61 P: 70 R: 20 O2: 99% on vent
General: intubated, sedated
HEENT: Sclera anicteric, PERRL 3->2cm, ETT in place. Small
edematous area on top of calveria, skin intact, no bony step
offs or depression, no racoon eyes or otorrhea or rhinorrhea,
facial bones intact.
Neck: supple, JVP not elevated. No pain to palpation of cspine.
CV: Distant quiet heart heart sounds, regular rate and rhythm,
normal S1 + S2, no apparent murmurs, rubs or gallops but exam is
limited
Lungs: Clear to auscultation bilaterally, mechanical breath
sounds no wheezes, rales, ronchi
Abdomen: soft, cannot assess tenderness, non-distended, active
bowel sounds, no organomegaly, midline surgical scar. Pelvic
girdle intact, no flexion.
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, normal tone in upper and lower extremities, does
not withdraw to pain, no reflex or babinksi response
D/C EXAM
VSS. AAOx3. Conversant, attention intact to months backward. No
nystagmus
Pertinent Results:
[**2197-9-27**] ADMISSION LABS
WBC-9.3 RBC-4.67 Hgb-14.9 Hct-42.8 MCV-92 MCH-31.9 MCHC-34.8
RDW-13.4 Plt Ct-244 [Neuts-77.6* Lymphs-17.7* Monos-3.4 Eos-1.0
Baso-0.4]
PT-12.6 PTT-22.2 INR(PT)-1.1
Glucose-97 UreaN-19 Creat-0.9 Na-142 K-4.4 Cl-111* HCO3-23
AnGap-12
ALT-21 AST-20 LD(LDH)-148 CK(CPK)-146 AlkPhos-80 TotBili-0.1
cTropnT-<0.01 x3
Calcium-8.4 Phos-3.3 Mg-2.1
TSH-0.47
BLOOD GAS: Type-ART Rates-/16 Tidal V-600 PEEP-5 FiO2-4.5
pO2-137* pCO2-55* pH-7.31* calTCO2-29 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
BLOOD GAS: Type-ART pO2-178* pCO2-40 pH-7.42 calTCO2-27 Base
XS-1 Intubat-INTUBATED
URINE
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
UreaN-872 Na-118 K-GREATER TH Cl-167
Osmolal-814
bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG
mthdone-NEG
D/C LABS
WBC-7.7 RBC-3.96* Hgb-13.0* Hct-36.2* MCV-91 MCH-32.9*
MCHC-36.0* RDW-13.1 Plt Ct-172
Glucose-92 UreaN-15 Creat-0.8 Na-139 K-3.9 Cl-107 HCO3-28
AnGap-8
Calcium-8.8 Phos-2.4* Mg-2.2 Iron-84
calTIBC-230* VitB12-648 Folate-13.0 Ferritn-87 TRF-177*
[**2197-9-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] MRSA SCREEN MRSA SCREEN-FINAL
EEG [**9-27**]
This telemetry captured no pushbutton activations. The record
showed primarily medication effect in the first couple of hours,
progressing to a more normal waking record, without areas of
focal slowing. At no point in the record were there any clearly
epileptiform discharges or electrographic seizures.
CT HEAD [**9-27**]
1. No acute intracranial process.
2. Paranasal sinus acute-on-chronic inflammatory disease;
correlate clinically.
CT C-SPINE [**9-27**]
1. No acute fracture or malalignment.
2. Paraseptal emphysema.
CXR [**9-27**]
The patient is situated on a trauma board, limiting assessment
for fine detail. Within that limitation, the endotracheal tube
tip sits 6 cm above the carina. The endogastric tube coils
within a prominent gas-distended stomach. A right IJ central
venous catheter tip sits in the mid-to-lower SVC. The heart size
is at the upper limits of normal. The mediastinal contours are
not widened. The mediastinal contours are not widened. The lung
volumes are low with minimal left basal atelectasis. There is no
pulmonary edema. There is no large pleural effusion or
pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname **] is a 46 yo M with hx of suicide attempts who
presented to [**Hospital1 18**] on [**2197-9-27**] with likely overdose of his home
oxcarbazepine and alprazolam after argument with his father. His
respiratory and mental status were stabilized in the ICU.
# Aprazolam/oxcarbazepine overdose
The initial etiology of the altered mental status was unclear.
The pt was intubated immeditately for airway protection. CT of
his head and C-spine had no acute pathology. The toxicolgy
serum screen was remarkable for no ethanol, and no other
intoxicants. The urine toxicology screen was positive for
benzodiazepines only. The pt had no initial reponse to narcan
by the paramedics, and had a normal blood glucose level in the
ER. His ECG was not suggestive of an acute cardiac or
toxidromic process, but was notable for Q-waves in inferior
leads. The pt was reported to have a seizure disorder, but had
no focal neurological findings or tonic-clonic movements or
abnormal eye gaze. The pt had no signs trauma anywhere on
physical exam. The pt remained unconcious initially while in
the ICU, but then in the AM became arousable to vocal and
painful stimuli. He had good respiratory function as assesed by
the ventilator, was on minimal ventilator support, and he had a
cough reflex, and had minimal secretions. The pt was extubated
without incident and maintained good oxygenation. A bedside
video EEG was initiated. The pt eventually became more alert
and oriented throughout the day. As the pt became more awake,
we were able to talk to him more, and he admited to taking his
Xanax and Trileptal in excess, reportedly 10mg yesterday. The
pt did well in the ICU and was transferred to the floor where he
was stable and his xanax was reinitated per psychiatry recs. He
was discharged with plan to f/u with [**Hospital1 **] Counseling and his
PCP. [**Name10 (NameIs) **] father will be in charge of administering his [**Name10 (NameIs) 96263**] and
helping him taper his dose downward from 10mg/day.
# Alcohol/benzodiazepine withdrawal
The pt had no signs of withdrawl initially, but he was started
on a CIWA and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] score at the time of admission. Later in
the evening the pt became increasingly agitated, requiring
several dose of lorazepam. Once in the late evening he became
acutely agitated and was threatening nurses. A Code Purple was
called and the pt was sedated with haldol and ativan. He
received 30mg of valium during the following day and his [**Last Name (NamePattern4) **]
was restarted.
#Seizure disorder
Reportedly longstanding. Pt had a bedside EEG here but removed
all of his EEG leads, after a few hours, and the study was
discontinued. The pt was then comfortable throughout the night
without any further incident. The pt was monitored more while
here, and had no further complaints. There was no evidence of
seizure during the hospitalization and his home seizure
medications were continued.
# Substance dependence
Longterm use of alcohol, with recent relapse, and alprazolam.
Would like to try home taper of this meds with his father giving
him appropriate amount. Ammenable to inpt stay if this is not
succesful.
# Anemia
HCT at admission was 43, fell to 36. Baseline 39-40. Normocytic.
Etiology of this unclear as there is no apparent source of
bleeding, T bili is normal- no suggestion of hemolysis. Possible
that one of the meds causes marrow supression. Iron studies
non-specific. Normal folate/b12. The inpatient team defers to
outpt work-up if indicated.
TRANSITIONAL ISSUES
-Patient to start outpt taper of alprazolam, with medication
beign administered by his father.
-Pt will make appointment with [**Hospital1 1680**] Counseling services.
Medications on Admission:
1. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO Q6H PRN as
needed for anxiety.
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Discharge Medications:
1. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. alprazolam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety: Do not exceed 9 mg per day. To be
tapered further by patient.
3. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as
needed for pain: Not to exceed [**2186**] mg/day.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H:PRN as needed
for pain.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a
day for 2 days: Take for a maximum of two days until you are
able to refill your [**Year (4 digits) **] prescription.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to take care of you during your stay at [**Hospital1 18**].
You were admitted here because you were unresponsive after
taking too much of your Trileptal and [**Hospital1 96263**] at home. Your family
called EMS and you were brought to the hospital. You were
intubated and placed on a ventilator to breath for you. As you
recovered from the overdose, the breathing tube was removed and
you were able to breathe on your own. You became agitated after
experiecing withdrawal from alcohol and Xanax. You were treated
with Valium for this and your Xanax was restarted. The
Psychiatry team was consulted and they helped you to create a
plan for reducing your use of Xanax. Your father will administer
you [**Name (NI) 96263**] while you slowly taper down from 10mg daily. At
discharge, he will give you 9mg each day. You should make a
follow-up appointment with [**Hospital1 **] Counselling; they can help you
continue to taper this medication. You were observed for
additional signs of alcohol or benzodiazepine withdrawal until
[**2197-9-30**] and were stable for discharge to home.
Your medications have been changed as follows:
1. STOP taking alprazolam 10mg daily as needed for anxiety
2. START taking alprazolam 9mg daily as needed for anxiety
3. As you do not have alprazolam at home, take valium 10mg three
times a day as needed until you are able to refill your
prescription from your primary care doctor.
Your other medications were not changed.
Please remember to call [**Hospital1 **] Counseling at the numbers below to
start outpatient counselling.
Followup Instructions:
Please call [**Hospital1 **] Counseling to set up an appointment as soon as
possible.
[**Hospital1 **] Counseling
[**Location (un) 538**]
[**Apartment Address(1) 96264**], [**Location (un) 86**], [**Numeric Identifier 7023**]
[**Telephone/Fax (1) 88923**]
We have made a follow-up appointment with your primary care
doctor:
Thursday [**2197-10-5**]
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital6 **]
Address: [**Apartment Address(1) 25834**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 19752**]
You may call his office on Monday to request prescription
refills.
Completed by:[**2197-10-2**]
|
[
"51881",
"2859"
] |
Admission Date: [**2130-10-8**] Discharge Date: [**2130-10-12**]
Date of Birth: [**2051-3-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fevers, Nausea/Vomiting
Major Surgical or Invasive Procedure:
R femoral CVL placement [**10-8**]
History of Present Illness:
79 F transfer from [**Hospital1 8**] for ? cholangitis. Pt had
intermittent epigastric pain for 2 weeks, nausea/vomiting, fever
of 101.8.
On presentation, pt had a grossly positive UA, WBC 39, normal
LFT's. CT abd showed choledochol cyst, B perinephric stranding.
The diagnosis of B pyelonephritis, sepsis was entertained. The
pt was transiently hypotensive on transfer requiring pressors.
Past Medical History:
HTN, h/o ulcers, arthritis, asthma,
Family History:
NC
Physical Exam:
T 101.8, hr 94, bp 145/45, 98% 6 L NC
NAD, no jaundice
[**Month (only) **] BS at B bases
RRR
soft, mild distention, + TTP at peri umbilical region
No R/G
No E/C/C
Rectal nl tone: guiaic +
Pertinent Results:
[**2130-10-8**] 05:45PM BLOOD WBC-39.7* RBC-2.86* Hgb-8.6* Hct-26.0*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.3 Plt Ct-313
[**2130-10-9**] 02:58AM BLOOD WBC-33.9* RBC-3.42* Hgb-10.3* Hct-30.2*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.8 Plt Ct-288
[**2130-10-9**] 02:04PM BLOOD Hct-30.6*
[**2130-10-10**] 05:18AM BLOOD WBC-29.7* RBC-3.64* Hgb-11.0* Hct-31.9*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.4 Plt Ct-361
[**2130-10-11**] 07:40AM BLOOD WBC-21.6* RBC-4.00* Hgb-12.1 Hct-35.3*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.1 Plt Ct-474*
[**2130-10-12**] 07:20AM BLOOD WBC-16.1* RBC-4.00* Hgb-11.9* Hct-34.8*
MCV-87 MCH-29.8 MCHC-34.3 RDW-14.7 Plt Ct-487*
[**2130-10-8**] 05:45PM BLOOD Neuts-91* Bands-0 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-10-9**] 02:58AM BLOOD PT-15.5* PTT-26.6 INR(PT)-1.5
[**2130-10-10**] 05:18AM BLOOD Glucose-124* UreaN-24* Creat-1.2* Na-137
K-3.4 Cl-104 HCO3-22 AnGap-14
[**2130-10-8**] 04:55PM BLOOD Glucose-105 UreaN-20 Creat-1.0 Na-137
K-2.7* Cl-101 HCO3-20* AnGap-19
[**2130-10-8**] 04:55PM ALT(SGPT)-25 AST(SGOT)-34 ALK PHOS-176*
AMYLASE-25 TOT BILI-1.3
[**2130-10-8**] 04:55PM LIPASE-18
[**2130-10-8**] 04:55PM ALBUMIN-2.9*
[**2130-10-8**] 04:57PM LACTATE-1.4
[**2130-10-8**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2130-10-8**] 05:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
Brief Hospital Course:
On presentation, pt had a grossly positive UA, WBC 39, normal
LFT's. CT abd showed choledochol cyst, B perinephric stranding.
The diagnosis of B pyelonephritis, sepsis was entertained. The
pt was transiently hypotensive on transfer requiring dopamine.
The pt had a R femoral CVL placed for fluid resusitation. The
pt clinically improved over the course of 4 days. She was
transferred to the floor the morning of HD 2 in a stable
condition on broad coverage antibiotics. Antibiotics were
narrowed to PO levofloxacin. The pt was tolerating a regular
diet and ambulating w/ PT.
Hospital coarse was remarkable for failure to void on HD 3 and
foley was repleced for 500cc urine. Another voiding trial was
made on HD 4. The pt failed to void and had her foley replaced
for 550 cc urine. The pt was dc'd with her foley in place.
The pt had bp which were labile from 140 systolic to 190's.
Blood pressure medications were adjusted and to be followed up
with her PCP at rehabilitation.
The pt's U Cx was negative, but she recieved antibiotics at the
OSH.
Physical therapy recommended rehab for strengthening.
The pt was having diarrhea on HD 4 and CDiff was sent wheich was
negative.
The pt was DC's to rehab with instructions to follow up with her
PCP regarding anti hypertensives. The pt was also instructed to
follow up with Dr. [**Last Name (STitle) **] regarding management of her choledochol
cyst.
Medications on Admission:
Celebrex
HCTZ 12.5'
Atenolol 100'
Protonix 40'
Fosamax
Lisinopril 5'
ASA
Discharge Medications:
1. Heparin Sodium (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 T > 101.5.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days. Tablet(s)
8. Hydralazine HCl 10 mg IV Q6H
prn bp > 160 systolic
9. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Location **] Manor
Discharge Diagnosis:
Bilateral pyelonephritis
Discharge Condition:
stable
Discharge Instructions:
Please call physician if experiencing fevers/chills, chest
pian/shortness of breath, nausea/vomiting. Please follow up
with PCP regarding hypertension medications.
Followup Instructions:
Please follow up with PCP in one week.
Please follow up with Dr. [**Last Name (STitle) **]; call the office for an
appointment.
Completed by:[**2130-10-12**]
|
[
"0389",
"78552",
"99592",
"49390",
"4019"
] |
Admission Date: [**2199-2-7**] Discharge Date: [**2199-3-3**]
Date of Birth: [**2199-2-7**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) **] [**Known lastname **] is a former 1.73
kg product of a 34 week gestation pregnancy born to a 32-year-
old G2, P0 woman. EDC was [**2199-3-21**].
Prenatal screens - blood type O positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta strep status unknown. The pregnancy was
complicated by spontaneous rupture of membranes at 34 weeks.
There was also increase in amniotic fluid of unclear
etiology. The infant was born by cesarean section secondary
to a nonreassuring fetal heart rate tracing and concerns for
possible placental abruption. He emerged active and vigorous.
He required oxygen and stimulation. Apgar scores were 8 at 1
minute and 8 at 5 minutes. He was admitted to the neonatal
intensive care unit for treatment for prematurity.
PHYSICAL EXAMINATION: Physical examination upon admission to
the neonatal intensive care unit: Weight 1.72 kg, 50th
percentile; length 42.5 cm, 25th percentile; head
circumference 30 cm, 25th percentile. GENERAL: Active infant
crying. Bruising noted on face, palms, elbows and left leg.
SKIN: Without rashes. HEAD, EARS, EYES, NOSE AND THROAT:
Normocephalic, anterior fontanel open and flat. Red reflex
examination deferred. Eyes small with some eyelid edema.
Small jaw, recessed tongue. Neck supple. CHEST: Lungs clear
bilaterally. CARDIOVASCULAR: Regular rate and rhythm without
murmur. Pulses +2. ABDOMEN: Soft without bowel sounds. No
masses or distension. Spine midline. No cervical dimple. Hips
stable. Clavicles intact. Anus patent. GENITOURINARY: Normal
preterm male. Testes palpable bilaterally. NEUROLOGIC: Tone
and extremities consistent with gestational age.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: [**Doctor Last Name **] required blow-by oxygen briefly
upon admission to the neonatal intensive care unit. He
transitioned to room air and was in room air for the
remainder of his neonatal intensive care unit admission. He
had rate episodes of bradycardia and at the time of discharge
he is breathing comfortably with a respiratory rate of 30 to
60 breaths per minute.
CARDIOVASCULAR: [**Doctor Last Name **] has maintained normal heart rate and
blood pressure. A murmur was noted in the 3rd week of life.
It was heard audibly best at the left upper sternal border
consistent with peripheral pulmonary artery stenosis. Four
limb blood pressures were within normal limits. EKG was
obtained and was also within normal limits. Chest x-ray
showed normal heart size and situs, and normal pulmonary
blood flow. At the time of discharge his heart rate is 140 to
150 beats per minute with a recent blood pressure of 67/47
with a mean of 55.
FLUIDS, ELECTROLYTES AND NUTRITION: [**Doctor Last Name **] was initially
NPO and received intravenous fluids. Enteral feeds were
started on day of life 1 and gradually advanced to full
volume. His maximum caloric intake was breast milk fortified
to 26 calories per ounce. At the time of discharge he is
breast feeding or taking breast milk fortified to 24 calories
per ounce with 4 calories by Enfamil powder. Weight on the
day of discharge is 2.315 kg which is 5 pounds 2 ounces with
corresponding head circumference of 32.5 cm and length of 47
cm.
INFECTIOUS DISEASE: [**Doctor Last Name **] was evaluated for Sepsis upon
admission to the neonatal intensive care unit. The complete
blood count was within normal limits. Blood culture was
obtained and there was no growth at 48 hours. He did not
receive any treatment with antibiotics.
GASTROINTESTINAL: Peak serum bilirubin occurred on day of
life 3 at 9.6, unconjugated, mg/dL. He received phototherapy
for approximately 72 hours. Most recent bilirubin on [**2199-2-18**], was 7.9 unconjugated.
HEMATOLOGIC: Hematocrit at birth is 54.7%. He is being
discharged home on supplemental iron.
NEUROLOGICAL: [**Doctor Last Name **] has maintained a normal neurological
examination during admission. There were no concerns at the
time of discharge.
SENSORY: Audiology - hearing screening was performed with
automated auditory brain stem responses. [**Doctor Last Name **] passed in
both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital3 9732**], [**State 14091**], [**Location (un) 86**],
[**Numeric Identifier 65470**]. Phone No. [**Telephone/Fax (1) 40664**].
CARE RECOMMENDATIONS:
1. Feedings - breast feeding or ad lib PO feedings, breast
milk fortified to 24 calories per ounce with 4 calories
of Enfamil powder.
2. Medications - Fer-In-[**Male First Name (un) **] 25 mg per ml, 0.4 ml PO once
daily. Goldline baby vitamins or other infant
multivitamin preparation 1 ml PO once daily.
3. Car seat position screening was performed. [**Doctor Last Name **] was
observed in his car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screens were sent on [**2-10**] and [**2-21**], [**2199**] with no notification of abnormal results.
5. Immunizations received - hepatitis B vaccine was
administered on [**2199-2-24**].
6. 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.
A) Born at less than 32 weeks.
B) Born between 32 and 35 weeks with two of the following:
1. daycare during RSV season.
2. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
3. with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
Follow up appointment recommend:
Appointment with Dr. [**Last Name (STitle) **] within 5 days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Suspicious for sepsis ruled out.
3. Unconjugated hyperbilirubinemia.
4. Cardiac murmur.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-3-3**] 01:18:27
T: [**2199-3-3**] 02:46:15
Job#: [**Job Number **]
|
[
"7742",
"V290"
] |
Admission Date: [**2175-2-23**] Discharge Date: [**2175-3-2**]
Date of Birth: [**2175-2-23**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] is a 36 week female infant born
to a 34 year old G4 P1, now 2 mother with [**Name2 (NI) **] type B
positive, antibody negative, RPR nonreactive, rubella immune
and hepatitis B surface antigen negative. The prenatal
course was significant for preterm labor at 24 5/7 weeks.
The mother received betamethasone and was hospitalized until
28 weeks gestation. Prior obstetrical history was
significant for cervical shortening noted at 24 weeks during
first pregnancy, received betamethasone x 2, delivery at 36
weeks by cesarean section due to breech presentation at
[**Hospital1 69**]. Infant did not require
admission to newborn intensive care unit.
For this pregnancy,the mother presented on day of delivery
with headache. There was no history of hypertension and there
were normal hypertension labs on the date of delivery.
Obstetrical examination revealed that she was 3 cm dilated.
Since a repeat cesarean section had been planned, it was
elected to deliver the infant by cesarean section on the
night of [**2-23**]. Group B strep status was positive.
There was no maternal fever. Rupture of membranes was two
minutes prior to delivery. No maternal intrapartum
antibiotics were given.
The infant was delivered on [**2175-2-23**] at 8:14 by
cesarean section. The infant emerged active, and the
obstetrical team assigned Apgar scores of 8 at one minute and
9 at five minutes of age. Neonatology consulted at fifteen
minutes of age due to respiratory distress. Due to
persistent and moderate distress, the infant was brought to
the newborn intensive care unit for evaluation.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.4,
respiratory rate 80, [**Year (4 digits) **] pressure 70/27, heart rate 157,
oxygen saturation 89 percent on room air. The infant was
placed on nasal cannula 150 cc at 100 percent. Weight 3220
grams (75-90th percentile), length 19 inches (75th
percentile), head circumference 34.5 cm (90th percentile).
The infant was in moderate respiratory distress, with
grunting and nasal flaring. She was responsive during the
exam. Pectus was present. The anterior fontanel was open
and flat. Nondysmorphic. Lips, gums and palate were intact.
Normal S1 and S2. No murmur was appreciated, but difficulty
to completely rule out in the setting of grunting. Breath
sounds were slightly coarse bilaterally and seemed equal. No
asymmetry of the chest wall was seen. The abdomen was soft,
nontender, nondistended. The extremities were well perfused.
Tone was average for gestational age. Normal female
genitalia. Hips were stable. Patent anus. Spine intact.
Skin was significant for bruising over the left eye.
[**Year (4 digits) **] glucose was 59.
HOSPITAL COURSE: RESPIRATORY: The infant was placed on
nasal cannula oxygen, 150 cc one hundred percent shortly
after admission to the newborn intensive care unit.
Respiratory distress persisted, and the infant was placed on
CPAP of 6. Chest x-ray was concerning for respiratory
distress syndrome. The infant was ultimately intubated at
about seventeen hours of age and received one dose of
surfactant on day of life one. She was extubated shortly
thereafter to continue with positive airway pressure and
successfully weaned to room air on day of life four. There
were no issues with apnea.
CARDIOVASCULAR: The infant's [**Year (4 digits) **] pressure has been stable
throughout her hospitalization. Heart rate has been 130-
160's. No fluid boluses or pressors were required.
FLUID, ELECTROLYTES AND NUTRITION: Shortly after admission
to the NICU, the infant was placed on intravenous fluids of
D10W running at 80 cc/kg/day. The infant remained on
intravenous fluids until respiratory distress was resolving
on day of life three, at which time the infant was started on
enteral feeds at 50 cc/kg/day. She is currently ad lib
feeding formula or breast milk without any signs of feeding
intolerance. Current fluid volume is a minimum of 120
cc/kg/day and breastfeeding.
Electrolytes were drawn at 24 hours of age: sodium 140,
potassium 5.1, chloride 110, total CO2 19. The infant is
voiding and stooling without difficulty.
Discharge weight is 2890.
GASTROINTESTINAL: Peak bilirubin on day of life 5 was
16.3/0.3. The infant was started on phototherapy.
[**3-2**] bili 15.1/0.3 on blanket. Switched to overhead lamp and
bili 9.4/0.3.Rebound done in 8 hours was 8.6/0.2..
HEMATOLOGY: Hematocrit on admission to the NICU was 46.8.
She has not received any [**Month/Day (4) **] products during her
hospitalization.
INFECTIOUS DISEASE: [**Month/Day (4) **] cultures were drawn upon admission
to the NICU. White count of 23,000, hematocrit 46, platelet
count 269,000 with 53 percent polys and 10 percent bands.
[**Month/Day (4) **] culture was negative. The infant received four days of
ampicillin and gentamicin with respiratory symptoms that were
slow to resolve. No other issues of infection.
Sensory: Hearing screen performed on [**3-2**] and passed.
PSYCHOSOCIAL: [**Hospital1 69**] social
work is involved with the family. The contact social worker
can be reached at [**Telephone/Fax (1) **].
CONDITION AT TIME OF DICTATION: Stable in room air,
tolerating ad lib feeds.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 58932**], [**Telephone/Fax (1) 58933**].
RECOMMENDATIONS: Ad lib feeds of breast milk or Similac.
Car seat position screening pending. First state newborn
screen was sent on [**2-28**]. No abnormal results have been
reported.
MEDICATIONS: None.
IMMUNIZATIONS: Hepatitis B on [**2175-2-28**]
Immunizations recommended: Synergist 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 32-35 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. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 36 weeks gestation.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Hyperbilirubinemia.
VNA to visit on [**2175-3-4**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Month (only) 58934**]
MEDQUIST36
D: [**2175-2-28**] 13:07:23
T: [**2175-2-28**] 13:36:57
Job#: [**Job Number 58935**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2146-5-30**] Discharge Date: [**2146-6-3**]
Date of Birth: [**2067-6-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE/angina
Major Surgical or Invasive Procedure:
[**2146-5-30**] s/p cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
78 yo female with known 3VD.Cath in [**4-19**] showed severe, diffuse
LAD dz, DIAG subtotal occluded, OM 1 80%, OM 2 80%, RCA 80%
ostial, 80% mid lesions.Despite medical management, she
continues to experience exertional dyspnea and recurrent angina.
Referred for surgical evaluation.
Past Medical History:
CAD
HTN
dementia
HTN
carotid dz. s/p right CEA [**2140**]
IDDM
hypothyroidism
childhood seizures
pacer placment [**2140**]
TAH
hernia repair
Social History:
retired
denies tobacco
denies ETOH use
lives with husband
Family History:
no premature CAD
Physical Exam:
64" 168#
right 146/61 left 151/65
WDWN in NAD
neck supple, full ROM, no JVD
CTAB
RRR, no m/r/g
soft, NT, ND, + BS
extrems warm, well-perfused, no edema
no obvious varicosities
alert and oeriented x3, MAE, grossly non-focal exam
2+ bil. fems, 1+ bil. DP/PTs
no carotid bruits appreciated
Pertinent Results:
[**2146-6-1**] 11:10AM BLOOD WBC-10.2 RBC-2.88* Hgb-9.4* Hct-26.1*
MCV-91 MCH-32.5* MCHC-35.8* RDW-15.1 Plt Ct-105*
[**2146-6-1**] 11:10AM BLOOD Glucose-248* UreaN-24* Creat-1.1 Na-137
K-4.7 Cl-105 HCO3-27 AnGap-10
Conclusions
PRE CPB The left atrium is markedly dilated. The left atrium is
elongated. No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The posterior mitral valve leaflet is shortened and
moderately to severely thickened. The anterior mitral leaflet is
less thickened.. Moderate, central (2+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST CPB Patient atrially paced. Normal biventricular function.
Moderate mitral regurgitation remains. Thoracic aorta appears
intact. No other changes from pre bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2146-5-30**] 12:06
[**2146-6-3**] 05:40AM BLOOD Glucose-174* UreaN-35* Creat-1.4* Na-138
K-4.5 Cl-102 HCO3-28 AnGap-13
Brief Hospital Course:
Admitted [**5-30**] and underwent cabg x3 with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
neosynephrine, insulin and propofol drips. Extubated that
evening. EP service came the next morning to evaluate a
junctional rhythm and interrogated her pacer. Chest tubes were
removed and she was transferred to the floor on POD #1. Beta
blockade was titrated and she was gently diuresed toward her
preop weight. Physical therapy worked with her for strength and
mobility. Her pacemaker was reinterrogated for inappropriate
pacing and mA were adjusted, CXR verified leads in place, and
plan for follow up in device clinic in 1 month. Her renal
function was increased to 1.4 with no change on repeat, plan for
follow up check in two days at rehab. She was ready for
discharge on POD 4 to rehab.
Medications on Admission:
lopressor 50 mg TID
lexapro 10 mg daily
isosorbide 60 mg daily
lantus insulin 52 units QAM
Regular insulin sliding scale [**Hospital1 **]
lorazepam 0.25 mg [**Hospital1 **]
plavix (LD [**5-14**])
crestor 10 mg daily
aricept 10 mg daily
ASA daily
levoxyl 100 mcg daily
alprazolam 0.25 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for anxiety .
6. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Levoxyl 100 mcg Tablet Sig: One (1) Tablet PO once a day.
10. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous once a day: please titrate up to home dose as
appetite improves - her original dose was 52 units qam .
11. insulin sliding scale with humalog
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 0 Units
161-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 6 Units
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Outpatient Lab Work
please check potassium, BUN and Cr [**6-5**] sunday and [**6-9**] thrusday
and call results to cardiac surgery [**Telephone/Fax (1) 170**]
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
CAD s/p cabg x 3
HTN
elev. chol.
carotid dz. s/p right CEA [**2140**]
IDDM
hypothyroidism
dementia
childhood seizures
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) 6700**] after discharge from rehab [**Telephone/Fax (1) 6699**]
Dr. [**Last Name (STitle) **] in [**2-13**] weeks after discharge from rehab [**Telephone/Fax (1) 8725**]
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Follow up with device clinic for changes with PPM
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2146-7-4**]
10:30
please check potassium, BUN and Cr [**6-5**] sunday and [**6-9**] thrusday
and call results to cardiac surgery [**Telephone/Fax (1) 170**]
Completed by:[**2146-6-3**]
|
[
"41401",
"4019",
"25000",
"2449",
"2720",
"V5867"
] |
Admission Date: [**2162-4-16**] Discharge Date: [**2162-4-27**]
Service: CARDIOTHORACIC
Allergies:
Vasotec
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic Stenosis
Major Surgical or Invasive Procedure:
[**2162-4-19**] Aortic Valve Replacement (21 StJude porcine)
History of Present Illness:
87 year old woman with hypertension presented to [**Hospital3 110856**] after awakening with chest discomfort on [**4-12**]. She had
had several months of progressive DOE and fatigue. She lives
alone and at baseline is self-sufficient. She had never had
chest pain before. She denied any history of syncope. At LGH,
she was found to have severe AS and was transferred to [**Hospital1 18**] On
[**2162-4-16**] for AVR.
Past Medical History:
Aortic Stenosis
Hypertension
Status post cholecystectomy 40yrs ago
Social History:
Lives alone(5 sons near by, one in ajoining unit)
Occupation:homemaker
Cigarettes: never
ETOH: less than 1 drink/week
Illicit drug use none
Family History:
non-contributory
Physical Exam:
Pulse: Resp:14 O2 sat: 98% RA
B/P Right:134/78 Left:
Height:61" Weight:164
General:WDWN
Skin: Dry [] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur [x] grade _4/6 SEM -> neck
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [n] _____
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:m Left:m
Pertinent Results:
[**2162-4-25**] WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3* MCV-95 MCH-29.5
MCHC-31.2 RDW-14.8 Plt Ct-196
[**2162-4-16**] WBC-4.1 RBC-3.59* Hgb-10.4* Hct-33.6* MCV-94 MCH-29.0
MCHC-31.0 RDW-14.2 Plt Ct-151
[**2162-4-25**] Glucose-183* UreaN-16 Creat-0.7 Na-139 K-4.5 Cl-96
HCO3-35
[**2162-4-16**] Glucose-176* UreaN-18 Creat-1.0 Na-141 K-4.3 Cl-104
HCO3-26
[**2162-4-16**] ALT-37 AST-55* LD(LDH)-233 AlkPhos-40 TotBili-0.3
[**2162-4-25**] Mg-1.9
MRSA SCREEN (Final [**2162-4-21**]): No MRSA isolated.
CXR: [**2162-4-24**]: There is cardiomegaly which is stable. There are
bilateral pleural effusions, right side worse than left as well
as a left retrocardiac opacity. No overt pulmonary edema or
pneumothoraces are seen. The tip of the right IJ Cordis is in
the superior SVC.
Echo: [**2162-4-19**]
PRE-CPB:
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
No thoracic aortic dissection is seen. The aortic valve is
bicuspid with horizontal commissure. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST-CPB:
A bioprosthetic valve is seen in the aortic position. The valve
appears well-seated with normally mobile leaflets. A tiny
filamentous mass is seen in the LVOT side of the aortic valve,
possibly debris from debridement or a suture. There are no
paravalvular leaks, there is no AI. The peak gradient across the
aortic valve is 21mmHg, the mean gradient is 9mmHg with CO of
3.5L/min.
Biventricular systolic function remain normal. Other valvular
function remain unchanged from pre-bypass.
There is no evidence of aortic dissection.
[**2162-4-26**] 05:40AM BLOOD WBC-5.4 RBC-3.33* Hgb-9.5* Hct-30.2*
MCV-91 MCH-28.6 MCHC-31.5 RDW-14.3 Plt Ct-181
[**2162-4-25**] 09:30AM BLOOD WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3*
MCV-95 MCH-29.5 MCHC-31.2 RDW-14.8 Plt Ct-196
[**2162-4-26**] 05:40AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-138
K-4.4 Cl-96 HCO3-36* AnGap-10
[**2162-4-25**] 09:30AM BLOOD Glucose-183* UreaN-16 Creat-0.7 Na-139
K-4.5 Cl-96 HCO3-35* AnGap-13
Brief Hospital Course:
The patient was brought to the Operating Room on [**2162-4-19**] where
the patient underwent Aortic valve replacement with a 21-mm
Biocor tissue valve. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. The
patient was gently diuresed toward the preoperative weight. She
exhibited a high degree AV block initially, which would show
signs of recovery prior to discharge. EP was consulted and made
recommendations. Beta blockade was attempted, however this
compromised her normal sinus rhythm. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. She will not be
discharged on a beta blocker, and nodal agents should not be
initiated in the future. By the time of discharge on POD 8 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**Hospital **] Rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
Lisinopril 40mg daily, Aldactone 25mg daily, nadolol 160mg daily
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. 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*
7. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
5 days.
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
11. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane four times a day as needed for sore throat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab Center
Discharge Diagnosis:
Aortic Stenosis
Hypertension
status post cholecystectomy [**90**] yrs ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 1:15 in the
[**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A
Please call to schedule the following:
Cardiologist Dr. [**Last Name (STitle) 5017**]
Primary Care Dr. [**First Name4 (NamePattern1) 9097**] [**Last Name (NamePattern1) 110857**] [**Doctor Last Name 110858**] [**Telephone/Fax (1) 66039**] in [**4-15**] 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:[**2162-4-27**]
|
[
"4241",
"4019"
] |
Admission Date: [**2114-3-14**] Discharge Date: [**2114-3-19**]
Date of Birth: [**2054-8-8**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 50-year-old female
with cardiac catheterization on [**2113-4-17**] secondary to
exertional angina, presented to [**Hospital1 188**] after two weeks of exertional chest pain. Patient was
noted to have tight LM and right ostial disease with stents
having been placed in left anterior descending artery and D1.
The patient presented for arterial revascularization,
coronary artery bypass graft x4.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastroesophageal reflux disease.
3. Coronary artery disease status post catheterizations and
stent in [**Month (only) 547**] and again in [**2113-6-17**].
PAST SURGICAL HISTORY: Appendectomy.
ALLERGIES: The patient has no known drug allergies and only
a shellfish and dye allergy.
MEDICATIONS AT HOME:
1. Aspirin 325 q hs.
2. Diovan 160 mg q hs.
3. Atenolol 50 mg q hs.
4. Cinastin 0.625 mg q hs.
5. Progesterone 10 mg q day for the first 10 days of each
month.
6. Zantac prn.
LABORATORIES: The patient had a white count of 12.7,
platelets 387. INR of 1.0.
Patient underwent a cardiac catheterization on [**2114-3-14**] which revealed left main and severe two vessel coronary
artery disease and normal left ventricular function. The
patient underwent a coronary artery bypass graft x4.
Postoperatively, the patient was extubated without incident.
Levophed was weaned off. The patient received multiple fluid
boluses and 1 unit of packed red blood cells.
Patient was in normal sinus overnight, and was transferred to
the floor on postoperative day one. The patient had an
uncomplicated course thereafter, and was felt to be ready for
discharge on postoperative day five, tolerating regular diet,
and ambulating well with good po pain control. The patient
is to be going home with followup with Dr. [**Last Name (STitle) 70**] in six
weeks and follow up with Cardiology in four weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home.
DIAGNOSIS: Status post coronary artery bypass graft x4.
MEDICATIONS:
1. Percocet 1-2 tablets po q4-6h prn pain.
2. Tylenol 650 mg po q4-6h prn.
3. Ibuprofen 400 mg po q6h prn.
4. Aspirin 81 mg po q day.
5. Colace 100 mg po bid.
6. Nitroglycerin 0.4 mg sublingual prn.
7. Atenolol 25 mg po q day per cardiologist's request.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2114-3-19**] 17:51
T: [**2114-3-19**] 17:53
JOB#: [**Job Number 40302**]
|
[
"41401",
"4019",
"2720",
"53081"
] |
Admission Date: [**2117-7-21**] Discharge Date: [**2117-7-31**]
Date of Birth: [**2050-6-9**] Sex: F
Service: SURGERY
Allergies:
Codeine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 yo female s/p motor vehicle crash vs. pole at approx 40 MPH;
? if fell asleep vs. syncopal episode this morning at the wheel.
She was taken to an area hospital where a CT scan of the neck
showed C2 vertebral foramina fracture, and was sent to [**Hospital1 18**] for
further managment. Her GCS was 15 upon arrival; she was also
complaining of pain in the back of her head and neck, but denies
weakness and numbness/tingling, though she does have severe pain
from her
orthopaedic injuries, including a left wrist fracture.
Past Medical History:
ONC HISTORY (per OMR, previous discharge summaries):
Ms. [**Known lastname 103705**] was diagnosed with her lymphoma following preop
workup in preparation for Nissen fundiplication mid-[**Month (only) 404**]
[**2116**]. During her pre-operative workup, a CXR showed a R
mediastinal mass. Since then, she has had multiple CT/MRIs for
further workup. Noted to have extensive lymphadenopathy both
above and below the diaphragm. Right cervical LN biopsy ([**2116-12-23**])
showed involvement by high grade non-Hodgkin B-cell lymphoma,
best classified as diffuse large B-cell-type. By
immunohistochemistry, the neoplastic cells are diffusely
immunoreactive for pan-B-cell marker CD20 with coexpression of
bcl-2, CD10 (minor subset), and bcl-6 (subset). The neoplastic
cells do not coexpress bcl-1 or CD5. Pan T-cell markers CD3 and
CD5 highlight background T-cells. By MIB-1 staining, the
proliferation fraction amongst large neoplastic cells is greater
than 90%. In-situ hybridization studies for [**Doctor Last Name 3271**] [**Doctor Last Name **] Virus
encoded RNA ([**Last Name (un) **]), was negative.
Restaging PET scans ([**2117-2-8**] and [**2117-3-24**]) revealed further
reduction in her disease burden. Course has been complicated by
peripheral neuropathy that was present prior to initiation of
chemotherapy but has been exacerbated by vincristine toxicity.
Now s/p 6 cycles of R-[**Hospital1 **].
Last cycle [**Date range (1) 101391**]. Tolerated well. Complicated by some dyspnea
during course that responded to d/c of standing fluids and 10 IV
lasix.
.
TREATMENT HISTORY:
[**2116-12-29**] Cycle 1 [**Hospital1 **]
[**2117-1-7**] Dose #1 Rituxan
[**2117-1-21**] Dose #2 Rituxan
[**2117-1-22**] Cycle 2 [**Hospital1 **]
[**2117-2-10**] Dose #3 Rituxan
[**2117-2-16**] Cycle 3 [**Hospital1 **]/
[**2117-2-26**] Dose #4 Rituxan
[**2117-3-9**] Cycle 4 [**Hospital1 **]
[**2117-3-26**] Dose #5 Rituxan
[**2117-3-29**] Cycle 5 [**Hospital1 **]
[**2117-4-15**] Dose #6 Rituxan
[**2117-4-19**] Cycle 6 [**Hospital1 **]
.
PAST MEDICAL HISTORY:
- Diastolic CHF - EF 60-70% in [**2-23**]; >60% with LVH in [**4-/2117**]
- atrial fibrillation, paroxysmal
- HTN
- Hypercholesterolemia
- Angina
- Asthma
- Palindromic Rheumatism
- Pancreatitis [**12-19**] Imuran
- GERD
- h/o of DVT [**8-24**] in Left leg, on lovenox
.
PAST SURGICAL HISTORY:
- R Cervical Lymph Node Biopsy
- Rhinoplasty
- ERCP and sphincterotomy
Social History:
Married with two children. Retired. Used to be a teacher,
librarian, and account manager. Quit smoking 41 years ago. 10
pack year history. Denies alcohol use and illicit drugs.
Family History:
Mom - no cancer. Maternal aunt - BR CA in 40's. Dad - cerebellar
hemorrhage; leg amputation due to "poor circulation."
Physical Exam:
Upon arrival:
T: 98 BP: 138/87 HR: 127 R 16 92% O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 4 to 3 EOMs INTACT
Neck: Supple.
Extrem: Warm and well-perfused. L wrist splint.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R Difficult to assess w/R wrist fx 5 5 5 5 5
L 5- 5- 5- 5- (painful) 5 5 5 5 5
Lower extremity exam also limited by pain.
Sensation: Intact to light touch bilaterally.
Reflexes: B Pa
Right 1 1
Left 1 1
Toes downgoing bilaterally
Rectal exam mildly decreased sphincter tone
Pertinent Results:
[**2117-7-21**] 02:15PM GLUCOSE-183* LACTATE-3.4* NA+-142 K+-3.9
CL--102 TCO2-24
[**2117-7-21**] 02:09PM UREA N-13 CREAT-0.7
[**2117-7-21**] 02:09PM CK(CPK)-238* AMYLASE-30
[**2117-7-21**] 02:09PM CK-MB-7
[**2117-7-21**] 02:09PM cTropnT-<0.01
[**2117-7-21**] 02:09PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-7-21**] 02:09PM WBC-16.0* RBC-4.41 HGB-13.6 HCT-39.4 MCV-89
MCH-30.7 MCHC-34.4 RDW-13.2
[**2117-7-21**] 02:09PM PT-13.1 PTT-25.3 INR(PT)-1.1
[**2117-7-21**] 02:09PM PLT COUNT-220
[**2117-7-21**]
NONCONTRAST CT HEAD: There is no intra- or extra-axial
hemorrhage, shift of
normally midline structures, edema, mass effect, or evidence of
infarct.
Hyperostosis frontalis is and a subcentimeter left frontal sinus
osteoma are
incidentally noted. There is no evidence of calvarial injury.
Comminuted
odontoid fracture is better evaluated on concurrent CT C- spine
performed at
outside hospital.
IMPRESSION: No acute intracranial process.
C-spine [**2117-7-23**]
FINDINGS: Please note that the study is markedly limited due to
patient
positioning, technique, and overlying collar. The known
fractures at C2 is
not well seen on this study. Prevertebral soft tissues appear
slightly
prominent.
IMPRESSION:
Known C2 fracture is not well seen on this radiograph due to
technique and
collar. Please refer to prior outside imaging for additional
reporting.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
TR Gradient (+ RA = PASP): *31 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2117-4-27**].
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Low normal LVEF.
RIGHT VENTRICLE: RV not well seen.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes. Suboptimal image quality as
the patient was difficult to position. The rhythm appears to be
atrial fibrillation.
Conclusions
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal / borderline (LVEF 50-55%). The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
consulted given the spine fracture. Initial discussions took
place between team and family regarding Halo placement; after
much discussions the decision was to manage the fracture non
operatively with a cervical collar that includes a thoracic
extension. This brace is not to be removed at all unless until
follow up with Neurosurgery in 2 weeks. She has experienced
considerable pain as a result of this injury. The Pain service
was consulted; she had already been started on long acting
narcotics, they made several new recommendations including
adding Neurontin and increasing the frequency of the long acting
narcotic. An antispasmodic was also added for the neck spasms
that she was experiencing which seemed to help.
Orthopedics was also consulted given her wrist fracture; this
was managed non operatively as well. She was placed in a splint
and will need to follow up in [**Hospital 5498**] clinic in 2 weeks.
She intermittently had periods of rapid atrial fibrillation;
Cardiology was consulted. She had been on beta blockers and
required intermittent IV doses to control her rate. Her oral
beta blocker was increased as well as her calcium channel
blocker. She continued to have periods of rapid AF. It was
recommended to add Digoxin. Once she received loading doses she
was started on .125 MCG daily; her HR has remained in the 70's -
80's.
She was evaluated by Physical and Occupational therapy and is
being recommended for acute rehab after her hospital stay.
Medications on Admission:
Acyclovir 400''', Creon20 497''', clonidine 0.2'', dilt 360',
lovenox 100'', fluconazole 200', flovent 2puffs daily, folic
acid 1', furosemide 29 qod, metoprolol 100 3tabs daily, K-Dur
20', bactrim 160/800 MWF, B12 500mcg 2tabs daily, loratadine
10', zegerid 40' qhs
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Zegerid 40-1,680 mg Packet Sig: One (1) PKT PO daily ().
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Enoxaparin 100 mg/mL Syringe Sig: One (1) ML Subcutaneous
Q12H (every 12 hours).
14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
17. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed
for breakthrough pain.
18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO EVERY OTHER DAY (Every Other Day) as needed for
constipation.
20. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please give at 0800 and 1400.
21. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): Please give at 2200.
22. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
24. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
25. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
26. Ondansetron 4 mg IV Q8H:PRN nausea
27. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
28. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
29. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
30. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Bilateral C2 vertebral foramina fracture (Hangman's fracture)/C2
body fracture
Manubrium fracture
Right rib fractures [**4-25**]
Left distal radial/ulnar styloid fracture
Atrial fibrillation
Discharge Condition:
Hemodynamically stable, tolerating a regular die, pain fairly
controlled and is requiring ongoing adjustment of her
medications.
Discharge Instructions:
It is important that the rehab facility coordinates your clinic
appointments for the same day; the clinics that you will need to
follow up in are on Tuesday's.
The cervical collar with thoracic extension MUST be worn at all
times and cannot be removed unless authorized by Dr. [**Last Name (STitle) 548**],
Neurosurgery [**Telephone/Fax (1) 1669**].
DO NOT bear any weight on your left wrist because of your
fracture.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 3816**] clinic with Dr. [**Last Name (STitle) **], Trauma
Surgery for your rib fractures; call [**Telephone/Fax (1) 6429**] for an
appointment. Inform the office that you will need a chest xray
prior to this appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery for your spine
fracture. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the
office that you will need a repeat CT scan of your cervical
spine for this appointment.
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. Call
[**Telephone/Fax (1) 1228**] for an appointment. The clinic will arrange for
xrays to be taken of your wrist.
The folowing appointments were already scheduled prior to this
hospital stay; you will need to call to cancel if unable to
keep:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2117-8-10**] 7:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2117-8-10**] 8:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2117-8-10**] 8:00
Completed by:[**2117-7-31**]
|
[
"51881",
"4280",
"42731",
"4019",
"2720",
"49390",
"53081"
] |
Admission Date: [**2200-12-15**] Discharge Date: [**2200-12-23**]
Date of Birth: [**2128-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Back/Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(Russian interpreter requested for the AM) 72 M w/ pmh of HTN,
CAD, Nonischemic cardiomyopathy (EF 40%) CKD, chronic abdominal
pain admitted on [**12-15**] with left sided abdominal pain, that
started acutely 4 hours prior to presentation and associated
with nausea. Patient has been most tender on the left side and
periumbilical region. Denied fevers, chills, new foods, sick
contacts. Different from his chronic abdominal pain.
.
In the ED, initial VS: 85 131/61 19 94% on RA. Exam noted for
tenderness on the left side. CT ABD/Pelvis showed Left sided
nephrolithiasis with mild left renal edema, perinephric
stranding, no other abdominal process. U/A showed blood but no
leukocytosis. Got 16 IV morphine, 8IV Zofran. Urology was
reportedly consulted in ED, though no note in chart or OMR.
.
On the floor the patient continued to have abdominal pain and
nausea only partly relieved by morphine. Of note, patient has
been getting 125cc/hr of IV fluids for the last 1.5 day, and did
not receive his home lasix dose.
.
Patient was noted to be hypoxic to 85% while on 3L while
sleeping this evening. Exam notable for bilateral crackles. He
complained of some shortness of breath. He received 40mg IV
lasix x1 with good urine output of 300cc+. ABG was 7.36/36/72
while on 100% NRB. CXR notable for bilateral pulm edema. Patient
had persistent O2 sats of 85%-90% on 6L nc. He was transferred
to the MICU for relative hypoxia and nursing concern.
.
.
On MICU eval patient complained more of abdominal pain, though
did not feel comfortable with breathing. This was confirmed with
a Russian interpreter. A trial of Bipap at his usual OSA
overnight settings was attempted, with sats still 90%.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea, or changes
in bowel habits.
Past Medical History:
HTN
Smoking
Polycythemia [**1-20**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-20**] HTN
CAD: last cath [**6-21**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR
Atrial fibrillation on coumadin
Medullary thyorid CA s/p thyroidectomy
Parathyroid adenoma s/p partial parathyroidectomy
TURP [**9-/2191**]
BPH
PUD s/p gastrectomy/Billroth II [**2172**]
[**Doctor First Name **] [**Doctor Last Name **] tear in [**2195**] p/w BRBPR
s/p CCY
ventral hernia
Raynaud's
hematuria with hx epidymitis
depression
Family History:
No h/o premature CAD, no family hx of Medullary thyorid CA
Physical Exam:
Vitals: T:97.8 BP: 152/60 P: 76 R: 18 O2: 95% on Bipap
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated though body habitus is quite
large, so this is difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, no murmurs
Abdomen: soft, mildly tender to deep palpation over R side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2200-12-18**] KUB: prelim read: Gas distended small bowel may
represent ileus vs early/partial obstruction.
.
[**2200-12-17**] Portable CXR: FINDINGS: Since the previous chest
radiograph, bilateral pleural effusions and pulmonary vascular
congestion have improved and are now minimal. No new
consolidation, left lower lobe atelectasis also improved with
partial reappearance of the left hemidiaphragm. Cardiomegaly is
unchanged. IMPRESSION: Overall improvement in pleural effusions,
pulmonary vascular congestion and
left lower lobe atelectasis.
.
[**2200-12-16**] Renal US: FINDINGS: Note is made that this is a limited
portable study. The right kidney measures 10.3 cm and the left
kidney measures 12.7 cm. There is a borderline pelvocaliectasis
seen in the left kidney which appears unchanged from the CT of
yesterday. No renal stone can be identified. No hydronephrosis
is seen in the right kidney. IMPRESSION: Mild fullness of the
left kidney, unchanged from the CT of [**2200-12-15**].
.
[**2200-12-15**] CT abd/pelvis without IV contrast: There is bibasilar
subsegmental dependent atelectasis at the lung bases. The heart
is enlarged as before. Coronary artery atherosclerotic
calcification is noted. Evaluation of the abdominal organs is
limited without IV contrast. Within this limitation, the liver
is unremarkable. The common bile duct measures up to 11 mm,
which is unchanged from prior. Gallbladder is not seen. The
pancreas demonstrates mild fatty atrophy. The spleen and adrenal
glands are unremarkable. The opacified stomach and
intra-abdominal loops of bowel are unremarkable. The left kidney
appears slightly edematous compared to the right and there is
mild left perinephric stranding. In addition, there is slight
engorgement of the left renal pelvis. There is a 2.5-mm
radiodensity along the expected course of the left mid ureter
(2:38) which likely represents a ureteral calculus. No other
calculi are identified. There is extensive atherosclerosis of
the abdominal aorta and several branches. A saccular infrarenal
aortic aneurysm is again noted measuring 3.0 (TRV) x 2.9 (AP) x
2.5 (CCN) is not significantly increased from prior when it
measured 2.9 x 2.8 x 2.5 cm. No free air or fluid is noted in
the abdomen. No mesenteric or retroperitoneal lymphadenopathy
meeting CT criteria for pathologic enlargement is noted. The
patient is status post partial gastrectomy with
gastrojejunostomy. The urinary bladder, distal ureters, seminal
vesicles, prostate, sigmoid colon and rectum are unremarkable.
There is no free fluid or pelvic or inguinal lymphadenopathy
noted. BONE WINDOWS: No suspicious lytic or sclerotic osseous
lesions identified.
IMPRESSION: 1. Left mid ureteral 2.5-mm stone with associated
left perinephric stranding and mild renal edema. 2. No evidence
of mesenteric ischemia, diverticulitis or acute aortic
pathology, although evaluation is somewhat limited on this
non-contrast-enhanced CT. 3. No significant change in the
saccular infrarenal abdominal aortic aneurysm compared to
[**2200-2-27**]. 4. Cardiomegaly.
.
[**2200-12-16**] EKG: "Fine" atrial fibrillation with ventricuilar
premature beats. Left ventricular hypertrophy. Intraventricular
conduction delay with left axis deviation may be due to left
ventricular hypertrophy and left anterior fascicular block. ST-T
wave abnormalities may be due to left ventricular hypertrophy,
intraventricular conduction delay and/or possible ischemia.
Since the previous tracing of [**2200-12-14**] no significant change.
.
[**2200-12-14**] 09:40PM PT-26.5* PTT-31.5 INR(PT)-2.6*
[**2200-12-14**] 09:40PM PLT COUNT-200
[**2200-12-14**] 09:40PM NEUTS-81.1* LYMPHS-13.2* MONOS-4.5 EOS-0.5
BASOS-0.7
[**2200-12-14**] 09:40PM WBC-10.0# RBC-4.80 HGB-13.3* HCT-40.4 MCV-84#
MCH-27.7 MCHC-32.9 RDW-15.6*
[**2200-12-14**] 09:40PM LIPASE-28
[**2200-12-14**] 09:40PM ALT(SGPT)-21 AST(SGOT)-24 ALK PHOS-76 TOT
BILI-0.6
[**2200-12-14**] 09:40PM estGFR-Using this
[**2200-12-14**] 09:40PM GLUCOSE-142* UREA N-38* CREAT-2.3* SODIUM-142
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
[**2200-12-14**] 10:37PM LACTATE-1.1
[**2200-12-15**] 01:50AM URINE HYALINE-[**2-20**]*
[**2200-12-15**] 01:50AM URINE RBC-[**11-7**]* WBC-[**2-20**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2200-12-15**] 01:50AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2200-12-15**] 01:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2200-12-15**] 01:50AM URINE GR HOLD-HOLD
[**2200-12-15**] 01:50AM URINE HOURS-RANDOM
[**2200-12-15**] 01:50AM URINE HOURS-RANDOM CREAT-176 SODIUM-48
POTASSIUM-72 CHLORIDE-40
Brief Hospital Course:
72 year old male with ephysema, OSA, cardiomyopathy (EF 40%),
CAD, CKD presents with nephrolithiasis, acute on chronic kidney
disease whose course has been complicated by pulmonary edema and
hypoxia requiring diuresis and now ileus vs partial obstruction.
.
#. Nephrolithiasis: This was the patient's first kidney stone. A
CT scan done initially showed perinephric stranding and a stone
in the left ureter. Urology evaluated the patient. He was
started on tamsulosin and restarted on flomax. The patient
developed ARF secondary to obstructive uropathy (see below), but
maintained good urine output. He was initially treated with iv
dilaudid (which was switched to tylenol and oxycodone secondary
to ileus) and ivfs, which was stopped secondary to volume
overload (see below). He was also treated with a course of
ceftriaxone for suspected pyelonephritis. He passed several
stones on this admission, and one was sent for analysis. A
repeat CT scan was done that showed an obstructive stone in the
UV junction with hydronephrosis and urology recommended
observation. Patient subsequently passed stone with improvement
of creatine, pain, and large quantity of diuresis.
.
#. Hypoxia: On presentation patient received fluid hydration for
nephrolithiasis and subsequently, developed hypoxia. He was
then transferred to the MICU. Patient was ruled out for
myocardial damage and CXR did not show evidence of
consolidation. His hypoxia was thought to be secondary to fluid
overload from cardiomyopathy and acute on chronic kidney disease
(see below). He was aggressively diuresed approximately 5 L in
the MICU with improvement of SaO2. Upon transfer back to the
floors, he was weaned onto room air keeping his SaO2 above 90%.
He was continued on his home CPAP overnight for OSA and lasix
was restarted at his home dose po.
.
#. Acute on chronic kidney disease: Baseline Cr 1.4-1.7.
Throughout hospitalization Cr peaked to 3.2 and subsequently
trended down after passing of multiple stones. Nephrology was
consulted and initially, the team suspected a pre-renal vs
vascular disease as possible etiology of his ARF. However, a
repeat CT abdomen was done that showed worsening hydronephrosis
and a ~4mm stone at the UV junction. Urology was then consulted
regarding surgery and advised monitoring the patient clinically
given his comorbidities and risk of anesthesia. Patient passed
a stone [**12-22**] and subsequent to this Creatine improved to
baseline and began putting out large amounts of urine. It was
ultimately felt that his ARF was likely secondary to obstructive
uropathy with resolution of passing of stone and
post-obstructive diuresis. Patient was discharged with follow
up with his outpatient nephrologist. Throughout this time his
lisinopril was held and not restarted on discharge.
.
#. Ileus: Patient developed ileus secondary to large quantity of
narcotics and was treated with an aggressive bowel regimen with
resolution of his symptoms.
.
#. Atrial fibrillation: On admission patient was
supratherapeutic. His coumadin dose was initially held and then
restarted at 2mg daily. INR remained therapeutic throughout.
Patient was continued on metoprolol for rate control.
.
#. Obstructive sleep apnea: He was continued on CPAP overnight
on home settings
.
#. Hypertension: His lisinopril was held in the setting of acute
on chronic renal desease. He was continued on his home regimen
of amlodipine and metoprolol.
.
#. Acute on chronic systolic heart failure: Patient had
pulmonary edema (see above) secondary to fluid overload and was
diuresed in the MICU. He was further managed with his home beta
blocker, lasix, and ACEi held due to kidney issues.
.
#. H/o PUD/gastritis: continued on home [**Hospital1 **] PPI
.
#. S/p thyroidectomy: continued on home levothyroxine
.
#. S/p parathyroidectomy: continued on calcitriol
Medications on Admission:
AMLODIPINE - 10 mg po qhs
ATORVASTATIN [LIPITOR] - 80 mg po daily
BIPAP - 12/8 CM H2O - NIGHTLY.
CALCITRIOL - (dc med) - 0.25 mcg Capsule - 2 Capsule(s) by mouth
twice a day
FINASTERIDE - 5 mg po daily
FLUOXETINE [PROZAC] - 20 mg po daily
FUROSEMIDE - 20 mg po daily
LEVOTHYROXINE - 200 mcg po daily
LISINOPRIL - 40 mg po daily
METOPROLOL SUCCINATE - 50 mg po daily
PANTOPRAZOLE [PROTONIX] - 40 mg po bid
TRAZODONE - 50 mg po qhs PRN insomnia
WARFARIN - 2.5-5 mg po daily
Aspirin 81 mg po daily
ASCORBIC ACID - 500 mg po daily
CALCIUM CARBONATE [CALCIUM 600] - 600 mg (1,500 mg) po tid
CYANOCOBALAMIN - 2,000 mcg po daily
DOCUSATE SODIUM [COLACE] - 100 mg po bid
FERROUS SULFATE - 324 mg (65 mg Iron) po daily
SENNA - 8.6 mg po bid PRN constipation
SIMETHICONE - 80 mg po qid
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Cyanocobalamin 1,000 mcg Tablet Sig: Two (2) Tablet PO once
a day.
16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day.
18. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO three times a day.
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
20. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
21. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain: not to exceed more than 4mg per day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Nephrolithiasis
Obstructive Uropathy
Urinary Tract Infection
Pulmonary Edema
Discharge Condition:
A&O x 3
Independent Ambulation
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 27530**],
We had the pleasure of taking care of you at [**Hospital1 18**]. You were
admitted to the hospital because you had abdominal pain from
kidney stones. While you were here we treated you with iv
fluids. However, because of your kidney dysfunction and heart
failure you developed difficulty breathing because of volume
overload, and so you were treated with lasix. Your kidney
stones passed on their own, and your kidney function has since
improved.
We have made the following changes to your medications:
1. We have stopped your Lisinopril because of your kidney
function, please see your PCP before restarting this medication.
2. We have discharged you on Coumadin 2mg daily. Please follow
up in [**Hospital3 271**] to have your INR checked.
3. We have started you on tamsulosin, please continue this
4. We have restarted your flomax, please continue this. Your
PCP will decide if you should stay on this medication.
5. We have started you on tylenol for pain. Do not exceed 4mg
per day.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Please make sure you follow up with your PCP and Nephrologist
(kidney doctor); see below.
Followup Instructions:
Follow up with PCP:
[**Name10 (NameIs) 357**] follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2200-12-26**] at 02:20p. His
office is in the [**Hospital Ward Name **] CENTER, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT
(SB).
Follow up with Nephrology:
Someone from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office will call you to schedule
an appointment time for you. You will need to follow up with
him regarding your kidney function and kidney stones. He may
decide to get an US of your kidney for further assessment.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2201-1-27**] 3:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2201-2-11**] 3:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2201-2-11**] 3:00
Completed by:[**2200-12-24**]
|
[
"5849",
"5990",
"4280",
"4019",
"41401",
"32723",
"42731",
"V5861"
] |
Admission Date: [**2132-5-15**] Discharge Date: [**2132-6-6**]
Date of Birth: [**2072-8-11**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Demerol / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
motorvehicle accident, arrived from OSH intubated
Major Surgical or Invasive Procedure:
T4-8 posterior spinal fusion [**2132-5-28**]
Tracheostomy tube placement [**2132-5-30**]
Percutaneous gastrostomy tube placement [**2132-6-2**]
IVC filter placement [**2132-6-3**]
History of Present Illness:
59F s/p MVA, unrestrained. Seen at outside hospital and
intubated for shortness of breath. Was unrestrained driver MVA
vs. tree admitted for multiple traumas including rib fractures
and fx vertebral body fractures.
The MVC occured on [**2132-5-15**] approximately 20:30. There was a
prolonged extrication and steering wheel deformity. The
patient was take to [**Hospital **] hospital and was found to have
multiple bilateral rib fractures, T6-T7 fractures, multiple
pulmonary contusions, liver capsue injury. She was intubated
for airway protection, transferred to [**Hospital1 18**] for care and further
trauma evaluation.
Past Medical History:
Congestive heart failure, diastolic dysfxn, Diabetes mellitus
type 2, Retinopathy, Neuropathy, History of heartburn, Sleep
apnea requiring CPAP, Hypertension, Hyperlipidemia, History of
diverticulosis, Fibromyalgia, Hypothyroidism, Osteoarthritis
limiting her activity including back pain and knee pain
Past Surgical History: Foot surgeries, D&C x2, Left knee
arthroscopy x2, Laparoscopic adjustable gastric band, Allergan
and [**Hospital1 **] laparoscopic band, 03/[**2128**].
Social History:
former accountant
no tobacco or ETOH
Married with 2 children
sedentary lifestyle
Family History:
No Significant Inheritable Disorder
Mother w/ osteoporosis, age [**Age over 90 **].
daughter w/ [**Name2 (NI) 933**] disease
another daughter w/ rheumatoid arthritis
Physical Exam:
On Admission:
VS: HR: 89, 109/48, RR 18
Gen: intubated/sedated
CVS: reg
Pulm: intubated, clear bilaterally
Ext: R hand contusion
On Discharge:
AFVSS
Gen: NAD, alert but does not follow commands
CVS: reg
Pulm: no resp distress
Abd: obese, S/NT/ND
LE: 1+ edema bilateral lower extremity
Pertinent Results:
List of Injuries
T6-T7 Vertebral body fracture
T6-T7 fracture/dislocation of thoracic spine.
Fracture through T7 spinous process extending down into the T8
level.
Right distal ulnar styloid fracture
Right [**Hospital1 **]-malleolar ankle fracture
Right calcaneus fracture
Right renal laceration
Left lung contusion
Fracture Left ribs [**12-20**] (displaced 2,3,6)& Rt 4th, R 5th x2, R6 R
7
hepatic subcapsular hematoma
MICRO:
[**5-17**]: Bcx x2 NGTD
[**5-17**] BAL: >100,000 S.aureus [**Last Name (un) 36**] oxacillin, Haemophilus
[**5-18**] ucx: Enterococcus <100K
[**5-25**] Sputum cx: GNR Stenotrophomonas
[**5-27**] Bl cx: NGTD
[**5-27**] Ucx: neg
[**5-27**] C diff: neg
[**5-27**] Cath tip aline: NGTD
[**5-27**] Cath tip CVL: NGTD
[**5-29**] Bcx: NG
[**5-29**] Ucx: NG
[**5-29**] Sputum cx: GNR 2+
[**5-29**] Cath Tip: NG
[**5-30**] C diff: NEg
[**5-30**] BAL: STENOTROPHOMONAS (XANTHOMONAS) [**First Name9 (NamePattern2) **] [**Doctor Last Name **] to
Bactrim, 10,000-100,000 ORGANISMS/ML. STAPH AUREUS COAG +.
~1000/ML.
[**5-30**] Bl cx: NG
[**6-1**] UCX: NG
[**6-1**] Bcx: P
IMAGING:
[**5-15**] Ct Head: Neg
[**5-15**] Ct C spine: no c spine fracture/ Non displace fracture of
right 1rs rib.
[**5-15**] CT Torso: subcapsular hematoma, Free fluid near spleen,
Collection near R anterior renal cortex. Gastric band, Bilateral
pulmonary contusions, No plueral effusions or PTX, Multiple
bilateral rib fractures, PArtial compression of T6 and lucencies
through T7 with presevation of spinal canal.
[**5-16**] IR: no bleeding identified
[**5-17**] CT Abd/P, Tspine: Stable hemoperitoneum hemorrhage within
the pelvis and surrounding the bowel loops. No evidence of bowel
wall thickening. Findings compatible with acute tubular necrosis
of the kidneys. Bilateral pulmonary contusion and bibasilar
atelectasis. Right displaced rib fractures left-sided rib
fractures. Probable 1 cm cyst in the left kidney. T6 and T7
vertebral body fractures with no retropulsion. Left L1
transverse process fracture.
[**5-17**] Renal US: Markedly limited exam. No hydronephrosis. Pulse
Doppler
waveforms of the renal vessels could not be obtained.
[**5-18**] CXR: Increase LLL , retrocardiac and Rll opacities.
[**5-20**] CXR: Inc bilat pl eff, worsening pulm edema and inc
consolidation R lung base
[**5-21**] CXR:mod pulmonary edema, moderate left.? ARDS.
[**5-21**] Ct RLE:Severely comminuted fracture of the calcaneus that
extends into the posterior and medial calcaneal facet and the
calcaneocuboid junction. Severe depression of the posterior
subtalar joint is noted measuring 14 mm.
[**5-23**] KUB: Air and stool is seen throughout the colon. No
evidence of obstruction.
[**5-23**] CXR: Combination of pulmonary edema and contusion and/or
pulmonary hemorrhage has not improved, there is a suggestion of
a new cavity or pneumatocele in the right mid lung. Moderate
left pleural effusion is stable.
[**5-24**] CXR: Improved aeration bilateral lobes
[**5-26**] CT Torso: No CT evidence of abscess. Improvement in
bilateral lung consolidation/ground glass opacity since [**2132-5-17**]
suggests resolving pulmonary contusion versus pneumonia.
Multiple rib and spine fractures are unchanged since [**2132-5-17**].
[**5-27**] fiducial markers at the T5/T6 , T6 and T7 vertebral bodies
fx.
[**5-30**] LENIs: neg
[**6-2**]: Worsening pulmo vasc congestion with asymmetric perihilar
edema, R>L.
[**6-3**] R knee: linear lucency extending through the median
eminence, which may represent a nondisplaced fracture. sm
effusion.
[**6-4**] CT head: airspace opacification c/w intubation/mech
ventilation. No bleed. No [**Doctor Last Name 352**]/white matter changes
Brief Hospital Course:
She was admitted to the trauma ICU after initial evaluation in
the emergency department. Resucsitation was continued. Serial
HCTs were followed for her hepatic hematoma. She required an
initial 2 units of blood transfusion during her resuscitation
however was found to have a decline in her hematocrit on HD#2
and she was taken to IR for angio and potential embolization
however no bleeding source was identified. She remained
hemodynamically stable but oliguric. Serial echocardiograms
were performed at the bedside for assistance with resuscitation.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18821**] monitor was placed on HD#3 for more accurate monitoring
of her hemodynamics and fluid status given her oliguria. A
repeat CT scan on HD#3 showed free fluid but no concern of
active bleeding. Her hematocrit stabilized. Spine surgery was
involved from admission and given her initial critical care
issues surgery was delayed until she was more stable. She was
logroll with turns but allowed to have her HOB elevated per
spine surgery as her injury was an extension injury and stable.
She required an insulin drip for hyperglycemia. Dr. [**Last Name (STitle) **],
her bariatric surgeon, took the fluid out of her gastric band on
hospital day #2. She went into acute renal failure and was
followed by nephrology for likely ATN and contrast induced
nephropathy. She ultimately had an HD line placed [**5-19**] and was
started on CVVH in order to aid diuresis for her upcoming spine
surgery. Her renal function gradually improved and this was
stopped on [**5-27**] with stabilization of her BUN/Cr. She was taken
to interventional radiology for placement of fiducials for
preoperative planning to aid with the localization of proper
thoracic spine levels during her planned surgery by Dr. [**Last Name (STitle) 1352**].
This was done on [**2132-5-27**] and she went to the OR for her
thoracic spinal fusion on [**2132-5-28**]. She tolerated the procedure
well and was stable postoperatively. Attempts to wean her
ventilator were slow but gradually improved. She had been on
antibiotics for a VAP from [**5-17**] and these were stopped on [**5-27**]
after a 10day course. A tracheostomy was placed on [**5-30**]. A
percutaneous gastrostomy tube was placed by IR on [**6-2**] with the
tube in the distal stomach beyond the gastric band. Tube feeds
were resumed on [**6-3**] (had previously been receiving TF via OGT
before trach placed). She tolerated trach mask on [**6-3**] and
remained of the ventilator. An IVC filter was placed [**6-3**] given
her prolonged recovery prognosis. A CT head was performed [**6-4**]
and an EEG on [**6-5**] to evaluate her failure to regain her
baseline mental status. The CT was unremarkable and the EEG
showed diffuse encephalopathy consistent with metabolic disorder
from her prolonged critical illness. Physical therapy worked
with her and got her out of bed to a chair. She was
transitioned to subcutaneous insulin and was able to come off of
her insulin gtt. Orthopedics followed her during her stay as
well. She was found to have a right calcaneous fracture and a
Right [**Hospital1 **]-malleolar ankle fracture which was managed
nonoperatively with an aircast boot with instructions for TDWB
on that extremity.
Medications on Admission:
MED: allopurinol 100", amitriptyline 75', atorvastatin 80',
zetia 10', fosinopril 80', lasix 80', insulin 5u TID, synthroid
88', toprol XL 250', omeprazole 20', lyrica 225', asa 81',
flintstones MVI
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for
lubrication.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. Metronidazole 1 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for rosecea.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for sbp<170.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Pantoprazole 40 mg Susp,Delayed Release for Recon Sig: One
(1) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Polytrauma (spine injury, extremity fractures, rib fractures,
altered mental status)
T6-T7 Vertebral body fracture
T6-T7 fracture/dislocation of thoracic spine.
Fracture through T7 spinous process extending down into the T8
level.
Right distal ulnar styloid fracture
Right [**Hospital1 **]-malleolar ankle fracture
Right calcaneus fracture
Right renal laceration
Left lung contusion
Fracture Left ribs [**12-20**] (displaced 2,3,6)& Rt 4th, R 5th x2, R6 R
7
hepatic subcapsular hematoma
Pneumonia
Diabetes Mellitus
Morbid Obesity
Respiratory Failure
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:
See d/c summary, page 1, and f/u instructions.
Call for danger signs or for other concerns
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks regarding your
ankle fracture. Call ([**Telephone/Fax (1) 2007**] to make an appointment.
Please follow up with Dr. [**Last Name (STitle) 1352**] in 2 weeks regarding your
spinal fusion. Call ([**Telephone/Fax (1) 2007**] to make an appointment.
Staples are due to be removed [**2132-6-21**]
Please follow up with the Acute Care Surgery clinic, Dr. [**Last Name (STitle) **],
in [**1-16**] weeks in . Call ([**Telephone/Fax (1) 27603**] to make an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"2760",
"2859"
] |
Admission Date: [**2138-9-27**] Discharge Date: [**2138-9-30**]
Date of Birth: [**2087-4-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
C6-c7 laminectomy, C5-6, c6-7 foraminotomies and c4-T1 posterior
instrumented spinal fusion.
History of Present Illness:
History of rollover motor vehicle accident with trauma to neck.
History of tingling in ulnar nerve distribution bilaterally.
past history of neck pain.
Past Medical History:
History of lumbar spine surgery done in the past.
Social History:
Occasional smoker
Physical Exam:
Neuro [**6-3**] in both upper and lower extremities.
SILT
Tenderness over neck.
Tenderness over left sided toes.
Pertinent Results:
[**2138-9-27**] 03:31AM PH-7.41 COMMENTS-GREEN TOP
[**2138-9-27**] 03:31AM HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET
HGB-0.3
[**2138-9-27**] 03:31AM GLUCOSE-98 LACTATE-2.1* NA+-138 K+-3.3*
CL--98* TCO2-24
[**2138-9-27**] 03:31AM HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET
HGB-0.3
[**2138-9-27**] 03:31AM freeCa-1.10*
[**2138-9-27**] 03:30AM URINE HOURS-RANDOM
[**2138-9-27**] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-9-27**] 03:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2138-9-27**] 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-9-27**] 03:20AM UREA N-10 CREAT-0.6
[**2138-9-27**] 03:20AM estGFR-Using this
[**2138-9-27**] 03:20AM LIPASE-28
[**2138-9-27**] 03:20AM ASA-NEG ETHANOL-143* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2138-9-27**] 03:20AM WBC-15.2* RBC-3.71* HGB-11.6* HCT-33.8*
MCV-91 MCH-31.4 MCHC-34.4 RDW-12.8
[**2138-9-27**] 03:20AM PLT COUNT-358
[**2138-9-27**] 03:20AM PT-13.2 PTT-25.5 INR(PT)-1.1
[**2138-9-27**] 03:20AM FIBRINOGE-285
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#1. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itchy.
Disp:*20 Capsule(s)* Refills:*0*
5. Estrogens Sig: One (1) Tablet DAILY (Daily): home med.
6. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for muscle spasms.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
C6 left side lamina and pedicle fracture with floating lateral
mass.
left 2nd toe proximal phalanx fracture.
Discharge Condition:
Stable.
Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
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 in a car
or chair for more than ~45 minutes without getting up and
walking around.
weightbearing as tolerated left foot with post-op shoe and buddy
tape for 2nd toe fracture.
- Rehabilitation/ Physical Therapy:
o 2-3 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.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- 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. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- 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 narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Followup Instructions:
follow up with Dr [**Last Name (STitle) 1007**] in 2 weeks following discharge. Please
call [**Telephone/Fax (1) 9769**] to make an appointment.
follow up in ortho trauma clinic in [**3-4**] weeks for left 2nd toe
fracture. call [**Telephone/Fax (1) 1228**] for appt.
Completed by:[**2138-9-30**]
|
[
"3051"
] |
Admission Date: [**2102-12-6**] Discharge Date: [**2102-12-21**]
Service: GREEN [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient was an 81 year old
woman at the time of admission, 82 years old at discharge who
presented with diffuse abdominal pain times one week,
increasing in intensity in the 24 hours prior to
presentation. It was associated with two episodes of coffee
ground emesis the evening prior to admission. No fever,
chills, shortness of breath, chest pain, bright red blood per
rectum or change in bowel or flatus habits. Patient had been
using increasing nonsteroidal anti-inflammatories over the
past three months for osteoarthritis. No history of ETOH
use.
PAST MEDICAL HISTORY: Arrhythmia (sick sinus syndrome with
intermittent/complete heart block) with pacemaker,
hypertension, mild aortic stenosis, CAD,
hypercholesterolemia, history of cardiovascular accident,
urinary incontinence, Diabetes mellitus Type II,
hypothyroidism, dementia of Alzheimer's type,
anxiety/depression.
PAST SURGICAL HISTORY: History of right hip fracture with
compression screw in [**2101-4-6**].
SOCIAL HISTORY: Resident of [**Hospital3 **] and Care
for the Aged.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS AT [**Hospital1 5595**]: Zyprexa 5 qhs, Paxil 20 qd, Simethicone
80 qid, Detrol 1 mg [**Hospital1 **], Trazodone 50 qhs, Naproxen 500 [**Hospital1 **],
Glucotrol 2.5 qd, Synthroid 50 qd, Ativan 0.5 [**Hospital1 **],
Pilocarpine 5 tid.
PHYSICAL EXAMINATION: Vitals Pulse 80, blood pressure 90/49,
respirations 24, 02 sat 100% NRB. This is an uncomfortable
female with distended, tympanitic abdomen with diffuse
guarding, greatest in the epigastric area. Coffee ground NGT
aspirate. Guaiac positive stool. No bright red blood per
rectum. Of note: Umbilical hernia.
LABORATORY DATA: CBC: WBC 4.5, hematocrit 33.2, platelets
455, N44, Bd29, L24, Chem: Na 134, Cl 96, BUN 41, potassium
5.0, C02 23, creatinine 3.3. ABG: Metabolic acidosis.
Cardiac enzymes: Within normal limits x 1 on admission.
Liver enzymes: Within normal limits except for amylase 246
and lipase 1320.
Chest x-ray: Significant for free intraperitoneal air. EKG:
Normal paced rhythm.
HOSPITAL COURSE: Initial course, patient given fluid
resuscitation, started on broad-spectrum antibiotics and
taken to the OR for emergent exploratory laparotomy.
Intraoperatively, the abdomen was found to be filled with
purulent material. A 1 cm perforation in the anterior
duodenum was identified and was repaired with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **].
A 7 cm exophytic mass was also found to be emanating from the
left hepatic lobe. An intraoperative consult was obtained
and the mass was removed by Dr. [**Last Name (STitle) **]. Of note: On
pathology, the liver mass was determined to be a hemangioma.
Postoperatively, the patient was transferred to the SICU and
was discharged fro the SICU to the General Floor on POD#3.
Respiratory: The patient was initially kept intubated
postoperatively in order to protect airway until metabolic
acidosis corrected. She was extubated on POD #1. Patient
experienced wheezing which was improved by albuterol
nebulizer. Cardiology: Rhythm - Pacemaker interrogated on
HD#1, POD#0 and found to be functioning normally. Pump:
Patient experienced some increased difficulty breathing on
POD#5 and was found to have evidence of worsening CHF. The
patient was started on Lasix. Cardiac enzymes/EKG were
checked on POD#8 and there was no evidence of myocardial
infarction as precipitant for worsening CHF. Patient managed
on Lasix and was eventually able to be taken off Lasix prior
to discharge. Patient was placed on a perioperative beta
blocker. ID: Patient was initially on Ampicillin,
Levofloxacin, Flagyl and Fluconazole for broad-spectrum
coverage. Peritoneal swabs grew micrococcus/Stomatococcus.
Above antibiotics were continued. On POD#7, patient spiked a
temperature to 101.8. Cultures were done and CT was done to
rule out abscess. Central line culture was initially
reported as positive for gram positive cocci so patient was
changed from ampicillin to Vancomycin to cover possible MRSA
however further reporting described mixed flora and
Vancomycin was discontinued. Broad-spectrum antibiotics were
discontinued on POD#11. Patient found to have H. pylori.
Treatment for this was begun with Clarithromycin and
amoxicillin when patient was able to take PO on HD#11.
Patient should continue this until [**2102-12-26**] along with
ongoing proton pump inhibitor. Endocrinology: NIDDM:
Patient's oral hypoglycemics held during the admission and
fingersticks were monitored. Patient was given coverage by
regular insulin sliding scale. FEN: Patient initially
presented in acute renal failure, most likely secondary to
decreased intravascular volume. Renal function normalized
following fluid resuscitation. Patient initially kept NPO.
Started on TPN POD#3. Patient began to tolerate sips of
clears on POD#11 and was advanced, tolerating diabetic diet
at discharge. Musculoskeletal: Patient continued to
complain of arthritis pain, but given history of duodenal
perforation decision was made to avoid further NSAID use.
Patient noted control of pain with acetaminophen and Ultram
around the clock. Psych: Patient placed on outpatient
medications when able to tolerate.
LINES: RIJ triple lumen, Foley.
DISCHARGE MEDICATIONS: As admission except Metoprolol 25 [**Hospital1 **]
added. Tramadol 50 mg PO q 6 hrs for arthritis pain. All
NSAIDs discontinued.
DISPOSITION: To [**Hospital 100**] Rehab.
DISCHARGE STATUS: Alert and oriented to person. Not
agitated. Able to hold logical and intelligent conversation
and follow commands. Unable to ambulate and requiring [**Doctor Last Name 2598**]
lift for out of bed. Tolerating full diabetic diet.
DISCHARGE DIAGNOSIS: Perforated duodenal ulcer, liver
hemangioma, acute renal failure, congestive heart failure,
diabetes mellitus Type II, depression, anxiety, dementia of
Alzheimer's type, arrhythmia, gastritis, hypotension,
osteoarthritis. Code status: DNR/DNI at [**Hospital1 5595**]. DNR/DNI
withheld for surgery. Discharge follow up with Dr. [**Last Name (STitle) **]
in [**1-9**] weeks. Follow up with [**First Name8 (NamePattern2) **] [**Doctor First Name **], cardiologist
after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 47939**]
MEDQUIST36
D:
T: [**2103-2-20**] 14:26
JOB#:
|
[
"5849",
"4280",
"42731",
"4241",
"25000"
] |
Admission Date: [**2142-5-18**] Discharge Date: [**2142-6-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M Chinese-speaking with Hepatitis B, hepatoma s/p
Radiofrequency ablation on [**2142-5-3**] who presented to ED with
abdominal pain that patient thought was constipation (no BM x
few days). He was having an annual physical in [**Month (only) 547**] with AFP
checked due to history of hepatitis B. This was elevated to
4527. He has a long history of hepatitis B as does his wife and
two sons. [**Name (NI) 6**] ultrasound was done on [**2142-3-21**] that showed a five
centimeter mass in the left hepatic lobe and two masses in the
right hepatic lobe, the largest measuring two centimeters. No
biopsy was done, but due to the history and the AFP it is
assumed that he has hepatocellular carcinoma. The patient was
seen by Dr. [**First Name (STitle) **] on [**2142-4-6**] for treatment options. Patient
underwent RFA on [**2142-5-3**]. Patient tolerated this procedure well
initally. Pt returned to [**Location **] c/o abd pain and decreased [**Known firstname **] intake
over 2 weeks PTA. Denied N/V, diarrhea, BRBPR, or respiratory
Sx.
.
In ED, T100.3, WBC 16.5 w/neutrophilia, lactate 5.4, and became
hypotensive to SBP 80s so started on sepsis protocol. Central
line placed, given 9L IVF, started on levophed x3hrs,
vanco/levo/flagyl for suspected GI vs resp source.
.
Pt admitted to MICU for sepsis.
Past Medical History:
-Hepatitis B
-Hepatoma: Dx [**2142-3-21**]; s/p radiofreq ablation [**2142-5-3**]; followed
by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
-diabetes mellitus, type 2, Dx last yr, no meds just diet &
exercise
-?glaucoma
-hearing loss
Social History:
He does not smoke or drink.
Family History:
Significant for father with liver cancer who died at age 85.
Physical Exam:
GENERAL: Mildly ill appearing male, in no acute distress.
VITAL SIGNS: T: 97.6, BP: 147/62, HR: 73-103, O2sat 96% on 2L
HEENT: Unremarkable. Sclerae are anicteric, conjunctivae pink.
Oropharynx is without lesions or erythema. MMM
LYMPHATICS: No cervical, supraclavicular, axillary, or inguinal
adenopathy.
NECK: Supple, L IJ in place.
LUNGS: Bronchial BS on the R, fine rales at L base. No wheezes
or rhonchi.
HEART: Regular rate and rhythm. PMI nondisplaced.
ABDOMEN: Mild distension with normal bowel sounds. Liver edge
is palpable one centimeter below the right costal margin. No
ascites appreciated.
EXTREMITIES: Without clubbing, cyanosis, hands and feet with
trace edema. Warm and well perfused.
Pertinent Results:
CXR [**2142-5-20**]:
There is continued mild congestive heart failure with slightly
increased moderate-sized right pleural effusion. There is
continued opacity in both lower lobes indicating atelectasis.
The possibility of superimposed pneumonia cannot be excluded.
The right jugular IV catheter remains in place. No pneumothorax
is identified. There is diffuse dilatation of the bowel,
probably due to ileus. Please correlate clinically.
.
CT abd [**2142-5-18**]:
IMPRESSION:
1) No evidence of hematoma or abscess.
2) Hypodense areas in the liver consistent with post-RF ablation
changes.
3) Focus of enhancement adjacent to the right lobe RF ablations
site, raising concern for persistent hepatoma.
4) Likely bibasilar atelectasis, although the presence of
infection cannot be entirely excluded.
.
RUQ Ultrasound ([**2142-5-18**])
IMPRESSION:
1) Multiple areas of heterogeneous echotexture consistent with
prior RF ablations sites.
2) No intra or extra-hepatic biliary ductal dilatation.
3) Gallstones, with gallbladder wall thickening and edema, which
can be seen in cirrhotic states
ECHO ([**2142-5-22**])
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF>75%). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mitral
regurgitation is present but cannot be quantified. The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but cannot be quantified. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
The patient is an 80 yo chinese-speaking male with hepatitis B
and hepatoma s/p radiofrequency ablation on [**2142-5-3**] who was
admitted to [**Hospital1 18**] on [**2142-5-18**] with enterococcus bacteremia and
sepsis admitted to the ICU on the MUST protocol. He found to
have adreanl insufficency and started on steroids. He
clinically improved and was sent to a regular medicine floor.
He was doing well until [**2142-5-24**] when he felt increased SOB. CXR
showed a greated increased right pleural effusion. He continued
to become tachycardiac and O2 requirements increased from 2L NC
to 100% NRB. His BP dropped to the 70's and he was intubated
and readmitted to the ICU. The patient was then intubated. A
thorocentesis produced 1.8L of bloody fluid from the right lung.
The hypotension initially required levophed but was eventaully
able to be stabalized with aggressive IV fluids and IV steroids.
Antibiotics were taped to ampicillin upon culture sensitivites.
After several days of fluid resusitation, the patient became
increasingly fluid overloaded. He was diuresed with IV lasix
for several days as his BP would tolerate. On [**2142-6-1**] the
patient began to be weaned off sedation and was able to breath
spontaneously over the ventilatior. He was successfully
switched to CPAP and later that day successfully ventilated.
Medications on Admission:
Pt was taking 600mg Motrin Q4 pfr abs pain prior to admission.
No other medications.
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Hepatitis B
Hepatoma
Respiratory Failure
Sepsis
Discharge Condition:
Death
|
[
"99592",
"486",
"78552",
"51881",
"5119",
"5849",
"2762"
] |
Admission Date: [**2170-9-7**] Discharge Date: [**2170-10-4**]
Date of Birth: [**2104-7-17**] Sex: M
Service: NEUROLOGY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
intraarterial tPA with Merci procedure and Penumbra device
Left frontal tooth extration ([**2170-9-24**])
PEG tube placement ([**2170-10-3**])
History of Present Illness:
66 y/o M with hx of CAD s/p CABG in [**2160**], DM, CHF, HTN, and PVD
presents with approximately a week long history of intermittent
chest pain. The pain would come on consistently after dinner and
be substernal and feel like burning. He would then get a "funny"
feeling down the lateral aspects of his arms and also start to
have some tingling in his gums. The pain would last for approx
40 minutes and then go away. He tried both tums and nitro and
got no relief.
.
On [**8-31**] he presented to [**Location (un) 620**] with these complaints and was
ruled out by EKGs and enzymes. He was worked up for atypical
chest pain. A CT of chest without contrast was negative. He was
started on prednisone for inflammation and doxycycline for
possible lymes disease (sounds like he had a positive culture).
He was discharged to home when two days ago he had the pain
again. Substernal, radiating to arms, no diaphoresis or
shortness of breath. It was while he was driving and was now
relieved by nitro (which was different than his other episodes).
He went to bed that night and then woke up again with the pain.
It again was relieved by nitro, so he decided to return to the
hopsital. He had positive Troponin rise, negative CK, and
possible new EKG changes with ST depressions. He was transferred
to here at that time.
.
On ROS he does endorse six months of increasing dyspnea on
exertion, fatigue and inability to get very far without needing
to sit down. Is dizzy when standing still. Has not fallen. No
fevers or chills or changes in weight.
Past Medical History:
-CAD s/p CABG in [**2160**] with SVG->diagonal, RCA, LAD, and distal
OM-1; LIMA->distal branch of LAD, s/p PCI [**1-/2160**] AMI/VF arrest s/p
PTCA of the LAD and Ramus, [**9-/2160**] IMI s/p PCI of the LCx and LAD,
[**5-/2161**] s/p multivessel PCI, [**4-2**] s/p DES to SVG->LAD
-Diastolic CHF
-Diabetes mellitus
-Hyperlipidemia
-Hypertension
-PVD s/p bilateral iliac stents [**12-29**] with bilateral ISRS [**8-1**]
s/p
PTA, moderated ISR of left iliac stent [**4-2**]
-s/p Cholecystectomy [**11/2163**]
-Cataract in right eye s/p lens implant [**8-/2166**]
-Diverticulosis and Diverticulitis, last colonoscopy [**3-3**]
-Chronic renal failure (baseline Cr 1.4)
-Arthritis
-Pleurisy
-Polycythemia [**Doctor First Name **]
-GERD
-COPD, PFTs [**11-2**] showed mild obstructive airway disease but not
consistent with emphysema, vital capacity 3.15 liters which was
73% of predicted, FEV1 was 2.60 liters which was 76% of
predicted.
-Severe back pain/Degenerative Disc disease- followed by Dr.
[**Last Name (STitle) 5456**]
[**Name (STitle) 93608**] hernia s/p repair
-L5-S1 spondylyitis
-Pancytopenia
-Fatty liver
Social History:
Lives at home with wife, is independent, continues to smoke 1
ppd for 45 years, occasional EtOH at social occasions, no
illicit drugs.
Family History:
Father with leukemia, CHF near the end of his life; Mother still
alive; one brother with hx of colon cancer, now in remission.
Physical Exam:
On admission:
VS - T 98.2, 134/81, P66-79, R 16-20, 97% on RA
Gen - in bed, sitting up, NAD
HEENT - ATNC, PERRLA, EOMI, supple neck, no JVD, no bruits
CV - RRR, no m,r,g
Lungs - CTA B
Abd - soft, NT, ND, no hsm or masses, normoactive bowel sounds
Ext - cool, no hair growth from mid shin down, nonpalpable
pulses, are dopplerable, sensation and motor grossly intact
Neuro - CN intact, moves all 4 extremities, no focal deficits
Physical exam at neurology unit admission:
NIH Stroke Scale Score:
1a. LOC: Arousable to minor stimulation = 1
1b. LOC Questions: Does not say month/age = 2
1c. Commands: Opens eyes on command, does not squeeze hands = 1
2. Best Gaze: Left gaze deviation = 2
3. Visual Field: Complete hemianopia = 2
4. Facial Palsy: Flattening of left NLF = 2
5. Motor Arm:
Left-No movement = 4
Right-No drift = 0
6. Motor Leg
Left-No movement = 4
Right-No drift = 0
7. No ataxia = 0
8. Sensory: Unilateral sensory loss on the left = 1
9. Best language: Mild to moderate aphasia = 1
10. Dysarthria: Severe aphasia = 2
11. Extinction/Neglect: Appears to neglect left side = 1
_______________________
Total Score: 23
Physical exam upon discharge:
Patient remains with eyes closed most of the time, even when
awake. At times he is able to say isolated words and 3 to 4
words sentences to express his feelings, and at times he just
mumbles. He is able to follow simple commands such as show [**Last Name (un) **]
fingers, but he also shows perseverating. His eyes movements are
impaired to vertical gaze deviation, and barely cross midline to
left and slow to the right horizontal movements. He does not
showed any voluntary movements from left upper and lower
extremities. Right extremities are normal in tone, strenght and
reflexes. There was a time that he presented less movement at
the right lower limb, but this was resolved.
Pertinent Results:
Labs ADMISSION:
[**2170-9-7**] 09:45PM CK(CPK)-154
[**2170-9-7**] 09:45PM CK-MB-10 MB INDX-6.5* cTropnT-0.12*
[**2170-9-7**] 09:45PM PT-13.2 PTT-71.2* INR(PT)-1.1
[**2170-9-7**] 01:05PM GLUCOSE-138* UREA N-28* CREAT-1.4* SODIUM-138
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2170-9-7**] 01:05PM CK(CPK)-168
[**2170-9-7**] 01:05PM cTropnT-0.13*
[**2170-9-7**] 01:05PM CK-MB-11* MB INDX-6.5*
[**2170-9-7**] 01:05PM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2170-9-7**] 01:05PM WBC-10.7 RBC-5.08 HGB-15.8 HCT-44.8 MCV-88
MCH-31.0 MCHC-35.2* RDW-14.3
[**2170-9-7**] 01:05PM NEUTS-64.1 LYMPHS-29.2 MONOS-4.4 EOS-2.0
BASOS-0.3
[**2170-9-7**] 01:05PM PLT COUNT-255
[**2170-9-7**] 01:05PM PT-14.4* PTT-145.9* INR(PT)-1.3*
Labs from Discharge:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-9-23**] 06:45AM 14.3* 3.81* 11.6* 33.6* 88 30.5 34.6 14.5
544*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2170-9-19**] 02:25AM 68.8 21.8 4.0 5.1* 0.3
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2170-9-24**] 10:30AM 30.0
[**2170-9-24**] 03:19AM 57.0*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-9-23**] 06:45AM 185* 20 0.9 136 4.4 102 23 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2170-9-20**] 10:55AM 20 31 58 69 0.3
OTHER ENZYMES & BILIRUBINS Lipase
[**2170-9-20**] 10:55AM 75*
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2170-9-19**] 02:25AM 3 0.10*1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2170-9-23**] 06:45AM 9.0 3.5 1.9
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2170-9-10**] 05:50AM 99 228*1 23 4.3 30
Other studies:
USG from lower extremities ([**2170-9-18**]):No evidence of deep vein
thrombosis in either leg
Chest CT [**2170-9-16**]
FINDINGS: Equivocal subsegmental filling defects in pulmonary
artery branches of left lower lobe that could represent flow
artifact in this study with respiratory motion. If high clinical
suspicious of pulmonary embolism, a repeat study is recommended.
Limited evaluation of lung parenchyma due to respiratory motion
does not reveal lung nodules or consolidation. Presence of
dependent atelectasis. No pleural effusion. Nasogastric tube can
be seen in the esophagus. Heart size is within normal limits.
Coronary stents and bypass graft is noted. Atherosclerotic
calcification in the aorta. No pericardial effusion. Bilateral
hilar lymph nodes are noted. Limited evaluation of the
abdominal organs is unremarkable.
BONE WINDOWS: Status post sternotomy. Degenerative changes seen
of the
thoracic spine.
IMPRESSION: Equivocal findings of pulmonary embolism and left
lower lobe, that could represent flow artifact. If high clinical
suspicious of pulmonary embolism, a repeat study is recommended.
REPEAT CHEST CT [**2170-9-17**]
FINDINGS: Equivocal subsegmental filling defects in pulmonary
artery branches of left lower lobe that could represent flow
artifact in this study with respiratory motion. If high clinical
suspicious of pulmonary embolism, a repeat study is recommended.
Limited evaluation of lung parenchyma due to respiratory motion
does not reveal lung nodules or consolidation. Presence of
dependent atelectasis. No pleural effusion. Nasogastric tube can
be seen in the esophagus. Heart size is within normal limits.
Coronary stents and bypass graft is noted. Atherosclerotic
calcification in the aorta. No pericardial effusion. Bilateral
hilar lymph nodes are noted. Limited evaluation of the
abdominal organs is unremarkable.
BONE WINDOWS: Status post sternotomy. Degenerative changes seen
of the
thoracic spine.
IMPRESSION: Equivocal findings of pulmonary embolism and left
lower lobe, that could represent flow artifact. If high clinical
suspicious of pulmonary embolism, a repeat study is recommended.
Neuroimaging:
CT [**2170-9-11**]
Hyperdensity of the right caudate head and putamen, presumably
reflecting hemorrhagic infarction, enhancement of infarcted
tissue, or both. There is also gyriform hyperdensity with the
same differential and a
possiblity of a small amount of subarachnoid hemorrhage. with
associated
moderately extensive subarachnoid hemorrhage.
Brain MRI/MRA ([**2170-9-12**])
1. Large acute infarction with extensive hemorrhagic
transformation in the
right middle cerebral artery territory. Small acute infarction
in the right anterior cerebral artery territory.
2. Successful revascularization of the right internal carotid
and middle
cerebral arteries
Brief Hospital Course:
He initially presented to [**Hospital1 **] [**Location (un) 620**] [**Date range (1) 93609**] with chest
pain and diaphoresis which did not respond to SL Nitro x3. He
was seen by Cardiology, and CEs showed CK 123->116->94, CK-MB
1.5->1.8->1.2, TropT 0.02->0.04->0.03. He was instructed to quit
smoking and follow up with his cardiologist. Per the cardiology
admission note, he was also "started on prednisone for
inflammation and doxycycline for possible lyme disease."
However, he continued to have substernal burning chest pain
radiating into
his bilateral arms over the past week. He returned to [**Hospital1 **]
[**Location (un) 620**] where CEs showed CK 164, CK-MB 5.1, and TropT 0.1, and
EKG per report showed old q in inferior leads, some 1mm
elevations, lateral ST depressions. He was continued on ASA,
loaded with
Plavix 300 mg, and started on heparin gtt. He was transferred to
[**Hospital1 18**] for further evaluation.
He was admitted to cardiology on [**2170-9-7**], continued on heparin
gtt, ASA 325 daily, Plavix 75 mg daily, and Crestor was changed
to Atorvastatin 80 mg daily. Trop T peaked at 0.17, CK-MB at 11.
He had a cardiac cathterization [**2170-9-10**] which showed known
occlusions of SVG-OM1, SVG-OM3, SVG-PDA, LIMA-D1; and Successful
PTCA and stenting of the proximal SVG-LAD graft with a Cypher
DES. During the cath, he received Bivalirudin bolus and gtt,
Fentanyl 200 mcg IV x1, Nicardipine 200 mcg IC bolus, Versed 1
mg IV x1, and Sodium Bicarbonate IV.
He was to be discharged home on [**2170-9-11**]. At 10:20 am the nurse
found him to be normal in his room. At approximately 11:10 am,
the nurses noted that the nurse call button had been pulled out
of the wall. He was found to have a dense left hemiplegia and
decreased responsiveness. A CODE STROKE was called. The patient
was found to be awake but with decreased alertness, left facial
droop, left hemiparesis, left eye deviation, and dysarthria.
NIHSS 23. Head CTA and CTP showed complete occlusion of the
cervical and intracranial right ICA and of the right MCA, the
right ACA is patent, likely supplied by the anterior
communicating artery, subtle loss of [**Doctor Last Name 352**]-white matter
differentiation and a large area of matched decreased cerebral
blood volume and flow in the right middle cerebral artery
territory, consistent with a large acute infarction, no evidence
of hemorrhage. He was taken immediately to cerebral angiography,
where he had IA tPA and MERCI to the right ICA, and Penumbra to
the right MCA, with IA NTG to right MCA for spasm. He was
intubated and transferred to the NeuroICU.
In the neurology ICU, he was maintained on aspirin and plavix.
MRI/MRA head showed a large acute infarction with extensive
hemorrhagic transformation in the right MCA territory, small
acute infarction in the right ACA territory, and successful
revascularization of the right ICA and MCA. Repeat Head CTs
showed increased mass effect and right uncal herniation, and he
was started on Mannitol. He remained stable and mannitol was
discontinued. TTE showed LVEF 40%, no thrombus/mass in the body
of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LV, no ASD or PFO. USG of the legs no evidence of
venous thrombosis. EEG [**2170-9-26**] showed asymmetry with low
voltage activity over the right side, and overall diffuse
encephalopathy. He had some fluctuations in his mental status
due to infection (see below) and remained significantly abulic.
At times during his stay, he complained of chest pain, but
cardiac enzymes were always unremarkable and EKG was unchanged.
He was maintained on ASA, plavix, and eventually
heparin/coumadin (see below). He was treated with
antihypertensives and cholesterol lowering medications.
After extubation he was found to have persistent high
respiratory rate (20-32). As this was concerning for pulmonary
embolism, he underwent two consecutive chest CTA; both revealed
a small lesion in the lower segment of the left inferior lobe.
Heparin was started on [**2170-9-18**], and warfarin 5mg daily was
started [**2170-10-3**] (held prior to this for procedures). Goal INR is
[**1-28**]. He was discharged on lovenox as a bridge to coumadin and
will need to have INRs checked until the INR is therapeutic.
He was noted to have a recent Lyme titer positive at his PCP's
office and was treated with Doxycycline 100 mg PO bid to
complete a 14 day course; discontinued on [**2170-9-19**]. He had a
fever [**2170-9-21**] and was diagnosed with a pseudomonas UTI. He was
initially started on cefazolin but this was changed to cefepime
after persistent fever. He completed a 7 day course on [**2170-10-2**].
His diabetes was managed by [**Last Name (un) **], with lantus, humalog, and
oral hypoglycemics. A1C was 13.7.
He had a loose left front tooth, which was extracted on [**2170-9-24**]
without complications.
He passed his swallow study but he was waxing and wanning in his
mental status and not holding well the PO intake. He had PEG
placed on [**2170-10-3**].
Medications on Admission:
ASA 325 mg daily
Plavix 75 mg daily
Imdur 30 mg daily
Valsartan 80 mg daily
Atenolol 25 mg daily
Crestor 10 mg daily
Ezetimibe 10 mg qhs
Niaspan 1000 mg daily
Tricor 145 mg qhs
Metformin 1000 mg [**Hospital1 **]
Glyburide 5 mg [**Hospital1 **]
Januvia 100 mg daily
Nexium 40 mg daily
Percocet 1 tab q6 hr PRN (usually takes [**Hospital1 **])
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. Niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
12. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
18. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) units
Subcutaneous Q12H (every 12 hours).
19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
20. Insulin Glargine Subcutaneous
21. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
1. NSTEMI
2. Coronary Artery Disease
3. Hyperlipidemia
4. Right MCA stroke
5. Left inferior pulmonary embolism
6. Urinary tract infection
7. loose tooth status post extraction
.
Secondary Diagnosis:
1. Diabetes
2. Hypertension
3. Positive Lyme titer
Discharge Condition:
He was abulic, preferring to keep his eyes closed (even when
awake), with decreased but appropriate speech output, ability to
follow commands with his right side, left neglect, and a dense
left hemiparesis.
Discharge Instructions:
You were admitted to the hospital for chest pain. It was
determined to be related to your heart because we saw a rise in
your cardiac enzymes. Your pain was also relieved by nitro,
again making us think it was related to your heart. We
monitored you over the weekend while you were on a heparin drip
through your IV. You did well and only had the recurrence of
chest pain once. Your cardiac enzymes also started to decrease.
Unfortunately before your discharge you presented subtle onset
of left sided weakness, and code stroke was called. You
underwent procedures to remove a clot from your left cerebral
artery. During this acute phase you were intubated with
mechanical ventilation. After your doctors noted that [**Name5 (PTitle) **]
presented fast breathing, and you were found to have pulmonary
embolism. To treat and prevent further episodes you need to take
coumadin to make your blood thinner.
You also had a broken tooth, which was removed during this
admission.
Although you passed the swallow evaluation you had significant
fluctuation of your mental status, which required a tube in your
stomach, so you can receive your medications and feeds
consistently.
Your diabetes was out of control and some adjustment of your
medications was required.
Please call your doctor or return to the hospital for any new
weakness, numbness, tingling, visual changes, loss of
consciousness, chest pain, shortness of breath, lightheadedness,
fainting, nausea, vomiting or any other conerns. Call 911 if it
is an emergency.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Cardiology:
Please follow up with Dr. [**Last Name (STitle) 5456**]. His phone number is
[**Telephone/Fax (1) 25798**] if you need to change your appointment.
Neurology:
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2170-11-5**] 2:00
Endocrinology:
Please contact [**Name (NI) **] Clinic to schedule a follow up appointment
[**Telephone/Fax (1) 40884**]
|
[
"41071",
"40391",
"5990",
"41401",
"4280",
"496",
"3051",
"4168"
] |
Admission Date: [**2112-2-2**] Discharge Date: [**2112-2-6**]
Date of Birth: [**2063-1-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
[**2112-2-2**] Redo VSD closure/TVRepair with 32 mm [**Company **]
annuloplasty ring
History of Present Illness:
49 yo F with h/o a VSD repair at age 9, now with small VSD and
moderate to severe TR.
Past Medical History:
Asthma
mild HTN
[**2070**] VSD repair
Social History:
works as legal secretary
lives with husband
Family History:
none
Physical Exam:
Discharge
97.0, 95 SR, 110/68, 20 94% RA Sat 72.7 kg
Neuro A/O x3 nonfocal
Pulm CTA
Cardiac RRR no m/r/g
Sternal inc with steris healing no erythema no drainage sternum
stable
Abd soft, NT, ND +BS
Ext warm trace edema
R groin inc healing steris no erythema no drainage
Pertinent Results:
[**2112-2-6**] 04:05AM BLOOD Hct-25.5* Plt Ct-143*
[**2112-2-5**] 06:25AM BLOOD WBC-11.0 RBC-3.11* Hgb-9.4* Hct-26.5*
MCV-85 MCH-30.3 MCHC-35.5* RDW-13.2 Plt Ct-106*
[**2112-2-2**] 11:20AM BLOOD WBC-13.4*# RBC-3.26*# Hgb-10.1*#
Hct-28.2*# MCV-87 MCH-31.0 MCHC-35.9* RDW-13.3 Plt Ct-157
[**2112-2-6**] 04:05AM BLOOD Plt Ct-143*
[**2112-2-3**] 12:30AM BLOOD PT-13.1 PTT-29.5 INR(PT)-1.1
[**2112-2-2**] 11:20AM BLOOD Plt Ct-157
[**2112-2-2**] 11:20AM BLOOD PT-18.9* PTT-150* INR(PT)-1.8*
[**2112-2-2**] 12:09PM BLOOD Fibrino-142*
[**2112-2-5**] 06:25AM BLOOD Glucose-105 UreaN-20 Creat-0.9 Na-136
K-4.4 Cl-101 HCO3-26 AnGap-13
[**2112-2-3**] 12:30AM BLOOD Glucose-114* UreaN-13 Creat-1.1 Na-139
K-5.4* Cl-111* HCO3-22 AnGap-11
[**2112-2-4**] 06:20AM BLOOD Mg-2.0
CHEST (PA & LAT) [**2112-2-5**] 8:21 AM
CHEST (PA & LAT)
Reason: evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman s/p TV repair/VSD closure
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
INDICATION: 49-year-old female status post tricuspid valve
repair and ventricular septal device closure. Evaluate pleural
effusions.
COMPARISON: AP semi-upright portable chest x-ray dated [**2112-2-3**].
AP UPRIGHT PORTABLE CHEST X-RAY: The patient is status post
median sternotomy and tricuspid valve repair. The cardiac
silhouette is stablely enlarged. Pulmonary vasculature is not
engorged and there is no pneumothorax. Linear atelectasis
aligning the right minor fissure is decreased. A small right
pleural effusion is slightly decreased from one day earlier, and
there is a persistent tiny left pleural effusion. Diffuse
bullous changes are again noted bilaterally.
IMPRESSION: Decreased small right, and tiny left pleural
effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SAT [**2112-2-6**] 11:00 AM
PATIENT/TEST INFORMATION:
Indication: Congenital heart disease. Valvular heart disease.
Intra-op TEE for Tricupid Valve Repair, VSD closure.
Height: (in) 64
Weight (lb): 150
BSA (m2): 1.73 m2
BP (mm Hg): 134/78
HR (bpm): 78
Status: Inpatient
Date/Time: [**2112-2-2**] at 09:33
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.7 cm
Left Ventricle - Fractional Shortening: *0.16 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Arch: 2.2 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.2 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter
or pacing
wire is seen in the RA. Dynamic interatrial septum. No ASD by 2D
or color
Doppler. The IVC is normal in diameter with <50% decrease during
respiration
(estimated RAP 11-15mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Mild global LV
hypokinesis. Mildly
depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global
RV free wall
hypokinesis. Abnormal diastolic septal motion/position
consistent with RV
volume overload.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque. Normal ascending aorta diameter. No
atheroma in
ascending aorta. Normal aortic arch diameter. No atheroma in
aortic arch.
Normal descending aorta diameter. No atheroma in descending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal
mitral valve
supporting structures. No MS. Mild (1+) MR.
TRICUSPID VALVE: Moderately thickened tricuspid valve leaflets.
Tricuspid
leaflets do not fully coapt. Moderate to severe [3+] TR.
Eccentric TR jet.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal pulmonic valve leaflets. No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1.The right atrium is markedly dilated. No atrial septal defect
is seen by 2D
or color Doppler.
2. Left ventricular wall thicknesses are normal. There is mild
global left
ventricular hypokinesis. Overall left ventricular systolic
function is mildly
depressed.
3.The right ventricular cavity is moderately dilated. There is
moderate global
right ventricular free wall hypokinesis. There is abnormal
diastolic septal
motion/position consistent with right ventricular volume
overload.
4.. The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis.
Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.The tricuspid valve leaflets are moderately thickened. The
tricuspid valve
leaflets fail to fully coapt. There is tethering of the septal
leaflet and
prolapse of the anterior leaflet of the tricuspid valve.
Moderate to severe
[3+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is
eccentric and may be underestimated.
8.There is no pericardial effusion.
9. There is an inlet Ventricular septal defect 0.7 cm in size
just underneath
the attachment of the septal leaflet to the interventricular
septum. There is
left to right flow across the interventricular septal defect.
POST-BYPASS: Pt is in sinus rhythm and is on an infusion of
milrinone,
epinephrine and phenylephrine
1. An annuloplasty ring is well seated in the tricuspid
position. Trace TR is
seen. A mean gradient of around 3-4 mm of Hg is seen across the
valve.
2. RV function is slighly improved. LV function also appears
slightly
improved. Septal thickening is improved.
3. Other findings are unchanged
4. Aorta is intact post decannulation
5. The inlet ventricular septal defect is no longer visualised.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2112-2-2**] 17:26.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
On [**2-2**] She was taken to the operating room where she underwent
a redo sternotomy redo VSD clsure and TVRepair. She was
transferred to the SICU in critical but stable condition on
milrinone, epinephrine and propofol. She was extuabted later
that same day. Her vasoactive drips were weaned to off by POD #1
and she was transferred to the floor. She continued to do well
postoperatively, and was ready for discharge on POD #4 with
services.
Medications on Admission:
singulair, albuterol, zyrtec, advair, flonase
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs Disk with Device(s)* Refills:*0*
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 weeks.
Disp:*2 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Held on ACE inhibitor since titrating up on betablocker and
blood pressure
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
VSD, TR
Asthma
Mild HTN
Discharge Condition:
Good.
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 349**] 1 week [**Telephone/Fax (1) 7401**]
Dr. [**Last Name (STitle) 20222**] 2 weeks
please call to make appointments
[**Hospital Ward Name 121**] 2 wound check please schedule with RN
Completed by:[**2112-2-6**]
|
[
"49390",
"4019"
] |
Admission Date: [**2124-5-17**] Discharge Date: [**2124-5-19**]
Date of Birth: [**2083-4-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
male with a history of Type 1 diabetes and a recent admission
for diabetic ketoacidosis, also with a history of alcohol
abuse and prior gastrointestinal bleed who presents to the
Emergency Room after an alcohol binge. The patient was
confused about his recent history and was not sure how he got
to the Emergency Room. He reports drinking approximately 1
[**12-29**] pints of Vodka on the day prior to admission and denies
other drug use. He is unsure whether he vomited or passed
out but per the Emergency Room report he had minimal coffee
ground emesis while in the Emergency Room. The patient
apparently left [**Hospital3 **] yesterday, went home and
started to drink. It was unclear whether he took any insulin
yesterday. He denied any fevers, chills, cough or other
upper respiratory symptoms. The patient denied a history of
melena, bright red blood per rectum. He does report
constipation for approximately four days. He has had no p.o.
intake for approximately two days, no dysuria. He does
complain of thirst, no chest pain, and no shortness of
breath. In the Emergency Department the patient's
fingerstick blood sugar was found to be 501. Chem-7 revealed
an anion gap of 31 and urinalysis revealed urine ketones.
The patient was given normal saline and started on insulin
drip. An nasogastric tube was placed and he was lavaged with
200 cc of normal saline which was clear. Intravenous
Protonix was given. A central line was placed in the femoral
vein. After approximately 2 liters of normal saline and an
insulin drip running at approximately 4 units/hour, blood
sugars were below 200 and the patient was started on
intravenous fluids of D5 normal saline plus 40 of [**Doctor First Name 233**]-Ciel.
The patient was admitted to the Medicine Intensive Care Unit
for management of his diabetic ketoacidosis.
PAST MEDICAL HISTORY: 1. Schizophrenia versus personality
disorder; 2. History of alcohol abuse with a history of
seizure and delirium tremens; 3. History of antisocial
behavior; 4. Status post appendectomy; 5. History of
gastrointestinal bleed secondary to peptic ulcer disease; 6.
Type 1 diabetes with prior history of diabetic ketoacidosis.
MEDICATIONS ON ADMISSION:
1. Ativan 2 mg p.o. b.i.d. and 1 mg p.o. prn
2. Lamictal 75 mg p.o. t.i.d.
3. Clozapine 125 mg p.o. b.i.d.
4. Antabuse 250 mg p.o. q. AM
5. Paxil 30 mg p.o. q. AM
6. Protonix 40 mg p.o. b.i.d.
7. Minocycline 50 mg p.o. b.i.d. for acne
8. PeriColace 100 mg p.o. b.i.d.
9. Lactulose 15 mg p.o. b.i.d.
10. NPH insulin 20 units subcutaneously q. AM and 10 units
subcutaneously q. PM
11. Regular insulin sliding scale as previously prescribed
12. Thorazine 100 mg p.o. q. 4 hours prn agitation
ALLERGIES: Haldol causes dystonia. The patient also with an
allergy to Navane.
SOCIAL HISTORY: The patient is divorced, living in a group
home. He has an extensive history of alcohol abuse. He
smokes one pack per day of cigarettes.
PHYSICAL EXAMINATION: Admission physical examination
revealed temperature 96.7, blood pressure 140/97, pulse 109
to 122, sating 97% on room air. General appearance, he is a
middle-aged white male in mild distress, complaining of
thirst. He is alert and oriented. Pupils are equal, round,
and reactive to light. Extraocular movements are intact.
Sclera are anicteric. Oropharynx was dry. Neck was supple
with no lymphadenopathy and no jugulovenous distension.
Cardiovascular, tachycardiac with a regular rhythm, normal
S1, S2 and no murmurs. Chest was clear to auscultation.
Abdomen was soft, mildly tender in the bilateral lower
quadrants with active bowel sounds. No rebound, no guarding
there is a well healed right lower quadrant scar, no
hepatosplenomegaly. Extremities, no cyanosis, clubbing or
edema. Skin, no rashes, no spider angiomata, no palmar
erythema. There was notable gynecomastia. Neurological
examination was nonfocal.
LABORATORY DATA: White blood cell count 20.4, hematocrit
32.7, platelets 531, sodium 137, potassium 4.1, chloride 94,
bicarbonate 12, BUN 19, creatinine 1.5 and glucose 487.
Anion gap of 31. ALT was 15, AST 24. Alkaline phosphatase
188, total bilirubin 0.2, LDH of 292. Amylase was 24, lipase
19, albumin 4.4, serum acetone was positive. Urinalysis
showed 40 ketones. Initial venous blood gas was 7.28, 33 and
37.
HOSPITAL COURSE: 1. Endocrine - The patient with a history
of Type 1 diabetes with recent alcohol binge, admitted in
diabetic ketoacidosis. The patient was initially started on
insulin drip with rapid closure of his anion gap and decrease
in his fingerstick blood sugars. He was then aggressively
hydrated for several days until tolerating adequate p.o. We
looked for explanations such as possible underlying infection
without clear infectious source. It is likely that his
alcohol binge had tipped him into diabetic ketoacidosis as he
had likely not taken his insulin for several days. After the
discontinuation of the insulin drip, the patient was returned
to his prior regimen of NPH in the morning and evening with a
regular insulin sliding scale to cover him between meals. He
was advanced to a diabetic diet.
2. Gastrointestinal - The patient with a history of
gastrointestinal bleed secondary to peptic ulcer disease
which was poorly characterized by history. While in the
Emergency Department the patient was noted to have scant
coffee ground emesis. Nasogastric lavage was negative. The
patient had been evaluated on a prior admission for similar
symptoms during which time Gastroenterology was consulted and
elected not to scope. A proton pump inhibitors was started.
This was thought to be secondary to gastritis. The patient
was on b.i.d. Protonix on admission. After his scant coffee
ground emesis in the Emergency Room on this admission, the
patient had no further evidence of gastrointestinal bleeding.
The hematocrit remained stable for the duration of his
hospital stay.
3. Psychiatric - The patient with a history of schizophrenia
versus a personality disorder. He was continued on his
outpatient psychiatric regimen. He was placed on a CIWA
scale for alcohol withdrawal prophylaxis which he was
exhibiting none at the time of discharge. He was also
started on b.i.d. standing Valium to prophylactically treat
him as we were concerned given the history of delirium
tremens and alcohol withdrawal seizures.
4. Disposition - The patient's primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 5762**] is actively pursuing Section 35 for acute alcohol
in-patient treatment. The patient has shown a propensity to
leave prior inpatient facilities again physicians' and care
providers' wishes in order to drink. He will likely be
transferred to a locked inpatient alcohol rehabilitation
[**Hospital1 **].
5. Fluids, electrolytes and nutrition - The patient was
aggressively hydrated and then transitioned over to a p.o.
diet. He was started on Thiamine, Folate and a multivitamin.
His electrolytes including his magnesium were aggressively
repleted.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Alcohol intoxification
2. Diabetic ketoacidosis
3. Hematemesis
DISCHARGE MEDICATIONS:
1. Valium 5 mg p.o. b.i.d., this was standing order starting
on [**2124-5-19**] which will be held for sedation. This should
be tapered off once there is no evidence of withdrawal
symptoms.
2. Protonix 40 mg p.o. b.i.d.
3. Valium 5 mg p.o. q. 1 to 2 hours prn for CIWA scale
greater than 10
4. Ativan 1 mg p.o. q.h.s. prn anxiety
5. NPH Insulin 20 units q AM, 10 units q PM
6. Regular insulin sliding scale, please see the attached
Page 1
7. Lamictal 75 mg p.o. t.i.d.
8. Multivitamin one tablet p.o. q.d.
9. Folate 1 mg p.o. q.d.
10. Thiamine 100 mg p.o. q.d.
11. Paxil 30 mg p.o. q.d.
12. Clozapine 125 mg p.o. b.i.d.
13. Thorazine 100 mg p.o. q. 4 hours prn agitation
14. Colace 100 mg p.o. b.i.d. prn constipation
15. Lactulose 30 cc p.o. q.d. prn constipation
DISCHARGE INSTRUCTIONS: The patient will likely be
transferred to Inpatient Locked [**Hospital **] Rehabilitation
Facility where he will be followed by his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) 5762**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2124-5-19**] 14:04
T: [**2124-5-19**] 16:05
JOB#: [**Job Number 95600**]
|
[
"2859"
] |
Admission Date: [**2135-4-22**] Discharge Date: [**2135-4-24**]
Date of Birth: [**2135-4-22**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is the 3.525
kg product of a 39 week gestation, born to a 32 year-old, G2,
P0 now 1 mother.
PRENATAL SCREEN: 0 positive, antibody negative, RPR
nonreactive, hepatitis surface antigen negative. Rubella
immune. GBS negative. Pregnancy reportedly benign. Mother
presented in spontaneous labor. Maternal temperature maximum
was 100.7. Range of motion 10 hours prior to delivery for
clear amniotic fluid. NICU team at delivery for poor fetal
heart tracing, long second stage of labor. Infant emerged
with heart rate less than 100 and no spontaneous breathing.
Poor tone and color. Positive pressure provided with some
improvement, however, developed grunting with continued mild
oxygen requirement and poor perfusion. Apgars were 1, 5 and
8 at 1 minute, 5 minutes and 10 minutes respectively.
PHYSICAL EXAMINATION: On admission, weight was 3.525 kg.
Positive molding with caput. Bruising over forehead. Eyes
deferred. Ears: Normal set. Palate intact. Intact
clavicles. Lungs clear at the apex, equal breath sounds
bilaterally, intermittent grunting. Cardiovascular: Regular
rate and rhythm. No murmur. 2+ femoral pulses. Perfusion
greater than 3+ seconds. Abdomen soft. Minimal bowel sounds.
Genitourinary: Normal female, patent anus. No sacral
anomalies. Hips stable. Symmetric moro and positive suck,
positive plantar reflex. Tone: Normal with good strength,
especially during exam.
HOSPITAL COURSE:
1. Respiratory: [**Doctor First Name **] was placed on nasal cannula oxygen
briefly and weaned to room air within the first 10 hours
of life. She has been stable in room air since that
time.
1. Cardiovascular: Initially received 1 normal saline bolus
secondary to poor perfusion with a nice response and
otherwise has been cardiovascularly stable.
1. Fluids, electrolytes and nutrition: Birth weight is
3.525 kg. Infant was started on 60 cc/kg/day of D-10-W.
Enteral feedings were initiated on day of life #1.
Infant is currently ad lib breast feeding with bottle
supplementation. Glucose sticks were borderline when IV
was weaned off and resolved nicely with PC feedings.
1. Hematology: Hematocrit on admission was 50.1.
1. Infectious disease: CBC and blood culture obtained on
admission: CBC was benign and blood cultures remained
negative at 48 hours at which time Ampicillin and
Gentamycin were discontinued.
1. Neurology: Appropriate for gestational age.
1. Hearing screen has not yet been performed but should be
done prior to discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To newborn nursery.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37243**], MD, telephone number [**Telephone/Fax (1) 66807**].
CARE RECOMMENDATIONS: Continue ad lib breast feeding with PC
feedings.
Medications: Non applicable.
Car seat position screening: Not applicable.
State newborn screens have been sent per protocol and have
been within normal limits.
Infant has yet to receive any immunizations.
DISCHARGE DIAGNOSES: Term infant with mild respiratory
distress, rule out sepsis with antibiotics.
[**First Name11 (Name Pattern1) 3692**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27992**], MD [**MD Number(2) 65951**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2135-4-24**] 20:44:37
T: [**2135-4-25**] 05:03:54
Job#: [**Job Number 66808**]
|
[
"V290",
"V053"
] |
Admission Date: [**2139-1-6**] Discharge Date: [**2139-1-13**]
Date of Birth: [**2068-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Melena, hypotension.
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 70 year old gentleman with ischemic cardiomyopathy EF
20%, atrial fibrillation on coumadin, history of Barrett's
esophagitis, colonic polyps, asthma, hypothyroidism, and
depression. He presents with black loose stools for one day.
Yesterday morning, the patient woke up and had diarrhea that was
black and tarry in nature. He proceeded to have a loose stool
movement every 15 minutes over the day. Over the course of the
day he became more lightheaded and this morning felt like he was
going to fall down prompting him to seek medical attention in
the ED. He did not notice frank blood in his bowel movements. He
also has had some nausea with poor appetite (has not eaten in
two days) but no vomiting or hematemesis. No abdominal pain. No
coldness in extremities.
.
The patient was bought in by his wife to the [**Name (NI) **]. There the
patient was noted to have a low blood pressure in the high 80s
systolic, P 105. Hct was 42 (baseline 31) and BUN/Cr 56/2.4
(baseline cr 1.5-1.8). NG lavage negative. Believed to be volume
depleted. He received 3 L NS, 2 units pRBC, and 1 unit FFP
(addtl' units ordered). Given IV protonix. Transferred to MICU,
on transfer pt says he feels somewhat better.
.
Of note, he is known to have Barrett's Esophagus seen on [**2133**]
EGD. In addition, he is s/p removal of adenomatous polyp (path
with dysplasia) in [**2134**], no polyps seen on [**2135**] colonoscopy.
Past Medical History:
11. CAD, s/p 1-vessel CABG and ascending aortic arch repair.
Last
cath in [**8-/2136**] with no significant CAD, patent LIMA to LAD.
P-MIBI in [**6-/2137**] with slight worsening of partially reversible,
moderate perfusion defects in the basilar anterolateral, mid
anterolateral, basilar posterolateral, mid posterolateral, and
lateral walls (entire lateral portion of the left ventricle).
2. Ischemic cardiomyopathy with EF 15-20%, NYHA class III.
3. Chronic renal insufficiency, baseline creatinine around
1.5-1.7
4. Atrial fibrillation
5. Hypothyroidism
6. Status post AICD placement, multiple firing episodes, last at
[**Hospital1 2025**] in [**9-/2137**] in setting of hypokalemia.
7. Asthma
9. Hyperlipidemia
10. Depression
11. Dementia
12. Anemia, baseline hct around 30.
13. Barrett's Esophagus seen on [**2133**] EGD
14. s/p removal of adenomatous polyp (path with dysplasia) in
[**2134**], no polyps seen on [**2135**] colonoscopy.
Social History:
Married, lives with wife, has five children. Formerly drank
alcohol but not since [**48**] years ago. No smoking or illicit drug
use. Retired painter.
Family History:
Non-contributory.
Physical Exam:
VS: T 97.6 P 77 BP 109/71 RR 22 O2 98 RA
Gen: WD/WN male Caucasian, NAD.
Eyes: Sclerae anicteric, PERRL.
Mouth: No bruising, no petechiae.
Neck: Obese, no JVD (JVP to 6 cm)
Chest: Lungs CTA b/l no wheezes, fair air movement
Abd: Obese, non tender, some nausea elicited with palpation.
Ext: No edema, faint but palpable DP pulses
Neurol: alert and oriented to time,place, and person
Pertinent Results:
[**2139-1-6**] 08:01PM HCT-35.2*
[**2139-1-6**] 02:56PM URINE HOURS-RANDOM UREA N-361 CREAT-43
SODIUM-85
[**2139-1-6**] 02:19PM HCT-34.0*
[**2139-1-6**] 12:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2139-1-6**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-1-6**] 10:15AM GLUCOSE-112* UREA N-56* CREAT-2.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2139-1-6**] 10:15AM estGFR-Using this
[**2139-1-6**] 10:15AM CK(CPK)-129
[**2139-1-6**] 10:15AM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-79
AMYLASE-84 TOT BILI-0.4
[**2139-1-6**] 10:15AM CK-MB-3 cTropnT-0.03*
[**2139-1-6**] 10:15AM LIPASE-33
[**2139-1-6**] 10:15AM DIGOXIN-1.3
[**2139-1-6**] 10:15AM CK-MB-3 cTropnT-0.03*
[**2139-1-6**] 10:15AM WBC-6.3 RBC-4.66# HGB-13.8*# HCT-42.0# MCV-90
MCH-29.7 MCHC-32.9 RDW-14.1
[**2139-1-6**] 10:15AM NEUTS-77.1* LYMPHS-11.5* MONOS-9.0 EOS-1.9
BASOS-0.5
[**2139-1-6**] 10:15AM PLT COUNT-160
[**2139-1-6**] 10:15AM PT-31.0* PTT-31.9 INR(PT)-3.3*
Brief Hospital Course:
Upper GI bleed:
Pt. initially with borderline hypotension and tachycardia.
Responded well to fluid resuscitation. Admitted initially to
ICU, where an EGD was performed on AM of hospital day 2. EGD
revealed duodenitis, no active bleed, no ulcer, Barrett's
esophagus. In the ICU, was transfused 2 units pRBC, 1 unit FFP.
Given initial low BP and GIB, all antihypertensives were
initially held, as was coumadin.Throughout the rest of hospital
stay, pt. had stable vital signs, no further GIB. Hct responded
appropriately to transfusion, remained stable.
Antihypertensives and coumadin were restarted on HD 3 and were
tolerated well.
Overall, continued ASA and warfarin, but stopped plavix after
consultation with Cardiology.
.
Respiratory distress/asthma flare:
On Hospital day 3, began to have increasing respiratory
distress. Exam notable for marked wheezing. CXR with no definite
infiltrates. While initially volume overloaded after MICU stay,
no longer had evidence of CHF. Overall, he was treated with
prednisone and nebs for asthma flare. Also empirically treated
for PNA - although limited evidence for this on cxr - with
rocephin/azithro. Will be d/c with levaquin to complete 7 day
course.
.
Chest pressure:
On the night of HD 3, patient had an episode of L-sided chest
pain that was ssociated with diaphoresis and an increased 02
requirement (responded to 2L NC). Pain resolved quickly with 3
SL nitroglycerin, albuterol neb, and IV lasix.
Cardiac enzymes were trended and over the following day climbed
from 0.05 to a peak of 0.08. He had no further events, and had
stress MIBI in hospital prior to discharge, which again
demonstrated his severe ischemic dilated cardiomyopathy and
also multiple predominantly fixed perfusion defects - previous
stress in [**2137**] with progressively worse reversible perfusion
defects. Will continue medicla management.
.
ARF on CKD:
Pt. had briefly elevated Cr, which returned quickly to baseline
with fluid resuscitation. In setting of GIB, seemed c/w
prerenal picture. ACEI was initially held, but restarted
without adverse effect once Cr returned to baseline. Remained at
baseline thereafter with re-introduction of meds.
.
Abdominal pain/constipation: On HD 3, pt. developed bilateral
lower quadrant abdominal pain, which he attributed to not having
had a bowel movement since admission to hospital. Abdominal
exam was benign, KUB unremarkable. Had relief
after BM.
.
Medications on Admission:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Aldactone 25 mg Tablet PO once a day.
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
4. Digoxin 125 mcg Tablet Daily
5. Atorvastatin 20 mg PO DAILY
6. Aspirin 81 mg Tablet, PO Daily
7. Clopidogrel 75 mg PO daily.
8. Lisinopril 5 mg PO Daily
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS adjusted
accordingly to INR.
10. Levothyroxine 112 mcg PO Daily.
11. Citalopram 60 mg PO Daily.
12. Pantoprazole 40 mg E.C. PO Q24H (every 24 hours).
13. Mexiletine 150 mg PO Q8H.
14. Docusate Sodium 100 mg PO BID.
15. Senna 8.6 mg PO BID prn.
16. Quetiapine 50 mg Tablet PO QAM, 25 mg PO QPM, 225 mg QHS.
17. Clonazepam 0.5 mg PO TID (3 times a day).
18. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]
19. Trazodone 25 mg Tablet PO HS PRN.
20. Donepezil 5 mg PO HS.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: [**1-13**] inh Inhalation
Q3-4H (Every 3 to 4 Hours) as needed. inh
10. Pantoprazole 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:*2*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nebulizer
Please dispense home nebulizer set-up.
17. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
18. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Disp:*180 neb* Refills:*2*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
22. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. Quetiapine 50 mg Tablet Sig: 4.5 Tablets PO QHS (once a day
(at bedtime)).
26. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
27. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
28. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. upper GI bleed secondary to gastritis, duodenitis
Secondary diagnoses:
1. CAD, s/p 1-vessel CABG
2. Ischemic cardiomyopathy with EF 15-20%, NYHA class III.
3. Chronic renal insufficiency, baseline creatinine around
1.5-1.7
4. Atrial fibrillation
5. Hypothyroidism
6. Status post AICD placement
7. Asthma
9. Hyperlipidemia
10. Depression
11. Dementia
12. Anemia, baseline hct around 30.
13. Barrett's Esophagus seen on [**2133**] EGD
14. s/p removal of adenomatous polyp
Discharge Condition:
Good
Discharge Instructions:
Continue all previously prescribed medications.
You may resume your usual diet
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight gain > 3 lbs.
Adhere to 2 gm sodium diet
Return to the hospital or call your doctor immediately for:
-Any further very dark or bloody stools
-Feeling weak or dizzy
-Fainting or feeling that you might faint
-Any trouble breathing
-Any other concerning symptoms
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to arrange a
follow-up appointment.
You will also need a repeat endoscopy to monitor your [**Doctor Last Name 15532**]
esophagus, which is a potentially pre-cancerous condition. Your
primary care doctor can arrange the appointment with
gastroenterology for you, or you can call ([**Telephone/Fax (1) 8892**] to
schedule an appointment. You should see them within the next 4
weeks.
|
[
"42731",
"486",
"5859",
"5849",
"4280",
"2851",
"V5861",
"2449",
"2724"
] |
Admission Date: [**2144-11-6**] Discharge Date: [**2144-11-10**]
Date of Birth: [**2086-5-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shoulder pain
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->OM1, OM2) [**2144-11-6**]
History of Present Illness:
Ms. [**Known lastname 105089**] is a 58 year oldfemale with a history of type 2
DM, hyperlipidemia, obesity and pericardial effusion requiring a
tap in [**2141**] of unclear etiology. Within the past month she has
complained of left shoulder and
scapular pain worse with activity. She states for the past
couple of years she has had bilateral shoulder pain that has
occurred shortly after radiation treatment. She had PT for a
couple of years without relief of should pain. Patient recently
went back to PT for left shoulder and scapular pain and was then
referred for a stress test. Patient denies shortness of breath
or chest discomfort. Patient states she has had bilateral LE
edema for the past couple of years. She denies claudication,
edema, orthopnea, PND and lightheadedness.
Past Medical History:
Hyperlipidemia
DM type 2
Lymphoma (retroperitoneal mass did not respond to chemo but good
result to xrt x 22- last time was 5 yrs ago)
Esophageal Reflux
Spinal Disorder (Para spinal mass)
Vertigo
Hypothyroidism
Obesity
Hernia repaired x2 umbilical
Pericardial Effusion [**8-12**] (TAP)
Appendectomy as an adult
Cholecystectomy
C-section x2
Social History:
Last Dental Exam:one month ago, no problems
Lives with:alone
Occupation:patient is an engineer
Tobacco: quit 20 years ago, [**2-8**] pack for 20 years
EtOH: a couple of drinks per month
Family History:
Father had CABG and a couple of MI's, and cancer.
Mother has diabetes
Physical Exam:
Pulse: Resp:18 O2 sat: 100
B/P Right:147/75 Left:
Height:5'3" Weight:210
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
Yes
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:- Left:-
Pertinent Results:
[**2144-11-9**] 06:23AM BLOOD WBC-12.3* RBC-3.46* Hgb-9.9* Hct-28.6*
MCV-83 MCH-28.7 MCHC-34.7 RDW-15.6* Plt Ct-178
[**2144-11-8**] 03:30AM BLOOD PT-14.2* PTT-26.2 INR(PT)-1.2*
[**2144-11-9**] 06:23AM BLOOD Glucose-130* UreaN-23* Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-30 AnGap-11
[**Known lastname **],[**Known firstname 105090**] [**Medical Record Number 105091**] F 58 [**2086-5-10**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2144-11-8**]
12:23 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2144-11-8**] 12:23 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 105092**]
Reason: please check for hemothorax, hemomediastinum
Final Report
CHEST RADIOGRAPH
INDICATION: Drop in hematocrit, questionable mediastinal
changes.
COMPARISON: [**2144-11-8**], 5:24 a.m.
Unchanged extent of the retrocardiac and left lower lobe
atelectasis.
Unchanged width and appearance of the mediastinum, without
evidence of
mediastinal density increase or diameter increase.
No pleural effusions. Unchanged size of the cardiac silhouette.
Unchanged
course of the right central venous access line.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: SUN [**2144-11-8**] 4:04 PM
Brief Hospital Course:
The patient was admitted and underwent CABGx3(LIMA->LAD,
SVG->OM1, OM2) on [**2144-11-6**]. The cross clamp time was 63 minutes
and total bypass time was 79 minutes. She tolerated the
procedure well and was transferred to the CVICU in stable
condition on Neo, Propofol, and insulin. She was extubated and
her chest tubes were discontinued on POD#1. She had some
hyperglycemia post op but the insulin drip was eventually weaned
off and she was transferred to the floor on POD#2. Her
epicardial pacing wires were discontinued on POD#3 and she was
discharged to home in stable condition on POD#4.
Medications on Admission:
GLIPIZIDE 10 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS] 100unit/mL Solution - 34 units before
bedtime once daily
LEVOTHYROXINE 75 mcg Tablet -one Tablet(s) by mouth daily
MECLIZINE Dosage uncertain
METFORMIN 1,000 mg Tablet -
0.5-1 Tablet(s) by mouth 1000mg in am, 500mg in afternoon and
1000mg in pm
PANTOPRAZOLE 40 mg Tablet, Delayed Release (E.C.) - one
Tablet(s) by mouth daily
ROSUVASTATIN [CRESTOR] 5 mg Tablet - one Tablet(s) by mouth
daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. metformin 500 mg Tablet Sig: One (1) Tablet PO LUNCH (Lunch).
Disp:*30 Tablet(s)* Refills:*2*
6. insulin glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous at bedtime.
Disp:*11 unit* Refills:*2*
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. 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*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Hyperlipidemia
DM type 2
Lymphoma (retroperitoneal mass did not respond to chemo but good
result to xrt x 22- last time was 5 yrs ago)
Esophageal Reflux
Spinal Disorder (Para spinal mass)
Vertigo
Hypothyroidism
Obesity
Coronary artery disease-s/p CABGx3 [**2144-11-6**]
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**12-3**] @ 1:15 PM
Cardiologist: Dr. [**Last Name (STitle) **] on [**12-21**] @ 10:00 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 1356**] in [**5-11**] 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:[**2144-11-10**]
|
[
"41401",
"25000",
"2724",
"53081",
"2449",
"V1582"
] |
Admission Date: [**2139-11-23**] Discharge Date: [**2139-12-8**]
Date of Birth: [**2082-4-6**] Sex: F
Service: SURGERY
Allergies:
Ethylene
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
To donate a portion of liver
Major Surgical or Invasive Procedure:
s/p living donor R hepatic lobectomy, cholecystectomy, intraop
cholangiogram, intraop ultrasound, Tru-Cut biopsy of liver
([**2139-11-23**])
ERCP
FISTULOGRAM
History of Present Illness:
Pt is 57yo female who decided to donate a portion of her liver
to her friend. Pt was worked up preoperatively and was found to
be a good candidate.
Past Medical History:
restless leg
anxiety
migraines
arrhythmia since [**2137**]
s/p appy '[**97**]
s/p tubal ligation '[**09**]
s/p TAH '[**29**]
s/p back synovial cyst excision [**1-20**]
s/p excision of benign kidney lesion [**4-20**]
Social History:
occassional social EtOH (glass of wine)
ex smoker - 2 ppd x 20-30 yrs, stopped [**2127**]
Family History:
Mom - pancreatic CA
Dad - CAD
Sister - [**Name (NI) **] disease, DM
Physical Exam:
AVSS T96.8 P80 144/82 R16 Wt 135lb
AAOx3, NAD
Non-icteric sclera, clear oropharynx
No cervical lymphadenopathy
RR S1 S2 no murmur
CTA b/l
soft NT ND, no HSM
Neuro grossly intact
Pertinent Results:
[**2139-11-23**] 05:24PM BLOOD WBC-15.5 Hct-38.4 Plt Ct-281
[**2139-11-23**] 05:24PM BLOOD PT-16.2* PTT-26.0 INR(PT)-1.7
[**2139-11-23**] 05:24PM BLOOD Glucose-123* UreaN-14 Creat-0.6 Na-144
K-4.5 Cl-113* HCO3-23 AnGap-13
[**2139-11-23**] 05:24PM BLOOD ALT-455* AST-677* AlkPhos-66 TotBili-2.0*
[**2139-11-23**] 05:24PM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.8
Mg-1.4*
[**2139-11-23**] 05:24PM BLOOD ALT-455* AST-677* AlkPhos-66 TotBili-2.0*
[**2139-11-24**] 02:14AM BLOOD ALT-398* AST-453* AlkPhos-61 TotBili-2.5*
[**2139-11-25**] 06:20AM BLOOD ALT-324* AST-269* AlkPhos-62 TotBili-1.8*
[**2139-11-26**] 03:25PM BLOOD ALT-210* AST-115* AlkPhos-74 TotBili-4.8*
[**2139-11-27**] 06:30AM BLOOD ALT-148* AST-71* AlkPhos-75 TotBili-4.7*
DirBili-3.4* IndBili-1.3
[**2139-11-28**] 06:25AM BLOOD ALT-116* AST-72* AlkPhos-90 Amylase-80
TotBili-5.1* DirBili-3.9* IndBili-1.2
[**2139-11-28**] 03:30PM BLOOD ALT-129* AST-87* AlkPhos-115 TotBili-5.9*
[**2139-11-29**] 07:50AM BLOOD ALT-105* AST-71* AlkPhos-130*
TotBili-5.4*
[**2139-11-30**] 06:35AM BLOOD ALT-93* AST-68* AlkPhos-171* TotBili-5.4*
[**2139-12-1**] 06:12AM BLOOD ALT-84* AST-66* AlkPhos-220* TotBili-5.8*
[**2139-12-2**] 06:25AM BLOOD ALT-74* AST-59* AlkPhos-281* TotBili-6.1*
[**2139-12-2**] 03:20PM BLOOD ALT-76* AST-59* AlkPhos-312* TotBili-5.9*
DirBili-4.5* IndBili-1.4
[**2139-12-3**] 06:12AM BLOOD ALT-66* AST-56* AlkPhos-329* TotBili-5.1*
[**2139-12-3**] 09:15AM BLOOD ALT-73* AST-61* AlkPhos-373* TotBili-5.6*
[**2139-12-4**] 06:27AM BLOOD ALT-63* AST-57* AlkPhos-366* TotBili-4.4*
[**2139-12-5**] 06:30AM BLOOD ALT-60* AST-59* AlkPhos-393* TotBili-4.6*
[**2139-12-6**] 06:55AM BLOOD ALT-53* AST-57* AlkPhos-354* TotBili-3.4*
[**2139-12-7**] 06:10AM BLOOD ALT-52* AST-59* AlkPhos-407* TotBili-2.9*
[**2139-12-8**] 06:30AM BLOOD ALT-50* AST-56* AlkPhos-402* TotBili-2.8*
[**2139-11-24**] Abd US - WNL / all vessels patent
[**2139-11-26**] HIDA scan - IMPRESSION: 1) Prolonged activity within the
liver parenchyma, consistent with cholestasis. 2) Activity
within the drain at 90 minutes and faintly within the abdomen at
24 hours, consistent with a bile leak. Due to the slow passage
of activity through the liver, the source of the lead cannot be
determined from this exam.
[**2139-11-27**] ERCP - IMPRESSION: Unremarkable appearance of apparent
left intrahepatic biliary ductal system. No evidence of leak
identified.
[**2139-11-27**] Abd US - FINDINGS: Ultrasound examination of the liver
shows mild prominence of the biliary ductal system, but without
focal lesions. Liver echo texture itself is unremarkable. A
small perihepatic fluid collection is again seen, which is not
significantly changed. The gallbladder is not seen. Duplex
Doppler examination of the liver shows normal color flow and
Doppler waveforms within the left portal vein, the left hepatic
vein, and the left hepatic artery.
[**2139-11-28**] Abd CT - IMPRESSION
1. Small amount of perihepatic fluid and periportal edema,
without evidence of compromised liver blood flow or abnormal
enhancement. The appearance is within normal range in this
immediate post-operative patient.
2. No loculated intraabdominal collections.
3. Bilateral pleural effusions, right greater than left.
[**2139-12-2**] Fistulogram - IMPRESSION:
Fistulogram demonstrating no communication between either JP
drain, and intrahepatic bile ducts.
Brief Hospital Course:
Pt presented to the OR on [**2139-11-23**] to donate her R lobe of liver.
Please see the operative report for details.
Pt did relatively well during the immediate postop period. Pt
experienced mild postop hypotension, which required the thoracic
epidural to be stopped. Surveillance abd US showed all the
vessels to the remaining L lobe of the liver to be patent. She
was transferred out of ICU on POD#1.
Pt experienced postop oliguria due to hypovolemia, which
responded to fluid boluses.
One of the JP drain was noted to have bilous output on POD#3. Pt
also had a fever > 101 on POD#3 and POD#4 but routine fever
work-up only found atelectasis. Total Bilirubin also increased
from 1.8 to 4.8. Neither HIDA scan nor ERCP show any definite
source of leak nor obstruction. Repeat US of the abdomen and a
CT of the abdomen did not reveal any biloma. Fistulogram via the
JP with bilious output did not reveal any source of leak. Pt was
continued on IV Unasyn and was carefully monitored.
During the course of hospitalization, pt complained of
intermittent abd pain and nausea and occassional, rare
non-bilious emesis. Her LFTs and total bilirubin continued to
gradually improve, and abd pain, nausea and vomitting resolved.
Pt was discharged POD#15 with JP intact and VNA services.
Medications on Admission:
Mirapex 0.25mg po qHS
diazepam 0.5mg po qPM
conjugated estrogen 0.625mg po qdaily
atenolol 50mg po qdaily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*1 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: HALF Tablet PO once a day: TAKE 10MG
A DAY FOR EDEMA.
Disp:*15 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed.
Disp:*30 ML(s)* Refills:*0*
6. 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:*2*
7. Imitrex 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
RIGHT HEPATIC LOBECTOMY [**2139-11-23**] FOR DONATION
PMH:
ARRYTHMIA, MIGRAINES, ANXIETY, RESTLESS LEG, S/P L PARTIAL
NEPHRECTOMY FOR ANGIOMYOLIPOMA, S/P APPENDECTOMY, S/P
HYSTERECTOMY
Discharge Condition:
GOOD/STABLE
Discharge Instructions:
EMPTY DRAINS. MONITOR FOR COLOR AND AMOUNT DAILY
CALL IF FEVER, CHILLS, NAUSEA, VOMITING, ABD PAIN, JAUNDICE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-12-16**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-12-23**] 10:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2139-12-28**]
|
[
"4019"
] |
Admission Date: [**2170-4-11**] Discharge Date: [**2170-4-15**]
Date of Birth: [**2109-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
CABG X2 - LIMA LAD, SVG-RCA
History of Present Illness:
60 M with known CAD, prior MI, s/p PCA/stenting presented with
DOE. Cath revealed severe multilevel disease.
Past Medical History:
CAD
MI
HTN
NIDDM
hyperchol
colon polyps
s/p bare metal stent to RCA [**2158**]
vasectomy
leg fx
T&A
deviated septum repair
Social History:
tob - quit 22 yrs ago, 20 PY hx
lives with wife
4-5 drinks per week
Family History:
father MI
uncle CABG
mother AAA
Physical Exam:
AAOx3 NAD
RRR
CTAB
sternum stable, c/d/i
soft NT/ND
no c/c/e
Pertinent Results:
[**2170-4-15**] 05:25AM BLOOD Hct-32.6*
[**2170-4-14**] 04:20AM BLOOD WBC-14.3* RBC-3.76* Hgb-11.1* Hct-32.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.3 Plt Ct-192
[**2170-4-13**] 02:33AM BLOOD WBC-13.4* RBC-3.11* Hgb-9.3* Hct-27.0*
MCV-87 MCH-29.8 MCHC-34.2 RDW-13.5 Plt Ct-179
[**2170-4-12**] 02:23AM BLOOD WBC-17.4* RBC-3.83* Hgb-11.3* Hct-32.9*
MCV-86 MCH-29.5 MCHC-34.3 RDW-13.5 Plt Ct-254
[**2170-4-11**] 02:06PM BLOOD WBC-17.8* RBC-3.91*# Hgb-11.6*#
Hct-33.8*# MCV-87 MCH-29.8 MCHC-34.4 RDW-13.1 Plt Ct-232
[**2170-4-11**] 12:58PM BLOOD WBC-13.5*# RBC-2.93*# Hgb-8.9*#
Hct-25.5*# MCV-87 MCH-30.4 MCHC-34.9 RDW-13.1 Plt Ct-210
[**2170-4-14**] 04:20AM BLOOD Glucose-134* UreaN-20 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-29 AnGap-12
[**2170-4-13**] 02:33AM BLOOD Glucose-139* UreaN-21* Creat-0.8 Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
Brief Hospital Course:
Pt underwent CABG on [**4-11**] without complications. CT was d/c's
POD1. he was transferred to the floor and diet was advanced as
tolerated and he worked with physical therapy and was cleared.
He had his pacing wires taken out on [**4-14**]. He is in good
condition for discharge [**2170-4-15**].
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*60 Packet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*20 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*20 Tablet(s)* Refills:*0*
11. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO daily ().
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] area vna
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
Please call or retrun if you have fevers >101, chest pain,
shortness of breath, or anything else that causes you concern
[**Last Name (NamePattern4) 2138**]p Instructions:
Call Dr. [**Last Name (Prefixes) **] for an appointment ([**Telephone/Fax (1) 1504**]
|
[
"41401",
"4019",
"25000",
"412",
"V4582"
] |
Admission Date: [**2145-9-28**] Discharge Date: [**2145-10-12**]
Date of Birth: [**2092-8-6**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypoglycemia/uremic encephalopathy
Major Surgical or Invasive Procedure:
Transfusion of 5 units packed red blood cells.
Tunnel line placement-Hemo-ultrfiltration.
Initiation of hemodialysis.
Thoracentesis for pleural effusion.
Right knee joint aspiration.
Bone marrow biopsy.
History of Present Illness:
53M with multiple medical problems including chronic renal
insufficiency and coronary artery disease recently underwent
pre-[**First Name3 (LF) **] kidney evaluation requiring elective cardiac
cath. The cath revealed 3 vessel coronary artery disease and he
underwent CABG [**2145-9-15**]. Two weeks later, he now presented to his
PCP's office (Dr. [**Last Name (STitle) 43109**] with SOB, edema and, possible
pneumonia. He was transported from PCP's office to [**Hospital1 18**] ER for
further evaluation and management.
Past Medical History:
CAD, s/p stent ([**12-19**] at [**Hospital1 1774**]), s/p CABG [**2145-9-15**] ongoing angina
Hypertension, h/o hypertensive urgency
Respiratory arrest [**2-/2145**] with resuscitation
Chronic diastolic heart failure
Chronic renal failure, secondary to ATN and diabetes
Angina pectoris
Diabetes
Obesity, s/p laparoscopic banding ([**Doctor Last Name **], [**12-25**]), with
subsequent removal of band after prolonged hospitalization in
[**10/2144**]
Hypercholesterolemia
OSA; has not used CPAP/BIPAP for years but does use 2L NC at
night
Psoriasis; Psoriatic arthritis
Chronic anemia
h/o TIA without residual symptoms
Motorcycle trauma ([**2144-11-8**]) with BL open Monteggia fractures,
R
knee degloving injury, hypotension, facial laceration s/p
ex-lap, and s/p cervical fusion with bone graft. ORIF R and L
elbows with hardware still in place, trach and peg
h/o hypernatremia
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Tobacco: Former smoker, quit [**9-/2143**] after 80 pack-year history.
ETOH: Former heavy drinker, currently only has one drink on
occasion. Illicits: does endorse very remote history of cocaine
use, no history of any drug use in many years.
Family History:
Father - Leukemia, [**Name2 (NI) 32071**] heart disease
Mother - Diabetes [**Name2 (NI) **] type 2
Sister - Diabetes [**Name2 (NI) **] type 2
Physical Exam:
On admission, vital signs were: blood pressure 110/50, pulse 69,
respiratory rate 18, and oxygen saturation 86% on 2L by nasal
cannulae. Mr. [**Known lastname **] was rather sleepy, easily arousable and
answered questions, but his wife provided most of the
information. She reported that her husband had not done well
since his discharge to home. He has had generalized weakness,
lack of appetite, increasing edema, shortness of [**Known lastname 1440**], chills
but no fever, diarrhea or emesis. Skin was dry with psoriatic
changes of nails. Sternal wound
moist not well approx at distal pole with yellow eschar- no
drainage- 3cm in length. Neck exam notable for trach scar.
Abdomen was firm and obese with a healed mid-abd incision,
psoriatic lesions, and 2 ventral hernias. It was soft and
nontender on exam. Extremities were warm and well perfused with
hard pitting edema from thighs to feet bilaterally. No
varicosities. There were early venous stasis changes
bilaterally. Left leg SVG harvest site-open and weeeping-
erythema or purulent drainage.
Pulse exam was as follows:
Femoral Right: +1 Left: 1+
DP Right: Left:
PT [**Name (NI) 167**]: Left: pedal pulses not palpable [**3-22**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
The remainder of the exam, including cardiac, neurologic and
respiratory components, was normal.
Pertinent Results:
LABS AT ADMISSION:
[**2145-9-28**] 02:02PM BLOOD WBC-11.3* RBC-2.93* Hgb-8.4* Hct-25.7*
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.0 Plt Ct-388#
[**2145-10-1**] 06:18AM BLOOD WBC-10.7 RBC-2.78* Hgb-7.9* Hct-24.6*
MCV-88 MCH-28.4 MCHC-32.1 RDW-15.7* Plt Ct-345
[**2145-9-28**] 02:02PM BLOOD PT-18.1* PTT-34.4 INR(PT)-1.6*
[**2145-9-29**] 03:12AM BLOOD PT-18.2* PTT-34.6 INR(PT)-1.6*
[**2145-9-28**] 02:02PM BLOOD Glucose-60* UreaN-169* Creat-5.8*#
Na-132* K-4.5 Cl-87* HCO3-26 AnGap-24*
[**2145-10-1**] 06:18AM BLOOD Glucose-91 UreaN-85* Creat-3.1* Na-139
K-3.9 Cl-95* HCO3-30 AnGap-18
[**2145-9-28**] 02:02PM BLOOD ALT-68* AST-60* LD(LDH)-336* CK(CPK)-515*
AlkPhos-578* Amylase-36 TotBili-0.3
[**2145-9-29**] 03:12AM BLOOD ALT-58* AST-47* AlkPhos-470* Amylase-70
TotBili-0.2
LABS AT DISCHARGE:
[**2145-10-12**]: CBC: WBC 6.0; Hct 24.4; Plt 299
Chemistires: Na 143 / L 4.3 / Cl 104 / bicarb 31 / BUN 47 / Cr
2.5 / Glu 128; Ca 8.8; Phos 3.4; Mg 1.8
MICROBIOLOGY:
[**2145-9-28**] Blood Culture #1:No Growth.
[**2145-9-28**] Blood Culture #2:No Growth.
[**2145-9-28**] Blood Culture #3:No Growth.
[**2145-9-28**] Urine Culture #1: <10,000 organisms/ml.
[**2145-9-28**] Urine Culture #2: No Growth.
[**2145-9-29**] MRSA Screen: neg
[**2145-9-30**] Sputum Culture: GRAM STAIN (Final [**2145-9-30**]): >25 PMNs
and <10 epithelial cells/100X field. 1+ GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE: RARE GROWTH OROPHARYNGEAL FLORA.
[**2145-10-3**] Blood Culture #1:No Growth.
[**2145-10-3**] Blood Culture #2:No Growth.
[**2145-10-3**] Blood Culture #3:No Growth.
[**2145-10-3**] Sputum Culture: GRAM STAIN <10 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory secretions. Bacterial culture results are
invalid.
[**2145-10-3**] Urine Culture:No Growth.
[**2145-10-4**] Blood Culture #1: No growth.
[**2145-10-4**] Blood Culture #2: No growth.
[**2145-10-4**] Catheter Tip Culture:No significant growth.
[**2145-10-5**] Sputum Culture:GRAM STAIN >25 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory secretions. Bacterial culture results are
invalid.
[**2145-10-5**] Pleural Fluid: 4+ (>10 per 1000X FIELD)
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. Fluid: no
growth. Anaerobic: no growth.
[**2145-10-7**] Urine Culture:NO GROWTH.
[**2145-10-8**] Joint Fluid:2+ (1-5 per 1000X FIELD) POLYMORPHONUCLEAR
LEUKOCYTES. NO MICROORGANISMS SEEN. Fluid: no growth.
LABS PENDING AT DISCHAGE:
[**2145-10-11**]: Blood culture: pending - please follow up at your
kidney doctor appointment
STUDIES:
[**2145-10-7**]: Knee XR: RIGHT KNEE: Images are somewhat limited due to
underpenetration. There is some prepatellar soft tissue
swelling, which is unchanged. There is persistent spurring of
the superior aspect of the patella. There is a suprapatellar
knee joint effusion. No acute fractures or dislocations are
seen. The joint spaces are relatively preserved. There are
surgical grafts. THE LEFT KNEE: Surgical clips are seen within
the medial soft tissues. Joint spaces are relatively preserved.
There is some minimal spurring of the superior aspect of the
patella as well as prepatellar soft tissue swelling. There is
also a small joint effusion.
[**2145-10-5**]: CXR: In comparison with the study of [**10-4**], there has
been some decrease in the left pleural effusion with residual
atelectasis at the base. No evidence of pneumothorax.
[**2145-10-5**]: CT Chest and Pelvis: 1. Postoperative changes in the
anterior mediastinum, without focal fluid collection. 2.
Moderate simple left pleural effusion with compressive
atelectasis of the left lower lobe. 3. Extensive atherosclerotic
calcification. 4. Diffuse subcutaneous edema consistent with
third spacing.
[**2145-10-4**]: CXR: IMPRESSION: AP chest compared to [**9-20**] through
[**10-3**].
Large scale opacification of the left lower lobe accompanied by
a least
moderate left pleural effusion may not be due to atelectasis
since there is slight rightward mediastinal shift. Findings are
concerning for infection either in the pleural space or
pericardial mediastinum, and the possibility of left lower lobe
pneumonia needs to be excluded as well. Right lung is grossly
clear. Overall size of the postoperative cardiomediastinal
silhouette is stable, increased compared to the preoperative
appearance. Right lung is grossly clear. A left-sided central
line ends alongside a supraclavicular dual channel right
internal jugular line at the junction of the brachiocephalic
veins. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] and I discussed these findings.
[**2145-9-30**]: ECHO: The left atrium is mildly dilated. The right
atrium is moderately dilated. 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. with normal free wall contractility. The ascending
aorta is mildly dilated. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
IMPRESSION: Symmetric LVH with preserved global systolic
function. Very limited study. Compared with the prior study
(images reviewed) of [**2145-9-14**], findings are probably similar.
Both studies are limited. If more definitive information about
wall motion is desired, consider repeating the study with echo
contrast.
[**2145-9-29**]: Tunneled cath insertion: IMPRESSION: Successful
placement of a tunneled right internal jugular dual-lumen
hemodialysis catheter, with ultrasound and fluoro guidance
measuring 27 cm tip- to- cuff and with the tip now terminating
in the right atrium. The line is ready to use.
[**2145-9-29**]: LENIs: No evidence of deep venous thrombosis in the
left lower extremity. The study and the report were reviewed by
the staff radiologist.
[**2145-9-28**]: Liver/Gallbladder ultrasound: 1. Normal study without
evidence of acute cholecystitis or cholelithiasis. 2. Small
right pleural effusion is incidentally noted.
[**2145-9-28**]: CXR: Limited study with decreased penetration in the
retrocardiac
region, an infection/consolidation in this region can not be
excluded.
Otherwise unremarkable, no pulmonary edema.
[**2145-9-28**]: EKG: Sinus rhythm with prolonged P-R interval.
Intraventricular conduction delay. Non-specific septal and
lateral ST-T wave changes. Compared to the previous tracing of
[**2145-9-17**] the QRS duration has shortened and the ST-T waves have
changed in the lateral leads. Clinical correlation is suggested.
Brief Hospital Course:
A/P: 53M with HTN, HL, DMt2, ESRD on newly initiated HD and on
renal tx list, OSA and dCHF on home O2, CAD s/p arrest in [**2-/2145**]
s/p CABG on [**2145-9-15**] admitted with worsening renal failure,
initiated on hemodialysis.
Mr [**Known lastname **] was readmitted after CABG weeks PTA now with
increasing lethargy, failure to thrive, and increasing shortness
of [**Known lastname 1440**]. Work up revealed hypoglycemia, uremic
encephalopathy-acute on chronic renal failure, left lower
extremity erythema, and question of pneumonia status post off
pump coronary artery bypass grafting x 3 on [**9-15**] requiring
transfer to CVICU for close monitoring. Dextrose infusion,
Ultrasound of left lower extremity which ruled out deep vein
thrombosis, trans thoracic echo showed global systolic function
(LVEF>55%) and no pericardial effusion. Renal was consulted and
hemodialysis was initiated. Hospital Day #1 elective intubation
was performed for respiratory support/airway management during
tunnel line placement. Mr. [**Known lastname **] was extubated in a timely
fashion with hemodynamic stability and neurologically intact.
Antibiotics were initiated empirically for possible
pneumonia/bacteremia on admission. Pan culture was negative. On
D#2 he was transferred to the step down unit for further
monitoring.
While in the step-down unit, he was nearly anuric, on dialysis,
and on the renal [**Known lastname **] list. He continued to require
supplemental oxygen and was found to have a significant L sided
pleural effusion. He underwent thoracentesis on [**10-6**] and
1.4 L of fluid was removed. He reported symptomatic relief but
remains on supplemental oxygen (2L). He also several days of
unexplained fevers up to 103, for which he received zosyn ([**9-28**]
- [**10-5**]) and a single dose of vancoymycin. Panculture was
negative and fevers resolved around [**10-5**]. Fevers resolved
about three days prior to transfer and were thought to be due to
gout. Patient did develop worsening joint pain (h/o serious MVA
in [**2144**] and significant known arthritis) in the setting of
decreasing his pain medication regimen, and a right knee joint
aspirate was showed needle shaped negatively birefringent
crystals consistent with gout. Of note, patient has had a
persistent anemia that has not responded to multiple
transfusions (5 u pRBC), and a bone marrow biopsy on [**10-8**]
was still pending on discharge to be followed up at his
outpatient hematology appointment.
Given multiple medical problems was transferred to medical
service on [**10-8**] for further management.
His medical issues at discharge are summarized below:
ESRD: He had tunnelled cath placed on [**9-29**] and hemodialysis was
begun on a Monday, Wednesday, and Friday schedule, which should
be maintained on an outpatient basis. Will require follow-up
with Renal as an outpatient as he is a new dialysis patient. He
is also on the renal transplatn list. He should continue his
sevelamer, Epo, and nephrocaps as well.
Possible line infection vs. skin infection: Patient developed
erythema and tenderness at the HD line site (R chest) on
[**2145-10-10**]. On the day of discharge, there was no pain but some
pruritis. He has had low grade fevers, most likely explained by
gout, and a normal WBC count. Blood cultures were drawn on
[**2145-10-11**], which will be followed up by the renal clinic (Dr.
[**Last Name (STitle) 4090**]. If the patient develops any fever, increased redness at
the hemodialysis line site, please check BCx from the line, and
consider starting empiric antibiotics for this.
Diastolic heart failure: Pleural effusion presumed secondary to
fluids from surgery in setting of dCHF and renal failure
requiring HD. Patient is now status post L thoracentesis on
[**10-5**] with no growth on culture. Pulmonary exam clear to
auscultation bilaterally at discharge and patient with 1L oxygen
requirement by nasal cannulae.
Anemia: Patient has had multiple tranfusions (has received 5
units of blood since [**10-3**]) during this admission without
response. A bone marrow biopsy was done on [**10-8**] with results
pending, to rule out myelodysplastic syndrome. This will
require outpatient follow-up with hematology.
Fevers of unknown origin: Fevers have resolved; patient now with
low grade temperatures (~99.1), no leukocytosis, and no
localizing symptoms; the fevers were most likely secondary to
gout. Pt with pain at HD cath site but does not appear infected
at this time. Urine and pleural fluid did not grow out any
microbiology.
Gout: Pain improved with 1 dose of colchicine. NSAIDs, steroids
and further colchicine were avoided in the setting of renal
failure and status post surgery (due to infection risk). Will
require outpatient follow-up for subsequent management of
flares; opioids for pain relief may be considered in the interim
if pain worsens.
Coronary artery disease: Patient is status post recent CABG on
[**2145-9-15**] and PCI in past. No evidence of ACS at this time. He
should continue his home medications of ASA 81, atorvastatin
80, zetia 10mg PO daily, metoprolol 50 [**Hospital1 **], plavix 77. He has
not tolerated Zestril in the past. Will defer on implementing
[**Last Name (un) **] as he is a new dialysis patient; we have discussed with
Renal and will defer this to the outpatient setting.
Type II Diabetes [**Last Name (un) **]: Blood sugars have been under fair
control on current regimen; will require continued outpatient
management to optimize glucose control.
Abnormal thyroid tests: TSH:6.2 Free-T4:0.81. Most consistent
with known primary hypothyroidism, but given borderline TSH,
there may be a component of sick euthyroid. Patient to continue
levothyroxine.
Obstructive sleep apnea: Does not tolerate CPAP. Outpatient
follow-up recommended.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1Tablet(s) by mouth DAILY (Daily)
ATORVASTATIN [LIPITOR] - 80 mgTablet - 1 Tablet(s) by mouth
once
a day
CALCITRIOL - 0.25 mcg Capsule 1 Capsule(s) by mouth once a day
CITALOPRAM - 20 mg Tablet - 1Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mgTablet - 1 Tablet(s) by mouth once a
day
DILTIAZEM HCL - 360 mg Capsule Sustained Release - 1 Capsule(s)
by mouth at bedtime
DOXAZOSIN - 4 mg Tablet - 1 Tablet(s) by mouth
EPOETIN ALFA [EPOGEN] - 40,000unit/mL Solution - 1 shot per
week if needed prn
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth once aweek
ETANERCEPT [ENBREL] - 50 mg/mL(0.98 mL) Syringe - 1 shot q week
weekly
EZETIMIBE [ZETIA] - 10 mgTablet - 1 Tablet(s) by mouth once a
day
FAMOTIDINE - 20 mg Tablet - 1Tablet(s) by mouth twice a day
FUROSEMIDE - 80 mg Tablet - 1Tablet(s) by mouth twice a day
GEMFIBROZIL - 600 mg Tablet - 1Tablet(s) by mouth twice a day
GLIMEPIRIDE - 4 mg Tablet - 1/2Tablet(s) by mouth twice a day
HYDRALAZINE - 25 mg Tablet -TWO Tablet(s) by mouth three times
a day
ISOSORBIDE MONONITRATE - 60 mgTablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
L-THYROXINE - - 0.05 once [**Last Name (un) 5490**]
LOSARTAN [COZAAR] - 25mgTablet - 2 Tablet(s) by mouth ONCE a
day
METOLAZONE - 2.5 mg Tablet - 1Tablet(s) by mouth q12
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for pain
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - - 81 mg Tablet, Delayed
Release (E.C.) - oneTablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] -
(Prescribed by Other Provider) - 600 mg (1,500 mg)-400 unit
Tablet - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 1
Capsule(s) by mouth once a day
FERROUS SULFATE - 325 mg (65 mgIron) Tablet - 1 Tablet(s) by
mouth twice a day
INSULIN NPH HUMAN RECOMB [NOVOLIN N] - 100 unit/mL Suspension -
per sliding scale
INSULIN REGULAR HUMAN [NOVOLIN R INNOLET] - 300 unit/3 mL
Insulin
Pen - as directed Insulin(s)
four times a day Sliding Scale: 61-120 mg/dL 0 Units
121-140
mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8
Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units
mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22
Units 321-340 mg/dL 24 Units 341-360 mg/dL 26 Units
361-380 mg/dL 28 Units 381-400 mg/dL 30 Units > 400
mg/dL 32 Units
MULTIVITAMINS WITH MINERALS - (OTC) - Tablet - 1 Tablet(s) by
mouth twice a day Recommended once per day for Lap Band
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-19**] Sprays Nasal
TID (3 times a day) as needed for xeronasia.
12. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Epoetin Alfa 4,000 unit/mL Solution Sig: Three (3) doses
Injection 3 times per week (Monday, Wednesday, Friday).
14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
22. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush:
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
.
24. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
25. Insulin Glargine 100 unit/mL Solution Sig: 14 units in the
AM, 18 units at bedtime units subcutaneously Subcutaneous twice
a day.
26. Insulin Lispro 100 unit/mL Solution Sig: Administer per
insulin sliding scale units Subcutaneous four times a day:
Insulin sliding scale attached.
27. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
28. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
29. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis:
End stage renal disease requring initiation of hemodialysis
Secondary Diagnoses:
- acute gout flare
- anemia
- coronary artery disease
- angina pectoris
- hypertension
- chronic diastolic heart failure
- diabetes
- chronic kidney disease
- rheumatoid arthritis
- hypercholesterolemia
Discharge Condition:
Stable, with low grade temperatures and stable gout, on
hemodialysis, with good oxygen saturation on 1L NC.
Discharge Instructions:
You were admitted to the hospital with shortness of [**Hospital3 1440**] and
increased swelling in your legs. You were found to have
worsening renal function. A tunnelled line was placed and
hemodialysis was initiated during your hospitalization, and you
are currently on the renal [**Hospital3 **] list. In addition, you
developed a pleural effusion while in the hospital, which was
tapped and drained (thoracentesis). You also developed some
fevers and an episode of gout, which was diagnosed by joint
aspiration of your right knee. You were treated with
antibiotics for eight days given fevers of unknown origin, which
are now thought to be due to your gout flare. In addition, you
were transfused 5 units of packed red blood cells while in the
hospital but your blood count did not rise as would expected. A
bone marrow biopsy was performed, and the results were still
pending upon your discharge.
Please continue to take your home medications, with the
following changes: We discontinued many of your blood pressure
and diuretic medications now that you are on hemodialysis
- please discontinue: amlodipine, calcitriol, diltiazem,
etanercept, furosemide, gemfibrozil, glimepiride, hydralazine,
isosorbide mononitrate, losartan, metolazone, and
oxycodone-acetaminophen. Please follow-up with your Renal and
Cardiology doctors [**First Name (Titles) **] [**Last Name (Titles) 51790**] your blood pressure control and
to consider restarting your Losartan.
- please reduce your doxazosin dose to 1mg (1 tablet) by mouth
at bedtime
- please take metoprolol 50mg by mouth twice a day
- please take sevelamer 800mg (2 tablets) by mouth three times a
day, with meals
- please also take the following as prescribed: Vitamin
B/C/Folate supplement, Colace, and subcutaneous heparin.
In addition, please do the following:
- adhere to 2 gm sodium diet
- shower daily including washing incisions
- do not swim or take baths
- monitor your wounds for infection. If you notice increased
redness, drainage, pain, or if you develop fevers, please notify
your doctor, as you may require antibiotics.
- report any fever greater than 101
- report any weight gain of greater than 2 pounds in 24 hours or
5 pounds in a week
- do not use creams, lotions, powders, or ointments to incisions
- do not drive for approximately one month, or while taking
narcotics
- do not lift more than 10 pounds for the next 10 weeks
If you develop shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] increase in leg swelling,
increased joint pain, or any other symptoms that concern you,
please contact your primary care physician or return to the
hospital.
Followup Instructions:
Hematology will contact you by phone to schedule a follow-up
appointment. Please follow-up on the results of your bone marrow
biopsy at this time. If you don't hear from them within 1 week,
call ([**Telephone/Fax (1) 14703**] to make an appointment.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43109**] (primary care) in [**3-23**]
weeks. Please have your rehabilitation facility schedule this
appointment. [**Last Name (LF) **],[**First Name3 (LF) **] S [**Telephone/Fax (1) 51791**]
Please follow up wtih Dr. [**Last Name (STitle) 4090**] [**Telephone/Fax (1) 2378**] (Renal). Please
have chemistries drawn for this appointment. The renal nurses
will call you at rehab to schedule a the appointment. At this
appointment, you need to follow up on the blood culture taken
from your hemodialysis line.
Please also follow-up with the following healthcare providers:
- [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-10-21**] 8:00
- [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-10-21**] 8:30
- [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 24317**], MD Phone:[**Telephone/Fax (1) 6429**] Date/Time:[**2145-12-7**] 1:00
|
[
"5849",
"486",
"40391",
"4280",
"V4581",
"32723",
"2449"
] |
Admission Date: [**2186-4-24**] Discharge Date: [**2186-5-7**]
Date of Birth: [**2124-6-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
SOB, receurrent tracheal stenosis
Major Surgical or Invasive Procedure:
[**2186-5-2**] Flexible bronchoscopy
[**2186-4-29**] Flexible bronchoscopy
[**2186-4-28**]: Rigid bronchoscopy with yellow [**Last Name (un) 48377**] tracheoscope.
Foreign body removal (Ultraflex stent in trachea).
[**2186-4-25**] 1. Flexible bronchoscopy. Rigid bronchoscopy.
Metal stent removal of proximal tracheal stent (alveolus 4 cm).
History of Present Illness:
61 y female with multiple medical problems who presents as a
consult for evaluation of recurrent tracheal stenosis. The
tracheal stenosis is secondary to
prolonged ICU stay w/intubation as well as traumatic
tracheostomy placement done 3 years prior following from a fall.
For approximately 2 months after removal of the tracheostomy the
patient did well but began to develop shortness of breath and
difficulty with inspiration. The patient relays that there were
2
areas of focal stenosis, the distal most which had a metal stent
placed across it. Subseuent to this the patient did well for [**9-3**]
months before having recurrence of symptoms. Repeat
bronchoscopy demonstrated restenosis, the prior stent was not
able to be removed and a second stent was placed over the
original. This required revisions x2 for stent migration. She
has not had a
bronchoscopy for approximately the past year with increasing
severity of symptoms. She is essentially bedridden secondary to
her morbid obesity as well as dyspnea when walking only [**2-28**]
steps. She has noted an increase in weight secondary her
imobility. She complains of cough, daily, productive of thin
yellow sputum, there is no hemoptysis, often the coughing fits
are severe and accompanied by post-tussis emesis/wretching. She
has describes mild orthopnea, and uses a BiPAP at night with
minimal symptom relief, and continues to have excessive daytime
sleepiness. She does not have any chest pain, nausea/vomiting,
no fever/chills, or epistaxis
Past Medical History:
1. Tracheal stenosis; secondary to prolonged
intubation/tracheostomy
2. COPD on BiPAP
3. HTN
4. CHF: diastolic
5. Morbid obesity
6. Anemia
7. Spastic bladder/incontinence
8. Hysterectomy
9. Left knee repair
10. Right breast lumpectomy; non-malignant
11. ? rheumatic fever as child
12. Diabetes
Social History:
lives alone in TN with assitance from son and caretaker. [**Name (NI) 4906**]
passed 11yrs prior secondary to asbestosis.
Tobacco: quit 4 years ago
Family History:
non-contributory
Physical Exam:
VS: T: 100.0 HR: 89 SR BP: 100/70 Sats: 93% 4L
General:
Pertinent Results:
[**2186-5-4**] BLOOD Hct-31.1*
[**2186-5-2**] WBC-8.5 RBC-3.97* Hgb-10.4* Hct-30.6* Plt Ct-275
[**2186-5-1**] WBC-11.0 RBC-4.16* Hgb-11.2* Hct-31.8* Plt Ct-261
[**2186-4-30**] WBC-8.4 RBC-4.26 Hgb-11.0* Hct-32.6* Plt Ct-267
[**2186-4-29**] WBC-7.0 RBC-4.38 Hgb-11.2* Hct-33.4* Plt Ct-249
[**2186-4-28**] WBC-7.6 RBC-4.68 Hgb-11.9* Hct-35.4* Plt Ct-276
[**2186-4-27**] WBC-7.9 RBC-4.37 Hgb-11.5* Hct-33.6* Plt Ct-249
[**2186-4-24**] WBC-7.6 RBC-4.79 Hgb-12.5 Hct-36.5 Plt Ct-255
[**2186-5-4**] Glucose-119* UreaN-24* Creat-0.9 Na-139 K-3.7 Cl-93*
HCO3-35*
[**2186-5-2**] Glucose-170* UreaN-20 Creat-0.8 Na-137 K-3.8 Cl-92*
HCO3-36*
[**2186-5-1**] Glucose-171* UreaN-19 Creat-0.9 Na-137 K-4.6 Cl-93*
HCO3-38*
[**2186-4-29**] Glucose-169* UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-94*
HCO3-36*
[**2186-4-25**] Glucose-202* UreaN-23* Creat-0.8 Na-140 K-3.6 Cl-99
HCO3-32
[**2186-5-4**] Mg-1.8
CXR:
04/09/09Fall.
Mediastinum appears widened but is similar to previous portable
radiographs with similar positioning dating back to [**2186-4-28**]. Cardiac silhouette is enlarged but unchanged. Near
complete collapse of right lower lobe is present with adjacent
small right pleural effusion. Improving opacity at the left
base, which is nearly resolved.
[**2186-5-2**] In comparison with the study of [**4-28**], the endotracheal
tube has been removed. The widening of the superior mediastinum
is somewhat less
pronounced. Bibasilar atelectasis and effusions persist.
Chest CT
[**4-28**]. No mediastinal hemorrhage. No evidence of vascular,
tracheal or
esophageal trauma.
2. Interval removal of tracheal stent with endotracheal tube in
place. No
change in tracheal thickening.
3. Bibasilar atelectasis.
[**4-25**] 1. Patchy opacity at the right and left lower lobes.
Appearance on the right particularly is concerning for
aspiration in light of recent bronchoscopy. Differential
includes atelectasis.
2. Markedly thickened trachea above patient's stent with
prominent
granulation tissue. Granulation tissue is also noted within the
stent. No
significant tracheomalacia.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted on [**2186-4-24**] for further airway management.
On [**2186-4-25**] she was taken to the operating room for . Flexible
bronchoscopy. Rigid bronchoscopy.
Metal stent removal of proximal tracheal stent (alveolus4 cm).
She was monitored in the PACU prior transfer to the floor with
oxygen saturations 94% 3L NC. Aggressive pulmonary toilet with
nebs were continued. She had CT airway which showed marked
granulated tissue at stent site. On [**2186-4-28**] Successful
removal of distal tracheal stent. Significant residual
granulation tissue, nearly completely
obstructing tracheal lumen. The patient remained intubated
overnight, to
undergo flexible bronchoscopy in the morning to reevaluate
airway mucosa and central airway obstruction. She was
transferred to SICU for further airway management. On [**2186-4-29**]
she had a bedside bronchoscopy which showed improved airway.
Granulated tissue remained. She was Extubated, with moderate
respiratory distress. Her respiratory status improved with
aggressive pulmonary toilet, BiPAP and Albuteral/atrovent nebs.
She transferred to the floor and her respiratory status slowly
returned to her baseline. On [**5-2**] a follow-up flexible
bronchoscopy showed the distal trachea granulation tissue mainly
at the posterior wall. On [**5-3**] she slipped while getting out of
bed. She was examined and no visual injury was noted. She was
followed by serial chest x-ray which showed a stable
Mediastinum widened. collapsed Right middle lobe and small
effusion. She was followed by physical therapy. The patients
respiratory status remained stable, she was observed for any
acute changes and on [**5-7**] was deemed fit for discharge back to
[**Location **]. AT the time of discharge the patient was
hemodynamically stable, her respiratory status was back to
baseline, she was tolerating a regular diet and did not have
significant pain complaints relating to her procedure.
Medications on Admission:
1. Spiriva 1 puff daily
2. Advair 250/50 2 puffs daily
3. Levalbuterol 1 puff qid prn
4. Detrol LA 2 mg PO daily
5. 81mg ASA PO daily
6. Gabapentin 800mg PO TID
7. Trazadone 50mg PO Qhs
8. Celebrex 200mg PO daily
9. Vytorin 10/40mg PO daily
10. Iron 325mg PO daily
11. Spirinolactone 12.5mg PO daily
12. Furosemide 40mg PO daily
13. Metoprolol 12.5mg PO BID
14. Cymbalta 60mg PO BID
15. Singulair 10mg PO daily
16 Omeprazole 20mg PO daily
____________
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
5. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
6. Ropinirole 1 mg Tablet Sig: Five (5) Tablet PO QPM (once a
day (in the evening)).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
17. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
18. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
19. Levalbuterol Tartrate 45 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Inhalation four times a day.
20. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop PO
DAILY (Daily).
21. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ninety (90) Units Subcutaneous twice a day.
22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Discharge Disposition:
Home With Service
Facility:
Gentiva Home Care
Discharge Diagnosis:
Tracheobronchomalacia, tracheal stenosis s/p stent removal x 2
COPD
Hypertension
Congestive Heart Failure-diastolic
Morbid Obsity
Anemia
Spastic Bladder/Incontinence
Hysterectomy
Discharge Condition:
Improved
Discharge Instructions:
Call your pulmonologist or PCP if develops increased shortness
of breath, cough or chest pain
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 unless otherwise
directed 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 ambulate several times per day.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as directed - Call for appointment in 1
month
([**Telephone/Fax (1) 17398**]
Follow-up with your PCP
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2186-5-12**]
|
[
"5180",
"32723",
"496",
"4280"
] |
Admission Date: [**2201-2-24**] Discharge Date: [**2201-3-6**]
Date of Birth: [**2201-2-24**] Sex: F
Service: NEONATOLOGY
ADMISSION DIAGNOSES:
1. Prematurity.
2. Sepsis evaluation.
HISTORY OF PRESENT ILLNESS: The infant is a 1450-gram female
born at 32 weeks to 28-year-old gravida 1, para now 2, mother
who presented in preterm labor on the day of delivery.
Her pregnancy was complicated with cervical shortening and
cerclage placement in the 20th week. Her twin was noted to
have ventriculomegaly on prenatal ultrasound. Mother was
treated with magnesium sulfate; however, she continued to
have progression of labor. Prenatal screens were negative.
Group B strep status was unknown. She received one dose of
betamethasone on the day of delivery.
Prenatal laboratories revealed A positive, hepatitis B
surface antigen negative, rapid plasma reagin was
nonreactive, antibody negative. Membranes ruptured at the
time of delivery. Cesarean section performed. Baby one
emerged vigorous. Received blow-by oxygen and stimulation.
Apgar scores were [**6-29**]. The baby was transported to the
Neonatal Intensive Care Unit for further management.
Initially she was grunting, flaring, and retracting; but was
pink, alert, and active. She was started on a continuous
positive airway pressure of 6; however, continued to retract.
She was intubated and given one dose of surfactant.
PHYSICAL EXAMINATION ON PRESENTATION: Pink, and active, and
nondysmorphic. Clear breath sounds bilaterally. No murmurs
appreciated. There were mild retractions. The abdomen was
benign. Neurologic examination was nonfocal and age
appropriate. Genitalia consistent with a female premature
infant. Normal hips. Patent anus. Head circumference was
28.5 cm.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: After receiving initial dose of
surfactant the infant was quickly weaned on ventilatory
settings. She was transitioned to continuous positive airway
pressure by day of life two. She was able to wean off
continuous positive airway pressure to room air by day of
life four. She was started on caffeine on day of life six.
This was after having four apneic and bradycardic episodes
within 24 hours. She has not had any further spells.
2. CARDIOVASCULAR ISSUES: The infant has remained
hemodynamically stable with no need for blood pressure
support. She has not had murmurs appreciated.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially started on intravenous fluids at 80 cc/kg per day.
She was initially started on a 10% dextrose infusion and then
started on parenteral nutrition on day of life two. She was
started on feeds day of life three with Premature Enfamil 20
calorie per ounce formula. She was advanced 15 cc per
kilogram twice per day and reached full feeds on day of life
eight. She is currently on a 22-calorie formula of Premature
Enfamil since day of life nine. Her electrolytes have
remained normal. Her latest were a sodium of 137, potassium
was 5.4, chloride was 105, and bicarbonate was 20. Her
full volume feeds is 150 cc/kg per day given via gavage.
Dextrose sticks have been stable.
4. HEMATOLOGIC ISSUES: The infant was started on
phototherapy on day of life two for a bilirubin of 6.4 and a
direct component of 0.3. Her peak bilirubin level on day of
life four. Her rebound bilirubin on day of life was 4.5 with
a direct of 0.2. Hematocrit at birth was 55 with platelets
of 265.
5. INFECTIOUS DISEASE ISSUES: The infant's initial white
blood cell count was 9.7 (with 41% polys and no bands). The
infant was started on ampicillin and gentamicin and was
continued until cultures were negative at 48 hours. She has
had no other infectious issues or concerns.
6. ROUTINE HEALTHCARE MANAGEMENT ISSUES: The infant has not
yet received hepatitis B vaccine. She has not had her
hearing screen.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Apnea of prematurity.
3. Feeding immaturity.
4. Sepsis evaluation.
MEDICATIONS ON TRANSFER: Caffeine citrate 10 mg PG daily.
PHYSICAL EXAMINATION ON DISCHARGE: The infant was
comfortable in isolette and appeared pink. Anterior fontanel
was soft, open, and flat. The palate was intact. Breath
sounds with equal entry and clear bilaterally. A regular
rate and rhythm. No murmurs appreciated. The abdomen was
soft, nontender, and nondistended. Femoral pulses were 2+
bilaterally. Normal female genitalia; appropriate for
gestational age. Warm and well perfused. Normal tone.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**First Name8 (NamePattern2) 55065**]
MEDQUIST36
D: [**2201-3-5**] 13:34
T: [**2201-3-5**] 14:07
JOB#: [**Job Number 55066**]
|
[
"7742",
"V290"
] |
Admission Date: [**2191-7-18**] Discharge Date: [**2191-7-23**]
Date of Birth: [**2119-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2191-7-18**] Mitral Valve Repair (28mm annuloplasty band and
quadrangular resection)
History of Present Illness:
71 y/o male with known coronary artery disease with increased
symptoms (dyspnea on exertion and chest tightness) who was
referred for cardiac cath. During cath he was found to have
severe mitral regurgitation and was then referred for surgical
intervention.
Past Medical History:
Coronary Artery Disease s/p LAD stent x 2 [**2184**], Hyperlipidemia,
B cell lymphoma s/p chemi/XRT and mediastinoscopy
Social History:
Auditor. Quit smoking 30 yrs ago (30ppy hx), [**4-9**] glasses
wine/wk.
Family History:
non-contributory
Physical Exam:
VS: 55 17 137/53 6'1" 113.4kg
HEENT: EOMI, PERRL, NCAT, OP benign
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR +murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+pulses
throughout
Neuro: MAE, A&O x 3, non-focal
Pertinent Results:
Echo [**7-18**]: PRE-BYPASS: The left atrium is mildly dilated.
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the
descending thoracic aorta. There is no aortic valve stenosis.
Mild to moderate ([**2-7**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
are myxomatous. There is moderate/severe mitral valve prolapse.
Moderate to severe (3+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. POST CPB: Preserved
biventricular systolic function. Posterior leaflet has been
resedted, and there is an annuloplasty ring in mitral position.
Trace MR and no evidence of dynamic LVOT obstruction. No other
change in valve structrue or function.
CXR [**7-22**]: Prior right internal jugular catheter has been
removed. No pneumothorax. There has been general overall
improvement with residual bilateral pleural effusions, greater
on the left side and associated atelectasis. I doubt the
presence of consolidation. A small amount of residual
postoperative gas is demonstrated along the anterior chest wall.
[**2191-7-18**] 03:30PM BLOOD WBC-10.7 RBC-3.04* Hgb-9.9* Hct-28.1*
MCV-92 MCH-32.6* MCHC-35.4* RDW-13.2 Plt Ct-146*
[**2191-7-20**] 01:41AM BLOOD WBC-11.5* RBC-2.48* Hgb-8.0* Hct-22.8*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.3 Plt Ct-144*
[**2191-7-22**] 07:35AM BLOOD WBC-9.6 RBC-2.46* Hgb-7.8* Hct-22.5*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.8 Plt Ct-213
[**2191-7-23**] 04:45AM BLOOD Hct-29.3*#
[**2191-7-18**] 05:08PM BLOOD PT-14.8* PTT-36.4* INR(PT)-1.3*
[**2191-7-20**] 01:41AM BLOOD PT-13.6* PTT-31.2 INR(PT)-1.2*
[**2191-7-18**] 05:08PM BLOOD UreaN-13 Creat-0.8 Cl-112* HCO3-24
[**2191-7-22**] 07:35AM BLOOD Glucose-108* UreaN-19 Creat-0.7 Na-136
K-4.3 Cl-98 HCO3-32 AnGap-10
[**2191-7-21**] 06:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.2
[**2191-7-20**] 08:30AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2191-7-20**] 08:30AM URINE RBC-[**4-10**]* WBC-0-2 Bacteri-MANY Yeast-FEW
Epi-0-2
Brief Hospital Course:
Mr. [**Known lastname 62132**] had his pre-operative work-up done as an outpatient
and was a same day admit for surgery. On 6.12 he was brought to
the operating room where he underwent a Mitral Valve repair
utilizing a Annuloplasty band and quadrangular resection. Please
see operative report for surgical details. He tolerated the
procedure well and was transferred to the CSRU in stable
condition for invasive monitoring. Later on op day he was weaned
from sedation, awoke neurologically intact and was extubated. On
post-op day one his chest tubes and Swann-Ganz catheter was
removed. He was weaned off of Inotropes on post-op day two and
was started on beta blockers and diuretics. He was gently
diuresed towards his pre-op weight during his hospital course.
Later on this day he was transferred to the cardiac surgery
telemetry floor. On post-op day three his epicardial pacing
wires were removed. He continued to make steadily clinical
improvements without complications post-operatively. Although he
did require several blood transfusions secondary to anemia with
a low HCT. Physical therapy followed patient during entire
post-op course and he was discharged home with VNA services and
the appropriate follow-up appointments on post-op day 5.
Medications on Admission:
Atenolol 25mg qd, Lisinopril 5mg qd, Lipitor 10mg qd, Aspirin
325mg qd, Plavix 75mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair
PMH: Coronary Artery Disease s/p LAD stent x 2 [**2184**],
Hyperlipidemia, B cell lymphoma s/p chemi/XRT and
mediastinoscopy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 8506**] Follow-up appointment should
be in 2 weeks
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**] Follow-up appointment should be
in 1 month
Completed by:[**2191-8-11**]
|
[
"4240",
"V4581",
"4019"
] |
Admission Date: [**2119-11-7**] Discharge Date: [**2119-11-7**]
Date of Birth: [**2051-5-11**] Sex: M
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea, vomiting, GTC
Major Surgical or Invasive Procedure:
Intra-arterial TPA
History of Present Illness:
Pt. is a 68 year old with a recent L cerebellar infarct and L
vert occlusion who presented to [**Hospital **] hospital earlier today
with nausea and dry heaves, and seized for > 30 minutes while
being worked up, who is transferred here for Neuro eval.
[**Name (NI) 1094**] wife reports that he complained of nausea and dizziness
this afternoon. These were the same symptoms he had when he was
diagnosed with a stroke on [**2119-10-15**], and he asked to be taken to
the hospital. He arrived there at 3:15. He did not complain
of, and she did not notice, any weakness, numbness, slurred
speech, facial droop, dysphagia, vision changes or vision loss.
She reports that since the stroke on [**10-15**] he has had some double
vision, but that this was not any worse today. He's also had
some balance problems, with a tendency to fall to the left, but
this has been improving lately, and earlier today he actually
walked without a walker for the first time since the stroke. He
initially had some L sided neglect, but this improved while he
was in the hospital and has not recurred. He never had any
weakness or facial droop that they remember.
Initially at OSH ED, they record that pt's speech was clear and
coherent, he moved all extremities, and had no facial assymetry.
They did not find any focal deficits. Around 6:00 he
complained of some tingling in his fingertips on the left, which
was a new symptom for him. He vomited once after that (time not
documented) A Head CT was performed and showed no mass, no mass
effect, no ICH, but evidence of a R BG lacune, low attenuation
in the L occipital lobe concerning for subacute infarction, and
small vessel ischemic changes. At 20:24 he became unresponsive
and started having a generalized tonic clonic seizure. He
received Ativan 4 mg, then Dilantin 1000 mg, and stopped seizing
at 21:01 finally. He was intubated then, and then at 21:15 had
another 5 minute seizure that aborted with another 2 mg Ativan.
He was transferred here for further care.
Past Medical History:
L cerebellar infarct and L vert occlusion- diagnosed at NYU (was
in [**Location (un) 7349**] on vacation at the time), started on Fragmin and
Coumadin,
with ASA and Plavix to "bridge" him until Coumadin therapeutic.
At [**Hospital1 **] Coumadin became therapeutic and Fragmin was
stopped,
and on [**11-1**] the Plavix was stopped as well.
HTN
borderline hyperlipidemia
Social History:
self employed insurance [**Doctor Last Name 360**], no tobacco, occasional glass of
wine. Married, lives with wife. Daughter is a SICU nurse here
at [**Hospital1 18**].
Family History:
no stroke, no MI, cousin with DM
Physical Exam:
BP- 103/65 HR- 108 RR- 16 O2Sat- 100% on AC
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: intubated, sedated, does not open eyes to voice
or sternal rub
Cranial Nerves: pupils 5 mm, NR bilaterally. + corneals
bilaterally, + gag on ETT. No EOM with Dolls.
Motor/Sensory:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Withdraws both arms on the plane of the bed with
nailbed pressure. Withdraws R leg minimally with pain, no
movement LLE with pain
Reflexes:
Trace throughout.
Toes mute bilaterally
Coordination, Gait: not assessed
Pertinent Results:
143 102 18
------------< 141
4.3 28 1.0
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
WBC 8.1 Hgb 15.8 Plt 288 Hct 44.1 MCV 90
N:82.9 Band:0 L:15.2 M:1.2 E:0.1 Bas:0.5
Plt-Est: Normal
PT: 13.1 PTT: 24.6 INR: 1.1
Imaging
CT, CTA Head, wet read: Acute to subacute lt pca distrib cva.
Take off of lt vert not identified and proximal portions display
several regions of marked atherosclerosis/narrowing. Distal
basilar displays abrupt cutoff with no filling of the proximal
pca's bilaterally with partial reconstit of flow from the rt mca
to the rt pca. Left pca is very attenuated. Right vert
terminates in rt pica.
Brief Hospital Course:
This is a 68 yo man with left cerebellar stroke and left
vertebral occlusion on [**2119-10-15**]. Now presented with new onset of
nausea, dizziness as well as two generalized seizures. Imaging
showed new left PCA stroke; CTA revealed occluded left vert and
clot in proximal basilar artery and distal basilar occlusion.
Patient was
started on heparin initially. He had pupils that were 5mm and
reactive to light and he had all brainstem reflexes. About [**2-18**]
hours later, he developed fixed pupils and had no left corneal
reflex. He also had decreased and decerebrate movements to
nailbed pressure. A repeat hCT and CTA showed the clot in the
proximal basilar artery and an occlusion of the most distal
basilar artery. He was taking to the angio suite. Angio showed
the occluded left vertebral artery and a hypoplastic right
vertebral artery. It was attempted to canulize the left
vertebral artery, but this is unsuccessful. Then a selective
catheter was placed into the right vertebral artery and the
patient was given 8mg of tPA into the distal basilar artery
beyond the proximal clot.
After extensive discussion with members of the patient's family
including his wife (health care proxy). His Living Will
indicated that he would not want life prolonging supportive
therapy. In view of his significant neurologic deficits his
family decided to make the patient CMO. The family requested the
[**Location (un) 511**] Organ Bank be contact[**Name (NI) **]. The patient did not exhibit
spontaneous respirations upon removal of the ventilator. He went
into asystole and expired. His organs were harvested by NEOB for
transplant in accordance with his family's wishes.
Medications on Admission:
Lisinopril 10 mg QD
Lipitor 80 mg QD- stopped [**11-3**] because of muscle pain in legs
ASA 81
Coumadin 5 mg QHS (INR therapeutic on d/c from [**Hospital1 **] on
[**11-1**]
per wife)
Atenolol 25 mg QD
MVI
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
na
Discharge Instructions:
na
Followup Instructions:
na
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"51881",
"4019"
] |
Admission Date: [**2160-6-27**] Discharge Date: [**2160-7-2**]
Date of Birth: [**2139-10-12**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Crohn's disease refractory to medical therapy.
Major Surgical or Invasive Procedure:
[**6-27**] Laparoscopic assisted ileo-cecectomy
History of Present Illness:
The patient with medically refractory Crohn disease and
recurrent obstructive episodes related to terminal ileal
disease.
Past Medical History:
Crohn's with terminal ileal disease, kidney stones
Family History:
NC
Pertinent Results:
[**2160-7-1**] 07:00AM BLOOD WBC-2.5* RBC-2.92* Hgb-9.2* Hct-26.0*
MCV-89 MCH-31.4 MCHC-35.3* RDW-16.0* Plt Ct-182
[**2160-6-30**] 06:21AM BLOOD WBC-2.4* RBC-2.84* Hgb-8.7* Hct-25.6*
MCV-90 MCH-30.6 MCHC-33.9 RDW-15.5 Plt Ct-150
[**2160-7-1**] 07:00AM BLOOD Plt Ct-182
[**2160-6-28**] 02:21PM BLOOD PT-14.1* PTT-28.9 INR(PT)-1.2*
[**2160-7-1**] 07:00AM BLOOD Glucose-91 UreaN-5* Creat-1.2* Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
[**2160-6-30**] 06:21AM BLOOD Cortsol-12.3
.
[**6-28**] CTA chest:
IMPRESSION:
1. No pulmonary embolism.
2. Bibasilar consolidations with collapse of the right lower
lobe and atelectasis at portions of the left lower lobe and
right middle lobe raising the possibility of aspiration.
3. Small amount of free air under the diaphragms.
4. Fatty infiltration of liver.
.
[**6-28**] CXR:
IMPRESSION: Free intraperitoneal air. Postop day 1, history
obtained from other imaging studies. That vital information was
not provided by the referring physician for this examination.
There is bibasilar atelectasis, right worse than left.
.
[**6-29**] CXR: IMPRESSION: Right basilar opacity, likely atelectasis.
Resolution of previously noted free intraperitoneal air.
.
[**6-30**] CXR: Opacification at the base of the right hemithorax with
relatively horizontal sharp upper border could be either middle
lobe atelectasis or posteriorly layering pleural effusion, not
appreciably changed since [**6-29**]. Small region of atelectasis in
the left base has improved since [**6-29**]. Upper lungs are clear.
Heart size normal. No pneumothorax.
Brief Hospital Course:
This patient was admitted on [**6-27**] for her procedure, which was
the same day of admission. She was prepared and consented as per
standard. There were no intra-op or post-op complications.
.
Overnight of POD0, her pain was controlled with a PCA and her
abdominal exam was benign. On POD1, the patient was noted to
have oxygen saturations in the 88-89% range on room air, with
minimal improvement with nasal cannula. She was put on a
non-rebreather and worked up for a PE which was negative. When
taken off the non rebreather, her 02 sats remained low, in the
70% reason, without any obvious reason. As a result, she was
transfered to the ICU, and seen by the Pulmonary service, who
thought this may be secondary to severe atelectasis or
aspiration pneumonia. She was started on broad-spectrum
antibiotics, and remained on oxygen; she was unable to tolerate
intermittent CPAP. She remained NPO.
.
On POD2, the patient remained in the ICU. She was seen by
physical therapy and was weaned from a non-rebreather to 4L of
oxygen via nasal cannula. She remained NPO and had some nausea,
which was relieved with Zofran. She remained NPO.
.
On POD3 ([**6-30**]), she was transfered to the floor. Her oxygen
saturations were 97% on room air. She otherwise was well. She
remained NPO overnight.
.
On POD4 ([**7-1**]), the patient's diet was advanced from sips to
clears; her pain control was adequate and she had no nausea or
vomiting. Her respiratory status was stable. She was ambulating
without difficulty and her abdominal exam was bengin.
.
The patient was discharged on POD5, in a stable condition. On
the morning of POD5, she did have one episode of vomiting, which
was non-biliosu and secondary to a headache. She was otherwise
well and without complaints; she was tolerating a regular diet
and her oxygen saturations were 98-99% on room air. No other
issues.
Medications on Admission:
6-MP, birth control
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed: Take with food.
Disp:*40 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Hold for loose stool.
Disp:*60 Capsule(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Crohns disease
Post-operative atelectasis, fever, and hypoxia
Discharge Condition:
Good
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain not relieved by pain medication
*Fever > 101.5
*Nausea, vomiting, diarrhea, or abdominal distention
*Inability to pass gas, stool, or urine
*If incision develops redness or drainage
*Shortness of breath, wheezing, or chest pain
*Any other symptoms concerning to you
You may shower and wash incision with soap and water, pat dry
No swimming or tub baths for 2 weeks
Avoid lifting more than 10lbs and abdominal stretching for 4
weeks
No driving or alcohol use while taking pain medication
You may also take Tylenol every 4-6 hours as needed for pain,
maximum of 3,000mg in 24 hours
Be sure to eat small frequent meals and drink fluids throughout
the day
Please continue to use the incentive spirometer 10 times every
hour during the day, deep breathing, coughing and walking
throughout the day
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks, call [**Telephone/Fax (1) 9**]
for an appointment
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2160-7-21**]
10:30
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 4 weeks for a repeat chest
X-ray and physical assessment, call [**Telephone/Fax (1) 3183**] for an
appointment
Completed by:[**2160-7-2**]
|
[
"5180"
] |
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