CODES
stringlengths 3
287
| SUBJECT_ID
int64 3
100k
| HADM_ID
int64 100k
200k
| TEXT
stringlengths 54
55.7k
|
---|---|---|---|
0389,78559,5849,4275,41071,4280,6826,4254,2639 | 3 | 145,834 | Admission Date: [**2101-10-20**] Discharge Date: [**2101-10-31**]
Date of Birth: [**2025-4-11**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Admitted from rehabilitation for
hypotension (systolic blood pressure to the 70s) and
decreased urine output.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male who had been hospitalized at the [**Hospital1 190**] from [**10-11**] through [**10-19**] of [**2101**]
after undergoing a left femoral-AT bypass graft and was
subsequently discharged to a rehabilitation facility.
On [**2101-10-20**], he presented again to the [**Hospital1 346**] after being found to have a systolic
blood pressure in the 70s and no urine output for 17 hours.
A Foley catheter placed at the rehabilitation facility
yielded 100 cc of murky/brown urine. There may also have
been purulent discharge at the penile meatus at this time.
On presentation to the Emergency Department, the patient was
without subjective complaints. In the Emergency Department,
he was found to have systolic blood pressure of 85. He was
given 6 liters of intravenous fluids and transiently started
on dopamine for a systolic blood pressure in the 80.s
PAST MEDICAL HISTORY:
1. Coronary artery disease with diffuse 3-vessel disease;
right-dominant, status post proximal left circumflex stent in
[**2101-7-9**] with occlusion of the distal left circumflex;
status post right coronary artery stent on [**2101-8-26**] (no
percutaneous coronary intervention to 99% diagonal left
circumflex, 80% small proximal left anterior descending
artery, or 80% small distal left anterior descending artery).
2. Congestive heart failure (with an ejection fraction
of 15% to 20%).
3. Type 2 diabetes with neuropathy.
4. Hypertension.
5. Diverticulosis (found on colonoscopy in [**2101-7-9**]).
6. Alzheimer's dementia.
7. History of gastrointestinal bleed (while the patient was
taking eptifibatide).
8. Cardiac risk factors (with a baseline creatinine
of 1.4 to 1.6).
9. Hypercholesterolemia.
10. History of methicillin-resistant Staphylococcus aureus
and Pseudomonas growth in wound cultures.
11. Severe peripheral vascular disease; status post left
femoral-AT bypass graft on [**2101-10-11**].
12. Chronic nonhealing foot ulcers.
13. Recent right pedal cellulitis.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Vancomycin 1 g intravenously q.24h. for a level of less
than 15 (started on [**2101-10-4**]).
2. Levofloxacin 250 mg p.o. q.d. (started on [**2101-10-4**]).
3. Metronidazole 500 mg p.o. q.8h. (started on [**2101-10-4**]).
4. Heparin 5000 units subcutaneous b.i.d.
5. Simvastatin 40 mg p.o. q.d.
6. Lisinopril 5 mg p.o. q.d.
7. Furosemide 40 mg p.o. q.d.
8. Vitamin E 400 IU p.o. q.d.
9. Atenolol 25 mg p.o. q.d.
10. Pantoprazole 40 mg p.o. q.d.
11. Ascorbic acid 500 mg p.o. b.i.d.
12. NPH 17 units b.i.d.
13. Regular insulin sliding-scale.
14. Bisacodyl 10 mg p.o./p.r. as needed.
15. Docusate 100 mg p.o. b.i.d.
16. Percocet 5/325 mg one tablet p.o. q.4-6h. as needed for
pain.
17. Aspirin 81 mg p.o. q.d.
18. Metoprolol 75 mg p.o. b.i.d.
SOCIAL HISTORY: The patient is retired and had been living
at home with his wife prior to his admission to the hospital
on [**2101-10-11**]; he had been living at [**Hospital3 1761**] for the day prior to admission. He is a
social drinker and has a 40-pack-year smoking history;
although, he quit smoking 20 years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed temperature was 96.1 degrees Fahrenheit,
heart rate was 83, blood pressure was 124/42 (following
administration of 3 liters of normal saline), respiratory
was 24, and his oxygen saturation was 100% on 2 liters nasal
cannula. His heart had a regular rate and rhythm. There
were normal first and second heart sounds. There was a 2/6
systolic ejection murmur, and there were no rubs or gallops.
His lungs were clear to auscultation bilaterally. His
abdomen was soft, nontender, and nondistended, and there were
hypoactive bowel sounds. He had a palpable bypass graft
pulse, [**Hospital3 17394**] dorsalis pedis and posterior tibialis
pulses bilaterally; and his surgical incision was clean, dry,
and intact. Please note that the above examination was done
by the Vascular Surgery team, which was the team that was
initially planning to admit the patient to the hospital.
PERTINENT LABORATORY DATA ON PRESENTATION: On initial
laboratory evaluation the patient had a white blood cell
count of 12.7, hematocrit was 30.2, and platelets
were 282,000. His PT was 13.5, PTT was 30.7, and INR
was 1.3. His serum chemistries revealed sodium was 136,
potassium was 5.4, chloride was 99, bicarbonate was 25, blood
urea nitrogen was 53, creatinine was 3.2, and blood glucose
was 91. His calcium was 8.2, magnesium was 2.4, and
phosphate was 4.8. Blood cultures drawn on admission were
pending, but ultimately negative. A urine culture taken on
admission was initially pending, but ultimately grew out
yeast. A sputum culture taken on admission was also
initially pending, but ultimately also grew out yeast.
RADIOLOGY/IMAGING: His admission chest x-ray demonstrated
stable prominence of the right main pulmonary artery; no
focal areas of consolidation; overall stable appearance of
the chest compared with a [**2101-10-15**] study. No
radiographic evidence of congestive heart failure or
pneumonia.
His admission electrocardiogram demonstrated a sinus rhythm,
nonspecific inferior/lateral T wave changes, low QRS voltages
in the limb leads, and T wave changes in V5 and V6 when
compared with an electrocardiogram dated [**2101-10-12**].
An initial abdominal CT was a limited noncontrast examination
that demonstrated diffuse vascular calcifications. No
evidence of an abdominal aortic aneurysm or free fluid,
incompletely imaged coronary artery calcification, a simple
left renal cyst, sigmoid diverticulosis, and an enlarged and
partially calcified prostate gland.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: The patient was initially admitted to
the Vascular Intensive Care Unit with hypotension, decreased
urine output, and acute renal failure; most likely secondary
to a presumed gram-negative urosepsis (although there were
never any positive culture data to confirm this diagnosis).
While boarding in the Medical Intensive Care Unit on the
night of admission, the patient had a sudden
cardiorespiratory arrest. He was resuscitated with
epinephrine, lidocaine, and direct current cardioversion
times four. He was also intubate for airway protection.
Following these measures, the patient returned to a sinus
rhythm with a systolic blood pressure of approximately 100;
the total time elapsed from the beginning of the arrest to
the return of a pulse was approximately 16 minutes. He
subsequently required double pressors to maintain his blood
pressure.
An echocardiogram performed at the bedside demonstrated a
trivial pericardial effusion and a left ventricular ejection
fraction of 20% to 25% in the setting of tachycardia and a
hyperdynamic right ventricle; suggesting elevated right-sided
filling pressures. Although the definitive etiology of this
arrest remained unknown, the most likely trigger was a
non-Q-wave myocardial infarction, as his troponin values were
elevated to greater than 50 following his arrest.
A repeat echocardiogram done on [**2101-10-21**]
demonstrated mild left atrial dilation, an ejection fraction
of 15% to 20%, resting regional wall motion abnormalities
including inferior, mid, and apical left ventricular
akinesis, depressed right ventricular systolic function, and
moderate mitral regurgitation. Compared with the prior study
of [**2101-10-20**]; the left ventricular function was
unchanged. There was moderate mitral regurgitation, and the
right ventricular function appeared worse.
On [**2101-10-21**], the patient was loaded with amiodarone
and was subsequently started on oral amiodarone. The
following day, he was started on heparin intravenously given
his elevated serum troponin to greater than 50; this
medication was continued for 72 hours. Given his elevated
troponins and non-Q-wave myocardial infarction, the patient
was a candidate for cardiac catheterization.
After discussions between the Medical Intensive Care Unit
team and the patient's family, however, the decision was made
to not pursue further invasive procedures given that the
patient had been made do not resuscitate/do not intubate
following the resuscitation mentioned above, and his family
no longer wished for aggressive resuscitating measures.
By [**2101-10-23**], he was off pressors and he was
restarted on a beta blocker and ACE inhibitor at low doses.
On the evening of [**2101-10-25**], the patient complained
of substernal chest pain that was relieved by NPG SL and
morphine. He also had ST segment depressions in V2 and V3
that reverted to baseline after the resolution of his pain.
Therefore, the patient was again started on heparin;
although, this was discontinued on [**2101-10-26**] when
the patient ruled out for a myocardial infarction by cardiac
enzymes. He again had substernal chest pain on [**2101-10-27**]; although, he had no electrocardiogram changes, and he
again ruled out for a myocardial infarction by cardiac
enzymes.
By hospital day four, the patient began to develop evidence
of congestive heart failure given his aggressive fluid
resuscitation, and gentle diuresis with furosemide was begun.
By the time of his transfer to the General Medicine Service
on [**2101-10-26**], the patient was still significantly
volume overloaded following his aggressive fluid
resuscitation in the Medical Intensive Care Unit. Therefore,
he was continued on the program of gentle diuresis given that
he was having signs and symptoms of right-sided congestive
heart failure. He achieved adequate diuresis by the time of
his discharge to rehabilitation, as his oxygen saturation was
greater than 95% on 2 liters nasal cannula.
2. INFECTIOUS DISEASE/SEPSIS: The patient was started on
gentamicin and piperacillin/tazobactam in addition to the
levofloxacin, metronidazole, and vancomycin he was already
taking for right lower extremity cellulitis prior to
admission for empiric coverage of a presumed gram-negative
urosepsis, and he was aggressively hydrated with intravenous
fluids.
On [**2101-10-21**], his levofloxacin and metronidazole was
discontinued, and he was started on fluconazole given the
growth of yeast on urine culture. He was taken off of
gentamicin on hospital day three, and his fluconazole was
discontinued on hospital day five (as per the Infectious
Disease Service). He was taken off of vancomycin on
[**2101-10-28**], and his piperacillin/tazobactam was
discontinued on [**2101-10-29**].
Despite the presumption of a gram-negative urosepsis
precipitating this admission, the patient did not have any
positive blood or urine cultures aside from the growth of
yeast in two urine cultures noted above. He remained
afebrile both before and after discontinuation of his
antibiotics, and he was found to be Clostridium difficile
negative on [**2101-10-28**].
3. PULMONARY: As noted above, the patient was intubated and
he was extubated on [**2101-10-24**]. He subsequently
developed wheezing and mild hypoxia; most likely secondary to
cardiac asthma and fluid overload in the setting of his
aggressive fluid resuscitation. He was gently diuresed
toward the end of his hospitalization, and by the time of his
he was maintaining an oxygen saturation of greater than 95%
on 2 liters nasal cannula, intermittent ipratropium
nebulizers, and chest physical therapy for clearance of his
respiratory secretions.
4. RENAL: The patient presented with acute renal failure
and prerenal azotemia that rapidly resolved following fluid
resuscitation. By the time of discharge, his serum
creatinine was stable and at his preadmission baseline.
5. NUTRITION: The patient was found to be profoundly
malnourished with a serum albumin of 1.8 on admission. Once
he was extubated and taking orals, he performed poorly on a
modified barium swallowing study and was started on a thin
liquid, ground-solid diet with whole medication tablets,
small bites and sips, upright posture with meals, and
aspiration precautions. He was also given ProMod shakes with
and between meals for nutritional supplementation of his
heart-healthy/diabetic diet.
6. VASCULAR: The patient's operative incisions and foot
ulcers continued to heal throughout this admission. He was
started on an multivitamin, vitamin C, and zinc for improved
wound healing.
7. HEMATOLOGY: The patient was transfused one unit of
packed red blood cells on [**2101-10-27**] to maintain a
hematocrit of greater than 30 given his history of severe
coronary artery disease. His hematocrit subsequently
remained stable.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Cardiorespiratory arrest.
2. Non-Q-wave myocardial infarction.
3. Acute renal failure.
4. Coronary artery disease with diffuse 3-vessel disease;
right-dominant, status post proximal left circumflex stent in
[**2101-7-9**] with occlusion of distal left circumflex; status
post right coronary artery stent on [**2101-10-27**] (no
percutaneous coronary intervention to 99%, distal left
circumflex, 80% small proximal left anterior descending
artery, 80% small distal left anterior descending artery).
5. Congestive heart failure (with an ejection fraction
of 15% to 20%).
6. Type 2 diabetes with neuropathy.
7. Hypertension.
8. Diverticulosis (found on colonoscopy in [**2101-7-9**]).
9. Alzheimer's dementia.
10. History of gastrointestinal bleed (while the patient was
taking eptifibatide).
11. Cardiac risk factors (with a baseline creatinine
of 1.4 to 1.6).
12. History of methicillin-resistant Staphylococcus aureus
and Pseudomonas growth in wound cultures.
13. Severe peripheral vascular disease; status post left
femoral-AT bypass graft on [**2101-10-11**].
14. Chronic nonhealing foot ulcers.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 400 mg p.o. b.i.d. (through [**2101-11-2**]), then 400 mg p.o. q.d. (times one week), then 200 mg
p.o. q.d.
2. Metoprolol 50 mg p.o. b.i.d.
3. Captopril 6.25 mg p.o. t.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Pantoprazole 40 mg p.o. q.d.
6. Heparin 5000 units subcutaneously b.i.d.
7. Multivitamin one tablet p.o. q.d.
8. Zinc sulfate 220 mg p.o. q.d.
9. Vitamin C 500 mg p.o. q.d.
10. Ipratropium nebulizers q.4-6h. as needed (for wheezing).
11. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed
(for pain).
12. Miconazole 2% powder to groin b.i.d.
13. Santyl lotion to heels b.i.d.
14. Regular insulin sliding-scale.
CODE STATUS: Do not resuscitate/do not intubate.
NOTE: If applicable, an addendum to this Discharge Summary
will be dictated to include follow-up appointments as well as
any changes to the medication list noted above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D. [**MD Number(1) 1605**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2101-10-31**] 01:07
T: [**2101-11-5**] 03:44
JOB#: [**Job Number **]
|
04111,2763,7994,1363,042,5715,V090,E9317,7907 | 4 | 185,777 | Admission Date: [**2191-3-16**] Discharge Date: [**2191-3-23**]
Date of Birth: [**2143-5-12**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath and fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
female with a history of human immunodeficiency virus (last
CD4 count 42 and a viral load of 65,000), cirrhosis,
diabetes, and hypothyroidism presented with eight days of
fevers to 104, chills, shortness of breath, cough, dyspnea on
exertion, and fatigue.
The patient states she has become progressively dyspneic to
the point where she is short of breath with speaking. She
has also had night sweats for the past two days and whitish
sputum. She complains of myalgias. No recent ill contacts.
[**Name (NI) **] known tuberculosis exposure.
In the Emergency Department, the patient was initially 96% on
room air, with a respiratory rate of 20, and a heart rate of
117. A chest x-ray showed diffuse interstitial opacities.
She received 3 liters of normal saline, clindamycin, and
primaquine for likely Pneumocystis carinii pneumonia. She
spiked a temperature to 102.1 and became progressively
dyspneic with her respiratory rate increasing to 40, and her
oxygen saturations dropping to 89% on room air. She was
placed on 6 liters by nasal cannula, and an arterial blood
gas showed 7.47/28/74. The patient was given prednisone and
aztreonam for possible cholangitis.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus diagnosed in [**2175**]; acquired
from her ex-husband (in [**2190-10-13**], CD4 count was 42 and
viral load was 65,000).
2. Cirrhosis; status post liver biopsy in [**2190-10-13**]
consistent with cytosis and sinusoidal fibrosis consistent
with toxic metabolic disease possibly from highly active
antiretroviral therapy.
3. Insulin-dependent diabetes mellitus since [**2190-10-13**].
4. Hypothyroidism.
5. Esophagogastroduodenoscopy in [**2190-11-13**] was normal
with no varices.
MEDICATIONS ON ADMISSION:
1. Viread 300 mg once per day.
2. Epivir 150 mg twice per day.
3. Acyclovir 400 mg twice per day.
4. Diflucan 200 mg twice per day.
5. Videx 400 mg once per day.
6. Zantac 150 mg once per day.
7. Klonopin as needed.
8. Lantus 6 units subcutaneously in the morning; no
sliding-scale.
ALLERGIES: PENICILLIN and SULFA DRUGS (cause a rash).
DAPSONE (causes nausea).
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient lives at home with her son. She
quit tobacco five years ago. No alcohol. No illicit drugs.
No intravenous drug use. No transfusions.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient had a temperature of 102.1, her heart rate was 118,
her respiratory rate was 40, her blood pressure was 117/57,
and her oxygen saturation was 89% on room air and 94% on 6
liters. In general, she was ill and toxic appearing. She
was unable to speak in complete sentences. She was
cachectic. Head, eyes, ears, nose, and throat examination
revealed anicteric. The mucous membranes were dry. The
extraocular movements were intact. No thrush. The neck was
supple. There was no jugular venous distention. Thorax
revealed bilateral basilar rales. No wheezes.
Cardiovascular examination revealed tachycardia. There were
no murmurs. The abdomen revealed mild diffuse tenderness to
percussion, hepatomegaly 6 cm below the costal margin, no
spleen palpated, positive bowel sounds. There was no rebound
or guarding. Extremities revealed no lower extremity edema.
Pulses were 2+. Neurologic examination revealed cranial
nerves II through XII were intact. Strength was [**5-18**] in all
extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient had
a white blood cell count of 9.7 (with 89% neutrophils and 7%
lymphocytes), and her hematocrit was 34.2. Chemistries were
within normal limits with a blood urea nitrogen of 9 and a
creatinine of 0.5. Her aspartate aminotransferase was 69,
her alanine-aminotransferase was 28, her alkaline phosphatase
was 994, and her total bilirubin was 2.2, and her direct
bilirubin was 1.5. Her lactate was 2.1. Urinalysis was
negative for leukocyte esterase or nitrites. It was positive
for 30 protein.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed
sinus tachycardia; unchanged from [**2187**].
A chest x-ray revealed bilateral interstitial opacities in
the left mid lung; consistent with Pneumocystis carinii
pneumonia or viral pneumonia.
A right upper quadrant ultrasound revealed no cholelithiasis.
No gallbladder wall edema. Common bile duct was 4 mm.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: From the Emergency Room, the patient
was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit secondary
to respiratory distress. Symptoms consistent with a
respectively alkalosis. A chest x-ray was consistent with
possible Pneumocystis pneumonia versus a viral pneumonia.
Given her allergies to both sulfa and dapsone, she was
started on empiric Pneumocystis carinii pneumonia coverage
with primaquine and clindamycin. She was also started on
prednisone given her low oxygen saturations, and given her
low PAO2.
In the [**Hospital Ward Name 332**] Intensive Care Unit, she requested noninvasive
positive pressure ventilation. A bronchoscopy was performed
with 1+ gram-positive cocci in pairs and positive
Pneumocystis carinii pneumonia. Acid-fast bacillus smears
were negative.
The patient's respiratory status continued to improve on her
medication regimen. She was weaned off of the noninvasive
positive pressure ventilation and eventually was able to
saturate 98% on room air. She was to be continued on
primaquine and clindamycin for a total of a 21-day course of
antibiotics as well as a 21-day steroid taper.
2. BACTEREMIA ISSUES: The patient's blood cultures from
admission from [**3-15**] and [**3-16**] grew out
methicillin-sensitive Staphylococcus aureus ([**4-19**] blood
cultures). At that time, the patient was started on
vancomycin therapy with quick clearance of her blood
cultures.
A transthoracic echocardiogram was performed to rule out
endocarditis, and it did not show any valvular abnormalities;
although, the tricuspid valve was obscured by her
peripherally inserted central catheter line. The subsequent
surveillance blood cultures from [**3-17**] on were negative,
and the patient was to be continued on vancomycin
intravenously for a 3-week course. After that time, blood
cultures should be repeated for surveillance. The patient
remained afebrile during the remainder of her hospital stay.
3. CIRRHOSIS ISSUES: The patient has Child A class
cirrhosis from a liver biopsy done in [**2190-10-13**]. Her
cirrhosis was thought to be secondary to her highly active
antiretroviral therapy. She was to follow up with Dr. [**Last Name (STitle) 497**]
in [**2191-4-14**] for a visit.
A right upper quadrant ultrasound was performed as the
patient's alanine-aminotransferase was slightly elevated and
was within normal limits.
4. HUMAN IMMUNODEFICIENCY VIRUS ISSUES: The patient was
restarted on her highly active antiretroviral therapy regimen
on hospital day four. The patient tolerated these
medications without any problems. She was also continued on
acyclovir and fluconazole for prophylaxis. The patient was
to follow up with Dr. [**Last Name (STitle) 20066**] in clinic over the next two
weeks.
5. DIABETES MELLITUS ISSUES: The patient was placed on
original regimen of Lantus without a sliding-scale secondary
to her steroid taper. Her blood sugars remained elevated
while in house; ranging from the 200s to the 400s. Her
Lantus was increased to 12 units subcutaneously in the
morning, and her sliding-scale was increased as well with
improved blood sugars. She was to be discharged on 12 units
of Lantus in the morning with a strict sliding-scale for the
next three days until her prednisone is tapered; at which
time her Lantus will be decreased to 7 units in the morning,
and her sliding-scale will be decreased as well.
6. HYPOTHYROIDISM ISSUES: The patient was continued on her
Levoxyl.
7. ACCESS ISSUES: A peripherally inserted central catheter
line was placed on [**2191-3-19**] for intravenous antibiotics.
It was found to be in the right atrium on chest x-ray and was
pulled back 6 cm with a repeat chest x-ray location in the
superior vena cava. She will need the peripherally inserted
central catheter line for 14 more days as she finishes her
course of intravenous vancomycin.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**Last Name (STitle) 497**] for cirrhosis and with Dr.
[**Last Name (STitle) 20066**] for her human immunodeficiency virus. She was to
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**] next
Friday for primary care.
MEDICATIONS ON DISCHARGE:
1. Prednisone 40 mg once per day times three days; then 20
mg once per day times 11 days.
2. Acyclovir 200 mg by mouth twice per day.
3. Fluconazole 200 mg by mouth twice per day.
4. Primaquine 26.3 two tablets by mouth every day (times 14
days).
5. Levoxyl 25 mcg by mouth once per day.
6. Tenofovir disoproxil fumarate 300 mg by mouth once per
day.
7. Lamivudine 300 mg twice per day.
8. Didanosine 400 mg by mouth once per day.
9. Lantus 12 units subcutaneously in the morning times
three days; and then 7 units subcutaneously in the morning.
10. Regular insulin sliding-scale as directed (per
sliding-scale).
11. Clindamycin 300 mg by mouth four times per day (times 14
days).
12. Vancomycin 750 mg intravenously twice per day (times 14
days).
13. Codeine/guaifenesin syrup 5 cc to 10 cc by mouth q.6h.
as needed.
14. Klonopin 0.75 mg by mouth in the morning and 0.5 mg by
mouth at hour of sleep.
15. Multivitamin one tablet by mouth once per day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 3476**]
MEDQUIST36
D: [**2191-3-23**] 14:55
T: [**2191-3-25**] 08:50
JOB#: [**Job Number 20067**]
|
2766,4440,40391,2767,2859,2753,V1582,9972 | 6 | 107,064 | Admission Date: [**2175-5-30**] Discharge Date: [**2175-6-15**]
Date of Birth: Sex: F
Service:
ADMISSION DIAGNOSIS: End stage renal disease, admitted for
transplant surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old
woman with end stage renal disease, secondary to malignant
hypertension. She was started on dialysis in [**2174-2-7**]. She currently was on peritoneal dialysis and appears
to be doing well. She has a history of gastric angiectasia
which she requires endoscopy. She was admitted on [**2175-5-30**] for
a scheduled living donor kidney transplant by her son, who is
the donor. She does have a donor specific antibody (B-51)
and will have a final T & B cell class match prior to
transplantation.
PAST MEDICAL HISTORY: End stage renal disease, secondary to
malignant hypertension on dialysis. History of anemia
following gastric angiectasia. She has no known history for
coronary artery disease for diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS: Unknown.
SOCIAL HISTORY: Married, lives with her husband. She has a
history of a half pack of cigarettes per day for 20 years.
Occasional alcohol.
PHYSICAL EXAMINATION: The patient was afebrile. Vital signs
were stable. Blood pressure was 124/58; heart rate 76; weight
160 pounds. Abdomen soft and nontender. She has a peritoneal
dialysis catheter in the right lower quadrant. She has good
femoral pulses bilaterally. Mild pedal edema.
HOSPITAL COURSE: On [**2175-5-30**], the patient went to the
operating room for living donor kidney transplant, performed
by Dr. [**Last Name (STitle) **] and assisting by Dr. [**Last Name (STitle) **]. Please see details
of this surgery in operating room note. Also during her
operating room time, the patient also had a right iliac
artery thrombosis. It was noted that at the end of the
completion of the procedure, that she had an ischemic
appearing right foot and absence of a right femoral pulse. In
the operation, there was some difficulty with arterial
anastomosis, renal artery to the left iliac artery and Dr.
[**Last Name (STitle) **] came to assist Dr. [**Last Name (STitle) **]. Again, please see
details of that operation in the operative report.
Postoperatively, the patient went to the Intensive Care Unit.
The patient had an A line, a central line, Foley. She was
placed on a heparin drip to keep PTT between 45 and 50. The
patient's dressing was clean, dry and intact. The patient had
2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains in place. Good femoral pulse and good
dorsalis pedis pulse. These pulses were palpable. The
patient was making good urine output postoperatively. Renal
was consulted and made recommendations. Postoperatively, the
patient had a renal ultrasound demonstrating an unremarkable
renal transplant ultrasound with normal size and appearance
of the transplanted kidney and normal arterial wave forms and
resistive disease, ranging from 0.63 to 0.75 throughout.
On postoperative day number one, the patient had another
ultrasound secondary to her hematocrit decreasing and they
wanted to rule out hematoma. The ultrasound demonstrated that
there was no hematoma seen adjacent to the transplanted
kidney. The transplanted kidney is minimally changed from
yesterday which was on [**2175-5-30**] with a small amount of pelvic
ectasis. Relatively unchanged resistive indices. The
patient did get multiple transfusions for her low hematocrit.
Her heparin was discontinued on [**2175-6-1**]. The patient received
1/2 cc per cc of replacement and on [**6-1**], Tacrolimus was
started. On [**2175-6-2**], the patient had some complaint of right
foot numbness. Lower extremity ultrasound was obtained to
rule out deep venous thrombosis and this showed no evidence
of right lower extremity deep venous thrombosis. On [**2175-6-2**],
WBC was 2.9, hematocrit of 35.2. Also on [**6-2**], PT was 13.5,
PTT was 36.7, INR of 1.2. Sodium that day was 129 and 4.4,
100 BUN, creatinine of 69 and 6.2 with a glucose of 96.
Vascular surgery continued to see the patient. It was
decided that hematocrit was stable, that heparin could be
continued. The patient was restarted on heparin. The patient
still complained of right foot numbness but it was about the
same and not worse. She was continued on all of her
immunosuppressive medications, including Tacrolimus, Valcyte,
Cellcept, Bactrim, Solu-Medrol. The patient was transitioned
from heparin to Coumadin. The patient was transferred to the
floor, continued to make excellent urine output. The patient
had another ultrasound on [**2175-6-6**] because there was blood in
her [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain and with the decreasing hematocrit.
Ultrasound demonstrated normal arterial and venous color,
blood flow and wave form with normal residual indices. 7.6
by 3.5 cm fluid collection, likely simply fluid, anterior to
the contrast. Focal area of heterogeneity within the lateral
aspect of the mid pole, probably which demonstrates normal
blood flow and may represent artifact; however, attention to
this area on a follow up scan is recommended to document
interval change or resolution.
On [**2175-6-9**], the patient's right lower extremity was swollen.
The patient complained of right hip and thigh pain, pitting
edema of right lower extremity greater than left lower
extremity so an ultrasound was performed which included the
right iliac artery. This demonstrated acute deep venous
thrombosis within the right common femoral and superficial
femoral veins which had developed since [**2175-6-2**]. There
is a right groin hematoma which was unchanged. The patient
continued to be anticoagulated for DVT. One drain was
eventually removed, continued on [**2175-6-12**] with drain output of
170, afebrile, vital signs stable. She went home with
services on the following medications: Valcyte 450 mg q.
day, Bactrim SS 1 tab q. day, Protonix 40 mg q. day, Nystatin
5 ml suspension, 5 ml four times a day, Colace 100 mg twice a
day, Movlapine 10 mg q. day, Percocet 22 tabs q. day,
Lopressor 100 mg twice a day, MMF 500 mg q.o.d. Coumadin 2 mg
q. day. This should be monitored to keep the INR between 2
and 3. Reglan 10 mg four times a day before meals and at
bedtime. Tacrolimus 10 mg p.o. twice a day. Potassium sodium
phosphate, one packet q. day and Compazine 10 mg q. 6 hours
prn. The patient has a follow up appointment with Dr.
[**Last Name (STitle) **], please call [**Telephone/Fax (1) 673**] for an appointment. The
patient needs to change dressings on her wound twice a day
located on her groin, place a dry gauze between the wound and
her skin. No heavy lifting of greater than 10 pounds for the
first 6 weeks after surgery.
DIAGNOSES: End stage renal disease, status post renal
transplant.
Arterial thrombosis.
Deep venous thrombosis.
Resolving hypertension.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 55494**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2175-9-15**] 16:39:51
T: [**2175-9-15**] 17:14:46
Job#: [**Job Number 55495**]
|
431,5070,4280,5849,2765,4019 | 9 | 150,750 | Admission Date: [**2149-11-9**] Discharge Date: [**2149-11-13**]
Date of Birth: [**2108-1-26**] Sex: M
Service: NEUROLOGY
CHIEF COMPLAINT: Weakness, inability to talk.
HISTORY OF THE PRESENT ILLNESS: This is a 41-year-old
African-American male with a history of hypertension who was
in his usual state of health until about 10:25 a.m. on the
morning of admission. He had gone to use the restroom and a
few minutes later his family found him slumped onto the
floor, apparently unable to talk and with weakness in his
right arm and leg. EMS was called and he was brought into
the Emergency Department at [**Hospital1 18**].
The patient has not had strokes or previous similar symptoms.
He has a history of hypertension but no history of cardiac
symptoms. The patient was unable to talk for examination and
no family members were present at the bedside and were not at
home (apparently they were on the way to the Emergency Room).
The history was obtained by EMS.
PAST MEDICAL HISTORY: Hypertension.
ADMISSION MEDICATIONS: The patient was on no medications
upon admission.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient lives [**Location (un) 6409**].
PHYSICAL EXAMINATION ON ADMISSION: During the five minute
examination, the patient became progressively less responsive
and then vomited requiring intubation and paralytics during
the examination. Vital signs: Blood pressure 229/137, heart
rate 85, respiratory rate 20, temperature 98.8. General:
This was a well-developed African-American male. HEENT: The
neck was supple without lymphadenopathy or thyromegaly.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs,
or gallops noted. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended with no hepatomegaly.
Extremities: No clubbing, cyanosis or edema noted.
Neurologic: On the mental status examination, the patient
was alert but nonverbal. Language was aphasic but can
comprehend one-step commands. There was no evidence of
neglect. The patient can follow one-step commands. On the
cranial nerve examination, his optic disk margins were sharp.
His extraocular eye movements were intact. His pupils were
equal and reactive to light. His face was symmetrical at
rest. Motor: He had normal bulk and tone with no tremors.
His power was 0/5 in the right arm and leg. His left arm and
leg was apparently [**5-5**]. Sensory: He was reactive to noxious
stimuli in all four extremities. His reflexes were minimal
throughout. His toes were mute bilaterally. Coordination
and gait examination was not tested.
LABORATORY/RADIOLOGIC DATA: White count 7.5, hematocrit 45,
platelets 258,000. PT 12.7, PTT 21.7, INR 1.1.
The EKG was normal sinus rhythm at 99 with normal axis and
intervals. LVH was noted. There were T wave inversions in
I, II, III, aVL, V1 through V3.
Serum and urine toxicology was negative. ESR was 18. The
urinalysis was negative. CT scan of the head showed 55 by 55
by 21 mm left putaminal bleed with a 5 mm midline shift to
the right.
Chest x-ray showed cardiomegaly with CHF.
HOSPITAL COURSE: 1. NEUROLOGIC: Left putaminal bleed
secondary to presumed hypertension. The patient's blood
pressure was initially controlled with a Nipride drip to keep
the cephalic pressure between 130-160. The Nipride drip was
then weaned as labetalol IV was added along with a
nicardipine drip. The patient was also given Dilantin load
followed by a maintenance dose of 400 mg q.d. His level has
been therapeutic around 20. Considerations for a CTA and
angiogram for possible AVM or aneurysm were considered but
the patient's renal function and health status did not allow
such studies to be done at the current time.
Repeated noncontrast CT of the head revealed no increase in
the bleeding but showed subsequently increases in cerebral
edema with some pressure onto the brain stem. The patient's
neurological examination did deteriorate to the point that he
only had reactive pupils that were equal and intact corneal
reflexes. In addition, he had a gag reflex. However, he
began to not move any extremities and not respond to any
noxious stimuli in the four extremities.
By 4:00 p.m. on [**2149-11-13**], his neurological condition
deteriorated to the point that his pupils were dilated and
nonreactive. He lost gag and corneal reflex. Calorics were
done at this time which revealed no response. Neurosurgery
was reconsulted for a question of craniotomy but they felt
that the patient would not be a candidate for the surgery in
that it would not help him. Mannitol was then started along
with hyperventilation to keep the PC02 below 30 in an attempt
to decrease the cerebral edema.
Despite clinical examination that the patient is clinically
brain dead, the family wishes to continue aggressive
treatment. The family requested that the patient be
transferred to the [**Hospital6 1129**]. However,
Dr. [**Last Name (STitle) 54029**] at the [**Hospital3 **] Stroke Service said
that the patient would not be accepted at the [**Hospital3 **] given that there would be no other intervention that
would be done differently at [**Hospital3 **].
2. CARDIOVASCULAR: As mentioned above, the patient was
initially started on a Nipride drip to control the blood
pressure between 130-160. However, he was slowly weaned off
the Nipride to be switched over to Cardene drip. The Cardene
drip was then weaned to allow for the addition of p.o.
Labetalol. Three serial CKs and troponins were checked and
found to be negative, thus, ruling the patient out for a
myocardial infarction.
3. PULMONARY: The patient was initially intubated when
first seen down in the Emergency Room for airway protection
since he vomited. He then showed a left lower lobe pneumonia
on the chest x-ray. He was started on levofloxacin and
Flagyl since the day of admission for aspiration pneumonia.
Vancomycin was added on day number four of hospitalization
due to sputum cultures showing Staphylococcus aureus
coagulase-positive organisms and gram-negative rods.
Susceptibilities are still pending. The patient did have one
or two episodes of desaturation secondary to breathing trials
and increased secretion in his nostrils. In an attempt to
decongest him, saline nasal spray was started.
4. RENAL: Acute renal failure secondary to dehydration.
The patient's creatinine upon admission was 1.4 and continued
to rise to 2 as he started third spacing his fluids. Urine
electrolytes were checked which showed a phena of less than 1
which is evidence of the patient being dehydrated and
prerenal. He was subsequently given IV fluids and his
creatinine improved to 1.6. A renal ultrasound was done
which showed no evidence of hydronephrosis.
5. INFECTIOUS DISEASE: Leukocytosis: Given the aspiration
pneumonia and elevated white count of 18.6, levofloxacin and
Flagyl were started on the day of admission. Blood cultures
were obtained. The first two sets showed one out of four
blood cultures that grew staphylococcus coagulase-negative.
Since this was deemed a contaminent, no further antibiotics
were given. However, on day number four of hospitalization,
his sputum culture returned showing Staphylococcus
coagulase-positive organisms so vancomycin was added. More
blood cultures were drawn but nothing has grown to date.
6. GASTROINTESTINAL: The patient was given and orogastric
tube for tube feeds. He had some high residuals so the tube
feeds were stopped. Reglan was then administered to promote
GI motility so that the tube feeds could be restarted.
7. FLUIDS, ELECTROLYTES, AND NUTRITION: Hyponatremia: The
patient's sodium slowly fell from 136 upon admission to 130
on the fourth day of hospitalization. It was felt that this
was due to salt wasting from his cerebral problems so he was
then fluid restricted. Although he has acute renal failure
secondary to dehydration and third spacing, it was felt that
he needed to be fluid restricted given that the overall
hyponatremia was more likely due to salt wasting.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2149-11-13**] 07:03
T: [**2149-11-13**] 19:46
JOB#: [**Job Number 54030**]
|
V3000,7742,76525,76515,V290 | 10 | 184,167 | Admission Date: [**2103-6-28**] Discharge Date: [**2103-7-6**]
Date of Birth: [**2103-6-28**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 48639**] is a 1,385
gram, former 30 and [**5-23**] week premature baby, born to an 18
year old, Gravida I, Para 0, now I, mother with prenatal
serologies as follows:
A positive, antibody negative, RPR nonreactive, hepatitis B
surface antigen negative; GBS unknown.
Pregnancy was complicated by PPROM on [**2103-6-23**] when the
mother was transferred from [**Name (NI) 1474**] Hospital to [**Hospital1 346**]. Mother received Betamethasone
times two as well as Ampicillin and Erythromycin. She
progressed to a spontaneous vaginal delivery on the morning
of [**2103-6-28**]. The baby emerged vigorous with spontaneous
cry; apgars of eight and nine. She was warm, dried and bulb
suctioned in the delivery room and brought to the Neonatal
Intensive Care Unit for further management for prematurity.
PHYSICAL EXAMINATION: Weight 1,385 grams (25th to 50th
percentile); length 38 cms (10 to 25 percentile); head
circumference 27.5 cms (10 to 25 percentile). She was an
active, alert infant, pink, appropriate for gestational age
of 31 weeks. Anterior fontanel was open and flat with some
molding and caput. No dysmorphism. Lungs clear to
auscultation. Heart regular rate and rhythm without murmurs.
Abdomen was soft without hepatosplenomegaly or masses. Hips
were stable. Premature female genitalia. Extremities were
well perfused.
HOSPITAL COURSE: 1.) Respiratory: Baby Girl [**Known lastname 48639**]
remained stable on room air throughout her Neonatal Intensive
Care Unit stay at [**Hospital1 69**]. She
had one apnea and bradycardia episode on day of life five,
requiring mild stimulation.
2.) Cardiovascular: Baby Girl [**Known lastname 48639**] had seemed
hemodynamically stable throughout her Neonatal Intensive Care
Unit stay. She had no murmurs on examination.
3.) Fluids, electrolytes and nutrition: Baby Girl [**Known lastname 48639**]
had gradually been advanced to total fluids of 150 cc per kg
per day; currently tolerating breast milk 22, maintaining
good blood glucose.
Her admission weight was 1,385 grams; her weight on day of
life seven prior to discharge was 1,445 grams.
Gastrointestinal: Baby Girl [**Known lastname 48639**]' bilirubin level peaked
on day of life three at 8.3, at which time phototherapy was
initiated. Subsequently, her bilirubin level was 4.2 on day
of life six, at which time the phototherapy was discontinued.
Her rebound bili on day of life seven was 5.1.
Infectious disease: Baby Girl [**Known lastname 48639**] was initiated on
Ampicillin and Gentamycin for rule out sepsis. Her blood
culture remained negative at 48 hours at which time the
antibiotics were discontinued.
Hematology: The patient's initial hematocrit was 42.8 and
required no transfusions during this admission.
Neurology: Baby Girl [**Known lastname 48639**] had a screening head
ultrasound on day of life seven which was negative.
CONDITION AT TRANSFER: Baby Girl [**Known lastname 48639**] has been stable on
room air and hemodynamically stable, tolerating full feeds of
breast milk 22.
DISCHARGE DISPOSITION: Baby Girl [**Known lastname 48639**] is being
discharged to [**Hospital1 1474**] special care nursery.
CARE AND RECOMMENDATIONS:
Feeds at discharge: Total fluids of 150 cc per kg per day
with breast milk 24.
MEDICATIONS: None.
STATE NEWBORN SCREEN: Sent.
FOLLOW-UP APPOINTMENT: Recommended in two to three days
after discharge from the Neonatal Intensive Care Unit.
DISCHARGE DIAGNOSES:
Prematurity at 31 weeks.
Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Name8 (MD) 48640**]
MEDQUIST36
D: [**2103-7-5**] 01:59
T: [**2103-7-5**] 13:41
JOB#: [**Job Number 48641**]
|
1913 | 11 | 194,540 | Admission Date: [**2178-4-16**] Discharge Date: [**2178-5-11**]
Date of Birth: [**2128-2-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
CC:[**CC Contact Info 71794**]
Major Surgical or Invasive Procedure:
STEREOTACTIC BRAIN BIOPSY, Neuronavigation guided tumor
resection.
History of Present Illness:
HPI: 50 year old female presents after having fallen in the
bathtub 4 days ago and hitting the back of her head. Since then
she has had a "massive headache" which did not resolve with
Tylenol. She states that she has a high threshold for pain and
did not realize how bad it was during the day while at work but
then when she got home at night she noticed it. The patient
noticed "silvery spects" in her vision and she had trouble with
some simple tasks like finding the tags on the back of her
clothing in the morning. She reported that she had to check
several times to make sure she did not put her clothes on
backwards. She has had some dizziness, but no nausea or
vomiting.
Her speech has not been affected.
Past Medical History:
Newly diagnosed GBM as above
otherwise, none
Family History:
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
T:98.4 BP:105/55 HR:95 RR:15 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 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 [**5-9**] throughout. No pronator drift.
When asked to rotate fists around each other, her right fist
orbits the left, which may show slight LUE weakness.
Sensation: Intact to light touch bilaterally.
Reflexes: intact
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
CT HEAD W/O CONTRAST [**2178-4-21**] 12:28 PM
CT HEAD W/O CONTRAST
Reason: please evaluate for any new changes
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with brain mass. Now has headache.
REASON FOR THIS EXAMINATION:
please evaluate for any new changes
CONTRAINDICATIONS for IV CONTRAST: None.
NON-CONTRAST HEAD CT SCAN
HISTORY: Brain mass. Now has headache. Evaluate for any changes.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: [**2178-4-17**] CT scan of the head, reported
by Drs. [**Last Name (STitle) 21881**] and [**Name5 (PTitle) **] as revealing "unchanged mass
effect and edema around large right parietal mass, without
evidence of new intracranial hemorrhage following biopsy."
FINDINGS: Since the prior study, there is now mild linear
hyperdensity within the basal cisterns of this could be
hemorrhage, occasionally the tributaries of the circle of [**Location (un) 431**]
can be somewhat denser appearing, in the setting of increased
intracranial pressure, which would mimic the presence of
subarachnoid blood.
No other new intracranial or extracranial abnormalities are
discerned.
CONCLUSION: Possible small amount of subarachnoid blood or
relatively stagnant vascular flow, in the face of increased
intracranial pressure, as noted above. We have telephoned (Dr.
[**Last Name (STitle) **] with this report immediately after the conclusion of the
study.
ADDENDUM: There is a tiny residual gas collection superior to
the biopsy site, definitely decreased in extent compared to the
prior study of [**4-17**].
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Cardiology Report ECG Study Date of [**2178-4-16**] 3:21:48 PM
Normal sinus rhythm. Within normal limits. No previous tracing
available for
comparison.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 142 82 [**Telephone/Fax (2) 71795**] 45 48
([**-7/2007**])
MR HEAD W & W/O CONTRAST [**2178-4-16**] 5:01 AM
MR HEAD W & W/O CONTRAST
Reason: evaluate extent of ring enhancing brain mass w/ edema
seen o
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with brain mass
REASON FOR THIS EXAMINATION:
evaluate extent of ring enhancing brain mass w/ edema seen on CT
EMERGENCY MRI SCAN OF THE BRAIN.
HISTORY: Ring-enhancing brain mass with edema seen on CT scan.
TECHNIQUE: Multiplanar T1 and T2-weighted brain images with
gadolinium enhancement.
COMPARISON STUDIES: None available at this time.
WET READ REPORT: Dr. [**Last Name (STitle) 71796**] interpreted this study as
revealing "bilateral parenchymal masses, suggesting metastatic
disease. The largest mass in the right parietal lobe has a
complex appearance, at least 5 cm in greatest dimension with at
least 8 cm greatest dimension of surrounding edema and 7 mm
leftward midline shift." Dr. [**Last Name (STitle) 71796**] is a member of the
"Nighthawk" Radiology group.
FINDINGS: The study indeed reveals a large right parietal,
irregularly thick ring enhancing mass, possibly with some tiny
"daughter" cystic components extending towards the cortical
surface. As mentioned in the wet [**Location (un) 1131**], there is a substantial
area of surrounding edema, with effacement of the right atrium
and approximately 7 mm leftward subfalcine herniation. A smaller
area of edema is seen within the white matter of the left
occipital lobe, but I cannot delineate any specific area of
enhancement associated with it. A third, very well circumscribed
18 x 26 mm area of elevated T2 signal is seen contiguous to the
left temporal lobe, and it is difficult to determine whether the
lesion is intra- or extra-axial in locale. Again, there is no
associated enhancement and no abnormal susceptibility is noted,
either. On the coronal post-contrast images, there is a
questionable area of enhancement, approximately 3 mm,
immediately subjacent to the left temporal lesion- I am not
certain that the two findings are necessarily related. The
principal vascular flow patterns are identified. There is no
overt extracranial abnormality noted.
CONCLUSION: Large right parietal lobe mass, which may represent
either a primary or metastatic brain neoplasm. The additional
abnormalities within the left temporal lobe and left occipital
lobe, while they may represent extremely unusual manifestations
of metastatic disease, which would then render the right
parietal lobe lesion more likely metastatic, could have
alternative diagnoses, including hemorrhage or a calcified left
temporal meningioma as an explanation for the left temporal
lesion, and either an inflammatory or ischemic process to
account for the left occipital lesion. I discussed this case
this morning with Dr. [**Last Name (STitle) **], it was decided that a non-contrast
head CT scan would be a helpful followup diagnostic procedure to
further characterize the left cerebral hemispheric lesions prior
to brain biopsy of the right parietal lesion.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2178-4-16**] 4:07 PM
CHEST (PORTABLE AP) [**2178-4-16**] 3:50 PM
CHEST (PORTABLE AP)
Reason: please evaluate preop
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with bilateral masses
REASON FOR THIS EXAMINATION:
please evaluate preop
INDICATION: Bilateral brain masses for pre-op evaluation.
PORTABLE CHEST: There are no priors for comparison. Heart size
is normal. Mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. Lungs are clear, and there are no
effusions or pneumothorax.
IMPRESSION:
1. No acute cardiopulmonary disease.
2. No evidence of a primary pulmonary neoplasm, but PA/Lateral
CXR or CT would be more sensitive than a portable study and may
be helpful for more complete assessment, if not already recently
obtained.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: FRI [**2178-4-17**] 9:02 AM
****
*******
Brief Hospital Course:
A/P: 50 year-old woman without significant PMH who presented
[**2178-4-16**] from OSH with new dx of brain mass after fall, with
biopsy that showed GBM, for which she had craniectomy/debulking
[**2178-4-23**] and was started on XRT without event.
.
1) Glioblastoma Multiforme: She was transferred to [**Hospital1 18**] after
fall and was noted to have a brain mass. She had a biopsy which
showed glioblastoma, WHO grade IV. She was noted on [**4-21**] to have
headache, with 4/18 she had mental status changes and imaging
c/w herniation. She was taken emergently to the OR [**4-23**] for
craniotomy and subtotal tumor debulking. She was then
transferred to Omed for XRT and chemotherapy. She was maintained
on keppra and decadron for seizure/cerebral edema prevention.
She was maintained on seizure precautions with frequent neuro
checks. She used a helmet with ambulation given s/p craniectomy.
She was started on XRT with temador. She remained stable without
signs of elevated intracranial pressure during this so was
thought stable to go home and continue XRT as an outpatient. She
was seen by PT and though stable to go home. She was continued
on pantoprazole and sliding scale insulin while on
dexamethasone.
.
Medications on Admission:
none
Discharge Medications:
1. Diabetic.com Starter Kit Kit Sig: One (1) kit
Miscellaneous once a day.
Disp:*1 kit* Refills:*0*
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: 0-15 units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale, check blood
glucose 4 times daily.
Disp:*QS units* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*2*
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO DAILY (Daily): 2 pills 30 minutes prior to
Temodar (chemotherapy) or [**1-6**] pills as needed every 8 hours for
nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
11. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. Melatonin Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
GLIOBLASTOMA
Discharge Condition:
STABLE
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. You will be contact[**Name (NI) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
regarding your Temodar prescription.
.
Please call your primary care physician or Dr. [**First Name (STitle) **] [**Name (STitle) 4253**]
if you experience headaches, visual changes, nasea, vomitting,
hiccups, change in strength, sensation, or coordination. These
could be signs of elevated intercranial pressure and could
require urgent treatment.
*
Please limit exercise to walking; no lifting, straining,
excessive bending.
Please continue to use your helmet with ambulation.
You may wash your hair only after sutures and/or staples have
been removed. You may shower before this time with assistance
and use of a shower cap.
Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please continue with your daily radiation therapy treatments: to
continue this as an outpatient you will need to call: ([**Telephone/Fax (1) 54862**] first thing in the morning of [**2178-5-12**]. If you have
any difficulty schduling these treatments or questions please
call ([**Telephone/Fax (1) 71797**] and ask for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 4253**] on [**Last Name (LF) 766**], [**2178-5-18**]. You should be contact[**Name (NI) **] with the time of this appointment
but if you do not hear from her office please call [**Telephone/Fax (1) 1844**].
.
Please call [**Telephone/Fax (1) 28193**] to schedule follow-up with your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 28190**] [**Name (STitle) 16528**] in the next 2 weeks.
|
9971,57410,4275,99811,4019,5680,55321,E8782,1570 | 12 | 112,213 | Admission Date: [**2104-8-7**] Discharge Date: [**2104-8-20**]
Date of Birth: [**2032-3-24**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 363**] is a
72-year-old male with a past medical history significant for
pancreatic cancer, ulcerative colitis, hypertension, status
post endoscopic retrograde cholangiopancreatography, and
status post total abdominal colectomy 20 years ago with an
end-ileostomy.
The patient underwent an endoscopic retrograde
cholangiopancreatography recently, but a stent was unable to
be placed. A computed tomography was performed which
demonstrated a head of the pancreas mass with dilated
intrahepatic duct along with vascular involvement of the
gastroduodenal artery and superior mesenteric vein. He
presented for exploratory laparotomy with possible pancreatic
mass resection.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Hypertension.
3. Benign prostatic hypertrophy.
PAST SURGICAL HISTORY:
1. Total abdominal colectomy with end-ileostomy.
2. Status post transurethral resection of prostate.
MEDICATIONS ON ADMISSION:
1. Moexipril 15 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Atenolol 25 mg by mouth once per day.
4. Allopurinol 300 mg by mouth once per day.
5. Multivitamin.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a thin,
cachectic Caucasian male who was alert and oriented times
three. In no apparent distress. The sclerae were anicteric.
The patient was jaundiced. The oropharynx was clear with
moist mucous membranes. The neck was supple and without
lymphadenopathy. The heart was regular in rate and rhythm.
The lungs were clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. There was a
well-healed midline scar and ileostomy present. The
extremities were warm without cyanosis, clubbing, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: His hematocrit
was 43.2. His INR was 1.2. Creatinine was 1.6. Aspartate
aminotransferase was 51, his alanine-aminotransferase was 89,
his alkaline phosphatase was 395, and his total bilirubin was
12.5.
BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission,
the patient was taken to the operating room where an
exploratory laparotomy was performed. The patient had
evidence of unresectable pancreatic cancer with biliary
obstruction seen intraoperatively. Adhesiolysis was
therefore performed along with a Roux-en-Y
hepaticojejunostomy, and open cholecystectomy, an open
pancreatic biopsy, and a gastrojejunostomy. The estimated
blood loss for the procedure was 250 cc.
The patient was discharged to the regular hospital floor
after being extubated in the Postanesthesia Care Unit in good
condition.
In the evening on postoperative day one, the patient was
taken back to the operating room emergently for likely
mesenteric bleeding. This was controlled with suture
ligation, and the patient was admitted to the Surgical
Intensive Care Unit postoperatively for close monitoring.
The patient remained intubated in the Intensive Care Unit on
pressor support and received total parenteral nutrition until
postoperative day seven. At this time, the patient's mental
status was extremely labile requiring Haldol for agitation.
The patient's hematocrit was stable at 35.8 at this time.
Tube feeds were initiated on postoperative day eight. On
postoperative day nine, the patient was transferred to the
regular hospital floor. At this time, tube feeds were held
for elevated residuals and nausea. He was still receiving
total parenteral nutrition at this time. The patient's
mental status was still not completely improved. A computed
tomography scan was performed on postoperative day ten which
did not demonstrate any intra-abdominal pathology.
The patient was started on sips on postoperative day eleven
and was started on his home medications. At this time, he
was seen by the Physical Therapy Service and was being
screened for rehabilitation placement.
However, on the evening on postoperative day twelve the
patient spiked a temperature to 101.5 degrees Fahrenheit. A
fever workup was done including a chest x-ray and blood
cultures.
Early the next morning, the patient was found unresponsive
without a pulse at approximately 2:45 a.m. At this time, a
code blue was called and advanced cardiac life support
protocol was initiated. However, the patient was asystolic
without any respiratory effort at this time. He did receive
multiple rounds of epinephrine along with attempts at
ventilation. However, the patient never regained electrical
activity and was pronounced deceased at 2:57 a.m. The
patient's wife was notified at this time. However, a
postmortem examination was declined.
CONDITION AT DISCHARGE: The patient expired on [**2105-8-21**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2105-3-16**] 16:05
T: [**2105-3-16**] 18:33
JOB#: [**Job Number 105917**]
|
41401,4111,25000,4019,2720 | 13 | 143,045 | Admission Date: [**2167-1-8**] Discharge Date: [**2167-1-15**]
Date of Birth: [**2127-2-27**] Sex: F
Service: Cardiac surgery
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old woman with
diabetes, hypertension, hyperlipidemia and obesity, with a
one to two months of chest burning with exertion. For the
past six months, she has been participating in a new vigorous
exercise program to lose weight. Her symptoms do gradually
resolve with rest, but they have started to occur now with
walking. She does acknowledge that there is associated
nausea, diaphoresis and shortness of breath. Now recently she
started to get symptoms for the past two days while at rest.
She was referred for an outpatient exercise tolerance test,
where she had chest pain and significant EKG changes. She was
referred to [**Hospital1 18**] for cardiac catheterization today, which
revealed significant left main artery disease. Just prior to
her transfer to [**Hospital1 18**], she did complain of chest pain and
back pain at about 7/10 intensity and a nitroglycerin drip
was started and she received 5 mg of IV Lopressor and 2 mg of
IV Ativan, which did resolve her pain. While she was in the
cath lab, she had an intraaortic balloon pump placed, and now
she is not actively complaining of any pain.
REVIEW OF SYSTEMS: She denies any orthopnea, lower extremity
edema, but she does acknowledge that she does have
dysmenorrhea.
PRIOR MEDICAL HISTORY: She has diabetes mellitus, type 2,
diagnosed in [**2157**]. She has been able to control it with diet
since [**2166-6-22**]; hypertension and obesity; however, she has
lost 40 pounds in the last six months.
SHE HAS AN ALLERGY TO SHELLFISH.
MEDICATIONS ON TRANSFERS TO [**Hospital1 18**]: Atenolol 50 mg a day,
lisinopril 10 mg a day, Lipitor 20 mg a day, aspirin 325 mg
once a day, progesterone, nitroglycerin drip, Lopressor,
Ativan.
SOCIAL HISTORY: She does not smoke. She does not use ethanol
and she does not use cocaine. Her father had a brain tumor.
Her brother did have coronary artery disease and a myocardial
infarction in his late 30s. Her mother has hypertension. She
does have a strong family history for hyperlipidemia.
PHYSICAL EXAMINATION: The patient is comfortable appearing,
in no apparent distress. Vital signs: Temperature 99.1, pulse
72, blood pressure 144/87. Pulse oximetry is 98% on room air.
Head and neck: PERRLA. EOMI. Anicteric. Mucous membranes
moist. Neck supple, no lymphadenopathy, no JVD. Cardiac:
Regular rate and rhythm. Lungs clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended, but
she is morbidly obese, positive bowel sounds. Her extremities
are warm, no edema. She has got 5/5 strength in all
extremities.
Her laboratories prior to admission from [**Hospital3 1280**] were
white count 7.4, hematocrit of 39.8, platelets 190,000.
Hemoglobin A1c was 7.1. Sodium was 140, potassium 4.1,
chloride 103, bicarbonate 28, BUN 14, creatinine 0.6. Total
cholesterol was 307, triglycerides were 79, and HDL was 50.
[**Last Name (STitle) 54218**], which was at [**Hospital3 1280**] (it was not at
[**Hospital1 18**]), showed diffuse left main and proximal left anterior
descending artery stenosis, 60% to 70%, which was ulcerative;
50% mid LAD stenosis; 50% left circumflex stenosis after OM1;
moderate right coronary artery stenosis; a normal ejection
fraction of 78%; no mitral regurgitation. Note that the right
coronary artery stenosis that I am reported is different than
what was actually reported on the initial catheterization
results from [**Hospital3 1280**]. This was discussed between Dr. [**Last Name (Prefixes) 411**] and Dr. [**Last Name (STitle) 911**], and was not actually considered to be
80% as previously reported.
So this was a woman who was considered to have unstable
angina but not actively ischemic. She was put on an
intraaortic balloon pump, followed in the cardiac care unit,
and was "preoped" and consented for a CABG on the next day
because of her three-vessel disease. She was made n.p.o.
after midnight and then in the morning she was taken to the
operating room.
On[**Last Name (STitle) 19203**] of [**2167-1-9**], Ms. [**Known lastname 42915**] went to the
operating room with Dr. [**Last Name (Prefixes) **] for bypass surgery.
Please refer to the previously dictated operative note by Dr.
[**Last Name (Prefixes) **] for the specifics of this surgery. In brief,
three grafts were made. One was a left internal mammary to
the left anterior descending artery and then two saphenous
vein grafts were connected to the OM1 and OM2. She was on
cardiopulmonary bypass for 76 minutes and the aorta was cross
clamped for 53 of those minutes.
She tolerated the surgery well and was transferred to the
intensive care unit on propofol and Neo-Synephrine drips.
Postoperatively, Ms. [**Known lastname 42915**] did extremely well. Her
intraaortic balloon pump and all of her intravenous drips
were discontinued on postoperative day one. On postoperative
day two she was extubated and on postoperative day three she
was transferred to the floor. Ms. [**Known lastname 54219**] major floor issues
were as follows.
Ms. [**Known lastname 42915**] was followed by physical therapy, which cleared
her to go home with home physical therapy to assist with
mobility, strength and endurance. She was also actively
diuresed with Lasix and had her potassium repleted
accordingly. Finally, she was noted to have hyperglycemia
while she resumed her regular diet. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8392**] consultation
was obtained and they recommended metformin 500 mg twice a
day to maintain euglycemia. She would follow her sugar as an
outpatient and report this back in an outpatient followup
appointment.
On [**1-14**] the patient's central line was discontinued.
She was scheduled to leave, but she developed chest pain;
however, this chest pain was considered not to be cardiac, to
be more gastrointestinal in nature, and she had ......... and
an EKG, both of which confirmed a noncardiac source for this
chest pain.
She is, therefore, on [**1-15**], postoperative day six,
being discharged home in good condition with home physical
therapy scheduled.
FINAL DIAGNOSES:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Obesity.
4. Hyperlipidemia.
5. Unstable angina.
6. Three-vessel coronary artery disease, status post
coronary artery bypass grafting, status post intraaortic
balloon pump.
7. Hypokalemia.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg t.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Captopril 50 mg p.o. t.i.d.
4. Lipitor 20 mg p.o. q.d.
5. Lasix 20 mg p.o. b.i.d. for one week.
6. Potassium chloride 10 mEq p.o. b.i.d. for one week.
7. Metformin 500 mg p.o. b.i.d.; follow your blood sugar
levels and follow up with [**Doctor First Name 8392**].
8. Percocet one to two tablets every four hours as needed
for pain.
9. Colace 100 mg p.o. b.i.d. as needed for constipation.
[**Last Name (STitle) 54220**]owup appointments are with Dr. [**Last Name (STitle) **], her primary
care physician, [**Name10 (NameIs) **] one to two weeks, Dr. [**Last Name (STitle) 911**], her
cardiologist, in two to three weeks, Dr. [**First Name (STitle) **] from [**Doctor First Name 8392**]
as directed, and Dr. [**Last Name (Prefixes) **] in one month. She is also
recommended to follow up in [**Hospital1 18**] Wound Care Clinic in one to
two weeks to remove her staples.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2167-1-14**] 16:37
T: [**2167-1-14**] 18:16
JOB#: [**Job Number 54221**]
|
2724,71946,7220,311,4589,78551,5119,4239 | 17 | 161,087 | Admission Date: [**2135-5-9**] Discharge Date: [**2135-5-13**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pressure/cardiac tamponade/ cardiogenic shock
Major Surgical or Invasive Procedure:
emergent sternotomy for pericardial window [**2135-5-9**]
History of Present Illness:
Underwent min. inv. PFO closure in [**12-11**]. Had emergent admission
on [**5-9**] for hypotension, pericardial effusion , pleural effusion
and chest pain for several days. Did not resolve with pain med
and had increasing SOB. Admitted to ER for emergent eval. and
bedside TTE. Started on dopamine drip for hypotension.
Past Medical History:
s/p min. inv. closure of Patent foramen ovale [**12-11**]; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
pt. in distress
SBP 70- 80's
lungs CTA
tachycardic, RR, no murmur or rubs
palpable pedal pulses
Pertinent Results:
[**2135-5-11**] 08:40AM BLOOD WBC-11.3* RBC-3.62* Hgb-9.9* Hct-28.8*
MCV-80* MCH-27.3 MCHC-34.3 RDW-14.4 Plt Ct-413
[**2135-5-9**] 11:45AM BLOOD Neuts-86.5* Lymphs-7.0* Monos-5.2 Eos-1.2
Baso-0.2
[**2135-5-11**] 08:40AM BLOOD Plt Ct-413
[**2135-5-11**] 08:40AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-136
K-3.7 Cl-102 HCO3-24 AnGap-14
[**2135-5-9**] 11:45AM BLOOD CK(CPK)-26
[**2135-5-9**] 11:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
Brief Hospital Course:
Admitted through ER as above and referred to CT [**Doctor First Name **] for
emergent pericardial window/pericardectomy via sternotomy, as
the patient was hypotensive.This was performed by Dr. [**Last Name (STitle) 1290**]
on [**5-9**]. Transferred to CSRU in stable condition on phenylephrine
and propofol drips. Extubated and awoke neurologically intact.
Beta blockade started on POD #1 and transferred out to the floor
to start increasing her activity level. Mediastinal tubes
removed on POD #1. Crepitus was noted on anterior chest wall
after pleural tubes removed on POD #2. Beta blockade also
titrated up. Crepitus improved and CXR confirmed. She made good
progress and was discharged to home with VNA services on POD #4.
Medications on Admission:
ASA 325 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 3 days.
Disp:*3 Packet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p emergent pericardial window via sternotomy [**2135-5-9**]
cardiogenic shock/tamponade
s/p Min inv. PFO closure [**12-11**]
s/p CVA
anxiety/depression
cervical disc herniation
patella-femoral syndrome
borderline hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
may shower over incision and gently pat dry
no lotions, creams or powders on incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] (PCP) in [**2-7**] weeks
follow up with Dr. [**Last Name (STitle) **] (Card)in [**3-11**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2135-5-13**] |
7455,45829,V1259,2724 | 17 | 194,023 | Admission Date: [**2134-12-27**] Discharge Date: [**2134-12-31**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
History of stroke
Major Surgical or Invasive Procedure:
[**2134-12-27**] Minimally invasive closure of patent foramen ovale
History of Present Illness:
Mrs. [**Known lastname 11679**] is a 47 year old female who suffered a cerebellar
stroke in [**2134-3-9**]. Workup at that time revealed a patent
foramen ovale. She is currently followed by Dr.
[**Last Name (STitle) 1693**](neurologist) from the [**Hospital1 18**]. Full hypercoagulability
workup was unremarkable. Since [**Month (only) 956**], she has had no other
neurological events. In preperation for surgical intervention,
she underwent cardiac catheterization in [**Month (only) **] which showed
normal coronary arteries and normal left ventricular function.
Past Medical History:
Patent foramen ovale; History of Stroke/TIA; Depression;
Anxiety; Borderline Hyperlipidemia; Herniation of Cervical
Discs; Patella-Femoral Syndrome; s/p Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
Vitals: BP 114/68, HR 90, RR 14
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2134-12-31**] 06:15AM BLOOD WBC-6.6# RBC-2.98* Hgb-9.1* Hct-26.1*
MCV-88 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-192
[**2134-12-27**] 06:19PM BLOOD WBC-10.5 RBC-3.42*# Hgb-10.5*# Hct-30.0*
MCV-88 MCH-30.8 MCHC-35.2* RDW-12.6 Plt Ct-138*
[**2134-12-31**] 06:15AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-140
K-5.1 Cl-106 HCO3-28 AnGap-11
[**2134-12-27**] 07:21PM BLOOD UreaN-11 Creat-0.8 Cl-112* HCO3-23
[**2134-12-31**] 06:15AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
Brief Hospital Course:
Mrs. [**Known lastname 11679**] was admitted and underwent surgical closure of her
patent foramen ovale. The operation was performed minimally
invasive and there were no complications. Following the
procedure, she was brought to the CSRU. She initially remained
hypotensive, requiring volume and Neosynephrine. Within 24
hours, she awoke neurologically intact and was extubated without
difficulty. By postoperative day two, she successfully weaned
from inotropic support. She maintained stable hemodynamics and
transferred to the floor. On telemetry, she remained mostly in a
normal sinus rhythm with brief periods of accelerated junctional
rhythm. She otherwise continued to make clinical improvements
and was cleared for discharge on postoperative day four. She
remained just on Aspirin therapy. Aggrenox was not resumed as
her PFO was surgically repaired. At discharge, her systolic
blood pressures were in the 100's with heart rate of 80-90. Her
room air saturations were 93% and she was ambulating without
difficulty. She had good pain control with Dilaudid and all
wounds were clean, dry and intact.
Medications on Admission:
Bupropion 150 [**Hospital1 **], Aggrenox qd, Centrum, Calcium, Erythromycin
eye gtts
Discharge Medications:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(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. 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Patent foramen ovale - s/p surgical closure; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-11**] weeks - call for appt,
[**Telephone/Fax (1) 170**]. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**3-11**] weeks - call for
appt. Local cardiologist, Dr. [**Last Name (STitle) 11255**] in [**3-11**] weeks - call for
appt
Completed by:[**2134-12-31**] |
78057,47829,V5869,78321,E9323,V5867,29633,78039,25080,4019,4264,2720,V170 | 18 | 188,822 | Admission Date: [**2167-10-2**] Discharge Date: [**2167-10-4**]
Date of Birth: [**2116-11-29**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Depression
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo M w/ Type 2 DM, depression who was admitted to Deaconness
4 for major depressive episode and possible [**First Name3 (LF) **]. While on [**Hospital1 **]
4, the patient was given ativan 1 mg x 1. His klonopin was held.
He was given [**1-11**] normal dose of NPH as NPO for [**Month/Day (2) **]. The
following am, the paitent was found to be shaking. He was given
2 mg ativan and became nonresponsive over the next 20 minutes
and a code was called. The patient's fingerstick was 30 so he
was given 1 amp of D50. He was also given 4 mg IV ativan. He
stopped shaking and mental status cleared in 30 minutes. He was
started on a dilantin load. He was seen by neuro who felt that
in the setting of hypoglycemia (severe)and withdrawal of his
Klonopin, he was at risk to have a seizure.
Past Medical History:
- IDDM, Type II
- OSA
- Borderline HTN
- Hypercholestremia
- h/o RBBB
PAST PSYCHIATRIC HISTORY:
Panic d/o x 20yrs on Klonopin x 12 yrs, occassional Xanax
Outpt psychiatry intermittently, until 4 weeks ago when he began
to see Dr. [**Last Name (STitle) 10166**] with significant depression since [**Month (only) 205**].
[**Month (only) 404**] of this year pt and wife sought counseling for sleep
issue with children x 2 sessions.
No assaultive or suicidal behavior
Social History:
SUBSTANCE ABUSE HISTORY:
Denies alcohol, tobacco or other street drugs. One episode of
MJ use
in [**2140**].
SOCIAL HISTORY:
Attorney for [**Company 28241**], [**Location (un) 511**] division. Married
to [**Doctor First Name **] for 11 yrs this [**5-11**] children 4yo [**Known firstname 122**] and 2
yo [**Doctor First Name **]. Denies physical or sexual abuse in past or
currently. Denies military or legal hx.
Family History:
Denies
Physical Exam:
VS: Tm 99.8 HR 87-133 (98) BP 117-166/75-97 RR 17-27
O2 Sat - 95-100% RA 2740/2455
GEN: NAD, sitting in bed
HEENT: PERRL, EOMI, sclera anicteric, mmm, no OP lesions
CV: Normal S1/S2, RRR, no m/g/r.
PUL: CTA b/l.
ABD: Soft, NT, ND +BS.
EXT: No edema.
Neuro: A and Ox3, CN 2-12 intact, M [**5-14**] UE/LE b/l, sensation
grossly intact
Pertinent Results:
[**2167-10-3**] 07:30PM BLOOD WBC-12.8* RBC-4.69 Hgb-13.8* Hct-39.7*
MCV-85 MCH-29.5 MCHC-34.9 RDW-13.9 Plt Ct-217
[**2167-10-3**] 07:30PM BLOOD Plt Ct-217
[**2167-10-4**] 07:45AM BLOOD Glucose-186* UreaN-12 Creat-1.0 Na-139
K-3.9 Cl-101 HCO3-25 AnGap-17
[**2167-10-3**] 07:30PM BLOOD CK-MB-1 cTropnT-<0.01
[**2167-10-3**] 06:14AM BLOOD CK-MB-1 cTropnT-<0.01
[**2167-10-2**] 03:38PM BLOOD Phenyto-15.5
[**2167-10-2**] 11:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-10-2**] 11:44AM BLOOD Type-ART pO2-198* pCO2-29* pH-7.54*
calHCO3-26 Base XS-3
.
EEG
This is a normal EEG in the awake and drowsy states. Note
is incidentally made of a resting tachycardia.
Brief Hospital Course:
A/P: 50M with history of hypertension, type II diabetes,
originally admitted to psychiatry for [**Month/Day/Year **], made NPO p MN for [**Month/Day/Year **]
in AM with 1/2 dose of insulin, who was found unresponsive and
in apparent seizure state, who was found to have a blood glucose
of 30.
.
1)Convulsions:
A code was called and the patient was given Ativan 2mg po x1, as
well as an amp of D50, loaded with Dilantin and transferred to
the MICU. The seizure was attributed to his hypoglycemic state,
although psych thought there was an element of Klonopin
withdrawal and thus continued to give Ativan 0.5mg po q4. Pt
had frequent BS checks in the MICU and patient recovered from
his initial event without any post-seizure sequelae. Pt
continued to be monitored and had no further events. Neurology
was consulted for his ? seizure event and after a negative exam
and negative EEG, concluded that it was all due to hypoglycemia,
and that further Dilantin would not be necessary.
Dilantin was d/ced and patient continued to do well. He was
eventually transferred to the floor. All home medications were
continued and patient continued to express interest in his [**Month/Day/Year **]
treatment on Monday, although refused to be transferred back to
[**Hospital1 **] 4.
All home medications although his insulin dose (nph 20 qPM) was
halved (--> NPH 10 qPM) on the floor, and his sugars were
running in the 150s-250s range.
Pt was sent home to return for [**Hospital1 **] on Monday as an outpatient.
Explicit instructions were given to take all medications as
normal the night before, including his Klonopin, and only take
[**1-13**] dose of NPH insulin the night before, NPO p MN, no morning
NPH dose, and to cover his elevated morning sugars with Humalog
at a conservative sliding scale. Goal sugars 150s-250s.
2) Type 2 DM - follow sugars closely
- Continue normal dose insulin while taking POs, and when NPO p
MN for [**Month/Day (4) **] in AM, pt was instructed to take [**1-13**] NPH dose the
evening before, no NPH in the AM, and to cover with Humalog prn
according to conservative insulin SS to prevent hypoglycemic
episodes.
.
3) Depression:
Pt with a h/o refractory depression that was originally admitted
to the psych service for [**Month/Day (4) **]. Psych consult remained aware as
pt was admitted to the MICU and then called out to the floors.
Recommended continuing his Klonopin 3mg po bid for his anxiety,
and added Ativan 0.5mg po q4 for coverage of his anxiety and
alleviation of ? withdrawal during periods when he is off the
Klonopin. Continued his home doses of Celexa, Nortriptyline,
Seroquel and trazodone for sleep.
Pt was to be discharged to return on Monday for [**Month/Day (4) **] treatments
as an outpatient.
.
4) F/E/N:
-Diabetic diet, replete lytes prn
.
5) Code: full
.
6) Dispo:
Medically cleared per MICU team as well as PCP. [**Name10 (NameIs) **] to be
discharged to follow up with outpatient [**Name10 (NameIs) **] on Monday.
Medications on Admission:
Nortriptylline 50mg qd (started a week PTA)
Seroquel 50mg tid
Klonopin 3mg [**Hospital1 **]
Lexapro 20mg po qd
Trazadone 200mg qhs
Crestor 10mg po qd
Insulin SS + NPH 20 qhs
Lisinopril 10mg po qd
Discharge Medications:
1. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM (in the morning) .
Disp:*qs units* Refills:*2*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5)
units Subcutaneous qhs (at bedtime) for 1 doses.
Disp:*qs units* Refills:*0*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous at bedtime: Please start after [**Hospital1 **]
treatments tomorrow night [**10-5**]. Do not use this dose when not
eating.
Disp:*qs units* Refills:*2*
11. Klonopin 1 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Major Depression
Hypoglycemic seizure
.
DMII
HTN
Discharge Condition:
Afebrile, FS running in high normal range, stable to be
discharged home.
Discharge Instructions:
1. Please return Monday morning to receive your [**Month/Year (2) **] treatment
with psychiatry as below. Please call [**Telephone/Fax (1) **] for your
scheduled time.
.
2. For preparations for [**Telephone/Fax (1) **] tomorrow morning:
(a) Please take NPH 5 units tonight, no regular insulin
(b) Do not take NPH morning dose tomorrow.
(c) Nothing to eat past midnight.
(d) Take your Klonopin 3mg dose tonight.
(e) No morning medications prior to [**Telephone/Fax (1) **] including Klonopin.
(f) Have fingersticks checked in morning, and prior to [**Telephone/Fax (1) **], and
give Regular Insulin based on sliding scale.
.
3. Please take your other medications as below.
.
4. If develop lightheadedness, dizziness, sweating, chest pain,
shortness of breath, confusion, or other symptoms, please call
Dr. [**First Name (STitle) **] (or Dr. [**Last Name (STitle) 10166**] or report to the nearest ER.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Hospital **] CLINIC Where: [**Hospital **] CLINIC
Date/Time:[**2167-10-5**] 8:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2167-11-11**] 9:50
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2167-11-17**] 1:30
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
Completed by:[**2167-10-5**] |
78057,E9323,47829,V5869,V5867,29633,78039,25080,78321,4019,4264,2720,V170 | 18 | 188,822 | Admission Date: [**2167-9-30**] Discharge Date: [**2167-10-2**]
Date of Birth: [**2116-11-29**] Sex: M
Service: PSYCHIATRY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 7342**]
Chief Complaint:
"I'm just so depressed, I can't do anything"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt reports 3-4 weeks ago he noticed an increase of stress at
work and at home at the same time that he was losing weight to
gain better control over his diabetes (40lb in [**5-15**] weeks). Pt
reports having increasingly frequent panic attacks which he
controlled with Klonopin and occassional Xanax. He also noticed
decrease in sleep, energy, concentration, interest and
motivation, and an increase in anhedonia over the past [**2-12**]
weeks.
His psychiatrist began Zoloft which after 3-4 days made him
jittery and this was switched to Celexa which he seems to be
tolerating better, although his neurovegetative sx seem to
worsen. He denies SI but reports fleeting, ego dystonic
thoughts of hurting his wife, and has not acted on any of these
thoughts. Pt reports ruminations concerning whether he is
schizophrenic, will have to stay in the hospital forever, or
will be on meds forever. Pt and wife also report guilt over
allowing two children to develop bad sleeping habits such that
now children and wife sleep in bed and pt sleeps in chair
downstairs.
Past Medical History:
- IDDM, Type II
- OSA
- Borderline HTN
- Hypercholestremia
- h/o RBBB
PAST PSYCHIATRIC HISTORY:
Panic d/o x 20yrs on Klonopin x 12 yrs, occassional Xanax
Outpt psychiatry intermittently, until 4 weeks ago when he began
to see Dr. [**Last Name (STitle) 10166**] with significant depression since [**Month (only) 205**].
[**Month (only) 404**] of this year pt and wife sought counseling for sleep
issue with children x 2 sessions.
No assaultive or suicidal behavior
Social History:
SUBSTANCE ABUSE HISTORY:
Denies alcohol, tobacco or other street drugs. One episode of
MJ use
in [**2140**].
SOCIAL HISTORY:
Attorney for [**Company 28241**], [**Location (un) 511**] division. Married
to [**Doctor First Name **] for 11 yrs this [**5-11**] children 4yo [**Known firstname 122**] and 2
yo [**Doctor First Name **]. Denies physical or sexual abuse in past or
currently. Denies military or legal hx.
Family History:
Denies
Physical Exam:
MENTAL STATUS EXAM ON ADMISSION
APPEARANCE & FACIAL EXPRESSION: well-groomed, anxious
POSTURE: sitting up in chair
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): none noted
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): cooperative in
conversation but somewhat guarded
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal flow, articulation and prosody
MOOD: anxious
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.): blunted
affect with moderate range/reactivity, congruent
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): No LOA/FOI, [**Doctor Last Name **],
circ
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS, DELUSIONS,
ETC.): Fears he is schizophrenic because of the thoughts to
hurt his wife, distorted thinking regarding work, somewhat
paranoid about confidentiality issues and conditions of CV
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP, APPETITE,
ENERGY, LIBIDO): poor sleep, energy, interest
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
fleeting thoughts as above to hurt wife, denies plan, SI
INSIGHT AND JUDGMENT: limited
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): not tested
MEMORY (SHORT- AND LONG-TERM): registration and long term intact
CALCULATIONS: not tested
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): above average
PROVERB INTERPRETATION: not tested
SIMILARITIES/ANALOGIES: not tested
PHYSICAL EXAM ON ADMISSION:
VSS, exam within normal limits
Pertinent Results:
[**2167-9-30**] 11:23AM %HbA1c-6.3*# [Hgb]-DONE [A1c]-DONE
[**2167-9-30**] 11:15AM GLUCOSE-255* UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
[**2167-9-30**] 11:15AM VIT B12-271 FOLATE-13.0
[**2167-9-30**] 11:15AM TSH-1.6
[**2167-9-30**] 11:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-9-30**] 11:15AM WBC-9.9 RBC-5.07 HGB-14.8 HCT-42.0 MCV-83
MCH-29.1 MCHC-35.2* RDW-13.9
[**2167-9-30**] 11:15AM PLT COUNT-217
[**2167-9-30**] 11:01AM URINE HOURS-RANDOM
[**2167-9-30**] 11:01AM URINE GR HOLD-HOLD
[**2167-9-30**] 11:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2167-9-30**] 11:01AM URINE RBC-0-2 WBC-[**3-14**] BACTERIA-MOD YEAST-NONE
EPI-0-2
Brief Hospital Course:
SOMATIC INTERVENTIONS:
The patient was continued on his outpatient medication regimen
of Lexapro, Nortriptyline, Seroquel, Klonopin and Trazodone. He
was also offerred Ambien at HS as needed. The patient was
admitted for ECT and was cleared by Medicine and Anesthesia.
Of note, per ECT consult, the patient's HS and a.m. doses of
Klonopin were held for procudure. Overnight, prior to transfer,
the DOC was called in response to the patient being agitated and
tremulous reporting "I'm going to die". Fingerstick glucose was
found to be over 300 - in response, the patient was given 10
units NPH and received Ativan 2mg IM with fair effect. On the
morning of transfer, the patient was again found to be tremulous
and disoriented, repeating that he felt he was going to die. He
was again given Ativan 2mg IM with minimal effect. Fingerstick
was checked and found to be 30. In the process of obtaining
D50, the patient began to demonstrate myoclonic jerking of arms
and legs. Code was called when the patient became unresponsive.
THERAPEUTIC INTERVENTIONS:
The patient is followed as an outpatient by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10166**] who
referred him to the inpatient unit for stabilization of his
significant depression as well as for evaluation for ECT. Mr.
[**Known lastname 28257**] admitted to significantly low mood since [**Month (only) 205**], and
endorsed neurovegetative symptoms consistent with an agitated
depression.
BEHAVIORAL:
The patient remained in good behavioral control for the duration
of his admission, requiring only 15 minute checks.
LEGAL:
The patient signed in under conditional voluntary upon arrival.
DISPOSITION:
The patient was transfered to an ICU bed after code was called
for unresponsiveness and possible seizure activity.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
AXIS I: MDD
AXIS II: Deferred
AXIS III: IDDM, Type II; OSA; Borderline HTN; h/o RBBB; Seizure
A/W hypoglycemia
Discharge Condition:
MENTAL STATUS EXAM ON DISCHARGE:
The patient is lying supine in bed, jerking arms and legs, with
writhing movements in his trunk. The patient is unresponsive,
will not attend to voice etc. Unable to make eye contact.
Unable to assess mood, affect or thought process and content.
Insight and judgment n/a.
Discharge Instructions:
Transfer to ICU bed
Followup Instructions:
- Transfer to ICU bed
- Psychiatry C/L service will follow while on Medicine
Completed by:[**2167-10-2**] |
80502,5990,5964,E8809,8220,73300,2948,4019,44321 | 19 | 109,235 | Admission Date: [**2108-8-5**] Discharge Date: [**2108-8-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male s/p unwitnessed fall at home; found at bottom of
stairs by family member; down for unknown period of time.
Patient unable to recall events surrounding the fall.
Past Medical History:
Atonic Bladder
Hypertension
Dementia
+VDRL
Social History:
Retired truck driverLives alone in 2 story building; has VNA to
change suprapubic tube. HHA to assist with ADL's. Has one son
who visits on weekends.
Family History:
Noncontributory
Physical Exam:
VS upon arrival to trauma bay:
T 96.4 BP 127/72 HR 89 RR 20 room air Sats 98%
Gen: NAD, alert
HEENT: PERRL, EOMI
Chest: CTA bilat, no crepitus
Cor: RRR
Abd: soft, NT, ND. Suprapubic catheter in place
Back: diffusely tender spine, no stepoffs, no deformities
Rectum: Normal tone, guaiac negative
Extr: no edema, DP 2+ bilat, FROM x4
Pertinent Results:
[**2108-8-5**] 04:00PM cTropnT-0.05*
[**2108-8-5**] 04:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2108-8-5**] 04:00PM TSH-1.5
[**2108-8-5**] 04:00PM PT-13.6* PTT-29.2 INR(PT)-1.2
[**2108-8-5**] 08:18AM GLUCOSE-155* LACTATE-2.7* NA+-137 K+-4.8
CL--101 TCO2-24
[**2108-8-5**] 08:18AM HGB-14.6 calcHCT-44
[**2108-8-5**] 08:10AM ALT(SGPT)-33 AST(SGOT)-54* CK(CPK)-371* ALK
PHOS-85 AMYLASE-71 TOT BILI-0.8
[**2108-8-5**] 08:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-8-5**] 08:10AM WBC-14.8* RBC-4.98 HGB-14.9 HCT-42.9 MCV-86
MCH-30.0 MCHC-34.8 RDW-13.8
[**2108-8-5**] 08:10AM PLT COUNT-230
CTA NECK W&W/OC & RECONS [**2108-8-7**] 11:03 AM
CTA NECK W&W/OC & RECONS; CT 150CC NONIONIC CONTRAST
Reason: r/o vascular injury (CTA neck only)
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **]yo M s/p fall with dens fx, change in MS
REASON FOR THIS EXAMINATION:
r/o vascular injury (CTA neck only)
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall with dens fracture, change in
mental status. Rule out vascular injury. CTA neck only.
TECHNIQUE: CTA neck with multiplanar reconstructions,
three-dimensional reconstructions.
FINDINGS: There is a plaque with ulceration at the origin of the
left internal carotid artery. The residual lumen at site of the
stenosis is approximately 3 mm. There is also an ulcerative
plaque seen in the right internal carotid artery at a similar
level without significant stenosis. The remainder of the
visualized vessels is within normal limits without stenosis,
extravasation or aneurysm formation. Calcified plaques are noted
in the aortic arch. The visualized soft tissue structures appear
unremarkable without pathologic enhancement. The visualized lung
portions are unremarkable without pneumo- or hemothorax. Mucosal
thickening is noted in the sphenoid and bilateral maxillary
sinuses without air fluid levels.
IMPRESSION: Plaque with ulceration at the proximal left internal
carotid artery with a residual lumen of 3 mm. This represents a
50% stenosis. Ulcerated plaque without significant stenosis in
the right proximal internal carotid artery. No active
extravasation.
PRELIMINARY REPORT: No active extravasation. Proximal right ICA
may contain a web as there is very focal narrowing. Proximal
left ICA has an area that may represent an ulcerative plaque or
early dissection. [**First Name8 (NamePattern2) **] [**Doctor Last Name 18954**] MDMBA
CT HEAD W/O CONTRAST [**2108-8-7**] 11:02 AM
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with agitation, s/p fall with dens fx
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CT SCAN OF THE BRAIN, [**2108-8-7**]
INDICATION: [**Age over 90 **]-year-old man with agitation after a fall and dens
fracture, rule out intracranial hemorrhage.
TECHNIQUE: Axial non-contrast CT scans of the brain were
obtained. Comparison is made to an MRI of the brain from
[**8-5**] and a CT scan of the brain from [**2108-8-5**].
FINDINGS:
There is no change in the appearance of the brain, compared to
previous studies. No acute hemorrhage is evident. There are no
abnormal extra-axial collections. There is no intracranial mass
effect or shift of structures. The ventricles are not dilated.
An old right cerebellar infarction and areas of white matter
hypodensity, likely chronic microvascular infarction, are noted
and unchanged.
There is mucosal thickening in the ethmoid and frontal sinuses
and a small amount of fluid in the right sphenoid sinus. The
mastoids are aerated.
IMPRESSION: Stable appearance of the brain, compared to recent
previous studies. No evidence of acute intracranial hemorrhage.
KNEE (AP, LAT & OBLIQUE) LEFT [**2108-8-8**] 1:38 PM
KNEE (AP, LAT & OBLIQUE) LEFT
Reason: r/o fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man s/p fall
REASON FOR THIS EXAMINATION:
r/o fx
INDICATION: [**Age over 90 **]-year-old man status post fall. Evaluate for
fracture.
THREE VIEWS OF THE LEFT KNEE:
There is a fracture of the inferior patella transfixed by a
cerclage wire. The fracture margins appear indistinct and old.
There is a joint effusion, with an equivocal fat-fluid level.
The oblique view demonstrates a vertical linear lucency with
could represent an more acute non- displaced fracture. If the
hardware in the patella was not placed in the past several weeks
or months, then that lucency does indeed represent a new non-
displaced patellar fracture. No other acute fracture is
identified about the knee.
IMPRESSION:
Old patellar fracture transfixed by cerclage wire. Probable new
nondisplaced patellar fracture.
ADDENDUM [**2108-8-10**] - Please note that the original house officer
dictation did not reflect the presence of the joint effusion or
suspected acute fracture. This change in [**Location (un) 1131**] was discussed
with [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**] on [**2108-8-10**] at 2:45 pm, who confirms that the old
patellar fracture was remote.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic Spine was
immediately consulted because of his cervical spine injuries.
Recommended non-surgical intervention with cervical collar for
2-3 months. Neurosurgery consulted for patient's cervical
fracture as well, recommendations for further radiologic imaging
to evaluate for any vertebral artery dissection and monitoring
neurological status. Vascular surgery consulted for likely
dissection of left ICA, recommendations for ASA for
anticoagulation; no Heparin given history falls; and re imaging
if patient develops signs and symptoms. Geriatrics consulted
given patient's mechanism of injury; delirium identified and
recommendations made re: treating his delirium; Olanzapine
started; bone densitometry while in rehab to screen for
osteoporosis and initiating Calcium with Vit D. Speech and
Swallow consulted for his dysphagia; bedside swallow study
performed. Recommendations for nectar thick liquids and ground
diet. Physical therapy consulted due to patient's decreased
functional mobility and falls; recommendations for rehab stay
after discharge from hospital. Patient sustained a mechanical
fall during his hospitalization; a head CT scan and films of his
left knee were obtained; no intracranial hemorrhage identified.
Knee films revealed questionable non displaced patellar
fracture, Orthopedics was consulted and recommended a knee
immobilizer and and follow up in 3 weeks.
Medications on Admission:
Aricept
Toprol
Trazadone
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Fall
C2 dens fracture
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your cervical collar for next [**9-12**]
weeks.
Follow up with Orthopedic Spine & Vascular Surgery after your
discharge.
Followup Instructions:
Follow up with Orthopedic Spine in [**3-7**] weeks after discharge,
call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up with Vascular Surgery, Dr. [**Last Name (STitle) **] in 4 weeks,
call [**Telephone/Fax (1) 2625**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
41401,4111,25000,2724,4019 | 20 | 157,681 | Admission Date: [**2183-4-28**] Discharge Date: [**2183-5-3**]
Date of Birth: [**2107-6-13**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with a 20 year history of hypertension and a ten year history
of Type 2 diabetes who demonstrated a positive exercise
stress test in [**2183-3-1**] suggestive for possible coronary
artery disease. The patient received a stress test as part
of a risk stratification workup and at no point demonstrated
any evidence of chest pain. A subsequent exercise MIBI study
performed [**2183-3-28**] revealed an exercise capacity of
only 2 minutes 15 seconds on the [**Doctor First Name **] protocol. There was
no chest pain noted on the test and the peak exercise
electrocardiogram showed 1.5 to 2 mm horizontal to upsloping
ST depression in the inferior leads and in V1 and V2.
Imaging studies revealed a large apical to a small anterior
defect that was reversible. The patient's ejection fraction
was noted to be 56% with normal wall motion. The patient
subsequently underwent a cardiac catheterization on [**2183-4-22**] which demonstrated three vessel coronary artery disease
and mild diastolic ventricular dysfunction. The patient was
thereafter referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for surgical
evaluation and was subsequently scheduled for a coronary
artery bypass graft on [**2183-4-28**].
HOSPITAL COURSE: On [**2183-4-28**], the patient underwent a
coronary artery bypass graft times three with grafts from the
left internal mammary artery to the left anterior descending,
saphenous vein graft to the right coronary artery and
saphenous vein graft to the obtuse marginal. The patient
tolerated the procedure well. The patient's pericardium was
left open. Lines were placed including an arterial line and
a Swan-Ganz catheter ; both atrial and ventricular wires were
placed; tubes placed included in a mediastinal and bilateral
pleural tubes. The patient was subsequently transferred to
the Cardiac Surgery Recovery Unit, intubated, for further
evaluation and management. Shortly after arriving in the
Cardiac Surgery Recovery Unit, the patient was easily weaned
and extubated without complication. On postoperative day #1,
the patient was noted to be stable for transfer to the floor
and was subsequently admitted to the Cardiothoracic Service
under the direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The patient's
postoperative course was uneventful and she progressed well
clinically. On postoperative day #1, the patient's chest
tube and Foley catheter were successfully removed without
complications. Follow up chest x-ray demonstrated no
evidence of pneumothorax, and the patient was noted to be
independently productive of adequate amounts of urine for the
duration of her stay. Physical therapy performed an initial
evaluation with the patient and followed her progress for the
duration of her stay. On postoperative day #3, the patient's
pacer wires were removed without complications and her
sternal incision was noted to be clean, dry and intact with
Steri-Strips in place. The patient was successfully advanced
to a regular diet, which she tolerated well and was noted to
have adequate pain control via oral pain medications. The
patient steadily advanced in her ability to ambulate freely
and was subsequently cleared for discharge to home by
physical therapy. The patient was subsequently cleared for
discharge to home on postoperative day #4, [**2183-5-3**], with
instructions for follow up.
CONDITION ON DISCHARGE: The patient is to be discharged to
home with instructions for follow up.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q.12 hours times ten days
2. Potassium chloride 20 mEq p.o. q. 12 hours times ten days
3. Colace 100 mg p.o. b.i.d.
4. Enteric coated Aspirin 325 mg p.o. q.d.
5. Percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain
6. Glipizide 5 mg p.o. q.d.
7. Lipitor 20 mg p.o. q.d.
8. Valsartan 160 mg p.o. q.d.
9. Lopressor 50 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain her
incisions clean and dry at all times. The patient may shower
but she is to pat dry the incisions afterwards; no bathing or
swimming. The patient may resume a regular diet. The
patient has been advised to limited physical activity; no
heavy exertion. No driving while taking prescription pain
medications. The patient has been advised to follow up with
her primary care provider within one to two weeks following
discharge. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]
within four weeks following discharge; the patient is to call
to schedule an appointment.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2183-5-3**] 23:29
T: [**2183-5-4**] 07:30
JOB#: [**Job Number 49530**]
|
41401,4111,25000,2724,4019 | 20 | 157,681 | Admission Date: [**2183-5-10**] Discharge Date: [**2183-5-12**]
Date of Birth: [**2107-6-13**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
woman status post coronary artery bypass grafting times three
on [**4-28**] and discharged home on [**5-3**], who the day prior
to admission noted increasing redness of her right lower
extremity at the saphenectomy site. She denied fevers,
chills or leg pain. She had no shortness of breath and
otherwise felt well.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass grafting. Non-insulin-dependent
diabetes mellitus. Hypertension. Arthritis. Total
abdominal hysterectomy. Appendectomy.
ALLERGIES: ZESTRIL.
MEDICATIONS: Lasix 20 b.i.d., Potassium Chloride 20 b.i.d.,
Colace 100 b.i.d., Aspirin 325 q.d., Glipizide 5 q.d.,
Lipitor 20 q.d., Valsartan 60 q.d., Lopressor 50 b.i.d.,
Percocet p.r.n.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.4??????, heart
rate 64 in sinus rhythm, blood pressure 156/43, respirations
20, oxygen saturation 98% on room air. General: Well
appearing in no acute distress. HEENT: Pupils equal, round
and reactive to light. Extraocular movements intact.
Anicteric. Noninjected. Neck: Supple. No lymphadenopathy.
Cardiovascular: Regular, rate and rhythm. Lungs: Clear but
with diminished breath sounds at the bases. Abdomen: Soft
and nontender. Positive bowel sounds. Extremities:
Dopplerable pulses of both dorsalis pedis and posterior
tibial bilaterally. Right lower extremity with multiple
areas of erythema and warmth. Tender to touch along the
saphenectomy site with scant serous drainage.
LABORATORY DATA: White count 14.1, hematocrit 30.5, platelet
count 494; sodium 136, potassium 4.9, chloride 101, CO2 22,
BUN 21, creatinine 1.1, glucose 195.
The patient at that time underwent a lower extremity
ultrasound to rule out deep venous thrombosis. The exam
showed no evidence of deep venous thrombosis.
HOSPITAL COURSE: The patient was admitted to
................... She was begun on Vancomycin and
Levofloxacin for her lower extremity cellulitis. Over the
next two days, the patient's cellulitis improved. On
hospital day #3, it was decided that she was stable and ready
for discharge to home.
At the time of discharge the patient's physical exam revealed
her vitals signs to be stable, afebrile and alert and
oriented times three. She moves all extremities. Breath
sounds were clear to auscultation bilaterally. Heart sounds
were regular, rate and rhythm. Sternal incision is healing
well with no erythema or purulence. Abdomen soft, nontender
and nondistended. Extremities with no edema. Right lower
extremity saphenous vein graft site incision clean and dry
with mild surrounding erythema decreased from the previous
day with no drainage at this time.
DISCHARGE MEDICATIONS: Lasix 20 mg b.i.d., Colace 100 mg
b.i.d., Aspirin 325 q.d., Percocet [**1-2**] tab q.[**4-6**] p.r.n.,
Glipizide 5 mg b.i.d., Lipitor 20 mg q.d., Valsartan 160 mg
q.d., Lopressor 50 mg b.i.d., Ciprofloxacin 500 mg p.o. q.12
hours x 10 days.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Non-insulin-dependent diabetes mellitus.
3. Hypertension.
4. Arthritis.
5. Total abdominal hysterectomy.
6. Appendectomy.
7. Cellulitis of the right lower extremity at saphenous vein
graft site.
DISPOSITION: She is to be discharged to home.
FOLLOW-UP: She is to have follow-up with her primary care
physician in two weeks. She is to follow-up with Dr. [**Last Name (STitle) 1537**] in
his office four weeks from the date of her initial discharge
from coronary artery bypass grafting; appointment to be made
by the patient.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2183-5-12**] 09:27
T: [**2183-5-12**] 09:32
JOB#: [**Job Number 49529**]
|
2749,43889,V1046,2720,1122,28521,25000,41401,4271,42731,5070,4592,4280,40391,5849,5781,78551,41071 | 21 | 109,451 | Admission Date: [**2134-9-11**] Discharge Date: [**2134-9-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
cardiac catheterization with placement of three stents and IABP.
Swan catheter placement.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 87 yo M with chronic kidney disease
s/p AV Graft placement [**8-2**], stroke, hypertension, diabetes, and
peripheral vascular disease presents with chest pain and
shortness of breath. He reports that his chest pain began
approximately one week ago. During the week it has gotten worse.
It is substernal, radiating to left shoulder, especially with
inspiration. It is associated with shortness of breath. He came
to the hospital today because the pain was much worse, [**9-6**]. In
addition, he noted today black stools. He has been taking iron.
He reports lightheadedness. Denies nausea, vomiting,
diaphoresis, arm paresthesias. He has also noticed a cough
recently but has not been able to produce sputum (though he
feels congested).
.
The pt was seen in Geriatric Urgent Care clinic on [**9-11**] for
dyspnea. He noted worsening in the supine position. An CXR at
the time to evaluate possible CHF showed "No evidence of
congestive heart failure or pneumonia. Elevation of the right
hemidiaphragm".
.
In the ED, the patient was given 80mg IV lasix x 2 with UOP of
100-200cc. He received nitropaste, lopressor IV and [**Last Name (LF) **], [**First Name3 (LF) **], and
morphine, and was started on a nitro gtt. Heparin was started as
well, and 1 unit PRBCs was transfused. He was given one dose of
protonix, levofloxacin and . BPs were in the 110s-120s/50s-60s,
HR 70s-80s. Renal, GI, and cardiology consults were called. The
patient continued to report [**9-6**] pain, eventually decreased to
[**6-6**] with titration of the nitro gtt. On arrival in the CCU, he
still reported [**6-6**] pain. He was on nitro at 120 mcg/min and
heparin at 850 units/hr.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertensive nephrosclerosis s/p right
upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis.
Graft placement was complicated by cellulitis, for which he was
treated with keflex
2. DM, on glyburide and glipizide at home
3. HTN, on clonidine, lisinopril, nifedipine
4. PVD s/p aortic bypass
5. CVA, with residual weakness of his left side
6. R CEA
7. Secondary hyperparathyroidism
8. Chronic anemia on procrit injections
9. Prostate CA on Lupron
10. Gout
Social History:
SOCIAL HISTORY: Lives at a senior facility in [**Location (un) 745**]. Has help
with cleaning, other chores. Denies alcohol and tobacco.
Family History:
Coronary artery disease
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, HR 75, BP 112/55, RR 28, Sao2 97%/4L O2 NC
HEENT: NCAT, PERRL, EOMI, dry mucous membranes, OP clear
Neck: JVP elevated approx 4cm above sternal notch
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Pulm: diffusely decreased BS on R. Bibasilar crackles.
Abd: soft, nontender, nondistended, BS+
Ext: warm and dry, 1+ pitting edema, 1+ bilateral pulses in PT
Neuro: alert and oriented, CN III-XII intact, moves all
extremities (strength not tested)
Pertinent Results:
EKG: NSR at 80bpm, axis in nl quadrant, QRS borderline, q waves
in V1-V3, ST depressions in I, II, aVL, V4-6, STE in V1-3,
biphasic TW in V4-6.
.
CXR [**2134-9-11**]: Interval development of perihilar patchy opacities
consistent with left ventricular heart failure.
CXR 8pm: read pending
.
[**2134-9-12**] Cath
COMMENTS:
1. Right heart catheterization revealed elevated right and left
sided
pressures. (PCWP = 25 mmhg).
2. Left heart catheterization revealed no evidence of systolic
hypertension. Calculated cardiac output and index were 5.0/2.8.
3. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The left main coronary
artery had
a 40% mid-vessel stenosis. The left anterior descending artery
had
diffuse proximal disease with serial 70-80% stenosis. The left
anterior
descending had mild diffuse disease in the mid and distal
segments. The
large first diagonal had an 80% proximal lesion. The left
circumflex
coronary artery had mild diffuse disease in the proximal, mid,
and
distal segments. There was a subtotal occlusion of the OM1.
The right
coronary artery was the dominant vessel. There was total
occlusion of
the right coronary artery in the proximal segment. The distal
RCA
filled via collaterals from the LCA septal branches.
4. No left ventriculography was undertaken given elevated Cr.
5. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a minivision 2.5 X 23 stent of the proximal OM1 with
lesion
reduction from 99 to 0%
6. Successful predilaton using a 2.0 X 20 Maverick balloon and
stenting
using 3.0 X 30 Driver stent of the proximal LAD with lesion
reduction
from 80% to 0%.
7. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a 2.25 X 15 minivision stent of the proximal D1 with
lesion
reduction from 80% to 0%. The final angiogram showed TIMI III
flow in
the vessels intervened with no residual stenoses in any of the
stents.
Thre was no distal embolisation or dissection noted in any
vessel.
8. Successful insertion of IABP via right femoral artery.
( see PTCA comments for the above procdures from 5 through to 8)
9. At the request of the renal consultants, a 12 French Dialysis
central
venous catheter was placed using the Seldinger technique in the
left
common femoral vein.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided pressures.
3. Preserved cardiac output/cardiac index.
4. Successful stenting of the OM, LAD and D1.
5. Successful insertion of IABP via right femoral artery.
6. Successful implantation of a central venous dialysis catheter
in the
left femoral vein.
URINE CULTURE (Final [**2134-9-23**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
>100,000 ORGANISMS/ML..
IDENTIFICATION BEING PERFORMED ON CULT# 196-9912C
[**2134-9-19**] AS
REQUESTED BY DR. [**Last Name (STitle) 9974**] ON [**2134-9-21**]..
Brief Hospital Course:
1. Rhythm: pt had 2 episodes of monomorphic VT accompanied by
fall in BP, LOC, terminated x 1 via precordial thumb.
Electrolytes were repeleted, pt was bolused with Amiodarone x 2,
and started on an Amio gtt. Amiodarone was then changed to po,
with a dosing schedule of 400 mg [**Hospital1 **] for one week, followed by
400 mg daily for one week, then 200 mg per day. Monomorphic VT
thought to be likely due to a fixed area of scarring from
previous MI. Placement of an ICD was discussed. However, given
the pt's poor prognosis for non sudden cardiac death reasons,
and given his increased infectious risk, it was decided to treat
his arrhythmia medically. Of note, the QT interval was
prolonged (506), likely secondary to amiodarone. Patient
remained in sinus rhythm on Amiodarone.
2. CAD: Pt with NSTEMI. Cath on [**9-12**] showed 3 vessel disease,
subsequently underwent successful stenting of OM, D1, LAD and
IABP placement. IABP was discontinued after the patient was able
to maintain his own pressure.
Echo completed on [**9-13**], which showed apical akinesis, with
severely depressed systolic function. Patient was initially
started on heparin and bridged to Coumadin, however, he had
another episode of guaiac positive stool, and given his history
of melena and coffee ground emesis, the risk for GI bleed was
thought to be high and anticoagulation was discontinued.
The patient was continued on an aspirin, Statin, beta blocker,
and was started on an ACE, all of which he will continue as an
outpatient. His swan and sheath were discontinued without
complications.
3.PUMP: CHF: EF 20% by ECHO
He was initially placed on Imdur/Hydral for afterload reduction
and an ACE was initially avoided in an attempt to salvage his
kidneys. However, he was eventually started on low-dose
lisinopril to be titrated up if necessary. Patient also
underwent hemodialysis on Mon/Wed/Fri schedule.
4. Renal: Chronic renal disease, secondary to hypertensive
nephrosclerosis, is status post graft placement with mature A-V
graft. Quentin catheter initially used, then discontinued once
graft accessible. On [**9-22**], graft noted to be difficult to
access per renal, patient underwent AV fistulogram, and
successful angioplasty was performed.
5. ID: Patient completed a seven day course of levofloxacin for
suspected pneumonia, white blood count noted to be persistently
elevated. Patient was pan cultured, and a urine culture was
positive for yeast. Foley catheter was discontinued and a
repeat culture was sent, also positive for [**Female First Name (un) **]. Patient
started on a 2 week course of Fluconazole. Blood cultures
pending at time of discharge, no growth to date.
6. Heme: anemia, likely anemia of chronic disease from chronic
renal disease. Patient also had an episode of melena and coffee
ground emesis, guaiac positive stool. Hematocrit was followed,
and patient was transfused as necessary to keep hematocrit above
30. Patient will need GI workup as an outpatient. Oral iron
supplementation was discontinued as patient receiving Fe in
addition to EPO and Procrit at hemodialysis
7. DM: Patient was started on glargine for persistent
hyperglycemia and covered with a regular insulin sliding scale
with Accu-Check to monitor.
8. Psych: Patient was continued on his home dose of Zoloft 100
mg once daily.
Patient tolerated a low Na/cardiac healthy diet and was placed
on a PPI for GI prophylaxis.
Patient was discharged to rehab facility with plan to follow up
with cardiology and PCP within the next month.
Medications on Admission:
. Nifedipine XL 60 mg daily
2. Calcitriol 0.25 mcg dialy
3. Lisinopril 2.5 mg once daily
4. Aspirin 325 mg once daily
5. Lasix 40 mg once daily
6. Glyburide 10 once daily recently changed to Glipizide
7. Clonidine 0.2mg [**Hospital1 **]
8. Zoloft 100mg daily
9. Simvastatin 40mg daily
10. Tums one tablet TID
11. Procrit injections 16,000 units q. week.
12. Lupron injections at Heme/[**Hospital **] clinic
13. Niferex 150 mg daily (supplemental iron).
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please continue to take twice a day for the next two
days. Please begin taking 400mg once a day on [**9-24**], and
continue for one week. Then please take 200mg once a day.
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Acute Coronary Syndrome
Congestive heart failure
chronic renal disease
urinary tract infection
Discharge Condition:
Good- patient hemodynamically stable and afebrile, heart rate
and rhythm has been well controlled.
Discharge Instructions:
We have started you on a new medication to help control your
heart rhythm, and a new medication to help control your blood
pressure. In addition, we have started you on a medication to
help treat a urinary tract infection. Please take these and all
of your medications as instructed. Please maintain all of your
follow-up appointments. Please return to the hospital if you
develop chest pain, shortness of breath, fevers, or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2134-10-14**] 2:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Known lastname 720**], M.D. Date/Time:[**2134-10-20**] 10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-11-24**] 10:00
You have an appointment scheduled with Dr. [**Last Name (STitle) **] at the [**Hospital 61**] [**Hospital 620**] campus on [**10-7**] at 10am. Please arrive
at 9:45am to register.
|
2449,4439,185,41401,2749,43889,2859,25000,V0980,99592,5720,00845,99859,6823,5119,70709,42731,40391,78552,0388,E8788 | 21 | 111,970 | Admission Date: [**2135-1-30**] Discharge Date: [**2135-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transfer from Nursing home for fever and elevated white count
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 yo M with PMH of DM, CAD, ESRD on HD who was transferred from
[**Hospital 26563**] Rehab to ED for eval of Fever.
.
Per referal note, patient 2 days ago developed increase
leukocytosis and delirim. Apparently, he was started on iv
vancomycin, Flagyl and Ceftazidime for PNA. On day of admission
patient developed a fever to 101.2, pulse 76 BP 102/68R 18 and
sat 92%. Blood Cx and Urine Cx were drawn.
.
Of note he was recently operated on by vascular [**Doctor First Name **] for a R sup
femoral and [**Doctor Last Name **] angioplasty and stenting along with Left femoral
patch angioplasty with bovine patch. He was discharged home on
Levoflox for probable RLL PNA
.
In the ED, VS 100.8 HR 85 BP 81/28 RR 20 Sats 95%. A femoral
line was placed and he was given 1000 cc NS. Given pooor
response, and after CVP measure 12, patient was started on
levophed and transfer to [**Hospital Unit Name 153**].
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertensive nephrosclerosis s/p right
upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis.
Graft placement was complicated by cellulitis, for which he was
treated with keflex
2. DM, on glyburide and glipizide at home
3. HTN, on clonidine, lisinopril, nifedipine
4. PVD s/p aortic bypass
5. CVA, with residual weakness of his left side
6. R CEA
7. Secondary hyperparathyroidism
8. Chronic anemia on procrit injections
9. Prostate CA on Lupron
10. Gout
Social History:
Denies past or present Tob, EtOH, or Illicit drug use. Was
living at a senior facility in [**Location (un) 745**] with his wife prior to
last admission. Now at [**Hospital 100**] Rehab.
Family History:
NC
Physical Exam:
T 99.7 BP 114/60 Hr 78 RR Sats 98% 4 L NC
General: Patient in mild apparent distress, alert, responding to
questions
HEENT: dry oral mucose, no LAD, JVD
Lungs: crackles bilaterally
CV: Regular heart sounds, soft holosystolic murmur RLSB
Back: sacral ulcers
Abdomen: BS +, soft, non tender non distended
Extremities: cold, distal pulses decreased, heel ulcers
bilaterally, necrotic. 3-4th underneath nail toe right foot
black. RU extremiti AVF , no trhill, no erythema.
Left upper extremity- picc line
Right femoral line in place
Neuro: patient alert, oriented to person, movilizing grossly all
extremities.
Pertinent Results:
[**2135-1-30**] 07:18PM LACTATE-1.6
[**2135-1-30**] 07:05PM GLUCOSE-200* UREA N-49* CREAT-4.2*#
SODIUM-137 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
[**2135-1-30**] 07:05PM CORTISOL-19.5
[**2135-1-30**] 07:05PM WBC-30.5*# RBC-3.05* HGB-9.1* HCT-29.6*
MCV-97 MCH-29.8 MCHC-30.7* RDW-16.9*
[**2135-1-30**] 07:05PM NEUTS-89* BANDS-1 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2135-1-30**] 07:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2135-1-30**] 07:05PM PLT SMR-NORMAL PLT COUNT-275
[**2135-1-30**] 07:05PM PT-18.1* PTT-31.7 INR(PT)-1.7*
Brief Hospital Course:
Assessment and plan:
87 yo M with MMP including DM, HTN, CAD, PVD on HD with L arm
fistula presents with septic shock.
.
1. Sepsis:
The pt was found to be hypotensive and febrile in the ED and
admitted through sepsis protocol. He was infused with muliple
boluses of normal saline, put on levophed for blood pressure
support. He was covered with broad spectrum antibiotic
empirically as culture data was sent. Blood cultures were found
to be positive for gram postive cocci which was ultimately shown
to be VRE. Vancomycin was changed to linezolid. The pt remained
hypotensive on pressors for the next several days and a work-up
was initiated to determine the source of infection. MRI of the
foot was pursued to r/o osteomyelitis, and a CT of the abdomen
was down to r/o an abdominal source of infection.
The CT Abdomen and pelvis showed possible abscess in liver
and spleen. There was also pancolitis. GI and Surgery were
[**Year/Month/Day 4221**] for assistance in the management of these problems.
For the pancolitis, the pt was kept NPO and he was treated for
possible c. diff infection while c. diff cultures were sent and
found to be positive. A RUQ U/S [**2135-2-2**] was pursued which showed
evidence of hypoechoic lesion could be flegmon or mass. It was
unable to be confirmed on imaging whether these lesions on CT
which were new compared with a previous scan in [**10-1**] were
abscesses vs possible mets from an unknown primary. IR was
[**Date Range 4221**] for possible drainage or biopsy, however option
declined given localization of lesions and the pts significant
bleeding risk. The GI team suggested an MRI to further evaluate
the liver lesions although this was unable to be pursued because
the pt was too unstable requiring pressors for bp support. A TTE
Echo was done to r/o endocarditis or abscess and was negative.
Head CT was negative for abscess as well.
.
2. CMO:
On the morning of [**2135-2-6**], the ICU team discussed with Mr
[**Known lastname **] wife and daughter the different alternatives for Mr
[**Known lastname **] care. It was explained that the feeling of the medical
staff and nurse staff was that Mr [**Known lastname **] has been extremily
uncomfortable with all the procedures that he undergoes during
the day. Despite giving pain medicines he has shown signs of a
lot of discomfort. We explained to the family that we would need
a NGT place in order to feed him and give him some of his
medicines now that he is having trouble swallowing given his
mental status. Also we have explained that we still not have a
clear dx on his liver lesions, and in order to obtained a dx he
might need a surgical intervention for biopsy. It would be a
long road ahead before he is able to go back to where he was
previously.
Ms [**Known lastname **] feels that her husband would not want to have all this
procedures done along the road and that we should change the
focus of care towards making him as comfortable as possible.
The antibiotics and pressors were d/c'ed. The plan was to
have no more dialysis. There were no more lab draws. A morphine
drip was started for pain. The pt remained arousable though
sleepy. His blood pressure was in the 80s-90s systolic off
pressors and his extremities continued to show evidence of
perfusion. On the evening of [**12-10**], he skin became more pale and
his sensorium less alert. At 2:08 am he was found to have ceased
respirations and was without a heart rate on the monitor. By
2:15 am he was pronounced deceased.
.
2. CAD: h/o MI.
Continued sinvastatin, aspirin until made CMO. BB and BP
medications were held in the setting of hypotension
.
3. Peripheral vascular disease: continued plavix, Aspirin until
CMO
The vascular team followed the pt.
.
4. DM: insulin sliding scale was continued before the pt was
made CMO.
.
#. ESRD: The pt continued to recieve periodic dialysis sessions
while in house until he was made CMO.
.
#. FEN:
He was kept NPO given the colitis and sepsis.
.
# Hypothyroidism: continued levothyroxine until CMO.
.
# PPX: Pantoprazole, pneumoboots until CMO.
.
#Code: DNR-DNI was changed to CMO on [**2-6**]
.
# Communication: Next of [**First Name8 (NamePattern2) **] [**Known lastname **], [**First Name3 (LF) **] wife, [**Numeric Identifier 26800**]
Medications on Admission:
1. Clopidogrel 75 mg qday
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Epoetin Alfa Injection
4. Sertraline 100 mg daily
5. Fexofenadine 60 mg [**Hospital1 **]
6. Amiodarone 200 mg qd
7. Aspirin 325 mg qday
8. Insulin Glargine 10u/hs.
9. Lisinopril 5 mg day
10. Multivitamin daily.
11. Oxycodone 5 mg q4h-6h
12. Pantoprazole 40 mg /day
13. Senna 8.6 mg [**Hospital1 **]
14. Levothyroxine 50 mcg /daily
15. Metoprolol Succinate 25 mg sustain release
16. Simvastatin 40 mg /daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
gram positive VRE sepsis
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
4019,29620,3488,E9503,E9502,9693,9678 | 22 | 165,315 | Admission Date: [**2196-4-9**] Discharge Date: [**2196-4-10**]
Date of Birth: [**2131-5-7**] Sex: F
Service: ICU
CHIEF COMPLAINT: Unresponsiveness
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female with a history of hypertension, depression, prior
suicide attempt by overdose, recently with exacerbated mood
disorder status post the death of her husband in [**2195-6-2**], now presented after being found unresponsive. The
patient's daughters found her in the morning of the day of
presentation, unresponsive with empty bottles of Ambien and
Zyprexa at the bedside. Pill count revealed that the patient
had likely taken 26 Ambien and 12 Zyprexa. The patient has
been unable to be alone secondary to depression with suicidal
ideation, and has been living with her daughters. They note
that the patient went to bed at 11 P.M. the night prior to
admission and was found at 11 A.M. unresponsive with
respiratory depression. The patient had seen her primary
psychiatrist the day before.
In the Emergency Department, the patient was charcoaled,
gastric lavaged, and intubated for airway protection. She
was hemodynamically stable. She was transferred to the
Intensive Care Unit.
In the Intensive Care Unit, the patient was able to open her
eyes, and was moving all four extremities and responsive to
command.
PAST MEDICAL HISTORY:
1. Hypertension
2. Depression with suicide attempt ten years ago by
overdose. The patient was hospitalized for two weeks at that
point. The patient's outpatient psychiatrist is Dr. [**Last Name (STitle) **].
ALLERGIES: No known drug allergies.
MEDICATIONS: Zyprexa 2.5 mg by mouth daily at bedtime,
Zestril 20 mg by mouth once daily, Ambien 10 mg by mouth
daily at bedtime, Estradiol 1 mg by mouth once daily,
nortriptyline 25 mg by mouth daily at bedtime, Klonopin 0.5
to 1 mg daily at bedtime, Biotin and calcium supplementation.
SOCIAL HISTORY: The patient lives with her daughter. [**Name (NI) **]
husband died in [**2196-1-2**]. The patient denied any
tobacco, alcohol or drug use.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: The patient's temperature was 97.7,
with a blood pressure of 130/65, pulse of 84, respiratory
rate of 14, and oxygen saturation of 100%. The patient was
ventilated on IMV pressure support with a rate of 14,
pressure support of 10, PEEP of 7.5, volume of 500, and 40%
FIO2. On general examination, the patient was a very
ill-appearing female, in no apparent distress. She was
intubated. Head, eyes, ears, nose and throat examination
revealed 1 to 2 mm nonreactive pupils. Neck examination
revealed no jugular venous distention and no bruits. Cardiac
examination revealed a regular rate and rhythm, normal S1 and
S2, and no murmurs, gallops or rubs. Pulmonary examination
revealed that the lungs were clear to auscultation
bilaterally. Abdominal examination revealed a belly that was
soft, nontender, nondistended, with normal bowel sounds.
Extremity examination revealed no edema, with 2+ dorsalis
pedis pulses bilaterally. Neurological examination revealed
a patient that was moving all four extremities, opening eyes
intermittently, withdrawing to pain. The patient had 2+ deep
tendon reflexes, and downgoing plantar reflexes.
LABORATORY DATA: The patient had a white blood cell count
of 5.1, hematocrit of 35.9, platelets of 259. The patient
had a sodium of 140, potassium of 4.4, chloride of 103,
bicarbonate of 28, BUN of 17, creatinine of 0.6, and glucose
of 102. The patient's INR was 1.1. The patient had an ALT
of 19, an AST of 26. Arterial blood gas was performed
post-intubation and was found to be pH of 7.47, PACO2 of 29,
and PAO2 of 287.
Electrocardiogram: Normal sinus rhythm at 80, with normal
axis, [**Doctor Last Name 1754**] and intervals, and ST elevations in V2 and
Lead I.
Other studies: Urine toxicology was negative, serum
toxicology was negative. Urinalysis revealed negative
nitrates, leukocytes, blood, no red blood cells, no white
blood cells, occasional bacteria, and less than one
epithelial cell.
Head CT: No signs of intracranial hemorrhage or mass effect.
HOSPITAL COURSE: The patient is a 64-year-old female with a
history of hypertension and depression with suicidal ideation
and previous history of overdose attempt, status post likely
overdose on Ambien and Zyprexa, status post intubation and
hemodynamically stable.
1. Toxicology: Patient with likely Ambien overdose and
Zyprexa overdose. Her symptoms of light coma, somnolence and
respiratory compromise were consistent with Ambien overdose.
The patient also had evidence of myosis, which was consistent
with Zyprexa overdose. The patient had been gastric lavaged,
charcoaled and supported in the Emergency Department. In the
Intensive Care Unit, the patient was supported with
intravenous fluids and gradually weaned on the ventilator to
the point where she was successfully extubated shortly after
arriving to the Intensive Care Unit.
2. Psychiatric: Patient with major depression, recently
exacerbated by the loss of her husband, now with a second
overdose attempt in her lifetime. Likely Zyprexa and Ambien
were the agents responsible. Multiple attempts were made in
the effort to contact the patient's outpatient psychiatrist,
Dr. [**Last Name (STitle) **]. She was unable to be reached. Psychiatry was
consulted, who felt that the patient needed inpatient
evaluation and treatment. They also recommended
psychotropics be avoided, and that the patient have a
one-to-one sitter. Social Work and Case Management were
consulted.
3. Cardiovascular: Patient was hemodynamically stable with
history of hypertension. Her antihypertensives were held.
Her electrocardiogram was unremarkable, although there were
no studies for comparison.
4. Pulmonary: Patient intubated secondary to decreased
mental status without a primary lung process.
Post-extubation arterial blood gas did not suggest any
obstructive lung process leading to hypercarbia or hypoxemia
from other pulmonary process. The examination was
unremarkable. A facile extubation was anticipated, and the
patient was extubated within several hours of arriving in the
Intensive Care Unit.
5. Psychosocial: Communication was maintained with the
patient's daughters, who also felt that the patient should
receive inpatient evaluation and treatment.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to an inpatient
psychiatric bed.
DISCHARGE MEDICATIONS: Zestril 20 mg by mouth once daily,
Estradiol 1 mg by mouth once daily.
DISCHARGE DIAGNOSIS:
1. Major depression
2. Ambien and Zyprexa overdose
3. Hypertension
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2196-4-10**] 02:10
T: [**2196-4-10**] 02:20
JOB#: [**Job Number 38050**]
|
V1582,V4579,V4581,2724,2720,4019,4241,78039,3485,2252 | 23 | 124,321 | Admission Date: [**2157-10-18**] Discharge Date: [**2157-10-25**]
Date of Birth: [**2082-7-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
[**2157-10-21**]: Left craniotomy for mass resection
History of Present Illness:
Mr. [**Known lastname 18661**] is a 75yo RHM with CAD s/p CABG, AS, HTN,
Hyperlipidemia, now here for resection of parasagittal
meningioma. Pt first noted symptoms three years ago with
dizziness, was evaluated in [**State 108**] where a head CT revealed L
frontal extraxial mass (~2cm per pt). Seen by a neurosurgeon in
[**State 108**] and told watchful waiting was best. However 6 weeks ago
the patient had an episode where his right lower extremity "gave
way." Occasionally "feels like wood." He underwent MRI scan
which revealed enlargement of the mass, with descriptions from
records documenting 2.5x3.4x2cm L frontal lobe extraaxial mass,
and also
a much smaller 12mmx8mmx4mm mass in the R temporal lobe (per
[**Hospital3 417**] report). He was started on decadron 1mg [**Hospital1 **].
Pt was scheduled for resection with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2157-10-22**].
However last night he was moving furniture, and upon moving a
bureau back into his home he developed a sensation of numbness
at his foot that travelled to his upper thigh over the course of
only a few seconds. He then noted rhythmic low amplitude shaking
of the limb that was not suppressable. His right arm then
extended outwards beyond his volitional control. His wife took
him to [**Hospital3 417**] where he was given ativan IV, loaded with
Fosphenytoin 1,000mg IV. The movements subsided in about 15
minutes. No loss of consciousness. No speech/language deficits.
No visual loss. He reports no further episodes since. Currently
feeling well. Denies any headaches. He does still feel a loss of
sensation in a stocking distribution of his right foot to his
ankle. When he walks he feels like he does not have command over
his right leg. No bowel or bladder dysfunction.
Past Medical History:
PMHx:
CAD- CABG x 4 ([**2153**]) here at [**Hospital1 18**]
HTN
AS- no syncopal symptoms.
Hypercholesterolemia
Past Surgical Hx:
Appendectomy
Bilateral Inguinal hernia repair
Anal fissure repair
Cholecystectomy
tonsillectomy and adenoidectomy
Social History:
Social Hx: married, retired electrical equipment designer with
three years of engineering training, Korean War Veteran,
Currently smokes pipe tobacco x last 55yrs, smoked cigarettes
during the war but none since, rare social ETOH use. No
illicits.
Family History:
Family Hx:
Mother- d. 93, CAD
Father- d. 73, Parkinson's Disease, CAD
Brother- d. 73, had hemo
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 97.3 BP: 118/70 HR: 71 R: 20 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. crescendo-decrescendo murmur best at RUSB radiates
throughout precordium and abdomen.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-29**] 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, 5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
sustained nystagmus at lateral end-gaze.
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 [**5-31**] throughout. No pronator drift
Sensation: Reduced to LT only on right foot in stocking
distribution to the ankle. Otherwise intact to light touch,
propioception, pinprick and vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2------> -
Left 2------> -
Toes mute bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Gait: good initiation, wide based, discoordinated stride with
right lower extremity, leans to the right. Absent Romberg.
Pertinent Results:
Labs on Admission:
[**2157-10-19**] 04:55AM BLOOD WBC-10.9 RBC-4.29* Hgb-13.4* Hct-38.9*
MCV-91 MCH-31.3 MCHC-34.6 RDW-14.4 Plt Ct-216
[**2157-10-19**] 04:55AM BLOOD Neuts-88.7* Lymphs-7.0* Monos-3.6 Eos-0.3
Baso-0.3
[**2157-10-19**] 04:55AM BLOOD PT-11.9 PTT-26.6 INR(PT)-1.0
[**2157-10-19**] 04:55AM BLOOD Glucose-141* UreaN-16 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-27 AnGap-13
[**2157-10-19**] 04:55AM BLOOD ALT-26 AST-21 AlkPhos-68 TotBili-0.8
[**2157-10-19**] 04:55AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.0 Mg-2.1
-------------------
IMAGING:
-------------------
MRI Head [**10-20**]:
FINDINGS: Limited post-contrast MRI of the brain demonstrates an
enhancing
left parafalcine lesion measuring approximately 2.1 x 3.3 x 3.5
cm. This
lesion is in close proximity to the adjacent sagittal sinus
although it does not appear to be involving the sinus. No other
abnormal enhancing lesions are identified. There is minimal
surrounding edema and no significant mass effect.
IMPRESSION: Dural-based enhancing lesion arising from the left
parafalcine
region with minimal mass effect and small amount of surrounding
edema. This
likely represents a meningioma.
MRI Head [**10-22**](post-op):
FINDINGS: Since the previous study, the patient has undergone
resection of
left parietal parafalcine extra-axial mass. Blood products are
seen in the
region with edema. Air is seen intracranially. Bilateral small
subdural
collections are seen. These findings are indicative of
post-operative change.No acute infarct seen. No midline shift or
hydrocephalus identified. No residual nodular enhancement is
identified.
IMPRESSION:
1. Status post resection of left parietal parafalcine mass with
expected
post-surgical changes of blood products and air in the region
and intracranial air and bilateral small subdural collections.
No acute infarct, mass effect, or hydrocephalus. No residual
nodular enhancement seen.
EEG [**10-20**]:
BACKGROUND: A 9 Hz posterior predominant rhythm was seen in the
brief
waking state.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from wakefulness to drowsiness but
did
not attain stage II sleep.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 60 bpm.
IMPRESSION: This is a normal predominantly drowsy routine EEG in
the
waking and drowsy states. There were no focal lateralize or
epileptiform features.
Brief Hospital Course:
Patient was admitted to the Neurosurgical service on [**10-18**]
following an episode of seizure. The patient underwent
resection of the left para-sagittal mass on [**10-21**]. He tolerated
this procedure well and remained neurologically unchanged
post-resection. He was taken to the ICU post-operatively for
close monitoring on POD0. On POD#1, he was transferred to the
neurosurgical floor. He was subsequently seen and evaluated by
PT and OT and was cleared for discharge home.
Medications on Admission:
Aspirin 81mg daily (currently held)
Tylenol PRN
Decadron 1mg [**Hospital1 **]
Amlodipine 5mg daily
Lisinopril 40mg daily
Simvastatin 40mg daily
Synthroid 50mcg daily
Decadron 2mg q6hrs
Dilantin 100mg PO TID
Nexium 40mg daily
Metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
left parasagital brain mass
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 shower from the neck
down. You will not need to have sutures removed, as Dr. [**First Name (STitle) **] has
used dissolvable sutures.
?????? 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:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-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 discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? You were on Aspirin, prior to your surgery. You may restart
this one week after your surgery.
?????? 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 taper, 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 [**8-5**] days (from your date of
surgery) a wound check(your sutures are dissolvable). This
appointment can be made with the Nurse Practitioner. 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.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-28**] at 10:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will / will not need an MRI of the brain with/ or without
gadolinium contrast. If you are required to have a MRI, you may
also require a blood test to measure your BUN and Cr within 30
days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **]
please make sure to have these results with you, when you come
in for your appointment.
Completed by:[**2157-10-25**] |
41401,4241,V4582,2724,4019,60000,3899,4111 | 23 | 152,223 | Admission Date: [**2153-9-3**] Discharge Date: [**2153-9-8**]
Date of Birth: [**2082-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, SOB, positive ETT
Major Surgical or Invasive Procedure:
[**2153-9-3**] Four vessel coronary artery bypass grafting(LIMA to LAD,
SVG to Diagonal, SVG to OM, SVG to PDA)
History of Present Illness:
This is a 71 year old male with known CAD. He underwent PTCA to
LAD and diagonal in [**2145**]. Prior to hernia repair operation, an
ETT in [**2153-7-27**] was notable for EKG changes. An ECHO in [**Month (only) 205**]
[**2153**] was notable for mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AS. The [**Location (un) 109**] was
estimated at 1.1 cm2 with peak/mean gradients of 34 and 22 mmHg.
The was mild concentric LVH with an LVEF of 60%. He was
subsequently referred for cardiac catheterization. This was
performed at the [**Hospital1 18**] on [**2153-8-16**]. Angiography showed a right
dominant system with 80% ostial LAD lesion; first diagonal had a
60% stenosis; the circumflex had a 60% lesion while the RCA had
a 40% stenosis. There was only mild AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.8 cm2
and mean gradient of 18mmHg. Left ventriculogram showed
preserved LV function. Based on the above results, he was
referred for CABG.
Past Medical History:
CAD - s/p PTCA, HTN, Hypercholesterolemia, BPH, Hernia,
Decreased hearing, s/p L knee arthroscopy, s/p appy
Social History:
50 year history of pipe smoking. Admits to [**5-2**] ETOH drinks per
week.
Family History:
No premature CAD
Physical Exam:
Temp 98.0, BP 126/74, HR 61, Resp 18(sat 98% on RA)
General: elderly male in NAD
Neck: supple, no JVD
HEENT: benign
Lungs: clear bilaterally
Heart: regular rate and rhythm, 4/6 SEM radiating to carotids
Abdomen: benign
Ext: warm, no edema, no varicosities
Neuro: nonfocal
Pulses: 2+ distally, no femoral bruits
Pertinent Results:
[**2153-9-8**] 10:00AM BLOOD Hct-26.1*
[**2153-9-5**] 05:55AM BLOOD WBC-8.6 RBC-2.89* Hgb-9.3* Hct-25.7*
MCV-89 MCH-32.0 MCHC-36.0* RDW-13.8 Plt Ct-113*
[**2153-9-6**] 05:45AM BLOOD UreaN-20 Creat-0.8 K-3.8
[**2153-9-5**] 05:55AM BLOOD Glucose-115* UreaN-20 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2153-9-6**] 05:45AM BLOOD Mg-1.9
Brief Hospital Course:
Patient was admitted and underwent four vessel CABG on [**2153-9-3**] by
Dr. [**Last Name (STitle) **]. Surgery was uneventful - see op note for further
details. Following the operation, he was brought to the CSRU in
stable condition. There he was weaned from inotropic support and
was extubated without difficulty. He was noted to have some
ventricular ectopy which improved after intravenous Lidocaine
and PO beta blockade. K and Mg levels were monitored closely and
repleted per protocol. He otherwise maintained stable
hemodynamics. Units of PRBCs were intermittently transfused to
maintain hematocrit close to 30%. On POD 1, he transferred to
the SDU. He remained in a normal sinus - no further ventricular
ectopy was noted. Beta blockade was slowly advanced as
tolerated. Over several days, he made clinical improvements. By
discharge, he was near his preoperative weight with oxygen
saturations over 96% on room air. He also worked daily with
physical therapy and made steady progress. His hospital course
was otherwise uneventful and he was cleared for discharge to
home on POD 5. He is scheduled to follow up with Dr. [**Last Name (STitle) **] and
his local cardiologist in approximately 4 weeks.
Medications on Admission:
Isordil 20 [**Hospital1 **], Lescol 40 qd, Accupril 40 qd, Hytrin 5 qd, HCTZ
12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, Cartia 80 qd, KCL 20 [**Hospital1 **], TNG prn
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. 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. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 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 DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*50 Tablet(s)* Refills:*0*
9. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p CABGx4 (Lima->LAD, SVG->Diag, SVG->OM, SVG->PDA)
PMH: CAD s/p PCI, HTN, ^chol, BPH, Hernia repair
Discharge Condition:
Good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 1 week
Dr [**Last Name (STitle) **] in [**3-30**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2153-9-20**] |
41041,41401,53081,25000 | 24 | 161,859 | Admission Date: [**2139-6-6**] Discharge Date: [**2139-6-9**]
Date of Birth: [**2100-5-31**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Inferior MI
Major Surgical or Invasive Procedure:
Cardiac catheterization with 4 overlapping stents to RCA
History of Present Illness:
39 yo male with history of GERD woke up w/ SOB and LUE
discomfort 1 day PTA. He presented to [**Hospital1 1474**] where he was
ruled out for MI by enzymes. He underwent stress test the
following day at [**Hospital1 1474**]. He developed SOB and shoulder pain
during the test. The stress test was discontinued and he
reportedly had STE inferiorly and w/ inf WMA on echo. He was
transferred to [**Hospital1 18**] for cath. At cath, he had 90% prox RCA &
80-90% mid-distal RCA lesions s/p 4 TAXUS stents w/ PCWP 17,
hemodynamically stable throughout.
.
Post-procedure he was doing well, no SOB, no CP on arm
discomfort and admitted to the CCU for monitoring.
Past Medical History:
GERD
Social History:
Works as police officer, lives alone, never married, no
children; + tobacco 1p/week x 5 yrs, quit yesterday, occ EtOH
last drink 4 days ago, no IVDU;
Family History:
father w/ MI's in 60's, + DMII;
Physical Exam:
97.1 123/78 12 100% 2L NC
Gen: cauc M lying in bed flat in NAD, alert, Ox3.
HEENT: anicteric
Neck: thick neck, no masses
Heart: RRR, S1, S2, no m/r/g
Lungs: CTBLA, no rales, no wheezing
Abd: NABS/S/NT/ND/no masses, no HSM
Ext: no edema
Pertinent Results:
Labs:
@ [**Hospital1 1474**] [**2139-6-5**]
Na 137 K 4.1 Cl 102 CO2 27 BUN 13 creat 1.0
glu 148 Ca 9.1 alb 4.2 T.bili 0.6 [**Doctor First Name **]/lip wnl alp phos 87
ALT/AST 167/71
.
# 1 CK 314 MB 1.2 TNI <0.10
# 2 CK 273 MB 3.6 TnI 1.0 [ref 0.0-0.4]
# 3 235 3.5 0.9
# 4 210 2.3 0.8
.
wbc 9 hct 43.5 plt 222 INR 1.0 PTT 22
chol 236 LDL 154 HDL 33 Trig 244
.
EKG: [**6-5**] 9am TW flattening inferior and 1mm STE in III;
post cath: TWI in III, aVF; q in III, hyperacute T's.
.
Cath: [**2139-6-6**]
LMCA 30%, distal LAD diffuse 40%, mid 50% prox large D1
LCx nl, RCA 99% prox w/ thrombus, TIMI 2 distal flow, diffuse
60-70% throughout mid-distal RCA
S/P 4 overlapping TAXUS stents to RCA
mean PCWP 17, RA mean 12
.
Echo [**2139-6-6**]
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). No abnormal regional left ventricular wall
motion is seen. The inferior wall is not well seen.
2. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
.
Rad @ [**Hospital1 1474**] by report: [**2139-6-5**]
CXR no acute disease
RUQ U/S cholelithiasis w/ gallstone possibly impacted in GB
neck;
Abd aorta U/S no aneurism, max diameter 2.7cm;
Hida scan - no cystic or CBD obstruction, wnl;
.
[**2139-6-9**] 07:10AM BLOOD WBC-9.1 RBC-4.56* Hgb-14.4 Hct-41.2
MCV-90 MCH-31.6 MCHC-34.9 RDW-12.7 Plt Ct-213
[**2139-6-9**] 07:10AM BLOOD Plt Ct-213
[**2139-6-7**] 04:00AM BLOOD PT-12.4 PTT-22.5 INR(PT)-1.0
[**2139-6-7**] 04:00AM BLOOD WBC-9.8 RBC-4.44* Hgb-14.1 Hct-40.4
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.8 Plt Ct-203
[**2139-6-6**] 06:54PM BLOOD Plt Ct-215
[**2139-6-9**] 07:10AM BLOOD Glucose-114* UreaN-11 Creat-1.0 Na-141
K-4.0 Cl-104 HCO3-26 AnGap-15
[**2139-6-6**] 06:54PM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-14
[**2139-6-7**] 04:00AM BLOOD ALT-166* AST-65* CK(CPK)-120 AlkPhos-93
TotBili-0.5
[**2139-6-7**] 04:00AM BLOOD CK-MB-3 cTropnT-0.04*
[**2139-6-9**] 07:10AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.2
[**2139-6-6**] 06:54PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
39 yo male with history of GERD admitted with IMI.
.
IMI - His EKG and cardiac enzymes were consistent with IMI. He
has risk factors that included family history and
hypercholesterolemia and tobacco use. He had a stent placed in
the RCA and was given aggrastat post cath for 18 hours. He was
continued on ASA, started on maximum dose statin, beta blocker
and ACE inhibitor, plavix. He should remain on plavix for at
least 6 months. Echo showed preserved EF. He was also counseled
on smoking cessation and diet/nutrition.
.
Hypercholesterolemia - He was started on maximum dose statin,
80mg atorvastatin. If his triglycerides remain elevated,
gemfibrozil could be added as an outpatient.
Elevated glucose: He may have glucose intolerance. He was
counseled on a low sugar diet and should have this followed up
by his PCP. [**Name10 (NameIs) 61986**] he can be managed with diet control only.
Transaminitis - He likely has NASH given hypercholesterolemia
and obesity; His
hepatitis serologies were pending at time of discharge. His
LFT's should be followed up in 6 weeks with initiation of statin
therapy.
Medications on Admission:
Outpt Meds: aciphex
Meds on transfer: ASA, plavix, lopressor, aggrastat
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:*6*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Aciphex 20 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:*6*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior MI
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Follow up with your cardiologist in [**Hospital1 1474**], Dr. [**Last Name (STitle) **], within
1 month.
Take your new medications as precribed. You must take plavix
every day for at least 6 months or until told to stop by your
cardiologist.
You are encouraged to go to cardiac rehab.
You should eat a low sugar diet as you are at risk for
developing diabetes.
Followup Instructions:
Follow up with your cardiologist in [**Hospital1 1474**], Dr. [**Last Name (STitle) **], within
1 month.
Follow up with your PCP with regards to possible early signs of
diabetes.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
4019,41401,25011,41071 | 25 | 129,635 | Admission Date: [**2160-11-2**] Discharge Date: [**2160-11-5**]
Date of Birth: [**2101-11-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
transferred from OSH for DKA, r/o MI
Major Surgical or Invasive Procedure:
s/p cardiac catheterization with stenting of left circumflex
artery
History of Present Illness:
58 yo male with hx type 1 DM on insulin pump, ?vertigo, no known
[**Hospital **] transferred to CCU for management of presumed DKA in the
setting of new EKG changes and borderline enzymes. No previous
CAD history althouth cath in '[**41**] reported to be negative with
subsequent negative stress test. Pt has history of vertigo with
recent flare after fall from slipping on ice. Otherwise, pt was
in USOH until 1 day prior to admission when his insulin pump
fell out at 2am. Pt took some short acting insulin, but no
lantus. Pt developed worsening nausea followed by several
episodes of emesis. Denies chest pain, SOB, diaphoresis. In OSH
[**Name (NI) **], pt was afebrile, hemodynamically stable, but found to have
blood sugar to 555, bicarb 18, anion gap 25, and ABG 7.27/38/73.
EKG was performed which showed diffuse ST depressions in V3-V6,
1, 2, AVF which were new from EKG from [**3-16**]. CPK and Tn were
negative but given DM, he was started on IV heparin and
integrillin and transfered to [**Hospital1 18**] for cath. Per OSH report,
head CT and CXR were negative. Repeat EKG showed decreased ST
depressions with 2nd Tn of 0.11 and CPK 153/MB 12. Recent
increased anion gap closed to 18. Pt remained chest pain free on
transfer to [**Hospital1 18**].
.
ROS: negative for recent fever, chills, cough, URI symptoms,
abdominal pain, diarrhea, constipation, dysuria, urinary
symptoms. Pt denies CP, SOB, PND, orthopnes, LE edema
Past Medical History:
Type I DM since [**2125**], on insulin pump
?vertigo
Spinal fusion, [**2155**]
R knee surgery
Social History:
quit tobacco 20 years ago, smoked 6-7 years
Denies ETOH; history of alcohol abuse
Denies drugs
Lives with wife
works as plumbing/electrician
Family History:
CAD in father and grandfather
Physical Exam:
VS: p96.2, p60, 90/44, 18, 100% 2L, FS 393
Pertinent Results:
[**2160-11-2**] 01:05AM WBC-12.2* RBC-4.17* HGB-13.1* HCT-37.9*
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0
[**2160-11-2**] 01:05AM PLT COUNT-269
[**2160-11-2**] 01:05AM NEUTS-84.6* BANDS-0 LYMPHS-9.5* MONOS-5.2
EOS-0.5 BASOS-0.2
[**2160-11-2**] 01:05AM PT-12.8 PTT-34.6 INR(PT)-1.0
[**2160-11-2**] 01:05AM GLUCOSE-378* UREA N-50* CREAT-1.6* SODIUM-134
POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-23 ANION GAP-19
[**2160-11-2**] 01:05AM CK(CPK)-153
[**2160-11-2**] 01:05AM CK-MB-12* MB INDX-7.8* cTropnT-0.11*
.
EKG (OSH): SR@80, nl axis/interval, borderline 1 degree AVD,
26-mm ST depressions in V3-V6, 2-3mm ST depressions in 2,3,f;
?ST elevation in V1, low limb voltage
.
old EKG ([**3-16**]): sinus brady @80 with atrial ectopy, low limb
voltage, nl axis/interval, no ST changes
Brief Hospital Course:
1. CAD: Initial EKG showed marked depressions in v3-6. On
admission to the CCU, art line was placed, after which pt was
noted to be bradycardic to the 40s and hypotensive to 70s
according to the art line. Pt was bolused with IVF without
significant increase in BP. Dopamine was started. Pt was
asymptomatic. Pt was taken emergently to the cath lab as we were
concerned about acute ischemia. Pt was found to have diffuse
disease and 60-70% stenosis of LCx. In retrospect, pt's
hypotensive episode was most likely spurious, as the arterial
line BP and cuff pressures did not correlate. Cuff pressures did
not drop below 90s systolic during the entire time. Pt may have
some arterial stenosis which led to spurious BP. By cardiac
enzymes, pt was found to have NSTEMI with peak CK of 573 and
peak Tn of 1.09. Pt was started on Aspirin, Statin, plavix. BB
and ACE were initially held in setting of "hypotension", but
then was started. Later, decision was made to perform another
cath and to stent the LCx lesion which was done successfully.
2. DM: Pt was admitted in DKA with AG 17. He was started on
insulin drip and IVF and frequent electrolyte checks/repletions.
Gap was successfully closed. Pt was transitioned to insulin
pump.
Medications on Admission:
Insulin pump
neurontin
Isopril
Actos
Lasix 80 qd
ASA 325mg 2 tabs qhs
alleve prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin Pump Eng/French R1000 Misc Sig: One (1) Miscell.
once a day.
9. Neurontin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
Disp:*270 Capsule(s)* Refills:*2*
10. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Glyset 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p non-ST elevation MI
DKA
Discharge Condition:
Stable
Discharge Instructions:
If you develop chest pain or difficulty breathing, call your
doctor or return to the emergency room
Followup Instructions:
Follow up with your primary care doctor: [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**Telephone/Fax (1) 17663**]
|
99604,4271,4280,42731,41401,412,5939,2720,60000 | 26 | 197,661 | Admission Date: [**2126-5-6**] Discharge Date: [**2126-5-13**]
Date of Birth: [**2054-5-4**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old male
with coronary artery disease status post myocardial
infarction, CHF with an ejection fraction of 15% and ICD for
DF/VT. Here for possible ICD malfunction after he was
shocked three times at home the night before admission to an
outside hospital. The first shock occurred on the morning
prior to admission with no preceding symptoms. The second
shock occurred while walking downstairs, and he reported
reaching out his arm. Third shock occurred shortly after
this when he was reaching out with his left hand, and the
final and fourth shock occurred when he was reaching out in
bed with his left arm and received multiple shocks in a row.
At the outside hospital, the patient had a magnet placed over
his ICD, and was given magnesium sulfate. He was
hemodynamically stable, and had no complaints otherwise.
On review of symptoms, the patient reported occasional
orthostatic hypotension, but denied chest pain, shortness of
breath, nausea, or vomiting. The patient denies fever or
chills. Denied bloody stools or black stools. The patient
denied orthopnea, PND, or dyspnea.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
and ischemic cardiomyopathy.
2. ICD for VF with second SVC coil because of high DFTs with
three-lead fracture in 03/99.
3. Atrial fibrillation.
4. Chronic renal insufficiency.
5. CHF with an EF of 15%.
6. Hypercholesterolemia.
7. Obesity.
8. History of unsuccessful VT ablation.
9. Osteoarthritis.
10. BPH.
11. Reactive airway disease.
12. Diabetes mellitus type 2.
MEDICATIONS:
1. Toprol 50 b.i.d.
2. Vasotec 10 b.i.d.
3. Lasix 40 b.i.d.
4. Imdur 60 q.d.
5. Lanoxin 125 mcg.
6. Levoxyl 125 mcg.
7. Lipitor 40.
8. Plavix 75.
9. Spironolactone 25.
10. Dofetilide 250 q.d.
11. Coumadin 10 two days a week, 7.5 five days a week.
SOCIAL HISTORY: Patient reports coronary artery disease in
his father. [**Name (NI) **] also has a 50 pack year smoking history, but
quit 34 years ago. He denies alcohol use.
ALLERGIES: Shellfish and IV dye, which causes hives, and
amiodarone which caused edema.
PHYSICAL EXAM ON ADMISSION: Temperature 97.7, heart rate of
80, blood pressure 86/52, respiratory rate 16. Saturating
97% on room air. Patient was alert and oriented times three
in no acute distress. Neck was supple. Pupils are equal,
round, and reactive to light. Clear oropharynx. There was
no JVD and no carotid bruits. Cardiovascular reveals
regular, rate, and rhythm with occasional irregular beats.
Faint systolic ejection murmur at the left lower sternal
border. Respiratory: Lungs are clear to auscultation
bilaterally. The abdomen was soft, nontender, nondistended.
Extremities revealed trace bilateral lower extremity edema.
SUMMARY OF HOSPITAL COURSE:
1. Cardiac rhythm: Patient is admitted with multiple shocks
from his ICD. The shocks had occurred when the patient was
using his left arm predominantly. This is likely due to the
fact that there was a device malfunction. The device was
interrogated, and found to be oversensing noise from certain
arm movements. The device was turned off and programmed DDD.
The INR was 2.5, so the patient was given vitamin K with plan
for future need revision.
Overnight the patient had a four-second pause on telemetry,
although the patient was asymptomatic. The patient returned
to the Electrophysiology Laboratory and had a pacing catheter
placed. The patient was transferred to the CCU on [**2126-5-7**] for further monitoring in the setting of transvenous
pacing. The patient remained comfortable and when his INR
trended down, he returned to the EP Laboratory for device
revision and lead revision. Patient tolerated the procedure
well.
After this, the patient returned to the [**Hospital3 **]
floors and received multiple shocks on the morning, which
were appropriate for ventricular tachycardia. The patient's
pacemaker was interrogated and found to be functioning well.
It was reprogrammed to over pace out of ventricular
tachycardia prior to shocking. The patient had additional
episodes of ventricular tachycardia, which were successfully
paced out of by his pacemaker. Patient was started on
lidocaine drip given his significant ventricular tachycardia
and the episodes of VT diminished significantly. The patient
was transitioned to mexiletine on the next day, and tolerated
this well. The patient had no further episodes of
significant ventricular tachycardia.
2. Coronary artery disease: The patient currently had no
symptoms. He was continued on his Plavix, statin,
beta-blocker, and Imdur. Patient was not admitted on an
aspirin, although he was given an aspirin during his
hospitalization given the fact that was Coumadin was held.
Plan for no aspirin on discharge with resuming his Coumadin
as per his prior home regimen.
3. Congestive heart failure: Patient has an ischemic
cardiomyopathy with an ejection fraction of less than 20%.
An echocardiogram on this hospitalization again revealed an
ejection fraction of 15-20%. While the patient was NPO
during episodes of this hospitalization, his Lasix and
aldactone was held; however, he was continued on his Lasix,
aldactone, digoxin, and ACE inhibitor. Patient had no
evidence of congestive heart failure during this
hospitalization and he resumed his prior medications before
discharge.
4. Endocrine: Patient with hypothyroidism: The patient was
continued on his Levoxyl. He was also maintained on a
regular insulin-sliding scale. Blood sugars remained in
normal levels, and he did not require significant amounts of
insulin.
5. Renal: Patient with chronic renal insufficiency.
Remained stable throughout this hospitalization.
6. Heme: Patient's INR was reversed with vitamin K, and the
patient was instructed to resume Coumadin dosing on the
evening following discharge. The patient will follow up with
his cardiologist or primary care physician for further
monitoring of his INR and adjustment of his Coumadin dose.
7. ID: The patient had a temperature greater than 101.5
following his pacemaker placement, and therefore was
continued on his cephalosporin, which was originally given
for prophylaxis. The patient was transitioned to p.o.
antibiotics, plan for seven-day course.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. ICD firing.
2. ICD revision.
3. Ventricular tachycardia.
DISCHARGE MEDICATIONS:
1. Furosemide 40 b.i.d.
2. Spironolactone 25 q.d.
3. Plavix 75 q.d.
4. Atorvastatin 40 q.d.
5. Levothyroxine 125 mcg.
6. Digoxin 125 mcg q.d.
7. Mexiletine 150 p.o. b.i.d.
8. Isosorbide mononitrate 30 q.d.
9. Enalapril 2.5 q.d.
10. Dofetilide 125 b.i.d.
11. Ibuprofen prn.
12. Metoprolol succinate 25 q.d.
13. Keflex 500 t.i.d. for three days.
14. Coumadin 7.5 mg p.o. q.d.
FOLLOW-UP PLANS: The patient will follow up with his primary
care physician in the week following discharge. In addition
to this, the patient will follow up with the
electrophysiologist, Dr. [**Last Name (STitle) **], on [**6-7**] in addition
to his appointment in Device Clinic on [**5-29**].
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2126-5-15**] 20:55
T: [**2126-5-17**] 08:54
JOB#: [**Job Number 20814**]
|
4263,2720,25000,412,496,4111,41401,30029,V1582,V4582,V174 | 28 | 162,569 | Admission Date: [**2177-9-1**] Discharge Date: [**2177-9-6**]
Date of Birth: [**2103-4-15**] Sex: M
Service: CSU
REASON FOR ADMISSION: Mr. [**Known lastname 26211**] is a postoperative admit
admitted directly to the Operating Room on [**9-1**]. He
was seen preoperatively on [**8-26**] after cardiac
catheterization.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26211**] is a 74-year-old man
with known CAD, had an MI and 79 and PTCA of his LAD and RCA
and [**2169**]. He had a stent to his diagonal in [**2175**], reports
dyspnea on exertion over the past several months accompanied
by leg cramps. Denies any chest pain, nausea, vomiting,
diuresis, syncope. Stress echo done recently shows an EF of
25 percent with anterior septal akinesis, septal and anterior
wall ischemia. A cath done at an outside hospital showed
three-vessel disease. Cath on [**8-26**] done at [**Hospital1 **] [**Hospital1 **]
showed an EF of 30 percent with anterior hypokinesis, left
main 60 percent LAD with a complex ostial lesion, left
circumflex with 100 percent OM-2 and RCA with 100 percent
proximal lesion.
PAST MEDICAL HISTORY: CAD status post MI, left bundle branch
block, COPD, hyperlipidemia, claustrophobia, diabetes
mellitus type 2.
PAST SURGICAL HISTORY: None.
ALLERGIES: States allergy to tetanus vaccine which causes
hives.
MEDICATIONS ON ADMISSION:
1. Pravachol 80 once daily.
2. Plavix 75 once daily.
3. Imdur 60 once daily.
4. Lopressor 25 once daily.
5. Ecotrin 325 once daily.
6. Flomax 0.4 at bedtime.
7. Amaryl 1 mg once daily.
8. Lisinopril 5 mg once daily.
9. Advair inhaler b.i.d.
SOCIAL HISTORY: Lives with his wife and [**Name (NI) 26671**]. Retired
police officer. Tobacco: Quit 3 years ago with EtOH rare
use.
FAMILY HISTORY: Has a brother with CAD.
PHYSICAL EXAMINATION: Height 6 feet. Weight 220. Vital
signs: Heart rate 65 sinus rhythm, blood pressure 104/50,
respiratory rate 12, O2 sat 96 percent on room air. General:
Lying flat in bed in no acute distress. Neuro: Alert and
oriented times three. Moves all extremities, nonfocal exam.
Respiratory: Clear to auscultation. Cardiovascular:
Regular rate and rhythm. S1-S2 with no murmurs, rubs or
gallops. No carotid bruits and no edema. Abdomen: Soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with no edema. No
varicosities. Left groin with dry sterile dressing and no
hematoma. Pulses: Radial are two plus bilaterally. Dorsalis
pedis and posterior tibial both one plus bilaterally.
LABORATORY DATA: White count 6.3, hematocrit 35.7, platelets
176, sodium 137, potassium 4.2, chloride 100, CO2 19, BUN 28,
creatinine 1.3, glucose 123, ALT 22, AST 14, alk phos 53,
total bili 0.3, albumin 3.4, PT 14.4, PTT 110.6, INR 1.3.
HOSPITAL COURSE: On [**9-1**], the patient was a direct
admission to the Operating Room. Please see the OR report for
full details. In summary, he had a CABG times five with a
LIMA to the LAD, saphenous vein graft to the PDA with a
sequential graft to OM-2, saphenous vein graft to the
diagonal with a sequential graft to OM-1. His bypass time was
101 minutes with a cross-clamp time of 67 minutes. He was
transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit. At the time of transfer, the patient was
AV paced at 86 beats per minute with a mean arterial pressure
of 58 and PAD of 17. He had propofol at 15 mcg/kg/min,
epinephrine at 0.02 mcg/kg/min and insulin at 2 units per
hour.
The patient did well in the immediate postoperative period.
His sedation was discontinued. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated
on postoperative day one. The patient continued to be
hemodynamically stable. He was weaned from his epinephrine
infusion. His chest tubes were discontinued. His PA catheter
was removed and he was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. His temporary pacing wires were removed
on postoperative day three. His activity was slowly advanced
with the assistance of the nursing staff as well as the
Physical Therapy staff. On postoperative day four, it was
decided that the patient will be ready and stable for
discharge to home on the following day.
PHYSICAL EXAMINATION: At this time the patient's physical
exam is as follows. Temperature 98.5, heart rate 83 sinus
rhythm, blood pressure 124/54, respiratory rate 18, O2 sat 96
percent on room air. Weight preoperatively was 100 kg, at
discharge is 105.3.
LABORATORY DATA: Sodium 138, potassium 4.7, chloride 101,
CO2 29, BUN 25, creatinine 1.1, glucose 156, magnesium 2.0,
white count 8.5, hematocrit 31.2, platelets 119.
PHYSICAL EXAMINATION: Neurologic: Alert and oriented times
three. Moves all extremities, nonfocal exam. Pulmonary:
Clear to auscultation bilaterally. Cardiac: Regular rate
and rhythm. S1-S2 with no murmur. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with 1-2 plus edema
bilaterally. Sternal incision: Sternum is stable. Incision
with dry sterile dressing, clean and dry. No erythema. Leg
incision on the left knee with Steri-Strips open to air. The
left leg is somewhat ecchymotic.
CONDITION ON DISCHARGE: The patient's condition at time of
discharge is good.
DISPOSITION: He is to be discharged to home with visiting
nurses.
DISCHARGE DIAGNOSES: CAD status post coronary artery bypass
grafting times five with LIMA to LAD, saphenous vein graft to
the PDA with a sequential graft to OM-2, saphenous vein graft
to diagonal with a sequential graft to OM-1.
COPD.
Hypercholesterolemia.
Diabetes mellitus type 2.
Left bundle branch block.
FOLLOW UP: The patient is to have follow-up with Dr.
[**Last Name (STitle) 26672**] in [**12-24**] weeks and follow-up with Dr. [**Last Name (STitle) 1860**] or Dr.
[**Last Name (STitle) 11679**] in [**12-24**] weeks and finally follow-up with Dr. [**Last Name (STitle) **]
in 4 weeks.
DISCHARGE MEDICATIONS:
1. Colace 100 mg b.i.d.
2. Aspirin 325 mg once daily.
3. Percocet 5/325 1-2 tablets q. 4-6 hours p.r.n.
4. Lisinopril 5 mg once daily.
5. Flomax 0.4 mg at bedtime.
6. Pravastatin 80 mg once daily.
7. Advair inhaler, 2 puffs b.i.d.
8. Amiodarone 400 mg once daily times one week then 200 mg
once daily times 1 month.
9. Metoprolol 25 mg b.i.d.
10. Amaryl 2 mg once daily.
11. Finally, the patient is to take potassium chloride
20 mEq b.i.d. times 7 days then once daily times 2 weeks
and Lasix 20 mg b.i.d. times 7 days and then once daily
times 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2177-9-6**] 14:16:56
T: [**2177-9-7**] 15:58:05
Job#: [**Job Number 26673**]
|
4019,2720,5939,41401,4271,4281,4111,4160,99674 | 30 | 104,557 | Admission Date: [**2172-10-14**] Discharge Date: [**2172-10-19**]
Service: [**Hospital Unit Name 196**]
IDENTIFICATION/CHIEF COMPLAINT: This is a [**Age over 90 **]-year-old male
with a history of coronary artery disease, re-do coronary
artery bypass grafting and hypertension, who presented to an
outside hospital with unstable angina.
PAST MEDICAL HISTORY:
1. Coronary artery disease:
a) The patient had coronary artery bypass grafting with a
saphenous vein graft to the left anterior descending artery,
a saphenous vein graft to the first obtuse marginal artery, a
saphenous vein graft to the third obtuse marginal artery and
a saphenous vein graft to the right coronary artery.
b) He had re-do coronary artery bypass grafting in [**2170**]
with a saphenous vein graft to the left anterior descending
artery with no bypass grafts to total occlusions of right
coronary artery and obtuse marginal artery grafts.
c) In [**2172-3-5**], the patient had a stent of the
saphenous vein graft to the left anterior descending artery
with a cardiac catheterization showing a left ventricular end
diastolic pressure of 17, an ejection fraction of 42% and mid
inferior akinesis and anterolateral akinesis/hypokinesis.
d) In [**2172-6-2**], the patient had a percutaneous
transluminal coronary angioplasty of a saphenous vein graft
to the left anterior descending artery with a left
ventricular end diastolic pressure of 19.
2. Hypercholesterolemia.
3. Hypertension.
4. Chronic renal insufficiency with a baseline creatinine of
1.9.
5. Hernia repair.
MEDICATIONS ON ADMISSION:
Aspirin 325 mg p.o. q.d.
Enalapril 10 mg p.o. b.i.d.
Metoprolol 25 mg p.o. b.i.d.
Lipitor 20 mg p.o. q.d.
Amlodipine 5 mg p.o. q.d.
Sublingual nitroglycerin p.r.n.
ALLERGIES: There were no known drug allergies.
HISTORY OF PRESENT ILLNESS: The patient was doing well post
percutaneous transluminal coronary angioplasty in [**2172-6-2**].
On [**2172-10-11**], he developed back pain while sitting.
This involved radiation to his left arm and also some
retrosternal chest pain. He also described some slight
shortness of breath with nausea and diaphoresis. This
episode of chest pain was not initially relieved with
sublingual nitroglycerin and the patient presented to [**Hospital6 18075**].
At [**Hospital6 2561**], the patient was found to have no
acute electrocardiogram changes and laboratory investigation
showed a CBC with a white blood cell count of 10.7, a
hematocrit of 36.6, a platelet count of 291 and a Chem 7
which was within normal limits with a BUN of 50 and a
creatinine of 1.9. His CK, MB and troponin I were noted to
be 64, 2.6 and 0.2. His second set of enzymes were also
normal. The patient was admitted and his chest pain was
treated with nitroglycerin and heparin drips. He was also
noted to have an asymptomatic run of ventricular tachycardia
of 27 beats without any hemodynamic compromise. The patient
was started on a lidocaine infusion at that time.
The patient was transferred to [**Hospital1 188**] on [**2172-10-14**] and was taken straight to the
cardiac catheterization laboratory. There, he was found to
have a cardiac output and cardiac index of 3.1 and 1.8
respectively. His right ventricular end diastolic pressure
was 16 and his pulmonary artery pressures were 48/28 with a
mean of 39. His wedge pressure was noted to be 29 and his
mixed venous oxygen saturation was 42. No left ventricular
angiography was done.
Examination of the coronary arteries showed a right dominant
system with a normal left main coronary artery. There was a
99% lesion at the first obtuse marginal artery and a 100%
lesion at the second obtuse marginal artery. His
posterolateral ventricular branch was noted to be occluded at
30%. The right coronary artery, which had a previous known
occlusion, was not injected. The patient's saphenous vein
graft to left anterior descending artery stent was found to
be 98% occluded and the patient underwent balloon
percutaneous transluminal coronary angioplasty and subsequent
brachytherapy with a residual occlusion of 10%.
SOCIAL HISTORY: The patient denied any history of tobacco
use. He consumed alcohol socially and currently lived alone
without support. The patient was capable of doing his own
shopping, cooking, cleaning and driving. He did have a
health care proxy by the name of [**Name (NI) 1743**] [**Name (NI) 7049**], who resided
at 74 [**Hospital1 36830**]in [**Hospital1 2436**].
FAMILY HISTORY: The family history was noncontributory.
PHYSICAL EXAMINATION: On examination, the patient was in no
apparent distress with vital signs showing a temperature of
96.9??????F, a blood pressure of 138/63, a heart rate of 87, a
respiratory rate of 20 and an oxygen saturation of 96% on a
nonrebreather mask. The neurological examination was
unremarkable. The patient was awake, alert and oriented
times three. On head and neck examination, the pupils were
equal and reactive to light. The extraocular movements were
intact. The oropharynx was moist.
On cardiovascular examination, the patient's jugular venous
pressure was 8-10 cm above the sternal angle. He had a
normal S1 and S2 with an S3 and S4. He did not have any
audible murmurs. The respiratory examination showed diffuse
crackles half way up his chest bilaterally with no wheezes.
The abdominal examination was unremarkable. The extremities
showed palpable bilateral dorsalis pedis pulses with no
edema. He had a right groin pulmonary artery catheter line
in place and his arterial sheath site was clean, dry and
intact with no bruit or hematoma.
LABORATORY DATA: The patient's cardiac care unit laboratory
values showed a white blood cell count of 14,200, hematocrit
of 27.6 and platelet count of 211,000. Chem 7 showed a
sodium of 129, potassium of 4.1, chloride of 97, bicarbonate
of 18, BUN of 46, creatinine of 2.1 and glucose of 217. CK
was 555, calcium was 9.0 and magnesium was 1.6. Arterial
blood gases showed a pH of 7.33, a pCO2 of 29 and a pO2 of
90.
ELECTROCARDIOGRAM: The patient's electrocardiogram on
[**2172-10-12**] showed him to be in sinus rhythm at 60
with a prolonged P-R interval, a normal P wave and a QRS axis
of -60 to -90. He also had a right bundle branch block with
a left anterior hemiblock. He had Q waves noted in leads III
and aVF. He also had some premature ventricular
contractions. There were T wave inversions in leads V1 to
V4, which appeared unchanged from his electrocardiogram from
[**2172-7-1**].
RADIOLOGY DATA: The patient's chest x-ray showed significant
pulmonary vascular redistribution cephalad.
HOSPITAL COURSE: Following cardiac catheterization, the
patient was continued on Plavix and received aggressive
diuresis for his elevated pulmonary capillary wedge pressure.
On [**2172-10-15**], the patient was noted to have
continued runs of nonsustained ventricular tachycardia and an
echocardiogram was done, which showed the patient to have a
moderately depressed left ventricular function with 1+ aortic
insufficiency, 2+ mitral regurgitation and 1+ tricuspid
regurgitation. He also was noted to have inferior and
inferoseptal hypokinesis. The pulmonary artery catheter was
removed along with the introducer on that day.
On [**2172-10-16**], the patient was noted to be in atrial
bigeminy in the morning and also continued to have short runs
of nonsustained ventricular tachycardia of three to four
beats. The patient continued with his intravenous diuresis
with 80 mg of Lasix q.d. and was subsequently transferred to
the floor. On [**2172-10-17**], the electrophysiology
department was informally consulted and the patient's
metoprolol dose was increased. The patient's rhythm
continued to be monitored.
On [**2172-10-19**], the patient was in stable condition
with adequate diuresis. His nonsustained ventricular
tachycardia continued to improve and the patient continued to
show no further episodes of nonsustained ventricular
tachycardia.
The patient was discharged home on [**2172-10-19**] in
stable condition.
DISCHARGE MEDICATIONS:
Plavix 75 mg p.o. q.d.
Enteric coated aspirin 325 mg p.o. q.d.
Lipitor 20 mg p.o. q.d.
Metoprolol 37.5 mg p.o. q.d.
Enalapril 10 mg p.o. q.d.
Amlodipine 5 mg p.o. q.d.
Lasix 40 mg p.o. q.d.
Colace 100 mg p.o. b.i.d.
Nitroglycerin 0.4 mg sublingual every five minutes p.r.n.
times three.
Protonix 40 mg p.o. q.d.
FOLLOW UP: The patient was instructed to follow up with his
primary cardiologist, Dr. [**Last Name (STitle) 1391**], at [**Hospital3 **] in the
upcoming week.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2172-10-20**] 14:46
T: [**2172-10-20**] 14:59
JOB#: [**Job Number 36831**]
|
3453,20190,515,486,4019,36250,E9331,4371 | 31 | 128,652 | Admission Date: [**2108-8-22**] Discharge Date: [**2108-8-30**]
Date of Birth: [**2036-5-17**] Sex: M
Service: Neurology
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old
gentleman with a history of Hodgkin's disease was transferred
here from [**Hospital3 **] Hospital because of intractable seizures
and decreased mental status.
He was in his usual state of health, active and playing golf,
until [**8-17**] when he began to become "confused" and developed
gait difficulties. According to the family, Mr. [**Known lastname **] was
behaving in a way that was perceived to be nontypical by family
members. [**Name (NI) **] was also having gait difficulties that were
considered to be mild, according to the family members.
Because of these symptoms, he was evaluated at [**Hospital3 **] Hospital
on [**8-17**]. At that time, a head computed tomography was
reported as normal. He was give a diagnosis of transient ischemic
attacks and was d/c home.
Over the next three days, Mr. [**Known lastname **] problems gradually
worsened. On [**8-20**], he was at home when he developed a
nonfocal onset of seizure which was later generalized. He
was transferred to the nearest Emergency Department where he
continued to have generalized seizures. He was given a
Dilantin load and phenobarbital. His systolic blood pressure
at that time ranged between 120 and 200s.
A repeat head CT was reported to be normal. Despite the Dilantin
load and the phenobarbiltal, the patient continued to have
clinical seizured. Therefore, he was started on an Ativan drip
and was admitted to the Intensive Care Unit. His Dilantin was
also continued on therapeutic levels. Despite the Ativan drip
and Dilantin therapeutic levels, Mr. [**Known lastname **] continued to be
unresponsive and had intermittent seizures. The rate of the
Ativan IV infusion was increased and the patient was intubated. A
lumbar puncture was performed on [**8-20**] at [**Hospital3 **] Hospital
and showed normal values.
A MRI with diffusion- weighted imaging showed diffuse
hyperintensity in the cerebral cortex (R > L) and both thalami.
At this point, the patient remained intubated and unresponsive
and was therefore transferred to [**Hospital1 18**] for further evaluation and
care.
PAST MEDICAL HISTORY:
1. Hodgkin's disease diagnosed in [**2106-4-11**] after
developing a respiratory infection. This was diagnosed as
nodular sclerosing Hodgkin's disease; stage III-B with
positive [**Doctor Last Name **]-Sternberg cells. A bone marrow biopsy was done
in [**2106-8-11**] which showed no bone marrow involvement.
2. Status post chemotherapy with bleomycin, Cytoxan,
vincristine, and procarbazine two years ago. This had to be
discontinued after three cycles because of interstitial lung
disease and because of myelosuppression with episodes of
neutropenic fever. Most recent surveillance computed
tomography scan revealed gradual interval progression of
Hodgkin's disease with slightly large mediastinal lymph
nodes.
3. Borderline hypertension.
4. Colonic polyps.
5. Tuberculosis.
6. Cataracts.
7. Macular degeneration.
MEDICATIONS ON ADMISSION: Aspirin, Prevacid, and Tylenol.
Ativan drip and Dilantin were started at the outside
hospital.
ALLERGIES: CEFTIN (causes a rash).
SOCIAL HISTORY: The patient was a retired chemistry teacher
and lived in [**Hospital3 **]. He was married with no alcohol or
intravenous drug use.
FAMILY HISTORY: Family history was noncontributory.
CONCISE SUMMARY OF HOSPITAL COURSE:
Mr. [**Known lastname **] was admitted to the Intensive Care Unit of [**Hospital1 18**] on
[**2107-8-23**]. A repeat LP on admission showed normal cells, glucose
and protein. A CSF sample was also obtained for viral cultures
and different viral and fungal Ab titers (including West Nile
Virus, Arboviruses, HSV, HBVs). Routine cultures for bacterial,
TB and other infectious agents were also normal. Cytology was
normal.
Despite the therapeutic levels of PTN and the IV infusion of
Ativan, electroencephalogram (EEG) on admission showed
epileptiform sharp spike activity suggestive of ongoing
epileptict activity. Therefore, a Penotarbital infusion was
started. The Pentobarbital infusion was titrated to obtain a
burst- suppression pattern on bedside 24 h, EEG monitoring. In
particular, the EEG showed sharp waves complexes every 6 to 10
seconds. Dilantin and Depakote were continued as well. At this
point, pressors were started to compensate to the Pentobarbital-
induced decreased cardiac function.
Mr [**Known lastname **] condition did not improve and another magnetic resonance
imaging examination ([**8-24**]) showed multicentric areas of T2
hyperintensity with more concentration in the right frontal as
well as bilateral thalami. Laboratory studies throughout Mr.
[**Known lastname **] admission included several blood cultures, urine cultures
and extensive toxic metabolic workup. Another LP for
cerebrospinal fluid analysis for infection, toxic metabolic and
cytological analysis was also performed.
In order to better elucidate the underlying pathology. A brain
and meningeal biopsy was performed on [**8-24**] in the right
frontal lobe.
In regards to empiric treatment, after the brain biopsy, the
patient received IV Solu- Medrol and high doses of antibiotics
with broad coverage. The Infectious Disease team was also
involved in the care of Mr. [**Known lastname **]. All the tests performed on his
tissues and fuids obtained under request of the ID team, had
thus far come back normal.
Brain and meningeal biopsy were remarkable for an meningitic
eosinophilic infiltrates and extensive ischemic cortical neuronal
damage (red neurons). There was no evidence of an infectious
[**Doctor Last Name 360**] on traditional staining and/or on electronic microscopy.
Several attempts in decreasing the dose of Pentobarbital resulted
in an increased epileptiform activity on bedside EEG monitor.
Mr. [**Known lastname **] condition deteriorated even further. He had developed
ileus, and his abdomen was hyperextended. He had been intubated
throughout his entire stay in the Intensive Care Unit and was
increasingly dependent on ventilatory support.
At this point, the patient's poor clincal status and prognosis
was thoroughly discussed with his closest family members. After
a family meeting, it was decided that Mr. [**Known lastname **] would no longer
benefit from aggressive support. Therefore, he was extubated
and expired briefly thereafter.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern1) 728**]
MEDQUIST36
D: [**2108-9-25**] 15:05
T: [**2108-9-25**] 16:30
JOB#: [**Job Number 33975**]
|
5191,496,42731,4538,53081,78057,4019,27801 | 32 | 175,413 | Admission Date: [**2170-4-4**] Discharge Date: [**2170-4-23**]
Date of Birth: [**2124-9-29**] Sex: M
Service: Thoracic Surgery
CHIEF COMPLAINT: Tracheal stenosis.
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with a history of chronic obstructive pulmonary disease
and obstructive sleep apnea who underwent uvulopalatotectomy
in [**2165**]. This was complicated by hemorrhage and a
tracheostomy for a period of two weeks.
Subsequently, he has had multiple dilatations for the
tracheal stenosis. He is now here for tracheal
reconstruction.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea, status post uvulopalatotectomy.
2. Tracheostomy for two weeks in [**2165**].
3. Chronic obstructive pulmonary disease.
4. Hypertension.
5. Atrial fibrillation. The patient has failed several
direct cardioversions.
6. Alcohol abuse.
7. History of cardiac catheterization in [**2169-6-28**]
with an ejection fraction of 69% and clean coronaries.
8. Kidney stones.
9. Umbilical hernia.
10. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Flovent, Atrovent, albuterol,
guaifenesin 500 mg p.o. q.d., prednisone 60 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., diltiazem 120 mg p.o. b.i.d.,
Zestril 10 mg p.o. q.d., amiodarone 200 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., digoxin 0.25 mg p.o. q.d.,
Colace 100 mg p.o. b.i.d., Klonopin 0.5 mg p.o. t.i.d.
p.r.n., trazodone 50 mg p.o. q.h.s. p.r.n., Lipitor 10 mg
p.o. q.d., Coumadin (which has been held).
ALLERGIES: PENICILLIN.
HOSPITAL COURSE: The patient underwent a rigid bronchoscopy
and direct laryngoscopy, tracheal resection and
reconstruction on [**2170-4-4**]. His intraoperative course was
uneventful. He was admitted to the Intensive Care Unit
postoperatively in an intubated condition. He remained
intubated overnight and was in a stable condition.
He was extubated on postoperative day one. He remained in
atrial fibrillation at this time. He was started on a
diltiazem drip for the atrial fibrillation with a rate
of 150s. He underwent a bronchoscopy which showed mild
anastomotic edema and was therefore continued on diuresis.
He remained in the Intensive Care Unit for the next few days
slowly improving with aggressive respiratory treatment. His
Coumadin was restarted on postoperative day three. He was
continued on antibiotics of vancomycin and Flagyl which had
been started in the initial postoperative period.
On postoperative day six, he complained of some left lower
extremity pain. He underwent a lower extremity noninvasive
study which revealed a left lower extremity deep venous
thrombosis. At this point, he was started on Lovenox as he
was not yet therapeutic on his Coumadin.
On [**2170-4-10**], he underwent another bronchoscopy which
again revealed mucosal edema at the anastomotic site. In the
next few days in the Intensive Care Unit were essentially
uneventful as he slowly improved, and his respiratory
function was slowly improving.
He was deemed ready for transfer to the regular floor on
postoperative day eight. He was stable on the floor over the
next few days. His Coumadin was continued until it reached a
therapeutic level, and at that point the Lovenox was stopped.
He continued to have left leg pain secondary to the deep
venous thrombosis and was treated with a morphine
patient-controlled analgesia. He had aggressive respiratory
toilet as well at this point. His clinical condition slowly
improved, and he started ambulating, and his respiratory
function improved as well.
On postoperative day 16 ([**2170-4-20**]), he went back to the
operating room for a bronchoscopy. At that time, his airways
were clean, and there was no mucosal edema. He was now ready
for discharge home on Coumadin.
MEDICATIONS ON DISCHARGE:
1. Diltiazem 120 mg p.o. b.i.d.
2. Lisinopril 10 mg p.o. q.d.
3. Amiodarone 20 mg p.o. q.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Vitamin A 25,000 units q.d.
7. Zinc 220 mg p.o. q.d.
8. Atrovent inhaler 2 puffs q.i.d.
9. Flovent 110 mcg 2 puffs b.i.d.
10. Lopressor 25 mg p.o. b.i.d.
11. Protonix 40 mg p.o. q.d.
12. Vitamin C 500 mg p.o. q.d.
13. Percocet one to two tablets p.o. q.4-6h. p.r.n.
14. Lipitor 10 mg p.o. q.d.
15. Coumadin 5 mg p.o. q.d. (INR is to be checked twice
every week by primary care physician and then subsequently
per primary care physician's recommendations).
DISCHARGE FOLLOWUP: Follow up with Dr. [**Last Name (STitle) 952**] in clinic in
one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2170-4-21**] 22:14
T: [**2170-4-24**] 20:01
JOB#: [**Job Number 35005**]
|
49390,4928,0389 | 33 | 176,176 | Admission Date: [**2116-12-23**] Discharge Date: [**2116-12-27**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old man
without a past medical history except for longstanding
asthma, who presents to the Emergency Department after having
seen his primary care this morning, and noted to have a
temperature of 103 F. Patient reports that he was in his
usual state of health last evening, however, but he awoke
this morning feeling generally unwell and subsequently had an
episode of nausea and vomiting with subjective fevers.
Patient denies chills.
REVIEW OF SYSTEMS: Positive for chronic nonproductive cough.
Negative for pleuritic chest pain, abdominal pain, dysuria,
or frequency, diarrhea, or hematochezia. He denies sick
contacts or travel history. He has had no hospitalizations
since [**2112**] at which time he had resection of a distal
pancreatic mass and splenectomy.
In the Emergency Department, the patient's temperature was
101.6 with stable vital signs.
PHYSICAL EXAM ON ADMISSION: Temperature 101.6, blood
pressure 126/42, heart rate 67, respirations 18, and
saturating 96% on room air. Generally, the patient was in no
acute distress. HEENT exam was unremarkable. He had no
lymphadenopathy in the cervical or axillary regions. Heart
sounds were normal. Lung exam was significant for coarse
breath sounds. Abdomen was benign. Extremities: He had
trace to +1 edema bilaterally.
LABORATORIES ON ADMISSION: White blood cell count 33.5 with
81% neutrophils, 12% bands, 6% lymphocytes, hematocrit 42.8,
platelets 545. Chem-7 was unremarkable. Lactate was 4.4.
Urinalysis was negative.
Chest x-ray: Negative for consolidation or effusion.
Blood cultures: Negative.
BRIEF SUMMARY OF HOSPITAL COURSE: Patient was admitted to
the Medical Intensive Care Unit according to the MUST sepsis
protocol. No infectious source was found. Patient's white
blood cell count continued to trend down on ceftriaxone,
which he was continued on for five days after which point he
was changed to oral Levaquin for a total of 14-day course.
Despite the diagnosis of fever of unknown origin, suspicion
for endocarditis was extremely low, and transthoracic
echocardiogram was also negative for vegetation. Patient
became afebrile two days after admission and continued to be
afebrile throughout his hospital course.
Lung nodule: CT torso was done to evaluate potential
abscesses, which could be the source of the patient's fever.
Incidentally, it was noted that patient had a spiculated
noncalcified pulmonary nodule measuring 1 cm in diameter from
the left lung apex. CT Surgery consulted during this
admission, and recommended a repeat CT scan in one month with
outpatient followup.
Asthma/emphysema: Patient was continued on his Flovent and
Serevent. He has no record of pulmonary function tests and
this will be done as an outpatient.
DISCHARGE DIAGNOSES:
1. Sepsis, fever of unknown origin.
2. Pulmonary nodule seen incidentally on CAT scan.
FOLLOW-UP INSTRUCTIONS: Patient was instructed to followup
with his primary care doctor, Dr. [**Last Name (STitle) 2903**] in one week. He was
also instructed to have a repeat CAT scan on his chest in one
month and this was scheduled for [**2117-1-26**]. He is
also to followup with Dr. [**Last Name (STitle) 175**], Cardiothoracic Surgery
after this CT scan. Lastly, he is to followup to get
pulmonary function tests on [**1-20**].
DISCHARGE CONDITION: Stable. Patient was afebrile and
clinically at his baseline.
DISCHARGE MEDICATIONS:
1. Serevent 50 mcg one inhalation p.o. q.12h.
2. Flovent two puffs b.i.d.
3. Levofloxacin 500 mg one p.o. q.d. for eight days to
complete a 14-day course.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 2543**]
MEDQUIST36
D: [**2117-2-2**] 19:47
T: [**2117-2-3**] 05:43
JOB#: [**Job Number 9903**]
|
3659,2449,4280,V5861,41401,4263,42822,42789 | 34 | 144,319 | Admission Date: [**2191-2-23**] Discharge Date: [**2191-2-25**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
1. Intubation
2. Permanent Pacemaker Placement
History of Present Illness:
Mr. [**Known lastname 66794**] is an 89 year old gentleman with a history of
atrial fibrillation on amiodarone and coumadin, CAD with 3VD
seen on cardiac cath in [**2186**], CHF with EF of 20%, who initially
presented to [**Hospital1 **] [**Location (un) 620**] last night complaining of a slow heart
beat. Per his wife at around midnight last night he came to bed
complaining that his heart was beating very slowly, he felt weak
and that he could "feel it in his chest." At that time he asked
his wife to call 911 and he was taken to [**Hospital1 **] [**Location (un) 620**] for further
evaluation. Per his wife he did not complain of any chest pain,
shortness of breath or nausea. Also, the family notes that he
has been having some falls/syncope at home including one event
that he did not remember in the past few weeks.
.
Per EMS report he was found to be pale, cool and diaphoretic on
initial examination. There he experienced some nausea, vomited
once, appropriate but lethargic, he was found to be bradycardic
to the 20's to 30's and was taken to [**Hospital1 **] [**Location (un) 620**]. En route to
[**Location (un) 620**] he was given atropine 0.5mg x 2 with no effect, he was
put on external pacing with electrical but not mechanical
capture. At [**Hospital1 **] [**Location (un) 620**] he was still bradycardic initially to
the 20's, was given atropine 1mg x 2, a right cordis was placed
and pacing wires were floated but kinked and were unable to
capture. His CK was 87, CK-MB was 2.1. He was then intubated
for reported AMS, external pacing was again attempted but there
was no mechanical capture. Throughout his course he was never
hypotensive with his episodes of bradycardia. EKG's done at [**Hospital1 **]
[**Location (un) 620**] showed at times a junctional rhythm, ventricular escape
and then bradycardia with his old LBBB. He was then transferred
to [**Hospital1 18**] for further management.
.
On arrival to the [**Hospital1 18**] ER his initial VS were: 96.8, 63,
113/60, 99% on 14x450, 5 PEEP, FiO2 of 100%. His heart rate
remained in the 50's, he was given fentanyl/versed for sedation,
an OGT was placed and he was transferred to the CCU. VS on
transfer were: 96, 51, 124/59, 97% on the above ventilator
settings. His CK was 88, CK-MB was 4 with a troponin of 0.04.
On arrival to the CCU his initial VS were: 97, 43, 130/57, 22,
100% on AC 14x450, PEEP of 5, FiO2 of 60%. He is currently
intubated and sedated, unable to respond to any questions, he is
moving his extremities.
.
Review of Systems: unable to obtain, patient is intubated and
sedated
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: 3 VD on cath in [**2186**], no
stenting or surgical options offered at that time
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Atrial Fibrillation on amiodarone and coumadin
- CHF with EF of 20%
- Hypothyroidism
- Glaucoma
Social History:
lives with his wife in [**Name (NI) 620**]
- Tobacco history: 31 pack year smoking history
- ETOH: none per records
- Illicit drugs: none per records
Family History:
colorectal cancer, diabetes, and stroke
Physical Exam:
Admission Exam:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG
tube
Cardiovascular: (S1: Normal), (S2: Normal), bradycardic, regular
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, pretibial erythema of the LLE
Skin: Warm
Right: Carotid 2+ DP 1+ PT dopplerable
Left: Carotid 2+ DP 1+ PT dopplerable
Pertinent Results:
ECHO [**2191-2-23**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20-25 %) with global hypokinesis (and inferior akinesis).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-9**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2188-4-7**],
the LV appears more dysynchronous
.
CXR [**2191-2-23**] Cardiomegaly with mild pulmonary edema. The
widened mediastinum may represent an enlarged aneurysmal
thoracic aorta or an aortic dissection.
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname 66794**] is an 89 year old gentleman with a history of
atrial fibrillation on amiodarone/coumadin, CAD with 3VD, CHF
with EF of 20% who presented with symptomatic bradycardia. He
was transferred to [**Hospital1 18**] for permanenet pacemaker placement.
Hospital course complicated by brief intubation for altered
mental status.
.
# RHYTHM / BRADYCARDIA: Review of EKGs prior to admission reveal
sinus arrest after a junctional rhythm and subsequent
ventricular escape. When he returned into sinus rhythm he had a
wider QRS interval and prolonged PR interval of 300 ms thank on
prior EKGs. Etiology unclear, may be secondary to conversion
pause or a toxic or metabolic condition pre-empting sinus arrest
with long PR and wide QRS. A free T4 was normal. The patient's
home dose of amiodarone was held with concern for toxicity. A
temporary pacemaker was placed and noted to be coiled in the IVC
and was thus subsequently removed. Coumadin was held in
anticipation of pacemaker placement. A permanent pacemaker was
placed on HD 2. Although the patient is a given EF of 20%
candidate for biventricular ICD placement, dicussion with the
patient and primary cardiologist prompted placement of pacemaker
only, to place the simplest device that would address his
bradycardia. Coumadin was restarted post procedure at his home
regimen, with follow-up at the [**Hospital1 **] [**Location (un) 620**] coumadin clinic.
.
# CORONARY ARTERY DISEASE: The patient has a history of three
vessel disease and was not on a statin or beta blocker as an
outpatient. He was started on atorvastatin 80mg daily, aspirin
325 mg daily. His cardiac enzymes were cycled and flat. Lipid
panel revealed an LDL of 105, HDL of 33 and total cholesterol of
173, the atorvastatin was discontinued at the time of discharge.
.
# AIRWAY PROTECTION: The patient was intubated prior to
admission to the intensive care unit due to altered mental
status in the setting of symptomatic bradycardia. He was
successfully extubated on admission to the CCU.
.
# SYSTOLIC CONGESTIVE HEART FAILURE: Most recent echo prior to
admission demonstrated EF of 20%. An echo on admission was
similar demonstrating more dysynchronous LV function. The
patient was continued on lisinopril at his outpatient dose of
5mg daily.
.
# HYPERTENSION: All antihypertensive medications were held given
bradycardia, and then restarted after pacemaker placement, he
was discharged on his home regimen.
.
# HYPOTHYROID: The patient was continued on home synthroid at
225mcg daily. Free T4 was normal with elevation of TSH. He was
dischargard on his home dose with outpatient PCP follow up for
further titration of his synthroid.
.
# GLAUCOMA: continued on his outpatient eye drop regimen
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP: needs coumadin monitoring and PCP follow up for
titration of his synthroid dose given elevated TSH. He will
follow up with the EP device clinic and also with Dr. [**Last Name (STitle) **] for
continued outpatient cardiology care.
Medications on Admission:
- Amiodarone 300mg daily
- Synthroid 225mcg daily
- Lisinopril 2.5mg [**Hospital1 **]
- ASA 81mg daily
- Lasix 40mg daily
- Coumadin 5mg 5 days per week, 2.5mg on M and F
- eye drops for glaucoma
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days.
[**Hospital1 **]:*8 Capsule(s)* Refills:*0*
2. Outpatient Lab Work
Please have your PT/INR checked on Tuesday [**2191-3-1**] at the
[**Hospital3 **]. PLease have this faxed to your PCP.
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. warfarin 2.5 mg Tablet Sig: AS directed Tablet PO once a day:
Take 1 tablet on Monday and Friday.
9. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain: This medication can cause drowsiness. .
[**Hospital1 **]:*15 Tablet(s)* Refills:*0*
10. Synthroid 200 mcg Tablet Sig: One (1) Tablet PO once a day.
11. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day.
12. amiodarone 200 mg Tablet Sig: 1.5 Tablets PO once a day.
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO AS directed:
Take 1 tablet Tues, Weds, Thurs, Sat, Sun.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Symptomatic Bradycardia
Permanent Pacemaker Placement
Chronic Systolic Congestive Heart Failure
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 66794**],
You were recently admitted to the Cardiac Intesive Care Unit for
a low heart rate, which made you feel ill. You presented
intubated (tube in your lungs helping you breathe), which was
quickly taken out. You had a pacemaker placed to help keep your
heart rate within a normal range. You tolerated this procedure
well.
.
In the hospital we found that your thyroid is not working
properly. For this reason your thyroid medication (Synthroid)
may need to be adjusted. Please remember to take this medication
daily and follow up with your Primary Care Physician to address
this.
.
We are making a few changes to your outpatient medications:
-Please START Keflex 500mg by mouth every 8 hours for the next
three days
-Please START Tramadol 25mg by mouth every 6hrs as needed for
pain
***This can cause drowsiness, do not take this medication when
doing activity.
-Please continue to take your Coumadin at the same dose (5mg
every day except for 2.5mg on Monday on Friday). We spoke with
the [**Hospital3 **] at [**Location (un) 620**]. Please have your labs
drawn on Tuesday [**2191-3-1**] for PT/INR. They will adjust your dose
as needed.
.
-Please continue to take your other medications as instructed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Name: [**Last Name (un) **],PERMINDER
Address: [**Apartment Address(1) 45001**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 29110**]
Appt: [**3-4**] at 11:30am
Department: CARDIAC SERVICES
When: MONDAY [**2191-3-7**] at 3:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] [**Location (un) 620**] Cardiology
Address: [**Street Address(2) 3001**], [**Location (un) 620**], MA
Phone: [**Telephone/Fax (1) 4105**]
Appt: [**3-22**] at 2:30pm
|
3962,4260,2875,9971,42731,42732,41401,4019,2449,25000,71590 | 35 | 166,707 | Admission Date: [**2122-2-10**] Discharge Date: [**2122-2-20**]
Date of Birth: [**2052-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
s/p AVR(21mm Aortic CE Magna pericardial)/MVR(25mm Metronic
Mosaic porcine)/CABGx2(LIMA->LAD, SVG->PDA)/Septal myomectomy
[**2122-2-10**]
History of Present Illness:
69 yo M with exertional SOB, echo at OSH showed severe AS and
cath showed 2VD.
Past Medical History:
HTN, DM2, ^chol, hypothyroid, arthritis, hyst
Social History:
stay at home mom
40 pack year tob
no etoh
Family History:
Brothers with [**Name2 (NI) **] in their 50s
Physical Exam:
Elderly female in NAD
Full dentures
Lungs CTAB
RRR 4/6 SEM ->carotids
Abd with well healed incisions, soft, NT/ND
Extrem warm, no edema
Brief Hospital Course:
She was taken to the operating room on [**2122-2-10**] where she
underwent an AVR (21 mm CE magna pericardial)/CABG x 2
(LIMA->LAD, SVG->PDA), MVR (25 mm [**Company **] mosaic porcine
mitral) and spetal myomectomy. She was transferred to the CSRU
in critical but stable condition paced with complete heart
block. She was extubated and weaned form her vasoactive drips
later that same day. She remained in complete heart block and
was seen by electrophysiology. On [**2-13**] she was reintubated and
had a [**Company 1543**] Sigma dual chamber pacemaker placed. She was
extubated on [**2-14**]. A HIT panel, which was sent for a platelet
count of 63, was negative. She went into aflutter and was
started on amiodarone and heparin and coumadin. She was
transferred to the floor on POD #5. She converted to sinus
rhythm. Her amiodarone was decreased due to prolonged QTC. Her
activity was advanced with nursung and PT. She was ready for
discharge home on POD 10.
Medications on Admission:
synthroid, KCL, lisinopril, lovastatin, metformin, atenolol.
glyburide
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 1 week then 200mg QD.
Disp:*36 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
pt to take 2mg on [**4-11**] then as directed by Dr [**Last Name (STitle) 71726**].
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**]
Discharge Diagnosis:
Aortic stenosis
HTN
NIDDM
^chol
hypothyroidism
s/p AVR/MVR/cabg/septal myomectomy
s/p PPM
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discahrge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with towel.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 71726**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 21056**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2122-2-20**] |
99831,99811,41511,4538,99672,496,41401,V4581,4019,60000,53081,V1051 | 36 | 122,659 | Admission Date: [**2131-5-12**] Discharge Date: [**2131-5-25**]
Date of Birth: [**2061-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Sternal click
Major Surgical or Invasive Procedure:
[**2131-5-15**] Sternal Debridement with Re-wiring
[**2131-5-17**] Emergency resternotomy for cardiac tamponade
[**2131-5-18**] Mediastinal washout/sternal plating/bil. pectoralis
flaps
[**2131-5-24**] PICC line placement
History of Present Illness:
Mr. [**Known lastname 27218**] is a 69 year old male who recently [**Known lastname 1834**] CABG
on [**2131-5-4**] by Dr. [**Last Name (STitle) 914**]. His postoperative course was
relatively uneventful. Since discharge, he has been concerned
about his chest incision. Patient stated he felt a "click" when
he coughed. He also noted a small amount of erythema and serous
drainage. His temperature at home has been at most, 100 F. He
has been short of breath with increasing fatigue and unable to
do his daily chores. Given the above complaints, he presented to
the ED and was subsequently admitted for further evaluation and
treatment.
Past Medical History:
Coronary Artery Disease - s/p recent CABG on [**2131-5-4**]
Chronic Obstructive Pulmonary Disease
Hypertension
History of Syncope
Depression
Benign Prostatic hypertrophy
GERD
Anxiety
Chronic Back Issues
History of Bladder Cancer - s/p Excision and BCG treatment
Social History:
Married, lives with his wife, 5 children. He is a retired truck
driver and currently helps out in his son??????s restaurant.
+tobacco 1ppd x 55 years. Occasional ETOH.
Family History:
Noncontributory
Physical Exam:
Vitals: T 98.3, BP 128/74, HR 94, RR 22, SAT 97 on 3L
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: bibasilar crackles noted
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema,
Pulses: palpable distally
Neuro: nonfocal
Sternum: positive click, no drainage, minimal erythema
Pertinent Results:
[**2131-5-13**] Chest CT Scan: Sternal dehiscence with an extensive
fluid collection extending along the entire length of the
sternum. While this measures simple fluid density, infection
cannot be excluded. Bilateral pleural effusions measuring simple
fluid density.
[**2131-5-17**] Echo: There is a moderate sized pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
[**2131-5-18**] LE U/S: 1. RIGHT LOWER EXTREMITY: Extensive thrombosis
of the right femoral vein along its entire length and no
significant internal flow. 2. LEFT LOWER EXTREMITY: No evidence
for DVT.
[**2131-5-18**] Echo: The right atrium is moderately dilated. A
mass/thrombus associated with a catheter/pacing wire is seen in
the right atrium and/or right ventricle. This mass disappeared
later in the exam. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. The left ventricular cavity is unusually small and
hyperdynamic. There is mild LVH. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. Right ventricular systolic function is
borderline normal. There are simple atheroma in the aortic arch
and the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. Moderate to severe
[3+] tricuspid regurgitation is seen. All findings discussed
with surgeons at the time of the exam.
[**2131-5-24**] UE U/S: Persistent areas of intraluminal thrombus in the
left IJ, and within the superficial veins of the left and right
cephalic veins, and new thrombus in the superficial left basilic
vein.
[**2131-5-12**] 05:45PM BLOOD WBC-12.8*# RBC-3.59* Hgb-10.4* Hct-30.1*
MCV-84 MCH-28.9 MCHC-34.5 RDW-15.5 Plt Ct-578*#
[**2131-5-17**] 01:06AM BLOOD WBC-20.1* RBC-2.50* Hgb-7.1* Hct-20.6*
MCV-83 MCH-28.6 MCHC-34.7 RDW-16.0* Plt Ct-601*
[**2131-5-19**] 03:02AM BLOOD WBC-30.5* RBC-3.08* Hgb-9.6* Hct-27.8*
MCV-90 MCH-31.2 MCHC-34.6 RDW-16.2* Plt Ct-188
[**2131-5-25**] 05:18AM BLOOD WBC-11.5* RBC-2.97* Hgb-8.8* Hct-26.3*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.6* Plt Ct-446*
[**2131-5-12**] 05:45PM BLOOD PT-12.3 PTT-30.4 INR(PT)-1.1
[**2131-5-18**] 10:56PM BLOOD PT-28.1* PTT-80.3* INR(PT)-2.9*
[**2131-5-25**] 05:18AM BLOOD PT-25.2* PTT-30.9 INR(PT)-2.5*
[**2131-5-12**] 05:45PM BLOOD Glucose-102 UreaN-23* Creat-1.5* Na-133
K-4.9 Cl-99 HCO3-26 AnGap-13
[**2131-5-20**] 03:20AM BLOOD Glucose-115* UreaN-21* Creat-1.4* Na-136
K-4.0 Cl-106 HCO3-22 AnGap-12
[**2131-5-25**] 05:18AM BLOOD Glucose-103 UreaN-23* Creat-1.3* Na-136
K-3.5 Cl-99 HCO3-28 AnGap-13
[**2131-5-18**] 06:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative
Brief Hospital Course:
Mr. [**Known lastname 27218**] was admitted [**5-12**] with sternal instability and
[**Month/Day (1) 1834**] chest CT scan which confirmed sternal dehiscence. It
was also notable for an extensive fluid collection extending
along the entire length of the sternum. He was empirically
started on antibiotics and taken to the operating room on [**5-15**]
for sternal re-wiring. There was no evidence of sternal wound
infection. Postoperatively, he was maintained on antibiotics and
wound irrigation. On [**5-17**] in the early AM, he became acutely
hypotensive and increased his chest tube drainage. Transferred
to the CSRU, Swan placed, and transfused one unit. Emergent Echo
revealed a moderate sized pericardial effusion that appeared
circumferential. His chest was ultimately opened emergently in
the unit for washout, and returned to the OR for complete
washout and a hole in the vein graft was sutured closed. Please
see op reports for surgical details. Following surgery he was
transferred to the with open chest and plastic surgery was
consulted regarding sternal plating. The following day he was
brought back to the operating room for chest closure. Echo done
at that time revealed an acute Pulmonary Embolism/Thrombus in
the RA/RV. This mass/thrombus disappeared later on exam. He then
[**Month/Year (2) 1834**] sternal plating closure/bil. pectoralis flaps done by
plastic surgery. Following surgery he was again transferred back
to the CSRU for invasive monitoring. Argatroban started for
presumed HIT (eventually came back negative) and Hematology
consulted. On [**5-21**] he was weaned from sedation, awoke
neurologically intact and extubated. Following extubation a
bedside swallow study was done, which he initially failed, but
repeated [**5-23**] with improvement. Also on [**5-23**] he was transferred
to the SDU for further care. Extremity U/S revealed thrombus in
his right femoral vein, left IJ, superficial veins of the left
and right cephalic veins, and in the superficial left basilic
vein. On [**5-24**] a PICC line was placed. Although operative wound
cultures were eventually negative, per ID, he will receive 4
weeks of vancomycin for high risk of sternal contamination. He
continued to improve and worked with physical therapy during his
post-op course for strength and mobility. On [**5-25**] he was
discharged to rehab facility with the appropriate follow-up
appointments. Of note, he will remain on Coumadin for DVT/PE for
minimum of 6 months.
Medications on Admission:
lasix 20 [**Hospital1 **]
aspirin 81 qd
plavix 75 qd
lipitor 20 qd
lisinopril 5 qd
lopressor 25 [**Hospital1 **]
detrol 4 qd
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours) for 1 months: via PICC line.
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please adjust for an INR [**2-10**] (for DVT/PE).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Sternal Instability/Dehiscence - s/p Sternal Re-wiring
Pulmonary Embolism
DVTs of LIJ, Right superficial femoral
PMH: Coronary Artery Disease - s/p recent CABG on [**2131-5-4**],
Chronic Obstructive Pulmonary Disease, Hypertension,
Gastroesophageal Reflux Disease, Anxiety, History of Bladder
Cancer - s/p Excision and BCG treatment
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. PLEASE SHOWER DAILY. No creams,
lotions or ointments to incisions. No driving for at least one
month. No lifting more than 10 lbs for at least 10 weeks from
the date of surgery. Monitor wounds for signs of infection.
Please call with any concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**4-12**] weeks, call for appt [**Social Security Number 27220**]
Dr. [**Last Name (un) **] in [**2-10**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**7-17**] days, call for appt [**Telephone/Fax (1) 1416**]
Completed by:[**2131-5-25**] |
V1051,30000,60000,4019,496,41400,5180,55321,41511,5185,486,99739 | 36 | 165,660 | Admission Date: [**2134-5-10**] Discharge Date: [**2134-5-20**]
Date of Birth: [**2061-8-17**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1430**]
Chief Complaint:
Recurrent ventral herniation with omentum up in the anterior
chest
Major Surgical or Invasive Procedure:
Ventral hernia repair, placement of SurgiMend and omentectomy.
Sternal plate removal.
History of Present Illness:
Mr. [**Known lastname 27218**] is a 72 y.o. male with PMH significant for CAD s/p
CABG ([**2131-5-4**]), COPD, HTN who presents with recurrent ventral
hernia.
Approximately three years ago ([**2131-5-18**]), the patient had a
sternal repair done with plates. He had an omental transfer and
at that time a ventral hernia repair to the anterior fascia at
the bottom of sternotomy lead to a hernia. This was actually
repaired primarily and reinforced with mesh. A separate new hole
was made through the diaphragm for the omental transfer. Over
time omentum and bowel has protruded up through this hole in the
diaphragm, as evidenced on a recent CT. He now comes in for
repair of this defect. In addition was planning on removal of
his plates as he was having some discomfort. He understood we
could not guarantee success and further intervention may be
required.
Past Medical History:
Coronary artery disease s/p 5 vessel CABG
Bladder cancer
BPH
Anxiety
COPD
History of DVT and PE (in [**2131**] treated with ? 6 months of
coumadin)
Social History:
He smoked one pack per day for over 59 years, active until
[**2134-5-10**], drinks alcohol socially ( 1 drink per month). No
illicits. Retired truck driver. Lives with wife independent in
ADLs.
Family History:
Father lung ca
brother throat ca
sister leukemia
brother colon CA
sister pancreatic ca
Physical Exam:
GENERAL: Comfortable and in NAD
HEENT: NCAT, sclerae anicteric. MMM.
PULM: CTAB, no rales/rhonchi/wheezes
CVS: RRR with no murmur/gallop/rubs; s/p sternotomy. Hardware
palpable
ABD: Soft/NT/ND
EXT: No c/c/e
Pertinent Results:
Initial Labs:
[**2134-5-11**] 06:15AM BLOOD WBC-15.6*# RBC-5.01 Hgb-14.4 Hct-42.2
MCV-84 MCH-28.7 MCHC-34.1 RDW-14.6 Plt Ct-224
[**2134-5-11**] 06:15AM BLOOD Glucose-124* UreaN-19 Creat-1.0 Na-140
K-4.2 Cl-106 HCO3-25 AnGap-13
[**2134-5-11**] 06:15AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9
Cardiac Enzymes:
[**2134-5-11**] 07:00PM BLOOD CK(CPK)-342* CK-MB-6 cTropnT-0.03*
[**2134-5-12**] 08:33AM BLOOD CK(CPK)-347* CK-MB-6 cTropnT-0.03*
ABG's:
Prior to Intubation - [**2134-5-12**] 03:22PM BLOOD Type-ART pO2-70*
pCO2-75* pH-7.22* calTCO2-32* Base XS-0
After Intubation - [**2134-5-12**] 06:48PM BLOOD Type-ART pO2-84*
pCO2-50* pH-7.36 calTCO2-29 Base XS-1
Prior to ICU Call-Out - [**2134-5-15**] 03:06PM BLOOD Type-ART pO2-64*
pCO2-41 pH-7.53* calTCO2-35* Base XS-10
[**2134-5-12**] 12:35PM BLOOD Lactate-1.0
[**2134-5-15**] 02:50PM BLOOD Lactate-1.7
Blood and sputum cx - No Growth to date.
ECG ([**2134-5-11**]) - Sinus rhythm. Normal tracing. Since the previous
tracing of [**2134-5-4**] sinus bradycardia is absent.
CXR ([**2134-5-11**]) - Mild bibasilar atelectasis documented on the CTA
performed subsequently, 8:00 a.m. on [**5-12**] and available at the
time of this dictation, in combination with pulmonary embolism
demonstrated on that study is sufficient to explain hypoxia.
There is no pulmonary edema. Heart size is probably normal and
unchanged. There is no pulmonary edema. Left pleural thickening
is chronic.
Echo ([**2134-5-12**]) - The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. RV appears to have normal free wall
contractility (poor image quality). There is abnormal septal
motion/position. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-5-19**],
the RV funciton has probably improved. If indicated, a cardiac
MRI may better assess RV size and systolic function.
CXR ([**2134-5-12**]) - IMPRESSION: Asymmetric pulmonary edema, new since
one day prior.
CTA Chest ([**2134-5-12**]) - IMPRESSION:
1. Left upper lobe lobar pulmonary embolism.
2. Partial right lower lobe collapse due to a combination of
dependent secretions and bronchial wall thickening, with
associated surrounding peribronchial lymph nodes which are
probably reactive; however, a followup CT is recommended in four
to six weeks to ensure resolution.
3. Diffuse ground-glass opacities superimposed on centrilobular
emphysema are most likely infectious (such as viral in origin);
aspiration and asymetrical edema are less likely.
4. Large fatty lesion posterior to the left scapula contains
internal septations; considering large size and septations, a
dedicated MRI with contrast is recommended for further
evaluation to help distinguish a lipoma from a low grade
liposarcoma.
5. New ventral hernia mesh with postoperative changes in the
soft tissues of the anterior chest and upper abdomen.
6. Diffuse coronary artery calcification with CABG.
Bilateral LENIs ([**2134-5-13**]) - IMPRESSION: No evidence of DVT of
bilateral lower extremities.
Brief Hospital Course:
The patient was taken to the operating room for a joint
procedure between Dr. [**First Name (STitle) **] of plastic surgery and Dr. [**Last Name (STitle) **]
of general surgery. He [**Last Name (STitle) 1834**] the following procedures:
(1) Repair of chest wall hernia (Dr. [**Last Name (STitle) **]
(2) Ventral hernia repair, placement of SurgiMend and
omentectomy. Sternal plate removal (Dr. [**First Name (STitle) **]
.
The patient tolerated the procedure well and was transferred to
the floor for routine post operate care. He initially had poor
pain control and his PCA was titrated up. He was kept strictly
NPO until return of bowel function. Unfortunately, he developed
acute respiratory distress during the early morning hours of
[**2134-5-12**] that necessitated transfer to the medical intensive care
unit.
.
# Pulmonary: On POD 2, the patient was transferred to the ICU
for ongoing respiratory distress and hypoxia. He had been on 4L
NC since he was in the OR; however, he desaturated to the high
80's. Also, he had had ongoing difficulty with deep breaths
secondary to abdominal pain. CTA during this decompensation
showed pulmonary embolism. Imaging was also concerning for
underlying pneumonia as well as fluid overload. Shortly after
transfer to the ICU, the patient was noted to have worsening
hypercarbic respiratory failure and depressed mental status.
Ultimately, he was intubated on [**2134-5-12**]. The patient was started
on antibiotics to cover for his pneumonia (see below). Diuresis
was intially limited [**2-9**] hypotension; however, his blood
pressures improved and he was ultimately diuresed. After a few
days of antibiotics and diuresis, the patient's respiratory
status improved. His sedating medications were weaned and he was
ultimately extubated on [**2134-5-15**]. He was called out to the floor
on the day following his extubation and remained stable from a
pulmonary standpoint.
.
During the initial workup of his respiratory distress, a left
upper lobe lobar pulmonary embolism was noted on CTA. Of note,
patient does have a history of clots right femoral vein, left
IJ, superficial veins of the left and right cephalic veins,
superficial left basilic vein, and pulmonary embolism in setting
of surgery for cardiac tamponade s/p CABG [**5-14**]. Per Hematology
patient should have a minimum of 6 months of anticoagulation. In
2 months the patient will follow-up with hematology for
additional work-up and determination of total length of
anticoagulation. Mr. [**Known lastname 27218**] was initially on a conservative
heparin drip given he is recently post-operative. He was
continued on heparin until his INR was therapeutic.
.
He continued on oxygen via nasal cannula at a rate of 4 LPM for
the remainder of his admission and was maintaining an oxygen
saturation > 94%. He continued pulmonary toilet with incentive
spirometry. He responded well to intermittent doses of lasix
and was started on standing lasix 20mg by mouth daily.
.
Pneumonia - Patient with likely pneumonia based on imaging and
clinical history (reported approximately 1 week of cough during
the week prior to surgery). Large amount of secretions noted
during intubation. Pt started on levofloxacin on admission to
ICU. After intubation, ceftriaxone was added as double-coverage
to treat for severe CAP. Sputum and blood cx were sent but had
no growth to date at the time of transfer out of the ICU. On
transfer out of the ICU, the patient was continued on
levofloxacin / ceftriaxone with an end date of [**2134-5-21**].
.
# Neuro: Post-operatively, the patient received Dilaudid via PCA
initially with poor pain control that was then transitioned to
PO dilaudid with good effect and adequate pain control.
.
# CV: Patient had troponin leak in setting pneumonia and
pulmonary embolism felt to be demand. The patient was evaluated
by the cardiology service during this admission. They
recommended that the patient should discuss with his outpatient
cardiologist the utility of continuing plavix, given the
anticoagulation that will be started for his PE. Plavix was
restarted towards the end of the [**Hospital 228**] hospital admission.
.
Multiple EKGs were performed throughout this hospitalization
that did not detect any new ST or T wave abnormalities or any
other findings concerning for ischemia.
.
# GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Intake and output were
closely monitored, and urine output was noted to be marginal on
several occasions. The patient initially received boluses of
IVF with improvement in his urine output. After these boluses,
however, the patient was thought to be in fluid overload and
received lasix. His urine output increased with lasix, as well.
.
The patient was continued on his home dose of finasteride for
his BPH.
.
ID: The patient was started on antibiotics for hospital acquired
pneumonia as above.
The patient's temperature was closely watched for signs of
infection.
.
# Hematology: The patient's hematocrit did trend downwards
slightly after his transfer to the ICU. Hematocrit was followed
and remained stable thereafter. Of note, when patient was
intubated, OG tube was placed and moderate amount of brown
guaiac positive liquid was aspirated back; patient was kept on
heparin gtt and started on [**Hospital1 **] IV PPI. When his plavix was
restarted, his PPI was transitioned to an H2 blocker due to the
interaction between these two medications.
.
# Musculoskeletal: The patient had difficulty ambulating and
getting out of bed. This was thought to be due to
deconditioning. A PT consult was requested and the patient
[**Hospital1 1834**] vigorous physical therapy. He will require continued
physical therapy at rehab.
.
# Prophylaxis: The patient was maintained on subcutaneous
heparin after his operation. He was transitioned to heparin
drip at the time of his pulmonary embolism, and eventually was
started on coumadin. At the time of his discharge, his INR was
4.1 ([**2134-5-19**]). His INR from [**2134-5-20**] was still pending.
Medications on Admission:
Albuterol aerosol 4 puffs daily
Amlodipine 10 mg PO daily
Aspirin 81 mg daily
Atenolol 25 mg PO daily
Atrovent 4 puffs daily
Citalopram 60 mg PO daily
Lisinopril 40 mg PO daily
Folic acid 1 mg PO daily
Iron 65 mg PO daily
Vytorin 10/80 mg PO daily
Omeprazole 40 mg PO daily
Oxycodone 5-10 mg PO BID:PRN
Plavix 75 mg daily
Finasteride 5 mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: Max 4000 mg Tylenol/day.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for sob, wheezing.
9. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: Two (2) Powder in Packet PO TID (3 times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours).
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Levofloxacin 750mg PO daily: Last dose Friday [**2134-5-21**].
17. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): Last dose Friday
[**2134-5-21**].
18. Warfarin 1 mg Tablet Sig: dose as necessary for INR [**2-10**]
Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1) Recurrent ventral herniation with omentum up in the anterior
chest
2) Pulmonary embolism
3) hospital acquired pneumonia
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:
Personal Care:
1. Leave your chest dressing in place until your follow up
appointment with Dr. [**First Name (STitle) **]. If your dressings get wet
underneath, you may remove them.
2. Clean around the drain site(s), where the tubing exits the
skin, with hydrogen peroxide.
3. Strip drain tubing, empty bulb(s), and record output(s) [**2-10**]
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr. [**First Name (STitle) **].
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. [**First Name (STitle) **].
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotic as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
7. 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.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Separation of the incision.
4. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
5. Fever greater than 101.5 oF
6. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Tuesday, [**2134-5-25**] at 9AM
at his office.
.
You are scheduled to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], a hematologist,
on [**2134-7-16**] at 10:30 AM on [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Clinical Center. Dr. [**Last Name (STitle) 27222**] will determine how long you
should remain on coumdin. Phone:[**Telephone/Fax (1) 22**]
Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] -
[**Doctor Last Name 15369**] to follow-up on your recent hospitalization and to
monitor your coumadin dose. Your goal INR is [**2-10**]. Your first INR
check out of the hospital will be on [**2134-5-21**].
Please follow-up with your cardiologist Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] discuss your
recent hospitalization and determine if you should re-start
plavix.
You should also call the Pulmonary Clinic as soon as possible
for the next availabe appointment. Their telephone number is
([**Telephone/Fax (1) 513**].
Completed by:[**2134-5-20**] |
41401,4111,496,4019,3051,53081,60000,V1051,5968 | 36 | 182,104 | Admission Date: [**2131-4-30**] Discharge Date: [**2131-5-8**]
Date of Birth: [**2061-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
positive stress test ; chest pain during hypertension to 220/110
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2131-4-30**]
CABGx5 (LIMA-LAD,SVG-Diag,SVG-OM1,SVG-OM2,SVG-PDA)[**5-4**]
History of Present Illness:
Mr. [**Known lastname 27218**] is a 69 yo M w/ h/o HTN and significant tobacco
use, who had a severe headache on [**2131-4-19**] without associated
symptoms (including weakness, visual changes), and was found to
be hypertensive to 220/110. He was transferred via ambulence to
[**Hospital 1474**] Hospital and in route complained of right sided chest
discomfort, associated with dyspnea and diaphoreiss. By report
he was administered SL NTG and nitro paste with improvement in
BP and chest discomfort. He subsequently underwen ETT with
pMIBI which demonstrated a perfusion deficit at rest and was
referred to [**Hospital1 18**] for cardiac catheterization and renal artery
angiogram.
.
Mr. [**Known lastname 27218**] also reports decreased exercise tolerance over the
past several months - previously he would be able to climb
several flights of stairs without difficulty; he currently gets
extremely dypsneic after 10 steps (<1 flight); no associated CP,
N, or diahphoresis. He denies orthopnea and PND.
.
He denies history of angina or CAD.
.
Mr. [**Known lastname 27218**] [**Last Name (Titles) 1834**] cardiac catheterization today and was
found to have 3VD, and a CABG is now planned. He took a dose of
plavix this morning.
.
ROS: denies recent illness, fevers, hematuria, melena, bloody
stools, abdominal pain, LE swelling. Reports 8lb intentional
weight loss (healthier diet)
Referred for CABG .
Past Medical History:
HTN
GERD
Bladder ca s/p excision x 2 and the BCG treatment
Syncopal episodes x 3 (episodes accompanied by diaphoresis and
nausea) with the last episode many years ago
H/O pneumonia x 3
Depression
Chronic back problems including disc herniation, s/p disc
surgery
Anxiety
COPD
BPH
Social History:
Married, lives with his wife, 5 children. He is a retired truck
driver and currently helps out in his son??????s restaurant.
+tobacco 1ppd x 55 years. Occasional EtOH. No illicits
Family History:
Noncontributory (h/o cancer)
Physical Exam:
138/61 51 16 100% RA 5'[**35**]" Wt:220 lbs
Gen: NAD, smiling
HEENT: aniecteric, PERRL, EOMI, MMM, no JVD, no bruits
CV: regular rhythm, ~60, no M/R/G
Chest: CTAB
Abd: Soft, NT/ND
R Groin: dressing C/D/I, no bruit or thrill
Ext: 2+ DP pulses bilaterally
Neuro: A&Ox3, fluent speech, normal ambulation, MAE
Pertinent Results:
[**2131-4-30**] 10:33AM BLOOD WBC-6.3 RBC-4.50* Hgb-12.6* Hct-35.9*
MCV-80* MCH-27.9 MCHC-35.0 RDW-15.2 Plt Ct-193
[**2131-4-30**] 10:33AM BLOOD Glucose-98 UreaN-21* Creat-1.0 Na-137
K-4.1 Cl-107 HCO3-24 AnGap-10
[**2131-4-30**] 10:33AM BLOOD ALT-8 AST-12 AlkPhos-63 TotBili-0.5
[**2131-4-30**] 10:33AM BLOOD %HbA1c-5.1
.
Recent testing:
[**2131-4-24**]: Echo showed a normal LV size and function. EF of
60-65%. The valves were all normal with trace TR. Pulmonary
systolic pressure was estimated to be 30-35%. [**2131-4-20**]: Nuclear
stress test where the patient exercised for 6 minutes 57 seconds
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol stopping due to shortness of breath and leg
pain. He achieved 68% of his predicted target heart rate. He
did not develop any arrhythmias or chest pain. The nuclear
images demonstrated a normal sized left ventricle. There was a
moderate sized reversible perfusion abnormality involving the
anteroapical and septal portion left ventricle. There was also a
question of a small reversible abnormality involving the
inferolateral portion left ventricle. The left ventricular wall
motion was normal. The LVEF was 62%.
.
[**2131-4-30**] Cardiac Catheterization
COMMENTS:
1. Coronary angiography of this right dominant system revealed
severe three vessel coronary artery disease. The left main
coronary artery had no angiographically apparent flow limiting
stenoses. The LAD was ectatic proximally and occluded in the
mid segment after a small diagonal. The LCX had a 90% stenosis
of the OM1 proximally and a 50% followed by a 70% stenosis in
the proximal and mid segment of the OM2. The RCA had a 90%
stenosis in the mid PDA.
2. Limited resting hemodynamics revealed mildly to moderately
elevated left sided filling pressures (LVEDP was 18 mm Hg).
Systemic arterial pressure was normal (aortic pressure was
121/73 mm Hg). There was no significant gradient across the
aortic valve upon pullback of the catheter from the left
ventricle to the ascending aorta.
3. Left ventriculography revealed a contrast calculated
ejection
fraction of 65%. No mitral regurgitation was noted. 4.
Bilateral selective renal angiography demonstrated widely patent
renal arteries.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal left ventricular systolic function.
3. Mildly to moderately elevated left sided filling pressures.
4. No angiographically apparent renal artery stenosis.
.
Pulmonary Function Tests:
[**2131-5-8**] 06:25AM BLOOD WBC-7.3 RBC-3.17* Hgb-9.1* Hct-26.3*
MCV-83 MCH-28.7 MCHC-34.6 RDW-15.5 Plt Ct-201#
[**2131-5-8**] 06:25AM BLOOD Plt Ct-201#
[**2131-5-8**] 06:25AM BLOOD Glucose-101 UreaN-14 Creat-1.3* K-5.1
Cardiology Report ECHO Study Date of [**2131-5-4**]
PATIENT/TEST INFORMATION:
Indication: Chest pain. Coronary artery disease. Hypertension.
Status: Inpatient
Date/Time: [**2131-5-4**] at 10:41
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 Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the
LA. No spontaneous echo contrast or thrombus in the body of the
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
symmetric
LVH. Normal LV cavity size. Mild regional LV systolic
dysfunction. No LV
mass/thrombus. Mildly depressed LVEF. Transmitral Doppler and
TVI c/w normal
LV diastolic function. No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
anterior apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending
aorta. Normal aortic arch diameter. Simple atheroma in aortic
arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
mitral
annular calcification. No MS. Physiologic MR (within normal
limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: 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. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB: 1.The left atrium is normal in size. No spontaneous
echo contrast is
seen in the body of the left atrium. No spontaneous echo
contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No atrial
septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size. There is mild symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. There is mild regional left
ventricular
systolic dysfunction with apical anterior hypokinesis.. No
masses or thrombi
are seen in the left ventricle. Overall left ventricular
systolic function is
mildly depressed. Transmitral Doppler and tissue velocity
imaging are
consistent with normal LV diastolic function.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated at a maximum of 3.7.
There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen.
6. The mitral valve appears structurally normal with trivial
mitral
regurgitation. Physiologic mitral regurgitation is seen (within
normal
limits).
7. There is a trivial/physiologic pericardial effusion.
POST-CPB: Patient is on phenylephrine infusion. Preserved
biventricular
systolic function with improvement of the anteroapical
hypokinetic segment.
LVEF now 55%. Trace MR. Aortic contour is normal post
decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2131-5-4**] 15:02.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 27219**])
RADIOLOGY Final Report
CHEST (PA & LAT) [**2131-5-7**] 11:20 AM
CHEST (PA & LAT)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
69 yoM s/p CABG and CT removal
REASON FOR THIS EXAMINATION:
r/o ptx
TWO VIEW CHEST OF [**2131-5-7**].
COMPARISON: [**2131-5-4**]
INDICATION: Chest tube removal.
Various lines and tubes have been removed since the prior
radiograph, and a very small left apical pneumothorax has
developed. Cardiac and mediastinal contours are within normal
limits for postoperative status of the patient. Small pleural
effusions and minor bibasilar atelectasis are noted. These
findings are superimposed upon subtle likely more chronic
peripheral and basilar interstitial lung disease.
On the lateral view, small air-fluid level is present in the
retrosternal region likely representing an anterior
hydropneumothorax, and additional air is present in the
retrosternal region, an expected postoperative finding given the
time interval since surgery.
IMPRESSION: Small left pneumothorax following tube removal.
Bibasilar atelectasis and small pleural effusions.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2131-5-7**] 1:12 PM
Brief Hospital Course:
A/P: this is a 69 yo M w/ h/o HTN and significant tobacco use,
who presents for cardiac catheterization after abnormal
perfusion scan, which revealed 3VD, prompting CABG.
.
#CAD:
-medication regiment modified: continue ASA, BB, imdur;
minoxidil discontinued and ACEI started.
.
#HTN: well controlled on BB, imdur, and ACEI
.
#BPH: continue proscar
.
#Bladder spasm s/p surgery and BCG tx: continue detrol
.
#GERD: continue ranitidine
.
#Depression/Anxiety: continue celexa
.
#h/o syncope: by report worked up extensively at [**Hospital1 1474**] w/o
diagnosis
-carotid U/S normal
-no events on telemetry
.
#COPD: per patient, recent diagnosis based on CXR at [**Hospital1 1474**]
during last hospitalization, not on any active medications
-no wheeze, no respiratory distress, good O2 sat
-PFTs performed and carotid U/S showed no significant stenoses.
[**Hospital1 **] cabg x5 with Dr. [**Last Name (STitle) 914**] on [**5-4**]. Transferred to the
CSRU in stable condition on titrated phenylephrine and propofol
drips.Extubated that evening and transferred to the floor on POD
#1 to begin increasing his activity level. Chest tubes and
pacing wires removed on POD #3.Nicotine patch continued. Made
good progress and cleared for discharge to home with VNA on POD
#4. Pt. is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
Lasix 20 mg daily
Minoxidil 25 mg daily
Detrol 4 mg daily
Ranitidine 300 mg [**Hospital1 **]
Atenolol 25 mg [**Hospital1 **]
Pro-Chlor 20 mEq daily
Plavix 75 mg daily (pt started 2 weeks ago but stopped 4 days
ago
and will restart 4/20/070)
Celexa 40 mg daily
Endocet 5/325 mg prn
ASA 81 mg daily
Proscar 5 mg daily
Imdur 30 mg daily
NTG 0.4 mg sl
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): 20mg [**Hospital1 **] x7days then
20mg QD x10 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours): 20 meq
[**Hospital1 **] x 7 days then
20meq QD x 10 days.
Disp:*48 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*0*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Detrol 2 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease, s/p CABGx5
PMH:Hypertension,Hyperlipidemia,GERD,Bladder
CA,Depression,COPD,BPH
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
no driving for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
wound clinic in 2 weeks ( [**Hospital Ward Name 121**] 2)
Dr [**Name (NI) 23019**] in [**2-10**] weeks
Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2131-5-8**] |
25000,41071,4280,496,53551,2851,486,41401,42789 | 37 | 188,670 | Admission Date: [**2183-8-21**] Discharge Date: [**2183-8-26**]
Date of Birth: [**2114-9-17**] Sex: M
Service: C-MED Gold
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
gentleman with a significant cardiac history with coronary
artery disease (status post coronary artery bypass graft),
hypertension, congestive heart failure, hyperlipidemia, and
diabetes mellitus who presented with worsening congestive
heart failure of several months in duration with new onset
chest pressure.
The patient was in his usual state of health until three days
prior to admission when he began to experience increasing
shortness of breath at rest and with exertion. However, the
patient was still able to walk his dog for approximately one
half of a mile per day. No paroxysmal nocturnal dyspnea. No
orthopnea. Minimal bilateral lower extremity edema at
baseline.
The patient had one episode of [**5-10**] chest pressure (his
anginal equivalent) with exertion three days prior to
admission which resolved after one hour.
On the day prior to admission, the patient had a second
episode of [**10-10**] chest pressure, substernal, and without
radiation. No associated nausea, vomiting, or palpitations.
Mild diaphoresis and lightheadedness. The patient took one
sublingual nitroglycerin, and his pain score went down to
7/10, and he presented to the [**Hospital1 188**] Emergency Department for evaluation.
In the [**Hospital1 **] Emergency Department, the
patient's chest pressure was relieved with aspirin, heparin,
nitroglycerin, and Integrilin. He also received metoprolol
intravenously. He did continue to be short of breath despite
receiving 80 mg of Lasix intravenously on arrival.
The initial electrocardiogram showed sinus tachycardia with a
left bundle-branch block and left atrial abnormality, without
any significant changed when compared to the previous tracing
of [**2183-2-22**]. His initial creatine kinase was 326
with a troponin T of 0.31.
Of note, the patient denies fevers or chills. He has a
slight cough with sputum. He is not on a low diet. No
recent dietary indiscretion.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
(a) Status post coronary artery bypass graft in [**2172**]; left
internal mammary artery to left anterior descending artery,
saphenous vein graft to right coronary artery, and saphenous
vein graft to diagonal.
(b) Persantine MIBI on [**2183-2-4**] demonstrated a
dilated left ventricle, partially reversible moderate
perfusion defect in the anterior left ventricular wall, with
moderate fixed deficits at the septal/inferior walls, global
and left ventricular hypokinesis with an ejection fraction of
21%.
2. Congestive heart failure; [**State 531**] Heart Association
class II. An echocardiogram on [**2183-1-31**] with
depressed left ventricular systolic function with an ejection
fraction of 20%.
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Onychomycosis.
7. Status post appendectomy.
8. Anemia with leukocytosis.
9. Chronic obstructive pulmonary disease; last pulmonary
function tests in [**2183-2-1**] with a mixed
obstructive/restrictive deficit.
MEDICATIONS ON ADMISSION:
1. Lisinopril 40 mg by mouth once per day.
2. Lipitor 20 mg by mouth once per day.
3. Cardura 2 mg by mouth q.h.s.
4. Celexa 40 mg by mouth once per day.
5. Coreg 12.5 mg by mouth q.a.m.
6. Digoxin 0.25 mg by mouth every day.
7. Lasix 80 mg by mouth once per day.
8. Lumigan 0.03% drops q.h.s.
9. Timoptic 0.25% drops both eyes q.a.m.
10. Excedrin by mouth as needed.
11. NPH insulin 95 units subcutaneously q.a.m. and 90 units
subcutaneously at dinner.
FAMILY HISTORY: Family history was noncontributory for
coronary artery disease.
SOCIAL HISTORY: The patient is a retired painter. He has
been married times 44 years. He has a 60-pack-year history
of tobacco; he quit 15 years ago. Occasional alcohol use.
No intravenous drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed his temperature was 98.4 degrees
Fahrenheit, blood pressure was 133/64, his heart rate was
107, his respiratory rate went from 40 to 24, and his oxygen
saturation was 95% on 2 liters. In general, an elderly
gentleman in no apparent distress. Head, eyes, ears, nose,
and throat examination revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light and
accommodation. Extraocular movements were intact. The neck
was supple. No lymphadenopathy. No thyromegaly.
Cardiovascular examination revealed a regular rate. Normal
first heart sounds and second heart sounds. No murmurs,
rubs, clicks, or gallops. Pulmonary examination revealed
decreased breath sounds at the bases bilaterally. No rales
or wheezes. The abdomen was obese, soft, nontender, and
nondistended. Normal active bowel sounds. No
hepatosplenomegaly or masses. Extremity examination revealed
2+ pitting edema bilaterally to the knees. Neurologic
examination revealed alert and oriented times three. Cranial
nerves II through XII were grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratories revealed creatine kinase was 326, CK/MB was 14,
troponin T was 0.25, and MB index was 4.3. His white blood
cell count was 7.8, his hematocrit was 33, and his platelets
were 281. Sodium was 135, potassium was 4.2, chloride was
99, bicarbonate was 28, blood urea nitrogen was 24,
creatinine was 1.1, and blood glucose was 303. Prothrombin
time was 13.8, partial thromboplastin time was 25.2, and his
INR was 1.3.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray demonstrated
cardiomegaly with pulmonary vasculature redistribution and a
new lingular opacity (pneumonia versus asymmetric pulmonary
edema), and a small calcified granuloma in the right upper
lobe (as previously demonstrated).
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the C-MED Service, placed on
telemetry, and continued on his outpatient cardiac
medications, as well as a nitroglycerin, heparin, and
Integrilin drips.
1. CONGESTIVE HEART FAILURE ISSUES: At baseline, the
patient had been on 2 liters nasal cannula of home oxygen.
His oxygen requirement remained stable while in house on 3
liters nasal cannula. He was saturating at 97%.
An echocardiogram was performed on [**2183-8-21**] which
demonstrated an ejection fraction of 20% with global
hypokinesis; consistent with prior examination.
The patient was continued on digoxin 0.25 mg by mouth once
per day and Lasix 80 mg intravenously once per day. Daily
weights and strict ins-and-outs were monitored. On the day
of discharge, the patient no longer had edema of the lower
extremities. He was saturating at 100% on 2 liters with his
lungs clear to auscultation bilaterally.
2. CORONARY ARTERY DISEASE ISSUES: The patient ruled in by
enzyme criteria; however, his electrocardiogram continued to
be unchanged with a left bundle-branch block at baseline.
There was consideration of catheterization during this
inpatient stay; however, given the patient's complications
with gastrointestinal bleeds, as well as his reluctance to
undergo this procedure, this was deferred.
The patient underwent a chemical stress MIBI on [**2183-8-26**]; during which time he had no anginal symptoms or
interpretable electrocardiogram changes. By verbal report,
the nuclear portion of this study demonstrated fixed defects
in the anterior/inferior walls with an ejection fraction of
20% and left ventricular cavity enlargement.
3. ANEMIA/GASTROINTESTINAL BLEED ISSUES: The patient had an
episode of melena on the morning of [**2183-8-22**]. He
denied bright red blood per rectum, hematemesis,
coffee-grounds emesis, nausea, vomiting, or abdominal pain.
He had never had symptoms of gastrointestinal bleeding in the
past.
A nasogastric lavage demonstrated no active upper
gastrointestinal bleed, and his vital signs remained stable
with a stable hematocrit at 29.8. Two large-bore intravenous
lines were placed, and the patient was transfused a total of
three units of packed red blood cells with 80 mg of
intravenous Lasix prior to this transfusion. He was also
started on Protonix 40 mg intravenously twice per day. The
Integrilin, heparin, and aspirin were held.
A Gastroenterology consultation was obtained, and an
esophagogastroduodenoscopy was recommended and performed on
the morning of [**2183-8-23**]. This demonstrated gastritis.
Nevertheless, due to the patient's gastrointestinal bleeding
he was transferred to the Medical Intensive Care Unit because
of concern over the initial hematocrit drop from 33 to 26
with a question of potential retroperitoneal bleed.
On [**2183-8-22**], when he was transferred to the Medical
Intensive Care Unit, an abdominal and pelvic computed
tomography without contrast was obtained which demonstrated
some cholelithiasis without evidence for cholecystitis, and
no evidence of retroperitoneal bleed.
An anemia workup was continued, and iron studies demonstrated
an elevated ferritin and decreased total iron-binding
capacity suggesting likely anemia of chronic disease with
acute anemia secondary to gastritis superimposed.
The patient remained stable and was transferred back to the
C-MED Service on the evening of [**2183-8-23**]. For the
duration of his inpatient course, the patient's hematocrit
remained stable at 32.7, and he did not experience subsequent
episodes of melena or hematemesis.
Of note, the aspirin, heparin, and Integrilin continued to be
held (this contributed to the unwillingness to perform
cardiac catheterization during this inpatient stay).
4. PNEUMONIA ISSUES: On admission chest x-ray, the patient
was noted to have a lingular infiltrate that was felt to be
new compared to prior studies. Of note, the patient's white
blood cell count was 7.8, but he did spike to 102.3 degrees
Fahrenheit on [**2183-8-22**]. Thus, it was felt that the
chest x-ray infiltrate was consistent with pneumonia, and he
was started on levofloxacin 500 mg once per day for a 10-day
course.
The patient's chest x-ray gradually improved during his
inpatient stay. On the day of discharge, his temperature was
99.6 with a white blood cell count of 13.3. Of note, his
maximum white blood cell count had been 13.9. The patient
had been afebrile for 48 hours prior to discharge.
5. DIABETES MELLITUS ISSUES: The patient was placed on an
insulin sliding-scale with four times per day fingersticks.
His glucose remained within normal limits during this
hospital course.
6. MENTAL STATUS CHANGE ISSUES: The patient was minimally
agitated during his Medical Intensive Care Unit stay. It was
felt that this was likely baseline dementia with superimposed
Intensive Care Unit delirium. He did have a recent head
computed tomography which showed no acute event.
Of note, his mental status was much improved upon transfer to
the floor.
DISCHARGE DISPOSITION: The patient was discharged on [**2183-8-26**]. His vital signs were stable. He was saturating at
100% on 2 liters nasal cannula. His creatine kinase levels
had been dropping from 187 to 108 with a troponin of 0.31.
He was asymptomatic.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Acute non-ST-segment myocardial infarction.
2. Pneumonia.
3. Coronary artery disease.
4. Gastrointestinal bleed.
MEDICATIONS ON DISCHARGE:
1. Lipitor 20 mg by mouth once per day.
2. Celexa 20 mg by mouth by mouth twice per day.
3. Doxazosin 2-mg tablets one tablet by mouth once per day.
4. Timolol eyedrops 0.25% one both eyes q.a.m.
5. Levofloxacin 500-mg tablets one tablet by mouth once per
day (for a 10-day course with day one being on [**2183-8-22**]).
6. Lisinopril 40 mg by mouth once per day.
7. Digoxin 250-mg tablets one tablet by mouth once per day.
8. Carvedilol 12.5 mg by mouth twice per day.
9. Protonix 40-mg tablets one tablet by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1445**] in the [**Hospital **] Medical Building, suite B, on [**2183-9-10**] at 11 a.m. (telephone number [**Telephone/Fax (1) 22111**]).
2. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4390**] in the [**Doctor Last Name 780**] Building, on [**2183-9-1**] at
12:10 p.m. (telephone number [**Telephone/Fax (1) 16315**]).
3. The patient was advised to call 911 or present to the
nearest Emergency Department with symptoms of chest pressure,
shortness of breath, jaw discomfort, palpitations, or
diaphoresis.
4. The patient was advised to resume all outpatient
medications; aside from aspirin.
[**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 25002**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2183-8-27**] 08:42
T: [**2183-8-28**] 14:08
JOB#: [**Job Number 25003**]
cc:[**Last Name (NamePattern4) 25004**] |
60883,0389,99592,5849,4280,42731,9982,9974,5601,6084,E8708,41400,V4581 | 38 | 185,910 | Admission Date: [**2166-8-10**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2090-8-31**] Sex: M
Service: UROLOGY
Allergies:
Inderal / Bactrim / Codeine / Penicillins
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
epididymitis
Major Surgical or Invasive Procedure:
incision and drainage of Fournier's gangrene
History of Present Illness:
The patient is a 75 year old male who was transferred from an
outside hospital because of a suspected myocardial infarction on
[**2166-8-10**] and possible need for cardiac catheterization. He was
admitted to the cardiology service initially. His symproms
actually began six days prior to admission with flu-like
symptoms. Then five days prior to admission, the patient began
complaining of a painful lump in his left testicle. His
symptoms gradually worsened, with increasing pain, erythema, and
edema of his left testicle. In addition, he complained of
difficulty urinating for two days prior to admission. He was
admitted to an outside hospital four days prior to admission
here, at which time a Foley catheter was placed and he was
started on IV Levofloxacin and Clindamycin (which was switched
to Levofloxacin and Vancomycin the following day) for
epididymitis diagnosed by ultrasound. The ultrasound also
showed questionable air in the scrotum. The patient was seen by
a urologist, Dr. [**First Name (STitle) **], as well as an infectious disease
specialist. He denied any trauma to his scrotum. He has no
significant urologic history. His prostate examination revealed
a 20 to 25 gram nonfluctuent prostate. He is not diabetic and
he is not immunocompromised. He reported that his pain has been
improving on the antibiotics. However, on the night prior to
admission he developed acute pulmonary edema, shortness of
breath, hypotension and EKG changes suggestive of myocardial
infarction (ST elevation in leads V1-[**Street Address(2) 23394**] depression in
V5-6). His peak troponin was 0.96. Neo-synepherine was started
upon admission because of hypotension, which was presumed to be
secondary to sepsis. Significant cardiac history includes a
CABG in [**2141**], hypertension, aortic stenosis, mitral
regurgitation, high cholesterol, and congestive heart failure
(EF of 40%). Upon re-evaluation at this hospital, his EKG
changes were thought to be secondary to demand ischemia, rather
than a myocardial infarction. In addition, the patient was
noted to be in acute renal failure, with a createnine of 1.8 on
admission, likely due to prerenal causes. Blood and urine
cultures from the outside hospital were all negative.
Past Medical History:
As above. Left femoral to popliteal bypass graft
Social History:
none significant
Family History:
none
Physical Exam:
General: no apparent distress
HEENT: pupils equal, round and reactive to light, extraoccular
muscles in tact
Neck: supple
Lungs: bibasilar crackles
Heart: irregularly irregular, 2/6 systolic ejection murmur
diffusely
Gastrointestinal: soft, nontender, nondistended, bowel sounds
positive
Genitourinary: enlarged (grapefruit sized) and edematous
scrotum, can not palpate testicles due to edema, bilateral
testicular tenderness (left greater than right), scrotal
erythema extending faintly up the groin creases, penile edema,
Foley in place with dark yellow urine
Extremities: full range of motion and 5/5 strength in all four
extremities
Neurologic: alert and oriented X 3, cranial nerves [**1-11**] intact
Pertinent Results:
[**2166-8-10**] 01:17AM BLOOD WBC-18.2* RBC-3.82* Hgb-12.5* Hct-36.0*
MCV-94 MCH-32.6* MCHC-34.6 RDW-14.0 Plt Ct-76*
[**2166-8-11**] 03:48AM BLOOD WBC-14.0* RBC-4.01* Hgb-12.5* Hct-38.4*
MCV-96 MCH-31.2 MCHC-32.6 RDW-14.6 Plt Ct-112*
[**2166-8-11**] 08:02AM BLOOD WBC-14.0* RBC-3.32* Hgb-10.5* Hct-32.3*
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.6 Plt Ct-99*
[**2166-8-11**] 01:20PM BLOOD WBC-13.9* RBC-3.20* Hgb-10.3* Hct-30.2*
MCV-95 MCH-32.3* MCHC-34.2 RDW-14.6 Plt Ct-99*
[**2166-8-12**] 02:24AM BLOOD WBC-10.5 RBC-3.35* Hgb-10.7* Hct-31.9*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.8 Plt Ct-121*
[**2166-8-12**] 12:30PM BLOOD Hct-28.5*
[**2166-8-13**] 01:53AM BLOOD WBC-9.3 RBC-2.91* Hgb-9.5* Hct-27.2*
MCV-94 MCH-32.7* MCHC-35.0 RDW-14.7 Plt Ct-99*
[**2166-8-14**] 02:30AM BLOOD WBC-8.8 RBC-2.90* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.3 RDW-14.6 Plt Ct-88*
[**2166-8-14**] 01:29PM BLOOD Hct-26.1* Plt Ct-73*
[**2166-8-14**] 11:43PM BLOOD Hct-28.8*
[**2166-8-15**] 03:20AM BLOOD WBC-7.3 RBC-3.15* Hgb-9.9* Hct-29.1*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.5 Plt Ct-53*
[**2166-8-15**] 02:32PM BLOOD WBC-8.8 RBC-3.07* Hgb-9.6* Hct-28.6*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-58*
[**2166-8-16**] 02:39AM BLOOD WBC-7.7 RBC-2.81* Hgb-9.0* Hct-25.9*
MCV-92 MCH-31.9 MCHC-34.5 RDW-14.6 Plt Ct-58*
[**2166-8-16**] 02:15PM BLOOD WBC-12.1*# RBC-3.18* Hgb-10.1* Hct-29.1*
MCV-92 MCH-31.8 MCHC-34.6 RDW-14.5 Plt Ct-63*
[**2166-8-17**] 02:38AM BLOOD WBC-7.6 RBC-3.16* Hgb-10.0* Hct-29.5*
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.6 Plt Ct-67*
[**2166-8-18**] 03:46AM BLOOD WBC-7.4 RBC-3.22* Hgb-10.1* Hct-30.0*
MCV-93 MCH-31.3 MCHC-33.6 RDW-14.7 Plt Ct-85*
[**2166-8-18**] 01:15PM BLOOD Hct-25.7*
[**2166-8-18**] 03:58PM BLOOD Hct-28.6*
[**2166-8-19**] 02:34AM BLOOD WBC-8.4 RBC-3.20* Hgb-10.0* Hct-30.9*
MCV-96 MCH-31.2 MCHC-32.4 RDW-14.5 Plt Ct-119*
[**2166-8-20**] 02:03AM BLOOD WBC-5.6 RBC-3.00* Hgb-9.4* Hct-28.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.5 Plt Ct-177
[**2166-8-21**] 02:37AM BLOOD WBC-5.3 RBC-2.98* Hgb-9.3* Hct-28.2*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.7 Plt Ct-183
[**2166-8-22**] 02:14AM BLOOD WBC-5.2 RBC-3.20* Hgb-10.0* Hct-30.2*
MCV-94 MCH-31.1 MCHC-33.0 RDW-15.5 Plt Ct-199
[**2166-8-10**] 01:17AM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.4
[**2166-8-10**] 01:17AM BLOOD Plt Smr-VERY LOW Plt Ct-76* LPlt-2+
[**2166-8-10**] 05:13PM BLOOD PT-15.6* PTT-50.6* INR(PT)-1.7
[**2166-8-11**] 02:30AM BLOOD PTT-53.2*
[**2166-8-11**] 03:48AM BLOOD Plt Ct-112* LPlt-2+
[**2166-8-11**] 08:02AM BLOOD PT-15.3* PTT-33.1 INR(PT)-1.6
[**2166-8-11**] 08:02AM BLOOD Plt Ct-99* LPlt-1+
[**2166-8-11**] 01:20PM BLOOD PT-14.8* PTT-32.0 INR(PT)-1.5
[**2166-8-19**] 02:34AM BLOOD Plt Ct-119* LPlt-1+
[**2166-8-21**] 02:37AM BLOOD Plt Ct-183
[**2166-8-22**] 02:14AM BLOOD Plt Smr-NORMAL Plt Ct-199 LPlt-1+
[**2166-8-10**] 01:17AM BLOOD Glucose-94 UreaN-42* Creat-1.8* Na-140
K-4.4 Cl-106 HCO3-21* AnGap-17
[**2166-8-10**] 05:13PM BLOOD Glucose-137* UreaN-55* Creat-2.6* Na-139
K-4.2 Cl-107 HCO3-20* AnGap-16
[**2166-8-11**] 08:02AM BLOOD Glucose-114* UreaN-52* Creat-2.0* Na-139
K-3.9 Cl-111* HCO3-19* AnGap-13
[**2166-8-11**] 01:20PM BLOOD Glucose-156* UreaN-49* Creat-1.9* Na-138
K-4.2 Cl-110* HCO3-22 AnGap-10
[**2166-8-12**] 02:24AM BLOOD Glucose-92 UreaN-42* Creat-1.7* Na-138
K-4.8 Cl-110* HCO3-20* AnGap-13
[**2166-8-12**] 12:30PM BLOOD Glucose-84 UreaN-35* Creat-1.5* Na-141
K-4.2 Cl-112* HCO3-22 AnGap-11
[**2166-8-16**] 02:39AM BLOOD Glucose-118* UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-106 HCO3-29 AnGap-8
[**2166-8-16**] 02:15PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-137
K-3.7 Cl-102 HCO3-29 AnGap-10
[**2166-8-17**] 02:38AM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-103 HCO3-30 AnGap-8
[**2166-8-17**] 10:16AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2166-8-18**] 03:58PM BLOOD K-4.4
[**2166-8-20**] 02:03AM BLOOD Glucose-116* UreaN-21* Creat-1.0 Na-138
K-3.8 Cl-110* HCO3-23 AnGap-9
[**2166-8-22**] 02:14AM BLOOD Glucose-126* UreaN-25* Creat-0.9 Na-140
K-4.2 Cl-112* HCO3-23 AnGap-9
[**2166-8-10**] 01:17AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2166-8-13**] 01:53AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2166-8-10**] 01:17AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.0 Mg-1.7
UricAcd-6.4
[**2166-8-12**] 02:24AM BLOOD Albumin-2.2* Calcium-8.4 Phos-3.6 Mg-2.3
UricAcd-5.9
[**2166-8-22**] 02:14AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.8
[**2166-8-11**] 01:01AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-43 pH-7.32*
calHCO3-23 Base XS--3
[**2166-8-11**] 01:36PM BLOOD Type-ART pO2-169* pCO2-48* pH-7.29*
calHCO3-24 Base XS--3
[**2166-8-15**] 03:38AM BLOOD Type-ART pO2-129* pCO2-43 pH-7.42
calHCO3-29 Base XS-3
[**2166-8-17**] 02:52AM BLOOD Type-ART Temp-37.8 Rates-/24 PEEP-5
FiO2-40 pO2-137* pCO2-46* pH-7.46* calHCO3-34* Base XS-8
Intubat-INTUBATED
[**2166-8-19**] 08:19PM BLOOD Type-ART pO2-114* pCO2-40 pH-7.43
calHCO3-27 Base XS-2
[**2166-8-21**] 04:14PM BLOOD Type-ART pO2-126* pCO2-32* pH-7.47*
calHCO3-24 Base XS-1
[**2166-8-22**] 05:30PM BLOOD Type-ART Temp-36.9 Rates-10/ Tidal V-900
PEEP-5 FiO2-40 pO2-130* pCO2-35 pH-7.48* calHCO3-27 Base XS-3
Intubat-INTUBATED
Brief Hospital Course:
The patient was admitted to the cardiology service at [**Hospital1 18**] on
[**2166-8-10**] for presumed myocardial infarction on electrocardiogram,
which was later attributed to demand ischemia due to sepsis. He
was initially started on neo-synephrine for hypotension. He was
continued on Vancomycin and Levofloxacin for his epididymitis.
The urology team saw and evaluated the patient as a consult
service under Dr. [**Last Name (STitle) 4229**]. Our suspicion of Fournier's gangrene
at that time was very low, considering his lack of risk factors
and lack of significant groin erythema, however a CT scan of his
abdomen and pelvis was ordered to rule out Fournier's. That CT
scan confirmed the diagnosis of Fournier's gangrene on the
morning of hospital day two (tracking of air around his left
hemi scrotum tracking up the left spermatic cord. At that time,
the patient was emergently rushed to the operating room for
emergent surgical debridement by Dr. [**Last Name (STitle) 4229**] and Dr. [**First Name (STitle) **], chief
urology resident. During the operation, the patient had the
majority of his left scrotum and all of his left testicle
removed. He was then admitted to the trauma intensive care
unit. He was sedated on Propofol with Fentanyl for pain. He
was started on a Levophed drip to maintain blood pressure. A
central venous line was placed, as well as a Swann Ganz
catheter. An oro-gastric tube was placed and put to gravity.
His Foley was continued from the operating room. Dressing
changes to his scrotum were scheduled for three times per day.
On postoperative day two, his maximum temperature was 101.0.
His Levophed drip was weaned to a low level. Tube feeds were
started through his NG tube. On postoperative day three, the
plastic surgery service began their evaluation of the patient
for future closure of his wound. His propofol was discontinued.
His Levophed was discontinued. He vomited twice and his tube
feeds were held for high residuals. He recieved one unit of red
blood cells for a hematocrit under 30, and his hematocrit
responded well. His acute renal appeared to have resolved, as
his createnine dropped down to 1.0. On postoperative day four,
his ventillator was weaned to pressure support, however he had
some apneic spells. A HIT panel was negative and his
subcutaneous heparin was restarted. He had some bedside
debridement by the urology team and his wound looked like it was
healing well. He was transfused with another unit of red blood
cells. The patient was noted to be roughly twenty liters
positive and diuresis with a Lasix drip was started as
tolerated. On postoperative day seven, the patient required
some propofol for sedation due to endotracheal tube and
oro-gastric tube irritation. A sputum culture came back
positive for MRSA sensative to Vancomycin. His wound cultures
were positive for mixed flora including Bacteroides, Provatella,
and coagulase negative Staphylococcus. A wound VAC was placed
by urology. On postoperative day eight, a post-pyloric feeding
tube was placed by interventional radiology because the patient
was not tolerating tube feeds via the oro-gastric tube. On
postoperative day nine, Dr. [**Last Name (STitle) 4229**] agreed to allow placement of a
tracheostomy tube and a PEG tube at a later date. The patient
had been unable to tolerate a ventillator wean up to this point,
most likely due to his fluid overload and his cardiac history.
Tube feeds were running at agoal of 90ml/ hour. On
postoperative day ten, his Flagyl and Levofloxacin were
discontinued. He was transfused one unit of blood for a
hematocrit less than thirty. On postoperative day twelve, he
recieved another unit of red blood cells.
On POD 14, a #8 percutaneous trach was placed at the bedside. A
perc PEG was placed uner direct visualization, but the tube was
pulled through the abdominal wall. The patient was subsequently
taken to the OR for an open gastrostomy tube which was placed
without further complication. Vancomycin was stopped on [**8-25**]
after a complete 14-day course. On [**2166-8-27**], the wound was
closed primarily at the bedside by the plastic surgery service.
TF were restarted on [**2166-8-27**] and advanced as tolerated. A PICC
line was also placed on [**2166-8-27**]. Propofol was d/c'd on [**2166-8-28**].
ON [**2166-8-28**], the patient spiked a temp to 102. Cultures were
drawn and the A-line tip sent for culture as well. [**2166-8-29**] tube
feeds were held for high residuals, an ileus was found on
imaginig. PT evaluation occured on [**2166-8-29**]. Trach mask trials
were started on [**2166-8-28**] and the vent weaned as tolerated, with
the patient still requring vent assistance most of the day.
Vancomycin was restarted on [**2166-8-30**] for MRSA sputum; it will be
continued for 7 days; the JP drain was removed on this day as
well. TF were restarted on [**2166-9-1**] and brought to goal over the
next day. The patient is now tolerating TF at goal with bowel
movements.
On [**2166-9-3**], the patient was tolerating TF at goal, having bowel
movements, tolerating trach mask trials daily, was working with
PT, had good pain control with roxicet elixer, was alert and
requring no sedation. He was subsequently transfered to rehab
for physical therapy and vent weaning.
Medications on Admission:
lipitor 20', atenolol 25', ASA 81', zestril 5', protonix 40'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
15. Morphine Sulfate 1-2 mg IV Q3-4H:PRN
prn breakthrough pain
16. Metoclopramide 10 mg IV Q6H
17. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
18. Vancomycin HCl 1000 mg IV Q 12H
19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
22. Midazolam HCl 0.5-1 mg IV Q4H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Fournier's gangrene
Discharge Condition:
stable
Discharge Instructions:
Tube feeds: promote with fiber @ 90cc/hr
[**Name8 (MD) **] MD for:
* fever
* inability to tolerate TF
* erythema/increased discharge from wound
* uncontrolled pain
Followup Instructions:
Abdominal staples to be removed on [**2166-9-8**]
Scrotal sutures to be removed 3 weeks after closure on [**2166-8-27**]
Vancomycin to be d/c'd [**2166-9-5**]
|
7742,V053,V058,V290,76519,7708,2765,V3000,769 | 39 | 106,266 | Admission Date: [**2114-11-29**] Discharge Date: [**2114-12-10**]
Date of Birth: [**2114-11-29**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**First Name4 (NamePattern1) 15406**] [**Known lastname 11622**] delivered at 35 weeks
gestation, birth weight 2775 grams, was admitted to the
Newborn Intensive Care Unit for management of prematurity and
respiratory distress.
estimated date of delivery [**2115-1-3**]. Prenatal screens
included blood type O positive, antibody screen negative,
Rubella immune, RPR nonreactive, and hepatitis B surface
antigen negative and group B strep positive. Pregnancy was
complicated by placenta previa noted on 18 week and 25 week
ultrasound and preterm contractions from 28 week gestation
managed with bed rest. Had intermittent vaginal bleeding.
spontaneous vaginal delivery under epidural anesthesia on
[**2114-11-29**] secondary to progressive preterm labor. Rupture of
membranes one hour prior to delivery. No maternal fever.
Received intrapartum antibiotics five hours prior to
delivery.
Infant emerged with a weak cry and well maintained heart
rate. Received oral and nasal bulb suctioning, tactile
stimulation and dried. Subsequently required brief positive
pressure ventilation for irregular respiratory effort.
Spontaneous regular respirations were established but the
infant was still pale with intermittent grunting and was
therefore grunting and was therefore transferred to the
Intensive Care Nursery from labor and delivery. Apgar scores
were 6 and 8 at one and five minutes respectively.
Examination of placenta at the delivery showed scattered old
clots without calcifications.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2775 grams (75th
percentile), length 50.5 cm (90th percentile), head
circumference 34 cm (90th percentile). A nondysmorphic pale
infant, palate intact, anterior fontanelle soft and flat,
moderate nasal flaring, moderate intercostal and subcostal
retraction, good breath sounds bilaterally with a few
scattered rales, well perfused with regular rate and rhythm,
femoral pulses present bilaterally, no murmur. Abdomen soft,
nondistended, no organomegaly, no masses, three vessel cord,
normal female external genitalia. Active alert infant with
tone slightly decreased moving all limbs symmetrically.
Normal reflexes. Hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: Placed
on nasal CPAP 6 cm of water on admission for respiratory
distress. Highest oxygen requirement on CPAP 45 percent.
Weaned to nasal cannula oxygen on day of life two. Required
supplemental O2 by nasal cannula until day of life seven.
Has remained in room air since with comfortable work of
breathing, respiratory rate 30 to 50s.
Respiratory: Has had several episodes of apnea and
bradycardia or oxygen desaturations since admission. Last
oxygen desaturations on [**12-6**], last bradycardia episode on
[**12-4**] associated with feeding.
Cardiovascular: Received one bolus of normal saline for
pallor on admission. Has remained hemodynamically stable
throughout hospital stay. A soft murmur was audible through
the first few days of life that has subsequently not been
heard.
Fluids, electrolytes and nutrition: Was n.p.o. on admission
and receiving D10W by peripheral intravenous. Started
enteral feeds on day of life two, on all breast or bottle
feed by day of life four with weight gain. Discharge weight
Gastrointestinal: Peak total bilirubin 13.1, direct .4. Did
not require phototherapy.
Hematology: Hematocrit on admission 41 percent.
Infectious disease: Received Ampicillin and Gentamicin for
48 hours for rule out sepsis. Respiratory distress though
secondary to mild surfactant deficiency. Initial CBC was
benign. Blood culture was negative. Received initial dose of
Synagis RSV prophylaxis.
Neurology: Examination age appropriate.
Sensory: Hearing screening was performed of automated
auditory brain stem responses passed both ears.
CONDITION AT DISCHARGE: Stable preterm infant.
DISCHARGE DISPOSITION: Discharged home with parents. Name
of primary pediatrician: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**], [**Hospital 2312**]
Pediatrics, telephone number [**Telephone/Fax (1) 37109**].
CARE RECOMMENDATIONS:
1. Ad lib demand breast feeding, follow weight gain.
2. Medication: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d.
3. Car seat test passed.
4. Immunizations received: Received hepatitis B
immunization and Synagis on [**2114-12-7**]. Immunizations
recommended: Synagis RSV prophylaxis to be
considered from [**Month (only) 359**] to [**Month (only) 547**] for infants who
meet any of the following three criteria: 1) born at
less than 32 weeks, 2) born between 32 and 35 weeks
with plans for day care during RSV season, with a
smoker in the household, or with preschool siblings
or, 3) with chronic lung disease.
FOLLOW UP APPOINTMENTS: 1) Follow up appointment with
pediatrician following discharge. 2) [**First Name (Titles) 1587**] [**Last Name (Titles) 28085**] made to [**Location (un) 86**] [**Hospital6 1587**], telephone number [**Telephone/Fax (1) 37525**].
DISCHARGE DIAGNOSES:
1. AGA preterm female.
2. Respiratory distress syndrome resolved.
3. Rule out sepsis.
4. Neonatal jaundice.
5. Apnea of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2114-12-9**] 04:69
T: [**2114-12-9**] 07:05
JOB#: [**Job Number 38966**]
|
496,70703,5121,78820,48282,V1005,1124,70705,5070,48241,5130,5185,1917,V1047,4019,2859,3051,7099,3485 | 41 | 101,757 | Admission Date: [**2132-12-31**] Discharge Date: [**2133-1-27**]
Date of Birth: [**2076-5-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Progressive signs of dizziness, visual difficulties, unsteady
gait
Major Surgical or Invasive Procedure:
Right-sided high frontal stereotactic biopsy, CT-guided target
point, definition and MRI-guided intraoperative imaging.
History of Present Illness:
The patient is a 56-year-old male with a history of colon
cancer, as well as testicular cancer, who presents with
progressive signs of dizziness, visual difficulties, unsteady
gait for approximately 12 months. He was worked up including an
MRI scan that showed a brainstem lesion. He was referred to the
brain tumor clinic for consideration of a biopsy.
The patient has been followed at the [**Hospital6 **] at [**Location 10050**]. He had been treated for a number of medical issues. He
was examined by Dr. [**Last Name (STitle) 66170**] whose physical exam reportedly
showed bilateral facial numbness and swaying, and a MRI of the
head was preformed. This demonstrated expansion of the
brainstem without significant contrast enhancement. The patient
was thus considered to have a brainstem glioma and started on
Decadron. The patient now presents for a surgical opinion. In
the office, the patient complains about dizziness, blurred
vision, double vision, occasional headaches, and unsteady gait.
He feels better with medications. He takes at baseline 2 Tylenol
a day. Has a history of arthritis in the lower back, otherwise,
he reports that the numbness in his hands has disappeared since
starting the Decadron. The patient has tapered his Decadron to a
dose of 2 mg p.o. b.i.d. The patient is otherwise feeling
himself stable. He was told that he had a left lazy eye at
baseline, but the patient is not quite sure about the symptoms.
He denies otherwise any extreme fatigue, weight loss or other
symptoms.
Past Medical History:
Hypertension
Hypercholesterolemia
Sigmoid colon cancer [**2125**]
Testicular cancer s/p Left orchiectomy and was found to be a
germ cell tumor T1, N0.was treated with adjuvant chemotherapy no
radiation.
Hemorrhoids
Recurrent bouts of thrush
Social History:
He is a high school graduate. He is an electrician. He is
divorced. He has no other people in the household. He has a
40-pack-year history of smoking. He drinks about three drinks a
week, and he denies any recreational drug use.
Family History:
His mother died at 63 of a heart attack. His father died at 44
after a MVA. He has two sisters 58 and 54, the 54-year-old has
gallbladder stones. Other than that, they both are healthy.
There are two brothers, one brother at 47 who has
hypertension and two daughters that are in good health.
Physical Exam:
GENERAL: He is alert, pleasant, middle-aged man in no acute
distress. Weight was 170 pounds, height was 74 inches, blood
pressure was 154/90, pulse of 96, respirations 20, temperature
of 97.4.
HEENT: The patient did have a head tilt to the left.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or
rubs.
LUNGS: Clear to auscultation.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: The patient is awake, alert and oriented. He has
bilateral reactive pupils. Eye movements are full and we cannot
detect a clear deficit of a particular muscle, at current, the
patient has no diplopia. Visual fields seem to be fully intact.
He has non-exhaustible end gaze nystagmus with rotatory
component. Face is symmetric. Tongue is midline. No
fasciculations. He has a hoarse voice. He has full strength
bilaterally. He has intact sensation and symmetric reflexes. The
patient does not have any memory problems, blackouts, nausea,
concentration, or speech problems, as well as hearing problems.
On motor examination, he was [**4-24**] bilaterally, normal tone, no
drift. I found no evidence of any weakness in his hands. Upper
sensory, he was intact to light touch throughout, and he was
intact to pinprick over in the hands
Reflexes were 2+ throughout.
Cerebellar: He had bilateral intention tremor in the hands as
well as finger tapping and rapid alternating movements were
fine. Foot tapping and heel-knee-shin was normal.
Gait: He had a wide based gait, he is unable to toe tandem or
heel walk.
Pertinent Results:
[**2132-12-31**] 09:40AM GLUCOSE-116* LACTATE-1.2 NA+-132* K+-4.0
CL--95*
[**2132-12-31**] 09:40AM TYPE-ART PO2-83* PCO2-35 PH-7.50* TOTAL
CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-SPONTANEOU COMMENTS-RM
AIR
[**2132-12-31**] 09:48AM PT-11.1* PTT-21.2* INR(PT)-0.8
[**2132-12-31**] 09:48AM PLT COUNT-241
[**2132-12-31**] 09:48AM WBC-17.9* RBC-4.30* HGB-12.2* HCT-34.0*
MCV-79* MCH-28.4 MCHC-35.9* RDW-17.9*
[**2132-12-31**] 09:48AM GLUCOSE-115* UREA N-16 CREAT-0.5 SODIUM-133
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
[**2132-12-31**] 11:21AM freeCa-1.12
[**2132-12-31**] 11:21AM HGB-11.1* calcHCT-33 O2 SAT-97 CARBOXYHB-1
[**2132-12-31**] 11:21AM GLUCOSE-129* LACTATE-1.7 NA+-133* K+-3.9
CL--98*
.
Pathology [**2132-12-31**]:
MIDDLE CEREBELLAR PEDUNCLE/PONS STEREOTACTIC BRAIN BIOPSY
(including intraoperative smear):
DIFFUSELY INFILTRATING FIBRILLARY ASTROCYTOMA. WHO ([**2126**]) grade
II out of IV.
.
Brief Hospital Course:
56 M with PMH sigmoid and testicular ca in [**2125**], HTN, COPD,
admitted for new diagnosis pontine glioma s/p posterior fossa
decompression and necrotizing pna.
.
# Pontine glioma:
56 year-old man initially seen and discussed in brain tumor
clinic. Patient taken to OR on [**12-31**] for brainstem lesion biopsy
under general anesthesia. Postoperatively stayed in the PACU 6
hours then transferred to floor. On postop day one patient
demonstrated difficulty of swallowing which he failed his speech
and swallow evaluation. Patient kept NPO, started IV fluids. On
[**2133-1-2**] patient taken back to OR for a suboccipital chiari
decompression. Patient tranferred to neuro ICU for hemodymanic
and neurologic monitoring. Due to postoperaive respiratory
secretion extubated on [**2133-1-4**] after bronchcospy.
.
Brain stem biopsy pathology result is significant for
infiltrative astrocytoma. Radiation oncology decided not to
perform radiation mapping and to hold off for another several
weeks before planning to start XRT, since patient has a slow
growing glioma, and XRT could exacerbate pna. Patient known by
Dr [**Last Name (STitle) 4253**] will follow up with him as scheduled. Patient was
transferred to Step-down unit on [**2132-1-7**]. His speech continued
to become more articulate and clear, and his mental status
continued to become more clear. The patient stated that his
dizziness has improved.
.
# Necrotizing pneumonia:
Patient has a known pulmonary process that been followed in
[**Hospital 669**] [**Hospital **] hospital in MA. In house repeat CT of the chest
significant for left lower lobe, consolidative opacity, with
central area of necrosis, an air-fluid level, and
low-attenuation material. Additionally, there are several areas
within the right and left lungs peripherally, with patchy
opacity and tree-in-[**Male First Name (un) 239**] opacities, concerning for multifocal
opacity. There is also a wedge-shaped opacity in the right lower
lung zone, some of which may represent atelectasis.There is a
3.3 x 2.6 cm nodule with multiple foci of calcification within
the left lower lobe. Attempt to obtain images from [**Hospital **] hospital
regarding pulmonary lesions for comparison, [**Name (NI) 653**] with
MEdical records to sent ua CD images. Medicine and
interventional pulmonary services recommended continue
antibiotics, and follow up with chest CT with and with out
contrast in 4 weeks in pulmonary clinic. In the mean time
[**Name (NI) 653**] with Dr [**First Name (STitle) **] at the [**Hospital **] hospital regarding
tranfering him over to VA regarding his known pulmonary process,
and colon carcinoma for further work up which he was agreed with
the transfer.
.
Pleural fluid culture grew out positive to MSSA, GNR, [**Female First Name (un) 564**]
albicans, staph coag neg. BAL culture grew out Stenotrophomonas
maltophila and Klebsiella sensitive to almost all abx tested.
ID was consulted and created antibiotic regimen of clindamycin,
bactrim, ceftriaxone, to be continued for 4-6 weeks. Levo was
completed for 2 weeks (last date [**2133-1-27**]). Patient should be
reassessed to refine abx regimen within 2-4 weeks. The patient
greatly improved on suctioning and chest PT, maintaining >95% RA
on the floor.
.
The following labs will need to be followed up after discharge:
LFTs, mycolytic/fungal cx, Cdiff x3, legionella urinary antigen
.
# Urinary retention:
Patient had no urine output after foley was d/ced. Straight
cath released 980 ml of urine. After 2 days of straight caths,
patient recovered normal urination, and does not have a foley
upon discharge.
.
# Skin lesions:
Dermatology consulted in reference to his left deltoid skin
lesion, non-bleeding which is present for 5 year according to
patient. Dermotalogy recommended excision of the lesion to rule
out melanoma once acute issues resolved with Derm Surgery
([**Telephone/Fax (1) 2977**]).
.
# Anemia:
Patient's Hct was around 25 during admission.
.
# HTN:
Controlled. Diltiazem and captopril were continued as per her
outpt regimen.
.
# Access: Picc placed [**2133-1-9**].
Medications on Admission:
The patient is a 56 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with a PMH significant for sigmoid
and testicular cancer in '[**25**], HTN, and COPD who was admitted to
the neurosurgery service on [**2132-12-31**] with a new diagnosis of a
pontine mass after 1yr of progressive dizziness and ataxia. He
underwent a stereotactic bx on [**12-31**] showing a low grade glioma
and received a palliative posterior fossa expansion on [**1-2**].
.
Routine pre-op CXR revealed multiple opacities and a 3x3 cm well
demarcated cavitary lesion with an air/fluid level in left
posterior lung. Following his surgery, he was extubated w/out
event but required reintubation later that evening [**1-22**]
desaturation. On [**1-3**], a chest CT was done which showed a
multifocal pneumonic process with LLL necrotizing PNA. He
underwent a bronch on [**1-4**] with BAL revealing MSSA and
stenotrophamonas and was started on Levofloxacin (now d10/14),
Vanco (since d/c), and Clinda (d10/42) at this time. Bactrim
(d5/14) was added on [**1-8**] when BAL grew stenotrophamonas.
.
During this time, he has been intermittantly hypoxic with thick
secretions requiring frequent suctioning. Over the past 2d, he
has been afebrile and his secretions have cleared appreciably.
He has maintained his O2 sats on 4L NC. Other than this, the
patient has been intermittantly hypertensive requiring the
addition of captopril to his outpatient regimen. He has also
failed numerous speech and swallow evaluations requring NG tube
feeds to maintain his nutritional status. From an oncologic
standpoint, his pontine lesion is not amenable to resection and
the plan is to initiate palliative radiation therapy. Per
neurosurgery, his prognosis is extremely poor. Finally, the
patient has requested transfer to the [**Location 1268**] VA system
over the past several days as he has received much of his care
at this hospital. Discussions are still ongoing to facilitate
this transfer.
.
PMH:
1. Colon cancer
2. testicular cancer
3. Hemorrhoids
4. Hypertension.
5. Thrush.
6. Hypercholesterolemia.
.
Transfer Meds:
Acetaminophen
Albuterol
Bisacodyl
Captopril
Clindamycin
Dexamethasone
Diltiazem
Docusate
HSQ
Sulfameth/Trimethoprim
Oxycodone
Nystatin
Nicotine Patch
Levofloxacin
Lansoprazole
Ipratropium
ISS
.
PE: 97.0 (98.5), 124/72, 81, 21, 95% 4L NC
Gen: Cachetic [**Male First Name (un) 4746**] sitting up in a chair in NAD
HEENT: MMM, PERRLA, EOMI, O/P clear w/ NGT in posterior
oropharynx
Neck: No LAD, No JVD
CV: RRR, S1/S2 wnl, -M/R/G appreciated
Lungs: Decreased breath sounds bilaterally L>R w/ coarse
inspiratory sounds bilaterally and anteriorly, -wheezes
appreciated, dullness to percussion at the L base
Abd: S/NT/ND, +BS
Ext: -C/C/E, 2+ peripheral pulses bilaterally
Neuro: CN 2-12 grossly intact, dysarthric, strength 5/5 in the
RLE, on the LLE he has decreased dorsal flexion in the
foot/flexion and extension at the knee/flexion at the hip,
mildly decreased L grip strength compared to R hand
================
Micro:
- Sputum [**1-3**]: E. coli (pan-sensitive), Coag + staph
(pansensitive)
- BAL [**1-4**]: Stenotrophamonas (sensitive bactrim), Coag + staph
(MSSA), sparse GNR
- MRSA/VRE swab: negative
================
CTA [**2133-1-9**]:
1. Some improvement in the consolidation in the left lower
lobe, although the large 4-cm cavitary lesion with an air-fluid
level persists, consistent with slight overall improvement in
necrotizing pneumonia.
2. New small cavitary lesion in the left upper lobe, possibly
related to aspiration. Of note, the patient has a small hiatal
hernia.
3. Improvement in some of the ground-glass opacities in the
right middle and upper lobes, with persistent 4-mm lung nodule.
4. Similar slightly prominent right hilar and mediastinal lymph
nodes.
6. No evidence of pulmonary embolism.
7. Similar calcified lung mass, possibly a hamartoma, although
metastatic colon cancer cannot be excluded.
.
CT Head ([**2133-1-9**]): No definite change in the mass effect
associated with the brainstem glioma. Interval development of a
small left frontal region subdural collection.
.
CXR [**2133-1-10**]: No interval change. Persistent opacity at the left
base. There is a 3.6-cm parenchymal opacity within the left
base as well which is also unchanged. There is no evidence for
overt pulmonary edema. The lines and tubes are stable in
position.
================
A/P: 56 yo M admitted for dizziness/weakness. Found to have a
pontine glioma now s/p posterior fossa decompression complicated
by necrotizing PNA and multiple episodes of hypoxia requiring
MICU level care. Called out to medicine service for further
management of his infection and pulmonary status.
.
# Hypoxia: He has been stable over the past few days w/ better
maintained SpO2. He has improved in the past w/with deep
suctioning. Chest CT c/w necrotizine PNA. He is on levo ([**1-9**]
-> 2 weeks), and clinda ([**1-9**] -> 6 weeks). Bactrim was started
on [**1-8**] (x 2 weeks): BAL + for stenotrophamonas.
- wean O2 as tolerated on the floor
- Per thoracic staff ([**2133-1-10**]) pt will need CT guided drain
placement this week; ? if best to schedule PEG at same time to
minimize procedures
- continue levaquin, clindamycin, and bactrim for full course
- will need repeat CT in 1 month
- continue nebs prn
- continue aggressive pulmonary toilet
- incentive spirometry on the floor
.
# Lung nodule. Chest CT from the VA on [**8-25**] demonstrated 2
lesions in LLL (anterior and posterior) both of which were felt
to be stable compared to prior CT [**2-/2127**].
- await old films being mailed from the VA
- f/u IP/thoracic recs
.
# Brainstem glioma. Prognosis estimated at a couple of months
per neurosurg. ? palliative radiation
- continue Decadron [**Hospital1 **] per neurosurgery
- continue prn pain meds
- Neurosurg following
- pt full code
- monitor CN exam, mental status, and strength exams
.
# Anemia. 4pt Hct drop on [**2133-1-9**], transfused on [**1-11**] w/
appropriate Hct elevation and has been stable overnight
- repeat Hct when called out to floor
- guaiac stools x3 then d/c if negative
- transfuse for Hct < 25
- continue PPI while on decadron
.
# HTN. BP well controlled on current regimen
- Continue diltiazem and captopril
- monitor BP and titrate prn
.
# Left deltoid lesion.
- f/u in Dermatologic surgery clinic on [**2133-1-15**] at 11am
.
# Communication: VA Chief - [**Telephone/Fax (3) 66171**].
Mrs. [**Name (NI) 66172**] (aunt) [**Telephone/Fax (1) 66173**] is HCP.
.
# FEN. TF's through NGT (failed video swallow again on [**2133-1-12**])
- continue aspiration precautions
- patient has decline PEG placement x2 per notes in chart
- will reevaluate patient's wishes once transferred to floor;
would be best to place PEG when placing drainage so as to
minimize procedures
- replete lytes prn
.
# Access: PICC line placed [**2133-1-9**]
.
# PPX. SC heparin, PPI, bowel regimen, ISS while on decadron,
replete lytes
.
# Code: Full
.
# Dispo: Patient would like to be transferred to [**Location 1268**]
VA. [**Name (NI) 1094**] aunt has a scheduled meeting today with Dr. [**Last Name (STitle) **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Hold
for lose stool.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-22**]
Puffs Inhalation Q6H (every 6 hours).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4-6H
(every 4 to 6 hours) as needed.
11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**]
Drops Ophthalmic PRN (as needed).
14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours): Started on [**1-2**] Total of 14
days then d/c. .
Discharge Disposition:
Extended Care
Facility:
VA
Discharge Diagnosis:
Right brainstem lesion
Discharge Condition:
Neurologically stable
Discharge Instructions:
Monitor suboccipital staple sites for drainage, erthyma,
swelling, fever greater than 101.5, seizure activity, visual
changes, weakness, numbness or any other neurologic symptoms
that may be concerning.
Keep your all appointments as sheduled.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 10 days from [**1-2**] for wound check
and staple removal or can be removed at the [**Hospital **] hospital.
Follow up with Dr [**Last Name (STitle) 4253**](neurooncology) and Dr
[**Last Name (STitle) 3929**](Radiation oncology) in brain tumor clinic on [**2133-1-26**]
at 1300 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **].
Follow up with Pulmonary Clinic in 4 weeks with a Chest CT with
and without contrast.
Follow up with Dr [**First Name (STitle) **], Dermatologic surgery
clinic([**Telephone/Fax (1) 2977**]for left deltoid lesion on [**2133-1-15**] at
1100.
Follow up with VA infectious disease for possible repeat CT
chest in 4 weeks.
Completed by:[**2133-1-27**] |
43819,43820,4019,412,41400,4280,42741 | 42 | 119,203 | Admission Date: [**2116-4-29**] Discharge Date: [**2116-4-30**]
Date of Birth: [**2055-2-25**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male whose chief complaint was shortness of breath. He has a
history of CVA, traumatic MI, and CHF, who presented with
shortness of breath times 5 days associated with anterior
intermittent chest pain without diaphoresis, palpitation,
PND, orthopnea, or syncope. The patient had traumatic
motorcycle accident with CVA and right hemiparesis and
slurred speech; and has a history of LV dysfunction diagnosed
years ago at an outside hospital and was maintained on Coreg
and Zestril. The patient's complaints prior to arrival to
the [**Hospital1 18**] was that he had shortness of breath and felt like
an asthma attack. He was having increasing inhaler use with
an intermittent left sided anterior chest pain. He also
noticed increasing right lower extremity swelling, went to
his PCP; EKG there was noted to have question of junctional
tachycardia versus atrial flutter versus 2 to 1 block. The
patient also had increased BNP at the outside hospital where
he was referred to 3000. He was noted to be in 94 to 95
percent on room air. Blood pressure was 110/76, heart rate
98. The patient was started on Lovenox, amiodarone drip, IV
nitroglycerine, Lasix, and Lopressor. He was ruled out for
myocardial infarction and then noted to have primary AV block
with right bundle-branch block around the ventricular
tachycardia. The patient was started on lidocaine and
continued on diuresis and referred at the [**Hospital1 18**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Dilantin 400 mg once a day.
2. Coumadin 3 mg once a day.
3. Ventolin.
4. Protonix 40 mg once a day.
5. Coreg 12.5 mg twice a day.
6. Zestril 30 mg once a day.
7. Norvasc 5 mg once a day.
8. Azmacort 2 puffs t.i.d.
9. Lasix p.r.n., dose unspecified.
10. Advair.
11. Digoxin 0.25 mg once a day.
12. Lovenox 40 mg subcutaneous q.12 hours.
13. Lidocaine GTT.
14. Amiodarone GTT.
PAST MEDICAL HISTORY: Significant for asthma, congestive
heart failure, cerebrovascular accident [**2106**]/[**2107**], status
post MVA 20 years ago, history of cholecystectomy, right
bundle-branch block diagnosed in [**2114-6-18**], melanoma on the
right side of back, dysphagia, and gastroesophageal reflux
disease.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] does not work
secondary to illness. No tobacco and he drinks only
socially.
FAMILY HISTORY: Significant for CAD in the mother.
LABORATORY DATA: On admission,
1. CK 56, troponin less than 0.04.
2. CK 49, troponin 0.04.
3. CK 32, troponin 0.04
Sodium 136, potassium 3.7, chloride 101, bicarbonate 28, BUN
17, creatinine 0.9, glucose is 111, calcium is 7.9, magnesium
1.3, phosphorus 3.0, white count of 0.1, hematocrit 33.5, and
platelet count is 213.
PHYSICAL EXAMINATION: Vitals: Temperature is 98.2 degrees,
heart rate 76, respiratory rate 16, and blood pressure
130/70. General: The patient is in no acute distress .
HEENT: Right pupil is fixed and left is minimally
responsive. EOMI. Anicteric sclerae. Moist mucous
membranes. Tongue deviates to the right. Right facial droop
is noted. JVP is 6 cm. Heart: Regular rate and rhythm with
no murmurs. Lungs: Clear to auscultation bilaterally.
Abdomen: Good bowel sounds, soft, nontender, nondistended.
Extremities: Free of any clubbing, cyanosis, or edema.
Neurologic: Exam is again significant for the right blown
fixed pupil, left minimally responsive pupil, and tongue
deviates to right. Strength is 5 out of 5 and symmetric in
the right upper and lower extremities. Strength is 3 out of
5 in the left upper and left lower extremities. No
resistance is noted. Reflexes are 2 plus throughout.
HOSPITAL COURSE:
1. Coronary artery disease: The patient was maintained on
aspirin, Coreg, and Zestril. Blood pressures were
followed closely for ischemia. There was no active
evidence of ischemia. Cardiac enzymes confirmed this.
Echocardiogram from [**2116-4-27**], revealed an EF of 25
percent, left atrium that is elongated, right atrium
mildly dilated, left ventricular wall thickness that is
normal. Left ventricular cavity size mildly dilated.
Overall, left ventricular systolic function severely
depressed. Right ventricular systolic function appears
depressed. Aortic root has normal diameters and the aorta
is mildly dilated; 2 plus MR is noted. Physiologic TR is
noted.
2. Rhythm: The patient was noted to have runs as
asymptomatic ventricular tachycardia. He was maintained
on amiodarone GTT and lidocaine GTT. EP was consulted and
the patient underwent VT ablation that was unsuccessful
secondary to aneurysm. The patient subsequently had [**Year/Month/Day 3941**]
that was placed on [**2116-4-29**]. The patient had a [**Company 1543**]
max-mode DR [**Last Name (STitle) 3941**] placed via right cephalic access with no
complications. Otherwise, the patient was maintained on
amiodarone 400 mg t.i.d. times 1 week, 400 mg q.d. times 3
weeks, and then 400 mg q.d. after that point. The patient
was also maintained on Coumadin and Lasix with good
effect.
3. Hypertension: The patient was maintained on Coreg and
Zestril for CVA. The patient was maintained on Dilantin.
His Dilantin dose was halved without patient's further
management.
4. Prophylaxis: The patient was maintained on subcutaneous
heparin, bowel regimen, PPI, and the patient's bilateral
knees were negative. The patient was a full code and was
discharged on [**2116-4-30**].
MEDICATIONS AT DISCHARGE:
1. Amiodarone 400 mg 1 tablet 3 times a day for 5 days, then
amiodarone 400 mg 1 tablet once a day for 3 weeks, and
then amiodarone 200 mg tablets 1 by mouth once a day.
2. The patient was maintained on Dilantin 200 mg once a day.
3. Tylenol 1 to 2 tablets q.4 hours p.r.n., as needed for
pain, not to exceed 4 gm a day.
4. Fluticasone 110 mcg 2 puffs b.i.d.
5. Lisinopril 5 mg 1 tablet once a day.
6. Aspirin 325 mg 1 by mouth once a day.
7. Atorvastatin 20 mg 1 tablet by mouth once a day.
8. Metoprolol 12.5 mg 1 by mouth twice a day.
9. Coumadin 5 mg tablets every night.
10. Keflex 500 mg 1 capsule by mouth 3 times a day for 2
days.
11. Lasix 20 mg once a day.
FOLLOW UP: He is to followup in the [**Hospital 3941**] clinic on [**2116-5-6**]
at 2 p.m. The patient is to see his primary care physician
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27542**] on [**2116-5-4**] at 10:30 a.m., where he is
to have his Chem-10, PT, PTT, INR, and Dilantin level
checked.
DISCHARGE DIAGNOSES:
1. Ventricular tachycardia, status post ventricular
tachycardia ablation.
2. Status post implantable cardioverter defibrillator
placement.
3. History of cerebrovascular accident.
4. History of hypertension.
5. Depressed ejection fraction.
DISCHARGE STATUS: He will be discharged to home.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2116-10-26**] 08:26:04
T: [**2116-10-26**] 14:25:00
Job#: [**Job Number 55436**]
|
E8210,5180,8052 | 43 | 146,828 | Admission Date: [**2186-10-1**] Discharge Date: [**2186-10-11**]
Date of Birth: [**2153-12-25**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Lipitor
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Thoracolumbar fusion T10-L3
History of Present Illness:
32 yo male s/p ejection off four [**Doctor Last Name **] after skidding on
leaves now with back pain.
Past Medical History:
Hyperlipidemia
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes intact at quads and achilles; + pain to
palpation midline lower back
Pertinent Results:
[**2186-10-9**] 09:40AM BLOOD Hct-32.5*
[**2186-10-8**] 08:30AM BLOOD WBC-12.0* RBC-3.38* Hgb-10.3* Hct-28.7*
MCV-85 MCH-30.5 MCHC-35.8* RDW-15.5 Plt Ct-325
[**2186-10-7**] 06:00AM BLOOD WBC-10.0 RBC-2.75* Hgb-8.6* Hct-23.7*
MCV-86 MCH-31.2 MCHC-36.3* RDW-15.0 Plt Ct-247
[**2186-10-6**] 04:19AM BLOOD WBC-10.9 RBC-3.23* Hgb-10.0* Hct-28.3*
MCV-87 MCH-30.9 MCHC-35.6* RDW-15.2 Plt Ct-283
[**2186-10-5**] 04:50PM BLOOD WBC-9.3 RBC-3.15* Hgb-9.6* Hct-27.1*
MCV-86 MCH-30.5 MCHC-35.5* RDW-13.8 Plt Ct-236
[**2186-10-8**] 08:30AM BLOOD Glucose-102 UreaN-9 Creat-0.6 Na-137
K-4.0 Cl-100 HCO3-29 AnGap-12
[**2186-10-7**] 06:00AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-99 HCO3-31 AnGap-9
[**2186-10-6**] 04:19AM BLOOD Glucose-160* UreaN-13 Creat-0.7 Na-137
K-5.1 Cl-102 HCO3-30 AnGap-10
[**2186-10-3**] 09:33PM BLOOD Glucose-176* UreaN-11 Creat-0.9 Na-133
K-5.2* Cl-104 HCO3-20* AnGap-14
[**2186-10-2**] 03:26AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-142
K-3.2* Cl-113* HCO3-22 AnGap-10
Brief Hospital Course:
Mr [**Known lastname **] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
thoracolumbar fusion for his T12 burst fracture. He was
informed and consented for the procedure and elected to proceed.
Please see Operative Note for procedure in detail.
Post-operatively his chest tube and drain were removed. Follow
up x-ray showed atelectasis involving the right middle and lower
lobes. Incentive spirometer was encouraged. Follow up films
were taken which showed a stable atelectasis which began to show
improvement after working with PT and IS encouragement.
Post-operatively he was administered antibiotics and pain
medication. His catheter and drain were removed POD 2 and he
was able to take PO's. His pain was well controlled and he
remained afebrile throughout his hosptial course.
He was able to work with physical therapy and made improvements
in strength and balance.
He will return to clinic in ten days. He was discharged in good
condition.
Medications on Admission:
Lipitor
Zetia
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
T12 fracture
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
TLSO for ambulation; may be out of bed to chair without.
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2186-10-11**] |
4439,V173,78057,2720,4019,3968,41401,4139,5960,42731 | 44 | 181,750 | Admission Date: [**2192-11-19**] Discharge Date: [**2192-11-27**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
80 year old white male with shortness of breath with exertion.
Major Surgical or Invasive Procedure:
CABG X 3
History of Present Illness:
This 80 year old white male with a history of HTN,
hyperlipidemia, PVD, afib, and CVA, was admitted for elective
cardiac cath [**2192-11-19**]. He has complaints of shortness of breath
with exertion and an ETT during which time he had left arm pain
which was relieved with SL NTG.
Past Medical History:
HTN
Hyperlipidemia
s/p CVA [**2179**], s/p bil. CEA
PVD
BPH
Afib
Diverticulitis
Sleep apnea
s/p AAA repair [**2187**]
s/p ventral hernia repair
s/p aorto-bifem [**2187**]
s/p TURP
Social History:
Married, lives with wife.
Cigs: quit 13 years ago, 30 pk. yr. history
ETOH: rare
Family History:
+ CAD
Physical Exam:
Gen: Elderly, white male, in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple , FROM, no lymphadenopath or thyromegaly, carotids
2+= bilat w/ bruits.
Lungs: Clear to A+P
CV: RRR without M/G, 3/6 SEM, rad to carotids and axilla
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext.: without clubbing, cyanosis, or edema, pulses 2+ radials,
2+ DP, 1+ PT bil.
Neuro: nonfocal.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2192-11-27**] 07:45AM 31.8*
specimen not received in stat bag
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2192-11-27**] 07:45AM 18.3*1 2.1
specimen not received in stat bag
1 NOTE NEW NORMAL RANGE AS OF 12A OF [**2192-8-14**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2192-11-27**] 07:45AM 34* 1.4* 4.0
specimen not received in stat bag
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2192-11-26**] 06:30AM 8.4 4.1# 2.1
Brief Hospital Course:
On [**2192-11-19**] the patient underwent cardiac cath which revealed:
70%LAD, 80% D1, 60% LCX, 90% rca, mild AS, AV gradient of
15mmHg. He had a heavily calcified aorta and coronaries. Dr.
[**Last Name (STitle) **] was consulted and on [**2192-11-20**] he underwent CABGx3 with
LIMA->LAD, SVG->PDA and OM. Cross clamp time was 63 minutes and
total bypass time was 47 minutes. He required a urology consult
intraoperatively and had to have a foley placed under cysto. He
tolerated the procedure well and was transferred to the CSRU in
stable condition on Neo and Propofol. He was extubated on his
postoperative night and had his chest tubes d/c'd and was
transferred to the floor on POD#2. On POD#4 he was in afib and
was very hpotensive and was transferred back to the CSRU. He
was started on Amiodorone and converted to SR. He was
transferred back to the fllor on POD#5 and had a few more
episodes of controlled AF. He was then anticoagulated with
heparin and coumadin and was discharged to rehab on POD#7 in
stable condition.
Medications on Admission:
Pronestyl 750 mg PO daily
Atenolol 25 mg PO daily
Allopurinol 300 mg PO daily
Minitron 2.5 mg PO daily
Lasix 20 mg. PO Q Mon., Wed., Fri.
Zocor 80 mg PO daily
ASA 325 mg PO daily
Cardura 2 mg PO BID
Atacard 16 mg PO 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Doxazosin Mesylate 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a
day: INR goal 2-2.5.
11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 10353**] TCU
Discharge Diagnosis:
coronary artery disease
HTN
hypercholesterolemia
BPH
PVD
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
no creams, lotions or powders to incision
may shower, no bathing or swinning for 1 month
Followup Instructions:
Make an appointment with you r uroligist for 1 week
Make an appointment with Dr. [**Last Name (STitle) **] in [**2-7**] weeks
Make an appointment with Dr. [**Last Name (STitle) 311**] in [**2-7**] weeks
Make an appointment with Dr. [**Last Name (STitle) **] in 1 month
Completed by:[**2192-11-27**] |
8249,9984,8730,87344,9110,9130,E8122,3051 | 45 | 157,907 | Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-20**]
Date of Birth: [**2087-1-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 40239**] is a 42-year-old
gentleman injured in a motorcycle versus car accident. The
patient was the passenger of the motorcycle.
PAST MEDICAL HISTORY: No prior medical problems.
MEDICATIONS: No outpatient medications.
SUMMARY OF HOSPITAL COURSE: The patient was brought to the
Trauma Bay where he underwent full evaluation and
resuscitation by the trauma team. The patient was found to
have a left open comminuted fracture of the left lower
extremity with a significant degloving injury. The patient
was taken to the Operating Room for washout and external
fixation of the patient's fracture by the orthopedic team.
In addition, the patient received a consult from the vascular
surgery team which determined that the patient was vascularly
intact. Following his initial washout, the patient was taken
to the Intensive Care Unit for close observation.
On hospital day #2, the patient was transferred to the floor
as he had been hemodynamically and neurologically stable. On
hospital day #4, the patient was taken to the Operating Room
again for a combined procedure with the orthopedic and
plastic surgery team. Orthopedic team placed an
intramedullary nail into the patient's left tibia. A plastic
surgery team then covered the patient's open defect with a
rectus free flap. The patient tolerated the procedure well
and there were no intraoperative complications. The patient
was initially monitored in the stepdown Intensive Care Unit
for close observation of this flap. The patient also had a
split thickness skin graft placed over the flap, as the
patient had significant loss of skin tissue from his
degloving injury. The patient did well after surgery and
flap had no complications. Throughout his stay, the patient
continued to have a strong Dopplerable signal both arterial
and venous and a good take of his skin graft.
On postoperative day #2, the patient was transferred to the
floor as he no longer required hourly flap checks. Beginning
on postoperative day #5, the patient was allowed to begin
dangling his left lower extremity which he tolerated without
any problems. On postoperative day #7, the patient was seen
by the physical therapist for instructions on non weight
bearing of the left lower extremity transfers to chair. At
this point, the patient was medically stable and ready for
discharge to a rehabilitation facility.
Throughout his stay, the patient was also given aspirin q day
and deep venous thrombosis prophylaxis with subcutaneous
heparin. The patient was also on Kefzol for the duration of
his stay.
DISCHARGE CONDITION: The patient was stable during
discharge.
DISCHARGE DISPOSITION: The patient will be discharged to a
rehabilitation facility, as the patient will have orthopedic
ambulatory difficulties given his non weight bearing status
on his left lower extremity. He will continue to be non
weight bearing on the left lower extremity with dangling
only, however the patient may transfer to a chair as long as
his left lower extremity is elevated.
DISCHARGE MEDICATIONS:
1. Keflex 500 mg po qid
2. Aspirin 81 mg po q day
3. Lopressor 25 mg po bid
4. Percocet 1 to 2 tablets po q 4 to 6 hours prn
5. Colace 100 mg po bid
6. Zolpidem 5 mg po q hs prn
OTHER INSTRUCTIONS: The patient may begin showering or
having a spray of water over his wound, however the patient
is not to have any tub soaks. The patient should not
progress on his weight bearing status until after his follow
up with Dr. [**Last Name (STitle) **] in one week.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**]
Dictated By:[**Last Name (NamePattern1) 17228**]
MEDQUIST36
D: [**2129-6-20**] 08:03
T: [**2129-6-20**] 08:12
JOB#: [**Job Number 40240**]
|
22809,2811,2809,2851,99811,99659,20300,5768 | 46 | 144,073 | Admission Date: [**2133-2-20**] Discharge Date: [**2133-2-24**]
Date of Birth: [**2059-2-21**] Sex: M
Service: [**Company 191**]-MEDICINE
CHIEF COMPLAINT: Status post ERCP bleed and transfer out of
SICU.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a pleasant
73-year-old gentleman with a past medical history significant
for multiple myeloma, peptic ulcer disease, cholangitis, iron
deficiency anemia, B12 deficiency anemia, status post
cholecystectomy and appendectomy, who was transferred to the
[**Hospital1 69**] from [**Hospital3 **] for
an ERCP. The patient had an ERCP that was done on [**2-9**], and had a stent placed with no significant findings
except for mild dilatation, but no stones or strictures. The
patient had developed gram-negative (Klebsiella grown and E.
coli) rod sepsis and jaundice prior to the first ERCP.
The patient did well for a few days, and then on [**2-18**],
presented with a one day history of right upper quadrant
pain, no nausea, vomiting, fever, or rigors. A MRI that was
done after [**2-9**] showed abnormal tissue in the region of
porta hepatis and some lymphadenopathy. So patient was
transferred here for a repeat ERCP.
During the ERCP procedure, the initial contrast revealed an
amorphous intraductal mass. With further manipulation and
extraction of the mass, there was an old blood clot and once
the blood clot was removed, bright red blood began to drain
from the biliary system. The GI fellow estimated about 1
unit of blood loss. The patient was stable and alert during
and after the procedure, and was transferred to the Intensive
Care Unit for further management and eventually to
Interventional Radiology for an A-gram.
An A-gram was done that showed no active bleeding, however,
the stent that was placed in the common bile duct was no
longer there. The patient was then transferred to the floor
after the hematocrit had been stable for greater than 24
hours and there was no evidence of any new acute bleed.
PAST MEDICAL HISTORY:
1. Multiple myeloma diagnosed in [**2128**].
2. Peptic ulcer disease.
3. Cholangitis.
4. Iron deficiency anemia.
5. B12 deficiency anemia.
6. Status post cholecystectomy in [**2128**].
7. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Iron 325 mg po q day.
2. Colace 100 mg po bid.
3. Levaquin 500 mg po q day.
4. Ambien 5 mg po q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his brother, [**Name (NI) **]
[**Name (NI) **], and the patient denies any alcohol, smoking, or IV
drug abuse at this time.
PHYSICAL EXAM ON ADMISSION TO THE UNIT: Temperature of 97.0,
blood pressure 130/55, heart rate of 105, respiratory rate
20, and O2 saturation 100% on room air. General:
Comfortable, in no acute distress. HEENT: Moist mucosal
membranes. Extraocular movements are intact. Pupils are
equal, round, and reactive to light and accommodation.
Cardiovascular: S1, S2 slightly tachycardic, no murmurs,
rubs, or gallops heard. Lungs are clear to auscultation
bilaterally. Abdomen is soft, nondistended, mild tenderness
in the epigastric area to deep palpation, decreased bowel
sounds. Extremities: No clubbing, cyanosis, or edema.
Skin: No evidence of any rash. Neurologic: Cranial nerves
II through XII tested grossly intact.
LABORATORIES ON ADMISSION: White count 5.3, hematocrit 21.2,
platelets of 301, sodium 133, potassium 3.1, chloride 106,
bicarb 20, BUN 13, creatinine 0.4, glucose 117, ALT 303, AST
167, alkaline phosphatase 704, total bilirubin 1.2.
HOSPITAL COURSE:
1. GI: Patient was admitted to the Intensive Care Unit after
an ERCP because of a bleed. The patient's hematocrit at that
time was 21.2 and the patient received 2 units and hematocrit
was checked q6h for 24-48 hours. His hematocrit continued to
remain stable between 25-27, however, one additional unit of
blood was given when the patient was transferred to the floor
and his hematocrit continued to remain stable in the range of
29-31. The patient also had a repeat CT angiogram for
pancreatic protocol that was done on [**2-23**], and it was
found that there was no evidence of any mass and patient had
a dilated common bile duct with wall thickening and
enhancement which is consistent with either hemobilia or
cholangitis.
However, patient's findings were most likely secondary to his
hemobilia since he did have a bleed after his ERCP. In
addition, the CT angiogram did show extensive bony
involvement of his multiple myeloma. Also during the
hospital course, the patient was started on broad antibiotic
coverage consisting of ampicillin, Flagyl, and Levaquin for
prophylaxis against developing cholangitis. During the
hospital course, the patient did not seem to have any right
upper quadrant tenderness or epigastric tenderness that would
be concerned with cholangitis, and on the date of discharge,
he was sent with Levaquin 500 mg po q day for seven
additional days.
The patient's diet was also slowly advanced. He was made NPO
after his procedure for about two days and was started on a
liquid diet and then eventually into a soft diet all of which
the patient tolerated well.
2. Oncology: The patient has a history of multiple myeloma,
and as per the CT angiogram, it appears that there is
extensive metastases to the bones. A brief discussion was
brought up with the patient regarding further management, and
if he wanted to see an oncologist at that time, he said that
his care is provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 49935**] in the [**Location (un) 5871**]
area, and patient would want to talk to him before pursuing
any further intervention. However, the patient would prefer
to let it be as it is, and did not appear to be interested in
any chemotherapy, or radiation therapy, or even talking to an
oncologist during this hospital course.
DISCHARGE DIAGNOSES:
1. Status post ERCP bleed.
2. Multiple myeloma.
DISCHARGE CONDITION: The patient is stable at time of
discharge.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q day.
2. Levofloxacin 500 mg po q day x7 days.
3. The patient is to continue taking all of his outpatient
medications.
FOLLOWUP: The patient was asked to setup an appointment with
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49935**] in the next 3-4 days.
The patient states that he would call and setup an
appointment, according to his own time.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2133-2-24**] 13:32
T: [**2133-2-24**] 13:35
JOB#: [**Job Number 49936**]
|
2724,412,V4582,311,56409,40390,2939,496,4280,42731,4241 | 49 | 190,539 | Admission Date: [**2186-11-21**] Discharge Date: [**2186-11-28**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2186-11-21**] - AVR 25mm St. [**Male First Name (un) 923**] Porcine Valve
History of Present Illness:
Splendid 80 year old gentleman who has severe aortic stenosis.
He sustained and inferior wall MI on [**2-/2178**] followed by a PTCA. He
recently had a colonic tumor/polyp removed in [**Month (only) 216**] and
developed chest pain as well as dyspnea perioperatively. A
cardiac catheterization was performed which revealed sever
aortic stenosis and no flow limiting disease. His ejection
fraction was preserved.
Past Medical History:
S/P Colonic polyp removal [**8-25**]
Left TKR [**2178**]
PTCA [**2178**]
IMI [**2178**]
HTN
AS
Hyperlipidemia
COPD
CRI
Depression
Erectile dysfunction
Social History:
Has not seen the dentist in 3 years. No tobacco, infrequent
alcohol use. Lives alone. Wife in nursing home.
Family History:
Mother [**Name (NI) 62389**] of endocarditis
Father died of accident
Physical Exam:
GEN: NAD, WDWN, 134/81 62 NSR
HEART: RRR, IV/VI systolic murmur
LUNGS: Clear
ABD: Benign
Pulses: No carotid bruits, no edema pulses intact
Pertinent Results:
[**2186-11-27**] 06:10AM BLOOD Hct-32.3*
[**2186-11-26**] 06:05AM BLOOD WBC-7.0 RBC-3.50* Hgb-10.9* Hct-31.0*
MCV-89 MCH-31.1 MCHC-35.0 RDW-15.4 Plt Ct-235
[**2186-11-26**] 06:05AM BLOOD Plt Ct-235
[**2186-11-27**] 06:10AM BLOOD UreaN-26* Creat-1.3* K-5.0
[**2186-11-26**] CXR
Borderline cardiac enlargement has decreased, comparable to the
preoperative appearance on [**10-23**]. Thickening of the right
costal and apical pleural margin is probably due to fat
deposition, not fluid, although a tiny volume of layering
pleural fluid is present bilaterally. No pneumothorax. No
pneumonia.
[**2186-11-22**] EKG
Sinus rhythm
Consider left atrial abnormality
Probable inferior myocardial infarction, age indeterminate
Inferolateral ST-T wave changes with slight ST segment elevation
- cannot
exclude in part ischemia/injury Clinical correlation is
suggested
Since previous tracing of [**2186-11-21**], first degree A-V delay
absent and further lateral ST-T wave changes seen
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 62390**] was admitted to the [**Hospital1 18**] on [**2186-11-21**] for elective
surgical management of his aortic stenosis. He was taken
directly to the operating room where he underwent an aortic
valve replacement utilizing a 25mm St. [**Male First Name (un) 923**] porcine valve.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, he awoke
neurologically intact and was extubated. He was initially
slightly confused requiring a sitter however his mental status
slowly cleared. Later on postoperative day one, he was
transferred to the cardiac surgical step down unit for
monitoring. He was gently diuresed towards his preoperative
weight. Beta blockade was discontinued for low blood pressure.
The physical therapy service was consulted to help increase his
postoperative strength and mobility. Mr. [**Known lastname 62390**] developed
atrial fibrillation which converted spontaneously back into
normal sinus rhythm. Mr. [**Known lastname 62390**] continued to make steady
progress and was discharged to rehabilitation on postoperative
day six. He will follow-up with Dr. [**Last Name (Prefixes) **], his
cardiologist and his primary care physician as an outpatient.
Beta blockade should be resumed as an outpatient when his blood
pressure can tolerate.
Medications on Admission:
Lopressor 25mg daily
Lasix 40mg daily
Celexa 20mg daily
Zocor 60mg daily
Aspirin 325mg daily
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: Take for three days then stop.
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**1-22**]
Tablets PO Q6H (every 6 hours) as needed for severe pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
Aortic Stenosis
Hyperlipidemia
PAF
HTN
COPD
IMI
PTCA [**2178**]
Postop confusion
Left TKR
Colonic polyp removal
CRI
Depression
Erectile Dysfunction
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of greater then 2 pounds in 24 hours.
4) Take lasix for 3 days until reach preop weight of 225 pounds
and then stop or as insturcted by physician. [**Name10 (NameIs) **] potassium with
lasix and stop when lasix stopped.
5) Please resume lopressor and or an ace inhibitor when blood
pressure can tolerate.
6) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 13175**] in 2 weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 51257**] in 2 weeks.
([**Telephone/Fax (1) 32468**]
Completed by:[**2186-11-28**] |
2841,5728,04111,07054,5712,58089,5849,78039,7907 | 52 | 190,797 | Admission Date: [**2191-1-10**] Discharge Date: [**2191-1-19**]
Date of Birth: [**2152-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Bacteremia, sz
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
HPI : MICU admission note reviewed. Briefly, this is a 38 yo M
h/o ETOH cirrhosis, MELD 27 on tx list initially presenting from
OSH with szs. ADmit to OSH [**2191-1-3**] with abd pain/fevers to 103.
Bl cxs grew MSSA in [**3-2**] bottles [**1-3**], 1/4 [**1-4**]. Started on
nafcillin. TTE neg for veg. CT abd neg. Started on flagyl for ?
C diff though no cx data. Afebrile since [**1-5**]. Has been
pancytopenic at OSH. On [**1-9**], pt had witnessed T-C sz X 2 min.
Givne IV ativan CT head neg. Debate re: starting AED, given
cirrhosis/tx status. Pt continued to have T-C szs q hour X 5.
Dr. [**Last Name (STitle) 497**] called and pt dilantin loaded. Pt tx'd to [**Hospital1 **] MICU for
further management.
.
Pt has remained afebrile and HD stable in the MICU. No further
szs. EEG and MRI head negative. Pt with HA on admission, but
resolved shortly so team decided no LP. TEE neg. Abd US with nml
doppler, mod ascites but no suitable spot for tap.
.
ROS: Pt currently denies HA/LH. Denies CP/SOB. +baseline mild
abd pain. No melena/brbpr.
Past Medical History:
HepC cirrhosis; patient has never been treated with
interferon/ribavirin
Alcoholic hepatitis in [**2190-4-29**] after a four month drinking
binge
anxiety
s/p appendectomy
Social History:
SH - Lives in RI with his parents, currently unemployed. Has a
h/o IVDU, starting at age 17, ended in his early 20s when he
spent several years in a residential drug rehab program He was
previously on methadone to treat heroin addiction; stopped in
[**2189-11-29**] He endorses only social alcohol use until [**Month (only) 958**]
[**2189**], when he began binge drinking up to a fifth of vodka a day
to cope with unemployment and methadone withdrawal; no alcohol
since [**2190-4-29**]. Smokes 1 ppd x 20 yrs.
.
Family History:
Grandparents c diabetes.
No history of CAD or liver disease.
Physical Exam:
Temp 99.2
BP 121/68
Pulse 81
Resp 21
O2 sat 98% RA
Gen - Alert, no acute distress
HEENT - extraocular motions intact, +icterus, mucous membranes
moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, mild R and LUQ tenderness, distended, +BS
Extr -trace b/l LE edema. 2+ DP pulses bilaterally
Neuro - no asterixis
Skin - spider angiomoas over chest
Pertinent Results:
[**2191-1-9**]
132 100 9 / 148 AGap=13
3.1 22 1.0
Ca: 7.8 Mg: 1.8 P: 3.2
ALT: 29 AP: 91 Tbili: 8.6 Alb: 3.1
AST: 55 LDH: 233 Dbili: TProt:
[**Doctor First Name **]: 49 Lip: 34
Phenytoin: 5.2
.
108
3.7 9.6 / 61
/ 27.9
N:68.1 L:23.5 M:6.6 E:1.3 Bas:0.6
Anisocy: 1+ Macrocy: 3+
Gran-Ct: 2490
PT: 24.7 PTT: 42.2 INR: 2.5
.
MICRO:
Blood cultures negative
.
IMAGING:
MRI HEAD:
FINDINGS: There is no slow diffusion to indicate an acute
infarct. There are no enhancing abnormalities. There is
increased T1 signal within the basal ganglia prior to the
administration of IV contrast. These findings are commonly seen
in patients with liver failure. There is no midline shift, mass
effect, or hydrocephalus. No areas of abnormal magnetic
susceptibility are noted. Normal vascular flow voids are
present.
IMPRESSION: No evidence of an enhancing abnormality or mass.
No acute infarct.
Increased T1 signal in the basal ganglia bilaterally consistent
with the patient's history of hepatic failure.
.
TEE:
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). The posterior pharynx was anesthetized with 2% viscous
lidocaine. No TEE related complications. 0.1 mg of IV
glycopyrrolate was given as an antisialogogue prior to TEE probe
insertion.
Conclusions:
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. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular systolic function is normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve.
IMPRESSION: No echo evidence of endocarditis.
.
RUQ Ultrasound:
IMPRESSION:
1. Successful ultrasound-guided diagnostic and therapeutic
paracentesis.
2. Hepatopetal flow of the main portal vein
.
RENAL ULTRASOUND:
The right kidney measures approximately 11.8 cm and the left
kidney measures approximately 11.5 cm. There is no evidence of
hydronephrosis or renal lithiasis bilaterally. Areas of ascites
are again demonstrated throughout the abdomen. No focal bladder
wall masses are identified in the prostate appears slightly
enlarged measuring approximately 5.1 x 4.3 x 4.3 cm.
IMPRESSION:
1. No evidence of hyrdronephrosis or renal lithiasis.
2. Mild prostatic hypertrophy.
3. Abdominal ascites
.
BONE SCAN
IMPRESSION:
1) No definite evidence of osteomyelitis.
2) Linear increased
lower sacral uptake consistent with a fracture.
3) Marked, diffuse bilateral increased renal uptake is
non-specific and may be secondary to interstitial nephritis
Brief Hospital Course:
38 y/o M w/ Alcohol/HepC cirrhosis with admitted with s. aureus
bacteremia, and seizure.
.
1) [**Name (NI) 11646**] unclear source. Patient did not have localizing
signs or symptoms (other than chronic abdominal pain) and did
not have a history c/w meningitis/meningoencephalitis. He
underwent TTE and TEE while in the ICU, both w/o evidence of
vegetation. Surveillance cultures remained negative (although
all drawn on abx) and patient was w/o evidence of embolic or
immunologic phenomena on examination. He remaineed afebrile in
house. He also underwent bone scan to r/o occult osteomyelitis,
which did not show evidence of infectious focus. LP was
deferred per neuro recommendations- it was felt that the patient
had been on antibiotics for approximately 5days on transfer from
OSH and his coagulopathy and thrombocytopenia would induce
additional risk for the procedure. At the OSH, the patient was
initially started on vancomycin and CTX. When sensitivities
returned as MSSA the patient was switched to nafcillin. He
completed 12 days of antibiotic therapy and subsequently
developed ARF (Cr peaked at 3.5) but rapidly recovered.
FENA>1%, u/s neg, eos neg (including peripheral), sediment
bland. Bone scan did show evidence of increased renal uptake
c/w intersitial nephritis. He completed the last two days of a
total 14 day course with vancomycin. He was afebrile on
discharge, w/ plan to obtain repeat blood cultures on Monday
[**1-24**].
.
2) [**Name (NI) **] unclear etiology. Patient w/o sz hx. Interestingly,
the patient seized at the OSH on hospital d3. This course was
concerning for etoh w/d but patient vehemently denies further
alcohol use. He was initially loaded on dilantin and
subsequently maintained on keppra. EEG did not show evidence
of sz focus. Plan for patient to f/u w/ Dr. [**First Name (STitle) 951**] of Neurology.
.
3) Acute hepatitis- patient admitted to OSH with AST of approx
80, ALT approx 40. These trended down following admission but
the patient subsequently developed a cholestatic appearance on
labs, with his bilirubin peaking at 15.7 and INR at 2.7. Both
were trending down on discharge. Again, the patient denied
alcohol use.
.
4) ARF- likely interstitial nephritis, as discussed above
.
5) ESLD- on discharge, plan to start re-start diuretics pending
evaluation of renal function on Monday. Patient was continued
on lactulose in house.
.
6) Abdominal Pain - chronic abdominal pain in house. Minimal
ascites but underwent ultrasound guided paracentesis that ruled
out SBP.
.
7) FULL code for this admission
Medications on Admission:
Meds (home):
1. Restoril 30mg QHS
2. Alprazolam 1mg TID
3. Furosemide 40mg QD
4. Aldactone 100mg QD
5. Lactulose 30cc TID
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
4. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Labwork Sig: One (1) once for 1 days: On Monday [**1-24**] you
need to have the following labs drawn: cbc, chem 10,
ast/alt/bili/inr, and blood cultures x2. Please ask the lab to
fax the results to [**Telephone/Fax (1) **].
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name 792**]VNA
Discharge Diagnosis:
1) ESLD
2) seizure
3) Staph aureus bacteremia
Discharge Condition:
Good, VSS, afebrile, renal function normal
Discharge Instructions:
1) Please continue to take your medications as directed.
2) You have been given a prescription for labs to be performed
on Monday, [**1-24**].
3) Please avoid taking NSAIDs (i.e. ibuprofen, naproxen, etc)
until your PCP or Dr. [**Last Name (STitle) 497**] has verified that your renal
function is OK. You should also avoid Ultram (tramadol)
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**6-7**] days.
.
Please follow up with Dr. [**Last Name (STitle) 497**] in Liver clinic as already
scheduled.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2191-1-27**] 11:40
.
Please follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] from Neurology in [**1-2**]
weeks. ([**Telephone/Fax (1) 12456**]
|
41021,30562,41401,4019,53081 | 53 | 155,385 | Admission Date: [**2170-3-20**] Discharge Date: [**2170-3-23**]
Date of Birth: [**2124-8-31**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with a history of GERD, standing with substernal chest
pain while working at a construction site, which he thought
was his GERD, then worsened in a few hours. After about 2
hours, he went to the emergency department. The pain was
radiating down both arms with his chest pressure. No nausea,
diaphoresis or shortness of breath. In the emergency
department, he was found to have lateral ST elevations in V4
through V6 and ST elevations in 2 equal to 3 and aVF. He
went into ventricular fibrillation arrest. In the emergency
department, he was shocked to normal sinus rhythm, given
thrombolysis with TNK. At 4:52 a.m., he was transferred to
[**Hospital1 18**] for emergent catheterization. At the catheterization,
they found right ventricular pressure of 38/14, pulmonary
capillary wedge mean pressure at 25, and 98 percent
thrombotic occlusion in OM1. PTCA and stent with heparin-
coated stent was placed. ST elevations resolved after
catheterization and patient was pain free. Patient then
developed automated idioventricular rhythm after TNK at
outside hospital. On arrival after catheterization here, he
was pain free with small right groin hematoma.
PHYSICAL EXAMINATION: Stable vital signs and normal sinus
rhythm. His temperature afebrile, heart rate 73, blood
pressure 128/71, respirations 16, oxygen saturation 95
percent on 2 liters. Generally, in no acute distress. Alert
and oriented x 3. No carotid bruits. HEENT: Mucous
membranes moist. JVP at 10 cm. Cardiovascular: Regular
rate and rhythm. No murmurs, rubs or gallops. Pulmonary:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended, normoactive bowel sounds.
Extremities: No edema. Trace dorsalis pedis pulses, 2 plus
posterior pulses bilaterally. Small right groin hematoma.
LABORATORY DATA: White count 11.8, hematocrit 40.6,
platelets 269, INR 1.3, sodium 137, potassium 4.6, chloride
104, bicarbonate 23, BUN 19, creatinine 0.9, and glucose 108.
HOSPITAL COURSE: Ischemia. Patient had inferior ST
elevation MI. He was given thrombolysis at the outside
hospital but was transferred for persistent pain and ST
elevations. His PTCA here was a heparin coated stent to the
OM 1. He was given aspirin, Plavix, Lopressor, Lipitor 80
mg, and started on ACE inhibitor. CK is peaked at 3869.
Pump likely moderate-sized inferolateral MI. Echocardiogram
showed left atrial elongation, mild symmetric left
ventricular hypertrophy, inferolateral hypokinesis/akinesis,
mild dilated aortic root, trivial MR ejection fraction of 30
percent. He was started on Coumadin and heparin for
increased risk of thrombosis with no telemetry events. He
will have a signal-average EKG and follow up with
electrophysiology for T-wave alternans in 3 to 4 weeks.
Cocaine use. Patient has been counseled regarding the risk
of using cocaine including risk of MI and CVA as well as
sudden death. He was seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2412**] and given phone
numbers for several detoxification programs.
DISCHARGE STATUS: Stable.
DISCHARGE DISPOSITION: Patient was discharged to home.
FOLLOWUP PLANS: Patient has to follow up with Dr. [**Last Name (STitle) 11493**], his
new cardiologist and primary care provider. [**Name10 (NameIs) **] will arrange
for the patient to begin a cardiac rehabilitation program.
The patient can go to his office at 11:00 a.m. on [**2170-3-26**].
He has also to follow up with Dr. [**Last Name (STitle) **] regarding his
signal-average EKG and
T-wave alternans testing for risk of further arrhythmias.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Pantoprazole 40 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 80 mg p.o. q.d.
5. Lisinopril 5 mg p.o. q.d.
6. Metoprolol sustained release 50 mg p.o. q.d.
7. Coumadin 7.5 mg p.o. h.s.
8.
Lovenox 80 mg subcutaneously b.i.d. until INR greater than 2.
[**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern1) **], [**MD Number(1) 10119**]
Dictated By:[**Last Name (NamePattern1) 15388**]
MEDQUIST36
D: [**2170-5-1**] 16:34:00
T: [**2170-5-2**] 10:51:49
Job#: [**Job Number **]
|
V4502,V4582,41400,V1011,25000,2449,4019,2720,4280,43310 | 55 | 190,665 | Admission Date: [**2136-4-3**] Discharge Date: [**2136-4-5**]
Date of Birth: [**2072-2-4**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Keflex / Catapres / Trazodone
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Admit for carotid angiography and possible intervention.
Major Surgical or Invasive Procedure:
S/P stenting of left carotid artery
History of Present Illness:
64 year-old woman, patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Dr. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) **], Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], with an extensive history of CAD,
now s/p recent left upper lobectomy for lung cancer with an
incidental finding of an old CVA on head CT postoperatively
prompting a workup that revealed 90% left internal carotid
stenosis on duplex, vs 55% on CTA of neck, now referred for left
carotid angiography to more clearly define her carotid anatomy,
and carotid intervention, if appropriate. Events were as
follows:
[**2128-9-28**] IMI - Treated with stenting of the RCA and LCx. Found
to have severe MR [**First Name (Titles) **] [**Last Name (Titles) 12876**] and was referred for
surgical repair.
[**2128-10-27**] Mitral valve surgery aborted after TEE at time of
surgery revealed largely normal mitral valve with improvement of
inferior hypokinesis compared to month prior.
[**3-/2129**] Cardiac Catheterization - Total occlusion of RCA stent and
patent LCX stent, mild to mod MR
[**7-/2129**] Pulmonary edema requiring intubation at an OSH. Transferred
to [**Hospital1 18**] and had a cardiac cath revealing T.O RCA and 40% CX
stenosis in prior stent. EF of 30%
[**2129**] AICD placement
[**2135-10-24**] Cath d/t worsening chronic angina and DOE and inferior
ischemia on dobutamine viability study. Angiography revealed 40%
LAD, 40% LCX ISRS, RCA totally occluded with distal filling via
left to right collaterals. S/P Unsuccesful recanalization of the
RCA. FFR of CX lesion demonstrated it to be a hemodynamically
insignificant lesion.
[**2136-2-2**] s/p VATS, left upper lobectomy and mediastinal lymph node
dissection d/t adenocarcinoma. Patient d/c'd on [**2-8**] and
readmitted on [**2-13**] d/t mental status changes and hypotension. A
chest CT was done which was negative for a PE. A CT of the head
was done revealing no evidence of intracranial hemorrhage, but a
hypodensity at the right temporo-occipital junction. This could
represent a late subacute to chronic infarct vs metastatic
disease. A CT with contrast was done the following day revealing
the same findings. A carotid series was therefore ordered and
done on [**2136-2-15**]. This revealed an 80-99% stenosis of the left
internal carotid artery and a <40% stenosis of the right
internal carotid artery. A TTE was done on [**2136-2-15**]. This
revealed an ef of 40% with 1+MR, small to moderate sized
pericardial effusion. Mild symmetric LVH. Hypokinesis noted in
the infero-septum, inferior and infero-lateral walls. Akinesis
noted in the basal infero-septum and inferior wall.
.
The patient was subsequently referred to see Dr [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]
as an outpatient who has recommended her for carotid angiography
and intervention. The patient was then seen in clinic by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of neurology who is in agreement that the head
CT scan abnormality is very likely an embolic stroke and feels
that left carotid intervention is appropriate. The patient was
also seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of neurosurgery who felt that
it is exceedingly unlikely that the lesion on CT scan represents
a malignancy vs. metastasis and cleared her to undergo a carotid
procedure. He recommended repeat head CT in 3 months.
.
Follow up studies have included:
[**2136-2-23**] Chest XRAY: Normal post left upper lobectomy appearance.
No evidence of any cardiopulmonary process.
[**2136-3-8**] CTA of neck: approximately 55% left sided carotid
stenosis at the bifurcation
[**2136-3-20**] CT of brain with and without contrast: No change of
right posterior temporal-occipital region, likely represents a
chronic infarct. Noted to have tortuous basilar artery. Basilary
artery summit positioned to the left of the midline. Just
anterior to the summit is a 2-mm area of contrast
enhancement--Finding could represent very tortuous origin of
left posterior cerebral artery or contigious tiny aneurysm.
.
In terms of symptoms, the patient denies any neurological
deficits, confusion,or lightheadedness. She further denies any
chest pain. She does report having dyspnea after climbing one
flight of stairs.
.
On day of admission, she underwent carotid angiography with
stent placement
Past Medical History:
s/p bronch/meds, 70 pck yr smoker, CAD s/p MI x 2 and stenting x
2, s/p AICD implant, EF 33%, hypothyroid, DM< s/p hysterectomy,
s/p appy, s/p varicose vein removal
Social History:
Married with two children who live close by.
Husband will drive her to the procedure.(+) cigarette smoking 80
ppy
history, quit in [**2128**], restarted in [**2129**], quit again [**9-6**]
Family History:
(+) [**Name (NI) 41900**] CAD Father had MI at 42yo and died.
Mother had CVA 54yo. Both sisters are healthy.
Physical Exam:
GEN: WD female in NAD
HEENT: PERRL, EOMI
NECK: No bruits, No LAD
CV: RRR no m,r,g
LUNG: CTA Bilat
ABD: Soft, NT, ND BSNA
EXT: No C/C/E
Neuro: CN II-XII intact, A and O x 3, no focal defecits
Pertinent Results:
[**2136-4-3**] 09:22PM WBC-11.6* RBC-3.81* HGB-11.2* HCT-32.4*
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.9
[**2136-4-3**] 09:22PM PLT COUNT-343
.
Cardiac Cath COMMENTS:
1. Access was retrograde via the RCFA with catheter placemnt
to the
aortic arch and bilateral common carotid arteries.
2. The aortic arch was a Type I arch with mild tortuosity of
the great
vessels and no angiographically significant lesions.
3. The right CCA was angiographically normal. The [**Country **] had a
mild 30%
lesion at the bifurcation. The [**Country **] filled the ipsilateral ACA
and MCA
without cross-filling. There was mild tortuosity of the
proximal
intracerebral vessels.
4. The left CCA was angiographically normal. The [**Doctor First Name 3098**] had a
calcified
eccentric 90% lesion at the bifurcation and filled the
ipsilateral ACA
and MCA.
5. Successful stenting of the [**Doctor First Name 3098**] with a [**5-10**] x 30 mm Acculink
stent
(see PTA comments).
FINAL DIAGNOSIS:
1. Severe left internal carotid artery stenosis.
2. Successful stenting of the left internal carotid artery.
.
ECG Sinus rhythm with ventricular premature complexes
Low QRS voltages - clinical correlation is suggested
Brief Hospital Course:
A/P: 64 year-old woman with question of significant carotid
stenosis, referred for carotid angiography.
.
PLAN:
.
# S/P Carotid Angiography with stent placement: She had left
ICA stent placed on day of admission without event. Developed
reflex hypotension and was placed on a low dose of
Neo-synephrine. This was weaned and by HD #1, her BP was
elevated and we resumed Carvedilol and ACE/Lasix at home doses
which were well tolerated. We continued continue ASA, Statin,
Plavix throughout admission. Her mental status remained
unchanged and her neuro exam was without focal defecits. She
did report occasional headache which responded well to PO meds.
She was discharged to home on HD #2 without event.
.
# Hypothyroidism: Levothyroxine Sodium 112 mcg PO DAILY
continued throughout admission.
.
#. DM: RISS and FS QACHS continued throughout admission.
.
# GERD: Cont. PPI throughout admission.
.
# PPx: PPI, Plavix, ASA
.
# CODE: FULL
.
# COMM: With pt
.
# DISP: To home with planned follow up as outlined above.
.
Medications on Admission:
ECASA 325mg daily
Lorazepam 0.5mg PRN anxiety
Metformin 850mg TID
Prilosec 20mg daily
Coreg 12.5mg [**Hospital1 **]
Lipitor 60mg daily
Lisinopril 10mg daily
Celexa 60mg daily
Levoxyl .112mcg daily
Sprinolactone 25mg daily
Lasix 20mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Fioricet [**Medical Record Number 3668**] mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for headache for 1 weeks: Max dose 6 tablets
in 24 hours. .
Disp:*48 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day: to be restarted [**2136-4-6**].
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: to be
restarted [**2136-4-6**].
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day: to be restarted [**2136-4-8**].
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Lipitor 20 mg Tablet Sig: Three (3) Tablet PO once a day.
11. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
S/P stenting of the left carotid artery
Secondary diagnosis:
Hypotension
Hypertension
Hypercholesterolemia
Hypothyroidism
Anxiety
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please keep all follow up appointments.
Please take all medications as prescribed. You should restart
you lasix and spironolactone tomorrow (Friday), you should not
restart your metformin until Saturday [**2136-4-9**].
Seek medical attention for fevers, chills, chest pain, shortness
of breath, lightheadedness, or any other concerning symtpoms.
Followup Instructions:
2. Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2136-4-12**] 9:30
3. Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2136-4-19**] 4:30
4. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-5-10**] 2:40
|
4019,2720,78039,4280,2761,53140,1628,1983 | 56 | 181,711 | Admission Date: [**2104-1-2**] Discharge Date: [**2104-1-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
NF admit seen and appreciated. Briefly this is a [**Age over 90 **] yo f w/ h/o
lung ca w/ metastasis to brain on XRT, s/p fall at NH on Sun
eve. No LOC. [**1-9**] lethargy, n/v,L arm weakness, sent to [**Hospital1 **]
[**Location (un) 620**] where she was noted to havv 3x3cm R posterior parietal
bleed. Tx to NSICU, started on dilantin (load) and decadron.
Deemed not a surgical candidate -> DNR/DNI.
Noted to be guiac pos, +hct drop, coffee grounds on NGL. GI
recommended transfusing to maintain hct.
Past Medical History:
Lung ca w/ mets to brain
high cholesterol
HTN
CAD
Lopresser 25mg tid
Social History:
lives at [**Location **], at baseline walks w/ walker.
speaks italian, some english
Physical Exam:
t 98.6, bp 120/68, p 88, r 20 97% ra
Elderly female, lying in bed, foam from mouth, responsive to
voice, can squeeze R hand.
R pupil 4mm, no reactive, L pupil reactive.
No cervical/sm/sc LA
Regular s1,s2. no m/r/g
LCA anteriorly.
Pertinent Results:
cbc:
8.9 8.6 229
27.1
electrolytes:
[**2104-1-2**] 04:51PM SODIUM-137
[**2104-1-2**] 04:51PM ALBUMIN-3.2*
[**2104-1-2**] 09:45AM SODIUM-131* POTASSIUM-4.1 CHLORIDE-95* TOTAL
CO2-30* ANION GAP-10
[**2104-1-2**] 03:57AM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-1.8
[**2104-1-2**] 03:57AM PHENYTOIN-10.2
MRI:On diffusion-weighted images there is a small area of
restricted diffusion along the falx within the left
occipitotemporal lobe. It is also bright on FLAIR-weighted
images and may represent a subacute infarct. Clinical
correlation is recommended. On gradient echo images there is a
large area of intraparenchymal hemorrhage within the right
parietal lobe and left thalamus which following administration
of gadolinium reveals ring-enhancing lesions. These are
suspicious for hemorrhagic metastases given the patient's
history. Additional ring-enhancing lesions throughout the supra-
and infratentorial compartments are visualized. There is a
moderate amount of peritumoral edema involving the right
parietal lobe lesion in addition to a second right parietal
lesion along the falx high in the vertex. The other areas of
metastases reveal a minimal amount of peritumoral edema.
.
cxr: Cardiomegaly and mild CHF. Nasogastric tube as described
above. Rounded opacity overlying the left hilum, which probably
representing aspiration pneumonia; however, left hilar mass
cannot be totally excluded. Please confirm resolution by
repeated chest x-ray after treatment, and if the lesion
persists, please evaluate by CT scan.
.
ct: Stable appearance of right parietal lobe and left thalamic
hemorrhages, which are concerning for hemorrhagic metastasis in
this patient with known metastatic lung carcinoma to the brain.
Brief Hospital Course:
[**Age over 90 **] yo f s/p INH in R parietal region, evidence of [**Hospital 58799**]
transferred to medicine, w/ pupillary assymmetry but no evidence
of neglect, responding to commands.
.
1) altered MS- likely bleed into metastatic lesion, although
unclear based on location of known lesions, vs component of
fall. as per NS, not a surgical candidate. seems unlikely that
pt will have dramatic cliical improvement given significant
edema, mass lesions, and no NS intervention.
-palliative XRT? family mtg tonite to discuss utility.
-cont dilantin px, particularly since pt has ? of witnessed sz
event.
-cont high dose decadron, q6h w/ fs.
-will clarify
.
2) GIB- drop in hct during admission and + NGL. GI input
appreciated felt likely [**1-9**] stress ulceration. Enteral
nutrition and PPI (usually oral) have been shown to reduce the
risk of ongoing bleeding.
-start TF's 10cc/h until nutrition recs
-IV protonix (given recent h/o GIB)
.
3) CAD/CHF- previously some CHF on CXR. oxygenating well.
euvolemic on exam despite significant anasarca of hands/feet-
minimal swelling of tibial surfaces so partially related to
restraints.
-cont lopresser
-d/c lipitor, rx for hepatic dz.
.
4) fen- ivf, tf's
.
5) ppx- ppi, pneumoboots
.
6) code- dnr/dni
On [**2104-1-4**] a family meeting was held with Oncology, Social Work,
Palliative Care Consult and primary medical team. At that time
the family decided to place comfort as the main goal of her
medical care. Her status was changed to "CMO".
Medications on Admission:
-lipitor 20
-protonix
-lopressor 25 tid
Discharge Medications:
Morphine Elixir
Scopolamine Patch
Ativan
Discharge Disposition:
Extended Care
Facility:
Wayside
Discharge Diagnosis:
Metastatic Lung Cancer
Intracerbral Hemmorhage
GI Bleed
Discharge Condition:
critical
Discharge Instructions:
Please keep patitent comfortable
No blood draws, tubes or restraints
Followup Instructions:
n/a
|
5990,40391,5856,25080,0414,4589,311,2948,78701,2449,V4501,28529 | 59 | 104,130 | Admission Date: [**2197-11-14**] Discharge Date: [**2197-11-19**]
Service: MEDICINE
Allergies:
Morphine / Shellfish
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
hypoglycemia and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD,
OM1 '[**91**], NSTEMI [**7-18**], DM2, RAS who presented to OSH from nursing
home with confusion and diaphoresis. Glucose noted to be in the
30's and given D50 with improvement in mental status. At OSH she
had abdominal pain and a CT Abd/Pelvis without contrast was
performed which showed no evidence of obstruction, free air, or
AAA but had significant bandemia. She was given Ceftriaxone and
flagyl and transferred to [**Hospital1 18**].
.
On transfer to [**Hospital1 18**] ED, SBP in 60's, hypoglycemic to 40's with
abdominal pain. She was guaiac (+) with dark flecks of material
on rectal. An NG lavage was done with bilious material which
cleared with 700cc NS (no blood). Surgery was consulted,
reviewed her CT scans from OSH and felt there was no acute
surgical issue. She was given Vanco x1. U/A was positive, and
patient was given 2 L NS with SBP into 120s and HR 60's. Blood
sugars improved to 140's with 1 amp D50. Blood and urine
cultures drawn. Patient was due for dialysis on the day of
admission. Renal was contact[**Name (NI) **] about missing her HD but felt no
acute need for HD. On admission, patient was unable to recall
preceding events. Does not remember why she was sent in from NH.
Denied fevers, chills, nausea, vomiting, diarrhea. Did complain
of some left-sided abdominal pain.
Past Medical History:
CAD
PCI LAD, OM1 '[**91**]
NSTEMI [**8-11**]
ESRD
Chronic HD
DM2
HTN
Dyslipidemia
Hypothyroidism
RAS
Dementia
Depression
RBBB/LAFB/Bradycardia
Staph Epidermis infection dialysis catheter [**7-18**]
OA
Social History:
Widowed. Lives at Pine Manor Nursing Center. STM loss.
Has 2 grown sons. [**Name (NI) **], [**Name (NI) 122**] is power of attorney and health
care proxy for patient.
Nonsmoker. Denies alcohol use.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA
GEN: awake, alert, oriented to self and year. Thought she was @
[**Hospital1 112**].
HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile,
nontender mass over R occiput (?lipoma). Pt states has been
present for x4mos.
NECK: supple, no JVD.
CV: RRR. Nl S1, S2. [**3-20**] sys murmur at LUSB.
PULM: bibasilar crackles.
ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound
or guarding.
BACK: No CVA tenderness
EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat.
No edema.
Pertinent Results:
[**2197-11-14**] 02:50PM PT-15.4* PTT-68.3* INR(PT)-1.4*
[**2197-11-14**] 02:50PM PLT SMR-NORMAL PLT COUNT-163
[**2197-11-14**] 02:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL BURR-1+
[**2197-11-14**] 02:50PM NEUTS-78.0* BANDS-0 LYMPHS-16.9* MONOS-3.9
EOS-1.1 BASOS-0.1
[**2197-11-14**] 02:50PM WBC-4.9# RBC-3.20* HGB-11.0* HCT-33.6*
MCV-105* MCH-34.4* MCHC-32.8 RDW-18.0*
[**2197-11-14**] 02:50PM CALCIUM-6.7* PHOSPHATE-7.1*# MAGNESIUM-1.4*
[**2197-11-14**] 02:50PM CK-MB-NotDone cTropnT-0.03*
[**2197-11-14**] 02:50PM LIPASE-12
[**2197-11-14**] 02:50PM ALT(SGPT)-18 AST(SGOT)-22 CK(CPK)-23* ALK
PHOS-91 TOT BILI-0.2
[**2197-11-14**] 02:50PM GLUCOSE-42* UREA N-60* CREAT-5.3*# SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-19* ANION GAP-24*
[**2197-11-14**] 09:30PM CK-MB-NotDone cTropnT-0.05*
[**2197-11-17**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2197-11-17**] 07:19PM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD WBC-5.1 RBC-3.76* Hgb-12.7 Hct-39.4
MCV-105* MCH-33.9* MCHC-32.3 RDW-17.5* Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Glucose-73 UreaN-26* Creat-5.1*# Na-140
K-3.9 Cl-100 HCO3-28 AnGap-16
[**2197-11-19**] 06:55AM BLOOD CK(CPK)-38
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
KUB: IMPRESSION: Nonspecific bowel gas pattern without evidence
of obstruction.
Brief Hospital Course:
87 year old female with ESRD on HD, CAD s/p MI and PCI, DM2, RAS
presented from OSH with hypoglycemia, hypotension, abdominal
pain, UTI, now normotensive with new epigastic pain and
persistent intermittent hypoglycemia.
--In the MICU, patient treated for UTI and question of urosepsis
with Cipro. Pyelonephritis was considered possible source of
abdominal pain. Urine cultures came back positive for
pansensitive E. coli and patient was continued on Cipro. There
was no growth in blood cultures. She was ruled out for MI with
mild troponin elevation in the setting of renal failure but flat
CKs. Patient was restarted on HD the day following admission.
Her labetolol, norvasc, clonidine, and isosorbide were held. She
had no further hypotension following initial volume
recessitation. However, she continued to be hypoglycemic at
times, thought most likely secondary to persistent blood levels
of glipizide in the setting of renal insufficiency as well as
poor po intake. Patient's po intake began to improve and prior
to transfer to the floor, BGs had improved to 70-140 [**11-16**]. MICU
stay also complicated by epigastric abdominal pain and emesis,
bilious and non-bloody. Pancreatic enzymes and LFTs were normal.
PTT and INR elevated in MICU. Heparin sc stopped. Both trended
down on repeat checks.
.
The morning after transfer, the patient was found to have
increasing nausea and vomiting that was poorly responsive to
anti-nausea meds. As there was concern for cardiac ischemia, an
EKG was done that showed new T-wave inversions in the lateral
leads. Pt had significan troponin elevation and cardiology was
consulted. Though the patient was likely having mild episode
of cardiac ischemia, given the patient's significant
comorbidities and resolvation of symptoms as well as no
hemodynamic compromise, the patient was treated medically with
aspirin, plavix, beta blocker and oxygen. The patient was
asymptomatic and had downtrending troponins. For the remainder
of the hospital, the patient has stable vital signs and no other
complaints of chest pressure.
.
# UTI: Urine culture positive for pansensitive E coli. Was
initially treated with cipro, but with the patient's nausea and
vomiting, it was changed to levofloxacin QHD. Pt now on day 6
of appropriate abx. Currently afebrile. CVA tenderness noted on
admission now resolved. Pyelonephritis possible cause of initial
abdominal pain but no clear evidence of that on CT abdomen from
OSH.
.
# ESRD on HD (Tues/Thurs/Sat) Pt now on MWF schedule,
nephrology following.
- next session due [**11-20**]
- monitor electrolytes
- continue nephrocaps
.
# EPIGASTRIC TENDERNESS/VOMITING: minimal epigastric tenderness
on exam, +N/V. Unclear etiology. LFTs, pancreatic enzymes
normal. [**Month (only) 116**] be [**3-16**] to gastroparesis given h/o DM and patient
reports chronic N/V prior to admission. Now asymptomatic, if
persists, nay need gastric emptying study.
.
# DMII: patient p/w hypoglycemia, now resolved. Was likely [**3-16**]
oral hypoglycemics in setting of worsened renal function due to
infection. Stable finger sticks on day of discharge, pt on
insulin sliding scale
- monitor QID finger sticks
- cont to hold glyburide as was hypoglycemic
- RISS if needed
.
# HTN: Labetalol, clonidine, and norvasc held on admission to
MICU given hypotension. Restarted prior to discharge.
.
# CAD: stable, denies CP. slight troponin elevation likely [**3-16**]
renal failure, but slight elevation likely due to mild ischemic
event, managed medically as pt has multiple comorbities. CK/MB
negative.
- continue ASA, Plavix, statin
.
# Right hip pain- pt given history of falling prior to
admission. X ray on admission showed no signs of occult fracture
though small linear lucency on x ray. Pt with large hematoma on
hip that precludes anticoagulation.
.
# HYPOTHYROIDISM: continue levothyroxine
.
# DEPRESSION: continue sertraline
.
# CODE: DNR/DNI confirmed with patient at the time of transfer
Medications on Admission:
ASA 325
Plavix
Labetalol 200 [**Hospital1 **]
clonidine 0.3mg po bid
sucralfate 1g qid
nephrocaps
FeSO4 325 qday
glyburide 5mg qday
isosorbide Mononitrate 60 qday
levothyroxine 100 qday
lipitor 80
norvasc 10 qday
sertraline 50 qday
colace/senna/dulcolax
protonix 40 qday
razadyne 4mg qhs
ativan 0.5mg qday prn
prochlorperazine 25 mg pr prn nausea
tylenol/benadryl prn
sl NTG prn
percocetq4 prn pain
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Sertraline 50 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).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous Q48H (every 48 hours): please give
at dialysis.
15. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
16. Razadyne 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
19. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED): Check glucose QID, if < 70
give [**2-13**] amp D 50 and [**Name8 (MD) 138**] MD, if 70-150 no insulin, if 151-200
give 2 U, if 201-250 give 4 U, if 300-350 give 6 U, if 351-400
give 8 U, if >400, give 10 U and [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25499**] Manor - [**Location (un) 47**]
Discharge Diagnosis:
Urinary tract infection, hypoglycemia
Discharge Condition:
Stable; tolerating PO intake and afebrile
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Please take your medications as directed
Please keep your follow-up appointments
Followup Instructions:
Please make an appointment with [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 69239**] for
the next 7-10 days.
Please return to your normal hemodialysis schedule
|
76527,76518,V3401 | 60 | 198,892 | Unit No: [**Numeric Identifier 66448**]
Admission Date: [**2146-11-12**]
Discharge Date: [**2146-11-14**]
Date of Birth: [**2146-11-12**]
Sex: F
Service: NB
HISTORY: Baby Girl ([**Name2 (NI) **]) [**Known lastname 66444**] is the former 34-3/7 week
female triplet #3 admitted to the NICU because of prematurity.
Obstetrician/[**Doctor Last Name 13675**] is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Mother is a 37-year-old G4, P0->3. Prenatal screens are O
positive, antibody negative, hepatitis B surface antigen
negative. RPR is nonreactive, Rubella immune. Past OB history
was remarkable for 3 SABs.
This pregnancy was complicated by:
1. Cholestasis treated with Actigal.
2. Abdominal lymphedema.
3. Pregnancy-induced hypertension - noted to have increased
BP and proteinuria on [**11-8**], treated with bed rest
and betamethasone.
Delivery by cesarean section was uncomplicated. Apgar was 9
at 1 minute and 9 at 5 minutes.
PHYSICAL EXAMINATION: The baby is [**Name2 (NI) **], breathing
comfortably in room air. Vital signs are temperature 96.9 on
admission and then up to 98. Heart rate was 162, respiratory
rate 68, blood pressure 67/42 with a mean of 58.
Normocephalic, anterior fontanelle soft and flat, palate
intact. Respiratory - breath sounds clear and equal. CVS -
S1, S2 normal intensity, [**1-13**] soft systolic murmur at the left
sternal border. Abdomen - soft with no organomegaly. GU -
normal female. Neuro - tone good, symmetrical exam. Admission
dextrose stick - 54.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: The baby has remained in room air. Baseline
respiratory rate is 30s- 50s and has not required any O2. No
apnea or bradycardia of prematurity documented.
Cardiovascular: Initial soft murmur has resolved. Baseline
heart rate is 130s-160. Blood pressure systolic is 60s-80,
diastolic 40-45 with means in the 50s-60s.
Fluid, Electrolytes and Nutrition: The baby has been ad lib
feeding PE 20, all p.o., with minimum increased to 80 ml per
kg per day today. D-sticks have consistently been greater than
50. The baby is voiding and stooling. Would continue to ad
lib feed. Mom does plan on doing some breastfeeding.
GI: Bilirubin today prior to transfer was 6.2/0.2.
Hematology: No blood type is available on this infant. The
baby has not required any blood transfusions during this
admission.
Infectious Disease: No issues. The baby was delivered for
maternal indications. No risk factors.
Neurology: The baby is appropriate for gestational age.
Sensory: Audiology screening has not been done. Would
recommend test prior to discharge. Ophthalmology exam is not
indicated. Gestational age is greater than 32 weeks.
Psychosocial: The parents look forward to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
transitioning closer to home with her siblings. They are
quite pleased with the triplets.
PRIMARY PEDIATRICIAN: Undecided.
CARE/RECOMMENDATIONS: Continue ad lib feedings of PE 24 with
iron and/or breast milk.
MEDICATIONS: None at the time of transfer.
CAR SEAT POSITION SCREENING: Has not been done to date.
IMMUNIZATIONS RECEIVED: None to date. Would recommend
hepatitis B vaccine prior to discharge.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria - i) born at less than 32
weeks; ii) born between 32 and 35 weeks with 2 of the
following - day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; or iii) 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 APPOINTMENTS: With primary care pediatrician per
routine. Consider VNA referral.
DISCHARGE DIAGNOSIS:
1. Prematurity, 34-3/7 weeks
2. Triplet #3.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2146-11-14**] 12:26:57
T: [**2146-11-14**] 13:31:46
Job#: [**Job Number 66449**]
|
9998,6930,5790,2639,2851,5781,2875,2880,20280 | 61 | 176,332 | Admission Date: [**2118-6-17**] Discharge Date: [**2118-7-20**]
Date of Birth: [**2063-10-21**] Sex: M
Service: OMED
Allergies:
Gluten / Betalactams / Vancomycin Hcl
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
54 year-old male with an enteropathy associated T-cell lymphoma,
status post hyper CVAD therapy and 5 cycles of CHOP, and
recently ICE chemotherapy and collection, being admitted for
auto-BMT.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy ([**2118-7-12**])
History of Present Illness:
54 year-old male with an enteropathy associated T-cell lymphoma
diagnosed in [**2115**], with known gastric and jejunal ulcers and
history of small bowel resection for microperforation, admitted
for auto-BMT on [**2118-6-17**]. He was previously treated with
hyper-CVAD (did not tolerate) and 5 cycles of CHOP. His course
was complicated by a bout of hepatitis in [**2118-4-19**] which was
felt to be chemical in etiology and led to weight loss, sprue
exacerbation and relapse. Following his bout of hepatitis, Mr.
[**Known lastname 45745**] was started back on TPN and has been doing well on it. He
was recently teated with a cycle of ICE chemotherapy and
collected in preparation for auto-BMT.
His bone marrow performed at the beginning of [**Month (only) **] revealed some
minimal involvement with his T-cell lymphoma. His liver biopsy
performed on [**2118-4-28**] revealed numerous apoptotic hepatocytes,
multiple small foci of sinusoidal mononuclear inflammation and
enlarged Kupffer cells consistent with acute hepatitis. No
neoplastic cells. Tissue EGD performed on [**2118-5-12**] showed some
involvement by enteropathy associated T-cell lymphoma in one
biopsy section.
Past Medical History:
1. Sprue: Diagnosis [**9-20**], which was refractory to gluten-free
diet at which point prednisone therapy was initiated. Further
investigation led to biopsy of small bowel and the diagnosis of
T cell lymphoma was made.
2. T cell Lymphoma: As per HPI.
3. Transaminitis: From [**Date range (1) 45746**] (peak AST 198, ALT 247, alk
phos 1062, negative HAV, HBV, HCV, HIV, CMV, toxo, VZV, HSV1,
HSV2). Thought to be secondary to chemo and/or TPN. Liver bx
revealed non-specific inflammation consistent with acute
hepatitis.
Social History:
Mr. [**Known lastname 45745**] lives with his wife, a nurse. [**First Name (Titles) **] [**Last Name (Titles) 42866**] 1 pack of
cigarettes per day, denies alcohol or illicit drug use.
Family History:
Mother with breast cancer. His father died of an unknown cardiac
event at the age 34. Mother, sister and grandmother have
diabetes mellitus.
Physical Exam:
On admission: Temperature 97.9, HR 80, RR 20, BP 86-98/50-64.
General: Cachectic man in NAD.
HEENT: PERRLA. Clear oropharynx.
NECK: JVP not elevated.
CVS: RRR. Normal S1, S2. No murmur, rub or gallop.
RESP: CTA bilaterally.
ABD: Soft and non-tender. No hepatosplenomegaly.
EXT: No cyanosis, clubbing or edema. 1+ dorsalis pedis pulses
bilaterally, 2+ peripheral pulses otherwise.
Neuro: CN II-XII intact. Strenght [**3-23**]. Reflexes 2+ throughout.
Sensation intact.
Pertinent Results:
Pertinent laboratory results on admssion include WBC-9.3
(differential NEUTS-87, BANDS-0, LYMPHS-6*, MONOS-6, EOS-0,
BASOS-0, ATYPS-0, METAS-0, MYELOS-1*), HGB-11.1, HCT-33.7, PLT
COUNT-521. Chemistry reveals GLUCOSE-104 UREA N-14 CREAT-0.4*
SODIUM-140 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-23. Mildly
elevated alkaline phosphatase on admission at 124, transaminases
within normal limits (ALT-9, AST-15, TOT BILI-0.1). Normal
coagulation profile.
Urinalysis negative
[**2118-5-31**] CMV IgG and IgM negative
Brief Hospital Course:
His hospital course will be reviewed by problems:
1) Enteropathy-associated T-cell lymphoma: He received Ara-C and
Etoposide (day -6 to -3) and melphalan (day -2) as part of the
BEAM protocol, followed by a rest day. Reinfusion was done on
[**2118-6-24**], which was well tolerated. His period of neutropenia
extended from [**2118-6-27**] to [**2118-7-7**], at which time his ANC was
back up to 2230. He had evidence of only mild oropharyngeal
mucositis which was treated with Peridex and Nystatin.
On [**2118-7-15**], Mr. [**Known lastname 45745**] had an acute transfusion reaction to
platelets, with hypotension, diffuse dermal edema and
periorbital edema, currently under investigation. He received
Solumedrol IV and Pepcid IV with symptomatic relief.
Premedication changed to Hydrocortisone 100 mg IV, Benadryl 50
mg IV, Pecid 20 mg IV, Tylenol 500-650 mg PO.
2) ID: Mr [**Known lastname 45745**] had an isolated temperature spike on [**2118-6-21**]
(day -3), at which time he was started on Vancomycin and
Levoquin (latter to be started as part of the protocol on
[**2118-6-22**]). He quickly defervesced, but developed a diffuse
maculopapular rash on [**2118-6-23**], at which time Vanco was D/C'd as
it was felt to be a possible culprit. Cultures from that time
were negative. He became febrile again on [**2118-6-30**], at which
time Vanco and Cefepime were started, and Levoquin was
discontinued. He remained persistently febrile and an antifungal
was added, along with Flagyl for a history of diarrhea
(eventually C. difficile negative). His rash persisted, and
decision was taken to D/C Cefepime (query contribution to
persistent rash) and start Aztreonam. Given worsening of the
rash with periorbital edema and query contribution to the fever,
along with possibility of drug fever, all antibiotics were
stopped on [**2118-7-6**] and he received 1 dose of Solumedrol. He
defervesced for 24 hours, then his temperature rose again. He
was restarted on Flagyl and Levo on [**2118-7-9**]. Ambisome was added
on [**7-10**] secondary to a finding of pulmonary nodules on CT scan,
however pulmonary did not feel these were significant, and
ambisome was d/c'ed on [**7-16**] since the patient was not
neutopenic. His temperature reached a peak to 104.6 on [**2118-7-10**].
CT chest on [**2118-7-10**] revealed multiple small non-specific
nodules, felt by pulmonary to be non-significant. CT abdomen and
pelvis negative on [**2118-7-10**]. Aztreonam was added to the regimen
on [**7-11**]. ID was consulted, and antibiotics were changed to
Meropenem and Flagyl, and continue Acyclovir. Daptomycin was
added on [**2118-7-12**] given persistent fever and desire to broaden
gram positive coverage (Vancomycin was felt to be a potential
culprit in the rash). All cultures negative thus far except for
a single bottle positive for Corynebacterium on [**2118-6-30**] felt to
be a contaminant. An MRI of the liver done on [**2118-7-13**] was
negative for hepatic candidiasis. Stool cultures were negative.
Repeat CMV negative. He defervesced on the above regimen. His
last temperature spike was on [**7-13**]. On [**7-18**] meropenem and
flagyl were discontinued, with no further fever spikes. He will
be discharged on acyclovir, and nystatin swish and swallow.
3) GI: On [**2118-7-8**], Mr. [**Known lastname 45745**] had a Hct drop from 27 to 21 with
frankly guaiac positive stools. The source was felt most likely
to be upper GI. He was seen by GI, who was reluctant to perform
a scope given the patient's low platelets and leukopenia,
although ANC > 500. Decision was taken to treat conservatively,
with blood product support. On [**2118-7-11**], his Hct dropped again
from 29 to 21.8 with persistent melanotic stools and he was
transferred to the ICU. An EGD was performed on [**2118-7-12**], which
revealed ulceration in D3 consistent with an area of ulcerative
duodenitis without active bleeding. The EGD was otherwise normal
to D2. Pill endoscopy was considered but cancelled given a prior
history of small bowel stricture. The bleeding was also not
significant enought for a tagged RBC scan. He received a total
of 6 units PRBCs in the ICU, and 4 units of platelets. He was
transferred back to the floor on [**2118-7-14**]. His Hct has remained
stable since transfer, without further melena. Protonix IV
changed to PO BID on [**2118-7-16**], which he will be discharged on.
4) Rash: History as above in ID section. He developed a diffuse
maculopapular rash on [**2118-6-23**], which changed to a diffuse
blanching erythematous rash on [**2118-7-6**] and persisted. He also
developped some periorbital edema on [**2118-7-6**] and received a
dose of Solumedrol. Dermatology was consulted, with an
impression of erythroderma. Levoquin, Cefepime and Vancomycin
considered potential culprits and to be avoided. He was treated
symptomatically with Triamcinolone, and the rash resolved.
5) FEN: Mr. [**Known lastname 45745**] was given TPN while he was here, in addition
to being encouraged to eat. He will go home with TPN cycled
over 10 hours at night, and encouraged to eat a gluten free
diet.
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
2. Nystatin Mucous membrane
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
MALT s/p auto-SCT [**2118-6-24**].
UGI bleed
Discharge Condition:
Good, stable.
Discharge Instructions:
Return to the hospital to have your blood drawn tomorrow. Take
all meds as directed.
Return if you experience any rectal bleeding or black stools,
shortness of breath, chest pain.
Take your temperature everyday and call Dr. [**Last Name (STitle) 410**] if it's
greater than 100.4.
Continue your TPN for 10 hours every night.
Followup Instructions:
Return to the unit tomorrow [**7-21**] for repeat blood work and to be
seen by Dr. [**Last Name (STitle) 410**].
|
0880,3510,2554,42731,4589,2765,1120,7994,2763,99591,0389,2762,5672,56983,99685,2848,20280 | 61 | 189,535 | Admission Date: [**2119-1-4**] Discharge Date: [**2119-2-3**]
Date of Birth: [**2063-10-21**] Sex: M
Service: MEDICINE
Allergies:
Gluten / Betalactams / Vancomycin Hcl
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
fevers neutropenia
Major Surgical or Invasive Procedure:
skin biopsy
History of Present Illness:
[**Known firstname **] [**Known lastname 45745**] is a 55-year-old man with a history of enteropathy
associated T-cell lymphoma dxed in [**2115**], 190 days status post an
autologous stem cell transplant.
His post-transplant course has been complicated by an upper GI
bleed with EGD demonstrating PUD, episode of Bell??????s palsy, and
pancytopenia. The suspicion is for bone marrow involvement of
his T cell lymphoma, but this has not been [**Location (un) **] out on bone
marrow biopsy and flow cytometry.
He presented to clinic today for platelet infusion, and his
vitals were the following: T101.3 BP 92/62 Pulse 120/min. He was
given Tylenol, 1L of NS over 2 hours, and blood cultures were
obtained from peripheral site and PICC line. Also sent UA,
urine cultures, and will have chest xray. He was given cefepime
2gm IV and neupogen 300mcg.
Past Medical History:
1. Sprue: Diagnosis [**9-20**], which was refractory to gluten-free
diet at which point prednisone therapy was initiated. Further
investigation led to biopsy of small bowel and the diagnosis of
T cell lymphoma was made.
2. T cell Lymphoma: As per HPI.
3. Transaminitis: From [**Date range (1) 45746**] (peak AST 198, ALT 247, alk
phos 1062, negative HAV, HBV, HCV, HIV, CMV, toxo, VZV, HSV1,
HSV2). Thought to be secondary to chemo and/or TPN. Liver bx
revealed non-specific inflammation consistent with acute
hepatitis.
Social History:
Mr. [**Known lastname 45745**] lives with his wife, a nurse. [**First Name (Titles) **] [**Last Name (Titles) 42866**] 1 pack of
cigarettes per day, denies alcohol or illicit drug use.
Family History:
Mother with breast cancer. His father died of an unknown cardiac
event at the age 34. Mother, sister and grandmother have
diabetes mellitus.
Physical Exam:
Vitals: 98.6, 115, 86/57, 20, 100% RA
Gen: alert/oriented; no acute distress
Heent: significant for petechiae in sublingual area; no other
oropharyngeal lesions.
Neck: supple, full range of motion; no lymphadnopathy; no JVD
Cv: RRR, no m/r/g
Resp: clear to auscultation bilaterally
Abd: soft,NT, NABS; no masses; no HSM
Extr: no c/c/e, 2+ dorsalis pedis pulses
Neuro: significant for strabismus; lateral deviation of right
eye
Pertinent Results:
[**2119-2-2**] 12:00AM BLOOD WBC-0.2* RBC-3.17* Hgb-9.1* Hct-27.2*
MCV-86 MCH-28.9 MCHC-33.7 RDW-16.3* Plt Ct-34*
[**2119-1-10**] 07:30AM BLOOD Neuts-60 Bands-26* Lymphs-10* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2119-1-10**] 07:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 18670**]
[**2119-2-2**] 09:33AM BLOOD Plt Ct-40*
[**2119-2-2**] 12:00AM BLOOD Fibrino-272#
[**2119-2-1**] 12:16PM BLOOD FDP-40-80
[**2119-2-2**] 12:00AM BLOOD Gran Ct-160*
[**2119-2-2**] 12:00AM BLOOD Glucose-113* UreaN-18 Creat-0.4* Na-136
K-4.1 Cl-103 HCO3-26 AnGap-11
[**2119-2-2**] 12:00AM BLOOD ALT-83* AST-112* LD(LDH)-1358*
TotBili-1.9* DirBili-1.1* IndBili-0.8
[**2119-2-1**] 12:16PM BLOOD ALT-96* AST-97* LD(LDH)-1162*
AlkPhos-382* Amylase-188* TotBili-1.6* DirBili-0.8* IndBili-0.8
[**2119-2-1**] 12:16PM BLOOD Lipase-27 GGT-602*
[**2119-2-2**] 12:00AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.9
[**2119-1-15**] 08:00AM BLOOD Hapto-245*
[**2119-2-2**] 07:26AM BLOOD Lactate-3.4*
[**2119-2-2**] 12:18AM BLOOD Lactate-2.8*
[**2119-2-1**] 05:28PM BLOOD Lactate-2.7*
Cultures:
Blood - persistently negative except a 1/2 bottles growing coag
negative staph early in his hospitalization
CMV VL - negative
IMAGING:
CT-abdomen:
IMPRESSION: 1. Moderate amount of free air in the abdomen, as
described above. There is abnormal thickening of small bowel
loops with a moderate amount of free fluid in the abdomen and
pelvis
PET ([**2119-1-11**]):
INTERPRETATION: An FDG-avid right adrenal mass is identified
measuring
approximately 2.3 x 1.1 cm, with a maximal SUV value of 13.9. In
retrospect,this right adrenal lesion was seen on the prior CT
scans dating back to [**2118-12-12**]. Additionally, there is mildly
increased FDG activity demonstrated within the medial limb of
the left adrenal gland with a small nodule seen measuring
approximately 1.7 x 1.0 cm. The maximal SUV value for this left
adrenal lesion is 3.0.
Additionally, there has been interval development of new foci of
abnormally
increased FDG activity within the osseous structures including
the right 1st rib, anterolateral portion of the right 2nd rib,
posterior right 8th rib, posterior aspect of the right 10th rib,
the left scapula, medial aspect of the left clavicle, and the T7
and L4 vertebral bodies.
Physiologic FDG uptake is seen in the myocardium, liver and
gastrointestinal tract.
Brief Hospital Course:
Admitted with neutropenic fever with no clear source. He has a
complicated past history of prolonged neutropenic fever, as well
as unexplained pancytopenia. His primary Oncologist has
suspected recurrence of his T-cell lymphoma, but has been unable
to conclude this based on several recent bone marrow biopsies.
PET scans showed activity in multiple sites including the axial
skeleton, lungs, and bilateral adrenal glands. CT-scan
demonstrated bilateral enlargement of adrenal glands. He
continued to spike high fevers and had several episodes of
hypotension, confusion, hyponatremia, and hypokalemia which were
felt to be related to adrenal insufficiency from either
lymphomatous infiltration of his adrenals of CMV adrenalitis.
He was placed on broad spectrum antibiotics including
ganciclovir for presumptive treatement of CMV virmeia and high
dose steroids. These antibiotics included daptomycin,
voriconazole, caspofungin, cefepime, and aztreonam. Daptomycin
was continued for his presumed Bartonella infection diagnosed
earlier with a postivie IgM titer and granulomas on a prior bone
marrow bx. His cultures were persitently negative with the
exception of a single bottle positive for coag negative staph
felt to be a contaminant. CMV viral titiers also remained
negative on at least 3 occasions and were checked weekly. His
fevers resolved with steroids and were attributed to recurrence
of his lymphoma. In the middle of his hospital course new skin
lesions were noted. Biopsy of a right chest lesion demonstrated
anaplastic transformation of his T cell lymphoma with markers
similar to those in his prior bone marrows. He was started on a
single round of pentostatin and cytoxan. After a brief reduction
in his LDH, his LDH started rising again. New skin lesions were
observed. Discussion was made to send him home on steroids and
return for further treatment, however he developed acute
abdominal pain, higher fevers, and peritonitis. CT abdomen
demonstrated free air in the peritoneum and focal thickenings in
several areas of his small bowel. In consultation with surgery,
it was felt that exploratory laparotomy would have a near fatal
outcome. REgardless, the patient and his family wanted
conservative management with antibiotics and PCA morphine. The
patient expired the next day. It is thought that his
performation occured following tumor regression within his small
bowel in the setting of chemotherapy and high dose steroids.
Medications on Admission:
-
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Anaplastic T cell lymphoma
Abdominal perforation with septic shock
Adrenal insufficiency
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
7100,7140,2859,99591,03849,1125 | 62 | 116,009 | Admission Date: [**2113-2-15**] Discharge Date: [**2113-2-19**]
Date of Birth: [**2044-5-8**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
altered mental status, hypotension
Major Surgical or Invasive Procedure:
R IJ central line
History of Present Illness:
68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.
In ED, initially given ASA, lopressor, then MUST protocol
started. Got 4.5L IVFs, started on levophed/vasopressin.
Lactate=4.4; Given dose of levo/flagyl. T 101.3 HR 115 BP 129/63
RR 18 96% on RA. Dirty urine.
In MICU, weaned off pressors. Switched to GENT for empiric
coverage of GNR bacteremia. Started on Fluconazole emperically
for yeast in the blood. Hydrated with IVF and remained
hemodynamically stable.
Transferred to Medicine on [**2112-2-17**].
Past Medical History:
SLE- on plaquenil
Social History:
doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer
Family History:
non-contributory
Physical Exam:
On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals: 97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash
Pertinent Results:
Admission labs:
*
WBC-2.0* RBC-4.29* Hgb-13.5* Hct-39.7* MCV-93 MCH-31.4 MCHC-33.9
RDW-13.6 Plt Ct-151
Neuts-78* Bands-7* Lymphs-13* Monos-2
Gran Ct-1680*
Glucose-125* UreaN-20 Creat-0.9 Na-138 K-3.3 Cl-105 HCO3-23
AnGap-13
BLOOD ALT-15 AST-18 AlkPhos-42 Amylase-32 TotBili-0.3
Albumin-2.7* Calcium-6.8* Phos-0.8* Mg-1.3*
BLOOD Cortsol-36.6*
BLOOD Genta-0.8*
BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-37 pH-7.40 calHCO3-24
BLOOD Lactate-4.4*
*
Micro:
Blood Cx [**2-14**]: Enterobacter (4/4 bottles) pansensitive, Yeast
Urine Cx [**2-15**]: Negative
Blood Cx [**2-17**]: no growth to date
Blood Cx [**2-18**]: no growth to date
*
Radiologic Studies:
CXR [**2113-2-15**]: negative for failure/infiltrate
CT abdomen [**2113-2-18**]: gallstones w/ gallbladder wall edema,
moderate bilateral pleural effusions, normal colon with no
evidence of diverticulosis/diverticulitis
*
Transthoracic ECHO [**2113-2-15**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-12**]+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
Brief [**Hospital **] Hospital Course is outlined below:
1) Enterobacter bacteremia: The patient was initially admitted
to the ICU on the MUST protocol based on a lactate of 4.4. He
was mildly hypotensive and febrile to 101.4. He was aggressively
hydrated with IVF and empirically initiated on amp/gent. He was
briefly placed on levophed/vasopressin pressors but was able to
be weaned off by his second hospital day. Blood cultures from
admission grew enterobacter in [**5-15**] bottles, pan sensitive. In
addition cultures were positive for yeast, unspeciated upon
discharge. Fluconazole was added to his regimen and ampicillin
was discontinued. The source of his infection was unclear,
although urine source was suspected given dirty urine on
admission. Admission urinalysis showed >50 RBCs, >50 WBC's and
moderate leukocytes, although urine cultures were negative. The
patient was transferred to the medicine service on [**2-17**], hospital
day #3. ID was consulted and recommended a switch to levaquin
based on culture sensitivities. Flagyl was also added for
empiric GI coverage pending further evaluation. CT abdomen was
performed and demonstrated no evidence of abscess or bowel
pathology. There was mention of gallstones and gallbladder wall
thickening suspicious for cholecystitis. However the patient
remained afebrile with no abdominal pains and normal liver
function tests. Given his clinical stability with maintenance of
his blood pressure off IVF, tolerance of PO intake, and absence
of fever, he was discharged to home on [**2-19**]. He was discharged
home on PO levaquin and PO fluconazole for a 14 day course based
on ID recommendations. Flagyl was discontinued. He will
follow-up with his PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.
2) Rheumatoid arthritis- previoiusly on plaquenil, so relatively
immunosuppressed. Granulocyte count on admission= 1680, so he
was not neutropenic. He was re-started on plaquenil after he was
clinically stable.
3) Anemia: secondary to SLE likely. Goal HCT>27. Hct remained
>30 through his hospital course. Initital decrease in hematocrit
was likely secondary to IVF hydration.
4) Edema: Noted peripheral edema following IVF hydration. He was
also noted to have bilateral pleural effusions by CT scan, also
likely secondary to aggressive fluid resuscitation. He was not
started on lasix since he was able to autodiurese well, with >2
liters off over the last 24 hours prior to discharge.
5) Mental status change: Initially delirious on admission,
likely secondary to his underlying infection. Once infection
cleared his mental status improved back to baseline. No further
evaluation was performed.
Medications on Admission:
home meds: plaquenil 200mg/400mg alternating days
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO EVERY OTHER DAY (Every Other Day).
2. Hydroxychloroquine Sulfate 200 mg Tablet Sig: Two (2) Tablet
PO EVERY OTHER DAY (Every Other Day): alternate days with 200mg
dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Enterobacter bacteremia (pan-sensitive)
Secondary Diagnosis:
1. SLE
2. Rheumatoid arthritis
Discharge Condition:
good. hemodynamically stable. afebrile.
Discharge Instructions:
Report fever, chills, lightheadedness, stomach pains or bleeding
to your PCP.
Please complete your antibiotic regimen as prescribed below.
Stay well-hydrated. Drink at least [**4-14**] 8oz glasses of water each
day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1007**] in [**2-12**] weeks at phone #
[**Telephone/Fax (1) 10492**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
3079,71945,4280,496,57420,4148,E8889,E8498,7808,2948 | 63 | 195,961 | Admission Date: [**2169-1-7**] Discharge Date: [**2169-1-7**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
right hip pain, fall
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 88 year-old man with dementia, COPD, CHF,
osteoarthritis s/p L hip replacement and h/o TIA who presented
to the ED after a fall. In the ED, he was initially stable, but
he began to become increasingly agitated and aggressive. He
received haloperidol and ativan, but remained combative. His O2
sats never dipped below 90% but he became even more agitated,
diaphoretic and, after discussion with the pt's daughter, the
decision was made to intubate him so a w/u of his fall could be
undertaken.
There was some concern about O2 sats in the low 90s, and after a
d-dimer returned at 1000, a CTPA was done. It was negative. A
head CT revealed no acute change. Hip films revealed.
He was admitted to the ICU intubated.
Past Medical History:
Dementia
COPD
CHF (EF unknown)
Osteoarthritis s/p L hip replacement
h/o TIA
Social History:
Lives at dementia [**Hospital3 **] facility
Family History:
non-contributory
Physical Exam:
VS: Temp: afebrile BP: 140/52 HR: 60 RR: 12 O2sat 93%
general: sedated, intubated
HEENT: PERLL, anicteric, MMM
Lungs: CTA anteriorly
Heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
Abdomen: nd, +b/s, soft, no masses or hepatosplenomegaly
Extremities: no cyanosis, clubbing or edema
Pertinent Results:
[**2169-1-6**] 08:45PM BLOOD WBC-12.9* RBC-4.94 Hgb-15.6 Hct-44.5
MCV-90 MCH-31.5 MCHC-35.0 RDW-13.7 Plt Ct-195
[**2169-1-6**] 08:45PM BLOOD D-Dimer-1009*
[**2169-1-6**] 08:45PM BLOOD Glucose-129* UreaN-19 Creat-1.2 Na-140
K-4.2 Cl-100 HCO3-28 AnGap-16
[**2169-1-6**] 08:45PM BLOOD CK(CPK)-101
[**2169-1-6**] 08:45PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-72
[**2169-1-7**] 12:05AM BLOOD Type-ART pO2-524* pCO2-36 pH-7.44
calTCO2-25 Base XS-1
CT head:
1. No hemorrhage or mass effect.
2. The temporal horns are prominent but there is no
hydrocephalus.
3. Paranasal sinus mucosal disease.
CTA chest:
1. No pulmonary embolus.
2. Mild CHF.
3. Gallstones.
Hip films: No acute fracture or dislocation of right hip.
Consider MRI if symptoms persist.
Brief Hospital Course:
This is a 88 year-old man with history of dementia, COPD and CHF
(EF unknown) who presented from his nursing home after falling
and having some right-sided weakness. In the ED, he became
agitated and combative and was intubated for workup.
## Agitation, intubation: CTA revealed no avute pathology. He
was extubated without difficulty.
## s/p fall: Hip films and CT head were unremarkable. Likely
mechanical fall. No events on telemetry.
## COPD: Extent of COPD unknown. Takes no meds at baseline.
Reason for intubation was not hypoxia.
## Cardiomyopathy: presumed ischemic in nature. Unknown EF, but
BNP <100 suggested no significant volume overload. He was
continued on atorvastatin 10.
Medications on Admission:
Furosemide 40 gm PO qd
Atorvastatin 10 mg PO qd
Quetiapine 25 mg PO qd
Sertraline 100 mg PO qd
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Springhouse
Discharge Diagnosis:
Primary:
Fall
Secondary:
Dementia
COPD
CHF (EF unknown)
Osteoarthritis s/p L hip replacement
h/o TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of a fall. You did not fracture any
bones.
Please take all of your medications as prescribed.
Please follow-up with your primary care doctor.
Followup Instructions:
Please follow up with your primary care doctor.
|
4210,03811,99591,30400,1120,5111,7895,71107,71104 | 64 | 172,056 | Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-18**]
Date of Birth: [**2116-6-27**] Sex: F
Service: ACOVE
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old
woman with a history of IV drug abuse, who initially
presented to an outside hospital on [**2143-3-2**] from a
drug and detoxification facility with a chief complaint of
headache, abdominal pain, and fever. At the outside
hospital, the patient was found to be febrile to 104.6
degrees F, and she subsequently developed hypotension with a
systolic blood pressure in the 80s.
During this initial evaluation, the patient was confused and
only intermittently answering questions. There was concern
for possible headache, neck stiffness, and photophobia, so
given the concern for meningitis, a spinal tap was done.
This study demonstrated 50 white blood cells (84%
neutrophils), 10 red blood cells, protein of 23, glucose of
86, and 0-5 yeast per high power field. Given these findings
and concern for meningitis, the patient received Vancomycin,
ceftriaxone, metronidazole, and gentamicin at the outside
hospital. Given the lack of Intensive Care Unit beds at the
outside hospital, the patient was therefore transferred to
the [**Hospital1 69**] for further
evaluation.
On arrival to the Emergency Department at the [**Hospital1 346**], the patient was found to have
icteric sclerae, a 2/6 systolic ejection murmur, abdominal
guarding, and right upper quadrant tenderness. Given the
concern for an abdominal process, the patient was given
levofloxacin and metronidazole; she was also given Ambisome
given the finding of yeast in her CSF at the outside
hospital.
In the Emergency Department, she had an abdominal ultrasound
that was negative for the presence of gallbladder or ductal
dilatation. Also at this time, the patient began to deny the
report that she was HIV positive; this report has been
obtained only by report and not by documented laboratory
testing from the outside hospital.
PAST MEDICAL HISTORY:
1. Intravenous drug abuse.
2. Cholelithiasis.
3. Cholecystectomy.
4. Spontaneous abortion x2.
5. Therapeutic abortion x1.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: The patient is a single mother of three
children ages 9, 8, and 2 years old. She is unemployed. She
last used heroin 3-4 days prior to admission; she began using
heroin one year prior to admission. The patient smokes a
third of a pack of cigarettes a day and denies any history of
alcohol abuse. She denies any history of providing sexual
favors for drugs or money. She says her only lifetime
partner is her husband.
INITIAL PHYSICAL EXAMINATION: Temperature 97.6, heart rate
95, blood pressure 113/71, respiratory rate 20, and oxygen
saturation 100% on room air. During this initial evaluation,
the patient was not reliable as a historian. She appeared to
be a well dressed well-nourished female in moderate distress
from "not feeling well", lying in bed, and subsequently
having emesis x1. HEENT exam: Extraocular movements are
intact. There was mild scleral icterus. Mild conjunctival
edema. Pupils are equal, round, and reactive to light.
There were small conjunctival hemorrhages on the right
greater than on the left. Her face was symmetric. Her neck
was stiff with pain with flexion half-way down towards the
chest. The right IJ central venous catheter was in place. A
small posterior cervical lymph node is palpable. Her
oropharyngeal examination was remarkable for upper dentures
with eroded mucosa and white plaques consistent with thrush
underneath. Her tongue was coated with a whitish film, and
she had a few petechiae on her upper palate. Her heart was
regular, rate, and rhythm, and there was a [**3-28**] holosystolic
murmur throughout the precordium that radiated to the axilla.
Her lungs were clear to auscultation bilaterally. Her
abdomen was soft, there were normoactive bowel sounds, she
had bilateral upper quadrant guarding, and mild abdominal
distention. The patient notes that her abdominal discomfort
has been present for the past five months. She had bilateral
upper extremity tract marks in her right forearm and in her
bilateral antecubital fossa that were clean. Scattered dark
macules were seen on her palms bilaterally. She had mild,
but not true CMT on pelvic examination. She was moving all
extremities freely and equally and had full strength on
neurologic examination.
Her laboratories from the outside hospital included the
following: Urinalysis was essentially negative. One out of
two blood culture bottles were growing gram-positive cocci in
clusters initially. Her CSF demonstrated 0-4 neutrophils and
0-5 yeasts per high power field, 10 red blood cells, 50 white
cells (80% neutrophils, 3% lymphocytes, 13% monocytes), 23
protein, and 86 glucose. Her complete blood count showed a
white count of 13.3, hematocrit 35.5, and platelets 110,000.
Differential for white count demonstrated 77 neutrophils, 14%
bands, 2% lymphocytes, and 6% monocytes. Her INR was 1.28
and her PTT was 49. Serum chemistries demonstrated a sodium
of 133, bicarbonate 21, BUN 34, creatinine 2.0. Of note, her
creatinine was 0.5 in [**2143-1-23**]. Her total bilirubin
is 3, direct bilirubin 2.3, ALT 967, AST 396, GGT 125,
alkaline phosphatase 156; her LFTs had been normal at
baseline one month prior.
Her electrocardiogram at the outside hospital demonstrated
sinus tachycardia at 112 beats per minute, normal axis, and
normal intervals.
Her head CT scan from the outside hospital demonstrated
motion artifact and normal volumes to the ventricles. An
abdominal ultrasound demonstrated increased echotexture to
the bilateral kidneys, and no evidence of hydronephrosis.
At the [**Hospital1 69**], her laboratories
demonstrated sodium 140, potassium 3.8, chloride 113,
bicarbonate 16, BUN 26, creatinine 1.5, and glucose of 204.
Her calcium was 5.8, magnesium 1.2, and phosphate 3. Her
white count was 12.2, hematocrit 29.7, and platelets of
60,000. Differential of her white count demonstrated 68%
neutrophils, 19% bands, 9% lymphocytes, and 4% monocytes.
Her fibrinogen was 477, FDP 10-40, and D dimer was pending.
Her ALT was 529, AST 150, alkaline phosphatase 97, amylase
46, lipase 23, and albumin 2.3. Her urinalysis had greater
than 50 red blood cells, [**7-2**] white blood cells, and
leukocyte esterase and nitrate were negative. Her PTT was
36.7 and her INR of 1.6.
Her abdominal ultrasound demonstrated minimal new
intrahepatic ductal dilatation and small pneumobilia. A HIV
test was done on admission to the [**Hospital1 190**] and was pending.
HOSPITAL COURSE BY SYSTEMS:
1. Infectious Diseases: While the patient was reported to be
HIV positive upon her arrival to the Emergency Department at
the [**Hospital1 69**], her HIV test
subsequently returned negative. She also informed her
caretakers that she had multiple HIV tests in the past, all
of which had been negative.
The report of "yeast" found in her CSF at the OSH was also
found to be false-positive. No yeast or fungal organisms
grew out the culture of her CSF, and a CSF Gram stain was
repeated twice at the outside hospital and found to be
negative both times. The patient received several doses of
Ambisome at the [**Hospital1 69**], but
once it had been confirmed that the finding of yeast was a
false-positive, her Ambisome was discontinued.
By hospital day three, the gram-positive cocci in clusters
that ultimately grew out from [**2-26**] blood culture bottles at
the outside hospital had been speciated as
methicillin-sensitive Staphylococcus aureus (MSSA). Once
this definitive speciation was made, the patient's antibiotic
regimen was tailored to include oxacillin and gentamicin; the
gentamicin was used for only four days in order to aid in the
clearance of her bacteremia. Given the finding of this
bacteremia and her alarming concert of symptoms on admission,
a transthoracic echocardiogram was performed on hospital day
two.
This study demonstrated a thickened posterior mitral leaflet
with a question of prolapse and at least mild-to-moderate
mitral regurgitation consistent with possible endocarditis.
Biventricular systolic function was preserved. Pulmonary
artery systolic hypertension was seen. Given these findings,
a transesophageal echocardiogram was performed on hospital
day three. This study demonstrated a moderate sized mitral
valve vegetation consistent with a diagnosis of bacterial
endocarditis.
Given this finding, it was felt that all of the patient's
initial signs and symptoms were consistent with bacterial
endocarditis. Given that the finding of yeast in the CSF was
found to be a false-positive, and given that all subsequent
Gram stain and culture data from the CSF remained negative,
the patient was not felt to have had bacterial meningitis at
any point (of note, two colonies of gram-positive cocci in
clusters were isolated from the patient's CSF culture;
however, these colonies were subsequently speciated as
coag-negative Staph, and were therefore thought to be a
contaminate.
Given the patient's LFTs abnormalities on admission, an
abdominal CT scan was done on hospital day two. This study
demonstrated a focal area of low attenuation in the contrast
enhanced right kidney, that was ultimately attributed to a
septic embolus to the right kidney. Also seen were large
bilateral pleural effusions with compressive atelectasis,
ascites, and free abdominal fluid, and a large amount of
pelvic fluid. These fluid collections were all thought to be
secondary to a systemic inflammatory response syndrome
secondary to the patient's underlying bacterial endocarditis.
In order to rule out the possibility of an epidural abscess,
a spinal MRI was done on hospital day four. This study
demonstrated no evidence of epidural abscess. Also of note,
a MRI of the head had been done on hospital day two in order
to further evaluate for the possibility of meningeal
inflammation. This study did not demonstrate any definite
evidence of a focal lesion in the third ventricle or a focal
mass within the brain.
Following the initiation of the appropriate antibiotic
therapy as noted above, the patient slowly began to improve
clinically. She initially continued to spike high fevers,
but she gradually defervesced. Her white count also
initially remained elevated, but this too gradually began to
trend down while on appropriate antibiotics. She did develop
reactive arthridities in both her left ankle and her left
hand. The Department of Rheumatology was consulted given
these reactive arthridities and recommended supportive care
to the area.
The patient's LFTs abnormalities present on admission
gradually normalized. Of note, however, the patient did
develop mild elevations in her alkaline phosphatase, amylase,
and lipase following the initiation of oxacillin therapy. It
was thought that these elevations may have been secondary to
oxacillin, but the elevations did not persist and had begun
to trend towards normal at the time of discharge. Given
these normalizations, and given that the patient's hematocrit
had been remaining stable (thus indicating that there was no
significant myelosuppression as a result of oxacillin
therapy), the patient was discharged with a plan for six
weeks of continued oxacillin therapy.
In order to rule out the possibility of mycotic aneurysm in
the brain, a MRI of the head was obtained on hospital day
seven. This study demonstrated no evidence of acute infarct
from septic emboli, and a subtle increased signal in the
right temporal region that could be within the sulcus. A
similar, but less apparent abnormality was also seen along
the sulcus of the left occipital region. These abnormalities
were nonspecific in nature, but were thought to possibly have
been due to a high protein content of the CSF. Given the
patient's overall clinical stability, however, the decision
was made to clinically follow the patient as an outpatient
following her discharge from the hospital.
Also of note, the patient had a cervical chlamydia probe
return positive during this hospitalization. She received
azithromycin 1,000 mg once during her hospitalization for
treatment of this chlamydia.
2. Cardiovascular: Given that the patient had significant
endocarditis, a Cardiology consult was obtained early in the
patient's hospitalization for evaluation of whether or not
the patient was a surgical candidate for her endocarditis.
Given that the patient did not have clinically significant
congestive heart failure or valvular dysfunction with
persistent infection after 7-10 days of appropriate
antibiotics, the patient was deemed not to be a surgical
candidate. She subsequently developed no significant
congestive heart failure, and she had no further embolic
phenomena following the septic embolus sheath to her right
kidney.
Given her bilateral pleural effusions and mitral
regurgitation, the patient was transiently on furosemide
during this hospitalization, but had no signs or symptoms of
congestive heart failure at the time of her discharge from
the hospital.
3. Rheumatology: As noted above, the patient initially
developed a left ankle reactive arthritis on hospital day
six. Given the asymmetric edema in her left ankle, a
Rheumatology consult was obtained. The Rheumatology service
agreed that the swelling in her left ankle was reactive
arthritis. The patient subsequently developed left hand
swelling later in her hospitalization, at which point the
Rheumatology service was reconsulted. They again felt that
the swelling in the patient's left hand was due to a reactive
arthritis that would be best managed with supportive care.
She was started on a 14 day course of naproxen for treatment
of the inflammation and swelling in her hand.
By the time of discharge, the patient's swelling in both her
left hand and her left ankle had improved dramatically, and
were nearly at their baseline.
4. Hematology: Soonafter admission, the patient manifested a
significant anemia with a hematocrit in the low 20s. The
etiology of this anemia was ultimately thought to be
multifactorial due to a combination of anemia of chronic
disease, recurrent phlebotomy, menstruation, and oxacillin
induced myelosuppression. There was no evidence of hemolysis
either by laboratory evaluation or by direct evaluation of
the peripheral smear. Given that the patient's hematocrit
was low, she was started on iron supplementation during this
hospitalization.
At the time of discharge, however, the patient's hematocrit
had been consistently stable for over one week, and the
decision was made to continue her on oxacillin for the time
being with twice weekly hematocrits following her discharge
from the hospital.
5. Psychiatry: By hospital day eight, the patient began
threatening to leave the hospital against medical advice due
to inadequate pain control. Given the concern for the
patient possibly leaving the hospital against medical advice
without plans for continued intravenous antibiotics, a
Psychiatry consult was requested. The Psychiatry service
felt that the patient had poor coping mechanisms given the
severity of her illness, and recommended initiation of an
atypical antipsychotic. In addition, they recommended
analgesia as necessary, including with narcotic medications
if necessary, in order to adequately control the patient's
pain. The patient was subsequently started on an atypical
antipsychotic, and her narcotic medication dosing regimen was
increased, with excellent therapeutic affect.
DISCHARGE CONDITION: Good.
DISCHARGE PLACEMENT: [**Hospital **] Hospital.
DISCHARGE DIAGNOSES:
1. Methicillin-sensitive Staphylococcus aureus endocarditis
complicated by right renal septic embolus.
2. Chlamydia.
3. Systemic inflammatory response syndrome.
4. Multifactorial anemia.
5. Reactive arthritis.
6. Intravenous drug abuse.
DISCHARGE MEDICATIONS:
1. Oxacillin 2 grams IV q4h through [**2143-4-15**].
2. Naproxen 500 mg po bid through [**2143-3-29**].
3. Pantoprazole 40 mg po q day.
4. Ferrous sulfate 325 mg po q day.
5. Quetiapine 25 mg po tid.
6. Hydromorphone 1 mg IV q4h prn pain.
FOLLOWUP:
1. The patient should have her hematocrit, alkaline
phosphatase, amylase, and lipase all checked twice a week
while at [**Hospital1 **]. The results of these blood tests should
be faxed to Dr. [**Last Name (STitle) 2504**] at fax #[**Telephone/Fax (1) 1419**] in the
Department of Infectious Diseases at [**Hospital1 190**].
2. The patient should arrange for a follow-up appointment
with Dr. [**Last Name (STitle) 2504**] by calling [**Telephone/Fax (1) 457**]. She should
arrange for this appointment during the week after she leaves
[**Hospital1 **].
3. The patient should call [**Telephone/Fax (1) 250**] to arrange for a
follow-up appointment with Dr. [**First Name (STitle) 2505**] during the week
following her release from [**Hospital1 **].
4. Note that the patient should receive the hepatitis A and
hepatitis B virus vaccines as an outpatient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2143-3-18**] 04:37
T: [**2143-3-18**] 07:17
JOB#: [**Job Number 2508**]
|
80012,30500,30560,E8147,8730,7812,37854,9518 | 65 | 143,430 | Admission Date: [**2132-8-10**] Discharge Date: [**2132-8-15**]
Date of Birth: [**2106-1-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 25-year-old male
pedestrian struck by a car while walking across the street
and thrown 10 feet. He was found unresponsive at the scene
with a GCS of 8. He became combative in the ambulance and
was taken to [**Hospital6 5016**]. He was hemodynamically
stable. At [**Hospital6 5016**], the patient was found to
have a subarachnoid hemorrhage on head CT along with a large
skull fracture. He was seen by Neurosurgery at [**Hospital6 10443**] but his family requested transfer to [**Hospital6 1760**].
At the outside hospital, the patient received 2 mg of Ativan
and mannitol and a question of Dilantin for his head injury.
On arrival, the patient was hemodynamically stable with a GCS
of 14, slightly agitated, but stable.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: Weekend use of alcohol.
PHYSICAL EXAMINATION: Vital signs: GCS 14. Alert and
oriented times one. Vitals: Temperature 97.2. Heart rate
100. Blood pressure 161/90. Respiratory rate 14. Oxygen
saturation 100% on four liters. Physical examination:
Pupils equal, round and reactive to light. Extraocular
movements intact. Face was stable. TMs were clear. Neck:
Trachea was midline with no crepitus. Mandible was stable.
His heart was regular rate and rhythm. Chest was clear to
auscultation bilaterally with no crepitus. Abdomen was soft,
nontender, nondistended and his fast exam was negative.
Rectal was normal tone, no gross blood, guaiac was negative.
Extremities without deformities. Patient was moving all four
extremities. His strength was equal throughout, as well as
his sensation and nonfocal neurological exam. There was a
small laceration noted on the right occipital area of his
head.
LABORATORIES: Patient had a normal hematocrit of 45.0. He
also had normal coagulations with a PT of 13, PTT of 23 and
INR of 1.2. Laboratories were also notable for an alcohol
level of 112 and a toxicology screen that was positive for
opiates and cocaine.
RADIOLOGY: Chest x-ray and pelvis x-ray were negative. CT
of the abdomen was negative. CT of the C spine was negative
for fracture. Plain films of the TLS spine were also
negative for fracture and stability. CT of the head showed
orbital frontal contusions with subarachnoid hemorrhage.
There was extra-atrial blood noted with a question of left
epidural versus subdural hemorrhage and there was a large
associated parasagittal skull fracture running along the
midline of the cranium into the left orbital area.
HOSPITAL COURSE: The patient was admitted to the Trauma
Surgical Intensive Care Unit for q. 1 hour neurological
checks, as well as for intravenous fluids. The patient was
protecting his own airway, so intubation was not of concern.
The patient had an immediate consultation from Neurosurgery
who recommended that operative management would not be
necessary that it was sufficient to continue with the q. 1
hour neurological checks, as well as following the coags
every 4 hours, as well as to try to limit the amount of
sedation in order to not cloud the examination of medical
status. The patient continued to remain agitative through
the first three hospital days requiring occasional use of
benzodiazepines and narcotics to relieve pain and agitation.
On hospital day number two, he received a repeat head CT,
which again demonstrated the parasagittal fracture, as well
as slight increase in the size of a frontal epidural
hemorrhage now with a right sided component. While in the
Trauma Surgical Intensive Care Unit, the patient was also
started on Dilantin for seizure prophylaxis, as well as on
oxacillin for infectious prophylaxis of the open head wound.
On hospital day number four, the patient's mental status had
improved enough, to where his agitation had decreased
slightly allowing him to be transferred from the Trauma
Intensive Care Unit to the floor still under a 1:1 sitter due
to occasional agitation. A Neurobehavioral consult was
obtained and per the recommendations of the Neurobehavioral
consult, the patient was removed from all sedating
medications aside from occasional Percocets for pain control
and instead was added Seroquel 25 q.p.m., as well as
trazodone 25 q.p.m. to repeat times one for helping the
patient sleep at night.
On hospital day number five, the patient was slightly
decreased in agitation in the morning, although, still
getting up out of bed and walking, even with a 1:1 sitter,
however, he continued to improve throughout the day clearing
his mental status, becoming alert and oriented times three
and becoming more aware of his surroundings. In an attempt
to try to regulate his sleep cycles and decrease the morning
agitation, the trazodone was discontinued, but the Seroquel
was continued. The morning of hospital day number six, the
patient showed a marked decrease in his agitation in the
morning, showing greater incite into his situation, not
getting out of bed on his own and being fully alert and
oriented.
Also, on hospital day number six, Occupational Therapy and
Physical Therapy, as well as Social Work were consulted.
Occupational Therapy and Physical Therapy had helped the
patient work with his cognitive and functional deficits,
principally, his gait, which was still mostly ataxic six days
following his head injury. Social Work was consulted
primarily for providing references for substance abuse
programs to deal with the patient's noted alcohol abuse. The
patient continued to deny any us of opiates or cocaine,
although, did not remember if he had taken any substances the
night the injury was sustained, so the patient was referred
to substance abuse clinics for further follow-up for this.
On hospital day number six, it was determined that the
patient would be eligible for [**Hospital **] rehabilitation
inpatient therapy, so that several facilities were contact[**Name (NI) **]
and one facility determined that the patient would be
suitable for a rehabilitation stay there. The patient was
stable enough for discharge to the rehabilitation facility
under constant 1:1 supervision to decrease any fall risk.
Thus, the patient was discharged to a neurological
rehabilitation facility on hospital day number six.
FINAL DISCHARGE DIAGNOSES:
1. Pedestrian struck by car.
2. Parasagittal skull fracture.
3. Frontal lobe contusions.
4. Bilateral epidural hemorrhages with result in cognitive
and functional disabilities.
5. Substance abuse.
POST DISCHARGE MEDICATIONS:
1. Dulcolax 5 mg 2 tablets q.d. as needed for constipation.
2. Tylenol 650 mg q. 4-6 hours as needed for pain.
3. Hydromorphone 10 mg, 1-2 tablets every 4 hours as needed
for pain.
4. Seroquel 25 mg, 1 tablet q.p.m. times four weeks.
5. Dicloxacillin 500 mg, 1 capsule po q. 6 hours times eight
days.
FOLLOW-UP:
1. The patient will be followed up at the Rehabilitation
Facility by a physician to take out the staples and evaluate
the head wound in seven to ten days.
2. Neurosurgery follow-up in three weeks with Dr. [**Last Name (STitle) 1327**]
with a repeat CT prior to the appointment.
3. Trauma Clinic in two weeks.
4. Neurobehavioral follow-up with Dr. [**First Name8 (NamePattern2) 51572**] [**Last Name (NamePattern1) **] in one
month.
5. Alcohol and other substance abuse. Patient was provided
referrals for follow-up at each of these places.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**First Name3 (LF) 51573**]
MEDQUIST36
D: [**2132-8-15**] 12:53
T: [**2132-8-15**] 13:18
JOB#: [**Job Number 51574**]
|
V3000,76519,76528,77089,7742,7793,7678,7661,V053,V293 | 66 | 104,518 | Unit No: [**Numeric Identifier 69381**]
Admission Date: [**2188-8-25**]
Discharge Date: [**2188-9-4**]
Date of Birth: [**2188-8-25**]
Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 5850**] was the 3.115
kg product of a 35 and [**4-11**] week gestation, born to a 27 year-
old, Gravida II, Para 0 now I. Blood type A positive,
antibody negative, hepatitis surface antigen negative,
Rubella immune, RPR nonreactive, GBS positive. Mother
followed at [**Name (NI) **] Clinic for diabetes, diagnosed in [**2176**].
Has a history of mild diabetic retinopathy. Mother admitted
to [**Hospital1 18**] due to preterm rupture of membranes for clear fluid.
Given gestational age, mother's labor was induced with
Pitocin. Labor progressed well. One hour prior to delivery,
fetal tachycardia was noted. Vaginal delivery required low
forceps assistance. Report of mild shoulder dystocia.
Initially, infant was floppy, dusky, no immediate spontaneous
cry and then onset of crying within 30 seconds. On warmer,
infant stimulated, continued crying, and received blow-by oxygen.
Left arm noted to have decreased spontaneous movements. Perfusion
and tone improved. Apgars were 7 and 8. Infant admitted to
newborn ICU.
PHYSICAL EXAMINATION: Weight 3.115 kg. Length 50 cm. Head
circumference 31.5 cm. Large for gestational age. Significant
molding with bruising on caput. No evidence of fullness in
back of head or along neck. Anterior fontanel soft and flat.
Mild bruising of left forehead and left cheek, due to forceps
placement. Eyes: No trauma of lids. External exam of eye
appears within normal limits. No evidence of trauma. Red
reflexes bilaterally. Nose within normal limits. Ears within
normal limits. Mild asymmetry and cry with the mouth. Palate
within normal limits. Clavicles within normal limits to
palpation. Chest clear and equal breath sounds, good air
entry. Cardiovascular: Normal heart sounds. No murmur.
Regular rhythm. Pulses 2+ to 4 extremities. Abdomen soft,
nondistended, nontender, no masses, no hepatosplenomegaly.
Genitourinary: Normal preterm female. Anus patent.
Extremities with symmetric spontaneous movement.
HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] was
admitted to the Neonatal Intensive Care Unit for management
of prematurity. On admission, she had
intermittent grunting which resolved within the first few
hours of life. She has remained stable in room air throughout
her hospital course. She was having occasional desaturations
with feeding. Last documented episode (with feeding) was on
[**2188-9-1**].
Cardiovascular: She has been stable throughout her hospital
course with no cardiovascular concerns.
Fluids, electrolytes and nutrition: Birth weight was 3.115
kg. Discharge weight is 3000 grams. Infant was initially started
on 60 cc/kg/day of D-10-W. Enteral feedings were initiated on day
of life #1 and infant has been ad lib feeding since that
time, taking in adequate amounts, demonstrating good weight
gain.
Gastrointestinal: Peak bilirubin was on day of life #7, 12.2.
She has not required any intervention.
Hematology: Hematocrit on admission was 48. She has not
required any blood transfusions.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign with a white count of 16.9;
platelet count of 143,000. 23 polys, 3 bands. Infant received
48 hours of Ampicillin and Gentamycin at which time they were
discontinued due to a negative blood culture.
Neuro: Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated auditory
brain stem responses and the infant passed bilaterally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],
telephone number [**Telephone/Fax (1) 47371**].
FEEDS AT DISCHARGE: Continue ad lib breast feeding.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Infant was placed in a car seat
for a 90 minute screening and the infant passed.
STATE NEWBORN SCREENS: Have been sent per protocol and have
been within normal limits.
Infant received hepatitis B vaccine on [**2188-8-30**].
DISCHARGE DIAGNOSES:
1. Prematurity born at 35 and [**4-11**] week gestation.
2. Transitional respiratory distress.
3. Rule out sepsis with antibiotics.
4. Mild hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2188-9-3**] 23:30:08
T: [**2188-9-4**] 05:15:22
Job#: [**Job Number 69382**]
|
431,2449,4019,2948,311 | 67 | 155,252 | Admission Date: [**2157-12-2**] Discharge Date: [**2157-12-2**]
Date of Birth: Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with
a history of hypertension, stroke, dementia, and depression,
some previous abdominal surgery, who is under full-time care
of two caretakers, who noticed today that the patient was
lethargic, and unable to get out of bed along with being
aphasic. This was noted at approximately 7 p.m. The patient
was reportedly globally weak. They also reported that his
eyes looked differently than they normally did. No other
history was able to be obtained at that time.
Upon further contact with the patient's sister, it was
determined that the patient is under the full-time care of
his caretakers and after his stroke four years ago in [**2153**],
she suffered from severe dementia along with inability to
engage in activities of daily living.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CVA.
3. DVT in [**2139**].
4. Abdominal hernia.
5. Dementia.
6. Depression.
PAST SURGICAL HISTORY: Multiple abdominal surgeries for
ventral hernia and incisional hernias.
MEDICATIONS: All antihypertensive medications.
ALLERGIES: Reactions unknown.
1. Sulfa.
2. Amoxicillin.
3. Codeine.
PHYSICAL EXAMINATION: Afebrile, pulse 70, blood pressure
240/109, systolic ranging from 162-270, respirations 16, and
O2 saturation is 100%. Patient is alert and acknowledges the
examiner. He speaks in short sentences. He has no right
gaze in each eye. He does have intact upward, downward, and
left gaze. Questionable facial droop on the right. He
follows commands in all four extremities. His strength is
[**5-23**] bilateral upper and lower extremities in the grip,
biceps, triceps, iliopsoas, gastroc, and [**Last Name (un) 938**]. His reflexes
are 1+ in the biceps, triceps, and quads bilaterally. His
toes are downgoing bilaterally. Sensory examination was
unable to be obtained. Fine finger movements are decreased
bilaterally.
LABORATORIES ON ADMISSION: White blood cell count 9.3,
hematocrit 54.1, platelets 183. Coags were 13.2, 35.5, and
1.2. Chemistry was sodium 137, potassium 5.1, chloride 100,
bicarb 20, BUN 24, creatinine 1.6, glucose 176. Initial
cardiac enzymes were negative.
RADIOLOGIC EXAMINATION ON ADMISSION: Head CT shows a 4.5 x
4.5 cm cerebellar hemorrhage in the right cerebellar
hemisphere, the fourth ventricle is effaced with blood
tracking into it and into the third and lateral ventricles as
well. There is periventricular edema indicating increased
ICP.
ASSESSMENT AND PLAN: A 75-year-old male with hypertension
now lethargic, aphasic with a left preferential gaze. Now
with large cerebellar bleed and blood in the third and fourth
ventricles.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Trauma SICU. Nipride drip was started. Blood pressure was
monitored with an arterial line. Blood pressures initially
were well controlled in the 130s systolic. We then placed a
ventricular drain. The patient prior to the ventricular
drain received 1 mg of midazolam and 1 mg of Morphine. The
patient tolerated the ventricular drain placement well.
After the ventricular drain was placed, the patient was
neurologically unchanged. The ICP at the time of ventricular
drain placement was approximately 8. The patient remained
with stable vital signs until approximately one hour after
the drain was placed at which time his blood pressure
increased. This increase was to the point, where the blood
pressure was in the low 200 systolic.
Nipride was pressed up and blood pressure was controlled down
into the high 170s. The patient then became apneic. His
systolic pressure dropped dramatically. He became
unresponsive. Neurologic examination at that time revealed
pupils were blown bilaterally. Patient was unresponsive. He
had no corneal or gag reflex. Patient's blood pressure then
continued to drop and he became asystolic.
Time of death was 3:55 a.m. The patient's sister was
[**Name (NI) 653**]. She did not wish to undergo autopsy. The medical
examiner was [**Name (NI) 653**] and he did not wish to go ahead with
examination.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2157-12-2**] 04:31
T: [**2157-12-2**] 04:57
JOB#: [**Job Number 111363**]
|
2768,311,2851,2449,4019,9982 | 67 | 186,474 | Admission Date: [**2155-2-25**] Discharge Date: [**2155-3-6**]
Date of Birth: [**2084-6-5**] Sex: M
Service: General Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 11907**] is a 70-year-old
gentleman who, in the past, had multiple abdominal surgeries.
As a consequence of his surgeries, he had developed very
large hernias along his midline incision and at the site of
his previous stoma in the left lower quadrant. He presented
to the office comlaining of post-prandial pain at his incisional
hernias. At that time, he had elected to undergo a ventral hernia
repair which was performed laparoscopically on [**2155-2-18**].
Postoperatively, the patient did well. He experienced some
nausea with abdominal distention which eventually resolved.
He was discharged uneventfully to the Transitional Care Unit
[**2155-2-22**], he was tolerating a regular diet and
passing flatus. Two days after his discharge, he developed a
fever up to 101.9??????, chills, nausea but with no vomiting
with mild left upper quadrant and abdominal pain. Pn
evaluation, he had an elevated white count of 13,000 and his
abdomen was very distended and tender on examination. A KUB
revealed a very large collection with an air fluid level in the
mid abdomen. A follow up CT scan confirmed free intraperitoneal
air and a large collection that appeared to be below the [**Doctor Last Name 4726**]-Tex
mesh that was placed on the previous surgery. With the
possibility of a bowel injury and perforation, the patient
was readmitted to the [**Hospital6 256**]
and he was taken back to the Operating Room for an
exploratory laparotomy.
PAST MEDICAL HISTORY:
1. Status post subtotal gastrectomy.
2. Status post colectomy and colostomy for an unknown
etiology.
3. Status post colostomy takedown.
4. Multiple incisional hernias, status post laparoscopic
repair as stated above.
5. Status post a stroke with residual poor memory and
confusion.
6. Hypertension.
7. Hypothyroidism.
8. History of depression.
ADMISSION MEDICATIONS:
1. Levoxyl 0.112 mg po q day.
2. Norvasc 5 mg po q day.
3. Wellbutrin SR 250 mg po q day.
4. Aspirin 81 mg po q day.
5. Dulcolax.
6. Milk of Magnesia.
7. Percocet prn.
8. Multivitamins.
9. Tylenol.
10. Senokot.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, no history of alcohol
consumption. He lives at home alone with daily assistance
from caregivers.
ADMISSION PHYSICAL EXAMINATION:
GENERAL: The patient was a 70-year-old male, mildly confused
in moderate distress. He appeared mildly uncomfortable.
VITAL SIGNS: He had a temperature of 100.6??????, heart rate of
91, blood pressure 130/72, respiratory rate 18 with an O2
saturation of 96% on room air.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light and accommodation. Extraocular movements
intact. Sclerae are anicteric.
HEART: Regular rate and rhythm. Normal S1 and S2. No
murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Distended, tympanitic with protrusion of hernias.
Diffusely tender to palpation and light touch, but
nevertheless, the patient remained with a soft abdomen. All
hernia sites were reducible. There was no erythema, no
drainage.
RECTAL (as per the TCU): Soft stool, low impaction, guaiac
positive.
EXTREMITIES: Warm, negative edema, hyperpigmented skin.
SIGNIFICANT LABS: White count of 13,000, hematocrit of 30.5,
platelet count of 328. Differential showed 74% neutrophils,
5% basophils, 9% lymphocytes. The urinalysis was negative.
Urine culture was negative. Electrolytes: Sodium 135,
potassium 3.9, chloride 99, CO2 26, BUN 26 with a creatinine
of 1.3 which was the patient's baseline and a glucose of 148.
HOSPITAL COURSE: On [**2155-2-25**] at 7:30 p.m. Mr.
[**Known lastname 11907**] was taken back to the Operating Room. He underwent an
exploratory laparotomy with oversewing of a left colonic
perforation, excision of the [**Doctor Last Name 4726**]-Tex mesh, evacuation of a
hematoma and placement of three [**Location (un) 1661**]-[**Location (un) 1662**] drains. The
patient tolerated the procedure well and he was transferred
under stable condition to the Surgical Intensive Care Unit
for close monitoring. Overnight, he remained hemodynamically
stable and he was weaned successfully and uneventfully off
the ventilator. He was started on vancomycin, ceftazidime
and Flagyl for broad antibiotic coverage.
By postoperative day #2, the patient was doing well. He was
spiking mild fevers to 100.6??????, but vital signs were stable.
His abdomen remained soft, slightly tender to palpation,
moderately distended. His white count came down to 8.8 with
a hematocrit of 27.5 and a platelet count of 220. His
electrolytes were within normal limits. His pain was well
controlled on morphine and he was kept NPO with a nasogastric
tube suction. Anticipating that the patient was going to be
nutritionally deprived, TPN was started that same day.
By postoperative day #3, the patient continued on vancomycin,
ceftazidime and Flagyl. His vital signs were stable. His
temperature started to trend down. He was not complaining of
significant pain and his nasogastric tube was discontinued. The
patient remained on the TPN. The wound that was left open for
closure was being packed with wet-to-dry gauzes and the dressings
were changed [**Hospital1 **]. There was no evidence of infection or drainage
and there was good granulating tissue.
By postoperative day #6, Mr. [**Known lastname 111359**] foley was discontinued and
his diet was advanced to clear liquids. On postoperative day #7,
he was tolerating clears well and his diet was advanced to
regular diet as tolerated. A physical therapy consult was
made and the patient was able to ambulate with the assistance
of the physical therapist. Two of his JP drains were
discontinued and only one was left in place. His po
medications were restarted. Nutritional service was
encouraging the patient to take his po supplements tid.
On postoperative day #8, his antibiotics were discontinued.
The patient remained afebrile and hemodynamically stable.
His abdomen was soft, mildly distended and still tender to
palpation. His wound was then packed [**Hospital1 **] and had good
granulation tissue and no infection or drainage. The JP #3
was discontinued later that afternoon.
By postoperative day #9, Mr. [**Known lastname 11907**] was screened by the TCU
and he was found to be stable to be transferred to this
facility to continue his recovery. His temperature at that
time was 98.9??????, blood pressure 110/60, heart rate of 60,
respiratory rate of 20, 97% O2 saturation on room air with
good urine output and his finger blood sugars below 190
currently on TPN. The patient was advanced to a regular diet
and nutrition service was keeping a calorie count on him.
According to the last calorie count, his intake was less than
300 calories, so it was decided to keep him on TPN. Today,
[**2155-3-6**], Mr. [**Known lastname 11907**] is being transferred to the
Transitional Care Unit to continue his recovery.
He is being transferred on these medications:
1. Levoxyl 0.112 mg po q day.
2. Aspirin 81 mg po q day.
3. Wellbutrin 250 mg po q day.
4. Colace 100 mg po bid.
5. Norvasc 7.5 mg po q day.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Exploratory laparotomy and repair of descending colon
perforation, status post laparoscopic LOA and ventral hernia
repair with mesh placement.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 111357**]
Dictated By:[**First Name3 (LF) 111360**]
MEDQUIST36
D: [**2155-3-6**] 10:30
T: [**2155-3-6**] 10:51
JOB#: [**Job Number 111361**]
|
5859,570,5849,2762,4254,486,042,2848,2875,4280,2859 | 68 | 108,329 | Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-19**]
Date of Birth: [**2132-2-29**] Sex: F
Service: MEDICINE
Allergies:
Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
increased lower extremity swelling. Concern about ability to
care for self at home.
Major Surgical or Invasive Procedure:
L femoral central line, R internal jugular central line, CVVH
History of Present Illness:
41F with advanced HIV/AIDS (last CD4 5 in [**8-23**], unknown viral
load) and cardiomyopathy (EF 20%) who was recently hospitalized
at [**Hospital1 18**] [**Hospital Ward Name **] for bibasilar pneumonia for which she
completed a full 2 week course of levo and flagyl. She is a
poor historian. She notes having leg swelling at that time and
was discharged to home 2 days ago with [**Male First Name (un) **] stockings. She says
she has been wearing her [**Male First Name (un) **] stockings since leaving the
hospital. She returned to the ED last night with complaints of
continued leg swelling and feeling week for the last two weeks.
She denies SOB, DOE, orthopnea, PND. She denies eating fast food
or salty foods, but then states she has been eating chicken
noodle soup from a can. She denies fever/chills. Denies cough
but has been spitting up clear fluid that looks like saliva.
Denies dysphagia. She has only got half of her prescriptions
since discharge from hospital, and says she has taken Bactrim,
immodium, digoxin, and pain medication. She does not know the
name, number, or type of HAART drugs that she takes, and only
identifies Bactrim as her "HIV medicine."
.
In the ER the patient received 10IV lasix, and a femoral line
was placed (she has VERY difficult access and last picc just
d/ced two days ago).
.
She denies feeling unsafe at home (although by report last night
this is her reason for admission). States she has her daughter
and [**Name (NI) 269**] to help her. She has occasional abdominal pain across
the top of her abdomen nad occasional associated nausea, but
none right now. No other complaints.
Past Medical History:
HIV/AIDS - h/o PCP x 2, MAC, cervical dysplasia, HSV anal
ulcers. CD4 ct 5 in [**2173-8-19**], viral load unknown
cardiomyopathy - EF 20% [**2173-12-28**]
new renal insufficiency since [**2173-11-18**] with baseline cr mid
2s
depression
asthma
Social History:
Divorced. Lives in apartment with 13 yo daughter. [**Name (NI) **] [**Name2 (NI) 269**] at
home. Pt reports feeling safe at home. Ambulates with walker.
Denies tobacco, alcohol, or other drug use.
Family History:
CAD: mother died age 57 MI
Physical Exam:
VS 97.7 112/68 18 on room air (O2 sat not yet checked)
Gen: sitting up in bed, very quiet speaking, NAD, pleasant
HEENT: NCAT
Neck: no LAD, no JVD
Cor: s1s2, +s3, no r/g/m, tachy
Pulm: CTA, decreased BS at B bases L>R, very mild crackle at R
base
Abd: soft, NTND, +bs, no hsm
Ext: [**Male First Name (un) **] stockings on, 2+PT pulses, 1+ pitting edema through, R
femoral line line in place, sanguinous drainage on dressing,
stockings to knees
Skin: no rashes
GU: foley catheter wtih yellow urine in bag
Pertinent Results:
-BNP 64,499. Digoxin 0.8. Creatinine 2.1 (lower than new
baseline since [**Month (only) **]). Hct 27.5 ( above baseline). Albumin
2.2.
-CXR: persistant bibasilar pna with persistant bilateral
effusions.
-Echo LVEF 20%, small-mod pericardial effusion with no
tamponade, global hypokinesis on [**2173-12-28**]
Brief Hospital Course:
Ms. [**Known lastname 31473**] is a 41 yo woman with end stage AIDS, HIV
cardiomyopathy with last EF [**12-24**] <20%, and HIV nephropathy with
very low UOP and nephrotic range proteinuria who was
hospitalized in [**Month (only) 1096**] for 3 weeks with bibasilar pneumonia
for which she was given a 2 week course of levo/flagyl. She was
discharged with stable LE edema and on an HIV salvage regimen
consisting of 5 HAART meds. She returned to the hospital one
day after discharge complaining of possible increased LE edema,
which was found to be unchanged from prior on exam. She seemed
to feel "unsafe" at home but was unable to elaborate on that.
Cultures from previous hospitalization returned at that time
with [**Doctor First Name **] in sputum and stool and she was started on treatment.
.
Five days after admission, the patient was prepared for
discharge to a [**Hospital1 1501**] with HIV specialty floor, when she complained
of new onset SOB, RR 30s-40s x hours, and eventual hypoxia. ABG
revealed lactic acidosis with lactate of 16 and ph of 7.19. FS
at that time was 24. This was all believed to be lactic acidosis
caused by HIV meds (zidovudine) interfering with mitochrondrial
function. She recieved 1 amp NaHCO3, 1 amp D50 and 500 cc NS
bolus.
.
She was transferred to the ICU, where she required CVVH for
lactic acidosis and D10 for hypoglycemia. She developed
multi-system organ failure, including liver failure, increased
oliguria, pancreatitis, and hemolysis. She responded well to
CVVH and after family meeting CVVH was discontinued and decision
was made not to restart dialysis of any sort even if her lactic
acidosis were to recur. She was treated with aztreonam and
vanco by levels for bilateral pneumonia. The patient expressed
an interest in going to hospice. A palliative care consult was
ordered and pt was transferred to floor.
.
The patient's 13 year old daughter is not aware of her mother's
HIV status and the patient has not been forthcoming about her
current prognosis. A family meeting with the patient, Drs.
[**Last Name (STitle) 31478**] and [**Name5 (PTitle) 31479**] social worker [**Name (NI) 30513**], the patient's
daughter [**Name (NI) 31480**], her daughter's cousin, and Ms. [**Known lastname 31476**]
sister-in-law. At this meeting the family was updated on the
patient's generally poor prognosis. The pt decided that she
would like to go to hospice, and understood the goals of
hospice. The pt was seen by Palliative care and she was placed
in a hospice of her choice. The pt stated she would like to
complete the course of PO antibiotics which were started in the
MICU. Her central line was pulled, uneventfully, on the day of
discharge. The patient was discharged on cefpodoxime and
azithromycin for 4 days to complete her course of antibiotics
for pneumonia. The pt will be continued on her digoxin for heart
failure, ipratropium nebulizer for shortness of breath, Bactrim
for PCP prophylaxis, [**Name9 (PRE) 31481**] for hyperphosphatemia secondary to
renal failure and lasix for shortness of breath and painful
lower extremity edema.
.
The pt reported that she will inform her family of the tranfer
to the hospice facility. Her brother was present for this
conversation.
Medications on Admission:
(unclear which meds pt was taking for the 2 days between
discharge from hospital and this admission but she reports not
missing any Bactrim doses)
(HAART meds are "salvage Tx")
bactrim
megace 40 qday
ritonavir 200 [**Hospital1 **]
lamivudine 100 qday
zidovudine 300 [**Hospital1 **]
tipranavir 500 [**Hospital1 **]
tenofovir 300qwed, sat
loperamide 2mg qid prn diarrhea
digoxin 125mcg qOd
azithromycin 600mg qwed
bactrim ss qday
oxycodone [**4-27**] q6h prn pain
protonix 40qday
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO qday prn as needed
for shortness of breath or painful edema.
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 4 days.
8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2542**] - [**Hospital1 1474**]
Discharge Diagnosis:
HIV/AIDS
Cardiomyopathy (EF 20%) [**2173-12-28**]
New renal insufficiency (baseline Cr 2s)
GERD
Asthma
Depression
Discharge Condition:
Stable
Discharge Instructions:
You are being transferred, at your request, to a hospice. Goals
of care are to continue meds by mouth that will help you feel
better or prevent further infections, but no IV's, labs, or
fingersticks will done.
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2174-1-18**] |
486,4254,42820,4280,5849,5859,2639,2848,2761,2859,V141,V071,042 | 68 | 170,467 | Admission Date: [**2173-12-15**] Discharge Date: [**2174-1-3**]
Date of Birth: [**2132-2-29**] Sex: F
Service: MEDICINE
Allergies:
Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Productive cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 31473**] is a 41yo F with AIDS, cardiomyopathy, asthma, CRF
who presents with two weeks of productive cough. Two weeks ago,
she developed a runny nose and a productive cough that was
stable for one week. Then, approximately one week ago, she began
developing a worsening cough with increasing sputum. The sputum
is green-yellow, without blood. She denies fevers, chills, night
sweats, chest pain (pleuritic or constant), SOB, DOE, orthopnea,
or PND. She has a history of disseminated MAC in [**6-/2173**] and PCP
[**Last Name (NamePattern4) **] [**2163**] and [**2170**]. She had been feeling well prior to this. She
currently denies HA, URI sx, neck pain, chest pain, SOB, abd
pain, back pain, n/v/d/c, dysuria/hematuria, or rash.
In the ED, she was hypothermic at 96.0 and hypotensive in the
60's, which improved to low 90's (her baseline per prior clinic
notes) with one liter NS. She got asa, atovaquone, and
levofloxacin.
Past Medical History:
-AIDS: Dx [**2163**]. Last CD4 5 and VL 70,500 on [**2173-9-1**]
-Disseminated MAC [**6-/2173**]
-HIV Nephropathy (FSGS) - baseline Cr 1.1
-PCP [**2163**] and [**2170**]
-CHF with EF 20-25% on [**6-/2173**] ECHO
-Childhood asthma
-GERD
-Cervical dysplasia
-HSV with subsequent anorectal ulcers
.
Social History:
Born in [**Country **], moved to the US as a teen. Ms. [**Known lastname 31473**] lives
with her 13yo daughter in an apartment in [**Name (NI) 5110**], MA. She
worked as a word processor formerly, now is on disability. She
never smoked and denies EtOH or illicit drug use. Has good
social support system (brother, other family members live
nearby).
Family History:
CAD: mother died at age 57 from an MI
Physical Exam:
T 96.0, BP 92/50, HR 92, RR 18, sat unobtainable (PO2 127 on
ABG)
GEN - cachectic female, looks older than age, mildly
uncomfortable, nad
HEENT - anicteric, op clear with mmm
NECK - supple, no jvd/lad/thyromegaly
CV - rrr, s1s2, ?s4, no m/r/g
PUL - no resp distress/acc muscle use, moves air well, bibasilar
rales r>l, no wheeze
ABD - scaphoid, soft, nt, nd, nabs, no hepatosplenomegaly
BACK - no cva/vert tenderness
EXT - no cyanosis/edema, warm/dry
NAILS - no clubbing, no pitting/color changes/indentations
NEURO - a&ox3, no focal cn/motor deficits
Pertinent Results:
Labs on admission:
WBC 2.8, Hct 26.7, MCV 81, Plt 247
diff: 80N* 2B 10L* 6M 2E
Ddimer 1203, granulocyte count 1090
Glu 83, BUN 34*, Cr 2.8*, Na 134, K 5.5, Cl 106, HCO3 17, AG 17
ALT 18, AST 55, LDH 446, AlkPhos 100, Amyl 237, Lip 133, Tbili
0.3
Ca 7.8, Phos 4.5, Mg 2.0
UA: staw yellow, clear, USG 1.008, LG blood, 500 prot, pH 6.0, 0
RBC, 0-2 WBC, occ bacteria, neg nitrites, neg LE
urine chem: Cr 10, Na 101, Alb 55.1, Prot/Cr 5510.0*
urine eos negative
.
Other labs:
TIBC 152, Ferritin >assay, TRF 117*
plasma osm 280
proBNP [**Numeric Identifier 31474**]
TSH 2.5, PTH 248
cosyntropin stim: random cortisol 19.7, 30 min cortisol 36.7,
60min 42.5
HBsAg neg, HBsAb neg, HBcAb neg, HCV Ab neg
.
Labs on discharge:
WBC 1.9, Hct 24.7, MCV 94, Plt 96
Glu 66, BUN 28, Cr 2.1, Na 135, K 3.6, CL 103, HCO3 23, AG 13
Ca 7.6, Phos 3.1, Mg 1.7
Dig 0.5
Albumin 2.2
.
Micro:
[**2173-12-31**]: stool NEG for C diff
[**2173-12-29**]: stool cx no micro, cyclospora, crypto/giardia, O+P; few
PMNs
[**2173-12-28**]: [**Month/Day/Year 1065**] isolators PND
[**2173-12-28**]: CMV VL not detected
[**2173-12-28**]: stool cx neg for microsp, cyclospora, O+P,
crypto/giardia
[**2173-12-27**]: stool cx for C diff toxin B PND
[**2173-12-27**]: stool cx neg for microspor, cyclospora, isospora, O+P,
Cdiff
[**2173-12-25**]: stool cx NEG for Cdiff
[**2173-12-24**]: blood cx x2 NGTD
[**2173-12-23**]: stool cx AFB PND
[**2173-12-21**]: blood cx x2 NGTD
[**12-18**]: induced sputum: neg for PCP, [**Name10 (NameIs) **] AFB on direct smear,
[**Name10 (NameIs) 1065**] cx NGTD, AFB cx + for AFB (speciation pending at State
Lab)
[**12-18**]: urine cx NGTD
[**12-18**]: blood/[**Month/Day (4) 1065**] cx NGTD
[**12-16**]: urine Legionella neg
[**12-16**]: Rapid Respiratory Viral Antigen Test (Final [**2173-12-17**]):
neg for
ADENO; PARAINFLUENZA 1,2,3; INFLUENZA A,B AND RSV; viral cx
pending
[**12-16**]: cryptococcal Ag: neg
[**12-16**]: CMV VL: negative
[**12-16**]: induced sputum: neg for PCP, [**Name10 (NameIs) 1065**] cx neg, AFB smear neg
[**12-16**]: stool cx neg for salmonella, shigella, campylobacter,
Cdiff
[**12-15**]: blood cx/AFB cx/[**Month/Year (2) 1065**] cx: NGTD
[**12-15**]: urine cx: NGTD
.
Imaging:
[**2173-12-28**]: ECHO - Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated with evere
global hypokinesis. No left ventricular thrombus is seen. The
right ventricular cavity is mildly dilated with moderate global
wall hypokinesis. The aortic leaflets are normal with good
excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate ([**12-20**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is a small to moderate sized circumferential
pericardial effusion without evidence for tamponade physiology.
Compared with the prior study (images reviewed) of [**2173-12-17**],
the pericardial effusion is slightly larger (specifically around
the right atrium). The estimated pulmonary artery systolic
pressure is higher, right ventricular free
wall motion may be slightly worse, and the severities of mitral
and aortic regurgitation are slightly increased.
.
[**2173-12-27**]: portable abdominal film - No dilated loops of large or
small bowel are seen to indicate obstruction. No definite free
intraperitoneal air is seen. There are bilateral pleural
effusions with lower lobe airspace opacities.
.
[**2173-12-24**]: CT a/p - 1. New, bilateral pleural effusions, right
greater than left. Ground-glass opacities at the left lung base
may represent fluid overload. 2. Cardiomegaly with interval
marked enlargement of the cardiac [**Doctor Last Name 1754**] from the previous CT.
Moderate pericardial effusion. 3. Diffuse bowel wall thickening
involving the right colon to a greater extent than the left.
These findings may represent infectious colitis or possibly
typhlitis. 4. Anasarca.
.
[**2173-12-21**]: KUB - Non-specific bowel gas pattern. No air-fluid
levels to suggest obstruction.
.
[**12-18**]: CXR - 1. Stable cardiomegaly. 2. Improvement of the
perihilar opacities with residual opacities at the bases. This
may be secondary to resolving pulmonary edema or infectious
process.
.
[**12-17**]: ECHO - The left atrium is elongated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed. Right ventricular chamber size
is normal. There is mild global right ventricular free wall
hypokinesis. The mitral valve leaflets are structurally normal.
Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion. LVEF <= 20%.
.
[**12-17**]: CXR - Successful placement of 39 cm total length double
lumen PICC line with tip in the superior vena cava, ready for
use.
.
[**12-16**]: portable CXR - 1. Enlarged cardiac silhouette suggesting
cardiomegaly or pericardial effusion, which has increased
compared to the prior examination. 2. Bilateral perihilar
opacities, likely due to pulmonary edema, increased compared to
the prior examination. Superimposed infection including PCP
cannot be excluded.
.
[**12-15**]: CXR - Enlargement of the cardiac silhouette suggesting
cardiomegaly or pericardial effusion that has progressed
compared to [**2173-8-13**]. Nonspecific bibasilar opacity suggests
edema or consolidation.
Brief Hospital Course:
# PNEUMONIA: It was felt that Ms. [**Known lastname 31473**] had a pneumonia on
admission. With her history of disseminated MAC and PCP in the
past, she was treated empirically for community-acquired
pneumonia (with 10 days of levaquin), MAC (with clarithromycin
and ethambutol), and PCP (with atovaquone originally, then
clindamycin and primaquine due to nausea and vomiting associated
with the atovaquone). ID was consulted and helped guide her
management throughout her hospital course. She was hypothermic
and hypotensive on admission, which raised concerns for sepsis,
but her BP responded to fluid boluses and her temperature came
up slightly. Induced sputum x3 was sent and were negative for
PCP, [**Name10 (NameIs) **] AFB culture came back positive for AFB on [**1-3**] (AFB
smears were negative x3). Identification of the organism is
still pending, but after confirming this with ID, it was felt
that this was most likely MAC and the patient was being
adequately treated with her current azithromycin dose (1200mg PO
1x/week).
.
# HIV: Ms. [**Known lastname 31473**] was not taking her HAART medications or her
prophylaxis upon admission, so her HAART regimen was suspended
until her acute pneumonia was treated and a discussion could be
had between the patient and her PCP. [**Name10 (NameIs) **] team was concerned that
many of her comorbidities, principally her cardiomyopathy and
her renal failure, were related to her HIV and would only
improve or remain stable with the administration of HAART. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] met with Ms. [**Known lastname 31473**] on 11R and it was decided to
restart antiretrovirals, with a 5 drug salvage regimen which ID
recommended based on her resistance profile. They also helped
make recommendations for her prophylaxis, so her ethambutol and
clarithromycin were changed to azithromycin 1x/week and her
clindamycin and primaquine were changed to Bactrim. She refused
to take atovaquone because of nausea and vomiting. Because of
her history of a Bactrim allergy, she was brought to the [**Hospital Unit Name 153**]
for Bactrim desensitization. Once she had begun prophylaxis and
tolerated the regimen well, she was restarted on a HAART regimen
which included zidovudine, tipranavir, ritonavir, tenofovir, and
lamivudine. She tolerated that regimen well with no change in
her symptoms (diarrhea, abd pain were unchanged) and she was
discharged on this regimen. Prior to discharge, social work
contact[**Name (NI) **] [**Name (NI) 1022**] [**Last Name (NamePattern1) 3912**] of the [**Name (NI) 392**]/[**Hospital3 **] AIDS Cares
Network at [**Hospital6 10353**] ([**Telephone/Fax (1) 31475**]) to set up
outpatient services for Ms. [**Known lastname 31473**].
.
# CARDIOMYOPATHY: Ms. [**Known lastname 31473**] was tachycardic and hypotensive in
the ER, with SBPs in the 60s. A BNP was checked in the ER and
was 32,538. Her SBP responded well to fluid boluses and came up
to the 90s. Her tachycardia persisted, however, EKGs showed it
was a sinus tachycardia. On the floor, she was monitored on
telemetry and she developed a HR of 170s overnight. She was
given PO and IV diltiazem which dropped her SBP and her HR to
the 70s. She was asymptomatic during this episode, but was
transferred to the [**Hospital Unit Name 153**] for closer monitoring. An ECHO showed
that her EF was < or =20% and she had severely depressed left
ventricular systolic function and mild global right ventricular
free wall hypokinesis. Her SBP came back up to the 90s in the
[**Hospital Unit Name 153**] and she was felt to be hemodynamically stable, so she was
transferred out the floor. Her volume status remained difficult
to assess as she appeared to be both total body overloaded (was
grossly edematous, with bilateral LE edema) and intravascularly
dry (no appreciable JVD, hypotensive, tachycardic, with acute on
chronic renal failure and oliguria). Renal was consulted and
after analyzing her urine sediment, felt that her picture was
most consistent with prerenal azotemia (on top of underlying HIV
nephropathy) and recommended IVF to correct her prerenal state.
She was given multiple liters of IVF with minimal improvement in
her UOP, BP and tachycardia. She become more volume overloaded
so she was given transfusions of pRBC (as her Hct was also in
the low to mid 20s), again with minimal improvement. Her Cr
remained elevated and her UOP remained poor. She was tested for
adrenal insufficiency given her persistently low BP, but she was
not adrenally insufficient by cosyntropin stimulation test. A
repeat ECHO was performed which again showed an EF of < or =
20%, dilated left and right ventricles, and moderate-severe
global hypokinesis bilaterally. There was no tamponade
physiology. Cardiology was informally consulted to see if there
would be utility to placing a line to measure CVP and then
perhaps diuresing her (likely with the addition of a pressor),
but it was felt that less invasive measures would be best in
this patient. She was restarted on digoxin (no loading dose) and
tolerated it well. Her digoxin level prior to discharge was
still subtherapeutic, but because of her renal function, it was
decided to keep her on this dose and recheck a dig level as an
outpatient. She was given metoprolol 12.5mg PO x1 to attempt to
slow down her HR, but dropped her SBP to the 70s. Her BP
responded to IVF boluses, but it was decided to not try any
further medications that could potentially drop her BP. She was
not able to be started on lasix, an ACE or spironolactone for
this reason. She was monitored on telemetry after starting the
digoxin and had one run of NSVT (13 beats).
.
# ARF: On admission, her Cr was 2.8 which appeared to be an
acute on chronic renal failure. Her urine lytes were consistent
with prerenal physiology and she was hydrated with IVF but with
only minimal improvement in her UOP. She maintained UOP of
15cc/hr for most of her hospital stay. Based on her urine
studies, it was felt that she was prerenal and needed IVF. She
was also given bicitra to attempt to correct the acidosis that
was developing from her renal failure. However, the more IVF we
gave, the more she seemed to third space and she developed
anasarca and lower extremity edema which was very troublesome to
her. Her BP was so low that we were never able to safely give
lasix to see if her UOP and edema would improve. With
administration of digoxin, her Cr began to improve and came back
down to her baseline of 2.1 by the time of discharge. She still
had significant proteinuria (spot Prot/Cr of 5510, dipstick
protein of 500) which was attributed to HIV nephropathy. Her
HAART regimen was dosed according to her discharge Cr, so her Cr
will have to be monitored closely as an outpatient and her
medications will need to be adjusted according to her CrCl.
.
# ABDOMINAL PAIN/DIARRHEA: Her abdominal pain became a more
prominent symptom once she developed anasarca. Multiple stool
studies were sent as she had frequent diarrhea, but all
cultures, including O+P and Cdiff, were negative. A CT scan of
her abdomen showed a question of typhlitis. KUB were negative
for free air or for obstruction/toxic megacolon. Ms. [**Known lastname 31476**]
abdominal pain seemed to wax and wane, but became less severe
once she began to autodiurese and her bloating and abdominal
distension resolved. Her greater concern was diarrhea. She felt
that each time she stood up, she had to have a bowel movement
and sometimes she would be incontinent because she could not
control the urge to defecate. All stool studies were negative,
including Cdiff toxin B. She was given loperamide to help
improve her diarrhea, which worked with some success. She was
given a prescription for this upon discharge, with instructions
to follow up on this symptom with her ID doctors as it could be
related to her medications (possibly the azithromycin or maybe
even her HAART regimen).
.
# ANEMIA: Ms. [**Known lastname 31473**] is anemic, with her baseline Hct in the mid
20s. She is asymptomatic from her anemia, but was given several
transfusions during her hospital stay in an attempt to increase
her BP and intravascular volume without causing third spacing.
However, her BP was minimally responsive to transfusions so they
were held unless she became symptomatic. Stools were guaiac
negative. Labs were most consistent with an anemia of chronic
disease. On discharge, her Hct was 24.5.
.
# FEN: IVF were given originally, but had to be held due to
anasarca. Her electrolytes were checked daily and were repleted
as necessary. Her K and HCO3 were often low and needed
repletion. Her Na also trended down, and she was briefly put on
a 1.5L/day fluid restriction to help bring her Na back to
normal. She was given a regular, low salt, heart healthy diet.
She was continued on Megace, though she frequently refused this
medication.
.
# PPX: Ms. [**Known lastname 31473**] was given heparin SC for DVT prophylaxis, but
she soon developed thrombocytopenia and it had to be stopped.
HIT antibodies were never sent. She was then given [**Male First Name (un) **] stockings
and pneumoboots for DVT prophylaxis. She was given a bowel
regimen originally, but by the end of her stay, she was having
frequent diarrhea and no stool softeners were needed. She was
also given a PPI for GI ppx.
.
# Access: She had a peripheral line originally, then a PICC line
was placed in her L arm due to poor IV access. The PICC line
worked well for her throughout her admission, without any
evidence of infection or cellulitis.
.
# Code: FULL. A discussion was had with the patient about her
code status and the patient did not seem to understand what it
meant to code someone or what it would mean for her as the
patient. It was decided, however, that she would be CPR not
indicated in case an event were to occur.
.
# Dispo: To home with services.
Medications on Admission:
Emtriva 200mg daily
Ethambutol 800mg daily (pt states not taking)
Famvir 250mg daily (pt states not taking)
Lisinoprol 10mg daily
Metoprolol 25mg [**Hospital1 **]
Rifabutin 300mg daily (pt states not taking)
Stavudine 30mg [**Hospital1 **]
Discharge Medications:
1. Megace Oral 40 mg/mL Suspension Sig: Ten (10) milliliters PO
once a day.
Disp:*1 bottle* Refills:*2*
2. Zidovudine 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*45 Tablet(s)* Refills:*2*
4. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(WE): Please take once a week (every Wednesday).
Disp:*30 Tablet(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Tipranavir 250 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
7. Ritonavir 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 2X/WEEK (WE,SA).
Disp:*60 Tablet(s)* Refills:*2*
9. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
AIDS
Cardiomyopathy
Congestive heart failure (EF <20%)
Acute on chronic renal failure
Pneumonia
Anemia
Discharge Condition:
Good. Afebrile, BP 94/68, HR 108, RR 18, sats 96% on RA
Discharge Instructions:
1. Please call your PCP or go to the ER if you develop any of
the following symptoms: fever >101, cough, chills, shortness of
breath, difficulty breathing, chest pain, palpitations, nausea,
vomiting, persistent diarrhea, abdominal pain, weakness,
swelling in your legs, or any other worrisome symptoms.
2. Please take your medications as prescribed every day. It is
very important that you take Bactrim every day. If you miss even
one or two doses, you may redevelop an allergy to it.
3. Please follow up with Dr. [**Last Name (STitle) **] in the next few weeks. Her
office will call you with an appointment tomorrow.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-21**] weeks. Her office
will call you tomorrow with an appointment.
2. Please call Dr.[**Name (NI) 31477**] office (cardiology) and set up an
appointment with him in [**1-22**] weeks. His office number is
[**Telephone/Fax (1) 4022**].
|
7764,76528,V3001,76517,76407,7756,7742,7793 | 69 | 190,201 | Admission Date: [**2129-3-21**] Discharge Date: [**4-9**] /[**2128**]
Date of Birth: [**2129-3-21**] Sex: F
Service: NB
HISTORY: Suzannah is a [**2057**] gram,35 and 4/7 weeks gestation
infant admitted for growth restriction and prematurity.
Maternal history: A 33-year-old G2, para 0, 1, woman with past
history notable for thyromegaly.
Prenatal screens: A positive, DAT negative, hepatitis B
negative, RPR nonreactive, rubella immune, GBS unknown.
ANTENATAL HISTORY: Estimated date of confinement was [**2129-4-21**]. The infant's estimated gestational age was 35 and 4/7
weeks at delivery. Pregnancy was complicated by
oligohydramnios, gestational hypertension and IUGR with head
spareing leading to cesarean section under spinal anesthesia
because of breech presentation. Rupture of membranes occurred
at delivery and yielded clear amniotic fluid. There was no
interpartum fever or other clinical evidence of
chorioamnionitis.
NEONATAL COURSE: The infant emerged with moderate tone, weak
cry but responded to drying, suction and tactile stimulation
with increased crying, and respiratory effort. Apgars were 8
at 1 minute and 9 at 5 minutes.
Infant was admitted to the [**Hospital1 **] NICU for prematurity.
PHYSICAL EXAMINATION: Admission weight was [**2071**] which is less
than the 10th percentile; length was 41.5 cm, less than 10th
percentile; head circumference 31.5 cm, 10th percentile.
NEUROLOGIC: The infant is alert, positive suck, positive
grasp, and symmetric tone. RESPIRATORY: The infant in room
air. Breath sounds are equal and clear. CARDIAC: Heart with
regular rate and rhythm. Normal S1 and S2. Femoral pulses +2.
HEAD, EARS, EYES, NOSE AND THROAT: Anterior fontanel soft.
Sutures apposed. EXTREMITIES: Moves all extremities well.
SKIN: Ruddy, pink, mild jaundice, acrocyanosis.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
patient has been in room air since birth. She had no
episodes of apnea of prematurity.
CARDIOVASCULAR: No murmur present.
FLUIDS, ELECTROLYTES AND NUTRITION: IV fluids and enteral
feeds began on day of admission to NICU. Full enteral feeds
of NeoSure 22 reached on day of life 5.
She initially was hypoglycemic secondary to her IUGR and
slowly weaned off her D10W IV fluids. She has remained
euglycemic on full enteral feeds of Neosure 24. Mom has little
breastmilk available..Her weight day prior to discharge was
2215 grams.
GASTROINTESTINAL: Bilirubin level on day of life 2 was
7.4/0.3. Phototherapy initiated on day of life 2. Peak
bilirubin level on day of life 3 of 7.5/0.3. Phototherapy was
discontinued for bilirubin of 5.8/0.3. Rebound bilirubin was
6.6/0.3 and her final level on [**3-28**] was 6/0.3.
HEMATOLOGY: Hematocrit on admission was 68.5, with platelet
count of 188. On day of life 2, the infant became hypoglycemic
requiring partial exchange transfusion thru a peripheral IV.
Hematocrit post exchange was 63.3, and last hematocrit
hematocrit on [**3-27**] was 60.4.
INFECTIOUS DISEASE: CBC with differential obtained on
admission. White count was 10.1, 33 polys, 1 band and 125
nucleated red blood cells. Blood cultures not performed. No
current concerns for sepsis.
NEUROLOGY: The infant does not meet the criteria for screening
head ultrasound.
Hearing screen prior to discharge: Passed on
Immunizations: Hepatitis B deferred until visit to
pediatrician.
NAME OF PRIMARY PEDIATRICIAN: [**Location (un) 2274**]/[**Hospital1 392**], Dr.[**Last Name (STitle) 64629**].
Appt on Wed or Thurs.
VNA to visit day post discharge.
Hip ultrasound recommended at 4-6 weeks of life for breech
presentation to be scheduled by Dr.[**Last Name (STitle) 64629**] as outpatient..
DISCHARGE DIAGNOSIS: Late preterm infant IUGR, S/P
hypoglycemia and polycythemia. S/P immature feeding.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
|
2662,2859,E9503,29590,2762,9695 | 71 | 111,944 | Admission Date: [**2164-2-3**] Discharge Date: [**2164-2-8**]
Date of Birth: [**2127-8-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Clozaril Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 36F h/o "schizophrenia" admitted for clozapine overdose.
Per report of her psychiatrist (per ED note) pt's mother was
treating her daughter at home for schizophrenia. She kept her
locked in the house during the days while she was at work
believing that the pt may be denied a Green Card upon receiving
the diagnosis of schizophrenia. Starting in [**Name (NI) 1096**], pt began
to express her desire to end her life, so mother sought medical
attention. On day of admission pt was found at home on the
floor, unconscious in a pool of vomit, surrounded by 5 empty
bottles of clozapine (100 25mg tabs per bottle). EMS was called,
pt was thrashing, incoherent and agitated. Taken to [**Hospital1 18**] ED
where she was intubated for airway protection.
In ED received Ativan 2 mg IV, activated charcoal,
succ/etomidate and 3L NS. Propofol gtt was ineffective in
sedating her so pt was paralyzed with vecuronium, thinking that
her lactate may improve if twitching stopped. Her lactate did
not improve and vecuronium d/c'd.
Past Medical History:
"Schizophrenia" symptoms started 10 yrs ago, worse over past
year, with SI since [**Name (NI) 1096**]
Mother reports that patient had "unknown" brain surgery for her
schizophrenia in [**Country 651**].
Social History:
Pt is a Chinese citizen. She has an associate degree and speaks
English. She lives with mother [**Name (NI) 1255**] [**Name (NI) **] [**Telephone/Fax (1) 60311**] who is
giving her psych meds from [**Country 651**] to prevent documentation of
diagnosis. Pt's psychiatrist's pager is [**Telephone/Fax (1) 60312**].
Family History:
no FH of psychiatric illness
Physical Exam:
96.3 137 114/38 100% on 0.5 Fi02
Genl: Well developed young woman, with intermittent jerking
HEENT: intubated
CV: rr no m
PULM: ctab
ABD: s, nt ,nd
EXT: no edema
NEUR: sedated, moving all 4 in intermittent asymmetrical jerks,
reflexes 2+ and symmetrical
Pertinent Results:
Labs on Admission:
TYPE-ART PO2-533* PCO2-37 PH-7.28* TOTAL CO2-18* BASE XS--8
LACTATE-7.0*
GLUCOSE-127* UREA N-11 CREAT-0.6 SODIUM-141 POTASSIUM-3.8
CHLORIDE-112* TOTAL CO2-17* ANION GAP-16
WBC-18.7* RBC-3.48* HGB-11.3* HCT-31.1* MCV-89 MCH-32.4*
MCHC-36.3* RDW-12.2 NEUTS-93.4* BANDS-0 LYMPHS-3.5* MONOS-3.0
EOS-0 BASOS-0.1
HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL PLT SMR-NORMAL
PLT COUNT-221
TYPE-ART PO2-298* PCO2-30* PH-7.33* TOTAL CO2-17* BASE XS--8
INTUBATED-INTUBATED
LACTATE-8.3*
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-50
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 TRANS EPI-[**2-4**]
HYALINE-[**5-11**]*
GLUCOSE-163* UREA N-16 CREAT-0.8 SODIUM-144 POTASSIUM-3.9
CHLORIDE-101 TOTAL CO2-17* ANION GAP-30*
ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-220 CK(CPK)-336* ALK PHOS-86
TOT BILI-0.5
LIPASE-21 CK-MB-7 cTropnT-<0.01
ALBUMIN-4.7 CALCIUM-9.6 PHOSPHATE-5.0* MAGNESIUM-1.5*
LITHIUM-<0.2
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
WBC-27.0* RBC-4.11* HGB-13.1 HCT-37.3 MCV-91 MCH-31.8 MCHC-35.0
RDW-12.3
[**2164-2-3**] 07:20PM NEUTS-90.0* BANDS-0 LYMPHS-5.4* MONOS-4.4
EOS-0 BASOS-0.2 HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
PLT SMR-NORMAL PLT COUNT-295
Studies:
CT HEAD W/O CONTRAST [**2164-2-5**] 2:14 PM - No evidence of
intracranial hemorrhage or mass effect. Post- procedural changes
of the frontal bones and overlying soft tissues, as well as
presumable post-procedure changes of the frontal lobe resulting
in unusual configuration of the frontal horns of the lateral
ventricles.
Brief Hospital Course:
36 yo Chinese speaking F with a 10 yr h/o schizophrenia s/p
questionable surgical procedure of her brain in [**Country 651**] and SI x3
months admitted with Clozaril overdose. Pt reportedly took 500
25 mg tabs in a suicide attempt. She received activated charcoal
in ED. She was intubated for airway protection given
obtundation. She was extubated on [**2-4**].
1. Clozaril overdose/Suicide Attempt s/p activated charcoal and
intubation for airway protection. She was successfully extubated
on [**2-4**]. Now stable on RA.
Her LFT's were initially elevated likely secondary to Clozaril
injestion, now WNL.
Pt is to go to Psych unit today, now that medically stable. She
was alert and oriented speaking softly in english prior to
discharge. She was responding appropriately to questions.
2. Altered mental status appears improved. Etiology secondary to
overdose. Toxic/metabolic causes were initially considered,
however pt improved without intervention. Head CT shows no acute
process. RPR and TSH normal.
- B12 deficiency, she received a B12 injection during this
admission. She will need to have a level checked in one month.
3. Lactic acidosis, resolved.
4. Leukocytosis - resolved. No evidence of infection. CXR and
U/A negative, urine cx negative. Blood cultures NGTD.
5. FEN - tolerating house diet.
6. Code - Full
7. Communication - Mother, [**Name (NI) 437**] [**Name (NI) **] [**Telephone/Fax (1) 60311**]
Medications on Admission:
Clozaril
Silpiride (selective dopamine D2 antagonist )
Na Deoxyribonucleotide Tabs
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
deacones 4
Discharge Diagnosis:
Clozaril overdose
Suicide Attempt
B12 deficiency
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician if you experience
shortness of breath or any other concerns.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-4**] weeks.
|
74689,7470,V290,76719,76528,76519,77981,2762,7742,7466,769,V3000 | 72 | 156,857 | Admission Date: [**2163-9-22**] Discharge Date: [**2163-9-29**]
Date of Birth: [**2163-9-22**] Sex: M
Service: NB
HISTORY: Patient is a 2.685-kilogram product of a 36-week
gestation born to a 32-year-old G5, P2 woman whose pregnancy
was notable on admission to [**Hospital1 18**] for preterm labor in mid
[**Month (only) **] at 32 wk GA. At that time, ultrasound revealed
polyhydramnios, not abe to see stomach bubble. on
previous ultrasounds, gastric bubble was seen. DDx at the time
was neuromuscular etiology or esophageal atresia.
No CNS abnormalities were noted on exam. Amniocentesis 46 xy
([**2163-8-30**]).Contractures were not noted at that time.
Mother noted decreased fetal movements in last weeks of
pregnancy. The mother received betamethasone ~[**2163-8-30**].
Maternal history is notable for gastric bypass surgery and
HSV. No lesions at the time of delivery though.
Prenatal screens are blood type O-positive, antibody
negative, HBsAg negative, RPR nonreactive, rubella immune,
GBS unknown. Mother was admitted several days prior to
delivery for induction given polyhydramnios and treated with
penicillin for GBS unknown status. The infant delivered by
SVD. At delivery, the baby emerged blue and apneic with
absent tone. Initial heart rate was approximately 60-80 beats
per minute which increased to 100 with bag mask ventilation.
No spontaneous movements were noted in the delivery room and
no respiratory effort.
Baby was intubated with a 3.0 ET tube and we were able to
visualize the vocal cords, but the tube met obstruction
shortly beneath the cords in the delivery room. We were able
to ventilate through the tube, but there was significant air
leak. The heart rate increased to 140. Apgar scores were 2,
2, 4, 4, and 4. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 37079**] was placed in the DR, and the
infant was brought to the NICU after brief viewing by mother.
On admission to the NICU, the baby was [**Name2 (NI) **] and well
perfused, saturations of 92. The initial chest x-ray showed
NG tube was actually in the stomach. ET tube was above the
thoracic inlet and there was chest wall movement. Patient was
well saturated. The attempt to advance the ET tube was
unsuccessful. The infant developed bradycardia to the 50s and
only was partially responsive to ventilation via the ET tube
even with pulling it back. The ET tube was then removed. Bag
mask ventilation reinitiated and the infant remained
unresponsive despite positioning and clearing of the airway.
Infant remained bradycardic requiring chest compressions for
approximately 30 seconds to 1 minute during the reintubation.
The heart rate responded up to 150 with placement of the ET
tube and there continued to be a large air leak. The infant
was then reintubated with another 3.0 ET tube which was able
to advance further and there was no air leak. Reason for
obstructive difficult intubation is not clear. No airway
problems since. Infant continues with respr failure mostly due
to CNS condition.
Birth weight of the infant was 2,885 which is 50th-75th
percentile, length 51 cm which is greater than 90th
percentile, head circumference was 34 cm which is 75th-90th
percentile.
PHYSICAL EXAM ON ADMISSION: Infant had generalized edema
noted at birth. The skin had petechiae around the face,
shoulders, arms, legs. Head had slightly wide- based eyes,
cephalohematoma right parietal-occipital region. Bruising on legs
and arms.
Lungs: Equal breath sounds to auscultation on ventilator, fair
air entry on conventional ventilation. Placed on HiFi.
CV: no murmur initially. Normal pulses. Normal precordium.
Abdomen was benign, no masses, no hepatosplenomegaly.
Genitalia: small( but not micro) phallus; undescended
testes. Anus patent. Back appears wnl.
Neurologic exam: Generalized severe hypotonia. Nnotable for no
spontaneous movement of extremities except small movements of
fingers and toes, ? slight hand movement, infrequent weak eye
openingg, ? true EOMs vs roving eye movment. No DTRs were
[**Name2 (NI) 63298**]. no gag reflex, no root, or no suck reflex and also
no grimace.
Extremities notable for clinodactyly of the 4th and 5th fingers
of the right hand.
Contractures of extremities: Right elbow extension is limited to
160 degrees. Third, 4th, and 5th fingers of the left hand were
held in flexion with contractures. There are rudimentary creases
on the palms and soles. Right knee extension is limited to 170
degrees. Eyes normal PERRL. EOMs appeared full, and there is
little response to noxious stimuli. The hips were held in breech
position for the 1st few hours after delivery. Anus was
patent and the spine intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant was intubated on admission and placed on high-
frequency oscillating ventilation after brief period of
conventional ventilation. The initial chest x-ray showed no
esophageal atresia with an orogastric tube going to the
stomach and bilateral lung opacification in association with
low lung volumes.
The infant had respiratory acidosis initially which resolved
within approximately 8-10 hours to normal blood gases. The
infant remained on high-frequency ventilation until day of
life 2. The infant did receive a single dose of surfactant
shortly after admission to the NICU. The infant has remained
on conventional ventilation since day 2. On [**9-24**] - 16, infant
wean to essentially basline current settings:
PIP weanded from 25 to 20, PEEP of 6, rate of 22, requiring
approximately 21-25% FIO2. PH ~7.28 -7.3. PCO2 on these settings
are ~50s.
The infant has spontaneous, shallow respirations (rr40-60s),
shallow, does not tolerate being off ventilator. No air leak
around the ET tube and the lungs are clear and equal with no
retractions.
Cardiovascularly: 2 echocardiograms:
1st echocardiogram ([**2163-9-23**]): PFO, small-to-moderate
PDA, severe tricuspid regurgitation, moderate mitral
regurgitation, qualitatively good biventricular function, and no
pericardial effusion.
2nd ECHO: ([**2163-9-27**]) minimal tricuspid regurgitation, trivial
mitral regurgitation, good left ventricular systolic
function, small-to-moderate patent ductus arteriosus with
left-to-right flow and no pericardial effusion.
Slight murmur noted on [**9-25**] - [**9-27**], not on [**9-28**]. Large murmur
c/w PDA noted on [**2163-9-29**] am. Mother refuses any further testing.
Recommend repeat ECHO on [**2163-9-29**] at [**Hospital1 336**]. Consider indocin.
BP stable (even on [**9-23**] with TR and MR): (60-70/40s),
extremities warm, normal pulses. Dopamine 3 mcg per kilogram per
minute for renal perfusion, but no indication for inotropic
support for cardiac reasons.
Generalized Edema thought to be due to immobility. Much less
edema over first 6 days. body.
Intermittent elevation in HR to 180-200 range began on [**9-27**].
Hct 31%. No hyperthyroidism. No fever. Good uop. nl BP.
HR did not decrease in response to fentanyl (in event HR
reflected pain that could not be detected due to
immobility).Volume of daily fluids were increased from 120 to 140
cc/kg/day. HR now 180s, still increases to 200-215 range when
disturbed. When undisturbed, TacyHR resolves to 160- 170.
Blood pressures have been normal.
Fluid, electrolytes, and nutrition: The infant has remained
NPO since birth. IV fluids via UVC on admission at 60 mL per
kilogram per day. Over the course of the last week, total fluids
have increased to 140 mL per kilogram per day which is where he
presently.. The UVC from admission is still intact.
He is on TPN: D10 and Intralipid. He showed no sign of suck or
gag or
any interest whatsoever in feeds. His most recent set of
electrolytes are:
He has hypoactive bowel sounds, soft abdomen, and flat
abdomen without masses. The liver is palpable at 1-2 cm below
the right costal margin. Peak bilirubin thus far has been 13
on day of life 5 with the most recent bilirubin being on the
day of transfer result of ________. The infant is presently
under phototherapy and has been under phototherapy since
[**2163-9-27**].
The infant had very poor urine output on the 1st day of life
and it was very dark in color. So renal ultrasound was
performed on [**2163-9-23**], which showed bilateral
echogenic renal parenchyma without evidence of hydronephrosis
or hydroureter. It is a nonspecific finding, but has been
described in so called "medical renal disease". The infant's
urine output greatly improved within 36 hours. UOP =>4
cc/kg/hr for past 2-3 days. BUN 16, Cr .01
Hematology: Mother's blood type was O-positive, antibody
negative, and the infant's blood was not typed. There has
been no blood transfusions given. The initial hematocrit on
admission was 47.1. The infant is out approximately 13 cc of
blood since birth with the most recent hematocrit being 31 on
day of life 5 ([**2163-9-27**]). The parents have been advised that a
blood transfusion may be necessary in the near future. But at
this time, the infant has not required a blood transfusion thus
far.
Platelets wnl. Petechiae noted at birth have not progressed.They
have improved. No bleeding problems noted during course.
Infectious disease: The infant was screened for infection at
admission. A CBC with differential and blood culture were
drawn. The CBC remained within normal limits. White count of
18.4, 17 neutrophils, and 0 bands. The blood culture remained
sterile. The baby was started on ampicillin, gentamicin, and
cefotaxime was added on 12 hours after life. The gentamicin
was discontinued after the 1st 24 hours and the ampicillin
and cefotaxime were discontinued on day of life 4. The
cultures remain negative. The infant has been off antibiotics
for the past 3 days and had no sign of infection at this
time.
Neurologic: The infant has presented with a grossly abnormal
neurologic exam since birth. Generalized severe hypotonia. The
infant has no reflexes or minimal reflexes at best. Has no tone.
Minimal movements. Only movements noted were eyes, minimal lids,
few fingers and toes on R and L, and spontaneous
shallow respirations. Neurology consultation:, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46082**],
Numerous studies for the baby including an EEG, LFTs, CPK,
electrolytes, lactate, pyruvate, CSF studies, a NCV/EMG,
muscular biopsy, brain MRI, and head ultrasound.
[**9-23**] CPK and Aldolase moderate elevation: [**Month (only) 116**] reflect muscle
release s/p delivery, needle stick, cardiac compressions.
[**9-23**] HUS: mild dilatation of the lateral and 3rd ventricles with
no abnormality of the brain noted.
EEG 10/ 14/05: burst suppression (severe). showed an abnormal EEG
for conceptual age due to presence of brief runs of rhythmic,
sharp discharges involving both temporal regions independently.
Additionally, the prolonged suppressive bursts are suggestive of
extensive areas of bilateral deep or midline brain lesions and is
concordant with the lack of reactivity or state transition,
although a severe encephalopathy of toxic, metabolic, or anoxic
etiology may also produce this pattern.
Ffollow-up EEG 10/17/055. This study showed an abnormal EEG in
wakefulness and sleep stages due to the presence of synchronous
and independent bitemporal spike and sharp discharges. This
finding indicates a focal abnormality in both temporal regions
and suggests an increased irritability which is considered a
paresthesia disorder. There was no clear seizure activity
recorded on the EEG.
A MRI was performed on [**9-26**]. The MRI shows: 1) Moderate
amount of subarachnoid hemorrhage. Small amount of
interventricular hemorrhage, right greater than left. No
overt hydrocephalus. 2) Foci of cytotoxic edema on diffusion-
weighted images, ADC map in the corona radiata bilaterally.
Left subcortical frontal white matter, and periventricular
white matter in the right temporal lobe. 3) Moderate sized
right parietal cephalohematoma. (Report by Dr. [**Last Name (STitle) 46082**] was
different from this. Will resolve discrepancy in reports)
Dr. [**Last Name (STitle) 46082**] had also recommended a lumbar puncture for further
studies including herpes PCR culture and lactate levels. Mother
refused LP study.
EMG /NCV was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36876**] on [**2163-9-27**]. EMG
non specific. NCV: no evidence of peripheral neuropathy.
A muscle biopsy has not been performed at this time.
Genetics: A genetic consul by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] and [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
(Fellow) from [**Hospital3 1810**]
Impression that infant's condition was likely to be a genetic
abnormality most likely affecting the CNS and it was difficult to
differentiate a syndrome from a sporadic case given the
limitations of the exam at the time. But he felt that
differentiation between the 2 would be important for recurrent
risk counseling with the parents, and he recommends rechecking
the karyotype results. Repeat chromosomes have not been sent at
this time. Parents are requesting to hold off on any large
amounts of blood draws and that is the reason for that being held
off so far.
On [**2163-9-28**] [**Hospital1 18**] cytogenetics is attempting to evaluate for
Prader- Willi deleltion. Not clear if this can be done on
amniotic fluid sample. Mother has refused further genetic testing
at this time. I have stressed the importance of this. Recommend
sending Signature Chip on fresh blood speicmen. Also need to
obtain blood acylcarnitine and carnitine.
Metabolic: State newborn screen ([**2163-9-25**]) shows no evidence of
abnormal results. Numerous metabolic studies have been performed,
many of which are still pending.
Blood sample from [**9-23**]: Lactate 2.4/ Pyruvate 0.13 ; ratio 18.4.
This was obtained within first few hours after resuscitation.
performed and resulted.
Liver enzymes are ALT 6, AST 62, an alkaline phosphatase 169,
blood lactic acid of 2.4, CPK 328, CK-MB 7.
Blood amino acids from [**9-23**] returned at time infant
transferred to [**Hospital1 336**]. Interpretation of serum aa faxed to
Genetic/Metabolic fellow ([**Initials (NamePattern4) **] [**Last Name (NamePattern4) 449**]) to assist in interpretation.
Serum amino acid results are included in transfer package.
Mother refused CSF exam. Thus no metabolic tests on CSF.
Serum and urine organic acid studies are still pending.
On [**2162-9-23**], aldolase elevation. [**Month (only) 116**] reflect muscle
release following resuscitation and needle sticks.
On [**2163-9-26**] urine for amino acids and urine for
organic acids were both obtained and sent to Quest Diagnostic
Lab in [**Hospital1 8**]. Results are pending.
Sensory: A hearing screen has not been performed yet, but will
need to be done prior to discharge.
An ophthalmology exam was performed on [**2163-9-28**] to rule
out any signs of congenital abnormalities associated with the
eyes. The results showed patchy intraretinal hemorrhages and
subconjunctival hemorrhages, both of which are nonspecific
findings and can be a result of coagulopathy versus delivery
trauma without any clear pattern to lead towards syndromic
causes.
Psychosocial: The social worker involved with this family at
[**Hospital1 69**] is [**First Name8 (NamePattern2) 36130**] [**Doctor Last Name 6861**], and
she can be reached at [**Telephone/Fax (1) 8717**]. The parents have
requested transfer to [**Hospital 511**] [**Hospital **] [**Hospital 36418**] NICU for
further care and evaluation.
They are appropriately concerned for this child's welfare and are
frustrated with no diagnosis, need for multiple tests. NICU
faculty and staff have had parent conferences on [**11-19**],
[**9-27**], [**9-28**]. Dr. [**First Name (STitle) **] spoke with Dr. [**First Name8 (NamePattern2) 63299**] [**Last Name (NamePattern1) **]
(Pediatrician) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 57436**] ([**Hospital1 336**] Neo).
The infant's condition at discharge is guarded.
Assessment: See Dr.[**Name (NI) 62797**] note from [**2163-9-29**].
Plan: Discharge disposition is transfer to [**Hospital 10908**] level III NICU.
Name of the primary pediatrician is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone
number [**Telephone/Fax (1) 63300**].
CARE AND RECOMMENDATIONS:
1. Continue further workup for neurologic, metabolic,
cardiac, and genetic etiologies of the infant's medical
condition.
2. The infant is on TPM.
3. The infant has received no immunizations thus far.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks gestation. 2. Born between 32 and 35 weeks with 2 of
the following: Either daycare during the RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities, or school-age siblings, or 3. With chronic
lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES: Respiratory distress syndrome,
arthrogryposis, sepsis suspect ruled out, relative
microcephali, profoundly abnormal neurologic condition, rule
out metabolic disease, rule out genetic or syndromic
etiology, patent ductus arteriosus, mitral regurgitation,
tricuspid regurgitation, hyperbilirubinemia, impaired renal
function.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2163-9-29**] 00:06:45
T: [**2163-9-29**] 05:21:04
Job#: [**Job Number 63301**]
|
9982,41001,5990,41401,4019,2720,V1042,V1582 | 73 | 194,730 | Admission Date: [**2170-12-22**] Discharge Date: [**2170-12-26**]
Date of Birth: [**2113-5-22**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chief complaint is status post acute
myocardial infarction complicated by ventricular fibrillation
at rest.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 18647**] is a 57-year-old
woman with no prior history of coronary artery disease;
however, with a remote 15-pack-per year history of tobacco
use and a family history positive for coronary artery disease
who was in her usual state of health until two days prior to
admission.
At that time, the patient noticed intermittent epigastric
discomfort and multiple episodes of chest pressure throughout
the day. Each episode lasted between 7 minutes and 15
minutes and occurred both with exertion and at rest.
On the morning of admission, the patient had one episode of
chest pressure and left-sided neck pain which lasted
approximately 15 minutes. This pain resolved spontaneously.
The patient was then well until 7 p.m. on the day of
admission; at which point she noticed increasing chest
pressure which prompted her to go to the Emergency Department
at an outside hospital.
En route to the Emergency Department, she developed worsening
substernal chest pain without any radiation. However, this
was associated with diaphoresis, nausea, vomiting, and the
feeling of doom.
In the Emergency Department, she developed further chest
pain. An electrocardiogram showed ST elevations in V2
through V6, and also in leads I and aVL, with ST depressions
in leads II, III, and aVF. The patient was given aspirin and
Retavase 10 mg intravenously times one; at which point, she
had ventricular fibrillation at rest. The patient was
shocked once at 200 joules and then 300 joules; after which
she returned to a normal sinus rhythm. The patient became
chest pain free after Retavase. The ST segment elevations
returned to baseline. The patient was then started on
heparin, Integrilin, and amiodarone and was transferred to
[**Hospital1 69**] Coronary Care Unit for
cardiac catheterization.
PAST MEDICAL HISTORY: Status post total abdominal
hysterectomy for endometrial cancer 30 years ago.
MEDICATIONS ON ADMISSION: Premarin 0.625 mg p.o. q.d. (for
one and a half years) and Citracal.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a nursery teacher. She lives with
her husband, her daughter, and her daughter's husband and
child. She has four children. She has a remote history of
tobacco use; 15-pack-per year history. She quit in [**2144**].
She denies any cocaine, heroin, or intravenous drug use.
FAMILY HISTORY: Her mother had a myocardial infarction at
the age of 55 to 60. Her brother had a myocardial infarction
at the age of 59. They are both status post coronary artery
bypass graft.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on arrival
revealed temperature was 97.6, heart rate was 99, in a normal
sinus rhythm, blood pressure was 102/64, respiratory rate was
26, oxygen saturation was 100% on 2 liters. General
appearance revealed a middle-aged woman in no acute distress;
moderately anxious, chest pain free. Head, eyes, ears, nose,
and throat examination revealed pupils were equal, round, and
reactive to light. The oropharynx with bleeding. The neck
revealed jugular venous pressure approximately 10 cm of
water. No bruits. The chest was clear to auscultation
bilaterally. Heart revealed a regular rate and rhythm. No
gallops and no murmurs. The abdomen was soft, nontender, and
nondistended with active bowel sounds. Extremities were warm
and obese. Dorsalis pedis pulses were palpable bilaterally.
Neurologically, alert and oriented times three. Cranial
nerves II through XII were intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed white blood cell count was 12.7, hematocrit was 41,
and platelets were 417. Chemistry-7 revealed sodium was 141,
potassium was 3.5, chloride was 100, bicarbonate was 23,
blood urea nitrogen was 20, creatinine was 0.9, and blood
glucose was 113. AST was 16, ALT was 12, albumin was 3.4.
Creatine kinase was 82. Troponin was 0.15 at the outside
hospital (where less than 0.2 is considered normal). PT was
10.6, INR was 0.8, PTT was 24.
RADIOLOGY/IMAGING: First electrocardiogram revealed a normal
sinus rhythm with a heart rate of 63, ST elevations in V2
through V6 in leads I and aVL. ST depressions in leads II,
III, and aVF.
Second electrocardiogram, status post Retavase revealed a
normal sinus rhythm with a heart rate of 64 with premature
ventricular contractions. Still with ST depressions in leads
III and aVF with resolution of ST elevations in leads V2
through V6, I, and aVL.
Third electrocardiogram, status post ventricular fibrillation
arrest and cardioversion, revealed a normal sinus rhythm with
a heart rate of 87. Complete resolution of ST depressions in
aVF and lead III and complete resolution of all ST elevations
in leads V2 through V6, I, and aVL.
Electrocardiogram at [**Hospital1 69**]
upon arrival revealed a normal sinus rhythm with a heart rate
of 82, good R wave progression. No Q waves. No ST
elevations.
HOSPITAL COURSE: Ms. [**Known lastname 18647**] is a 57-year-old woman who
presented status post anterolateral myocardial infarction;
successfully treated with thrombolytics.
Ms. [**Known lastname 18647**] was continued on a heparin drip and Integrilin drip
from admission until Monday, [**2170-12-24**] when she went
to cardiac catheterization. During this time she was
consistently chest pain free.
The cardiac catheterization showed single vessel disease with
90% stenosis at the origin of the left anterior descending
artery. The proximal left anterior descending artery lesion
was stented with good flow. An echocardiogram showed severe
focal hypokinesis of the anterolateral septum with an
ejection fraction of 51%.
After cardiac catheterization, she received Integrilin
infusion for another 18 hours. She was then loaded on
Plavix, and she was continued on Plavix 75 mg p.o. q.d. Her
peak creatine kinase was 270. A fasting cholesterol panel
was obtained which showed total cholesterol of 239,
low-density lipoprotein of 140, and high-density lipoprotein
of 61. Therefore, she was started on atorvastatin 10 mg p.o.
q.d. Premarin was stopped.
Her heart rate remained in a normal sinus rhythm with a rate
ranging between 80 to 105. She was started on Lopressor
which was titrated up as tolerated; up to 75 mg p.o. b.i.d.
which was then converted to Toprol-XL at discharge for
patient convenience. However, her heart rate continued to be
slightly elevated; ranging between the 80s and 90s.
Therefore, a thyroid-stimulating hormone was obtained to rule
out hypothyroidism.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES: Aborted anterolateral myocardial
infarction.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg p.o. q.d. (for one month).
2. Aspirin 325 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Toprol-XL 100 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with cardiac rehabilitation
in [**Location (un) **].
2. The patient was also to follow up with her primary care
physician within the next two weeks.
3. To follow up Dr. [**Last Name (STitle) **] if her insurance permits this
within the next one month.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 27069**]
MEDQUIST36
D: [**2170-12-26**] 11:47
T: [**2170-12-28**] 09:15
JOB#: [**Job Number **]
|
3558,53081,25000,2720,4019,V1582,99709,5990,5180,9973,4241,5533 | 75 | 112,086 | Admission Date: [**2147-4-5**] Discharge Date: [**2147-4-11**]
Date of Birth: [**2070-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine / Pentothal / Percodan / Talwin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/ presyncopal events
Major Surgical or Invasive Procedure:
[**2147-4-5**] - AVR with 21 mm CE pericardial valve
History of Present Illness:
76 yo female with several episodes of pre-syncope while dancing
. Has DOE and ETT was positive. Echo revealed AS with normal EF.
Cath showed severe AS with [**Location (un) 109**] 0.6 cm2, minimal CAD, AV gradient
56 mm mean. Referred to Dr. [**Last Name (STitle) 1290**] for AVR
Past Medical History:
AS
HTN
elev. chol.
NIDDM
diverticulosis
hiatal hernia
obesity
PNA X 3
PSH: C-sections x3, right TKR, chole, bladder suspension with
urethral sling,appy,coccygectomy,
Social History:
lives with husband
quit smoking 30 years ago
rare ETOH
Family History:
brother had CABG at age 66
mother/brother/sister with CHF
Physical Exam:
HR 88 RR 16 BP 106/60
5'3" 195#
NAD
no jaundice
EOMI, carotid bruits versus transmitted AS murmur
CTAB
3/6 SEM radiates throughout precordium
abdomen midline scar
2+ radial/DP/PT pulses RKR scar
no varicosities
neuro nonfocal
Pertinent Results:
[**2147-4-7**] 05:40AM BLOOD WBC-15.3* RBC-2.66* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.7 MCHC-33.6 RDW-15.6* Plt Ct-126*
[**2147-4-9**] 09:25AM BLOOD Hct-30.9*#
[**2147-4-7**] 05:40AM BLOOD Plt Ct-126*
[**2147-4-11**] 05:49AM BLOOD UreaN-11 Creat-0.6 K-4.0
[**2147-4-9**] 09:25AM BLOOD Mg-2.0
[**2147-4-9**] CXR
Small left-sided effusion. Status post aortic valve replacement.
No consolidation demonstrated.
[**2147-4-5**] ECHO
PRE-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. Mild to moderate ([**1-30**]+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Insufficient time to measure MV or AO valve gradient/area before
beginning CPB. LVOT = 1.8. Annulus = 2.2.
Post-CPB: Well seated and functioning aortic valve prosthesis.
No leak, no AI. Other parameters remain as pre-bypass. Intact
aorta. Good biventricular
systolic function.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2147-4-5**] for surgical
management of her aortic valve disease. She was taken to the
operating room where she underwent an aortic valve replacement
utilizing a 21mm pericardial valve. Postoperatively she was
taken to the cardiac surgical intensive care unit. On
postoperative day one, she awoke neurologically intact and was
extubated. She was then transferred to the cardiac surgical step
down unit for further recovery. Mrs. [**Known lastname **] was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Her pacing wires and drains were removed per protocol
without incident. On postoperative day five, Mrs. [**Known lastname **] had a
fever spike. She was pan cultured and empirically started on
ciprofloxacin.Her urine culture was positive for E.Coli and
ciprofloxacin was continued. She complained of numbness of her
right lateral thigh which improved slowly. It was presumed that
this was related to a right lateral femoral cutaneous nerve
neuropathy likely from positioning. Mrs [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
six. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
zocor 40 mg daily
glucotrol 5 mg daily
zestril 10 mg daily
ASA daily
fish oil daily
folic acid daily
Vit. C daily
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day) for 5 days.
Disp:*10 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
s/p AVR
AS
elev. chol. HTN
UTI
NIDDM
diverticulosis
GERD
hiatal hernia
obesity
s/p bladder suspension
Discharge Condition:
stable
Discharge Instructions:
1) You may shower and pat wound dry
2) No lotions, creams or powders on incisions
3) No driving for one month
4) No lifting greater than 10 pounds for 10 weeks
5) Call for fever, redness, or drainage
6) Take lasix with potassium for five days then stop.
7) Take ciprofloxacin for five days then stop.
8) Take vitamin C and iron for 1 month and stop.
9) Call with any questions or concerns.
Followup Instructions:
see Dr. [**Last Name (STitle) 1290**] in the office in 4 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 58201**] in [**1-30**] weeks
see Dr. [**Last Name (STitle) 5310**] in [**3-3**] weeks
Completed by:[**2147-4-28**] |
41061,4280,41401,2720,2721,2740 | 77 | 142,768 | Admission Date: [**2164-11-18**] Discharge Date: [**2164-11-20**]
Date of Birth: [**2119-5-12**] Sex: M
Service: CCU/MEDICINE
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 13143**] is a
45-year-old gentleman with a past medical history of
hypercholesterolemia and hypertriglyceridemia and gout who
was in his usual state of health until 2:00 a.m. on the day
of admission. At that time, the patient was awakened by
associated with diaphoresis. The pain resolved spontaneously
after ten minutes but then recurred 20 minutes later, [**7-31**] in
intensity and again associated with diaphoresis. It was also
associated this time with dizziness and the pain was
radiating into his sternal area. There was no associated
shortness of breath, nausea, vomiting, or palpitations.
the Emergency Department by his wife who is a nurse
practitioner. He was taken via ambulance. His pain at that
time was [**1-1**] after two sublingual nitroglycerin. At the
outside hospital, the patient was found to have ST
depressions in leads II, III, and aVF and he was hypertensive
with a blood pressure of 200/110. He was given sublingual
nitroglycerin, heparin drip, and beta blocked and
subsequently experienced a witnessed V-fib arrest and
required shocking with 200 joules.
He returned to sinus bradycardia and then a normal sinus
rhythm. He was started on a lidocaine drip and then
transferred to the [**Hospital1 18**] Cath lab for persistent
discomfort/chest pain.
At cardiac catheterization, the patient had the following
hemodynamics. Cardiac output was 5.24 with a cardiac index
of 2.48. The pulmonary capillary wedge pressure was elevated
at 26 and his right atrial pressure was 13. On angiography
he had a left dominant system with luminal irregularities in
the LAD, 30% stenosis of the left circumflex, and the
patient's ramus was completely occluded. The ramus was
Angio-Jetted and then stented with restoration of TIMI-III
flow.
The patient was then transferred to the CCU. On review of
systems in the CCU, the patient denied chest pain, shortness
of breath. On review of systems, he states that he was
noticing minimal bilateral lower extremity edema prior to
admission but denied dyspnea on exertion, orthopnea, PND, or
palpitations.
PHYSICAL EXAMINATION IN THE CCU: Vitals: Temperature 98,
blood pressure 127/56, pulse 82, saturation 96% on 2 liters
nasal cannula. The patient had a Swan-Ganz catheter in
place. In general, the patient was lying in bed in no
apparent distress. He was speaking in full sentences.
HEENT: The pupils were equal, reactive, and round to light
and accommodation. The oropharynx was clear and dry. He was
anicteric. The neck was supple. No bruits. JVP could not
be adequately assessed. His lungs were clear to auscultation
anteriorly and laterally. His abdominal examination revealed
a soft abdomen, nontender, nondistended, no masses. Arterial
and venous sheaths were in place in the right groin without
hematoma or ooze. His pulses were full times four, warm and
well perfuse. The neurological examination was grossly
intact.
LABORATORY DATA AND OTHER STUDIES: The patient's EKG in the
CCU was normal sinus at 93, axis within normal limits,
intervals within normal limits. His EKG showed right atrial
enlargement and T wave flattening in leads F and aVL.
He had a hematocrit of 39.7, white count 15.7, hemoglobin
13.3, platelet count 271,000. Chemistries revealed a sodium
of 138, potassium 4.4, chloride 101, bicarbonate 25, BUN 19,
creatinine 1.1, glucose 124. His magnesium was 1.5. His
first CK was 1506 with an MB of 232. Prior CKs at the
outside hospital included a CK of 169 with an MB of 2.2 and a
troponin of 0.15.
Chest x-ray at the outside hospital showed clear lung fields
and no cardiomegaly.
PAST MEDICAL HISTORY:
1. Gout.
2. Hypertriglyceridemia and hypercholesterolemia; at last
check total cholesterol 278 with a triglyceride level of
1,000.
PAST SURGICAL HISTORY: Bilateral knee menisci repair.
MEDICATIONS AT HOME:
1. Lipitor 20 q.d.
2. Tums p.r.n.
3. Indocin p.r.n. for gout.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient works in IT for [**Company **].
He is married and lives with his wife and son. [**Name (NI) **] is a
nonsmoker. He does not use intravenous drugs. He drinks
6-12 beers per week.
FAMILY HISTORY:
1. Mother with MI at age 42.
2. Father with CVA at age 68. The patient's father also
suffered from gout.
HOSPITAL COURSE:
1. CARDIAC: From a cardiac standpoint, the patient is
status post his first MI which was in the ramus
distribution. He also had symptoms of CHF with elevated
wedge pressures and left-sided pressures. The patient was
placed on metoprolol, Captopril, and was given Lasix 20 mg IV
times one to mobilize the fluid from his elevated pulmonary
capillary wedge pressure.
The patient was also placed on aspirin 325 mg p.o. q.d.
Status post stenting of the ramus, he was placed on Plavix 75
q.d. which to be continued for nine months status post
stenting. The patient's CK peaked at 1,711 on the evening of
[**2164-11-18**] and then on [**2164-11-19**] his CK was 1380, on [**2164-11-20**],
the day of discharge, his CK had fallen to 409.
The patient's cholesterol panel came back with a total
cholesterol of 209, HDL 42, calculated LDL of 90 and a
triglyceride level of 386 with a cholesterol to HDL ratio of
5. Realizing that these levels are not accurate during an
acute event, the patient was continued on his outpatient
regimen of Lipitor 20 q.d. and was told to follow-up with his
outpatient cardiologist for remeasurement of the cholesterol
panel and appropriate adjustment of his Lipitor dosage.
The patient's LFTs were also checked on [**2164-11-20**] as he was
being continued on a statin. His ALT was slightly elevated
at 73. His AST was essentially within normal limits at 48,
alkaline phosphatase and total bilirubin were normal at 94
and 0.7 respectively. The patient was old to follow-up with his
primary cardiologist regarding appropriate dosage of the statin.
RHYTHM: From a rhythm standpoint, the patient was status
post V-fib arrest in the setting of an MI. He was placed on
telemetry and monitored closely for recurrent episodes of
V-tach. He had one episode on [**2164-11-19**] of a 14-beat run of
V-tach that was asymptomatic. His electrolytes were within
normal limits including his magnesium which had been repleted
and was 2.2 at the time of the arrhythmia. The patient was
kept on telemetry through [**2164-11-20**] and had no recurrent
episodes of V-tach or nonsustained V-tach or PVCs for that
matter.
The patient had an echocardiogram to help risk stratify him.
His echocardiogram showed a normal EF of 55%. The left
atrium had a normal size. The left ventricle had normal wall
thickness. Cavity size and systolic function was within
normal limits with no noted wall motion abnormalities. His
right atrium was normal size as well as his right ventricle.
His valves were all stated to be structurally normal. He had
mild mitral annular calcification with trivial MR.
It was felt that the patient would not require an EP study
with this normal EF and with no recurrence of the ventricular
arrhythmia. The patient had originally been on a lidocaine
drip and this was discontinued 24 hours after his event.
PUMP FUNCTION: As stated, above this was completely normal
on his echocardiogram with an EF of 55%.
CARDIAC FOLLOW-UP: The patient was to see his primary care
physician [**Name Initial (PRE) **] few days after discharge, Dr. [**Last Name (STitle) **], at
[**Hospital3 1196**]. His primary care physician will
refer him to a cardiologist at [**Hospital1 **].
Of note, the patient's wife is a nurse practitioner [**First Name (Titles) **]
[**Last Name (Titles) **] and is very involved in the patient's care.
She has already arranged for the patient to follow-up in
cardiac rehabilitation at [**Hospital1 **]. The patient was
advised to take a week off from work and attend cardiac
rehabilitation.
He was seen by physical therapy during his stay and was able
to walk two flight of stairs without chest pain or shortness
of breath.
2. RHEUMATOLOGY: The patient has a history of gout and did
have a gouty flare of the arch of his right foot on the
evening of [**2164-11-19**]. He was initially given Percocet for
pain management as it was felt that Indocin should be avoided
in the setting of acute MI. However, with the patient's
normal EF and absence of ventricular scarring, his risks for
wall rupture was extremely low. Therefore, the patient was
told that he could have a trial of colchicine and if this did
not work he could resume his outpatient medication of
Indocin.
He was started on colchicine on the day of discharge, given a
trial dose of 0.5 mg p.o. and would be discharged on the
following medications.
DISCHARGE MEDICATIONS:
1. Lisinopril 5 mg q.d.
2. Atenolol 25 mg q.d.
3. Atorvostatin 20 mg q.h.s.
4. Aspirin 325 mg q.d.
5. Plavix 75 mg q.d.
6. Colchicine 0.5 to 1 mg q.i.d. for a maximum of 8 mg q.d.,
titrate to pain relief or development of side effects,
nausea, vomiting, or diarrhea. These instructions were gone
over thoroughly with the patient.
DISPOSITION: The patient was discharged to home with his
wife.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36
D: [**2164-11-20**] 12:16
T: [**2164-11-23**] 09:52
JOB#: [**Job Number 47526**]
|
96500,042,07054,5715,30401,2848,9694,E8502,E8532 | 78 | 100,536 | Admission Date: [**2177-2-14**] Discharge Date: [**2177-2-17**]
Date of Birth: [**2128-7-1**] Sex: M
Service: [**Company 191**] EAST
CHIEF COMPLAINT: Lethargy.
HISTORY OF PRESENT ILLNESS: This is a 48-year-old HIV
positive African-American male with a history of
polysubstance abuse, hepatitis C, cirrhosis and hypertension
who was admitted to [**Hospital 10073**] Hospital on [**2177-2-10**], for
detox following a recent binge using crack cocaine (about one
gram per day), alcohol (one pint of wine per day) and Xanax
and Klonopin while on Methadone maintenance. On [**2177-2-12**], he was noted to have fluctuating mental status
(somnolence, disorientation) and after being found down
beside his bed confused, with a bloody nose and a blood
pressure of 170/130, he was presumed to have had a seizure.
He was given 1 mg of Ativan and was brought to the [**Hospital1 1444**] Emergency Department.
Following a negative head CT, no further seizures and stable
vital signs, the patient was discharged back to Bornwood on
an Ativan taper. On [**2177-2-13**], the patient was reported
to be lethargic and ataxic, with a blood pressure of 150/100.
EMT brought the patient back to [**Hospital1 188**] Emergency Department, where his vital signs included a
blood pressure of 190/90, pulse of 88 and a respiratory rate
of 4, satting 94% on room air. The patient was barely
responsive to sternal rub, with constricted pupils and was
started on Narcan, receiving a dose of 0.06 mg/hour with good
effect. He was admitted to the MICU in the early a.m. on
[**2177-2-14**]. It was difficult to obtain additional history
from the patient at this time. Subsequently it was learned
that the patient received some OxyContin 40 mg from a friend
while at detox, and remembers taking it prior to admission to
the hospital, although he is unclear as to what day he took
it.
PAST MEDICAL HISTORY:
1. HIV positive since [**2162-3-12**]. A CD4 count of 78 with an
undetectable viral load was noted in [**2176-9-10**] as per the
patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**]. The
patient has a history of thrush as per previous dictation
summaries. There is a question of a history of PCP in the
past. The patient was on HAART, but this was discontinued in
the fall of last year because of decompensating liver disease
in the setting of hepatitis C.
2. Multisubstance abuse including intravenous drug abuse.
The patient has a long-standing history of multisubstance
abuse going back 25 years that includes intravenous heroin
and cocaine abuse, benzodiazepine use including Xanax and
Klonopin, and ethanol. The patient has been in and out of
rehabilitation facilities in the past, stays on long term
Methadone maintenance. While the patient does admit to
recent use of cocaine, ethanol, and benzodiazepines, he
denies use of heroin for several months, stating that he does
not crave heroin while he is on Methadone.
3. Hepatitis C positive. The patient has active hepatitis C
disease with a high viral load and is not a candidate for
therapy at this time considering his current treatment for
depression. His albumin has been as low as 2.5 in the past
but has improved since holding HAART therapy. He has no
history of ascites or gastrointestinal bleed. The patient
falls between Child Class B and C cirrhosis.
4. Pan cytopenia likely secondary to HIV and ethanol abuse.
5. Hypertension.
6. Depression.
7. History of tuberculosis exposure.
8. History of bacterial endocarditis, Staph positive in the
past ([**2161**] and [**2168**] hospitalizations).
9. History of sternoclavicular septic arthritis in [**2167**].
10. Status post motor vehicle accident with head trauma.
11. Bilateral leg pain and numbness secondary to peripheral
neuropathy.
12. Status post appendectomy.
13. Status post inguinal hernia repair.
14. Question of a distant history of seizure.
MEDICATIONS PRIOR TO ADMISSION:
1. Methadone 55 mg q. day.
2. Prozac 20 mg q. day.
3. Ativan 1 mg t.i.d. taper.
4. Thiamine.
5. Folate.
6. Clonidine 0.2 t.i.d. p.r.n.
7. Motrin 400 mg q. 4h. p.r.n.
8. Mylanta 30 cc q. 4h. p.r.n.
9. Ativan 1 mg p.o. q. 4h. p.r.n.
SOCIAL HISTORY: The patient lives with his wife in
[**Location (un) 686**] and has five children and several grandchildren.
He is retired since [**2172**] after working for American Airlines
as a ramp worker. He now lives on SSI with Mass Health and
Veterans benefits that cover his medications. As previously
mentioned, he has an extensive history of intravenous drug
abuse that includes intravenous heroin and cocaine abuse that
extends back for decades. His recent binge was attributed to
increased depression of recent time because of his inability
to stay clean, his cirrhosis and chronic illnesses, a recent
fight with his wife, multiple deaths in the family, and an
upcoming court date next week for a DUI that he was arrested
for in [**Month (only) 404**] of this year. The patient has a one pack per
day smoking history and, while he denies extensive abuse of
alcohol, he does admit to recently drinking one pint or one
bottle of wine per day.
ALLERGIES: The patient has allergy to Bactrim that causes
him to have a rash. The patient has an allergy to nafcillin
which has also given him exfoliative dermatitis of the palms
and soles in the past.
FAMILY HISTORY: The patient's mother is healthy at age 83.
The patient's father is 82 years old, suffering from diabetes
mellitus. The patient has two sisters who have died of
cancer, one at the age of 58 and one who passed away in her
20's. There is no family history of substance abuse. There
is a question of a history of depression in the patient's
mother.
REVIEW OF SYSTEMS: At admission the patient denied
complaints of headache, chest pain, shortness of breath,
nausea, vomiting, fevers or chills. He had no complaints of
diarrhea, constipation or abdominal pain at the time. No
dysuria or increased urinary frequency.
PHYSICAL EXAMINATION AT PRESENTATION: On physical
examination at presentation to the Intensive Care Unit floor
the patient had the following vital signs: He was afebrile
with a heart rate of 75, blood pressure of 139/101, a
respiratory rate of 18 and he was saturating 100% on room
air. General appearance: The patient was very somnolent,
but responsive to questions and without tremulousness. On
examination of the head, eyes, ears, nose and throat, the
patient was normocephalic, atraumatic. Mucus membranes were
dry. Pupils were 4 mm and reactive to light bilaterally.
The patient's neck was supple without lymphadenopathy. On
pulmonary examination the lungs were clear to auscultation
bilaterally without wheezes or crackles. On cardiovascular
examination, there was a normal rate and rhythm with normal
S1, S2. A systolic murmur was appreciated at the apex. On
abdominal examination normal bowel sounds were present. The
abdomen was soft, non-tender and non-distended. The
extremities were without edema or cyanosis. On neurological
examination, the patient was alert and oriented times three.
Cranial nerves II through XII were intact. No focal motor
deficits were appreciated.
PERTINENT LABORATORY DATA ON PRESENTATION: The patient had
the following laboratories on admission: A complete blood
count revealed a white blood cell count of 1.9 with an ANC of
700, hematocrit of 32.5 and a platelet count of 53,000.
Chem-7 (hemolyzed) showed a sodium of 137, potassium of 4.8,
chloride of 103, bicarbonate of 31, BUN of 13, creatinine of
0.8 and a glucose of 118. A serum tox screen for aspirin,
ethanol, acetaminophen, benzodiazepines, barbiturates, TCA
was negative.
RADIOLOGY/STUDIES AT ADMISSION:
1. Electrocardiogram: Sinus rhythm, with left ventricular
hypertrophy and left atrial abnormality. Nonspecific ST
changes were observed. Q2 prolongation that is new on this
EKG was observed compared with previous [**2170-12-16**] EKG.
2. Chest x-ray: Mild to moderate cardiac enlargement with
prominent left ventricle contour. Wide thoracic aorta. No
evidence of pulmonary congestion or infiltrates.
3. Head CT: Head CT from [**2177-2-12**] Emergency Department visit
showed mild focal dilatation, with a normal ventricular
system. No midline shift, mass, mass effect, hemorrhage was
observed. Chronic paranasal sinus disease was noted.
IMPRESSION AT ADMISSION: This is a 45-year-old
African-American male with a history of polysubstance abuse,
HIV and hepatitis C who came to the Emergency Department with
stuporous mental status changes from detox facility. This
was felt to be most likely from an opiate overdose, as the
patient appeared to respond to Narcan while in the Emergency
Department. Infection as a possible etiology for mental
status changes could not be completely ruled out in this HIV
positive patient with his last CD4 count of 78. However, the
patient does recall taking an extra 40 mg of OxyContin prior
to admission on top of his maintenance Methadone dose of 55
mg per day and benzodiazepine taper that he had been started
on after his [**2177-2-12**] Emergency Department visit, making
overdose more likely.
HOSPITAL COURSE IN THE INTENSIVE CARE UNIT:
[**Unit Number **]. Neurological: Patient's mental status changes which
included increased lethargy to stuporousness, pinpoint pupils
and decreased respiratory rate in the setting of Methadone,
benzodiazepine and opiate use make opiate overdose the most
likely cause of this patient's presentation. The patient
showed good response to naloxone throughout his stay in the
Intensive Care Unit which was continued as a drip until [**2177-2-15**], with dramatic improvement in the patient's state of
alertness. Other causes for his change in mental status
included withdrawal from benzodiazepines and alcohol,
electrolyte abnormalities, infection, intracranial processes,
as well as renal hepatic disease. For that reason,
electrolytes were followed, calcium, magnesium, phosphate
levels were sent. An LP was also performed. The patient was
pan cultured, including cultures for blood, urine and
cerebrospinal fluid. Because of the patient's history of
alcohol and benzodiazepine use with the last alcohol use
likely on [**2177-2-10**], there was a possibility of
withdrawal in this patient, so a CIWA protocol with diazepam
q. 4h. for a score greater than 10. Clonidine p.r.n. was
also continued for the possibility of developing opiate
withdrawal. In this patient with depression, his Prozac was
held while he was in the Intensive Care Unit. A Neurology
consult felt that the seizure on [**2177-2-12**], was most
likely secondary to a combination of withdrawal from both
alcohol and benzodiazepines. As recent cocaine was evident
in the urine tox screen, there was some concern of a cerebral
infarct, but a negative CT and nonfocal neuro examination
made this less likely. Liver function tests and ammonia were
also sent in this patient with a history of hepatitis C.
Patient's laboratory values while in the Intensive Care Unit
on [**2177-2-14**], included a calcium of 8.0, magnesium of 1.4
and a phosphate of 3.1. The patient's PT was 13.7, INR was
1.2 and PTT was 37.7. The patient had an elevated AST of
101, an ALT of 52, an alkaline phosphatase of 129, and a
total bilirubin of 0.8. His albumin was 2.7 and was repeated
that same day and found to be 3.1. Amylase was 98 and lipase
was 63. The patient had an ammonia elevated to 95 with no
history of previous baseline ammonia recorded in the past. A
urine tox screen was positive for cocaine and Methadone and
negative for benzodiazepines. An LP was performed on [**2177-2-14**], which showed 0 white blood cells, 6 red blood cells,
a protein of 37, and a glucose of 57. The Gram stain was
negative for PMNs, no microorganisms were seen. Cryptococcal
antigen was not detected, and fluid, acid fast, viral, and
fungal cultures were sent.
2. Infectious Disease: This patient is HIV positive and
hepatitis C positive, and it is possible that infection could
also be an underlying cause of his mental status changes. As
mentioned he was pan cultured, including blood, urine, CSF
and stool cultures. Tests for CD4 count and viral load were
sent. The patient reported that he has not been on
retrovirals since the fall of last year. Liver function
tests were ordered to follow up the status of his cirrhosis,
and were elevated as previously mentioned in this dictation.
Throughout the patient's duration in the Intensive Care Unit,
he did not complain of fevers, shortness of breath or
productive cough, dysuria, or other complaints suggestive of
infectious process.
3. Pulmonary: The patient's respiratory rate improved on
Narcan drip while in the Intensive Care Unit and there was no
need to intubate.
4. Cardiac: The patient has a history of hypertension and
has used beta blockers in the past. He has not been on his
hypertensive medication during the past several days while at
detox. His pressures remained elevated while in the
Intensive Care Unit. In the evening of [**2177-2-14**], he was
hypertensive to 206 and was given a dose of hydralazine for
control of his pressure. Subsequently, lisinopril 5 mg q.
day and hydrochlorothiazide 25 mg q. day were begun to better
control his pressure. The patient's EKG showed an increased
QT prolongation from prior EKG, in the setting of a potassium
of 3.4 upon repeat Chem-7 on [**2177-2-14**]. It was unclear
that any of the other medicines that the patient were taking
should be associated with causing this QT prolongation. The
patient's potassium was repleted.
5. Hematology. The patient's pan cytopenia was noted on
CBC. This was stable throughout his stay in the Intensive
Care Unit.
6. Renal/Fluids, Electrolytes and Nutrition. The patient
was given maintenance fluids of one-half normal saline 100 cc
per hour. These were maintained until the patient's mental
status improved. He began tolerating p.o.'s on [**2177-2-15**]. Because of the patient's elevated ammonia, he was
placed on a low protein diet once he was able to tolerate
p.o.'s. Electrolytes were followed daily and were repleted
as necessary, with potassium and magnesium requiring
repletion. The patient was placed on thiamine, folate and a
multivitamin considering the patient's history of alcohol
abuse.
7. Gastrointestinal: The patient has a history of cirrhosis
in the setting of HAART use that was discontinued in [**2176-9-10**] with a history of ethanol abuse. He has had elevated
transaminases, PT and albumin of 3.1 and elevated ammonia.
Lactulose was started at 30 cc t.i.d., titrated to less than
two stools per day to treat the elevated ammonia. Hepatitis
C serologies were not sent at this time and will likely be
followed as an outpatient.
8. Prophylaxis. The patient was placed on subcu heparin and
Pepcid IV q. day.
SUMMARY OF INTENSIVE CARE UNIT STAY: The patient's mental
status continued to improve on Narcan drip which was weaned
over 12 hours to a respiratory rate greater than 11.
Cultures remained negative during the ICU stay. The patient
was able to tolerate p.o.'s prior to transfer. Vital signs
were stable, although his blood pressures remained elevated
prior to transfer. The patient was transferred to the [**Hospital Ward Name 8559**] [**Company 191**] Service on [**2177-2-15**].
HOSPITAL COURSE ON THE FLOOR ([**2177-2-15**] to [**2177-2-17**]):
1. Neurological: On arrival to the floor, the patient was
breathing comfortably in no acute distress and was alert and
oriented with some depressed mood. He did complain of some
symptoms of nausea, chills, diaphoresis, aches and pains,
diarrhea, that he thought were consistent with his typical
withdrawal symptoms. He was continued on the CIWA protocol
with p.r.n. diazepam, and clonidine was continued for his
complaints of opiate withdrawal. His Methadone was begun on
the floor at a dose of 55 mg q. day. Lactulose was also
considered in light of his elevated ammonia, although
encephalopathy appeared to be unlikely in this patient with
no asterixis or additional changes in mental status. We
continued to follow daily labs which showed a white blood
cell count of 1.7, hematocrit of 32.6 and a platelet count of
47,000, with an ANC of 740. Electrolytes showed a sodium of
137, potassium 3.3, chloride 107, bicarbonate 22, BUN 8,
creatinine 0.5 and glucose 98. Calcium was 7.5, magnesium
1.8 and phosphate was 3.0. While the PT and INR were now
normal, PTT remained slightly elevated at 39. The patient
was offered a nicotine patch for his nicotine addiction which
he declined. The patient's mental status continued to be
stable during his stay on the floor, with no signs of overt
anxiety, hallucinations, instability, but the patient was
somewhat depressed and nervous, which he admitted was
primarily due to his worry about personal stressors. His
symptoms of opiate withdrawal were also negligible during his
second and third days on the floor. Prozac was restarted on
his last day of admission for depression. It appeared that
the patient had very few symptoms of ethanol withdrawal,
however, his blood pressure did remain elevated throughout
his stay but without tachycardia. The patient's symptoms of
opiate withdrawal seemed to be well controlled on his
Methadone maintenance dose although the patient did receive
one to two doses of benzodiazepine per day, and requested
clonidine on his final day of admission p.r.n. However, the
patient does admit that he feels better than he has in years
physically but admits that it is psychological problems and
depression that make him feel most concerned at this time.
We had several discussions with the patient regarding the
seriousness of this hospital admission and the risk of poor
outcome if he continues such risky behaviors, as this
overdose might have been life threatening. The patient is
actually quite thoughtful and clearly depressed with his
current health situation, living environment ("my
neighborhood is full of drugs"), and life stressors (several
deaths in the recent past in his family).
2. Infectious Disease. The patient's CD4 count was found to
be 48 during this admission and his viral load is still
pending. The patient remained afebrile throughout his
admission, without complaints of fever, productive cough,
dysuria, abdominal pain, or other clinical signs concerning
for infection. Blood, stool and cerebrospinal fluid cultures
have been negative to date. Prophylaxis was begun for PCP
with dapsone and fluconazole was also started in this patient
with a history of thrush. However, fluconazole was
discontinued prior to __________ as prophylaxis is not
indicated routinely in HIV positive patients. As the
patient's CD4 count is below 50, toxoplasmosis titers were
also sent, and should be followed up for possible
toxoplasmosis prophylaxis as well as [**Doctor First Name **] prophylaxis as an
outpatient.
3. Cardiovascular. The patient's EKG was repeated on [**2177-2-16**], and was found to be unchanged from admission EKG,
with suddenly prolonged QT interval. Potassium was also 3.2
on [**2177-2-16**], and was repleted. The patient's blood
pressure continued to be elevated throughout his stay on the
floor, in the 150's to 180's over 90's to 100's. The dose of
lisinopril was increased to 10 q. day, and it was decided
prior to discharge to change the patient's blood pressure
regimen to 10 mg lisinopril b.i.d., to discontinue the
hydrochlorothiazide, and to begin Norvasc 5 mg p.o. q. day.
4. Pulmonary. The patient was breathing comfortably with
normal respiratory rate and saturating well on room air
throughout his stay on the floor. While the patient
complained of some runny nose on transfer to the floor, he
developed no other symptoms suggestive of a serious
respiratory infection. This patient does have previous
hospitalizations because of pneumonia with a question of PCP
pneumonia in the past.
5. Renal. The patient had normal creatinine throughout his
hospital stay. His urinalysis was negative except for a
negative urobilinogen in this patient with advanced liver
disease. Urine culture was positive for group B Strep which
was an endogenous organism not considered needing to be
treated.
6. Fluids, Electrolytes and Nutrition. The patient's lytes
were followed and were repleted while he was on the floor.
Potassium remained slightly low throughout and was repleted
with 40 mEq of KCl during each of his stays on the floor and
was increased to 60 mEq on [**2-17**]. He was maintained on a
low protein diet in light of his elevated ammonia which was
up to 148 on his day of discharge. He was continued on
thiamine, folate and multivitamin and additional B12 and
folate studies were sent and are still pending. He tolerated
p.o. liquids and solids well throughout his stay on the
floor. No complaints of nausea or vomiting.
7. Gastrointestinal. In this patient with hepatitis C
positive cirrhosis his albumin came back at 2.8 on [**2177-2-16**]. We continued to follow an ammonia which was 148 prior
to discharge, and lactulose was poorly tolerated by the
patient and was discontinued on his final day of admission.
The patient was requesting therapy options for his liver
disease and seemed most concern with this of his health
issues. Unfortunately, Interferon therapy may be
contraindicated in this patient on Zoloft with clear symptoms
of depression. As an outpatient it would be recommended that
he receive vaccination such as hepatitis A in light of his
liver disease. While this patient has no prior history of
gastrointestinal bleed, we began Imdur for GI prophylaxis,
and it is recommended that he have an
esophagogastroduodenoscopy as an outpatient.
8. Hematology. The patient's pan cytopenia was stable while
on the floor. The patient did complain of a nose bleed one
morning in the setting of low platelet count that he
described as robust, but which stopped easily and did not
recur. In light of the patient's pan cytopenia which may be
likely due to ethanol use, HIV, liver disease, it was thought
that B12 and folate should also be checked.
9. Prophylaxis. The patient remained on heparin subcu
b.i.d. and ranitidine 150 mg p.o. b.i.d. throughout his stay
on the floor.
CONDITION AT DISCHARGE: The patient was in good condition at
discharge. He was not complaining of symptoms of alcohol
withdrawal, and was maintained on CIWA protocol greater than
8 during his last three days on the floor. Methadone
maintenance was restarted with good effect. He was primarily
concerned with psychosocial issues of maintaining sobriety, a
safe drug-free environment, his chronic health issues, family
stressors, and tomorrow's pending court appearance.
Depression, for these reasons, is a concern in this patient
who appears to have overdosed on narcotics leading to this
admission.
DISCHARGE STATUS: The patient was discharged back to
[**Hospital 10073**] Hospital, where he was first admitted last Monday
([**2177-2-10**]) to begin a detox program prior to this
hospitalization. He wishes to return to Bornwood to continue
his detox in a safe environment where he can try to address
his recurrent urges for polydrug abuse. [**Hospital 10073**] Hospital is
located at [**Street Address(2) 10074**] in [**Location (un) **], [**Numeric Identifier 10075**].
DISCHARGE MEDICATIONS:
1. Thiamine 100 mg q. day.
2. Folic acid 1 mg q. day.
3. Multivitamin.
4. Dapsone 100 mg q. day.
5. Methadone 55 mg q. day.
6. Fluoxetine 20 mg q. day.
7. _____ 10 mg b.i.d.
8. Ativan 1 mg q. 4h. p.r.n.
9. Clonidine 0.2 mg t.i.d. p.r.n.
10. Potassium chloride 20 mEq b.i.d.
11. Norvasc 2.5 mg p.o. q. day.
12. Magnesium oxide 400 mg p.o. q. day.
13. Imdur 30 mg q. day.
DISCHARGE INSTRUCTIONS AND FOLLOW UP:
1. The patient was instructed to call his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**], after discharge to set up a
follow-up appointment in one week if he desired to continue
having her involved in his care.
2. As the patient mentioned a desire to transfer his care
from the V.A. Hospital, as he has had some negative
experiences there in the past, we have set up an appointment
for him with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Associates, [**Hospital1 1444**], for this Thursday, [**2-20**], at 2:00 p.m., the [**Hospital Ward Name 23**] Building. At this
appointment the patient will be able to follow up his pending
laboratory studies which include pending cultures, his viral
load, his toxoplasmosis cultures. Also potassium and ammonia
levels should be checked at this time. As the patient's
blood pressures have been elevated during his hospital stay
and his blood pressure control medications are still being
optimized, his blood pressure should be checked during this
visit and modification of his medical regimen should be
considered. Pending results of the toxoplasmosis titers, the
patient should be considered for a toxo and [**Doctor First Name **] prophylaxis,
considering his CD4 count of 48. Also consider a hepatitis A
vaccine and confirm hepatitis B status in this patient. As
this patient was noted to have a slightly prolonged QT
interval on EKG, it would also be useful to recheck an EKG
during this visit. While this patient has had no complaints
of gastrointestinal bleed in the past, he should be sent for
endoscopy to look for varices as an outpatient. The patient
has also been requesting psychiatric and/or social work
support as he has numerous psychosocial stressors and needs a
support network to help him with his depression and with the
numerous issues involving his drug abuse and health care
problems. This patient should also be set up to be followed
in the [**Hospital3 **].
3. The patient was also scheduled to visit the Pain Clinic
at [**Hospital1 69**] this Thursday with
Dr. [**Last Name (STitle) **] on [**2-20**] at 12:40 p.m. This visit is
important in light of his chronic back pain and peripheral
neuropathy, which the patient states have been a factor in
his persistent drug use.
4. Continue with Methadone maintenance program as previous
to admission.
5. Consider contacting [**Name (NI) 10076**] for acupuncture treatments as
the patient has requested this therapy which has worked for
him in the past.
DISCHARGE DIAGNOSES:
1. Opioid and benzodiazepine intoxication.
2. Polysubstance abuse.
3. HIV positive.
4. Hepatitis C positive.
5. Hypertension.
6. Depression.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Name8 (MD) 10077**]
MEDQUIST36
D: [**2177-2-17**] 16:59
T: [**2177-2-17**] 16:15
JOB#: [**Job Number 10078**]
|
41011,4271,41401,42689 | 79 | 181,542 | Admission Date: [**2175-9-25**] Discharge Date: [**2175-9-29**]
Date of Birth: [**2123-6-11**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain, caused by anterior STEMI.
Major Surgical or Invasive Procedure:
Emergent cardiac catheterization.
Removal of thrombus from the LAD coronary artery.
Placement of a drug-eluting stent in the proximal LAD.
History of Present Illness:
52M w/no signif PMH, developed left arm discomfort at 1pm today
while in scout classes, [**2-18**], no SOB, no LH/Dizzyness, no
diaphoresis, no N/V. Paid no attention, discomfort started to
move up along arm to shoulder and then LACW as day progressed.
By 8pm patient had decided to rest, lay in bed to relieve
discomfort but to no avail, pain at that time had increased to
[**7-20**] and very noticible in the chest area. Called EMS and taken
to [**Hospital6 33**] (arrived at 940pm). ECG there
demonstrated STE in I,aVL, V1 with hyperacute T waves in V2-V5,
ST depressions in II, III, F with TWI III, F, all consistent
with anterior transmural infarction. He rec'd ASA 325mg, plavix
300mg, iv heparin, and eptifibatide (single bolus and infusion).
Also rec'd nitroglycerin x1 which decreased pain from [**7-20**] to
[**2-18**].
Transferred to [**Hospital1 18**] for emergent cath and continuing care.
Past Medical History:
Anxiety, per PCP.
Social History:
SOH: neg x 3, good exercise and diet.
Family History:
FM: father with MI in 70's, GF both paternal and maternal with
MI in 60-70's.
Physical Exam:
Gen: NAD, comfortable, A/Ox3.
V/S: 98.8 (afeb) 64 96/44 20 98%RA
HEENT: HNCAT
CV Pump: nl S1,S2. No m/r/g.
CV Rhythm: RRR with occasional rare infrequent PVCs.
Pulm: CTAB. Respirations comfortable.
Abd: S/NT/ND.
Vasc: Hematoma at R femoral access site continues to resolve.
Pertinent Results:
Cadiac Cath: 100% occluded pLAD; Cypher stent 3.5x13 placed by
PTCA.
Hemodynamics: RA mean 15/a wave 17/v wave 18/, RV 38/11/17, PCW
mean 30/ v wave 37/ a wave 27, Ao 102/76/89, Pa sat 71%.
Peak cardiac enzymes: CPK 3169, CK-MB 494, Troponin-T 8.23.
Lipid profile: HDL 41, LDL(calc) 101, TG 110 (all wnl).
Brief Hospital Course:
100% occluded pLAD found at emergent cath, cleared by
thrombectomy.
Cypher stent 3.5x13 placed by PTCA.
Patient noted to have AIVR w/ mild hemodynamic intolerance
during AV dysyncrony. IABP was placed [**3-13**] persistent borderline
hypotension. Patient's hemodynamics remained stable and the IABP
was removed approximately 18 hours later.
The patient was noted have brief runs of NSVT on telemetry, in
the range of [**12-4**] beats. These were likely secondary to
reperfusion irritability, and have subsequently subsided without
further intervention.
Echocardiogram revealed anterior wall hypokinesis and apical
akinesis.
Patient was begun on tailored
ASA/Plavix/Lipitor/ACE-inhibitor/Metroprolol medication regimen,
and also on coumadin for anticoagulation in the setting of wall
hypokinesis.
Medications on Admission:
None.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) 80mg Subcutaneous
twice a day for 2 weeks.
Disp:*28 syringes* Refills:*0*
9. Outpatient Lab Work
Check Hct% and INR on Monday [**2175-10-2**].
Please send results to Dr.[**Last Name (STitle) 57699**] at [**Hospital6 33**].
[**Telephone/Fax (1) 57700**].
10. Outpatient Lab Work
Check Hct% and INR on Thursday [**2175-10-5**].
Please send results to Dr.[**Last Name (STitle) 57699**] at [**Hospital6 33**].
[**Telephone/Fax (1) 57700**].
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior MI.
Discharge Condition:
Good.
Discharge Instructions:
Please return to the emergency department for re-evaluation if
you experience chest pain, nausea, shortness of breath,
dizziness, disorientation or any other symptoms that concern
you.
It is essential that you remember to take all your medications
on time as prescribed. Remember to keep your appointments.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **].[**Last Name (STitle) 57699**]
([**Telephone/Fax (1) 57700**]) to achieve appropriate coumadin levels. Your
appointment wiht Dr.[**Last Name (STitle) 57699**] is scheduled for 11.30am on
Monday [**2175-10-2**]. Follow-up cardiology care has been arranged
with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45945**] ([**Telephone/Fax (1) 14967**]). You have an appointment
to see him at 3.15pm on Tuesday [**2175-10-3**]. Dr[**Last Name (un) 57701**]
practice is located at [**Street Address(2) **] in [**Location (un) 936**], in the
old [**Last Name (un) 14223**] Shoe Building. Please remember to bring your [**Company 57702**] card.
Completed by:[**2175-9-29**] |
E916,87342,80416 | 80 | 115,385 | Admission Date: [**2148-11-11**] Discharge Date: [**2148-11-16**]
Date of Birth: [**2104-12-13**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
male with no significant past medical history who was working
on his welding job when a metal object came and hit him in
the forehead. The patient lost his balance and fell back and
hit the back of his head. No loss of consciousness at the
scene by report. On transport to [**Hospital3 3834**] the
patient had loss of consciousness. Head CT at the outside
hospital showed a frontal bone sinus fracture and
pneumocephalus with a positive occipital fracture. There was
a question of a contusion versus a bleed in that region. The
patient had emesis times two. He was confused and agitated
on arrival to the [**Hospital1 69**].
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: None.
SOCIAL HISTORY: Positive marijuana two times per day,
occasional alcohol, occasional tobacco.
PHYSICAL EXAMINATION: Temperature 36.7. Heart rate 80.
Blood pressure 127/67. Respirations 18. O2 sat 98%.
General no acute distress. Pupils are equal, round and
reactive to light. Face was symmetric. Tongue midline.
Laceration on the forehead, which was sutured. Heart is
regular rate and rhythm. Lungs clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended. Pelvis
is stable. Extremities no gross deformities. Palpable
dorsalis pedis pulse and posterior tibial pulse bilaterally.
LABORATORY DATA: Hematocrit 40, white blood cell count 20,
platelets 234, sodium 139, potassium 3.6, chloride 104,
bicarbonate 23, BUN 14, creatinine .9, glucose 196, blood gas
on admission was 7.35/44/127/22/-1. Head CT at the outside
hospital showed a frontal bone sinus fracture with
pneumocephalus and also an occipital fracture. At this
institution C spine plain films were negative. Chest x-ray
was negative. Pelvis x-ray was negative.
HOSPITAL COURSE: The patient was admitted to the Trauma
Surgery Service. He had a four vessel angiogram performed on
[**11-11**], which showed no evidence of carotid dissection,
no evidence of vertebral dissection and no evidence of
intracranial vascular pathology. He was admitted for
neurological checks and started on Clindamycin. He was
placed in the Intensive Care Unit for neurological checks. A
CT of his head was stable and CT C spine revealed no obvious
pathology. A repeat CT on [**11-15**] showed decrease in air in
bifrontal areas and the patient's neurological examination
was stable. He was tolerating a regular diet at the time of
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with follow up with Dr. [**Last Name (STitle) 1327**]
from neurosurgery.
DISCHARGE DIAGNOSES:
Status post trauma with pneumocephalus and occipital bone
fracture along with frontal bone sinus fracture.
[**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2149-3-19**] 12:50
T: [**2149-3-21**] 09:27
JOB#: [**Job Number 47440**]
|
431,20210,4019 | 81 | 175,016 | Admission Date: [**2192-1-9**] Discharge Date: [**2192-1-11**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Intracerebral hemorrhage
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 72539**] is an 85 year old right-handed man with a history of
hypertension (per his wife it is not severe) and cutaneous
T-cell lymphoma (stable for 17 years), who is transferred from
[**Hospital **] Hospital with the diagnosis of left intraparenchymal
hemorrhage. Per his wife he had not recently been ill and was
feeling quite well this morning, without complaint of headache,
visual changes, or new trouble with his balance. He has chronic
low back pain and had an appointment with his chiropractor this
morning. He told his wife he was going to work out after that,
and left the house at about 11 a.m. The chiropractor then
called his wife, saying that he looked rather shaky. Mr.
[**Known lastname 72539**] then apparently left the office and sat in the driver's
seat of his car, with the door open. Someone noticed that he
did not look well and called EMS.
They found him with right face/arm/leg weakness and slurred
speech. His blood glucose was 91 and BP was 168/98. He was
brought to [**Hospital **] Hospital where his initial BP was 151/72 and
his HR was 57. He was afebrile. There he was described as
having no speech output but he was following commands. He was
not coagulopathic, with an INR of 0.95, PTT of 29.9, and
platelets of 322. He had a head CT which revealed a small
(about 3 x 2.5 cm) hemorrhage in the left external capsule, with
no midline shift and no intraventricular blood. He was then
transferred to [**Hospital1 18**] for further workup.
Upon arrival here his blood pressure was elevated at 188/77 and
he was given hydralazine. He was taken for head CT, and per
recommendation of Neurosurgery, CTA (presumably to look for
dissection, although per his wife he gets no neck manipulation).
Review of systems: No recent fever, weight loss, cough,
rhinorrhea, shortness of breath, chest pain, palpitations,
vomiting, diarrhea, or rash. No complaints of headache,
diplopia, dysarthria, tinnitus, vertigo, dysphagia, weakness,
numbness, or paresthesias prior to this event.
Past Medical History:
- Cutaneous T-cell Lymphoma - followed by Dr. [**Last Name (STitle) 72540**] at BU;
diagnosed in [**2174**], s/p treatment with "photopheresis" and
currently maintained on a medication called "Targretin"
- Hypertension - per his wife they have never been told that it
is severe
- S/p "tongue cancer" ?leukoplakia
- Chronic back pain
Social History:
Lives with his wife.
Family History:
Father deceased from MI in his late 70's. No stroke that his
wife knows of.
Physical Exam:
(initially examined while lying flat awaiting CT, then later
seen while sitting up, when much more awake)
T Afebrile HR 54 BP 140/63 RR 18 Pulse Ox 98% on 2L NC
General appearance: Sleepy 85 year old man in NAD
HEENT: NC/AT, neck supple
CV: Regular rate and rhythm without murmurs, rubs or gallops. No
carotid or vertebral bruits.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended
Extremities: no clubbing, cyanosis or edema
Mental Status: (when lying flat) Somnolent. No spontaneous eye
opening, briefly opens eyes to sternal rub but requires repeated
stimulation. Mute. Does not repeat, does not follow commands.
Does not mimic movements. Decreased attention to the right side
of space.
(when sitting up about 30 minutes later) Awake, eyes
spontaneously open and looking around the room (prefers left),
still mute, does not repeat or follow commands, does not mimic,
but seems to recognize wife and son-in-law, and they thinks he
understands a little bit of what they say.
Cranial Nerves: Pupils are pinpoint and non-reactive. Does not
blink to threat with either eye (but based on visual attention
likely has right homonymous hemianopia). Optic disc margins
could not be visualized. Gaze is midline and conjugate, when
sleepy could doll to either direction. There is no nystagmus. +
corneals, +grimace to nasal tickle bilaterally. Right UMN facial
weakness. Tongue is midline. Weak gag.
Motor System: Exam somewhat limited due to global aphasia and
initially, somnolence. Normal muscle bulk. Flaccid on right
side. Spontaneously moves left arm and leg antigravity.
Extensor postures right arm to noxious stimuli, and makes no
movement with right leg, which is held externally rotated.
Reflexes: Deep tendon reflexes are trace on the left, absent on
the right. Plantar responses are flexor on the left, extensor
on the right. No [**Doctor Last Name 937**].
Sensory: Withdraws to noxious stimuli with left arm and leg,
grimaces and extends right arm, does not respond to noxious in
right leg.
Coordination, Gait: Could not assess.
Pertinent Results:
At [**Hospital **] Hospital:
2.5>11.1/33.2<322
PT 11.6 INR 0.95 PTT 29.9
UA: SG 1011, negative
129 96 21 100 AGap=17
4.5 21 1.0
Comments: K: Hemolysis Falsely Elevates K
estGFR: 71 / >75 (click for details)
MCV 92
3.3 > 11.4 < 322
32.5
N:62.6 L:22.9 M:11.5 E:2.9 Bas:0.2
PT: 13.1 PTT: 27.2 INR: 1.1
Imaging:
CXR: negative for CHF or PNA
Head CT/CTA [**1-9**]: FINDINGS: There is a large 4.1 x 7.8 cm
intraparenchymal hematoma in the left basal ganglia,frontal and
temporal lobes with intraventricular extension. There is midline
shift of approximately 8.8 mm with effacement of the ipsilateral
ventricle. There is mild trapping of the contralateral
ventricle. There are confluent hypodensities in the
periventricular and subcortical white matter compatible with
small vessel ischemia in a patient of this age group. There is a
prominent right frontal extra-axial space. There are secretions
in the right maxillary sinus.
Evaluation of the CTA of the brain demonstrates no aneurysm or
hemodynamically significant stenosis. There is calcification of
the cavernous carotid arteries bilaterally. There is mild
stenosis of the left PCA.
Evaluation of the CTA of the neck demonstrates calcified
atheromatous plaquing at the origin of the right distal common
carotid artery and bulb extending to the proximal ICA. There is
approximately 50% stenosis of the distal common carotid
artery/carotid bulb and mild stenosis of the proximal ICA which
does not appear to be hemodynamically significant.
There is a focal calcific plaque at the origin of the right
vertebral artery which is occluded.
IMPRESSION:
1. Large left intraparenchymal hematoma in the left basal
ganglia and frontal and temporal lobes.
2. No underlying lesion noted on the CTA.
3. Approximately 50% stenosis of the right carotid bulb
extending to the proximal ICA with a calcified plaque.
4. Occlusion of the right vertebral artery with a calcific
plaque at the origin.
EKG: Sinus bradycardia
First degree A-V delay
Consider left atrial abnormality although baseline artifact
makes assessment difficult
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 [**Telephone/Fax (2) 72541**] 31 54
Head CT [**1-10**]: FINDINGS: Again seen is a large evolving 7.4 x 3.8
cm left intraparenchymal hematoma centered in the left basal
ganglia. There is surrounding edema which causes moderate mass
effect. There is compression of the left lateral ventricle and
entrapping of the right lateral ventricle. Ventricular size has
not changed compared to the prior study. A small amount of blood
is seen layering the right atrium and a moderate amount of blood
is seen layering the left atrium. Again seen is 9 mm rightward
subfalcine shift. The osseous structures are unchanged. There is
mild mucosal thickening of the right maxillary sinus.
IMPRESSION:
1. Evolving left intraparenchymal hematoma centered at the left
basal ganglia with surrounding edema resulting in a 9-mm of
rightward subfalcine herniation and mass effect on the left
lateral ventricle.
2. Moderate amount of intraventricular hemorrhage. The size of
the ventricles has not changed compared to prior study.
Brief Hospital Course:
85 year old man with history of hypertension, now with left
external capsule hemorrhage, which had more than doubled in size
in the past 4 hours, although he had no evidence of
coagulopathy. He had significant involvement of most of the
left hemisphere, blood in the left lateral ventricle, midline
shift and right subfalcine herniation. The etiology of the
hemorrhage was most likely hypertensive, although the location
was a bit unusual (would expect basal ganglia or thalamus), but
another spike in his blood pressure may have been responsible
for the expansion of the bleed. The subcortical location would
not be typical for amyloid angiopathy. Clinically, on initial
exam, he was fairly awake, although he was globally aphasic and
had a dense right hemiparesis. He was at significant risk for
deterioration of his mental status, especially given the
subfalcine herniation. His prognosis for meaningful recovery,
i.e. without major disability, was poor.
We discussed this at length with Mr. [**Known lastname 72542**] wife and
son-in-law. [**Name (NI) **] had expressed to his family quite clearly that
he did not wish to be kept alive on a long-term basis by
artificial means, did not want any heroic measures, and would
not want to live with major disability. Neurosurgery had spoken
with the family about the possibility of an EVD, but Mrs.
[**Known lastname 72539**] felt that he would not want to have any surgical
intervention. She expressed that initially he could be
intubated if his mental status were to decline, but if the
intubation were to become prolonged, they would reconsider
whether they wanted to keep the tube in. They did not want him
to be resuscitated (i.e. no CPR, shocks, meds) if his heart were
to stop beating.
Neuro: Patient was admitted to Neurology ICU where serial
neurochecks were performed. Mannitol 50g IV was given initially
in the ED and then continued 25mg every 6 hours thereafter with
parameters to hold subsequent doses for Na >150 or Osm >320. He
was loaded with 1g Dilantin which was subsequently discontinued
upon re-evaluation in the am since his bleed was subcortical and
risk of seizure was low. Head of bed elevated greater than 30
degrees and kept euthermic and euglycemic. Repeat head CT the
following morning showed an evolving left intraparenchymal
hematoma centered at the left basal ganglia with surrounding
edema resulting in a 9-mm of rightward subfalcine herniation and
mass effect on the left lateral ventricle. There was also a
moderate amount of intraventricular hemorrhage. The size of the
ventricles had not changed compared to prior study. Clinically,
patient was more somnolent with less spontaneous movement.
Meeting was again held with the family regarding his clinical
status and family made decision to make patient do not
resuscitate and do not reintubate. The following morning the
patient's family made him comfort measures only and he was
called out of the surgical intensive care unit to the floor. He
was subsequently discharged to hospice care.
CV: Ruled out myocardial infarction. EKG notable for first
degree AV block and sinus bradycardia without priors for
comparison. Continued cardiac telemetry while in ICU. Goal SBP
< 160, MAP < 130 and gave metoprolol standing and hydralazine as
needed. Continued lipitor 10mg QD.
PULM: Patient did not require intubation.
FEN: Patient was kept nothing per mouth as aspiration precaution
and family declined nasogastric tube feedings. His serum sodium
downtrended to 127 and he was fluid restrict and treated with
hypertonic 3% saline at a slow rate with good result.
PPX: PPI, Insulin SS, maintain euthermia, boots, bowel regimen
Medications on Admission:
Aspirin 81 mg daily
Beta blocker
Lipitor
Targretin
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever, pain.
Disp:*60 Suppository(s)* Refills:*0*
2. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for secretions.
Disp:*10 Patch 72HR(s)* Refills:*0*
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
secretions.
Disp:*60 Tablet, Sublingual(s)* Refills:*0*
4. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO Q1H (every
hour) as needed for agitation.
Disp:*30 mg* Refills:*0*
5. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-1 mL PO Q2-3H
as needed for pain.
Disp:*25 mL* Refills:*0*
6. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
Disp:*30 suppositories* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1121**] VNA
Discharge Diagnosis:
Left external capsular bleed
Intraventricular hemorrhage
Discharge Condition:
Responsive with movement to noxious stimuli, some spontaneous
left sided movement, no speech or eye opening, follows no
commands.
Discharge Instructions:
Takes medications as needed.
Call your PCP with any concerns.
Followup Instructions:
With PCP as needed.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2192-1-11**] |
43310,39891,3963,40391,70715,53081,2720,25000,4148 | 83 | 158,569 | Admission Date: [**2142-4-1**] Discharge Date: [**2142-4-8**]
Date of Birth: [**2076-9-15**] Sex: F
Service: C MEDICINE
HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old female
with a past medical history of coronary artery disease,
status post CABG, ischemic cardiomyopathy with an EF of 20%,
status post left parietal CVA, and bilateral carotid aortic
stenosis, status post left CEA, who was transferred from an
outside hospital for right carotid artery stenting.
At the outside hospital, the patient was treated for CHF
exacerbation with successful diuresis. Her hospital course
at that time was complicated by nausea, vomiting, with
elevated alkaline phosphatase and GGT status post right upper
quadrant ultrasound without evidence of stones or ductal
dilatation with trace ascites. GI was consulted with
assessment of CHF versus possible gastritis.
A second complication included right MTP ulcers, status post
debridement. No evidence of osteomyelitis. This was treated
with Keflex for a ten day course.
The next issue included acute on chronic renal failure with
creatinine peak at 2.8, BUN 71. Renal consult for this felt
that it was believed to be due to worsened CHF.
On presentation, the patient reported minimal shortness of
breath with significant fatigue and weakness. She denied
chest pain, abdominal pain, orthopnea, PND, or fever and
chills.
REVIEW OF SYSTEMS: Pertinent for chronic nausea for weeks
with intermittent vomiting.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post CABG in [**2136**].
2. Status post catheterization in [**2141-11-7**] with
patent graft.
3. Ischemic cardiomyopathy with an EF of 22% with basal mid
inferior, posterior hypokinesis.
4. Bilateral carotid artery stenosis, status post left CEA.
5. Left parietal CVA.
6. Type 2 diabetes mellitus.
7. Chronic renal insufficiency.
8. Hypercholesterolemia.
9. Hypertension.
10. Status post cholecystectomy and total abdominal
hysterectomy.
11. GERD, positive H. pylori.
ALLERGIES: Question of an ACE inhibitor causing RTA.
ADMISSION MEDICATIONS:
1. Lasix 160 mg p.o. q.d.
2. Zaroxolyn 5 mg p.o. q.d.
3. Nitroglycerin paste two inches q. six hours.
4. Coreg 12.5 mg b.i.d.
5. Hydralazine 25 mg p.o. q.i.d.
6. Plavix 75 mg p.o. q.d.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d.
8. Keflex 500 mg p.o. t.i.d.
9. Glucotrol XL 5 mg q.d.
10. ECASA 81 mg p.o. q.d.
11. Zoloft 25 mg p.o. q.d.
12. Bactroban cream b.i.d. to feet.
SOCIAL HISTORY: The patient is married. She has a prior
tobacco history of 40 plus years for one to two packs per
day, quit a month ago. Denied ethanol or illicit drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.0, BP 142/56, heart rate 50, respiratory rate 22, SP02 93%
on 2 liters. General: The patient was in no acute distress,
a pleasant female who appeared chronically ill. HEENT:
Normocephalic, atraumatic. Surgical left pupil. Extraocular
movements intact. Moist mucous membranes. Clear oropharynx.
Neck: Supple, no lymphadenopathy, positive JVP. Pulmonary:
Decreased breath sounds one-fourth of the way up on the
right. No wheeze. Cardiovascular: Regular rate and rhythm
with S3 and a II/VI systolic murmur at the left lower sternal
border. Abdomen: Soft, obese, bowel sounds positive,
positive hepatomegaly. Extremities: No edema. The right
MTP revealed a shallow-based ulcer, 1+ DP pulses on the
right. The left MTP showed a healing ulcer, 1+ DP pulses on
the left. Neurological: The patient was awake, alert, and
oriented. Cranial nerves II through XII were intact. The
patient was noted to be diffusely weak, right upper extremity
[**5-12**], deltoid, biceps, triceps, sensation diminished to light
and pinprick, stocking glove distribution.
ADMISSION LABORATORY DATA/STUDIES: The EKG showed sinus
bradycardia at 52 beats per minute with leftward axis. There
were T wave inversions in the anterolateral leads and [**Street Address(2) 4793**]
depression also in the anterolateral leads which were
unchanged from [**2142-3-21**].
The admission laboratories were pertinent for a hematocrit of
32.4. Sodium 140, potassium 3.6, chloride 87, bicarbonate
40, BUN 60, creatinine 2.6, glucose 69.
Chest x-ray showed cardiomegaly and mild failure.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service and ruled out for a myocardial infarction. She
continued diuresis until her baseline weight. The day after
admission, the patient underwent stenting and PTA of the
right ICA with good results.
Post procedure, the patient had a hematocrit drop and was
given 1 unit of packed red blood cells to return to greater
than 30. Also, postoperatively, the patient had episodes of
bradycardia to the 40s. This was due to the procedure being
near the carotid body. She was asymptomatic when this rate
drops. Also of note, the patient's creatinine increased to
3.4.
The patient appeared intravascularly depleted and she was
given IV fluid hydration.
DISCHARGE DIAGNOSIS:
1. Right internal carotid artery stenosis, status post
stent.
2. Chronic renal failure.
DISPOSITION: The patient was discharged to home with VNA
Services. Of note, the patient refused rehabilitation.
DISCHARGE MEDICATIONS:
1. Isosorbide mononitrate 30 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Pyracin calcium 2% cream applied topically b.i.d.
5. Fluoxetine 20 mg p.o. q.d.
6. Prochlorperazine malleate 10 mg p.o. q. six hours p.r.n.
nausea.
7. Glucotrol XL 5 mg p.o. q.d.
8. Hydralazine 25 mg p.o. q. six hours.
9. Lasix 40 mg p.o. q.d.
10. Carvedilol 3.125 mg p.o. b.i.d.
11. Zantac 150 mg q.h.s.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on
Wednesday on [**2142-4-11**] and follow-up with her primary
care physician in one week.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**First Name (STitle) 36870**]
MEDQUIST36
D: [**2142-4-7**] 08:42
T: [**2142-4-8**] 14:58
JOB#: [**Job Number 41437**]
|
1919 | 84 | 120,969 | Admission Date: [**2196-2-2**] Discharge Date: [**2196-2-4**]
Date of Birth: [**2151-10-21**] Sex: F
Service:
NOTE: Originally admitted overnight on [**1-12**] and
discharged on [**1-13**], and readmitted on [**2-2**] for
further treatment.
CHIEF COMPLAINT: Headaches times seven to eight weeks.
HISTORY OF PRESENT ILLNESS: This is a 44-year-old
right-handed white female who presents with a history of
seven to eight days with global headache and new onset of
nausea with vomiting times one on the morning of admission on
[**1-12**]. She called her primary care physician and was
seen and evaluated at the [**Hospital 1474**] Hospital with a workup
including a head CT and magnetic resonance imaging scan
positive for a 2.5-inch tumor in the left parietal region
with moderate surrounding edema.
The patient came to the Emergency Room at the [**Hospital1 346**] at that time and was admitted
overnight for further evaluation and was subsequently
discharged home with 24 hours, and is now readmitted on
[**2-2**] for definitive surgical treatment of this lesion.
She reports that in retrospect she has felt occasional vague
weakness, and vague occasional dizziness, and "just not
right" for the past three to five weeks. She also noted that
it would take her longer to calculate and balance her
checkbook or to do simple mathematics. She denies any visual
changes or impairments to vision or hearing. She denies any
weakness, numbness or paresthesias of the arms or legs.
PAST MEDICAL HISTORY: (Previous medical history includes)
1. A tubal ligation.
2. She is gravida 2, para 2 with both pregnancies completing
normal spontaneous vaginal deliveries.
MEDICATIONS ON ADMISSION: She is on no current medications.
ALLERGIES: Reports an allergic reaction to TETANUS in the
past.
REVIEW OF SYSTEMS: Review of systems was unremarkable and
noncontributory.
SOCIAL HISTORY: She is a nonsmoker with a negative alcohol
history. She is a married woman with a supportive family.
She works part time at a local restaurant.
FAMILY HISTORY: Mother had epilepsy and breast cancer.
Father had a history of cancer.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination she was afebrile with stable vital signs, and
oxygen saturation was 99% on room air. She was a
well-developed, well-nourished white female in no acute
distress. The examination of the head, ears, nose, eyes and
throat, heart, lungs, and abdomen were essentially
unremarkable. There was no clubbing, cyanosis or edema of
the extremities. The neurologic examination showed the
patient to be awake, alert, and conversant, and oriented
times three with speech fluent and no dysnomia or paraphrasic
errors. Pupils were equal, round, and reactive to light and
accommodation. Extraocular movements were intact. Visual
fields were full to confrontation. The tongue was midline.
The smile was equal. The face was symmetric, and there was
no drift. Strength showed full 5/5 strength in all muscle
groups of the bilateral upper and lower extremities. Sensory
examination was intact to light touch, pinprick and
proprioception. The deep tendon reflexes were 2+ throughout
with plantar responses downgoing bilaterally. There was no
ankle clonus, and finger-to-nose test was intact without any
dysmetric movements.
RADIOLOGY/IMAGING: The CT from the outside hospital and the
magnetic resonance imaging done at the [**Hospital1 190**] confirmed the presence of a 4-cm X 5-cm
irregular shaped enhancing lesion with central necrosis and
surrounding edema located in the medial left posterior
parietal area with some lateral deviation and compression of
the posterior [**Doctor Last Name 534**] of the ventricle.
HOSPITAL COURSE: The impression was that of a 44-year-old
right-handed white female with headaches times seven to eight
days, and studies positive for a lesion in the posterior and
medial parietal area, and she was therefore admitted on
[**2-2**] for craniotomy and excision of this lesion.
She was taken to the operating room on the morning of
admission where under general endotracheal anesthesia the
patient underwent a left parietal craniotomy with resection
of lesion. The patient tolerated the procedure well. The
tumor specimen was given to the pathologist with frozen
section showing a high-grade astrocytoma.
The patient tolerated the procedure well and was taken to the
Postanesthesia Care Unit in stable condition. She spent the
first night in the Postanesthesia Care Unit with
postoperative check showing the patient to be neurologically
stable and was subsequently discharged to the hospital floor
on the first postoperative day, and subsequently to that was
noted to be ambulating with minimal discomfort and minimal
headache. She was taking solid food and liquids by mouth
without difficulty. Her intake and output was considered
quite adequate. Then she was subsequently discharged to home
with arrangements to be followed up in the Brain [**Hospital 341**] Clinic
in approximately two weeks' time.
CONDITION AT DISCHARGE: Condition on discharge was stable
and improved.
DISCHARGE DIAGNOSES: A left parietal brain tumor.
MEDICATIONS ON DISCHARGE: Medications on discharge included
Decadron and Zantac, and she was given a prescription for
Percocet for relief of mild headache.
DISCHARGE FOLLOWUP: She was given an appointment for
followup in the Brain [**Hospital 341**] Clinic in early [**Month (only) 956**] with
plans for probable radiotherapy to the tumor bed.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2196-2-18**] 11:49
T: [**2196-2-20**] 05:41
JOB#: [**Job Number 37532**]
|
99591,V433,V4581,V1079,3051,3320,32723,78843,60001,2449,2724,3004,41400,42731,23875,486,5853,V4281,0389 | 85 | 112,077 | Admission Date: [**2167-7-25**] Discharge Date: [**2167-7-30**]
Date of Birth: [**2090-9-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Weakness/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia,
non-hodgkins lymphoma, and Parkinson's who was relaeased from
the hospital 2 months ago for a pneumonia. He brought in from
his ECF because of fever to 105 and new weakness, and sob. He
says he has had a cough and SOB for the last few weeks. Today he
was unable to get up and go to the bathroom. He denies any
fevers prior to today. He denies any pains including chest and
abdominal pain. In the ED a CXR showed possible RLL PNA versus
atelectasis. His UA was neg, he got 3 sets of blood cultures. He
was given Vanc/zosyn/azithro in the ED for emperic coverage of a
HCAP, tylenol 325 after 650 earlier in the day for his fever and
4L of IVF. His EKG showed sinus tachycardia in the ED.
On arrival to the MICU,
in rigors, not febrile at this time, has cough, no pain.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. 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. AS s/p porcine Aortic Valve Replacement ([**2162-3-3**])
2. CAD s/p CABG x 2 (LIMA to LAD, SVG to OM [**2162-3-3**])
3. CKD
4. Depression / anxiety, currently treated only with diazepam
qhs. Previously on Effexor and benzo and Seroquel (stopped in
[**2157**] due to EPS/?PD)
5. hyperlipidemia on crestor
6. Hypothyrodism
7. Tremor
8. Gait disorder, thought by Dr. [**Last Name (STitle) **] to be primarily due to
posterior column dysfunction
9. BPH s/p TURP, no longer on Flomax; nocturia x hourly
10. non-Hodgkin's Lymphoma s/p chemo/BMT @OSH was in remission
until current thrombocytonia
11. OSA on prior sleep study; pt refuses CPAP; wife says no
snoring. M-III to M-IV airway, with extra neck soft tissues.
Social History:
Married, kids in CA (just visited, as above), lives with wife.
Retired from cigarette sales ~15y ago.Chronic/progressive health
problems as above. Smoked heavily in military ~50y ago, but quit
cigs and now smokes occasional cigars "do not inhale" for many
years. Says 1-2 beers per night, but formerly drank heavily (up
to ~15 years ago when he retired). Denies any h/o illicit drug
use or supplements.
Family History:
Non-contributory
Physical Exam:
Admission Exam:
Vitals: T: 98.6 BP: 166/87 P: 136 R: 39 O2: 99
General: Alert, rigors
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Tachycardic, crisp S1, s2, no rubs, gallops
Lungs: Scattered wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
Pertinent Results:
[**2167-7-25**] 04:50PM WBC-6.9# RBC-3.59* HGB-10.4* HCT-32.3*
MCV-90# MCH-29.1# MCHC-32.2 RDW-22.5*
[**2167-7-25**] 04:50PM NEUTS-57 BANDS-4 LYMPHS-23 MONOS-11 EOS-0
BASOS-0 ATYPS-4* METAS-0 MYELOS-0 BLASTS-1* NUC RBCS-1*
[**2167-7-25**] 04:50PM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2167-7-25**] 04:50PM PLT SMR-VERY LOW PLT COUNT-31*
[**2167-7-25**] 04:50PM PT-13.6* PTT-28.1 INR(PT)-1.3*
[**2167-7-25**] 04:50PM CALCIUM-8.7 PHOSPHATE-1.2*# MAGNESIUM-1.8
[**2167-7-25**] 04:50PM CK-MB-1 cTropnT-<0.01
[**2167-7-25**] 04:50PM CK(CPK)-71
[**2167-7-25**] 04:50PM GLUCOSE-113* UREA N-22* CREAT-1.4* SODIUM-133
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
[**2167-7-25**] 05:04PM LACTATE-0.9
[**2167-7-25**] 06:30PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2167-7-25**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-7-25**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2167-7-25**] 06:30PM URINE UHOLD-HOLD
[**2167-7-25**] 06:30PM URINE HOURS-RANDOM
CXR [**7-25**] PA and lateral
The patient is status post median sternotomy for CABG. Heart
remains mildly enlarged with left ventricular predominance. The
patient is status post aortic valve replacement. The
mediastinal contours are unchanged, with mild calcification of
the aortic knob again demonstrated as well as a mildly tortuous
course of the thoracic aorta. The pulmonary vascularity is not
engorged. Streaky opacities in the lung bases are nonspecific,
possibly reflecting atelectasis though infection cannot be
excluded. No pleural effusion or pneumothorax is visualized.
There are no acute osseous abnormalities.
IMPRESSION:
Streaky bibasilar opacities, which could reflect atelectasis
though infection cannot be completely excluded.
Brief Hospital Course:
76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia,
non-hodgkins lymphoma, and Parkinson's who was relaeased from
the hospital 2 months ago for a pneumonia who returns with a
HCAP and new a. fib w/ rvr. Was treated in the ICU and
transferred to the floor to complete 10 day course of
antibiotics.
1) HCAP pneumonia/sepsis- Pt initially sirs criteria, and
presented with dry cough x2 weeks, new weakness, and his CXR was
concerning for a new RLL inflitate. With the pt's history of
Parkinson's disease, was at risk for aspiration due to
dysphagia, and thus cause recurrent pneumonia. Pt's fever curve
improved with vancomycin, cefepime and azithromycin for a 10 day
course (through [**2167-8-6**]). Blood cultures were negative. Pt's dry
cough did not improve with cough syrup, tessalon perles and
nebulizer treatments and thus had an ENT consult which found
mild irritation of vocal cords most likely related to acid
reflux or viral infection. Laryngoscopy did not show vocal cord
paralysis and structurally normal. Cough mildly improved while
on the floor, but still with significant cough at discharge. He
was started on prednisone 40 mg PO daily for a 4 day total
course to end on [**2167-8-2**].
2) New Atrial fib w/ rvr in 120s likely due to stress of
increasing cardic output in septic picture. Other concerns
included his thyroid medicine and new ischemia but TSH normal
and cardiac enzymes were negative. Pt was rate controlled with
metoprolol 50mg TID and was successfully converted to NS rhythm.
Echo was done which showed LVEF>55%, no thrombus. Pt's CHADS2
score at 1. Aspirin was held due to thrombocytopenia.
Metoprolol was discontinued given his reactive airways and
wheezing. On stopping, patient tended to be borderline
tachyardia with intermittent atrial fibrillation and bigeminal
PACs. When his pulmonary symptoms resolve, metoprolol should be
considered if his tachycardia/afib persists at rehab.
3) Parkinson's disease: Was continued on home pramipexole during
course and was evaluated by speech and swallow for dysphagia; pt
was cleared for regular solid PO intake.
4) MDS/Non-Hodgkin's lymphoma: s/p chemo and BMT, chronic
thrombocytopenia. Pt had no bleeding issues. Patient required
transfusion of 1 unit of platelets prior to PICC line placement
but otherwised remained above transfusion threshold without
evidence of bleeding.
5) Hyperlipidemia: Rosuvastatin was continued throughout course.
6) BPH: Tamsulosin was continued throughout course.
7) Depression/Anxiety: Stable, PRN diazepam. Was requiring
approximately one additional dose of diazepam daily.
8) Hypothyroid: continue home Levothyroxine Sodium 50 mcg PO
DAILY. TSH normal.
9) Left ear ceurmen: Stable.
10) Constipation: Continued Lactulose, Polyethylene Glycol,
Docusate Sodium 100 mg PO BID, and Senna 1 TAB PO BID.
# Transitional issues:
- Consider starting patient on metoprolol for new atrial
fibrillation, was started in house, then discontinued given
reactive airways. Should be restarted if he continues to have
tachycardia/afib once pulm symptoms resolve.
- Patient should continue full treatment for HCAP with
vancomycin 1g IV Q12 and Cefepime 2 g IV Q12H through is PICC
line, both through [**2167-8-6**].
- PICC line okay to use by nursing staff at rehab. CXR confirmed
placement on [**7-29**] and has been used here.
- Patient started on prednisone 40 mg PO daily for reactive
airways, which should continue through [**8-2**].
- Patient started on high dose PPI while in house given ENT
evaluation of laryngeal inflammation from possible reflux. This
should be discussed with PCP and [**Name9 (PRE) 31042**] in 2 weeks.
Continued high dose PPI has multiple risks and these should be
weighed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Record.
1. Diazepam 5 mg PO DAILY:PRN anxiety
2. Lactulose 15 mL PO DAILY constipation
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever
6. Codeine Sulfate 15-30 mg PO Q4H cough
7. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough
8. Benzonatate 200 mg PO TID:PRN cough
9. Docusate Sodium 100 mg PO BID
10. Senna 1 TAB PO BID
11. pramipexole *NF* 0.5 mg Oral TID Parkinson's
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
13. Levofloxacin 500 mg PO Q24H PNA Duration: 13 Days
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Tamsulosin 0.4 mg PO HS BPH
16. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days
Left ear at bedtime
17. Rosuvastatin Calcium 10 mg PO DAILY
Discharge Medications:
1. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days
Left ear at bedtime
2. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
4. Benzonatate 200 mg PO TID:PRN cough
5. Codeine Sulfate 15-30 mg PO Q4H cough
6. Diazepam 5 mg PO DAILY:PRN anxiety
7. Docusate Sodium 100 mg PO BID
8. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough
9. Lactulose 15 mL PO DAILY constipation
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. pramipexole *NF* 0.5 mg Oral TID Parkinson's
14. Rosuvastatin Calcium 10 mg PO DAILY
15. Senna 1 TAB PO BID
16. Tamsulosin 0.4 mg PO HS BPH
17. CefePIME 2 g IV Q12H
Continue through [**8-6**].
18. Vancomycin 1000 mg IV Q 12H
Continue through [**8-6**].
19. PredniSONE 40 mg PO DAILY Duration: 3 Days
Continue through [**8-2**].
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Primary:
Health care associated pneumonia
New atrial fibrillation
Secondary:
Myelodysplastic syndrome
Thrombocytopenia
Discharge Condition:
Patient is afebrile with stable vitals. Satting mid 90s on RA.
He is in and out of a fib and borderline tachycardic in the
90s-100s. Lung exam with inspiratory and expiratory wheezing
and transmitted upper airway sounds, breathing is nonlabored.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - With walker or aid.
Discharge Instructions:
Dear Mr. [**Known lastname 35501**],
You were admitted to the [**Hospital1 69**]
for symptoms concerning for pneumonia. We treated your pneumonia
with antibiotics and your fevers resolved. You will need to
continue taking antibiotics at the rehab facility. A PICC line
was placed in your left arm and it's placement was confirmed
with an x-ray, so your antibiotics can be given at rehab. You
were also started on steroids (prednisone) for a total of 5 days
to help with your breathing.
It was a pleasure taking care of you at the [**Hospital1 18**].
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2167-8-6**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appt with Dr. [**Last Name (STitle) 35507**] at [**Hospital 10596**]. You will be called at home/rehab with the appointment.
If you have not heard or have questions, please call ([**Telephone/Fax (1) 35513**].
Department: DERMATOLOGY
When: MONDAY [**2167-8-17**] at 9:30 AM
With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2167-10-15**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2167-11-25**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2167-7-30**] |
4412,41401,E8798,60000,53081,30000,3320,99811,V4282,20280,4241 | 85 | 116,630 | Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-10**]
Date of Birth: [**2090-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2162-3-2**] Cardiac Catheterization
[**2162-3-3**] Aortic Valve Replacement (29mm CE pericardial valve),
Ascending Aorta Replacement (28mm gelweave graft), Coronary
Artery Bypass Graft x 2 (LIMA to LAD, SVG to OM)
History of Present Illness:
71 y/o male who has been followed by cardiologist for years for
asymptomatic aortic stenosis. [**Month/Day/Year **] stress test to determine
his functional capacity, d/t cardiologist concerned if his
Parkinson's could be masking symptoms of aortic stenosis. No EKG
changes, but after 46 seconds his BP dropped from 110/70 to
98/70 and the test was stopped. Echo did reveal severe aortic
stenosis with a bicuspid valve. In terms of symptoms he does
feel fatigued with dyspnea on exertion occuring after [**1-12**] block.
Referred for cardiac cath to further evaluate.
Past Medical History:
Aortic Stenosis, Parkinson's Disease, non-Hodgkin's Lymphoma s/p
chemo and stem cell transplant (in remission), Anxiety,
Gastroesophageal Reflux Disease, Benign Prostatic Hypertrophy
s/p TURP
Social History:
Married, does not work. Denies ETOH or Tobacco use.
Family History:
Non-contributory
Physical Exam:
VS: 92 16 104/71 6'2" 180#
Gen: NAD
Skin: Unremarkable
HEENT: EOMI, PEERL, NC/AT
Neck: Supple, FROM, -JVD, -Bruits
Chest: CTAB -w/r/r
Heart: RRR 2/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE
Discharge
Neuro Alert, oriented x3, MAE r=l strength no tremors
Pulm CTA decreased at bases bilat
Cardiac RRR no M/R/G
Abd Soft, nt, nd +BS
Sternal inc midline healing no drainage/erythema steris sternum
stable
Leg inc Left EVH steris no erythema/drainage
Ext warm +1 edema, pulses palpable
Pertinent Results:
[**2162-3-2**] CNIS: On the right, peak velocities are 65, 60, and 53
cm/sec in the ICA, CCA, and ECA respectively. This is consistent
with no stenosis. On the left, peak velocities are 50, 71, and
40 cm/sec in the ICA, CCA, and ECA respectively. This is
consistent with no stenosis.
[**2162-3-2**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system demonstrated a two vessel CAD. The LMCA
was patent. The LAD had a 70% proximal and a 90% mid vessel
stenoses. The LCx was patent but there was an 80% stenosis in
the OM1. The RCA had mild nonflow limiting disease. 2. Resting
hemodynamics revealed normal right and left sided filling
pressures with an RVEDP of 8 mm Hg and a mean PCWP of 10 mm Hg.
The cardiac index was preserved at 2.33 l/min/m2. 3. Left
ventriculography was deferred. 4. There was a severe aortic
stenosis with a peak to peak gradient of 45.89 mm Hg and a
calculated [**Location (un) 109**] of 0.62 cm2. 5. Peripheral angiography
demonstrated no right iliac disease. 6. Short run of SVT during
the case that terminated spontaneously.
[**2162-3-3**] Echo: PRE-BYPASS: 1. The left atrium is normal in size.
No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. 2. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). 3. Right ventricular chamber size and free wall
motion are normal. 4. The aortic root is mildly dilated at the
sinus level. The sino-tubular junction is preserved. The
ascending aorta is moderately dilated. The aortic arch is mildly
dilated. There are complex (>4mm) atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. 5. The aortic
valve is bicuspid. The aortic valve leaflets are severely
thickened/deformed and extremely calcified. There is severe
aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation
is seen. 6. The mitral valve leaflets are mildly thickened.
Trace to Mild (1+)mitral regurgitation is seen. POST-BYPASS: Pt
is being atrially paced and is on an infusion of phenylephrine
1. AV bioprosthesis well seated in good position. No significant
perivalvular gradient. Trace central valvular AI is noted, no
perivalvular leak seen. Aortic graft noted in ascending aorta.
2. No wall motion abn noted, maintained LV and RV function 3.
Aortic contours unchanged 4. Remaining exam unchanged
[**2162-3-4**] UE U/S: Grayscale and Doppler images of the left IJ,
subclavian, axillary, brachial, basilic, and cephalic veins were
performed. Normal flow, augmentation, compressibility, and
waveforms are demonstrated. Intraluminal thrombus is not
identified.
[**2162-3-2**] 07:40AM BLOOD WBC-5.4# RBC-4.23* Hgb-12.8* Hct-35.8*
MCV-85 MCH-30.2 MCHC-35.6* RDW-15.0 Plt Ct-133*
[**2162-3-3**] 03:34PM BLOOD WBC-6.4 RBC-2.24* Hgb-6.8* Hct-19.9*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.8 Plt Ct-172#
[**2162-3-7**] 05:45AM BLOOD WBC-6.2 RBC-4.08* Hgb-12.0* Hct-35.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 Plt Ct-133*
[**2162-3-2**] 07:40AM BLOOD PT-12.7 INR(PT)-1.1
[**2162-3-5**] 03:08AM BLOOD PT-12.8 PTT-32.0 INR(PT)-1.1
[**2162-3-2**] 07:40AM BLOOD Glucose-104 UreaN-27* Creat-1.2 Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
[**2162-3-7**] 05:45AM BLOOD Glucose-90 UreaN-28* Creat-1.2 Na-136
K-4.0 Cl-101 HCO3-28 AnGap-11
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 35501**] [**Last Name (Titles) 1834**] a cardiac cath on
[**2162-3-2**]. Cardiac cath revealed severe aortic stenosis along with
2 vessel coronary artery disease and a dilated ascending aorta.
He was then referred for surgical evaluation. [**Date Range **] all
pre-operative testing and was brought to the operating room on
[**2162-3-3**]. He [**Date Range 1834**] an Aortic Valve Replacement, Asc. Aorta
Replacement, and Coronary Artery Bypass Graft x 2. Please see
operative report for surgical details. He did have significant
amount of post-op bleeding that required multiple blood
products. Following surgery he was transferred to the CSRU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation awoke neurologically intact and extubated.
On post-op day one there appeared to be left arm edema with
bluish discoloration and left-sided neck bulge. All left arm
peripheral IV's and arterial line were removed, vascular surgery
was consulted and an upper extremity ultrasound was performed.
Ultrasound was negative for DVT. His chest tubes and epicardial
pacing wires were removed per protocol. Diuretics and
beta-blockers were initiated and he was gently diuresed towards
his pre-op weight. On post-op day two he was transferred to the
telemetry floor. He continued to improve post-operatively and
worked with PT for strength and mobility. Left arm swelling and
neck bulge has resolved. Clinically he appeared to be doing
well but needed additional PT and was discharged to rehab
facility on post-op day seven.
Medications on Admission:
Primidone 150mg qhs, Mirapex 0.5mg TID, Diazepam 4mg [**Hospital1 **],
Zyprexa 5mg qhs, Omeprazole 20mg prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis, Asc. Aortic Aneurysm, Coronary Artery Disease
s/p Aortic Valve Replacement, Asc. Aorta Replacement, Coronary
Artery Bypass Graft x 2
PMH: Parkinson's Disease, non-Hodgkin's Lymphoma s/p chemo and
stem cell transplant (in remission), Anxiety, Gastroesophageal
Reflux Disease, Benign Prostatic Hypertrophy s/p TURP
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) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 10548**]
Dr. [**Last Name (STitle) 22741**] after discharge from rehab [**Telephone/Fax (1) 35502**]
Please call to schedule all appointments
Completed by:[**2162-3-10**] |
4240,74561 | 86 | 190,243 | Admission Date: [**2146-4-6**] Discharge Date: [**2146-4-10**]
Date of Birth: [**2100-12-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exerion and intermittent palpitations
Major Surgical or Invasive Procedure:
Mitral Valve repair with 30mm ring and closure of ASD with
pericardial patch
History of Present Illness:
This 45 year old patient with a known heart murmur as a child
recently developed shortness of breath and palpitation and was
investigated and was found to have primum atrial septal defect
with a cleft mitral valve leaflet with a mild mitral
regurgitation and mild tricuspid regurgitation with right
ventricular dilation. In view of this finding, she was
electively admitted for surgical repair.
Past Medical History:
h/o R Breast Cancer s/p lumpectomy and XRT [**2138**] with breast
reconstruction left Breast reduction
Social History:
Denies Tobacco or ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 135/85 70 98%RA
General: WD/WN female in NAD
Skin: Warm, pink, well-perfused
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD or thyromegaly
Lungs: CTAB -w/r/r
Heart: RRR +S1S2 w/ 2/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, -c/c/e, 2+ pulses
Pertinent Results:
Echo [**4-6**]: The left atrium is markedly dilated. The right atrium
is moderately dilated. A left-to-right shunt across the
interatrial septum is seen at rest. A primum atrial septal
defect is present. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is moderately
dilated. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. POST CPB: A prosthetic
patch is visualized on the IAS, at the position of the primum
defect with no residual shunt on CFD. An annuloplasty ring is
seen in the mitral annular position, which is well seated and
mecahnically stable. Peak gradient across the mitral valve = 16
mm. Hg. Mean gradient 7 mm Hg. Mitral valve area by continuity
equation was consistently obtained to be 2-2.4 sq.cms. Mitral
valve area by planimetry of the mitral leaflets was 3 sq. cms.
Preserved bivertricular systolic function.
CXR [**4-9**]: 1. Decreasing right apical pneumothorax. 2. Worsening
bibasilar opacities, likely due to atelectasis, although
differential includes aspiration and infectious pneumonia.
[**2146-4-6**] 03:23PM BLOOD WBC-13.0*# RBC-2.73*# Hgb-8.0*#
Hct-23.3*# MCV-85 MCH-29.3 MCHC-34.4 RDW-13.2 Plt Ct-191
[**2146-4-8**] 07:25AM BLOOD WBC-7.3 RBC-2.44* Hgb-7.0* Hct-20.7*
MCV-85 MCH-28.9 MCHC-34.0 RDW-13.9 Plt Ct-156
[**2146-4-10**] 04:45AM BLOOD Hct-19.3*
[**2146-4-6**] 05:20PM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.3*
[**2146-4-7**] 03:45AM BLOOD PT-13.8* PTT-25.5 INR(PT)-1.2*
[**2146-4-6**] 05:20PM BLOOD UreaN-9 Creat-0.6 Cl-110* HCO3-21*
[**2146-4-8**] 07:25AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-135
K-3.8 Cl-103 HCO3-26 AnGap-10
[**2146-4-10**] 04:45AM BLOOD UreaN-8 Creat-0.6 Na-135 K-4.2
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname **] was electively admitted
for surgery following out-patient pre-operative work-up. She was
brought to the operating room on [**4-6**] where she underwent a
repair of her mitral valve and closure of a ASD y Dr. [**Last Name (Prefixes) **]. Please see operative report for surgical details. She was
then transferred to the CSRU on minimal BP support for invasive
monitoring. Later on op day she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day tow her
chest tubes were removed and she was weaned off Neo-Synephrine.
She was then transferred to the cardiac surgery step down floor.
Both beta blockers and diuretics were started and she was gently
diuresed towards her pre-operative weight. Both Vitamin C and
Iron were started secondary to patient being anemic (although
asymptomatic so wasn't transfused). Epicardial pacing wires were
removed on post-op day three. Physical therapy followed patient
during post-op course for strength and mobility. She continued
to improved post-operative with stable labs, vital signs and
physical exam on day of discharge. She was discharged home on
post-op day 4 with VNA services and the appropriated follow-up
appointments.
Medications on Admission:
Aspirin, Lisinopril
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CAPITOL VNA
Discharge Diagnosis:
Mitral Regurgitation/Atrial Septal Defect (ASD) s/p Mitral Valve
Repair and closure of ASD Repair
h/o R Breast Cancer s/p lumpectomy and XRT [**2138**] with breast
reconstruction
left Breast reduction
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in four weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 64623**] in two weeks [**Telephone/Fax (1) 64624**]
Dr. [**Last Name (STitle) 39450**] in two weeks [**Telephone/Fax (1) 64625**]
Completed by:[**2146-5-24**] |
7775,7707,769,7742,76524,76515,V3101,77211,77081,7766,V290,V053 | 87 | 190,659 | Admission Date: [**2191-2-25**] Discharge Date: [**2191-4-25**]
Date of Birth: [**2191-2-25**] Sex: M
Service: NB
IDENTIFCATION: Baby [**Name (NI) **] [**Known lastname 4068**] is a 59 day old former 27 [**6-15**] wk
twin with a history of mild BPD and necrotizing enterocolitis,
being transferred from [**Hospital1 18**] NICU to [**Hospital 1474**] Hospital.
HISTORY: Baby [**Name (NI) **] [**Known lastname 4068**] was born weighing 1275 g at 27-6/7
weeks gestation. He is twin #1 who was admitted to the NICU
for management of prematurity. This infant was born to a 35-
year-old G5, P3, now 5 mother. Prenatal screens were blood
type A negative, antibody positive for anti-[**Doctor First Name **] antibody,
HBsAG negative, RPR nonreactive, rubella immune, GBS
negative. This pregnancy was complicated by spontaneous twin
gestation, preterm labor, and positive PPD with negative
chest x-ray. Mother was admitted on [**2191-1-28**] at [**Hospital1 18**]
and received IV magnesium sulfate and betamethasone x2 doses.
She was discharged shortly thereafter. She presented to
[**Hospital 1474**] Hospital and was transferred to [**Hospital1 18**] in active
labor on the day of delivery. Maternal medications were
isoniazid and vitamin B6 for PPD. Prenatal sepsis risk
factors include prematurity and multiple gestation. No maternal
fever. Ruptured membranes less than 24 hours. No fetal
tachycardia. Maternal anesthesia by spinal. Infant was
delivered by cesarean section. Apgars of 8 and 9.
EXAMINATION ON ADMISSION: Weight was 1275 g which is 75th
percentile, length 36.5 cm which is 25th-50th percentile,
head circumference 27 cm which is 50th-75th percentile. A
nondysmorphic infant, anterior fontanelle soft and flat. Red
reflex was difficult to assess as appears to still have
membrane covering bilaterally. Ears - normal set. Palate -
intact. Clavicles - intact. Lungs with initial poor aeration
and retractions. After intubation, breath sounds much
improved with decreased retractions. CV - normal rate and
rhythm, no murmur, 2+ femoral pulses. Abdomen - soft,
positive bowel sounds, no hepatosplenomegaly. GU - normal
preterm male and testes down bilaterally. Patent anus. Sacral
and back anomalies not present. Hips are stable. Extremities
- pink and well-perfused.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: The infant presented with respiratory distress
syndrome on admission to the NICU, and was intubated and given
2 doses of Surfactant. He was able to be extubated to CPAP by
day of life [**1-10**], but required treatment with CPAP through [**2191-4-5**] (day of life 39) when he successfully weaned to a
nasal cannula. Oxygen requirement on CPAP was generally 21-30%.
He weaned to room air successfully on [**2191-4-7**] which was day of life 41 and he has remained on room
air since that time. He was treated for apnea of prematurity
starting on day of life 1 with caffeine citrate in
preparation for extubation. He remained on caffeine through
[**2191-4-12**], which was day of life 46. He has had no
apnea or bradycardic episodes since [**2191-4-15**]. Given
prolonged requirement for CPAP and nasal cannula, course is
consistent with mild BPD.
Cardiovascular: The infant was hemodynamically stable on
admission, without need for blood pressure support or evidence of
a significant PDA. An intermittent murmur has been noted over
the last several weeks of hospitalization. X-ray revealed normal
heart size, EKG on [**4-21**] was unremarkable, and 4-extremity
blood pressures were within normal limits. The murmur is most
likely a physiologic flow murmur, and can be followed clinically
at this time.
Fluids, Electrolytes and Nutrition: A UAC was placed on
admission to the NICU and a peripheral IV. The infant
received IV fluids and remained NPO until enteral feedings
were started on day of life 3. A PICC line was placed on
[**2191-2-28**] which was day of life 3, for
hyperalimentation at that time. Enteral feedings were slowly
advanced and full feedings achieved by [**2191-3-10**], which
is day of life 13. Calories were then concentrated to a
maximum caloric intake of 30 calories per ounce of breast
milk with ProMod. Iron and vitamin E were initiated on [**2191-3-14**], which was day of life 17. On [**2191-3-27**], the
infant began to have heme-positive stools which were also
bloody. A KUB was done at that time which showed pneumatosis, and
the infant was diagnosed with necrotizing enterocolitis. CBC and
blood cx were unremarkable, and serial KUBs normalized over time.
The infant was treated with bowel rest with PN and antibiotics
for 14 days. Enteral feedings were restarted on [**2191-4-10**]
and advanced slowly. Full feedings were achieved by [**2191-4-16**]. Calories were further concentrated to 24 calories. The
infant is presently taking PE 24 at 140 ml/kg/day, p.o./p.g. and
has been restarted on iron and vitamin E. He has been tolerating
enteral feedings, doing some p.o. feedings with fair
coordination. Stools are heme-negative. The most recent set
of electrolytes were done on [**2191-4-9**] with sodium of
134, K of 4.7, chloride 104, CO2 of 23. The infant's most
recent weight is 2905 gm. At the present time, his length
is approximately 25th percentile. His weight is about the
50th percentile and his head circumference is also the 50th
percentile.
GI: The infant was treated for hyperbilirubinemia with a
total of 6 days of phototherapy and a peak bilirubin level of
6.3/0.3.
Hematology: The infant's blood type is O positive, DAT
negative. He has received no blood product transfusions. His
most recent hematocrit was 27 on [**2191-4-9**] with a
reticulocyte count of 8% at that time and he remains on
elemental iron at this time. Hematocrit at birth was 48.
Infectious Disease: A CBC and blood culture were screened on
admission. The CBC was within normal limits. The infant
received a total of 48 hours of ampicillin and gentamicin.
Pending a negative blood culture, the antibiotics were
subsequently discontinued at that time. The next issue with
sepsis was an episode of necrotizing enterocolitis on [**2191-3-27**] at which time the infant was started on Zosyn. A CBC
and a blood culture was done. The CBC was within normal
limits. The blood culture remained negative. The infant was
treated for a total of 14 days of Zosyn for the necrotizing
enterocolitis. A rotavirus was sent on [**2191-3-31**] to rule
out rotavirus which came back negative at that time. There
have been no further concerns with sepsis.
Neurology: The initial head ultrasound was done on [**2191-3-4**] which showed a right germinal matrix hemorrhage.
Follow-up ultrasound was done on [**2191-3-11**] which showed
an evolving right germinal matrix hemorrhage. Another head
ultrasound was done on [**2191-3-28**] which showed a resolved
right germinal matrix hemorrhage, and was otherwise normal.
Sensory:
Audiology - a hearing screen has not been performed on this
infant yet, but is recommended prior to discharge from the
hospital.
Ophthalmology - Eye exams were done periodically, without
evidence of retinopathy of prematurity. Most recent exam on
[**2191-4-18**] which showed immature retinas to zone 3 with no
ROP. Recommendation was for follow-up 3 weeks after that time,
which will be the 1st week of [**Month (only) 116**].
Psychosocial: A [**Hospital1 **] social worker has been involved with the
family. If there are any social work concerns, the [**Hospital1 **]
social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital 1474**] Hospital, Level
II Newborn Nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) 233**] from [**Hospital1 1474**], telephone
number [**Telephone/Fax (1) 50563**].
CARE RECOMMENDATIONS: Feedings of PE 24 with iron p.o. p.g.,
encourage p.o. feeding. He is taking approximately 140
ml/kg/day.
Medications are ferrous sulfate 0.25 ml p.o. once daily and
vitamin E 5 units p.o. once daily.
Car seat position screening is recommended prior to discharge
from the hospital.
Newborn screens have been sent. The first newborn screen
showed an elevated 17-OH, but repeat screens have been within
normal limits.
Immunizations received - the hepatitis B vaccine was given on
[**2191-3-26**] and Synagis was given on [**2191-4-22**].
Immunizations recommended - Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria - i) born at less than 32
weeks gestation; ii) born between 32 and 35 weeks with 2 of
the following - either day care during RSV season, a smoker
in the household, neuromuscular disease, airway abnormalities
or school age siblings; or iii) 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.
DISCHARGE DIAGNOSES: Respiratory distress syndrome,
prematurity, twin gestation, rule out sepsis with
antibiotics, apnea of prematurity, anemia of prematurity, Grade 1
intraventricular hemorrhage, necrotizing enterocolitis.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2191-4-24**] 22:15:40
T: [**2191-4-24**] 23:16:41
Job#: [**Job Number 65908**]
|
86113,5119,4239,E966 | 88 | 123,010 | Admission Date: [**2111-8-29**] Discharge Date: [**2111-9-3**]
Date of Birth: [**2087-12-1**] Sex: M
Service: TRAUMA SX
HISTORY OF PRESENT ILLNESS: Patient is a 23-year-old
gentleman who was in his usual state of health when in the
early on the day of admission was reportedly stabbed in the
chest. It is unknown the actual sequence of events. It is
reported that the patient had been stabbed, entered his
vehicle, began to drive and subsequently crashed into some
parked cars. Patient was taken from his car and brought to
the [**Hospital1 69**] with initial heart
rate in the 90s, blood pressure in the 90s and saturation of
98%.
The patient, upon entering the Trauma Room, had a heart rate
of 78, blood pressure of 98/66, respiratory rate of 24 and
saturating at 100% on room air. The patient underwent a DPO
which was negative and VATS exam which showed a pericardial
effusion. He was resuscitated with four liters of lactated
ringers and a unit of blood in the Trauma Room. The patient
was then moved to the Operating Room for emergent exploration
of the wound.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: None.
SOCIAL HISTORY: Patient is an information technology worker
at a computer firm at [**Hospital1 8**].
PHYSICAL EXAMINATION: Head and neck are within normal
limits. Chest had bilateral breath sounds. Abdomen soft,
nontender, nondistended. He had positive extremity pulses.
Patient had a 3 cm stab wound of the fifth intercostal space
on the left.
LABORATORY: On admission white count was 9.8, hematocrit
36.6, platelets 161,000. PT was 14.5, PTT 28.5, INR 1.5.
Urinalysis was negative. Sodium 145, potassium 3.6, chloride
112, bicarbonate 19, BUN 10, creatinine 0.9. Glucose 151.
Amylase 54, calcium 7.4, magnesium 1.5, phosphorus 2.4.
ETOH was 245. Other tox screen was negative.
Arterial blood gas drawn once he was intubated initially was
7.33, 37, 205, 20.
Chest x-ray showed an enlarged cardiac silhouette and slight
widening of mediastinum. A subsequent head CT Scan was
negative. Subsequent C spine CT Scan was negative for
injury. CT Scan of the abdomen was also negative. AP pelvis
was negative.
HOSPITAL COURSE: Upon being transferred to the Operating
Room for emergent exploration, the patient lost blood
pressure and in the Operating Room underwent an emergent
thoracotomy and exploration. Injury to the right ventricle
was found and repaired. The patient was resuscitated
successfully and was transferred to the Intensive Care Unit
in stable conditions on no pressors. Patient's postoperative
course is as follows.
In the Intensive Care Unit the patient was weaned and
extubated on postoperative day #1 without any incident. The
patient had a postoperative echo which was within normal
limits. Postoperative day #2, the patient was transferred to
the floor for the remainder of his recovery. The patient had
a right chest tube discontinued and his diet was advanced.
He was evaluated by Physical Therapy and began to ambulate.
On postoperative day #3 the patient had a temperature spike
to 102.7 F. Blood cultures were sent which have only been
only significant for one bottle out of four with staph
coagulase negative. He was started on Vancomycin. He
subsequently defervesced. His white count went to a high of
10.6 and more recently is 7.7. The left chest tubes were
discontinued without incident. The wound was examined. It
has been clean, dry and intact. The patient had a second
echo was [**2111-9-1**] for evaluation of the valves which showed
no vegetations.
On postoperative #5 his antibiotics were discontinued. The
patient was ambulating, tolerating diet and is now stable and
ready to go home.
DISCHARGE DIAGNOSES:
1. Stab wound to the right ventricle status post emergent
thoracotomy and surgical repair.
DISCHARGE MEDICATIONS:
1. Percocet one to two p.o. q. four hours p.r.n.
2. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: Patient will follow up in Trauma
Clinic in one week to have staples removed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2111-9-3**] 09:52
T: [**2111-9-8**] 11:05
JOB#: [**Job Number 44168**]
|
V3101,7742,76516,76527,22801,V290 | 89 | 188,646 | Admission Date: [**2185-6-17**] Discharge Date: [**2185-6-21**]
Date of Birth: [**2185-6-17**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 48217**]-[**Known lastname 48218**], twin #1 was born at
33-3/7 weeks gestation by cesarean section for a
nonreassuring fetal heart rate. The mother is a 27-year-old
gravida 1, para 0, now 2 woman. Her prenatal screens are
blood type O negative, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, and group B
Strep unknown. The mother did receive RhoGAM at 28 weeks
gestation. This pregnancy was complicated by
pregnancy-induced hypertension. The mother did receive a
full dose of betamethasone prior to delivery. The patient
was being induced due to the hypertension and was on
magnesium sulfate. This infant emerged after three hours of
rupture of membranes with clear amniotic fluid. The infant
emerged vigorous. Apgars were eight at one and nine at five
minutes.
The birth weight was 1,600 grams, the birth length was 43 cm,
and the birth head circumference was 30 cm.
The admission physical examination reveals a vigorous,
nondysmorphic premature infant. Anterior fontanel is soft
and flat, positive bilateral red reflex, intact palate.
Respirations comfortable. Lung sounds clear and equal.
Heart with a regular, rate, and rhythm, no murmur, pink and
well perfused. Present femoral pulses. Abdomen is soft with
normal masses. Normal female preterm genitalia, patent anus.
Spine straight and without dimple. Stable hip examination
and symmetric tone and reflexes. A capillary hemangioma on
the right upper quadrant of the abdomen and a mongolian spot
on the sacrum.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory status: Infant has remained in room air
throughout her NICU stay. She has had no apnea, or
bradycardia, or desaturations.
2. Cardiovascular status: She has remained normotensive
throughout her NICU stay. There are no cardiovascular
issues.
3. Fluids, electrolytes, and nutrition: At the time of
transfer, her weight is 1,500 grams. Her length is 43 cm,
and her head circumference is 30 cm. Enteral feeds were
begun at the time of admission and advanced without
difficulty to full volume. She is taking breast milk or
preemie Enfamil 20 calories/ounce taking all oral feeds
between 80 and 100 cc/kg/day. Supplementation with gavage may
be neccessary when volumes are increased further. Discharge
weight 1500 down 15 grams from yesterday.
4. Gastrointestinal status: Phototherapy was begun on day of
life #1 for a bilirubin of total 8.6, direct 0.5. Her
bilirubin on [**2185-6-19**] was total of 7.9, direct 0.3, and then
6.3/0.3 on [**6-21**]. Phototherapy was discontinued early this
morning. The infant's blood type is B negative with a
microscopic Coomb's positive felt to be secondary to maternal
RHogam treatment.
5. Hematology: The infant has received no blood product
transfusions during her NICU stay. Her hematocrit at the
time of admission was 46.7% with a platelet count of 324,000.
6. Infectious disease status: Blood culture was drawn at the
time of admission and it remains negative to date. A
complete blood count at the time of admission showed a white
count of 8 with a differential of 32 polys and 0 bands. She
has never received any antibiotic treatment.
7. Sensory status: Hearing screening has not yet been done,
but is recommended prior to discharge.
8. Psychosocial: Parents have been involved in the infant's
care throughout their NICU stay. Mother speaks Creole and
English.
CONDITION ON DISCHARGE: The infant is discharged in good
condition, and the infant was transferred to [**Hospital 1474**]
Hospital for level two nursery for continuing care. The
primary pediatric provider has not yet been identified.
CARE AND RECOMMENDATIONS AFTER DISCHARGE: Feedings:
Advancing as tolerated. Oral feedings of breast milk or
preemie Enfamil with added calories as needed.
MEDICATIONS: The infant is discharged on no medications.
A car seat position screening test is recommended prior to
discharge.
A State Newborn Screen was sent on [**2185-6-21**].
The infant has not yet received any immunizations. She does
not yet meet the weight requirement for her first hepatitis B
vaccine.
Follow-up bilirubin is recommended tomorrow.
DISCHARGE DIAGNOSES:
1. Prematurity of 33-3/7 weeks gestation.
2. Twin #1.
3. Sepsis ruled out.
4. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2185-6-21**] 01:12
T: [**2185-6-21**] 06:16
JOB#: [**Job Number 48219**]
|
4470,2765,20008,99812,51881,135,53100,2866,5559 | 91 | 121,205 | Admission Date: [**2177-4-23**] Discharge Date:
Service:
NOTE: This is a preliminary Discharge Summary based on the
[**Hospital 228**] hospital course while she was on the Medicine
Service prior to being transferred to the Oncology Service.
HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname 26681**] [**Known lastname 17744**] is an
81-year-old female with a complicated past medical history
who presented with several months of fevers as well as rash
of approximately three weeks duration.
The patient's past medical history dates back to [**2172**], at
which time she had a medical workup for abdominal pain,
weight loss, and anorexia. She had a CAT scan done on
[**2173-1-5**] that showed significant abdominal
adenopathy, extensive adenopathy displacing the bowel in the
periaortic, aorta cava, and mesenteric area. She had a bone
marrow biopsy done on [**2173-1-13**] that showed no
evidence of malignancy. In [**2173-2-4**], the patient then
had a retroperitoneal node biopsy done via a mini-laparotomy
procedure which showed granulomatous lymphadenitis with
noncaseating granulomas. This was acid-fast bacillus
negative as well as GMS negative and PAS negative. At this
time, the patient obtained the diagnosis of sarcoidosis.
Also in [**2173-2-4**], the patient had the onset of
low-grade temperatures as well as some early satiety, and she
continued to have abdominal pain. She had an abnormal xylose
test done in [**2173**]. At this point, again, the working
diagnosis on this patient was sarcoidosis. Her blood was
tested and was negative for histoplasmosis,
coccidioidomycosis, blastomycosis. As well, she had a
purified protein derivative placed which was negative. No
steroids were started at this time.
Approximately one year ago, in [**2175**], the patient was
diagnosed with Crohn's disease. It is my understanding that
this was a clinical diagnosis, as there was no documented
colonoscopy. The patient was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]
as well as by a gastroenterologist at an outside facility.
The medications used to treat her Crohn's disease included
prednisone, 6-MP, methotrexate, as well as Remicade. Her
cycles of Remicade were in [**2176-10-5**], [**2176-10-5**], and [**2177-3-7**]. It is not entirely clear to me
at this time what the sequence of medical therapy was for her
Crohn's disease. She also had approximately a 6-month course
of high-dose steroids for the Crohn's disease with a taper
prior to starting her first Remicade cycle.
The patient then had an admission to the [**Hospital1 346**] from [**2-19**] to [**2177-2-25**];
at which time she was admitted for diarrhea, fever, chills,
sweats, as well as bloating. She was thought at that time to
have a Crohn's flare (plus or minus gastroenteritis). She
was treated with ciprofloxacin, Flagyl, and stress-dose
steroids. At that time, she improved and her fevers stopped.
It should be mentioned at this time that the patient had
intermittent fevers occurring weekly and spiking up to 103
for approximately four to five months prior to her admission
to the hospital in [**2177-4-4**]. Cultures were done during
her [**Month (only) 404**] admission, and they were negative. After she
finished a 10-day course of antibiotics, her fevers recurred.
On [**2177-3-12**], she had a Remicade infusion and felt
well for a few weeks following that; and then, on
[**3-20**], she was seen by Dr. [**Last Name (STitle) 1940**] in the clinic. At
that time she looked tired and exhausted, although her
Crohn's disease was quiescent. She then experienced
recurrent fevers in late [**2177-3-7**] and was treated
with ciprofloxacin and Flagyl from [**4-4**] to [**4-17**]. At
that time, her fevers remitted and she felt somewhat better.
On [**4-21**], the patient's fevers returned, and she was
spiking to 103 at home, continued to have night sweats (which
was essentially her baseline with these fevers). She also
has episodes where she becomes somewhat lethargic and nearly
unresponsive during the hour or so before she is going to
have a temperature spike. She also experiences rigors. All
of this history is obtained from family members as well as
from the patient herself.
REVIEW OF SYSTEMS: Review of systems was also positive for
weight loss and lethargy (as mentioned) during the
temperature spikes and drenching night sweats. Otherwise,
negative for headache and visual changes. No sinus
congestion. No dysphagia. No cough. No shortness of
breath. No nausea or vomiting. No abdominal pain. No joint
pain. No other localizing symptoms to correlate with these
fevers.
Approximately three weeks prior to admission, the patient
mentioned that she noted a nodule in her right axilla. Over
time, the patient developed significant/enumerable nodules
and papules covering her sternum, her breasts, her abdomen,
her upper extremities, her upper back, and the back of her
neck, as well as her scalp. These nodules spared her palms,
and spared her left extremities, and also spared her face.
She was seen by a dermatologist at an outside facility, and a
biopsy was done. When she was admitted to the hospital on
[**4-21**], she was carrying the presumptive diagnosis of a
cutaneous lymphoproliferative disorder, but that had not been
further characterized when she was admitted to the hospital.
The patient was scheduled to have an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Hematology/Oncology on [**2177-4-23**].
However, she came to the Emergency Department (brought by her
husband) in the setting of having a temperature spike and her
usual rigors, sweats, and lethargy. She was noted to have
what the husband felt was mild respiratory distress with deep
inspiration, and what he characterized as respiratory
difficulty.
In the Emergency Department the patient was treated with
ampicillin, levofloxacin, and Flagyl as well as intravenous
fluids. She was admitted for further workup.
PAST MEDICAL HISTORY: Her past medical history has been
detailed above. Also significant for uterine suspension in
[**2141**], as well as total abdominal hysterectomy/bilateral
salpingo-oophorectomy in [**2144**]. She also does carry the
diagnosis of Crohn's disease and sarcoidosis (as mentioned).
MEDICATIONS ON ADMISSION: Her medications on admission to
the hospital included prednisone 15 mg p.o. q.d., 6-MP 75 mg
p.o. q.d., multivitamin p.o. q.d., Premarin, Fosamax,
Omega -3 fatty acids. She is status post Remicade cycle on
[**2177-3-12**]. She takes folic acid and an iron
supplement as well.
ALLERGIES: The patient has no known drug allergies; however,
it is noted in her history that in the past she has been
treated with PENTASA and METHOTREXATE without good effect on
her Crohn's disease. It is not believed that she actually
has a frank allergy to PENTASA or to METHOTREXATE.
FAMILY HISTORY: Family history is significant for diabetes
mellitus. Mother died of stomach cancer and a pulmonary
embolism, and a daughter who has survived breast cancer.
SOCIAL HISTORY: No history of tobacco. Occasional alcohol
one to two times per week. No history of intravenous drug
use. She works as an artist. She was born in [**Location (un) 86**]. Her
first husband was in the military, and she has lived in
[**State 48158**], [**State 26110**], [**State 9896**]., as well as [**Location (un) 6482**]. She
is currently married to her second husband. [**Name (NI) **] family is
very supportive of her and has been giving her tremendous
support during the past year and a half when she has been
suffering from these recurrent fevers and an ongoing workup
for them.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination her temperature maximum was 104.2, in the
Emergency Department temperature was 101. On admission heart
rate was 102, blood pressure of 122/59, oxygen saturation of
100% on room air, respiratory rate of 16. Examination of her
skin revealed multiple welts, circumscribed, round,
nontender, firm, nonulcerative papular lesions/nodules
ranging from 2 mm to 5 mm over her arms, chest, back,
abdomen, breast, scalp, and neck; sparing her face, palms
lower legs and feet. Head, eyes, ears, nose, and throat
examination was normocephalic and atraumatic. Pupils were
equal, round, and reactive to light. Extraocular movements
were intact. She had a left cataract. There was no
oropharyngeal erythema. No exudate. No oral lesions. The
appearance of her face was somewhat cushingoid. The neck was
supple. There was no lymphadenopathy. Lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed carotids with normal volume with brisk upstroke, no
bruits. Jugular venous pulse at 4 cm. A regular rate and
rhythm. Normal first heart sound and second heart sound. No
third heart sound. No fourth heart sound. A [**3-12**]
holosystolic murmur. The abdomen was soft, nontender, and
nondistended, normal active bowel sounds. Extremities were
without cyanosis, clubbing or edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Initial laboratory
data included a white blood cell count of 11.7 (with
55% polys, 15% bands, 11% lymphocytes, 9% monocytes, 1
metamyelocytes, 1 myelocyte, 1 promyelocyte. Hematocrit
of 37.9, platelet count of 402, mean cell volume of 81.
Urinalysis with a specific gravity of 1.035, 0 to 2 red blood
cells, 6 to 10 white blood cells, few bacteria. Her Chem-7
was sodium of 132, potassium of 6.6 (hemolyzed, repeated
at 5.7), chloride of 97, bicarbonate of 22, blood urea
nitrogen of 23, creatinine of 0.8, glucose of 103. ALT
of 33, AST of 124, alkaline phosphatase of 184, total
bilirubin of 0.5. INR of 1.7.
RADIOLOGY/IMAGING: Electrocardiogram with sinus tachycardia
at 106, flat T waves in aVL and III.
CT scan showed bilateral atelectasis at the lung bases, small
stone in the gallbladder, as well as perihepatic ascites, and
a small amount of pelvic ascites.
HOSPITAL COURSE: In summary, then, Ms. [**Known lastname 17744**] is an
81-year-old female with a history of sarcoid and Crohn's
disease who has had recurrent temperature spikes times
approximately six months as well as an approximate year and a
half history of low-grade fevers prior to these temperature
spikes. She also presents with a progressive skin eruption
consisting of papules and nodules over the past three weeks.
She is admitted with fever, dehydration, and a further
evaluation of this rash.
The [**Hospital 228**] hospital course while she was on the Medicine
Service is as follows:
The patient had a consultation by Hematology/Oncology on the
day following admission, at which time a bone marrow biopsy
was done, and the slide from the outside facility was read of
her cutaneous lesions. She was found to have CD30 positive
and CD68 positive anaplastic large cell lymphoma.
Subsequent studies of her bone marrow and her peripheral
blood showed that she had large cell anaplastic lymphoma in
the peripheral blood as well as in the bone marrow.
Additional biopsies of the skin were done in the [**Hospital 2652**]
Clinic.
The patient also had a Gastrointestinal consultation for
further evaluation of her question of Crohn's disease. In
terms of management of that, however, when the patient
presented during this hospital admission, her Crohn's disease
did not seem to be an active issue, as she was not
complaining of any diarrhea or abdominal pain.
The patient was doing well on [**4-23**] and [**4-24**]; however,
on [**4-25**], her hospital course took a much different
course. It was noted that her platelet count was 360 on
[**4-23**] and dropped to 169 on [**4-25**]. Following that
through, from the [**4-25**] to the [**4-28**], she continued to
have a rapid decline in her platelets; such that, on
[**4-28**], her platelets were 18. Similarly, her INR
continued to climb. Her fibrinogen continued to fall, and
the patient appeared to be flora DIC. She had a lactate
level drawn which was 15.5 (consistent with a metabolic
acidosis). Her bicarbonate fell to a low of 7 on [**4-26**].
She was subsequently started on bicarbonate. The patient had
a hematocrit drop from 39 to 29, and she was transfused with
2 units of packed red blood cells.
The patient had a head CT done to further evaluation the
lethargy and dramatic change in her mental status in her
peri-febrile states. Her head CT was negative for any bleed,
any evidence of a regional infarction, or any mass lesions.
She was transferred to the Intensive Care Unit for
approximately a 12-hour period of time for further management
of her DIC; however, she was then returned to the floor
because it was the feeling that the care she was getting on
the floor was not significantly different from that which
would be done in the Intensive Care Unit.
At the time the patient was transferred from the Medicine
Service to the Oncology Service, she was in flora DIC. She
had received bicarbonate; and at the time of transfer, her
bicarbonate was back within the normal range. Her platelets,
INR, and fibrinogen continued to be followed daily. Prior to
transfer to the Oncology team she was started on methotrexate
p.o. She received three doses of that as well as aggressive
hydration. She was also started on allopurinol and folic
acid. It was felt that the patient's DIC as well as
metabolic acidosis was perhaps due to tumor burden versus
tumor lysis. The question of tumor lysis seemed less likely
given that the patient started to decompensate prior to
receiving the methotrexate.
A discussion was had with the family on multiple occasions,
and ultimately the family decided that the patient's code
status would do not resuscitate/do not intubate; however,
they chose a course of therapy that would include oral
methotrexate. They were unwilling to make the patient
comfort measures only; and, similarly, they were unwilling to
pursue a more aggressive chemotherapy regimen such as CHOP
with methotrexate. The patient was able to participate in
all of these discussions regarding her code status and
regarding her treatment of her large cell anaplastic
lymphoma.
The remainder of her hospital course, while she is on the
Oncology Service, will be dictated in a subsequent Discharge
Summary. She had not been
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 29450**]
MEDQUIST36
D: [**2177-5-2**] 15:09
T: [**2177-5-3**] 04:59
JOB#: [**Job Number 108699**]
|
36221,7742,77211,76502,77181,2762,7707,769,7766 | 92 | 142,807 | Admission Date: [**2122-12-13**] Discharge Date: [**2123-3-4**]
Date of Birth: [**2122-12-13**] Sex: F
Service: Neonatology
This is a dictation to cover the patient from admission
through the beginning of [**Month (only) 956**].
Patient was a 24 months seven week infant admitted to the
NICU for care of extreme prematurity.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The patient required intubation and
ventilation shortly after birth. She was treated with three
doses of Surfactant and required mechanical ventilation
through the entire month of [**Month (only) 404**]. She developed no
evidence of a patent ductus arteriosus. During the first
several days of life, she required treatment with fluid
boluses and dopamine infusion to maintain blood pressures in
the normal range. She developed mild metabolic acidosis
related to renal immaturity that required treatment with
sodium bicarb infusions.
2. Fluids, electrolytes, and nutrition: Patient received
parenteral nutrition from the initial days of her
hospitalization until feeds were started during the middle to
latter part of [**Month (only) 956**]. She tolerated the feeding advance
well until the end of [**Month (only) 404**] at which time, she developed
abdominal distention and abnormal KUBs which prompted
treatment as medical NEC.
3. Hematologic: Complete blood count on admission showed a
hematocrit of 40.9 with a white count of 15.9. Platelet
count was 294,000. A differential showed 37 polys and 23
bands. The patient received multiple red cell transfusions
during the course of [**Month (only) 404**].
4. Infectious Disease: Because of the patient's marked
bandemia and the notation of gram-negative rods on initial
Gram stain examination of the amniotic fluid, she was treated
with a 10 day course of ampicillin and gentamicin. This was
later changed to cefotaxime because of the presence of
gram-negative rods.
The CSF examination done on the fourth day of life showed 0
white cells and 94 red cells. Blood cultures remained
negative during her initial hospital stay as did CSF.
5. Gastrointestinal: Patient experienced unconjugated
hyperbilirubinemia. She was treated with phototherapy. Her
maximum bilirubin was 4.2/0.2 on the second day of life.
6. Neurological: The patient had a head ultrasound done
during the first several days of life. This demonstrated a
Grade I interventricular hemorrhage. A repeat ultrasound
scan done on the [**12-22**] showed echogenicity of the
caudal thalamic groove along with increased echogenicity of
the ependymal lining of the trigone. There was no suggestion
of changes related to PVL. Findings were thought to be
consistent with a grade [**12-3**] hemorrhage in the left lateral
ventricle. Ventricular size was normal. The patient has
manifested in age appropriate nonfocal neurological
examination during her hospital stay during this month.
DIAGNOSES:
1. Twenty-four and a half week infant.
2. Respiratory distress syndrome.
3. Bronchopulmonary dysplasia.
4. Metabolic acidosis.
5. Hypotension.
6. Presumed sepsis.
7. Grade [**12-3**] interventricular hemorrhage.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**],
M.D.50-470
Dictated By:[**Last Name (NamePattern1) 37102**]
MEDQUIST36
D: [**2123-4-22**] 12:24
T: [**2123-4-22**] 12:25
JOB#: [**Job Number 45988**]
|
2762,7707,77211,7742,7766,36221,76502,77181,769 | 92 | 142,807 | Admission Date: [**2122-12-13**] Summary Date: [**2123-1-29**]
Date of Birth: [**2122-12-13**] Sex: F
Service: NEONATOLOGY
INTERIM SUMMARY
NOTE: This summary refers to hospital course from [**2123-1-4**]
through [**2123-1-29**]. Please refer to patient chart for
history, physical and hospital course from admission through
HOSPITAL COURSE BY SYSTEMS:
(1) RESPIRATORY: [** First Name **] is a 24-1/7 weeker who was 27-2/7
weeks at the beginning of the month with significant lung
disease and evolving chronic lung disease. She was on SIMV,
relatively high settings at the beginning of the month. Over
the course of the first three days, she was weaned down to
transitioned to a CPAP of 7 on [**2123-1-7**] and about 40% to 50%.
Over the course of the next two weeks, [** First Name **] transitioned
down to a nasopharyngeal CPAP of 5 with an exception of two
days, where chest films showed mild atelectasis on the right
upper lobe, requiring two days of CPAP of 6. She is
currently on a CPAP of 5 and 27% to 35%.
Her FIO2 has increased over the course of the last week, most
likely secondary to her anemia. She is not on any diuretic or
fluid restriction. She is on caffeine of 7
mg/kg per day. She has more recently had apnea of
prematurity that again is likely associated with her anemia.
The plan is to transfuse [** First Name **] with packed red blood cells
today, and then transition her from CPAP likely to nasal
cannula over the next few days.
(2) FLUIDS, ELECTROLYTES, NUTRITION: I received [** First Name **] on a
total fluids of 150 cc/kg per day and mostly PN, as she was
completing a rule-out NEC at the beginning of the month. On
[**2123-1-11**], [** First Name **] was started on trophic feeds, which she
tolerated for two days, and a feed advancement was slowly
undertaken. By [**2123-1-15**], it was evident that [** First Name **] was not
going to have any difficulties with refeeding, and so she was
progressed to full feeds and then subsequently progressed to
increased calories over the course of the next week.
Currently, she is on 150 cc/kg per day of PE 30 with ProMod
q.4 hours over 40 minutes, and she seems to tolerate that
just fine without any issues.
(3) GI: Prior to this month's service, there were some
questionable abdominal exams with pneumatosis, so [** First Name **] was
started on antibiotics and made NPO with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 37079**], for
which she completed a 10-day course of rule out NEC with no
clinical signs of necrotizing enterocolitis. The [**Last Name (un) 37079**]
was discontinued on [**2123-1-6**] with no clinical change. Feeds
were started as outlined above, and she has been tolerating
that with no issues.
(4) HEMATOLOGY: [** First Name **] has anemia of
prematurity. She received one transfusion on [**2123-1-12**] with
a mild bump in her hematocrit. [** First Name **]'s subsequent hematocrit
was 26.6 and a reticulocyte count two weeks after the last
transfusion was 1.9. Epogen was considered but was not
instituted. Because of [** First Name **]'s mild increasing oxygen
requirement and increase in apneas, [** First Name **] was given 20 cc/kg
of packed red blood cells (PRBCs) in two aliquots on
[**2123-1-29**] with a dose of Lasix in between. We plan to follow
her anemia of prematurity clinically subsequently.
(5) I.D.: [** First Name **] completed 10 days of ampicillin and
gentamicin for her rule out necrotizing enterocolitis on
[**2123-1-8**]. Clindamycin was not used because necrotizing
enterocolitis was not supported radiographically.
(6) NEUROLOGIC: [** First Name **] has had normal head ultrasounds in her
first 10 days and subsequently on day of life 30, [**2123-1-12**].
Plan would be to follow another head ultrasound at 60 days
and/or prior to discharge, given her clinical status.
(7) OPHTHALMOLOGIC: [** First Name **] had her first ophthalmologic exam
on [**2123-1-26**], was negative for retinopathy of prematurity but
was still immature. Plan to follow up ophthalmologic exam in
two weeks.
(8) SOCIAL: Parents are involved. They are
from [**Hospital1 1474**], but when [** First Name **] is off CPAP would request a
transfer to [**Hospital6 33**] for the duration of her
care. Their pediatrician is undetermined as of yet.
Reviewed By: DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-622
Dictated By:[**First Name3 (LF) 43833**]
MEDQUIST36
D: [**2123-1-29**] 15:08
T: [**2123-1-31**] 09:48
JOB#: [**Job Number 45987**]
1
1
1
DR
|
769,7742,76523,7766,76503,77081,77981,77181,7470,V3000,36221,2707 | 93 | 160,481 | Admission Date: [**2128-3-17**] Discharge Date: [**2128-3-18**]
Date of Birth: [**2128-3-17**] Sex: F
Service: NB
This is an interim summary for the hospital course in [**Month (only) 547**].
HISTORY OF PRESENT ILLNESS: [**Known lastname 1894**] [**Known lastname 61503**] is a 775-gram
product of a 26-week gestation born to a 30-year-old G1/P0
(to 1) woman whose pregnancy was notable for an admission to
[**Hospital1 18**] with cervical shortening on [**2128-3-2**]. She was
treated with bed rest and betamethasone. Mother's history is
notable for insulin-dependent diabetes and a seizure disorder
(for which she is being treated with Trileptal).
Antibiotics were begun this afternoon. There was no fever or
other sepsis risk factors noted.
Maternal prenatal screens: GBS unknown, O positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune. Rupture of membranes occurred on
the day of delivery.
Labor progressed steadily leading to spontaneous vaginal
delivery. The baby required intubation for respiratory
distress in the delivery room. Apgar's were 7 at one minute
and 9 at five minutes. The infant was brought to the NICU
after visiting with the family.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 775
grams. She is patent nondysmorphic infant with a foul smell
noted. Skin with bruising noted about the trunk. HEENT exam
was within normal limits. Cardiovascular exam revealed S1 and
S2 without murmur. Lungs revealed coarse breath sounds
bilaterally. The abdomen was benign. Neurologic exam was
nonfocal. Tone was slightly decreased throughout. The patient
was moving all 4 extremities. Hips were normal. Anus was
patent. The spine was intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: The patient was intubated in the delivery
room. Received 2 doses of surfactant and is currently in
SIMV at settings of 16/5 at a rate of 18. FiO2 is room
air.
2. CARDIOVASCULAR: The patient has had no murmur. She has
received 2 normal saline boluses for hypotension. Blood
pressure currently is within normal limits.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially on enteral feedings at 100 cc/kg/day. A UVC and
UAC were placed. Electrolytes yesterday evening revealed a
slightly high sodium, and therefore fluids were increased
to 120 cc/kg/day.
4. GASTROINTESTINAL: The patient was started on phototherapy
for an 8-hour bilirubin level of 3.5/4/0.2.
5. INFECTIOUS DISEASE: The patient was started on ampicillin
and gentamicin. Blood culture and CBC were obtained. Due
to the thick green and yellow secretions that were noted
as well as foul smelling fluids, the decision was made to
treat with 7 days of antibiotics.
CONDITION ON DISCHARGE: Fair.
NAME OF PRIMARY CARE PEDIATRICIAN: Unknown.
CARE RECOMMENDATIONS:
1. Feedings: The patient is currently n.p.o.
2. Medications: The patient is currently on ampicillin and
gentamicin.
3. State newborn screen status: Has not been sent.
4. Immunizations: The patient has not received any
immunizations.
DISCHARGE DIAGNOSES:
1. Respiratory distress syndrome.
2. Hypotension - resolved.
3. Presumed sepsis.
4. Hyperbilirubinemia.
5. Prematurity at 26 and 1/7 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2128-3-18**] 12:20:25
T: [**2128-3-18**] 13:11:11
Job#: [**Job Number 61504**]
|
36221,76523,77181,7766,769,77081,77981,76503,7470,V3000,2707,7742 | 93 | 160,481 | Admission Date: [**2128-3-17**] Discharge Date: [**2128-4-20**]
Date of Birth: [**2128-3-17**] Sex: F
Service: NB
ADDENDUM: This is an interim discharge summary. Interim date
[**2128-4-20**].
HISTORY OF PRESENT ILLNESS: Remains the same as previously
dictated by Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 4223**] on [**2128-3-18**].
PHYSICAL EXAMINATION ON ADMISSION: Remains the same as
previously dictated by Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 4223**] on [**2128-3-18**].
INTERIM SUMMARY OF HOSPITAL COURSE BY SYSTEM DURING THIS
PERIOD:
1. RESPIRATORY: She was weaned from the ventilator and
extubated to CPAP on day of life 26. She had been loaded
with caffeine prior to extubation and currently is on CPAP
+5 at 20% to 30% oxygen. She had upwards of 3 spells which
usually self resolved in any 24-hour period. Her caffeine
was discontinued on the [**3-20**] secondary to
tachycardia.
1. CARDIOVASCULAR: She was treated during the first week of
her life with 1 course of betamethasone, and on day of
life 8 had an echocardiogram that revealed a tiny PDA, and
she was without murmur at that time. She was stable until
day of life 16 when a loud murmur was noted, and an
echocardiogram revealed a moderate PDA with continuous
left-to-right shunting. Arrangements were made, and she
was transported over to [**Hospital3 1810**] where she had
a PDA ligation on the [**3-5**]. She did well both
before and after this procedure with no inotropic support
needed. She has been cardiovascularly stable with normal
blood pressures and perfusion since surgery.
1. FLUIDS, ELECTROLYTES, AND NUTRITION: Just prior to her PDA
ligation she had reached full feedings. She was made
n.p.o. around the time of her surgery, and feedings were
reinitiated on day of life 22; which was postoperative day
4. Her feedings were slowly advanced, and she reached full
enteral volume by postoperative day 7. She is currently on
Similac Special Care 30 calories; plus ProMod, vitamin E,
and iron. Her most recent weight is 980 grams.
1. GI: She was initially on phototherapy, but this was
discontinued on day of life 7 for a bilirubin of 1.9. She
was restarted when her bilirubin went up to 3.2 on day of
life 9. It peaked at 4.1 on day of life 11, and it was
discontinued when it went down to 2.5. Her rebound
bilirubin on day of life 16 was 2.3.
1. HEMATOLOGY: She was transfused with 20 cc/kg of packed red
blood cells on day of life 12 for a hematocrit that was
26%. She was transfused another 20 cc/kg on day of life 20
for a hematocrit of 31.6%. Her most recent hematocrit is
42% from the [****]. She is on iron.
1. INFECTIOUS DISEASE: She initially completed a 7-day course
of vancomycin and gentamicin. Prior to her antibiotics
being discontinued, she had a lumbar puncture performed
that had 42 red blood cells and 2 white blood cells. She
received 3 doses of Kefzol perioperatively around the time
of her PDA ligation. She has had no other infectious
disease issues throughout this interim summary.
1. NEUROLOGY: She had a normal head ultrasound on day of life
5, on day of life 14, and also on day of life 30. She has
her first eye exam scheduled for the [**2-20**]. She has
not yet had a urine screening, nor has she received a
hepatitis B vaccination.
DISCHARGE DIAGNOSES: Prematurity at 26 weeks, respiratory
distress syndrome, presumed sepsis (resolved),
hyperbilirubinemia, patent ductus arteriosus, status post
indomethacin 1 course patent ductus arteriosus, status post
ligation surgically, anemia of prematurity requiring packed
red blood cell transfusion x 2.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 61506**]
MEDQUIST36
D: [**2128-4-20**] 16:24:43
T: [**2128-4-20**] 17:22:20
Job#: [**Job Number 61507**]
|
2707,36221,V3000,7742,7470,77981,76503,77081,77181,7766,76523,769 | 93 | 160,481 | Admission Date: [**2128-3-17**] Discharge Date: [**2128-4-5**]
Date of Birth: [**2128-3-17**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 61503**] was the 775-gram product of a 26-
weeks gestation born to a 30-year-old G1, P0 now 1 mother.
This pregnancy notable for admission at [**Hospital3 **] with
cervical shortening on [**3-2**]. Mother was treated with bed
rest and betamethasone. History is also notable for insulin-
dependent diabetes and a seizure disorder, which is being
treated with Trileptal.
PRENATAL SCREENS: O positive, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown.
Infant delivery by normal spontaneous vaginal delivery.
Apgars assigned at 7 and 9.
PHYSICAL EXAM ON ADMISSION: Birth weight 775 grams. Infant
was pink, nondysmorphic with a foul smell, passing stools.
Skin with bruising about trunk. Head and neck: Within normal
limits. Cardiovascular: Normal S1, S2 without murmurs. Lungs:
Coarse with breath sounds bilaterally. Abdomen is benign.
Neuro: Nonfocal. Tone: Slightly decreased throughout, moving
all 4 extremities. Hips: Normal. Anus: Patent. Spine: Intact.
HISTORY OF COURSE BY SYSTEMS: Respiratory: On admission to
the newborn intensive care unit, [**Known lastname 1894**] was demonstrating
respiratory distress and was intubated. Max ventilator
settings were 18/5 and a rate of 25. She remains ventilated
to date. Her most recent capillary blood gas was 7.37, PCO2
of 38, PO2 of 121. She is currently on a PIP of 19, a PEEP of
5 with a rate of 20. She is being treated empirically with
caffeine citrate with no documented episodes of apnea or
bradycardia.
Cardiovascular: Infant has been treated with indomethacin x2
courses, last course ending on [**2128-3-23**]. Repeat
echocardiogram on [**4-2**] demonstrated a moderate PDA with
continuous left-to-right flow with maximum instantaneous
gradient is approximately 20 mmHg. Mildly dilated left
ventricle with good left ventricular function.
In light of these findings and it would have been her 3rd
course of indomethacin, decision was made at that time to
plan for ligation at [**Hospital3 1810**].
Fluid and electrolyte: Birth weight was 775 grams. She was
initially started on 100 cc per kilogram per day at D5 PN.
Enteral feedings were initiated on day of life 5. She reached
a maximum of 135 cc per kilogram per day of Special Care 20
at which time the patent ductus arteriosus was documented,
and the infant has been NPO. She is currently on 130 cc per
kilogram per day of D10 PN, and her current weight is 800
grams.
Her most recent set of electrolytes are from [**2128-4-4**] and
they are still pending.
GI: Peak bilirubin was on day of life 13 of 4.1/0.2. She has
been off phototherapy since [**3-31**] and her rebound bilirubin
was 2.3/0.3 on [**4-2**].
Hematology: Hematocrit on admission was 40.3. She has
received 40 cc per kilogram of pack red blood cells. Her most
recent hematocrit is on [**4-4**] of 31.6.
Infectious disease: A CBC and blood culture obtained on
admission. CBC was benign. Blood cultures remained negative.
Infant was treated for 7 days of ampicillin and gentamicin
for thick green and yellow secretions noted at delivery as
well as foul-smelling fluid. CBC remained benign. Lumbar
puncture was within normal limits, and infant discontinued
vancomycin and gentamicin on [**2128-3-24**]. She has had no
further antibiotics during this hospital course.
Neuro: Head ultrasound was performed on day of life #5 and
was within normal limits. Repeat was on [**3-31**], also within
normal limits.
Psychosocial: A social worker has been involved with the
family and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Guarded.
DISCHARGE DISPOSITION: To [**Hospital3 1810**]. Pediatrician
not yet identified.
CARE AND RECOMMENDATIONS: Continue 130 cc per kilogram per
day of PN D10 with intralipids.
MEDICATIONS: Not applicable.
State newborn screen has been sent per protocol and has been
within normal limits. Infant has not received any
immunizations.
DISCHARGE DIAGNOSES: Premature infant at 26-weeks gestation
now corrected at 28-5/7 weeks gestation, mild respiratory
distress syndrome, patent ductus arteriosus, apnea and
bradycardia of prematurity, anemia of prematurity,
hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-4-4**] 23:10:37
T: [**2128-4-5**] 06:17:38
Job#: [**Job Number 61505**]
|
77181,7766,769,76503,7742,V3000,2707,36221,76523,7470,77981,77081 | 93 | 160,481 | Admission Date: [**2128-3-17**] Discharge Date: [**2128-6-17**]
Date of Birth: [**2128-3-17**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 1894**] [**Known lastname 61503**] delivered at 26-0/7-weeks
gestation was admitted to the newborn intensive care unit for
management of prematurity and respiratory distress. Her birth
weight was 775 grams. At discharge, she is [**Age over 90 **]-days old, 39
weeks postmenstrual age.
Mother is 30-year-old gravida 1 woman with estimated date of
delivery [**2128-6-23**]. Her prenatal screens included blood
type O-positive, antibody screen negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
and group B Strep unknown. The pregnancy was complicated by
cervical shortening with funneling, preterm labor, insulin-
dependent diabetes, and a seizure disorder treated with
Trileptal. Progressive preterm labor with rupture of
membranes led to a spontaneous vaginal delivery on [**2128-2-26**]. She was intubated in the delivery room for respiratory
distress. Apgar scores were 7 at 1 minute and 9 at 5 minutes.
PHYSICAL EXAM ON ADMISSION: Weight 775 grams (50th
percentile), length 33 cm (25th percentile), head
circumference 23 cm (25th percentile). Infant was pink,
nondysmorphic with a foul smell, skin with bruising about the
trunk. Head and neck: Within normal limits. Cardiovascular:
Normal S1, S2 without murmur. Lungs: Coarse with breath
sounds equal bilaterally. Abdomen is benign. Neuro: Nonfocal
with slightly decreased tone throughout, moving all 4
extremities. Hips: Normal. Anus: Patent. Spine: Intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Placed
on SIMV of 25 breaths per minute with pressures of 18/5 on
admission. She received a total of 2 doses of surfactant for
respiratory distress syndrome. [**Known lastname 1894**] was extubated to CPAP
on day of life 25. She weaned to nasal cannula oxygen on day
of life 57. She weaned to room air on day of life 85 ([**2128-6-10**]). [**Known lastname 1894**] was started on diuretic therapy with
Diuril on day of life 51 ([**2128-5-7**]) to treat her chronic
lung disease. She remains on Diuril at time of discharge. Her
dose is 50 mg twice a day, which is equal to 40 mg per
kilogram per day. At time of discharge, her respiratory rates
are in the 40s-60s with mild baseline subcostal retracting.
[**Known lastname 1894**] was treated with caffeine citrate for apnea of
prematurity. The caffeine citrate was discontinued on day of
life 55 ([**2128-5-11**]). Her last apnea and bradycardia event
was on [**2128-5-25**].
Cardiovascular: [**Known lastname 1894**] received 2 courses of Indocin for
patent ductus arteriosus. A repeat echocardiogram on day of
life 16 demonstrated a moderate patent ductus arteriosus with
continuous left-to-right flow. The decision was made to
surgically ligate the patent ductus arteriosus, which was
done on [**2128-4-5**]. A soft flow murmur is heard
intermittently at time of discharge.
Fluid, electrolytes, and nutrition: She initially was
maintained on total parenteral nutrition. Enteral feeds were
started on day of life 8 with Special Care formula. She
reached full volume feeds on day of life 15 without problems.
She was placed NPO for her PDA ligation. Her feeds were
restarted again on day of life 21. She gradually advanced to
30 calories per ounce, plus ProMod without problems. She
developed bloody stools on day of life 58 secondary to
formula intolerance and was changed to Nutramigen. She has
done well on Nutramigen. At discharge, she is taking
Nutramigen 24 calories per ounce by concentration with 6
calories per ounce of corn oil to equal 30 calories per
ounce. She is feeding well adlib, taking 70-80 mL every 4
hours with weight gain.
She is receiving supplemental potassium chloride due to
diuretic therapy and her most recent electrolytes were on
[**2128-6-16**] showed a sodium of 139, potassium 5.7, chloride
106, and CO2 22.
Her discharge weight 2455 grams. Length 47.5 cm. Head
circumference 32 cm.
GI: [**Known lastname 1894**] developed bloody stools on day of life 58 ([**2128-5-14**]) thought due to protein intolerance. Feedings were
changed to Nutramigen with the resolution of bloody stools.
[**Known lastname 1894**] received phototherapy early in her hospital course
for indirect hyperbilirubinemia. Her peak total bilirubin was
4.1 with a direct of 0.2.
Hematology: [**Known lastname 61508**] blood type is O-positive. Her direct
Coombs is negative. She received a total of 4 pack red blood
cell transfusions during her hospital course with the last
pack red blood cell transfusion on [**2128-5-2**]. Her most
recent hematocrit was 26% on [**2128-6-11**]. She is receiving
supplemental iron.
Infectious disease: She received 7 days of ampicillin and
gentamicin following delivery for suspected sepsis. Her blood
culture and lumbar puncture were negative. She received 3
doses of Kefzol with her PDA ligation. She received 48 hours
of vancomycin and gentamicin on day of life 54, rule out
sepsis. The sepsis was ruled out with a negative blood
culture and a benign CBC.
Neurology: [**Known lastname 1894**] has had 3 head ultrasounds with the last
being at 1 month of age and all were normal.
Sensory: Hearing screening was performed with automated
auditory brain stem responses. [**Known lastname 1894**] passed in both ears.
Ophthalmology: Eyes were examined most recently on [**6-14**]
revealing retinopathy of prematurity. Her retinopathy has
regressed from stage II to stage I. Her most exam showed
stage II, zone II 4 o'clock hours in the right eye, stage I,
zone II [**3-26**] o'clock hours in the left eye. A follow-up exam
is scheduled in a week.
Psychosocial: [**Hospital1 69**] social
work was involved with the family. The contact social worker
is [**Name (NI) 5036**] [**Name (NI) 4467**], and she can be reached at [**Telephone/Fax (1) 8717**]. The
parents are unmarried. Father of baby is involved and his
last name is [**Name (NI) 61509**]. [**Known lastname 61508**] last name will be changed to
[**Name (NI) 61509**] following discharge.
CONDITION ON DISCHARGE: Stable infant with chronic lung
disease.
DISCHARGE DISPOSITION: Discharged home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], M.D. in [**Hospital1 3597**],
[**State 350**], telephone number [**Telephone/Fax (1) 45059**].
CARE AND RECOMMENDATIONS:
1. Feeds: Nutramigen 30 calories per ounce adlib.
2. Medications: Diuril 50 mg orally every 12 hours, potassium
chloride 6 mEq orally twice a day, and ferrous sulfate 0.2
mL orally once a day.
3. Car seat position screening was passed.
4. State newborn screens have been done per state protocol
and all have been normal.
5. Immunizations received: Received Pediarix on [**5-18**],
hemophilus vaccine on [**5-18**], and PCV7 on [**5-18**]. She
received a 2nd dose of hepatitis as Recombivax on [**6-17**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the 3 criteria: 1. Born at less than 32 weeks, 2. Born
between 32 and 35 weeks with 2 of the following: daycare
during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED:
1. Follow up with pediatrician.
2. Early intervention referral made to family support early
intervention in [**Location (un) 4047**], telephone number [**Telephone/Fax (1) 44332**].
3. VNA referral made to [**Hospital1 3894**] Health, telephone number [**Telephone/Fax (1) 61510**].
4. Referral made to infant followup program.
5. Ophthalmology appointment with Dr. [**Last Name (STitle) **] at [**Location (un) **] Eye
Associates for [**2128-6-22**] at 1 p.m., telephone number
[**Telephone/Fax (1) 60296**].
DISCHARGE DIAGNOSES:
1. Prematurity at 26-weeks gestation.
2. Respiratory distress syndrome resolved.
3. Patent ductus arteriosus.
4. Status post patent ductus arteriosus ligation.
5. Suspected sepsis resolved.
6. Rule out sepsis.
7. Suspected mild protein intolerance.
8. Indirect hyperbilirubinemia resolved.
9. Chronic lung disease.
10. Apnea of prematurity resolved.
11. Anemia.
12. Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-6-16**] 22:42:45
T: [**2128-6-17**] 05:21:42
Job#: [**Job Number 61511**]
|
33520,51884,486,42731,4019,60000,42789,2859 | 94 | 140,037 | Admission Date: [**2176-9-2**] Discharge Date: [**2176-9-25**]
Date of Birth: [**2101-9-20**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
weakness and shortness of breath
Major Surgical or Invasive Procedure:
endotracheal intubation and extubation
arterial line placement
placed on assist controlled ventilation
History of Present Illness:
74 yo M with history of BPH, HTN, s/p recent cervical
laminectomy fusion [**2176-8-24**] for cervical stenosis who presented
to the ED from rehabilitation facility when he was noted to be
febrile to 102.2, tachycardic and diaphoretic on routine vital
check.
.
The patient was discharged from orthopedic service to rehab on
[**2176-8-28**]. He was discharged in cervical collar and on
Ciprofloxacin for treatment of UTI. Per family, the patient was
feeling well until 3 days prior to admission, when he complained
of trouble sleeping at night. The next day he started feeling
lightheaded. He has been feeling weak and was complaining of SOB
for several days. They also report that he has not been able to
eat due to shortness of breath. Family reports minimal po
intake. Per family, he also has been more listless over the last
several days. Per nursing home notes, the patient has not had
adequate pain relief despite Percocet standing q6 hrs and prn q
4hrs. Per family, the patient's upper extremity weakness
initially improved following the surgery, but lately he has not
been able to lift his arms off the bed to wave.
.
In the ED, VS T 98.7 (then spiked to 101.6), HR 78, BP 160/96,
97% RA. CXR showed RLL and RML opacities interpreted as PNA vs.
atelectasis. The pateint received Metronidazole 500mg IV,
Levofloxacin 500mg IV, Acetaminophen (Liquid) 650mg, Morphine
2mg IV, Lorazepam 2mg IV, Metoprolol 5mg IV x 2, Vancomycin 1000
mg IV once, Zosyn 4.5 mg IV once. Shortly after receiving
morphine and Ativan, he was noted to be lethargic. ABG was
checked and was 7.33/85/100 on 2L NC (previous ABG 7.41/pCO2
39/pO2 49 in [**2176-1-31**]). He was placed on BiPAP 15/5 FiO2 0.5
in the ED for hypercapnea. Narcan was not given.
.
While in the ED, the patient was also evaluated by orthopedics.
The wound was examined and cleared. Orthopedics recommended C
spine films. Currently, he denies any chest pain and is asking
for a sleep medication.
Past Medical History:
1. spinal stenosis s/p cervical laminectomy C3,4,5 and fusion on
[**2176-8-24**] by Dr. [**Last Name (STitle) 363**]
2. neurogenic bladder
3. BPH
4. HTN
Social History:
No tobacco, no ETOH. For approximately a month prior to his
surgery [**2176-8-24**], he was bed bound. Prior to that, he was getting
around in a wheelchair secondary to lower back pain. He lives
with his wife and his son. [**Name (NI) **] is unable to perform any of his
ADLs, his son does these for him. His is a former car mechanic.
Family History:
Non-contributory
Physical Exam:
Upon presentation to [**Hospital Unit Name 153**]:
VS: AF; HR 115; BP 138/75; 99% on 2L NC
General: thin chronically ill appearing elderly man lying bed,
breathing using accessory muscles
NECK: hard cervical collar in place
HEENT: NC, AT, PERRL, no scleral icterus, OP clear
CV: regular, nlS1/S2 no M/R/G
PULM: decreased breath sounds on right
ABD: soft, NT, ND +BS, no rebound or guarding
EXTR: no C/C/E; hands and feet cool to touch; DP and radial
pulses are 2+ bilaterally
NEURO: EOM intact, bilateral 4/5 weakness in upper extremities;
able to move hands/fingers, but unable to lift up arms off the
bed; Babinski equivocal
Pertinent Results:
Upon presentation:
[**2176-9-2**] 11:00AM GLUCOSE-77 UREA N-13 CREAT-0.2* SODIUM-133
POTASSIUM-4.6 CHLORIDE-86* TOTAL CO2-45* ANION GAP-7*
[**2176-9-2**] 11:00AM WBC-10.6# RBC-3.80* HGB-12.7* HCT-37.3*
MCV-98 MCH-33.5* MCHC-34.1 RDW-15.4
[**2176-9-2**] 11:00AM PLT COUNT-401#
[**2176-9-2**] 02:01PM LACTATE-2.3*
[**2176-9-2**] 03:47PM TYPE-ART PO2-100 PCO2-85* PH-7.33* TOTAL
CO2-47* BASE XS-14
.
[**2176-9-3**]: MRI c-spine: Postsurgical changes of C3-C5
decompressive laminectomies without evidence for recurrent
spinal stenosis, abnormal fluid collection or pathological
enhancement. However, assessment of hemorrhage is limited.
.
[**2176-9-16**]: EMG Abnormal study. The electrophysiologic findings
are most consistent with a generalized, severe, chronic and
ongoing disorder of motor neurons or their axons, affecting the
cervical, lumbar, and thoracic regions; however, severe, chronic
and ongoing cervical, thoracic, and lumbosacral
polyradiculopathies could also give rise to these
electrophysiologic findings. There is no evidence for a
generalized polyneuropathy, for a generalized myopathy, or for a
pre- or post-synaptic disorder of neuromuscular transmission.
Brief Hospital Course:
# Hypercapnic respiratory failure: This was felt to be a
combination of neuromuscular failure c-spine disease and ALS. He
completed a course of antibiotics (Vancomycin and Zosyn) for
pneumonia. s/p trach and PEG, stable on ventilatory settings.
Vent settings at discharge: AC Vt 450, 0.4 FiO2, RR 10 PEEP 5.
He was discharged to [**Hospital1 **] Rehab and will further
work on means to regain some of his voice while at rehab.
.
# ALS: recent diagnosis during this admission, He was started on
Rilutek per neuro recs.
.
# Labile BP: The patient's BP was initially very difficult to
manage, ranging from 60s/30s to SBP 200s. He was originally
treated with IVFs and pressors. The patient was able to mentate
with sBP in the 60s and BP improved upon awakening and with
decreased sedation. The patient's BP has been stable on
stimulation and midodrine. On the day of discharge, BP ranged
from 70-150; however, patient asymptomatic.
.
# Pain: Adequate control with lidocaine patch, fentanyl patch,
gabapentin. PRN Morphine and PRN Ibuprofen. Gabapentin dose at
discharge increased to 1200 TID.
.
# S/p cervical laminectomy. Patient with pain and weakness. Was
originally wearing a hard cervical collar at all times, and
changed to [**Location (un) 2848**] J collar which should be worn when out off
bed/changing position. Per recs, may be taken off while lying in
bed. Continue pain medications as needed.
.
# Fever. The patient was originally febrile with CXR showing RML
and RLL infiltrate vs atelectasis. He was originally started on
antibiotics and found to have an eosinophilia which was
attributed to zosyn. All cultures including BAL were negative
(except for yeast from likley colonization). Antibiotics were
eventually discontinued and the patient remained afebrile.
.
# PPX. Heparin SQ and PPI while NPO.
.
# FEN. s/p PEG, continue tube feeds.
# Code. Full.
.
# Access. PIV
.
# Communication. [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Name (NI) 22924**] (son/HCP) [**Telephone/Fax (1) 27951**]; [**Name (NI) **]
[**Name (NI) 22924**] (granddaughter) [**Telephone/Fax (1) 27952**]
.
# OUTSTANDING ISSUES at DISCHARGE:
1. Per orthopedics, he will need repeat films of C-spine (AP and
lat) once he is at rehab.
2. As he is transferring care to [**Hospital1 336**], he will need neurology
follow-up for his ALS.
Medications on Admission:
1. Gabapentin 600 mg PO TID
2. Tamsulosin 0.4 mg PO HS
3. Lisinopril 10 mg PO DAILY
4. Timolol Maleate 0.5 % [**Hospital1 **]
5. Latanoprost 0.005 % HS
6. Tolterodine 2 mg PO BID
7. Bisacodyl 10 mg Tablet Daily prn
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Trazodone 50 mg PO HS prn
11. Oxycodone-Acetaminophen 5-325 q 6 hrs standing and [**12-4**] tab
q4 prn
12. Ciprofloxacin 500 mg PO Q12H for 7 days
13. Senna 2 tabs qhs
14. Ativan 1 mg po qhs prn
15. Maalox 30 cc po qid prn
16. APAP 650 mg po q 4hrs prn
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
2. Senna 8.8 mg/5 mL Syrup [**Month/Day (2) **]: One (1) Tablet PO HS (at
bedtime).
3. Timolol Maleate 0.5 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic
DAILY (Daily).
4. Latanoprost 0.005 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic HS
(at bedtime).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
8. Ferrous Sulfate 325 (65) mg Tablet, Delayed Release (E.C.)
[**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed.
10. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
11. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 6-10 Puffs
Inhalation Q4-6H (every 4 to 6 hours) as needed.
12. Riluzole 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
13. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Midodrine 5 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q 8H (Every 8
Hours).
15. Fentanyl 75 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
16. Ketoconazole 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: One (1) PO Q6H (every
6 hours) as needed for pain.
18. Gabapentin 400 mg Capsule [**Hospital1 **]: Three (3) Capsule PO TID (3
times a day).
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
20. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) **]
Discharge Diagnosis:
Primary:
amyotrophic lateral sclerosis
s/p cervical laminectomy
labile hypertension
Secondary:
benign prostatic hypertrophy
Discharge Condition:
stable
Discharge Instructions:
You were diagnosed with amyotrophic lateral sclerosis.
Please continue all medications as prescribed. Please attend all
follow-up appointments.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
2761,7234,4240,4589,07999,4019,42789,78841 | 94 | 183,686 | Admission Date: [**2176-2-25**] Discharge Date: [**2176-2-29**]
Date of Birth: [**2101-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
1. endotracheal intubation
2. central venous catheter placement
History of Present Illness:
74 y/o M w/past hx of HTN and cervical radiculopathy, who
presented today c/o weakness. He stated that he thought he had
the flu over the past few days, with a nonproductive cough,
headache, and general weakness. Very poor PO intake. He was
recently prescribed effexor, and took his first dose this AM.
Approximately one hour after that, he felt much weaker. EMS was
called and on arrival his bp was 80/60. He received 1 L NS and
his bp responded to 120s.
On arrival to the ED, his bp was 110s-120s/60s with a pulse in
the 60s. He was awake, alert, and answering questions. His only
complaints were of a headache, and he felt like he had to
urinate but was unable to. He denied any chest pain, shortness
of breath, abdominal pain. Mild nausea but no vomiting. While
examining him, he became bradycardic to 42 and hypotensive to
60/40. He was febrile to 101.2 and diaphoretic. He received 2L
NS wide open with a mild response in his bp to 70s/50s. He was
put on peripheral dopamine. Bedside echo revealed no pericardial
effusion, possibly depressed EF, no visible aortic aneurysm, and
a dilated IVC. He was taken urgently to CT scan to r/o PE and
dissection.
In the CT scanner, he vomited. no aspiration observed and CXR no
infiltrate. No blood in vomit. He then became tachycardic to the
130s (narrow complex) which appeared to be SVT per ED resident
no ECG confirmation in CT. Dopamine stopped with normalization
of HR. He then again became tachycardic in the 130s, and this
time broke with carotid massage back down to 70. Still
hypotensive in 70s and so started on neo. CT showed no PE or
dissection.
When he returned, intubated for airway protection given vomiting
and hemodynamic instability. Never hypoxic or with resp
distress. Good mentation per family. vanc/levoflox/flagyl and
decadron. Lactate was 1.6 and he had 1600 cc UOP. His SBP came
back up to the 160s and the neo was weaned off. Multiple
attempts at right subclavian caused 2 arterial sticks. CXR
showed no pneumo/hemothorax.
Subsequently became hypotensive again, and placed back on neo
and dopa. Right IJ placed. Sent to CCU. Given total of 3
liters NS.
Recently had epidural steroid inject ion [**2-23**]. No worsening of
back pain since that time.
Past Medical History:
1. HTN
2. Cervical radiculopathy
3. Low back pain s/p lumbar epidural steroid injection [**1-8**]
Social History:
never smoked, no alcohol. lives with son. uses [**Name2 (NI) **] at
baseline. Has normal mental status. has home PT.
Family History:
non-contributory
Physical Exam:
Tm 101.2, Tm 99.8, bp 114/63, map 80, p 80 NSR
Vent: AC 600/5/r12/40%, rr (obs) 17, PIP 15
ABG: 7.34/44/371
I/O: UOP>30cc/hr
drips: neo 0.19, dopa 3
gen: well, nontoxic
lungs: CTAb
CV: s1/s2, rrr
abd: soft, nttp, nabs, nd
ext: no edema, warm, dry, dp2+
neuro: pupils 3mm equal, MAE, cantonese speaking only,
intubated.
skin: no rash or skin breakdown anteriorly
Pertinent Results:
Laboratory:
labs at discharge:
wbc 4.7, hct 41.2, plt 148
Na 134, K 3.6, Cl 110, HCO3 22, BUN 11, Cr 0.8, glucose 95, Ca
8.6, Mg 1.8, Ph 2.9.
.
Microbiology:
[**2-25**] Blood culture: pending.
[**2-25**] Urine culuture: negative.
[**2-26**] DFA for influenza: negative.
.
Imaging:
[**2-25**] CXR:
Clear lungs.
[**2-25**] CT chest/abdomen/pelvis:
1. No evidence for pulmonary embolus or aortic dissection.
2. Focal mesenteric region of increased attenuation which most
likely represents inflammation secondary to mesenteric
panniculitis, or less likely trauma, edema, or tumor (lymphoma).
There is no evidence of mesenteric vasculature or bowel
compromise. A biopsy or CT scan in the future may provide
further diagnostic information.
3. Fluid within the esophagus which increases this patient's
risk of aspiration.
4. Multiple low-attenuation lesions throughout the liver which
most likely represent simple liver cysts; however, an ultrasound
examination could be performed for confirmation when the patient
is clinically stabilized.
[**2-27**] TTE:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Preserved global and regional biventricular systolic
function.
Brief Hospital Course:
74 M with fever and hypotension intubated electively for airway
protection.
.
# Hypotension:
He was hypotensive in the emergency department which was of
unclear etiology. This was thought most likely to be due to
hypovolemia due to dehydration as his blood pressure normalized
with IV fluids. By the end of his hospitalization he had
actually started to become hypertensive and was started on
lisinopril 10 mg daily. His HCTZ was not restarted as it was
thought this may have been contributing to his hyponatremia.
.
Fever:
This was of unclear etiology and was attributed to a likely
viral syndrome. He had no localizing signs or symptoms of
infection. A test for influenza was negative as was a urine
culture. Blood cultures were pending at discharge. He was
initially treated with broad spectrum antibiotics including
vancomycin, levofloxacin, and metronidazole. Once his culture
data was negative he was switched to po levofloxacin and he was
discharged to complete a seven day course.
.
# Resp Failure:
He was intubated in the ED for airway protection but he was
successfully extubated shortly after arriving to the MICU and
maintained a normal O2 saturation throughout the rest of his
hospital course.
.
# Hyponatremia:
On admission he was initially hyponatremic with a sodium of 129.
This was thought to be due to a combination of hypovolemia from
dehydration as well as HCTX effect. With hydration and stopping
his HCTZ his sodium normalized and at discharge it was 134.
.
# Cervical radiculopathy:
He has a history of this and was last seen in neurology clinic
in [**2169**]. He intermittently complained of neck pain during his
admission and was set up with a follow-up appointment in
neurology with Dr. [**First Name (STitle) **] on [**4-8**] at 3:00.
.
# Lower back pain:
He has a history of chronic lower back pain and spinal stenosis
and has been followed in the pain management center. He was
kept on his gabapentin and has a follow-up appointment with the
pain clinic.
.
# Urinary hesitancy:
This is also a chronic issue for him and he was started on
tamsulosin during his hospitalization with some effect. He has
a follow-up appointment in the urology clinic.
.
# Focal mesenteric thickening on CT scan:
His abdominal exam was benign and he did not complain of
abdominal pain. The general surgery service was consulted and
did not recommend any intervention.
.
# Dispo:
He was discharged to home with plans for home physical therapy
as he had previously had. He was also set up for appointments
with his PCP, [**Name10 (NameIs) **] pain clinic, urology, and neurology.
Medications on Admission:
Gabapentin 300 mg qd
Spectravite Senior
Super B-complex
Omega3/Omega6 Fish Oil
HCTZ 25 mg qd
Xalatan 0.005% eye drop
Timolol 0.5% opthalmic solution
Effexor - started day of admission.
Discharge Medications:
1. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
1. Viral syndrome.
Discharge Condition:
Stable.
Discharge Instructions:
1. You are being discharged to home.
2. Please take your medications as prescribed.
--We started lisinopril for your blood pressure. Please take
this until you see Dr. [**First Name (STitle) **] next week and you can have your blood
pressure checked.
--We started tamsulosin for your urinary frequency.
--You should continue to take levofloxacin (an antibiotic) for
three more days.
3. Please come to your follow-up appointments (see below).
4. If you experience any fevers, chills, sweats, dizziness, or
other concerning symptoms, please seek medical attention.
Followup Instructions:
1. You have an appointemnt with Dr. [**First Name (STitle) **] on Wednesday [**3-6**]
at 2:00 pm. Please call his office at [**Telephone/Fax (1) 27950**] if you need
to reschedule this appointment.
2. Provider: [**Name10 (NameIs) 9894**],[**Name11 (NameIs) **](A) PAIN MANAGEMENT CENTER
Date/Time:[**2176-3-8**] 1:30
3. Provider: [**Name10 (NameIs) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2176-3-20**] 3:30 - urology appointment.
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-4-8**] 3:00 - neurology appointment.
Completed by:[**2176-3-1**] |
8604,4821,5185,4538,86509,86402,V461,8072,85181 | 96 | 170,324 | Unit No: [**Numeric Identifier 56203**]
Admission Date: [**2156-3-31**]
Discharge Date: [**2156-4-29**]
Date of Birth: [**2116-10-2**]
Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 39-year-old gentleman,
who sustained a 30-foot fall, hitting a porch prior to
landing on the ground. There was no loss of consciousness,
and the patient arrived in the Trauma Bay complaining of a
chest pain on arrival. He was noted to have a massive
bleeding from his oropharynx and became hypotensive to the
60s. He was emergently intubated, and a right femoral cordis
was placed. His blood pressure improved with a fluid
resuscitation, and his chest x-ray was clear. He had good
saturations after intubation. A DPL was performed given his
hypotension as an unknown source that was positive after
instillation of 1 L of saline. He was also noted to have a
left upper extremity open fracture. He was taken emergently
to the operating room for exploration.
PAST MEDICAL HISTORY: Unknown.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: No known drug allergies.
MEDICATIONS: None known.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Initial physical exam: Heart rate was
88, blood pressure 82/palpations, and 02 saturation 90
percent. The patient had an unstable face with a lip
laceration and blood in his oropharynx. GCS of 15. Pupils
equal, round, and reactive with TMs clear. Heart: Regular
rate and rhythm. S1 and S2. Chest: Clear to auscultation
bilaterally. Sternum stable with no crepitus. Abdomen is
soft, nontender, and nondistended. Rectal was guaiac
negative with a normal prostate and normal tone. Back showed
no step-offs or lacerations. Pelvis was stable. Left
forearm with an open fracture unstable with a 2 plus radial
pulse. Right arm question dislocation, and left and right
lower extremities are without deformities.
LABORATORY DATA: White blood cell count 8.1, hematocrit
38.9, and platelets 244,000. Chemistry-7: Sodium 143,
potassium 4, chloride 104, and bicarbonate 29. PT was 12.2,
PTT 19.4, INR 1.0, fibrinogen 199, and lactate was 3.5. ABG:
pH was 7.38, pCO2 43, pO2 232, bicarbonate 26, and base
deficit minus 2. UA was moderate blood and urine tox
negative. Initial films: Chest x-ray negative and pelvis
negative. Left forearm showed an ulnar fracture with radial
head displacement. Left shoulder was negative. Left wrist
was negative. Right shoulder, a nondisplaced fracture of the
greater tuberosity. A right humeral neck fracture that was
nondisplaced and impacted. CT of the head: Frontal
contusion, small temporal bleed, frontal sinus fracture of
the anterior and posterior table, and Le [**Location 56204**] fracture.
CT of the C-spine was negative. CT of the chest showed
bilateral pneumothoraces, right greater than left, with a
right upper lobe collapse and a sternal fracture.
BRIEF HOSPITAL COURSE: As per HPI, Mr. [**Known lastname 20598**] was taken
emergently to the operating room for exploration. On
entering the abdomen, they found a laceration of the
transverse mesocolon, splenic decapsulation, liver
laceration, and multiple colonic deserosalizations. The
splenic decapsulation was repaired, as were the serosal
injuries to the colon. The transverse mesocolon was
repaired, as was the liver laceration. The Orthopedic
Surgery team then came into the operating room for washout
and closed reduction of his left Monteggia fracture of the
radial head without long-arm splinting. He remained
hemodynamically stable throughout the procedure without
hypothermia. Of note, prior to this, because of the known
intracranial hemorrhage with hemodynamic instability,
Neurosurgery was called for bolt placement. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ICP
monitor was placed with pressures in the 10 to 13 range. He
was also placed on IV Ancef perioperatively. He was then
taken to the Trauma ICU where several consults were obtained,
including an Ophthalmology consult regarding his orbital wall
fractures. They did not identify any entrapment on CT and
recommended outpatient followup. He had subsequent bilateral
chest tubes placed and a subclavian line placed on return to
the ICU. He was seen by Oromaxillofacial Surgery regarding
his facial fractures and was taken to the operating room on
[**2156-4-12**] for open reduction and internal fixation of his mid
face fractures. Of note, he had a large laceration of his
eyebrow/nasal region that had been closed on the day of
admission. Of note, because of his multiple facial injuries
and his deteriorating respiratory status over the course of
his ICU stay, he ended up developing Pseudomonas in his
urine. A tracheostomy was performed on [**2156-4-7**]. He also
had an IVC filter placed on [**2156-4-12**] after bilateral lower
extremity ultrasound revealed a right common femoral vein
nonocclusive thrombus. A CTA of the chest to evaluate for
pulmonary embolus was negative, but was a poor quality study.
He was subsequently additionally started on a heparin drip.
However, there was difficulty in making him therapeutic, and
a Hematology consult was obtained. However, he was deemed to
have no identifiable hematologic problem and was eventually
maintained on goal PTT. Coumadin was subsequently started.
He was maintained on antibiotics for the Pseudomonas in his
sputum. He did continue to spike temperatures during his ICU
stay and required frequent suctioning and aggressive
pulmonary toilet to manage his copious secretions. After
recovering from his last operation, which was the ORIF of his
facial fractures, he was finally transferred to the floor on
[**2156-4-20**]. Due to the fact that he was now a candidate for
anticoagulation, Vascular Surgery was re-consulted and his
IVC filter was removed. He was then placed on Lovenox for
anticoagulation purposes. He was able then to ambulate with
physical therapy. However, he continued to have a very poor
p.o. intake. We strongly encouraged p.o., and he stabilized
his intake and was cleared by Speech and Swallow and was
deemed stable for discharge to home from that standpoint. He
was also placed on a Passy-Muir valve, which he tolerated
well. He defervesced, and his antibiotics were stopped, and
he remained without any further infectious issues. His
mental status improved, and he was able to follow commands,
and he was oriented x 3. Once his mental status had
improved, his C-spine was clinically cleared and his C-collar
was removed. He was followed up by Orthopedic Surgery, who
revised his cast after doing repeat films of his left upper
extremity. He continued to progress well, and he was deemed
stable for discharge to home on postoperative day numbers 29
and 17, which was also hospital day number 30.
DISCHARGE DIAGNOSES: Status post fall with multiple
injuries, including:
Mesocolic laceration.
Splenic laceration.
Liver laceration.
Colonic deserosalization x 3.
Le [**Location 56204**] fracture with fractures of the anterior and
posterior table of the frontal sinus.
Open left ulnar fracture with radial head dislocation.
Dislocated right shoulder reduced with greater tuberosity
fracture nondisplaced.
Status post exploratory laparotomy.
Status post open reduction and internal fixation of the left
ulna.
Status post tracheostomy placement.
Respiratory failure with ventilator-associated pneumonia,
resolved.
Right common femoral vein deep vein thrombosis.
Status post inferior vena cava filter placement and removal.
Status post bronchoscopy.
DISCHARGE MEDICATIONS:
1. Lovenox 90 mg subcutaneously q.12h.
2. Percocet 1 to 2 p.o. q.4-6h. p.r.n.
3. Peridex mouthwash p.r.n.
4. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: The patient will be discharged to home
with services.
DISCHARGE INSTRUCTIONS: The patient should keep his left arm
cast on and leave tracheostomy capped, right arm, to have a
full range of motion and weightbearing as tolerated. Keep
left arm elevated and use saline drops in both eyes p.r.n.
FOLLOWUP: Follow up with the Trauma Clinic in 2 weeks, with
[**Company 191**] associate, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 2 weeks, with [**Hospital3 56205**] Center in 2 weeks, and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
Orthopedic Surgery in 2 weeks, and with Oromaxillofacial
Surgery on [**2156-5-10**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2156-6-21**] 08:21:01
T: [**2156-6-21**] 13:45:06
Job#: [**Job Number 56206**]
|
4401,4019,2720,42731,4111,4241,41401 | 97 | 127,870 | Admission Date: [**2105-4-28**] Discharge Date: [**2105-5-6**]
Date of Birth: [**2031-12-8**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with known coronary artery disease. He is status post
coronary artery bypass grafting in [**2083**], PTCA to the right
coronary artery in [**2093**], and PTCA of the saphenous vein graft
in [**2099**].
He has had recent increase in frequency of chest pain.
Catheterization on the day of admission revealed diffuse
coronary artery disease. The [**Hospital Unit Name 196**] Team consulted CT Surgery
for a coronary artery bypass grafting.
PAST MEDICAL HISTORY: Coronary artery bypass grafting in
[**2083**] with saphenous vein graft to left anterior descending.
Stenting in [**2093**] of the right coronary artery and stenting in
[**2099**] of his saphenous graft. The patient had a right renal
artery stent in [**2104-1-16**]. Hypertension.
Hypercholesterolemia. Tobacco abuse. Back surgery. Hernia
repair. Appendectomy.
MEDICATIONS ON ADMISSION: Aspirin 325 p.o. q.d.,
Nitroglycerin patch, Lisinopril 40 p.o. q.d., Nadolol 10 mg
p.o. q.d., Hydrochlorothiazide 25 mg p.o. q.d., Nifedipine 90
mg p.o. q.d., Pravachol 10 mg p.o. q.d., Vitamin E, Prilosec
20 mg p.o. q.d.
ALLERGIES: INTRAVENOUS DYE WHICH CAUSES HIVES.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory.
PHYSICAL EXAMINATION: General: The patient was in no acute
distress. He was alert and oriented times three. Lungs:
Clear to auscultation bilaterally. Cardiovascular: Regular,
rate and rhythm. Normal S1 and S2. There was a grade 3/6
systolic ejection murmur. Abdomen: Soft, nontender,
nondistended. No organomegaly. Extremities: He had +2
pulses throughout with no peripheral edema. Neurological:
Grossly intact.
LABORATORY DATA: White count 5.2, hematocrit 37.3, platelet
count 176; INR 1.1; urinalysis was negative; chemistry showed
a sodium of 138, potassium 4.0, chloride 104, bicarb 28, BUN
27, creatinine 0.8, glucose 127; LFTs were all within normal
limits.
Chest x-ray showed no acute cardiopulmonary disease.
ASSESSMENT AND PLAN: This was a 73-year-old male with
recurrent diffuse coronary artery disease and coronary artery
bypass grafting in the past, now requiring coronary artery
bypass grafting of diffuse coronary artery disease.
The patient will be brought to the Operating Room with Dr.
[**Last Name (STitle) 70**] for coronary artery bypass grafting.
HOSPITAL COURSE: On [**2105-4-30**], the patient was brought
to the Operating Room for a redo coronary artery bypass
grafting times two and aortic valve replacement. The patient
tolerated the procedure well and was transported intubated to
the PACU in stable condition on a Levophed drip, Milrinone
drip, and a Propofol drip. The patient had atrial wires and
a chest tube.
On postoperative day #1, the patient was continued on his
Levophed drip and Milrinone drip over night. The patient was
extubated over night and was on a nasal cannula of 4 Lungs:,
oxygen saturation 95% on room air. The patient's vital signs
were otherwise stable.
The patient had a postoperative hematocrit of 26.8; otherwise
laboratory values were all within normal limits. The patient
was encouraged to be out of bed. Drips were weaned. The
patient was started on his Plavix.
On postoperative day #2, the patient was off all drips, was
started on Aspirin 325 per day and Captopril 6.25 t.i.d. The
patient was afebrile in sinus rhythm. The patient had an
oxygen saturation of 96% on 2 L nasal cannula. The patient
had minimal output from the chest tubes.
The patient's white count was 9.7, hematocrit 25.4, otherwise
other labs were all within normal limits.
The patient's chest tubes were removed, and the patient was
transferred to the floor. On postoperative day #2, the
patient was also seen by Physical Therapy.
On postoperative day #3, the patient was still in the
Intensive Care Unit. The patient was kept in the Intensive
Care Unit due to bed availability.
The patient was afebrile with a T-max of 99.7??????. The patient
developed atrial fibrillation over night; however, the
patient was rate controlled. The patient had an oxygen
saturation of 96% on 2 L nasal cannula.
The patient's hematocrit on postoperative day #3 was 23.9.
Other lab values were all within normal limits. The patient
was started on Lopressor 12.5, Heparin drip at 600. The
patient's wires were removed.
The patient self-converted to normal sinus rhythm with
occasional premature atrial contractions. The patient
remained in normal sinus rhythm, and his Heparin drip was
held. The patient was continued on Lopressor and Captopril,
and tolerating it well.
On postoperative day #4, the patient's hematocrit was 22.3.
The patient was transfused 2 U packed red blood cells. The
patient's Lopressor was increased. The patient was continued
on Captopril. The patient was transferred to the floor.
On postoperative day #5, the patient was on Aspirin, Lasix,
and Metoprolol 25 b.i.d. The patient was in sinus rhythm.
The patient had an oxygen saturation of 94% on room air.
The patient was out of bed with Physical Therapy. Follow-up
hematocrit revealed a hematocrit of 29.8, which was up from
22.3. The patient was ambulating at a physical therapy level
of 5. The patient's Metoprolol was increased to 25 t.i.d.
The patient tolerated this well.
On postoperative day #6,the patient was at a physical therapy
level of 5. The patient was tolerating a regular diet, and
the patient was in stable condition, and it was felt that the
patient could be discharged home with VNA services. The
patient was therefore discharged home with VNA services in
stable condition.
DISCHARGE PLANNING: The patient will follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in six weeks. The patient will follow-up with Dr.
[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**]; the patient will call the office for an
appointment in two weeks.
DISCHARGE MEDICATIONS: Darvocet 1 tab p.o. q.6 hours p.r.n.
pain, Metoprolol 25 mg p.o. t.i.d., Pravastatin 20 mg p.o.
q.d., Lasix 20 mg p.o. b.i.d. for 10 days, Colace 100 mg p.o.
b.i.d., Zantac 150 mg p.o. b.i.d., Aspirin 325 mg p.o. q.d.,
Ibuprofen 600 mg p.o. q.8 hours.
DISCHARGE DIAGNOSIS:
1. Status post redo coronary artery bypass grafting times
two and aortic valve replacement.
2. Coronary artery disease.
3. Hypercholesterolemia.
4. Renal artery stenosis.
DISCHARGE STATUS: The patient is discharged to home in
stable condition with VNA care for wound evaluation and
hemodynamic monitoring.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2105-5-5**] 11:46
T: [**2105-5-5**] 22:33
JOB#: [**Job Number 40229**]
|
2449,4373 | 98 | 188,606 | Admission Date: [**2137-4-2**] Discharge Date: [**2137-4-9**]
Date of Birth: [**2096-10-18**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old
female with complaints of headache and dizziness. In [**2137-1-30**], the patient had headache with neck stiffness and was
unable to walk for 45 minutes. The patient also had a
similar episode a year and a half ago where she had inability
to walk without pain. She had a headache at that time which
was relieved with Tylenol.
PAST MEDICAL HISTORY: Hypothyroidism.
ALLERGIES: Penicillin and Bactrim which causes a rash.
MEDICATIONS: Levoxyl 1.75 mg.
PHYSICAL EXAMINATION: On physical examination, her blood
pressure was 104/73, pulse 79. In general, she was a woman
in no acute distress. HEENT: Nonicteric. Pupils are equal,
round, and reactive to light. Extraocular movements are
full. Pharynx is benign. Tongue midline. Neck is supple.
Chest was clear to auscultation. Cardiac: S1, S2, regular,
rate, and rhythm. Abdomen is soft, nontender, nondistended,
negative bruits. Extremities: No clubbing, cyanosis, or
edema. Palpable pulses. Gait was steady.
The patient is being admitted status post cerebral aneurysm
with clipping. The patient underwent right MCA and a right
A-comm aneurysm clipping via a right pterional craniotomy
without intraoperative complication. Postoperative vital
signs are stable. Patient was afebrile. She was awake,
alert. Pupils are equal, round, and reactive to light. EOMs
are full. No facial droop, no drift. Strength down the legs
was [**6-3**].
On postoperative day #1, the patient was taken to
arteriogram, where she underwent a cerebral angiogram to
evaluate clipping of the aneurysm. It was found at that time
that the patient had a third aneurysm and that the MCA
aneurysm which was clipped was at the origin of the anterior
temporal artery and not the one at the MCA bifurcation. The
patient was therefore taken back to the operating room for a
clipping of the second MCA aneurysm without intraoperative
complication.
The patient was monitored in the Surgical Intensive Care
Unit. She was alert, awake, oriented, complaining of severe
headache, moving all extremities. EOMs full, negative drift,
a smile was symmetric, IP is [**6-3**]. The patient was then
discharged to the floor on [**2137-4-5**]. She has been out of
bed and ambulating with Physical Therapy, tolerating a
regular diet, and voiding spontaneously.
She has been seen by Physical Therapy, and was found to be
safe to discharge to home with home physical therapy on
[**2137-4-9**]. Her incision is clean, dry, and intact and she
is neurologically stable.
DISCHARGE MEDICATIONS:
1. Hydromorphone 2-6 mg po q4h prn.
2. Synthroid 175 mcg po q day.
3. Colace 100 mg po bid.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP INSTRUCTIONS: She will follow up in 10 days for
staple removal with Dr. [**Last Name (STitle) 1132**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2137-4-8**] 08:14
T: [**2137-4-8**] 08:20
JOB#: [**Job Number 95045**]
|
41401,4139,4019,2720,7820,V1083,6000 | 99 | 187,373 | Admission Date: [**2184-7-29**] Discharge Date: [**2184-8-4**]
Date of Birth: [**2111-4-7**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male admitted to [**Hospital1 69**] due to
new onset of angina and a positive stress test.
He was fine until approximately two weeks prior to
presentation when he started developing exertional chest
pain. The pain resolved with rest. He had a stress test
which showed inferolateral ST changes. An echocardiogram was
negative for ischemia. Ejection fraction was 60%. The
patient had a catheterization which showed 3-vessel disease.
He was referred to Cardiothoracic Surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Basal squamous cell skin cancer.
3. Hemorrhoids.
PAST SURGICAL HISTORY:
1. Status post hemorrhoidectomy
2. Status post tonsillectomy and adenoidectomy.
3. Status post knee arthroscopy.
ALLERGIES: SULFA, SHELL FISH, and DYE.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., Zestril 10 mg p.o. q.d., Centrum
p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure
was 155/76, heart rate was 48. Chest was clear to
auscultation bilaterally. Cardiovascular revealed a regular
rate and rhythm. Extremities were well perfused, no edema.
The abdomen was soft, nontender, and nondistended.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 13.3,
hematocrit was 46.2, platelets were 230. Sodium was 138,
potassium was 4.7, chloride was 101, bicarbonate was 26,
blood urea nitrogen was 19, creatinine was 1.2. INR was 0.9.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2184-7-29**] where he had a coronary artery bypass
graft times three with left internal mammary artery to left
anterior descending artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to ramus. The operation was
without complications. Pacing wires as well as chest tube
were placed intraoperatively. The patient was transferred to
the Surgical Intensive Care Unit in stable condition.
On postoperative day one, the patient was afebrile. Vital
signs were stable. He was extubated without complications.
His chest tube was removed successfully.
On postoperative day two, the patient remained afebrile.
Vital signs were stable. His intravenous line and Foley were
removed. The patient was transferred to the floor.
On postoperative day three, the patient remained afebrile.
Vital signs were stable. He started working with Physical
Therapy. He complained about pain and weakness in his left
arm. The patient reported it was worse immediately
postoperatively and slowly improved with time. On serial
examinations which were performed, the patient's strength had
improved over the preceding two days.
On postoperative day four, an Occupational Therapy
consultation was obtained who found that the patient did not
need immediate Occupational Therapy treatment at this time.
Their recommendation was to follow up on an outpatient basis
in two to three weeks if he did not recover significantly at
this time. The patient remained afebrile. Vital signs were
stable. He was exercising with Physical Therapy. No
concerns. No active issues.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was discharged to home without
[**Hospital6 407**].
DI[**Last Name (STitle) 408**]E FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (Prefixes) **] in four weeks for a postoperative check. The
patient was to follow up with his primary care physician in
two to three weeks for his left arm numbness and weakness; if
symptoms do not improve at that time, he may request referral
to the outpatient Occupational Therapy.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. b.i.d. (times seven days).
2. Potassium chloride 20 mEq p.o. b.i.d. (times seven days).
3. Zantac 150 mg p.o. b.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Percocet one to two tablets p.o. q.4h. as needed.
6. Tylenol 650 mg p.o. q.4-6h. as needed.
7. Lopressor 25 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; stabilized.
2. Status post coronary artery bypass graft times three.
3. Hypercholesterolemia.
4. Hypertension.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2184-8-3**] 18:32
T: [**2184-8-3**] 19:32
JOB#: [**Job Number **]
|
99602,4241,4411,4260,42731 | 100 | 153,952 | Admission Date: [**2157-8-10**] Discharge Date: [**2157-8-16**]
Date of Birth: [**2085-8-31**] Sex: F
Service:
ALLERGIES: Sulfa.
MEDICATIONS: Hydrochlorothiazide 25 mg q d.
PAST MEDICAL HISTORY: Aortic insufficiency.
PAST SURGICAL HISTORY: Status post AVR.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
female who is status post AVR in [**2139**] for aortic stenosis
with prosthetic valve, symptomatic, during routine echo which
showed severe aortic insufficiency and poorly functioning
valve, although patient remained asymptomatic. The patient
also underwent cardiac catheterization which showed again
significant valvular dysfunction with insignificant coronary
artery disease.
PHYSICAL EXAMINATION: Pulse 77 and regular, blood pressure
154/66. HEENT: No lymphadenopathy. Neck, no JVD, bruits.
Chest, clear to auscultation bilaterally. Heart, regular
rate and rhythm, 4/6 systolic ejection murmur at second
intercostal space, radiating up to the neck. Extremities,
warm, well perfused, no edema. Pulses strong and equal
bilaterally. EKG, PVCs, no ischemia.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2157-8-10**]. During placement of monitoring lines by
anesthesia team, the patient became asystolic for a brief
period of time and came back after chest compressions,
Atropine and Epinephrine. Intraoperatively the patient had
supracoronary aortic rupture which required large graft
placement. She also had aortic valve successfully replaced
with 21 mm pericardial valve. Pacing wires as well as
mediastinal and pleural tubes were placed intraoperatively.
The patient was transferred to ICU in stable condition. On
postoperative day #1 the patient had a few episodes of
asystolic which resolved spontaneously and did not require
any treatment. Patient was afebrile, vital signs were
stable. Postoperative day #2 the patient was extubated
without complications and episodes of atrial fibrillation
responded to two Amiodarone boluses. She was also started on
Lasix. She was transferred to the regular floor in stable
condition. On postoperative day #3, overnight, patient had
an episode of atrial fibrillation. She again responded
really well to Amiodarone boluses, was started on oral
Amiodarone. Her chest tube was discontinued without
complications. Foley was discontinued. Postoperative day #5
wires were taken out without complication, patient again had
an episode of atrial fibrillation responding really well to
Amiodarone and remained afebrile, vital signs stable,
ambulating well with PT. No concerns, no active issues.
DISCHARGE MEDICATIONS: Enteric coated Aspirin 325 mg po q d,
Tylenol 325 mg 1-2 tabs po q 6 hours prn, Percocet 1-2 tabs q
4-6 hours prn, Amiodarone 400 mg tid for 7 days, then 400 mg
[**Hospital1 **] for 7 days, then 400 mg q d, Lasix 20 mg po bid for 7
days, potassium chloride 20 mEq one tablet po bid for 7 days.
CONDITION ON DISCHARGE: Good.
DI[**Last Name (STitle) 408**]E STATUS: The patient is discharged home. The
patient should follow-up with Dr. [**Last Name (Prefixes) **] in four weeks
for postoperative follow-up.
DISCHARGE DIAGNOSIS:
1. Non functioning AVR, status post AVR re-do.
2. Aortic rupture, status post supracoronary aortic graft
placement.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2157-8-15**] 13:56
T: [**2157-8-15**] 14:03
JOB#: [**Job Number 106751**]
|
99602,4241,4411,4260,42731 | 100 | 153,952 | Admission Date: [**2157-8-8**] Discharge Date: [**2157-8-18**]
Date of Birth: [**2085-8-31**] Sex: F
Service: Cardiac Surgery
This is an addendum to a discharge summary.
On the night of [**8-15**], the patient had a 10 second
complete heart block. While she was walking with the family,
the patient collapsed, felt nauseated. Afterwards, the
patient's amiodarone was discontinued. The patient was moved
to bed rest, had a electrodes placed in her chest rest of the
night and the next day were unremarkable. EP was consulted
who recommended discontinuing amiodarone which was done, as
well as pacemaker placement. That night, the patient had
another episode of complete heart block which lasted
approximately six seconds. The patient was in bed, did not
have nausea or any other symptoms after that or prior to that
episode. The patient remained afebrile. Rest of vital signs
stable. The patient was in normal sinus rhythm.
On postoperative day #6, the patient had a dual chamber
pacemaker placed by EPS service. Operation went without
complications. It was reported that the patient is now
ventricularly paced, but has atrial fibrillation as an
underlying ............., so the patient was started on
Warfarin when she came back to the floor as well as restarted
on amiodarone in an attempt to convert the patient.
Po[**Last Name (STitle) **]ative day #7, the patient is afebrile. Vital signs
are stable. The patient will be discharged home with follow
up by pacemaker clinic, EPS service and Dr. [**Last Name (Prefixes) **].
DISCHARGE MEDICATIONS;
1. Aspirin enteric coated 325 mg po qd
2. Tylenol 325 mg 1 to 2 tablets po q6h
3. Percocet 1 to 2 tablets po q 4 to 6 hours prn
4. Amiodarone 400 mg [**Hospital1 **] for four days, then 400 mg po qd
for four weeks, then 200 mg qd
5. Lasix 20 mg po bid x7 days
6. Potassium chloride 20 milliequivalents 1 tablet po bid
for seven days
7. Coumadin 2 mg po qd
8. Docusate sodium 100 mg po bid
DISCHARGE CONDITION: Good
DI[**Last Name (STitle) 408**]E STATUS: The patient is discharged home. The
patient should have her INR checked in the next 48 hours and
call her primary care doctor with the results and Coumadin
dose adjustment. The patient should follow up with Dr. [**Last Name (Prefixes) 411**] in four weeks for postoperative check. The patient
should follow up in pacemaker clinic in one week.
DISCHARGE DIAGNOSES:
1. Aortic insufficiency, status post AVR repair
2. Status post aortic rupture, super coronary aortic graft
3. Complete heart block with permanent pacemaker placement
4. Atrial fibrillation
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2157-8-18**] 08:54
T: [**2157-8-18**] 09:05
JOB#: [**Job Number 106752**]
|
51881,5070,48240,5121,5185,4275,3481,78003,2762 | 101 | 175,533 | Admission Date: [**2196-9-26**] Discharge Date: [**2196-10-12**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 724**] is an 82 year-old Asian
male with a history of dementia, who was transferred from the
MICU to the floor following a long stay for respiratory failure,
complicated by fevers and complicated by bilateral iatrogenic
pneumothoraces requiring chest tube placement. Briefly the
patient was admitted on [**2196-9-26**] following a respiratory and
cardiac arrest after choking on food. The patient was
resuscitated and intubated in the field by EMS. Estimated total
time of arrest (cardiac and respiratory) was 5 to 15 minutes
including 5 to 10 minutes of CPR. In the Emergency Department
the patient received a left pneumothorax following an attempted
left subclavian line placement. This left pneumothorax required a
chest tube. The Emergency Department course is also notable for
hypotension requiring Levophed, as well as witnessed aspiration
event. Upon arrival to the [**Hospital Unit Name 153**] complications of the left chest
tube resulted in a left tented pneumothorax as well as a right
sided pneumothorax presumed secondary to high PIPs in the 90s.
The cardiac surgery was consulted and bilateral chest tubes were
placed. The patient was initially begun on Levofloxacin/Flagyl
for presumed aspiration pneumonia with bilateral infiltrates on
chest x-ray. The patient intermittently spiked fevers in the
[**Hospital Unit Name 153**] for which Vancomycin was added on [**2196-9-30**]. In addition,
the patient had episodes of supraventricular tachycardia, which
was responsive to Adenosine and vagal maneuvers. A neurology
consult was obtained who felt that anoxic brain injury was highly
unlikely and his prognosis for recovery was poor. After an
extensive discussion with the patient's family the patient's code
status was changed to DNR/DNI. On [**2197-10-5**] the patient was
extubated and bilateral chest tubes were discontinued. Since
[**2197-10-5**] the patient remained hemodynamically stable and the
patient was transferred to the floor on [**2196-10-6**].
PAST MEDICAL HISTORY:
1. Dementia of Alzheimer's type.
2. Prior CEAs.
ALLERGIES: Bacitracin and Neosporin.
MEDICATIONS AT HOME:
1. Aricept 10 mg po q.d.
2. Zyprexa 25 mg po q.d.
3. Prevacid 30 mg po q.d.
4. Tube feeds.
ANTIBIOTICS WHILE INPATIENT:
1. Levofloxacin 500 mg q.d.
2. Vancomycin 500 mg q 24.
3. Flagyl 500 mg q 8 hours.
4. Subcutaneous heparin.
SOCIAL HISTORY: The patient is a resident of the [**Hospital3 45444**] facility). The patient's son [**Name (NI) **] is health
care proxy. The patient's daughter [**Name (NI) **] is power of attorney.
The patient's wife is living in she lives at home in [**Location (un) 86**]. The
patient has five children, four of whom who live locally and one
who is in route to the hospital.
PHYSICAL EXAMINATION ON TRANSFER: Temperature 97.3.
Temperature max 99.6. Heart rate 57. Blood pressure 95 to
130/35 to 60. Respiratory rate 12 to 14. O2 saturation
100%. In general, the patient is unresponsive to verbal
stimuli, but responsive to pain. Coarse upper airway sounds
are audible. Cardiovascular distal heart sounds without
murmurs. Lungs very coarse breath sounds, positive upper
airway noise, positive rhonchi. Abdomen soft, nontender,
nondistended. No masses, bowel sounds are positive.
Extremities bilateral upper extremities and bilateral lower
extremities with marked edema.
LABORATORY DATA ON [**2196-10-5**]: White blood cell count 10.4,
hematocrit 28.3, sodium 141, potassium 4, chloride 106,
bicarb 27, BUN 22, creatinine 0.5, albumin 2.3, calcium 7.6,
magnesium 1.9.
RADIOLOGY: Chest x-ray on [**10-6**] bilateral basilar lower lobe
opacities right greater then left increasing over the past
few days.
MICROBIOLOGY: [**10-1**] blood cultures times two, sputum is
negative. Urine is negative. [**9-29**] blood cultures times two
are negative. Urine is with positive coag negative staph.
Electrocardiogram on [**9-26**] normal sinus rhythm at 94 beats
per minute, right bundle branch block, low limb voltage.
IMPRESSION: The patient is an 82 year-old Asian male with
baseline dementia who is initially admitted after a prolonged
cardiac/respiratory arrest. He was admitted to the Medical
Intensive Care Unit with anoxic brain injury secondary to
prolonged cardiac and respiratory arrest. In addition his
hospital course was complicated by pneumothoraces as well as
continued aspiration. A neurology consult was obtained to
evaluate the patient and their overall consensus was that this
patient's prognosis was very poor. Upon transfer to the floor
the patient was currently aspirating with worsening bilateral
lower lobe infiltrates, and the risk of recurrent arrest or
decompensation was high.
HOSPITAL COURSE: 1. Pulmonary: The patient continued
aspirating. He remained on high oxygen flow by shovel mask. The
was continued with supplemental oxygen with suctioning prn.
2. Cardiovascular: The patient is hemodynamically stable,
blood pressure in the 90 to 120 range.
3. Infectious disease: Afebrile times 48 hours with negative
culture workup thus far. His fevers are likely secondary to
aspiration pneumonitis/pneumonia versus central in origin.
Because of worsening infiltrates the patient was continued on
aspiration coverage with Levofloxacin/Flagyl.
4. Renal: The patient's BUN to creatinine ratio was steadily
increasing. This increasing ratio is likely indicated of a
prerenal insufficiency. Intravenous fluids were given to the
patient to assist with the prerenal condition.
5. Neurology: As per the neurological evaluation significant
neurological recovery was very unlikely and the and patient's
prognosis was poor.
6. FEN: The patient's tube feeds were continued initially.
7. Prophylaxis: The patient was kept on a PPI and
subcutaneous heparin.
8. Code status: A family meeting was carried out with the
[**Hospital 228**] health care proxy, son [**Name (NI) **] and power of attorney
daughter [**Name (NI) **]. The [**Hospital 228**] medical condition was discussed
and at the patient's current state he was at extremely high risk
of decompensation and another cardiopulmonary arrest. The
patient on transfer to the floor was DNR/DNI. A family meeting
on [**2196-10-7**] with the son [**Name (NI) **] and daughter [**Name (NI) **] to represent the
family. The [**Hospital 228**] medical condition and treatment were
discussed in depth regarding DNR/DNI, intravenous fluids,
antibiotics, deep oropharyngeal suction, laboratory draws, chest
x-rays and blood cultures. [**Doctor Last Name **] stated that the family had
already made peace with their father's health condition and he
voiced the preference that the patient be kept comfortable. [**Doctor Last Name **]
also stated that he wished that his father would "go peacefully"
with no intervention. [**Doctor Last Name **] and [**Location (un) **] stated that they did
not want any intravenous fluids or any pressors. It was decided
by the family to discontinue all lines, intravenous fluids, with
prn morphine given for comfort. In addition, the family declined
deep oropharyngeal suctioning and laboratory draws. Regarding
feedings, daughter felt that the nasogastric tube feedings "would
not change anything" and they opted to have the nasogastric tube
feeds discontinued as well. The patient's family stressed that
the primary role is that the patient is to be kept comfortable
and peaceful. A plan was made that the patient would be kept on
supplemental oxygen for comfort, given prn morphine, oral
suctioning as needed for comfort, as well as Scopolamine patches
to decrease secretions.
From [**10-8**] through [**2196-10-12**] the patient was kept comfortable with
oxygen, morphine and prn Tylenol. Throughout his course the
patient remained unresponsive, though the patient did once open
his eyes to touch. The patient's course continued to decline
from [**10-7**] through [**10-12**] and he was without spontaneous movement.
On [**10-10**] the patient began having increased secretions, increased
gurgling and his respiratory status became more labored. In
addition, the patient began to have increased work of breathing.
Supplemental oxygen, Scopolamine patches to decrease secretions
and morphine GTT were continued for comfort. On [**2196-10-12**] at 12:17
p.m. the patient expired.
DISCHARGE DIAGNOSES:
1. Dementia secondary to Alzheimer's disease.
2. Aspiration of food causing cardiac arrest.
3. Anoxic brain damage secondary to prolonged
cardiopulmonary resuscitation.
4. Continued aspiration pneumonitis/pneumonia.
5. Iatrogenic pneumothorax status post subclavian line
attempt.
6. Left tension pneumothorax, secondary to displacement of
left sided chest tube, which also resulted in a small right
pneumothorax.
7. Status post placement of bilateral chest tubes and
removal of bilateral chest tubes.
8. Acute respiratory failure, requiring ventilator support
while in the Medical Intensive Care Unit.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Numeric Identifier 45445**]
MEDQUIST36
D: [**2197-5-13**] 02:19
T: [**2197-5-16**] 12:43
JOB#: [**Job Number 45446**]
|
V3000,769,7742,7793,76517,76526,75261,75263,V290 | 102 | 195,700 | Admission Date: [**2196-2-27**] Discharge Date: [**2196-3-31**]
Date of Birth: [**2196-2-27**] Sex: M
Service:
DISCHARGE DIAGNOSES:
1. Premature male infant 32-1/7 weeks gestation.
2. Status post respiratory distress syndrome.
3. Hypospadias with chordee.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] was born at [**2132**] [**Year (4 digits) **]
at 32-1/7 weeks gestation to a 34-year-old gravida 3 para 0
now one B+ female whose remaining prenatal screens were
noncontributory. Pregnancy was conceived via in-[**Last Name (un) 5153**]
fertilization.
A uterine hematoma was noted at seven weeks with a normal
fetal survey. She was admitted at 25 weeks in preterm labor
and was treated with a course of betamethasone at that time.
She has remained hospitalized at bed rest and magnesium
sulfate. Preterm premature rupture of membranes occurred 11
hours prior to delivery. She received intrapartum
antibiotics and induction began. She had a normal
spontaneous vaginal delivery and the infant's Apgars were 4
6,7 at 1, 5, and 10 minutes. Infant had a cry, but became
apneic soon thereafter. He received positive pressure
ventilation for 1-2 minutes. He was brought to the NICU at
[**Hospital3 **] Hospital with blow-by oxygen without incident.
His admission examination was remarkable for a hypospadias
with chordae and a meatus at the base of the phallus with
testes high in the scrotum.
On admission, the baby weighed [**2132**] [**Name2 (NI) **], length 45 cm, head
circumference 32 cm, all appropriate for gestational age.
PROBLEMS DURING HOSPITAL STAY:
1. Respiratory: Infant was intubated on admission to the
NICU. Received one dose of Surfactant with a x-ray
consistent with hyaline membrane disease. He remained
intubated from [**2-27**] until [**2-28**] when he went to continue his
positive airway pressure briefly and then oxygen via nasal
cannula, and by [**2-29**] later that evening was in room air. He
remained in room air throughout the remainder of his hospital
course. There were no episodes of apnea or bradycardia of
prematurity.
2. Cardiac: He had no murmurs present, and had stable blood
pressures throughout.
3. Infectious Disease: Patient had an initial sepsis rule
out. Was on ampicillin and gentamicin for 48 hours once
blood cultures were negative.
4. Feeding and nutrition: Infant currently is feeding adlib
demand and being put to breast for no more than 1x/day. He
is currently on mother's milk 24 calories per ounce and his
weight prior to discharge was 2490 [**Month/Day (4) **].
5. Hematology: Mother is B+. Baby had a peak bilirubin of
11.8 for which he underwent several days of phototherapy.
6. Genitourinary: Patient was noted on admission to have a
significant hypospadias and chordee with a cleft-like area and
the meatus appears to be somewhere along the shaft of the
penis. He has two testes high in the scrotal sac. This was
discussed at length with the parents, and as an outpatient, he
will be referred by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] to
Urology, and this will be anticipatory of surgery at some
later date around the first year of life.
On his initial state screen, we were notified that the
17-hydroxyprogesterone was elevated. Two further state
screens were sent following the initial abnormal on [**3-2**].
Repeats were [**3-7**] and [**3-16**]. Both of these were within
normal limits. He also had electrolytes drawn that were
normal. There was some question as to whether this could
have been a virilized female, however, the physician
staff and [**Name Initial (PRE) **] agree that there are definitely two testes high
in the scrotum with normal electrolytes and followup state
screen normal for 17-hydroxyprogesterone that this patient
was indeed a male.
Hearing screening performed on [**3-13**] and was normal.
Hepatitis B immunization #1 given on [**3-21**].
DISCHARGE MEDICATIONS:
1. Poly-Vi-[**Male First Name (un) **] 1 cc daily.
2. Fer-In-[**Male First Name (un) **] 0.2 cc daily.
FOLLOW-UP PLAN: The patient is to be followed at [**University/College **]
Vangard, [**Hospital1 3494**] Center with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],on [**4-4**] and at
a future date, Urology appointment to be made by Dr. [**First Name (STitle) **].
VNA is to come to home the day post discharge to check
infant's weight and see how mother/baby are doing.
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2196-3-30**] 09:32
T: [**2196-3-30**] 09:45
JOB#: [**Job Number 48866**]
|
2559,78321,V1582,4019,486,1623,431,1983 | 103 | 130,744 | Admission Date: [**2144-8-12**] Discharge Date: [**2144-8-20**]
Date of Birth: [**2084-4-14**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old,
right handed female who started experiencing nausea and
vomiting one week ago. She felt dizzy and had diplopia. She
fell the day prior to admission and was brought back to bed
and could not get out of bed until the day of admission when
EMS was called. She was brought to [**Hospital3 4527**] Hospital
where a CT of her head showed left frontal hemorrhage and
right occipital hemorrhage. Also a mass was detected on her
chest x-ray and confirmed by chest CT. Patient was then
transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY: Lumbar diskectomy. Hypertension.
Depression.
ALLERGIES: None known.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.day, Univasc
30 mg q.day, thiamine 100 mg IM, MVI one p.o. q.day, Levaquin
500 mg IV q.24 hours, atenolol 75 mg p.o. q.a.m., Norvasc 10
mg p.o. q.day, folate 1 mg p.o. q.day, Tylenol and magnesium.
PHYSICAL EXAMINATION: The patient's heart rate was 46, blood
pressure 158/51, SAO2 96 percent, respiratory rate 19.
Patient was awake, alert, slightly lethargic, oriented times
two. Lungs were clear, left lung slightly coarse breath
sounds. Abdomen soft, nontender. Cardiac regular rate and
rhythm. Extremities had no edema. Neurologic exam showed an
awake, slightly lethargic, oriented times two, not to time,
slightly reversed when following commands. Right eye had
slightly decreased adduction, slight decreased elevation of
the right eye. Also left lateral gaze nystagmus. Face was
symmetric. Frontalis was intact. Moderate dysarthria. No
obvious drift. Upper and lower extremities were full [**5-18**] for
muscle. Reflexes were 1+ in the upper extremities and 1 in
the lower extremities. No Hoffmann, no clonus. Sensation
was intact to lower extremities bilaterally.
LABORATORY DATA: White count 10.6, hematocrit 27.4,
platelets 309. INR 1.3, PTT 33.2. Sodium 139, potassium
3.4, chloride 106, CO2 22.
HOSPITAL COURSE: The plan for this patient was admission to
the ICU, obtain an MRI with gadolinium. She was made NPO, IV
fluids at 80 an hour. Neuro checks were q.one hour. She was
given mannitol 25 q.four hours and Decadron 8 mg q.four
hours. On [**8-13**] the patient was noted to be arousable,
oriented to person only, very dysarthric, more lethargic than
the previous day. She had received Ativan at the time of
examination. She did have a slight right drift. She had an
MRI which showed a large right cerebellar T2 hypointense and
T1 hyperintense mass which measured about 5 cm in maximal
dimension. A DWI scan [**Month (only) 3780**] loss of signal in the
right cerebellum and left frontal lobe. MR [**First Name (Titles) 4058**]
[**Last Name (Titles) 3780**] flow in both intracranial carotid arteries and
in the anterior middle cerebral artery. There was flow in
the vertebral arteries. The impression was cerebellar and
cerebral hemorrhagic masses consistent with metastasis. The
cerebellar mass is large and there is superior herniation
into the cerebellum and compression of the fourth ventricle.
Given the patient's exam and MRI findings, it was felt that
the patient should have an emergent craniotomy for removal of
this tumor and the hemorrhagic lesion. Prior to surgery
patient did have an interventional pulmonology consult. They
saw her and felt she had a left upper lobe mass infiltrate
with the diagnosis that included possible pneumonia versus
lung mass versus combination. They did follow her throughout
her stay here and did not recommend that she needed
bronchoscopy at this time. They referred her to oncology.
The patient was brought to the O.R. on [**2144-8-13**] where she
underwent craniotomy and removal of the right cerebellar
hemorrhagic lesion. Patient did well intraoperatively and
had no complications. On post-op day one patient was awake,
oriented times name only, inattentive, unable to follow
midline commands. She had abduction depression of the right
eye. Pupils were 5 to 3.5 in the right eye and left eye 4.5
to 2.5. She had a question of bilateral slight pronator
drift, greater on the right than the left. Recommendations
were to keep her blood pressure less than 150, use minimal
Ativan only and to slowly advance her diet. Her post-op
hematocrit was 25.9. Also on the 1st she had repeat MRI
which showed status post resection of right cerebellar
hemorrhagic lesion without residual enhancement. Left
frontal hemorrhagic lesion with enhancement was suggestive of
metastatic disease.
The patient did require the use of Nipride to keep her
systolic blood pressure less than 140. She did have periods
of agitation at times. On [**8-15**] patient was awake,
continued in the ICU. Her face was symmetric. No rebound,
no drift. Finger to nose showed slight right dysmetria.
Patient was advanced out of bed to a chair. Her activity was
also increased. Patient was continued on IV Decadron 4 mg
q.six hours. In the late afternoon of the 2nd, patient was
transferred out of the unit awake, alert and oriented times
three, moving all extremities. Vital signs were stable. She
did see physical therapy when moved to the floor who
recommended that she receive visitations every day by them to
assist with her impaired mobility and help with her impaired
mental status.
On [**8-16**] the patient was awake, alert, oriented,
tolerating a diet, ambulating with help. Her dysarthria was
noted to be improved. She had a slight right drift noted.
Her dysmetria was also improved. Her Foley was removed.
Decadron was continued to be weaned. Occupational therapy
also saw her and assisted her with safety awareness and
helped her with her upper extremities. On the 5th oncology
saw patient who felt that she most likely will receive
palliative chemotherapy with radiation rather than systemic
chemo. Patient's special stains for melanoma were found to
be negative on [**8-19**]. Patient will need to go to a rehab
facility for further assistance with her gait and
rehabilitation needs. She is to follow up in the brain tumor
clinic with Dr. [**Last Name (STitle) 724**]. She also needs to follow up with
hematology/oncology here at [**Hospital1 188**].
The patient was treated with Levaquin for pneumonia that was
diagnosed prior to admission. She received 10 days of
Levaquin therapy.
DISCHARGE INSTRUCTIONS: To keep the staples clean and dry,
do not get them wet. She should have them removed on
[**2144-8-26**]. She can come back to [**Hospital Ward Name 121**] 5 to have those removed
or she can have them removed at her rehab facility. Right
now her appointment for the brain tumor clinic is pending.
Also her appointment with oncology is pending at this time.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcu.
2. Regular insulin sliding scale.
3. Nicotine patch 20 mg per 24 hours.
4. Lopressor 50 mg [**1-16**] tablet b.i.d.
5. Protonix 40 mg q.day.
6. Oxycodone with acetaminophen one to two tablets p.o.
q.four to six hours.
7. Decadron taper down to 2 mg p.o. b.i.d.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 13027**]
MEDQUIST36
D: [**2144-8-19**] 10:24
T: [**2144-8-19**] 10:29
JOB#: [**Job Number 51303**]
|
7784,V502,7746,76529,76408,7756,V3001 | 104 | 164,025 | Admission Date: [**2184-10-17**] Discharge Date: [**2184-10-26**]
Date of Birth: [**2184-10-17**] Sex: M
Service: NB
HISTORY: Latrell [**Doctor Last Name **] (aka Baby [**Name (NI) **] [**Known lastname 32126**]) is the 2345 g
product of a term pregnancy (estimated date of confinement
[**2184-10-31**]) born to a 17 year old gravida 1, para 0 mom.
PRENATAL SCREENS: Blood type A+, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, group beta strep status unknown.
This pregnancy was complicated by growth restriction of
unclear etiology. This infant was delivered by cesarean
section with Apgar scores of 8 at 1 minute and 9 at 5 minutes
of age. He was taken to newborn nursery. He was noted to have
a blood glucose of 36 shortly after admission to the newborn
nursery. He was p.o. fed, and blood glucose remained in the
30s. Was therefore transferred to the newborn intensive care
unit for further management of hypoglycemia.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2345 g (10th
percentile), length 48.5 cm (about 50th percentile), head
circumference 30 cm (less than 10th percentile). Vital signs:
Temperature 97.3, heart rate 142, respiratory rate 52,
temperature initially 96.5 but repeat 97.3, blood pressure
within normal limits. Head, ears, eyes, nose, throat: Infant
normocephalic, atraumatic. Anterior fontanel open and flat.
Palate is intact. Red reflex present bilaterally. Neck:
Supple. Respiratory: Lungs clear bilaterally. Cardiovascular:
Heart regular rate and rhythm. No murmur. Femoral pulses 2+
bilaterally. Abdomen: Soft with active bowel sounds. No
masses or distention. GU: Normal male. Testes descended
bilaterally. Anus: Patent. Hips: Stable. Spine: Midline.
Clavicles: Intact. Neurologic: Good tone. Normal suck and
normal gag.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Latrelle
has been in room air for the duration of his hospitalization.
He has not required any supplemental oxygen or respiratory
support.
Cardiovascular: The infant has had stable blood pressures
throughout his hospitalization. No fluid boluses or pressors
were required.
Fluids, electrolytes and nutrition: Upon admission to the
newborn intensive care unit, blood glucoses remained in the
30s. An IV of D10W was initiated at 60 cc/kg per day with
resolution of acute hypoglycemia with glucoses rising into
the 50s. Has remained stable for the remainder of
his hospitalization, with blood glucose ranging anywhere from
50-73. He is currently taking ad lib feeds of Enfamil 20 calorie
without difficulty. His initial p.o. feeding efforts were slow,
and he did require some gavage feeds around day of life 2 and 3.
His intake has improved, and he is currently taking in about
154 cc/kg per day of 20 calorie per ounce formula. His weight at
time of discharge home is 2300 g.
GI: Bilirubin on day of life 3 was 13.9 with a direct
bilirubin of 0.4. Phototherapy was initiated at that time.
Phototherapy was discontinued on day of life 5 for a
bilirubin of 9.2/0.3, and a rebound bilirubin on day of life
6 was 8.2/0.3.
Hematology: This baby has not received any blood products
during his NICU admission. His hematocrit on admission was
50.
Infectious disease: Upon admission to the newborn intensive
care unit, a CBC with a blood culture was drawn which showed
a white count of 20.2, hematocrit of 50, a platelet count of
167, a differential of 74% polys, 7% bands. He did not receive
antibiotics as there were no maternal risk factors
for sepsis. His hypoglycemia resolved quickly.
Neurology: Head ultrasound not indicated for this 38-week
infant.
Sensory: Audiology - A hearing screen has not yet been
performed; will be done prior to his discharge from the
hospital. Ophthalmology - Eye exam not indicated for this 38-
weeker.
Psychosocial: [**Hospital1 69**] social
work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **]. This is a young 17-year-
old mom who is being supported by her mother, who has had the
other set of baby tags so as to be able to visit the infant.
The father of the baby is involved.
CONDITION AT TIME OF TRANSFER TO NEWBORN NURSERY: Infant stable
in room air. Taking p.o. feeds without difficulty and maintaining
blood glucoses without difficulty. Requiring isolette for
thermoregulatory support.
CONDITION AT TIME OF DISCHARGE HOME: Stable in room air and open
crib, feeding well and gaining weight.
DISCHARGE DISPOSITION: Home with mother.
SOURCE OF PRIMARY PEDIATRIC CARE: [**Location (un) 669**] Comprehensive Community
Health Center.
CARE RECOMMENDATIONS:
Feeds: Ad lib. demand feeds of 20 calorie per ounce formula with
iron.
MEDICATIONS: None.
CAR SEAT POSITIONING SCREENING: Not indicated.
STATE NEWBORN SCREEN: The official state newborn screen was
sent on [**10-20**], and no abnormal results have been
reported.
IMMUNIZATIONS RECEIVED: None. MOther declined hepatitis B
vaccine in hospital.
IMMUNIZATIONS RECOMMENDED: RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following: daycare during RSV season, smoker in household,
neuromuscular disease, airway abnormalities or school-age
siblings, or 3) with chronic lung disease. Influenza
immunization is recommended annually in the fall for all
infants once they reach 6 months of age. Before this age and
for the 1st 24 months of the child's life, immunization
against influenza is recommended for household contacts and
out-of-home care givers.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Appointment
with primary pediatrician is recommended within 3 days.
DISCHARGE DIAGNOSES:
1. Small for gestational age.
2. Hypoglycemia, resolved.
3. Hyperbilirubinemia, resolved.
4. Temperature instability, resolved.
5. Status post circumcision.
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2184-10-24**] 00:58:32
T: [**2184-10-24**] 10:06:05
Job#: [**Job Number 63089**]
|
7806,486,4280,3334 | 105 | 128,744 | Admission Date: [**2189-2-21**] Discharge Date: [**2189-2-25**]
Date of Birth: [**2153-9-26**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 6995**] is a 36 yo F w/end-stage [**Location (un) 6988**] disease who
was recently dc'd from the MICU on [**2189-2-2**] after tx for PNA and
SVT (requiring cardioversion) who was brought in by family after
she was noted to be febrile to 102F. Her sister and caregivers
noted a productive cough, congestion, but deny witnessing
diarrhea/vomiting. She was also noted to have depressed mental
status and decreased po intake over the past few days. Family
denies noticing respiratory distress. Per the family, her
baseline SBPs in 80's-90's.
.
In the ED, the pt was noted to be febrile to 103.2 and
tachycardic to 104. Her BP was 107/63 with a respiratory rate of
20 and a room air O2 saturation of 97%. She had poor air
movement on lung exam and cool extremities. Of note, the patient
is nonverbal at baseline and does not follow commands.
.
A CXR in the ED did not show any new focal infiltrates or
effusions. There was no evidence for active CHF. It appeared
improved vs. [**2189-2-2**].
An EKG revealed old, nonspecific ST/TW changes laterally and
diffuse low-voltage. Blood cultures and urine culture were sent
from the ED. She was started on levofloxacin/flagyl.
Past Medical History:
[**Location (un) 6988**] Disease
Anemia
CHF: EF 10%
Nonverbal at baseline
Social History:
MEDS:
Tylenol
Ensure
.
SocHX: Patient lives at home with sister and brother. She also
goes to daycare. She is non-verbal at baseline.
.
Family History:
father who passed away of [**Name (NI) **] dz
Physical Exam:
97.7, 67, 84/51, 16,
GEN: Awake, occasional tracks to voice, nonverbal. Appears in
NAD.
HEENT: PERRL bilat., MM moist, no LAD.
CV: RRR, difficult exam secondary to pt motion
RESP: diffusely diminished breath sounds at bases, coarse upper
airway sounds bilaterally at apices.
ABD: soft, NT/ND. +bs
EXT: wdwp.
NEURO: ++choreoathetoid movements. unable to test.
Brief Hospital Course:
A/P: 35 yo F w/end stage [**Location (un) 6988**], recent dc from MICU for
PNA/SVT, who presented with fever, cough, and altered mental
status. Despite improved CXR, concern for PNA.
.
1. Fever: Pt with fever at home to 103, recent hospitalization
and tx for PNA. Despite improved cxr, lungs are most likely
source of infection. UA was negative. Blood cultures from prev
hospitalization NGTD. Cultures from ED were also neagitve. The
patient was started on broad spectrum antibiotics initially but
then converted to oral levaquin and flagyl. The patient was
afebrile while hospitalized.
.
2. [**Location (un) 6988**]: Pt has end-stage [**Location (un) 6988**] disease. Dr
[**Last Name (STitle) **] was aware that the patient was hospitalized and spoke
with the family about goals of care.
.
3. SVT: Hx of recent SVT requiring cardioversion. Started on
amiodarone at d/c from hospital on last admission. The patient
had no issues with tachycardia this admission.
.
4. CHF: Pt has CHF w/EF 10% by report. No clinical evidence of
failure. Pt did not have any fluid overload issues while
hospitalized.
Medications on Admission:
-lasix
-asa
-amiodarone
-amoxicillin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*qs Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Fever
--------
Secondary
Hunnington's Disease
Congestive Heart Failure
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were treated in the hospital for fever. We did not find a
source of infection. You were treated in the ICU because your
initial blood pressure was low but then transferred to the
floor. You were treated with antibiotics for a presumed
pneumonia given the symptoms that you came in with. You should
finish the course of antibiotics when at home.
Call your primary care provider or return to the emergency
department for any of the following:
fever, chills, chest pain, shortness of breath, nausea,
vomiting, diarrhea, constipation, or other concerning symptoms
Other than the new prescription for antibiotics, we did not make
any changes to your home medications. Please resume your home
medications upon discharge
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in one week. Please call [**Telephone/Fax (1) **]
to schedule an appointment.
Follow up with Dr [**Last Name (STitle) **] for further care.
|
5070,0389,27651,7895,5119,4254,42731,5849,99591,42789,3334,2859,7906 | 105 | 161,160 | Admission Date: [**2189-1-28**] Discharge Date: [**2189-2-2**]
Date of Birth: [**2153-9-26**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
delta MS, lethargy, ?sepsis
.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Hx obtained per ED notes and sister
.
HPI: 35F with [**Location (un) 6988**] disease who presented today from
daycare after her healthcare providers noted that she was
lethargic. They were initially unable to obtain a blood
pressure. The patient was noted to have a very rapid heart
rate. Vitals were finally obtained and were as follows: BP 70/50
(baseline SBPs 80-90), HR 113, O2 sat 99% on 3L NC.
.
The patient was transferred to [**Hospital1 18**] where she was noted to have
a temp of 101.4, HR 200 and SBP 80s. EKG was noteworthy for a
wide complex tachycardia. The patient received adenosine 6mg and
then 12mg with no improvement. She was cardioverted into sinus
rhythm. Her D-dimer was elevated at 3590, lactate was 2.5 and
trop T 0.39 in the setting of renal insufficiency. A CT-A was
negative for a PE. The patient was transferred to the MICU for
further mgmt.
.
Past Medical History:
[**Location (un) 6988**] Disease
Anemia
Nonverbal at baseline
.
Social History:
MEDS:
Tylenol
Ensure
.
SocHX: Patient lives at home with sister and brother. She also
goes to daycare. She is non-verbal at baseline.
.
Family History:
father who passed away of [**Name (NI) **] dz
Physical Exam:
T 97.7, HR 65-68, BP 91-97/61-63, R 14-21, O2 sat 100%2l
GEN: thin appearing female lying in fetal position in NAD
HEENT: MM dry, OP clear
HEART: nl rate, S1S2, no gmr
LUNGS: CTA b/l
ABD: flat, soft, NT, ND, +BS, negative guardin, negative rebound
tenderness
EXT: wwp, +dp b/l
NEURO: unable to assess
.
Pertinent Results:
CT-A [**2189-1-28**]
IMPRESSION: No evidence of pulmonary embolism. Poorly defined
opacities within the lungs bilaterally, possibly representing
combination of atelectasis and consolidation. Air bronchograms
in the right middle lobe suggests possible infection.
.
CXR [**2189-1-28**]
IMPRESSION: Left lower lobe process suggesting pneumonia.
.
ECHO [**2189-1-28**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis. No masses or thrombi are seen in the left
ventricle. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. Moderate (2+)
mitral regurgitation is seen. The mitral regurgitation jet is
eccentric. The tricuspid regurgitation jet is eccentric and may
be underestimated. There is a small pericardial effusion.
.
IMPRESSION: Dilated cardiomyopathy with severely depressed LVEF.
EF 10%.
.
EKG ventricular tacchycardia at 200bpm
.
[**2189-1-28**] 10:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-1-28**] 08:30PM GLUCOSE-100 SODIUM-141 POTASSIUM-4.8
CHLORIDE-111* TOTAL CO2-20* ANION GAP-15
[**2189-1-28**] 08:30PM LD(LDH)-493*
[**2189-1-28**] 08:30PM CALCIUM-8.2* PHOSPHATE-3.8 MAGNESIUM-2.1
[**2189-1-28**] 08:30PM OSMOLAL-308
[**2189-1-28**] 08:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-1-28**] 08:30PM WBC-7.8 RBC-4.09* HGB-10.5* HCT-32.2* MCV-79*
MCH-25.8* MCHC-32.7 RDW-16.2*
[**2189-1-28**] 08:30PM PLT COUNT-140*
[**2189-1-28**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2189-1-28**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2189-1-28**] 04:00PM URINE RBC-0-2 WBC-[**3-2**] BACTERIA-RARE YEAST-FEW
EPI-[**3-2**]
[**2189-1-28**] 04:00PM URINE MUCOUS-MOD
[**2189-1-28**] 03:33PM LACTATE-2.5*
[**2189-1-28**] 02:53PM GLUCOSE-116* UREA N-51* CREAT-1.7* SODIUM-140
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
Brief Hospital Course:
A/P: 35F w/HD who presents with lethary course complicated by
tachycardia and possible sepsis.
.
1. Hypotension- probably [**1-30**] AVNRT vs. ventricular tachycardia
in a pt w/baseline EF 10%- cardiology was consulted in the ED
where it was thought that pt should be managed medically. She
received Adenosine x 2 w/o effect and then was cardioverted.
This was in the setting of infection and deyhdration. Since
arrival she is +9L. CT-A was negative for a PE; random cortisol
33.
- trending cardiac enzymes: 0.39, most likely elevated [**1-30**]
cardioversion
- EP following, plan for medical management of tachycardia
w/Amiodarone: on drip yesterday for 24 hours, started po 200 q
daily [**2189-1-31**].
- cardiology and EP satisfied with patients stability, may
recommend lisinopril low dose as an outpatient, follow up in 1
month with cardiology
.
2. PNA- Patient received levaquin, vanc, flagyl and ceftriaxone
in the ED. Imaging concerning for pneumonia.
- trend leukocytosis and fever curve
- change Unasyn for coverage of aspiration PNA to Augmentin
500mg PO TID today([**3-7**])
- blood cultures: pending
- urine cultures: NGTD final
.
3. Delta MS: Per patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and pt's sister-
patient is at baseline. Lethargy may have been [**1-30**] infection.
Will continue infectious w/u and treatment. tox screen negative
except for benzos.
.
4. Elevated liver enzymes: most likely [**1-30**] shock liver,
hypotension during v-tach and cardioversion; KUB was normal
[**2189-1-31**].
- trend LFT's: improving over time
- RUQ ultrasound: liver and gallbladder normal with right
pleural effusion and ascites;
.
5. Anemia: stable over hospital course
- Will monitor daily
- Patient has a hx of anemia.
.
6. Elevated D-dimer
CTA-negative, may be acute phase reactant.
.
7. FEN
-Replete lytes, aspiration precautions.
.
8. PPX: pneumoboots, heparin SC and PPI
.
9. FC confirmed with sister
.
Brother:
[**Name (NI) 6989**] [**Telephone/Fax (1) 6990**](c), [**Telephone/Fax (1) 6991**] (h)
Francetta [**Telephone/Fax (1) 6992**]
Medications on Admission:
none
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Ten (10) ml PO TID (3 times a day) for 7
days.
Disp:*210 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**First Name9 (NamePattern2) 269**] [**Location (un) **]
Discharge Diagnosis:
supraventricular tachycardia requiring cardioversion
pneumonia
Discharge Condition:
stable and improving
Discharge Instructions:
You will be discharged home today after being in the hospital
for both a fast heart rate and a pneumonia. Both of these were
controlled in the hospital, and you will be sent home with two
new medications.
The antibiotic Augmentin is to help treat your pneumonia. You
will take this for the next 7 days.
You are also prescribed Amiodarone. This medicatoin is to help
control your heart rate. You must take this everyday.
If you should develop any chest pain, shortness of breath,
nausea, vomiting, difficulty eating, cough, fever or any other
concerns, please call Dr [**Last Name (STitle) 6993**] or return to the emergency
department
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 6993**] within the next week. Dr
[**Last Name (STitle) 6993**] should set up a follow up with Cardiology within the
next month.
|
2888,2768,2752,V0262,4019,4275,30550,2760,78039,5849,3481,42741 | 106 | 145,167 | Admission Date: [**2192-8-9**] Discharge Date: [**2192-8-15**]
Date of Birth: [**2164-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Found down, s/p cardiac arrest
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
28 y/o male with unknown PMH who was found down in [**Location (un) 538**]
after 911 call. His identity was initially unknown on admission
on [**2192-8-9**] and he was identified on [**2192-8-11**]. Physician was
driving by the scene with his wife and responded by initiating
CPR approximately 15 minutes after man went down. EMS arrived on
the scene soon after call was made by unknown observer. Patient
was a well-dressed male thought to be in his 30s without any
evidence of track marks or drug use. His pupils were dilated. He
was intubated in the field. He was found in PEA arrest.
According to rhythm strips obtained from EMS, his first rhythm
was sinus bradycardia and he was given epinephrine and atropine.
He then went into WCT followed by MMVT. He was then shocked with
200 J and rhythm became PMVT and was shocked for the second time
with 300 J. He then went into ST and recovery of pulse. He
received a total of 2 mg of epinephrine and 2 mg of atropine
with 2 shocks (200 and 300J). He was then transported to [**Hospital1 18**]
ED.
.
In the ED, his pupils were fixed and dilated B/L. FAST was
negative. CXR revealed distended stomach. CT of head, chest,
abdomen, pelvis, C-spine were all negative. The patient was
transferred to the CCU hemodynamically stable on the ventilator.
Past Medical History:
PHM (obtained from family after patient was identified):
Hep B+
Hep C+
h/o IVDA
.
PSH:
None known
Social History:
SH: Has a h/o drug abuse and has served time in jail. He
currently lives with his grandparents in [**Location 4288**].
Family History:
NC
Physical Exam:
PE:
Vitals:
97.4 153/87 105 14 100% on AC TV 600 RR 14 PEEP 5 FiO2 100
General: Sedated, on vent, myoclonic jerking
HEENT: Pupils 4 mm fixed and dilated. MMM. ET tube in place.
Neck: No JVD.
CV: ST. Normal S1, S2 without m/r/g.
Pulm: CTAB, no wheezes or crackles.
Abd: Soft, NT/ND with normoactive BS.
Ext: No c/c/e. 2+ DP B/L.
Neuro: Intermittent myoclonic jerking. GCS 3.
Pertinent Results:
[**2192-8-9**] WBC-18.1* RBC-4.90 Hgb-14.2 Hct-40.3 MCV-82 MCH-28.9
MCHC-35.1* RDW-13.0 Plt Ct-271
.
[**2192-8-10**] WBC-26.0* RBC-5.60 Hgb-15.2 Hct-43.5 MCV-78* MCH-27.1
MCHC-34.9 RDW-13.1 Plt Ct-226
.
[**2192-8-11**] WBC-19.9* RBC-5.08 Hgb-14.3 Hct-40.1 MCV-79* MCH-28.1
MCHC-35.7* RDW-13.3 Plt Ct-222
.
[**2192-8-12**] WBC-20.7* RBC-4.53* Hgb-13.4* Hct-36.3* MCV-80*
MCH-29.5 MCHC-36.9* RDW-13.5 Plt Ct-223
.
[**2192-8-13**] WBC-34.6*# RBC-5.41 Hgb-14.8 Hct-42.6 MCV-79* MCH-27.4
MCHC-34.8 RDW-13.6 Plt Ct-214
.
[**2192-8-14**] WBC-29.2* RBC-5.33 Hgb-15.0 Hct-42.5 MCV-80* MCH-28.1
MCHC-35.2* RDW-14.0 Plt Ct-217
.
[**2192-8-15**] WBC-29.9* RBC-4.26* Hgb-12.0* Hct-35.5* MCV-83 MCH-28.1
MCHC-33.7 RDW-14.0 Plt Ct-240
.
[**2192-8-15**] WBC-30.4* RBC-4.15* Hgb-11.5* Hct-34.1* MCV-82 MCH-27.7
MCHC-33.7 RDW-13.8 Plt Ct-201
[**2192-8-12**] Neuts-84.1* Lymphs-10.4* Monos-4.6 Eos-0.7 Baso-0.2
[**2192-8-14**] Neuts-85.5* Lymphs-10.2* Monos-3.7 Eos-0.4 Baso-0.2
[**2192-8-9**] Fibrino-174
[**2192-8-9**] UreaN-16 Creat-1.5*
.
[**2192-8-9**] Glucose-207* UreaN-16 Creat-1.2 Na-136 K-3.8 Cl-102
HCO3-20* AnGap-18
[**2192-8-10**] Glucose-122* UreaN-13 Creat-0.8 Na-136 K-3.7 Cl-104
HCO3-18* AnGap-18
[**2192-8-10**] Glucose-120* K-3.9
[**2192-8-11**] Glucose-102 UreaN-11 Creat-1.0 Na-142 K-5.2* Cl-111*
HCO3-24 AnGap-12
[**2192-8-11**] K-5.2*
[**2192-8-11**] K-4.6
[**2192-8-12**] Glucose-121* UreaN-11 Creat-1.4* Na-146* K-4.3 Cl-116*
HCO3-25 AnGap-9
[**2192-8-13**] Glucose-129* UreaN-12 Creat-1.3* Na-150* K-2.5* Cl-113*
HCO3-22 AnGap-18
[**2192-8-13**] Glucose-172* UreaN-15 Creat-1.2 Na-152* K-3.1* Cl-117*
HCO3-21* AnGap-17
[**2192-8-13**] Na-149* K-3.1*
[**2192-8-14**] Glucose-193* UreaN-18 Creat-1.5* Na-144 K-4.1 Cl-112*
HCO3-15* AnGap-21*
[**2192-8-14**] UreaN-23* Creat-2.7*# Na-142 K-4.9 Cl-111* HCO3-19*
AnGap-17
[**2192-8-15**] Glucose-186* UreaN-36* Creat-5.2* Na-139 K-5.7* Cl-108
HCO3-14* AnGap-23*
[**2192-8-15**] Glucose-159* UreaN-38* Creat-5.5* Na-138 K-4.8 Cl-106
HCO3-15* AnGap-22*
[**2192-8-9**] ALT-398* AST-224* LD(LDH)-339* AlkPhos-133*
Amylase-131* TotBili-1.0
[**2192-8-9**] CK(CPK)-79
[**2192-8-10**] ALT-423* AST-252* CK(CPK)-524* AlkPhos-130*
TotBili-1.9*
[**2192-8-11**] ALT-392* AST-251* CK(CPK)-298* AlkPhos-112 TotBili-1.6*
[**2192-8-12**] CK(CPK)-1768*
[**2192-8-14**] ALT-242* AST-656* AlkPhos-105 TotBili-0.5
[**2192-8-15**] ALT-377* AST-1447* LD(LDH)-4377* AlkPhos-119*
TotBili-1.1
[**2192-8-15**] ALT-427* AST-1832* LD(LDH)-5187* AlkPhos-123*
TotBili-1.4
[**2192-8-9**] CK-MB-NotDone cTropnT-<0.01
[**2192-8-10**] CK-MB-82* MB Indx-15.6* cTropnT-1.45*
[**2192-8-11**] CK-MB-55* MB Indx-18.5*
[**2192-8-15**] Calcium-6.5* Phos-9.0* Mg-2.1
[**2192-8-9**] Calcium-8.5 Phos-1.6* Mg-1.8
[**2192-8-15**] Calcium-6.5* Phos-9.0* Mg-2.1
[**2192-8-9**] TSH-4.0
[**2192-8-12**] HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-NEGATIVE
[**2192-8-15**] HBsAg-NEGATIVE
[**2192-8-9**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2192-8-10**] Carbamz-<0.5*
[**2192-8-10**] Phenyto-<0.6* Valproa-<3*
[**2192-8-12**] HCV Ab-POSITIVE
[**2192-8-12**] HCV Ab-POSITIVE
[**2192-8-9**] freeCa-1.11*
[**2192-8-11**] freeCa-1.09*
.
Imaging Studies:
1. CXR [**2192-8-9**]
The ET tube tip is positioned approximately 2 cm from the
carina. There has been interval placement of an OG tube,
extending beyond the GE junction, though the tip is not
visualized on this study. The cardiac and the mediastinal
contours are within normal limits. The lungs are clear. No
pleural effusion or pneumothorax seen. The soft tissue and
osseous structures are stable in appearance.
IMPRESSION: The OG tube extends beyond the GE junction, though
the tip is not visualized on this image.
.
2. CT Head, C-spine, Chest, Abdomen, Pelvis W/Contrast
The study is limited secondary to motion. No definite hemorrhage
is identified.
No fracture or subluxation.
No evidence of traumatic injury.
.
3. Echo [**2192-8-10**]
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Overall left ventricular systolic
function is mildly depressed with mild global hypokinesis more
prominent in the distal inferior, distal septal and apical
segments. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. EF 45%
.
4. EEG [**2192-8-10**]
This is a markedly abnormal electroencephalogram due to the
presence of a suppressed background interrupted by rhythmic
sharply
contoured and evolving epileptiform activity. This EEG is
consistent
with brief periods of electrographic seizures on a suppressed
background. The team was called and notified of this result.
.
5. EEG [**2192-8-13**]
This is an abnormal 24 hour bedside telemetry due to the
presence of a low voltage, diffusely slow background activity.
This
suppressed activity may be seen with diffuse subcortical
dysfunction, as
occurs with CNS depressant medications or diffuse cerebral
ischemia.
.
Culture Results
[**2192-8-9**] SCx
GRAM STAIN (Final [**2192-8-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2192-8-13**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
[**2192-8-12**] UCx
URINE CULTURE (Final [**2192-8-14**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML.
All BCx were negative
Brief Hospital Course:
28 y/o male with no known PMH at the time found down s/p cardiac
arrest. PEA then VT then VF. Successful resuscitation with 2
shocks. The patient suffered anoxic brain injury s/p cardiac
arrest.
.
1. s/p cardiac arrest
The patient was initially found down in [**Location (un) 538**]. Please
see above HPI for further details. After arriving at [**Hospital1 18**] ED,
he was ruled out for any traumatic injury. He was then
transferred to the CCU for further evaluation and management
after his cardiac arrest. Due to his recent VF arrest, the
hypothermia protocol was initiated and the patient was cooled
for 18 hours. GCS before protocol was initiated was 3. The
patient met all inclusion criteria and he had none of the
exclusion criteria. Following the cooling protocol, he was
re-warmed. Upon initial arrival to the CCU, his EKG was analyzed
for any evidence of arrhythmia or abnormality that would explain
his cardiac arrest. Echocardiogram was performed soon after the
patient arrived in the CCU which was negative for any structural
abnormality of the heart. See full echo report above for
details. Initial tox screen was positive for opiates and benzos.
The leading diagnosis after cardiac causes were ruled out were
possible substance abuse causing respiratory suppression then
hypoxia which may have induced the cardiac arrest. Since the
patient was never awake from presentation, obtaining any HPI was
impossible. After talking with his family, they mentioned that
he had a history of substance abuse and was most likely using
heroin and/or benzos prior to being found down. The exact
etiology of what caused the patient's cardiac arrest remained
uncertain. Due to the patient's anoxic brain injury and after
consulting neurology, the family decided to withdraw support on
[**2192-8-15**] and the patient expired soon afterwards.
.
2. Anoxic brain injury
After the patient was transferred to the CCU, neurology was
consulted so they could perform an exam while patient was off
sedation prior to initiating cooling protocol. Upon arrival to
the CCU, the patient was having myoclonic jerking which was more
consistent with anoxic brain injury than seizure activity.
Neurology recommended EEG and then continued EEG monitoring. On
initial exam, the patient did have a gag reflex and corneal
reflexes. However, as his hospital course progressed, all of his
reflexes were absent, even off sedation for 48 hours. He was
monitored continuously with EEG which showed no signs of
activity. He was maintained initially on Dilantin to control any
seizures secondary to anoxic brain injury and that was
eventually discontinued. Organ bank saw the patient and
determined that he was not a suitable candidate for organ
donation. During the last two days of the patient's
hospitalization, he began to show evidence of multi-organ
failure and required pressor support to maintain his BP. After
several discussions with the family, CCU team, and neurology, it
was communicated that the patient would never return to normal
functioning. The family decided in complete agreement to
withdraw support on [**2192-8-15**] and the patient passed away soon
after the night of the 16th at 21:15. The family declined
autopsy.
Medications on Admission:
Unknown
Discharge Medications:
The patient expired on [**2192-8-15**].
Discharge Disposition:
Expired
Discharge Diagnosis:
The patient suffered a cardiac arrest and subsequent anoxic
brain injury. The family decided to withdraw support on [**2192-8-15**]
and the patient expired later that evening at 21:15.
Discharge Condition:
The patient expired.
Discharge Instructions:
The patient expired.
Followup Instructions:
The patient expired.
Completed by:[**2192-8-21**] |