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53291,5856,99681,40391,2851,V4511,V4582,25200,2749,2724,515,5533,53550,4589,53560,53085,2767 | 107 | 174,162 | Admission Date: [**2122-5-14**] Discharge Date: [**2122-5-18**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
hypotension, Hct drop
Major Surgical or Invasive Procedure:
EGD [**2122-5-15**]
Blood transfusion [**5-14**]
History of Present Illness:
70-year-old man status post kidney transplant now on HD
initially presented with dyspnea and epigastric pain. Patient
reports symptoms began suddenly yesterday while watching TV,
with sudden SOB and mild epigastric discomfort. Pt reports that
at some point today he had mild chest discomfort, similar to
that he has regularly, and took a nitroglycerin. He denies
nausea, vomiting, hematemesis, hematochezia or melena. He
denies history of recent bleeding, dizziness, or light
headedness.
.
In the ED, initial vital signs were:97.6 76 107/93 18 99%. CXR
was clear. While he was in the ED he became hypotensive to the
80s and received several IVF totalling to 750cc. He had an
episode of melena and coffee ground emesis. He was lavaged
which resulted in bright blood (thought to be traumatic) that
cleared quickly with few coffee grounds, no bile was drawn back.
CTA torso showed no PE or abdominal perforation. EKG also
showed no ST depressions in lateral leads, but troponin 0.06.
Renal was consulted and concerned about K of 6.1 and recommended
urgent dialysis. During his ED stay he received 5mg IV morphine
for epigastric pain, started on a protonix drip. Pt was
transfered to MICU with 2PIVs and stable vital signs.
.
In the MICU, patient reports continued epigastric discomfort,
but no further nausea, emesis, or melena.
.
ROS:
Denies fevers, chills, change in weight, headache, dizziness,
orthopnea/PND or palpitations, urine production, lower extremity
edema, new pains, rash.
Past Medical History:
[**7-/2121**]: Rx allergy: Cephalosporins (cefazolin), s/p graft
embolect
- Subdural Hematoma: ER [**Hospital1 18**] [**6-19**]
- ESRD s/p kidney transplant and rejection, now on hemodialysis
- Glomerulonephritis
- CAD: cardiac cath [**2119-9-26**]: completely occluded LCx
(unchanged since [**2113**]), 50% lesion LAD (vs 30% prior) &
completely stenotic RCA
- Cath [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA after rotablation of
heavily calcified artery
- Hyperparathyroidism
- Anemia
- Gout
- Hyperlipidemia
- Hypertension
- Eosinophilia (? 2o Strongloides)
- Multiple lung nodules of unknown etiology
- Hypogonadism
- Obesity
- Bronchospasm
- Hx PPD positive but ruled out for pulmonary TB recently
- chronic SDH s/p [**2119**]
- [**2121-8-25**] Left IJ tunnelled catheter placement
.
PAST SURGICAL HISTORY:
- Cardiac catherization on [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA
after rotablation of heavily calcified artery.
- [**2113**] - Left brachial artery to cephalic vein primary AV
fistula.
- [**2114**] - Revision of AV fistula with ligation of side branches
- [**2114**] - Creation of left upper arm arteriovenous graft,
brachial to axillary.
- [**2115**] - Thrombectomy with revision of left arm arteriovenous
(AV) graft
- [**2115-4-11**] Cadaveric kidney transplant, right iliac fossa. (Dr.
[**First Name (STitle) **]
- [**2117-8-13**] - Right upper arm brachial - axillary graft (Dr.
[**First Name (STitle) **]
- [**2119**] - RUE AVG Fistulogram, angioplasty of intragraft
partially occluding clot
- [**2120**] - RUE AVG Thrombectomy, fistulogram, arteriogram, 8-mm
balloon angioplasty of outflow stenoses.
- [**2121**] RUE graft thrombectomy
- [**2121**] [**2121-12-12**] tunneled HD catheter placement and AV fistula
ligation
Social History:
-Tobacco: smoked for a few years as a teenager
-EtoH: denies
-Illicits: denies
-Lives alone w Cat; has three sons that are not very involved in
his life; walks with a cane. Has VNA once a month and meals on
wheels.
-Previously worked as a zoo keeper [**Last Name (NamePattern1) 20122**] Zoo
Family History:
No history of kidney disease, + history for DM, HTN
Physical Exam:
ADMISSION EXAM:
GENERAL - well-appearing gentleman, sedated, in NAD, no
respiratory distress, warm to touch.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace edema bilaterally., 2+ peripheral
pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Discharge exam
O: 98.0 136/88 75 18 100%ra
GENERAL - obese latino male in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Hematoma on back is
unchanged.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace edema bilaterally, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs
[**2122-5-14**] 02:45PM BLOOD WBC-11.6* RBC-3.17*# Hgb-8.5*# Hct-29.4*#
MCV-93 MCH-26.9* MCHC-29.0* RDW-19.5* Plt Ct-183
[**2122-5-14**] 09:48PM BLOOD WBC-13.6* RBC-2.59* Hgb-7.1* Hct-23.9*
MCV-92 MCH-27.3 MCHC-29.6* RDW-19.4* Plt Ct-168
[**2122-5-14**] 02:45PM BLOOD Glucose-144* UreaN-137* Creat-8.7*#
Na-137 K-6.1* Cl-97 HCO3-20* AnGap-26*
[**2122-5-14**] 02:45PM BLOOD ALT-25 AST-20 AlkPhos-107 TotBili-0.2
[**2122-5-14**] 02:45PM BLOOD Albumin-3.4* Calcium-7.5* Phos-3.1#
Mg-2.9*
.
Cardiac labs
[**2122-5-14**] 02:45PM BLOOD CK-MB-4 cTropnT-0.06* proBNP-4103*
[**2122-5-14**] 09:48PM BLOOD cTropnT-0.05*
[**2122-5-15**] 02:26AM BLOOD CK-MB-3 cTropnT-0.10*
[**2122-5-15**] 09:53AM BLOOD CK-MB-4 cTropnT-0.15*
.
Discharge labs
[**2122-5-18**] 06:30AM BLOOD WBC-8.5 RBC-2.96* Hgb-8.5* Hct-28.1*
MCV-95 MCH-28.8 MCHC-30.3* RDW-19.0* Plt Ct-153
[**2122-5-18**] 06:30AM BLOOD Glucose-119* UreaN-49* Creat-8.1*# Na-135
K-4.4 Cl-94* HCO3-27 AnGap-18
[**2122-5-18**] 06:30AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.3
.
EKG [**2122-5-14**]: Sinus rhythm. Left atrial abnormality with a change
in atrial morphology compared to the previous tracing of
[**2122-1-20**]. There are new ST-T wave changes recorded in leads I
and aVL as compared with prior tracing which may represent
active lateral ischemic process. Followup and clinical
correlation are suggested.
.
EKG [**2122-5-15**]: Sinus rhythm. Compared to the previous tracing of
[**2122-5-15**] there is further improvement inthe inferolateral ST-T
wave abnormalities. Followup and clinical correlation are
suggested.
.
CXR [**2122-5-14**]: No acute cardiopulmonary process. Persistent
increased
interstitial markings in the lungs compatible with chronic
interstitial
disease. Interval resolution of the right mid lung opacity since
prior.
.
CTA [**2122-5-14**]:
1. No evidence of acute pulmonary embolism or acute aortic
dissection.
2. Extensive atherosclerotic disease involving the aorta, major
visceral
arteries and coronary arteries.
3. No evidence of bowel perforation or other acute abdominal
pathology.
4. Scattered colonic diverticulosis without evidence of acute
diverticulitis.
.
EGD [**2122-5-15**]:
Esophagus:
Lumen: A medium size hiatal hernia was seen.
Mucosa: A salmon colored mucosa distributed in a segmental
pattern, suggestive of long segment Barrett's Esophagus was
found.
Stomach:
Mucosa: Localized erythema and erosion of the mucosa with no
bleeding were noted in the antrum. These findings are compatible
with Moderate gastritis.
Duodenum:
Mucosa: Diffuse continuous friability, erythema and congestion
of the mucosa with no bleeding were noted in the duodenal bulb
compatible with Moderate duodenitis.
Excavated Lesions Five ulcers ranging in size from 4 mm to 6 mm
were found in the duodenal bulb. Two of these had visible vessel
in center. 6 cc epinephrine was injected in one and 4 cc in the
other. 2 Endoclips were placed on the the larger ulcer
successfully.
IMPRESSION:
Medium hiatal hernia
Moderate gastritis
Moderate duodenitis
Ulcers in the duodenal bulb
Mucosa suggestive of Barrett's esophagus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
70 yom with history of ESRD on HD, CAD s/p [**Month/Day/Year **] in [**2120**], p/w
epigastric pain, hematemesis, melena, and dyspnea X 1 day, found
to have duodenal ulcers, s/p clipping and epinephrine, with
course complicated by demand ischemia.
.
# Hematemesis/Melena, GI bleeding, acute bood loss anemia: Pt
with Hct drop to 23.9 from 29.4 on admission. He received 2
units of PRBC transfused on [**2122-5-14**]. He was briefly intubated
for EGD performed on [**5-15**] which showed multiple duodenal ulcers,
two with visible vessels. Both were injected with epinephrine,
and 2 Endoclips were placed on the the larger ulcer
successfully. He was quickly extubated without complication.
HCT remained stable thereafter. His diet was advanced to
clears, and he was maintained on [**Hospital1 **] PPI. Low dose aspirin 81mg
was restarted given his CAD, and decision to restart plavix was
made. His Cardiologist was [**Name (NI) 653**], and [**Name2 (NI) 20207**] a note
from [**2120**]:
.
"This patient has a drug-eluting stent placed in [**2121-1-8**]
for recurrent in-stent restenosis inside a prior drug-eluting
stent from [**2119-9-9**]. He should be on uninterrupted aspirin
for life as well as lifelong clopidogrel (or equivalent
anti-platelet) therapy given the anatomical substrate of a
bilayer of drug-eluting stents that puts him at very high risk
for late and very late stent thrombosis. Late stent thrombosis
carries significant mortality and morbidity risks. The only
circumstance for which we would consider stopping dual
anti-platelet therapy would be intracranial bleeding."
.
He was put back on aspirin 325mg daily and plavix 75mg daily. He
was started on low dose BB, and as he tolerated this well his
home metoprolol succinate 100mg daily was restarted. Because he
is high-risk to bleed, and remains on dual-anti-platelet
therapy, he should have several hct checks in the near future.
His home PPI was also increased.
.
Additionally, an H pylori serology was checked, and came back
equivocal. As this is a potentially reversible risk factor, it
was decided to treat him with PPI, metronidazole x 10 days (he
has PCN allergy), and clarithromycin x10 days.
.
# Hypotension: In the setting of his GIB. This resolved, and he
remained normotensive. We continued to hold his home
antihypertensives in the MICU and these were restarted on the
floor, where his pressures remained stable.
# Demand Ischemia: Pt with EKG on admission showing ischemic
appearing T waves in I and aVL, as well as ST-T wave flattening
in leads V5-V6 andII and aVF. This was concerning for ischemia,
but eventually resolved on subsequent EKG. Thought to be demand
related to the setting of hypotension and anemia. Aspirin 325
and plavix 75 daily were restarted. He was continued on his home
pravastatin 10mg daily, and his LDL was at goal <70. He was
symptomc free on discharge.
.
# Interstitial lung diseae: Initially maintained on IV
methylprednisolone in the setting of his NPO status, and once
diet was advanced he was restarted on home dose of prednisone
30mg, with bactrim PPX. Given his upper GI bleed, his
pulmonologist was [**Name (NI) 653**], and felt that his prednisone could
be lowered to 20mg daily. He will f/u w/ pulmonary on [**5-21**]
.
# CKD on HD: MWF dialysis sessions. Dialysis was deferred on
Friday [**5-15**] given hypotension, but was restarted the following
day. He was continued on sevelemer, calcinet, and nephrocaps,
though sevelemer dose was decreased, and calcium acetate
started, per renal recommendations. Last dialysis sessions was
Monday [**5-18**].
.
# CAD, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]: As above, initially held ASA, plavix, BB
given that patient was bleeding and hypotensive. He was
maintained on his pravastatin 10mg daily. Eventually, all CAD
meds (see above) were restarted. His aspirin and plavix should
NEVER be stopped, except in setting of truly life-threatening
bleed, given the way this pt is stented puts him at very high
risk for in-stent thrombosis. Per Dr [**Last Name (STitle) **]: "need to balance the
risk and consequences of recurrent GI bleeding vs. the risks and
consequences of stent thrombosis in his RCA. Patients with stent
thrombosis carry a 20-40% mortality and a 30-40% chance of a
large non-fatal MI"
.
# Gout: Continued allopurinol.
.
# Code status: full (confirmed)
===================================
TRANSITIONAL ISSUES
# needs to have hct checked frequently in near future to ensure
no recurrent bleeding
# Repeat EGD 4-6 weeks, per GI.
Medications on Admission:
allopurinol 100 mg qod
B complex-vitamin C-folic acid 1 mg daily
clopidogrel 75 mg daily
metoprolol succinate 100 mg daily
sevelamer carbonate 800 mg 5 tabs tid
pravastatin 10 mg daily
aspirin 325 mg daily
cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
oxycodone 5 mg Tablet q6h prn pain
fluticasone 50 mcg/Actuation Spray daily
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler prn
docusate sodium 100 mg daily
Bactrim DS [**Name (NI) 20208**] (unclear if taking)
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal once a day.
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation PRN as needed for shortness of breath or
wheezing.
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO M/W/F ().
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
13. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
18. Outpatient Lab Work
[**2122-5-20**]: Hematocrit - Please fax results to Dr. [**First Name (STitle) **].
Phone: [**Telephone/Fax (1) 608**]
Fax: [**Telephone/Fax (1) 4647**]
Discharge Disposition:
Home
Discharge Diagnosis:
duodenal ulcers, gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 20118**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a gastrointestinal bleed. This was found to be from ulcers
in your stomach. For this, you had an endoscopy, and the
bleeding was stopped. Changes were made to your medications,
which should also help prevent more bleeding.
Your duodenal ulcers may be related to a stomach infection from
Helicobacter pylori. This is a common infection that can
pre-dispose you to ulcers. You will receive 10 days of
antibiotics to treat this infection.
Please have your blood counts (Hematocrit) checked at dialysis
on Wednesday.
You will follow-up with the GI doctors and [**Name5 (PTitle) **] likely need
another endoscopy in 4 - 6 weeks.
The following changes were made to your medications:
** DECREASE sevalamer to 800mg tablets, take THREE (3) tablets
THREE (3) times a day (you had previously been taking 5 tablets
3 times a day)
** DECREASE prednisone to 20mg once daily (you had been on 30mg
once daily)
** START pantoprazole 40mg by mouth twice daily (You will take
this instead of the 20 mg daily dose you were previously taking)
** START calcium acetate 667mg tablet, 1 tablet three times a
day with meals
** START metronidazole 500mg by mouth twice a day for 10 days
[antibiotic]
** START clarithromycin 500mg by mouth twice a day for 10 days
[antibiotic]
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2122-5-25**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS Best Parking:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2122-6-3**] at 2:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: PFT
When: THURSDAY [**2122-5-21**] at 1 PM
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2122-5-21**] at 1 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2122-5-21**] at 2:00 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
2767,28521,41401,E8780,4280,2811,V1005,27800,2749,25200,40311,41071,42833,5856,99681 | 107 | 182,383 | Admission Date: [**2121-11-30**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
69 year old male per OMR h/o ESRD, failed renal tx, s/p
thrombectomy of AV fistula, CHF, CAD s/p stents presenting with
shortness of breath. Onset was 2 hours prior when he returned
from church and sat down on his couch. He reported it felt
similar to past CHF exacerbations in that it was sudden in
onset, exacerbated by activity, no relieving factors. He denied
fevers or chills, reported positive nonproductive cough,
positive subjective lower extremity edema that is symmetric,
positive unintentional weight gain of approximately 10 pounds
over the past few weeks, no chest pain, no headache or change in
vision, no abdominal pain, no dysuria or urinary frequency, no
focal tingling or weakness. no change in medication.
.
In the ED, his initial 02sat was mid-80s on a NRB mask. He was
started on bipap. His initial labs were notable for a K+ 8.2, Cl
91, BUN/Cr 82/12.1, pro BNP 3760, trop 0.08. After insulin,
dextrose, albuterol and calcium, his repeat K+ was down to 6.0.
His EKG showed NSR at 60, 1 deg AVB, LAD, NO hyper acute T
waves. He was able to be taken off BiPap and at the time of
transfer, his 02sat was 98% on 4LPM via NC.
.
On arrival to the MICU, his HR was 63, BP 155/67, Sp02 98% on
2LPM via NC
.
Past Medical History:
PAST MEDICAL HISTORY:
- [**7-/2121**]: Rx allergy: Cephalosporins (cefazolin), s/p graft
embolect
- Subdural Hematoma: ER [**Hospital1 18**] [**6-18**]
- ESRD s/p kidney transplant and rejection, now on hemodialysis
- Glomerulonephritis
- CAD: cardiac cath [**2119-9-26**]: completely occluded LCx
(unchanged since [**2113**]), 50% lesion LAD (vs 30% prior) &
completely stenotic RCA
- Cath [**2119-9-28**] s/p 2 Xience DES to RCA after rotablation of
heavily calcified artery
- Hyperparathyroidism
- Anemia
- Gout
- Hyperlipidemia
- Hypertension
- Eosinophilia (? 2o Strongloides)
- Multiple lung nodules of unknown etiology
- Hypogonadism
- Obesity
- Bronchospasm
- Hx PPD positive but ruled out for pulmonary TB recently
- chronic SDH s/p [**2119**]
- [**2121-8-25**] Left IJ tunnelled catheter placement
.
PAST SURGICAL HISTORY:
- Cardiac catherization on [**2119-9-28**] s/p 2 Xience DES to RCA
after rotablation of heavily calcified artery.
- [**2113**] - Left brachial artery to cephalic vein primary AV
fistula.
- [**2114**] - Revision of AV fistula with ligation of side branches
- [**2114**] - Creation of left upper arm arteriovenous graft,
brachial
to axillary.
- [**2115**] - Thrombectomy with revision of left arm arteriovenous
(AV) graft
- [**2115-4-11**] Cadaveric kidney transplant, right iliac fossa. (Dr.
[**First Name (STitle) **]
- [**2117-8-13**] - Right upper arm brachial - axillary graft (Dr.
[**First Name (STitle) **]
- [**2119**] - RUE AVG Fistulogram, angioplasty of intragraft
partially occluding clot
- [**2120**] - RUE AVG Thrombectomy, fistulogram, arteriogram, 8-mm
balloon angioplasty of outflow stenoses.
Social History:
-Tobacco: smoked for a few years as a teenager
-EtoH: denies
-Illicits: denies
-Lives alone w Cat; has three sons that are not very involved in
his life; walks with a cane. Has VNA once a month and meals on
wheels.
-Previously worked as a zoo keeper [**Last Name (NamePattern1) 20122**] Zoo
Family History:
-No history of kidney disease, + history for DM, HTN
Physical Exam:
Vitals: T: BP: 155/67 P: 63 R: 18 O2: 97% on 2LPM via NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2121-12-2**] 06:44AM BLOOD WBC-9.1 RBC-4.51* Hgb-11.8* Hct-38.9*
MCV-86 MCH-26.2* MCHC-30.4* RDW-18.0* Plt Ct-218
[**2121-12-1**] 08:34AM BLOOD WBC-9.1 RBC-4.29* Hgb-11.3* Hct-36.7*
MCV-85 MCH-26.2* MCHC-30.7* RDW-18.0* Plt Ct-220
[**2121-12-1**] 12:01AM BLOOD WBC-14.2*# RBC-4.74 Hgb-12.8* Hct-40.3
MCV-85 MCH-27.0 MCHC-31.7 RDW-18.1* Plt Ct-303
[**2121-11-30**] 05:10PM BLOOD WBC-8.5 RBC-4.53* Hgb-12.1* Hct-39.0*
MCV-86 MCH-26.8* MCHC-31.1 RDW-17.9* Plt Ct-256
[**2121-11-30**] 05:10PM BLOOD Neuts-79.9* Lymphs-17.3* Monos-1.3*
Eos-0.7 Baso-0.9
[**2121-12-2**] 06:44AM BLOOD Plt Ct-218
[**2121-12-1**] 08:34AM BLOOD Plt Ct-220
[**2121-12-1**] 08:34AM BLOOD PT-11.8 PTT-20.8* INR(PT)-1.0
[**2121-12-2**] 06:44AM BLOOD Glucose-94 UreaN-42* Creat-7.3*# Na-139
K-4.6 Cl-93* HCO3-27 AnGap-24*
[**2121-12-1**] 08:34AM BLOOD Glucose-90 UreaN-53* Creat-9.0*# Na-140
K-4.5 Cl-92* HCO3-29 AnGap-24*
[**2121-12-1**] 12:01AM BLOOD Glucose-125* UreaN-36* Creat-5.8*# Na-139
K-3.3 Cl-92* HCO3-27 AnGap-23*
[**2121-11-30**] 05:10PM BLOOD Glucose-155* UreaN-82* Creat-12.1* Na-137
K-8.2* Cl-91* HCO3-24 AnGap-30*
[**2121-12-1**] 08:34AM BLOOD CK-MB-2 cTropnT-0.10*
[**2121-12-1**] 12:01AM BLOOD CK-MB-2 cTropnT-0.07*
[**2121-11-30**] 05:10PM BLOOD CK-MB-2 cTropnT-0.08* proBNP-3760*
[**2121-12-2**] 06:44AM BLOOD Calcium-8.2* Phos-8.7* Mg-2.0
[**2121-12-1**] 08:34AM BLOOD Calcium-8.0* Phos-8.8*# Mg-1.9
Echocardiography [**12-1**]:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2121-1-25**],
LV systolic function is now more vigorous.
Chest x-ray [**11-30**]:
IMPRESSION: Mild interstitial pulmonary edema, slightly improved
from the
prior study.
[**2121-12-3**] 06:58AM BLOOD WBC-10.9 RBC-4.48* Hgb-11.9* Hct-37.9*
MCV-85 MCH-26.6* MCHC-31.4 RDW-18.3* Plt Ct-243
[**2121-12-4**] 07:00AM BLOOD WBC-10.5 RBC-4.39* Hgb-12.3* Hct-39.0*
MCV-89 MCH-28.0 MCHC-31.5 RDW-18.4* Plt Ct-189
[**2121-12-3**] 06:58AM BLOOD Plt Ct-243
[**2121-12-4**] 07:00AM BLOOD Plt Ct-189
[**2121-12-3**] 05:05PM BLOOD Glucose-123* UreaN-41* Creat-7.2*# Na-143
K-4.1 Cl-93* HCO3-29 AnGap-25*
[**2121-12-4**] 07:00AM BLOOD Glucose-91 UreaN-55* Creat-9.1*# Na-142
K-4.9 Cl-92* HCO3-30 AnGap-25*
[**2121-12-3**] 09:10PM BLOOD CK-MB-2 cTropnT-0.15*
[**2121-12-4**] 07:00AM BLOOD CK-MB-2 cTropnT-0.15*
[**2121-12-3**] 05:05PM BLOOD CK-MB-2 cTropnT-0.16*
[**2121-12-3**] 06:58AM BLOOD Albumin-4.1 Calcium-7.9* Phos-11.2*#
Mg-2.3
[**2121-12-3**] 05:05PM BLOOD Calcium-8.3* Phos-6.7*# Mg-2.1
[**2121-12-4**] 07:00AM BLOOD Calcium-8.2* Phos-9.3*# Mg-2.3
Brief Hospital Course:
# Respiratory distress: Pt reported to the ED with a sudden
onset of shortness of breath. In the ED, he was initially
desatting to the 80s on a NRB, was put on Bipap, improved quite
rapidly and was eventually able to be weaned down to a NC and
was stable on 2L upon arrival in the MICU. His 02 sat was
continuously monitored. An echocardiography was done (EF>55%),
the results of which are above.
.
#Chest pain: Pt developed left sided chest pain, accompanied by
diaphoresis and mild dyspnea while moving around on [**2121-12-3**].
Pain resolved after about half an hour with sublingual
nitroglycerin and maalox and simethicone. EKG at the time
showed new ST depressions and T wave inversion in I, aVL.
Troponins were cycled and were 0.16, 0.16, 0.15. In the
morning, repeat EKG showed persistent T wave inversions, but
resolution of ST depression. The overall picture was consistent
with an NSTEMI. The patient underwent a nuclear stress test
which showed normal myocardial uptake and preserved EF of 59%.
He did not undergo catheterization as his stress test was
normal.
.
# Hyperkalemia - emergent hemodialysis at the bedside was
performed and the repeat K+ after dialysis was 3.3.
.
# ESRD - received emergent hemodialysis at the bedside and
resumed on his regular schedule.
.
# CAD - he was continued on his ASA, beta blocker, statin, and
plavix. He had a repeat echo, the results of which are above.
His cardiac enzymes were trended.
.
# Gout - continued allopurinol
.
# Hyperlipidemia - continued statin
.
# Hypertension - continue beta blocker
.
.
Transitional Care Issues:
Has outstanding blood cultures that needs to be followed up on.
Medications on Admission:
- albuterol
- allopurinol
- cinacalcet (sensipar)
- clopidogrel
- fluticasone
- metoprolol succinate
- nitroglycerin
- oxycodone-acetaminophen
- pravastatin
- sevelamer carbonate
- ASA
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation twice a day as
needed for shortness of breath or wheezing.
10. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as required: as required for chest pain.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-9**]
sprays Nasal once a day: each nostril.
15. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: pulmonary edema, hyperkalemia
Secondary: end stage renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known firstname 20204**],
It was a pleasure to look after you at the [**Hospital1 827**]. You were admitted with difficulty breathing.
We found that your potassium level was high. You were admitted
to the ICU and given oxygen. We also treated you with
hemodialysis to remove potassium and fluid. your breathing
improved and you are back at your baseline [**Last Name (un) 14836**] at the time of
discharge. The renal team will coordinate further dialysis at
your outpatient facility.
We made no changes to your home medications.
Please followup with your doctors, see below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: ADVANCED VASC. CARE CNT
When: THURSDAY [**2122-1-8**] at 10:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2122-1-22**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2122-1-22**] at 2:30 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
41401,4111,4019,2720,412,V1582 | 108 | 123,552 | Admission Date: [**2109-10-25**] Discharge Date: [**2109-11-1**]
Date of Birth: [**2037-12-2**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male with a history of an inferior wall myocardial infarction
approximately six years ago. An echocardiogram in [**2107**]
showed an ejection fraction of 30%. Chest pain with rest and
on exertion was the chief complaint and the patient was
admitted on [**2109-10-21**] to the emergency room for rule out
myocardial infarction. An exercise tolerance test at that
time showed an inferior wall defect and now anterior wall
ischemia. A cardiac catheterization showed the left main
coronary artery to be 30% occluded proximally and 60%
occluded distally, the left anterior descending artery to
have 70% mid-occlusion and 80% ostial occlusion, the right
coronary artery to have 100% ostial occlusion and the left
circumflex coronary artery to be occluded.
PAST MEDICAL HISTORY: The past medical history included
hypertension, hypercholesterolemia, gastroesophageal reflux
disease, inferior wall myocardial infarction and bradycardia.
MEDICATIONS ON ADMISSION:
Aspirin 325 mg p.o. q.d.
Monopril 5 mg p.o. q.d.
Lipitor 10 mg p.o. q.d.
Nitroglycerin patch.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 70**] to
the operating room for coronary artery bypass graft times
four on [**2109-10-28**] with a left internal mammary artery graft
to the left anterior descending artery, a reversed saphenous
vein graft to the obtuse marginal artery and a right coronary
artery grafts to the second obtuse marginal artery and the
posterior descending artery.
Postoperatively, the patient did well. In the intensive care
unit, the patient was extubated and weaned off all drips.
The chest tube was discontinued without incident. The
patient was ambulating at level 5 before discharge. Upon
discharge, the chest was clear to auscultation. The heart
rate was regular and normal sinus rhythm. The incision was
clean with no drainage and no pus. The sternum was stable.
Postoperatively, the patient's hematocrit was low and
required several units of blood transfusion. Upon discharge,
however, the hematocrit was 25 and the patient was
asymptomatic with no dizziness, no shortness of breath and no
orthostatic hypotension.
DISPOSITION: The patient will be discharged home with
[**Hospital6 407**] care.
DISCHARGE MEDICATIONS:
Lopressor 12.5 mg p.o. b.i.d.
Lasix 20 mg p.o. b.i.d.
Potassium chloride 20 mEq p.o. b.i.d.
Aspirin 81 mg p.o. q.d.
Lipitor 20 mg p.o. q.d.
Iron sulfate 325 mg p.o. t.i.d.
Percocet one to two tablets p.o. every four to six hours
p.r.n. for pain.
FOLLOW UP: The patient was told to follow up with Dr.
[**Last Name (STitle) 70**] in three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2109-11-1**] 15:15
T: [**2109-11-1**] 16:48
JOB#: [**Job Number **]
|
V0254,V4512,V4511,V5861,V1581,44389,5533,2875,33829,78904,28529,3559,2767,4589,2753,58381,7100,4239,4254,5609,2851,53140,5856,40301 | 109 | 102,024 | Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD,
malignant HTN, history of SVC syndrome, and history of Posterior
Reversible Encephalopathy Syndrome (PRES) and intracerebral
hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**],
[**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for
hypertension, but most recently for diarrhea in addition to
hypertension.
.
In the ED, vitals were 98 90 102/65 20 98% RA. She was
complaining of abdominal pain X 3 hours, more severe than usual
[**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg
IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt
stable for floor; however, BP rose during ED course to SBP 270.
She then received hydral 50 PO X 1, home aliskeren, labetalol
1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine
2.5 mg IV X 1 and started on nicardipine gtt.
.
Upon arrival to the floor, she complains of severe abd pain
which started earlier today, it is sharp all over her abd and
constant. It feels different from her usual abd pain, although
she is not able to characterize it more. She has been having
some nausea and bilious emesis X 1 earlier today. She has been
having some mild diarrhea 2-3 episodes of loose, greenish stools
for the past few weeks. She denies any chest pain, headache,
vision changes. She was not able to take all of the medications
due to her GI distress.
.
While in the MICU she was weaned off a nicardipine drip and her
diarrhea resolved. Her BP remained WNL while on her home regimen
and she was transferred to the floor in stable condition. Last
HD was [**2142-5-21**].
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and
now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension and history of hypertensive crisis
with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to
frequent hospitalizations and inability to see in outpatient
setting - has appt scheduled with gyn on [**5-25**]
17. History of two intraparenchymal hemorrhages that were
thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] which has resolved
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother and brother. On disability for multiple medical
problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
100/63 81 18 100RA
GENERAL: Pleasant, thin young female sitting in the bed in NAD
watching TV.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP
clear. Neck Supple, No LAD.
CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB.
LUNGS: Breathing comfortably, CTAB, good air movement
biaterally.
ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No
rebound or guarding.
EXTREMITIES: No edema. Right femoral HD line nontender,
nonerythematous.
SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm
scattered along her lower extremities.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation to light touch throughout. 5/5 strength in her upper
and lower extremities
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2142-5-20**] 09:14PM LACTATE-0.9
[**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93
MCH-29.2 MCHC-31.6 RDW-18.8*
[**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2142-5-20**] 09:13PM PLT COUNT-145*
[**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137
POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*
[**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1
[**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93
MCH-30.2 MCHC-32.5 RDW-19.2*
[**2142-5-20**] 08:55PM PLT COUNT-126*
[**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2*
[**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT
BILI-0.4
[**2142-5-20**] 07:40AM LIPASE-58
Brief Hospital Course:
KUB: SBO
Head CT: (prelim read from radiology). unchanged from prior head
CT, no intracranial hemorrhage
EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3
(old), TW inversion V6 (new) compared to prior EKG [**5-15**].
CT CHEST/ABD: Preliminary Read
Normal aorta without dissection or acute abnormality. No PE.
Stable trace
ascites and small right pleural effusion. Unchanged small
pulmonary nodules
and lymphadenopathy in the chest. No acute abnormalities in the
abdomen to
explain epigastric pain.
EGD: Ulcer at GE junction.
# Hypertensive urgency: This is a chronic issue related to ESRD.
Head CT was negative for intracranial bleed. Weaned off
Nicardipine gtt and BP well controlled on home regimen.
Continued her home regimen of: Aliskiren 150 mg po bid,
Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID,
Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet
Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were
lower (see below) patient's BP meds were held occasionally, but
as she was transfused and the BPs started to trend back up the
meds were re-initiated. She then developed hypotension in the
setting of poor PO intake during her SBO. BP meds were held and
then re-initiated as the pressure came back up once she was able
to eat.
# Abdominal pain/UGIB: The patient has chronic abdominal pain
with previous negative workups. At first the pain resolved and
she was continued on her outpatient regimen of: 2-4 mg po
dilaudid q4 h as needed. GI was c/s re: abd pain and rec
CTA-abdomen to eval for mesenteric ischemia vs. partial SBO,
however with ESRD did not initially want to get CTA so KUB was
ordered. This showed no SBO. They recommended checking urine
porphyrobilinogen and serum lead levels which were negative and
LFTs were at baseline. The patient then developed a different
type of pain associated with her incision site. Pain service was
consulted and did a bupivicaine injection at the site which did
help. They will continue to follow her. She then developed a
third type of pain associated with a burning sensation in her
chest. EKG was unchanged from prior. A few hours later she had 3
episodes of coffee-ground emesis. She was placed on IV PPI and
transfused two units of blood. Afterward the pain resolved and
her hct remained stable. GI felt that the patient would need
general anesthesia in order to undergo an EGD which showed an
ulcer at the GE junction. She was started on empiric treatment
for H. Pylori and serologies were sent which came back negative
so the antibiotics were stopped. Her pain was controlled with
her outpatient regimen of PO dilaudid. She will follow up with
Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if
there has been resolution of the ulcer.
# SBO: Continued to be nauseous and vomited intermittently. she
was started on reglan and continued on zofran and compazine PRN
howeve she continued to have n/v. A KUB was done which showed an
SBO. Surgery was consulted, NGT was placed, she was made NPO and
serial abdominal exams were done. Eventually she was able to
transition to clear diet and then tolerated a regular diet
without pain or vomiting.
#. Fever: On hospital day #6 she spiked a fever to 101. Blood
and urine cultures were sent and a cxr were negative, however
she then had a seizure and in the post-ictal state aspirated
after vomiting. She had an episode of hypoxia with this and was
transferred to the ICU. In the ICU LP was attempted to rule out
meningitis as a possible cause of a seizure but this was
unsuccessful. Broad spectrum antibiotics were initiated (vanc
ctx) at meningeal dosing. She improved over the next few days
and antibiotics were discontinued because the suspicion for a
bacterial meningitis was low.
#. Seizure: This occured in the setting of fever, hypotension,
and initiation of reglan for vomiting. Neurology was consulted
and felt she should be continued on keppra indefinitely. EEG was
non-revealing. She should be continued on keppra 1gm with
dialysis three times weekly.
# ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent
dialysis on normal schedule.
# SLE: She was continued on prednisone 4mg daily. With multiple
abdominal symptoms it was thought she may have lupus flare in
the abdomen. C3, c4 were equivocal for active lupus flare, and
[**Doctor First Name **] was positive, as would be expected in lupus.
# Anemia: Has anemia of chronic renal disease and her Hct was
high on admission and epo was held per renal. However, her Hct
trended all the way down to 20 and she was borderline
hypotensive for her (ie SBP 120) and she developed coffee ground
emesis so she was transfused 2 units. Afterward her Hct was
stable at 25. She was also re-started on EPO per renal for her
chronic anemia. Hemolysis labs were negative.
# History of thrombotic events/SVC syndrome: She is
anticoagulated with warfarin as an outpatient. Previous
documentation in OMR states she does not need to be bridged
while subtherapeutic. Continued coumadin 4 mg po daily however
INR became supratherapeutic and the coumadin was then held. She
was started on heparin gtt while awaiting EGD. After EGD the
coumadin was re-started at 3mg daily however, in setting of poor
po intake her INR was supratherapeutic - likely [**2-12**] nutritional
deficiency of vitamin k. coumadin will be restarted when INR [**2-13**]
at dialysis.
# OSA: She is on CPAP at a setting of 7 as an outpatient.
Continued CPAP
#. CIN1: On last pap had CIN1. OB/GYN service was called re:
doing colposcopy in hospital as patient rarely makes o/p
appointments, hwoever they do not do this procedure in hospital
especially because it does not have to be done emergently - just
within one year. Will need outpatient colposcopy at some point
in next few months as they do not do this procedure in the
hospital.
# RLL nodule: A new 10 x 5 mm nodularity was found incidentally
within the right lower lobe of the lung on an abdominal CT.
This should be reassessed in 3 months.
# ACCESS: PIV, right groin HD line
# CODE: Full code
Medications on Admission:
1. Aliskiren 150 mg PO bid
2. Citalopram 20 mg PO DAILY
3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT
4. Hydromorphone 2 mg 1-2 Tablets PO Q4H
5. Fentanyl 25 mcg/hr Patch 72 hr
6. Gabapentin 300 mg PO TID
7. Hydralazine 100 mg PO Q8H
8. Hydralazine 100 mg PO BID PRn fro SBP> 180.
9. Prednisone 4 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Labetalol 1000 mg PO TID
12. Nifedipine 90 mg PO QAM
13. Nifedipine 60 mg PO QHS
14. Warfarin 3 mg PO Once Daily
15. Lidocaine 5 %(700 mg/patch) Topical once a day.
16. Nifedipine 90 mg PO once a day as needed for for SBP
persistently above 200.
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
UGIB- Ulcer at GE junction
Hypertensive Emergency
Anemia
ESRD on HD
SBO
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You had
an injection of lidocaine to help the pain around your surgery
sites. You then had some blood in your vomit. You were treated
for a bleed in your stomach with a blood transfusion and
medications. You stopped bleeding and felt better. You had a
scope of your abdomen that showed an ulcer. You were treated
with medications for this and need to have another scope of your
abdomen in 6 weeks. You also had high blood pressures while you
were here because you could not take your medicines with your
nausea and vomiting. Once you were on your home medicines your
blood pressure was better.
Medication Changes:
CHANGE: Pantoprazole to 40mg TWICE daily
Please call your PCP or come to the emergency room if you have
fevers, chills, worsening abdominal pain, nausea, vomiting,
blood in your vomit, blood in your stools, black/tarry stools or
any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**]
weeks for an EGD to re-look at your ulcer.
Please follow up with the OB/[**Hospital **] clinic for a colposcopy on
Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**].
Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in
the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm.
Completed by:[**2142-6-6**] |
7100,28521,3643,58381,5856,40301 | 109 | 108,375 | Admission Date: [**2140-2-2**] Discharge Date: [**2140-2-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: EMERGENCY
Allergies:
Penicillins / Morphine / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 22F with a hx of lupus , ESRD on HD and malignant
hypertension who presents today "feeling out of sorts."
Following dialysis on Saturday the patient reports feeling weak.
Her BP was 147/60. She also states that the pain from the
uveitis in her L eye has gotten worse.
.
In the ED the patient's vitals were as follows: T 99, HR 71, BP
209/118, RR 16, O2 sat 98%RA. She was started on a labetolol gtt
with marginal improvement in her pressures. The patient was tx
to the ICU for further mgmt.
.
ROS is negative for any chest pain, SOB, and n/v. She reports
that since she's started the nicardipine she has been having
some urinary retention.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
-No family history of SLE.
-Grandfather has HTN.
-Distant history of DM.
-No history of clotting disorders
-No other history of other autoimmune diseases
Physical Exam:
T 98.2 HR 75 BP 190/115 R 14 O2 sat 100% RA
GEN: pleasant female in NAD, A & O X 3
HEENT: MMM, OP clear, no LAD
HEART: nl rate, S1S2, iii/vi HSM along LLSB
LUNGS: CTA b/l, no rrw
ABD: benign
EXT: dialysis line in L thigh, site c/d/i
Pertinent Results:
HEAD CT: no acute evidence of hemorrhage.
CHEST PA and L: no acute cardiopulmonary process.
Brief Hospital Course:
22F with hx of lupus and subsequent complications who presents
today with hypertensive emergency.
P:
# Hypertensive emergency - Precipitant is unclear. [**Name2 (NI) **]
reports that she is compliant with medications. Pain from
uveitis may have been a precipitant. This may also reflect a
progression of her disease.
- Placed on labetalol gtt for SBP as high as 220 with fair BP
control; transitioned back to po labetalol once BP was
reasonably well controlled. Pt refused additional
antihypertensives, saying, "You new doctors [**Name5 (PTitle) **] in here and
think you can make my blood pressure perfect, but I have high
blood pressure all the time and always have."
- Will continue home medications
- According to renal (Dr [**Last Name (STitle) 7143**], who follows pt), she insists
that no volume be removed at HD, saying that when volume is
removed, she feels "terrible." As a result, her volume status
complicates her blood pressure management
- After patient was informed that she would have to wait until
4pm for hemodialysis, she left against medical advice.
.
# ESRD - [**2-12**] to lupus nephritis. Patient will be receiving
transplant kidney from mother. Cont [**Name2 (NI) 44537**]. Renal offered
patient dialysis while in house
.
# Headache - Patient reported retro-orbital pain with uveitis.
Head CT was negative for intracranial hemorrhage.
.
# Uveitis - Followed by outpatient optho specialist. Patient
specifically refused evaulation by [**Hospital1 18**] ophtho consult despite
retro-orbital pain.
.
# Anemia - Hct has fallen from 35 to 27 within the past month.
Will repeat. Baseline anemia [**2-12**] renal disease. Receives EPO at
HD.
Medications on Admission:
Clonidine 0.3mg Q24H
Ativan 1mg q4-q6h
Sevalamer 800mg TID
Lisinopril 40mg [**Hospital1 **]
Valsartan 320mg daily
Labetalol 600mg TID
Prednisone 40mg daily
Moxifloxacin TID
Nicardipine 30mg q8h
Scopalamine
Discharge Medications:
same
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency; end stage renal disease due to lupus
nephritis
Discharge Condition:
fair
Discharge Instructions:
Follow up with your PCP within the next week.
.
Continue hemodialysis on your regular schedule.
|
04119,5855,4372,7100,7907,78039,40391,58281,4329 | 109 | 110,668 | Admission Date: [**2140-8-25**] Discharge Date: [**2140-9-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transfer from MICU, initially admitted for hypertensive
emergency
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 23 year old female with h/o SLE, lupus nephritis
and ESRD on HD, and poorly controlled HTN on multiple
medications presenting on [**8-25**] with unresponsiveness, bilateral
lower extremity weakness, and nausea/vomiting. She was in her
USOH until 2 days pta, when she developed n/v, and on the day of
admission, she was found lying on the floor unresponsive to
family members. Upon awakening she found that she could not
move either of her legs. She was taken to the EW, where she had
BP 260s/200s, had a non-contrast head CT showing left frontal
ICH, right parieto-occipital ICH, and edema throughout
bilaterally thought to be c/w PRES (posterior reversible
encephalopathy syndrome) with superimposed ICH, and had a
MRI/MRV to exclude venous thrombosis showing ICH in the
parieto-occipital lobes bilaterally and pons without venous
sinus thrombosis. She had a tonic-clonic seizure in the ED
terminated with 2 mg IV lorazepam. Neurosurgery was consulted
and felt that she should be managed non-surgically, a labetalol
drip was started with a target SBP of 160s-180s, and she was
admitted to the MICU.
.
In the MICU, she was initially maintained on the labetolol gtt.
She was also started on dilantin for seizure prophylaxis. She
was intubated to have an MRI of the head, as there was concern
for sinus venous thrombosis. MRI was negative for thrombosis.
She transiently required phenylepherine for BP maintenence while
she was on a propofol gtt for maintenence of sedation. She was
extubated on [**8-26**]. While in the ICU she was seen by nephrology
who did not think she needed acute HD. Hematology was also
consulted as the patient had thrombocytopenia and hemolytic
anemia. They did not think she had TTP and thought it was more
likely [**Last Name (un) 1724**] from hypertensive emergency. Additionally, she had
[**3-12**] sets of blood cultures from [**8-25**] grow oxacillan resistant
coagulase negative staph and was started on vancomycin. TTE was
done and negative for vegetation. Her PO BP meds were uptitrated
in the ICU and SBPs have been <180s in the past 24 hours. She
was transferred to the Medicine Team.
.
Upon transfer to Medicine team, the patient's SBPs were being
maintained between 150-160's and on po medications. She denied
fever, chills, nausea, vomiting, headache, chest pain, or
shortness of breath.
Past Medical History:
# Lupus - Diagnosed [**2134**] (16 years old)
- Diagnosed when she had swollen fingers, arm rash and
arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
# CKD/ESRD secondary to SLE - [**2135**]
# HTN - [**2137**]
- baseline BPs 180's/120's
- previous history of hypertensive crisis with seizures
# Uveitis secondary to SLE - [**4-15**]
- s/p left eye enucleation [**2139-4-20**] for fungal infection
# Thrombocytopenia - previous thrombocytopenia and hemolytic
anemia (TTP vs malignant HTN were considered on DDx)
# HOCM - per Echo in [**2137**]
# Anemia
# Vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera
injection requiring transfusion
# History of Coag negative Staph bacteremia and HD line
infection - [**6-15**] and [**5-16**]
# Previous history of SVC and UE clot, previously maintained on
coumadin
- SVC venogram performed [**2139**] s/p coumadin therapy revals patent
SVY and subclavian
- ?APLS but never has had positive anti-phospholipid antibody
Social History:
SH: Lives in [**Location 669**] with mother, who works at [**Hospital1 18**], and her 16
year old brother. She was able to graduated from high school but
unable to work since then secondary to her illness.
Drugs: ??????
Tob: ??????
Alc: ??????
Family History:
No family history of SLE
MGF: HTN, MI, stroke in 70s. No clotting disorders in family. No
history of autoimmune disease.
Physical Exam:
Vitals: T 97.6 HR 102 BP 176/100 RR 16 O2 sat 100% RA
General: Patient is a young African American female, sitting up,
talking on phone, NAD
HEENT: Left eye s/p enucleation. otherwise NCAT.
Neck: Supple
Pulmonary: CTA b/l
Cardio: Regular. +III/VI early systolic murmur throughout
precordium, loudest at LLSB.
Abdomen: SOft, non-tender, non-distended. NABS
Ext: No C/C/E
.
Neuro:
CN 2-12 intact, except EOMI and pupilary light reaction not
tested
Muscle strength intact in upper and lower extremities b/l
.
ON TRANSFER TO MEDICINE:
========================
Vitals: T 97.2 HR 92 BP 154/90 RR 16 O2 sat 100% RA
GEN: NAD, pleasant, sitting in bed.
HEENT: Left eye s/p enucleation. o/w NCAT, OP - no erythema, no
exudate, no LAD
PULM: CTAB, no w/r/r
CV: RRR. +III/VI early systolic murmur throughout precordium,
loudest at LLSB. No rubs/gallops
ABD: NABS, soft, NDNT
EXT: no c/c/e
Pertinent Results:
ADMISSION LABS:
===============
14.4
8.2 >------< 56 MCV 84
41.7
135 109 50
----|----|-----< 103
6.1 14 5.1
free Ca 1.14
.
PERTINENT LABS DURING HOSPITALIZATION:
======================================
Hct Trend: 41.7 - 40.2 - 39 - 30.4 - 26.9 - 25.1 - 23.2 - 21.7 -
25.4 - 25.8 - 27.0 - 28.6 - 25.7 - 27.9
Platelet Trend: 56 - 70 - 59 - 40 - 37 - 44 - 107 - 108 - 148 -
165 - 150 - 139 - 170 - 173
.
[**2140-8-25**] 10:51AM Glucose-94 Lactate-1.2 Na-136 K-6.3* Cl-114*
calHCO3-14*
[**2140-8-25**] 02:23PM Lactate-2.2*
[**2140-8-25**] 04:12PM Lactate-1.0 K-5.1
[**2140-8-25**] 10:51AM Type-[**Last Name (un) **] pH-7.19*
[**2140-8-25**] 01:48PM Type-ART pO2-117* pCO2-24* pH-7.27* calTCO2-12*
Base XS--13
[**2140-8-25**] 04:12PM Type-ART Temp-37.6 Rates-/22 pO2-106* pCO2-25*
pH-7.32* calTCO2-13* Base XS--11 Not Intubated
[**2140-8-25**] 07:47PM Type-ART Temp-36.9 Rates-16/ Tidal V-500 PEEP-5
FiO2-100 pO2-336* pCO2-29* pH-7.26* calTCO2-14* Base XS--12
AADO2-365 REQ O2-64 -ASSIST/CON Intubat-INTUBATED
[**2140-8-25**] 11:02PM Type-ART Temp-36.9 Rates-18/ Tidal V-500 PEEP-5
FiO2-40 pO2-208* pCO2-25* pH-7.30* calTCO2-13* Base XS--11
-ASSIST/CON Intubat-INTUBATED
[**2140-8-26**] 01:27AM Type-ART Temp-36.7 Rates-/20 Tidal V-450 PEEP-5
FiO2-40 pO2-207* pCO2-28* pH-7.30* calTCO2-14* Base XS--10
Intubat-INTUBATED Vent-SPONTANEOU
[**2140-8-26**] 03:59AM Type-ART Temp-36.7 pO2-108* pCO2-31* pH-7.35
calTCO2-18* Base XS--7 Intubat-NOT INTUBA
[**2140-8-26**] 08:25PM Type-[**Last Name (un) **] Temp-37.0 pO2-41* pCO2-36 pH-7.33*
calTCO2-20* Base XS--6 Intubat-NOT INTUBA
.
[**Doctor First Name **]-POSITIVE Titer-1:320
ACA IgG 11.4 ACA IgM 9.0
ESR 15
C3-55* C4-13
Haptoglobin trend: <20 - 69
LDH: 326 - 256 - 246
Retic Count: 1.8 - 2.0
[**Doctor Last Name 17012**] Negative
Urine 24 hr Creat-630
.
MICROBIOLOGY:
=============
[**8-25**] Blood Cultures from venipuncture: Staph, coag negative x 2,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-25**] Blood Cultures from arterial line: Staph, coag negative x
2, susceptible only to rifampin, tetracycline, and vancomycin.
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures from catheter tip: Staph, coag negative,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-28**] Blood Cultures x 2 from femoral NGTD
[**8-28**] Blood Culture from femoral: enterobacter>15
[**8-28**] Blood Cultures x 2 NGTD
[**8-31**] Blood Cultures pending
[**9-1**] Blood Cultures pending
.
STUDIES:
=========
CHEST (PORTABLE AP) [**2140-8-25**]
IMPRESSION: AP chest compared to 11:49 a.m.:
Tip of the new endotracheal tube, with the chin slightly flexed
is no more than 15 mm above the carina, 2 cm below optimal
placement, as reported to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2026**] on
[**8-25**]. An ascending caval catheter ends in the low right atrium.
Nasogastric tube ends in the stomach. There is no pneumothorax
or pleural effusion. Lungs are clear and heart size is normal.
No pneumothorax.
.
MRA BRAIN W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Multifocal areas of cortical T2 signal hyperintensity, some
with foci of recent hemorrhage. The most affected areas are the
parietal and occipital lobes, as well as the pons. The
appearance may represent posterior reversible encephalopathy
syndrome. Hemorrhage and pontine involvement in this disorder is
somewhat unusual, but has been described in the literature.
.
2. No definite evidence of major venous sinus thrombosis.
Nevertheless, if further evaluation is felt necessary
clinically, axial and coronal-acquired 2D time-of-flight MR
venography sequences could be performed, allowing each of the
major venous sinuses to be imaged orthogonally, a procedure
which would minimize any in-plane flow artifacts simulating
thrombus. However, this diagnosis, even at present, is
considered highly unlikely.
.
CT HEAD W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Acute intraparenchymal hemorrhages peripherally in the right
parietoccipital and left frontal lobes, with surrounding edema
and local mass effect.
.
2. Vasogenic and interstitial edema in a strikingly symmetric
and posterior distribution involving both [**Doctor Last Name 352**] and white matter
of the occipital lobes and frontalparietal regions, bilaterally.
.
COMMENT: These findings are highly suggestive of PRES
(hypertensive encephalopathy), with development of superimposed
hypertensive hemorrhages. However, given the history of SLE,
suspicion of underlying "lupus anticoagulant" and non-arterial
distribution of edema and hemorrhage, cerebral venous (including
dural venous sinus) thrombosis should be excluded, and urgent
MRI with MRV has been recommended, below.
.
The results were discussed with Dr. [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) **], EU
resident, at the time of study.
.
2. Right maxillary sinus mucus retention cyst.
.
CHEST (SINGLE VIEW) [**2140-8-25**]
IMPRESSION: Unremarkable chest radiograph.
.
EKG [**2140-8-25**]
Sinus tachycardia. Voltage criteria for left ventricular
hypertrophy. Diffuse ST-T wave abnormalities, most likely
related to left ventricular hypertrophy. Compared to the
previous tracing of [**2140-7-30**] lateral ST-T wave abnormalities have
improved.
TRACING #1
.
EKG [**2140-8-26**]
Sinus tachycardia. Compared to the previous tracing of [**2140-8-25**]
no significant diagnostic change.
TRACING #2
.
ECHO [**2140-8-26**]
Conclusions:
The left atrium is normal in size. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. The gradient increased with the Valsalva manuever.
The findings are consistent with hypertrophic obstructive
cardiomyopathy (HOCM). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2140-5-20**], no
change.
.
IMPRESSION: No valvular vegetations seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 23 yo female with a h/o SLE with secondary lupus
nephritis, uveitis s/p left eye enucleation, question of APLS
and poorly controlled HTN who presented on [**8-25**] with N/V,
lethargy, fatigue and headaches, found to have hypertensive
emergency,who subsequently seized. CT head showed multiple
intraparenchymal hemorrhages.
.
# Hypertensive Emergency with ICH: Patient initially presented
with significantly elevated blood pressures resulting in end
organ damage causing seizure and intracranial hemorrhage. Her
intracranial bleed appears to be most consistent with PRES,
though septic emboli are on the differential. Goal SBP 150-160s.
Continued dilantin 100 mg tid for seizure prophylaxis, and pt
scheduled for follow up at neuro clinic in two weeks after
discharge. Continued po regimen of labetolol 1000 mg TID,
hydralazine 75 mg PO BID (the only change in home meds),
lisinopril 40 mg [**Hospital1 **], valsartan 320 mg PO daily, nicardapine 60
mg PO TID, as well as clonidine patch when transferred to the
floor. Pt achieved goal of SBPs in 150-160s on this regimen and
was discharged home.
.
# Bacteremia: She had high grade bacteremia with 6/6 bottles on
[**8-25**] growing oxacillan resistant coagulase negative staph. HD
cath was d/c'ed. A TTE was negative for vegetation. Blood
cultures from [**8-27**] and [**8-28**] showed NGTD. Pt started on
vancomycin. Levels were followed to achieve therapeutic goals.
Ideally, vancomycin would be continued for 14 days after first
negative blood cultures. Repeatedly, pt was told that
vancomycin was superior to linezolid for bacteremia, but she
still refused PICC. Thus, pt started on po linezolid and
discharged with linezolid. She will need close follow up for
bone marrow suppression secondary to linezolid.
.
# Thrombocytopenia: Patient has had previous episodes of
clinical illness with acute drop in platelets with question of
consumptive coagulopathy from thrombosis vs. secondary to
malignant hypertension. Received one unit platelets with
placement of R femoral line. Platelets slowly improved over
hospitalization. Evaluated by heme who did not think
thrombocytopenia was consistent with TTP, but more likely to be
due to malignant hypertension. Platelets counts improved with
improvement in blood pressures.
.
# SLE: The patient was previously treated with
Cytoxan/Prednisone and on admission was on low dose prednisone.
There had been concern in the past for anti-phospholipid
syndrome but her APA testing has been negative. Rheum consulted.
Pt on 15 mg prednisone during hospitalization and discharged
with this dose and follow up.
.
# CKD stage V - Patient most recently had not been to HD for 3
weeks because she did not like the way it made her feel. Some
residual kidney function and awaiting kidney transplantation
from a relative. HD catheter was pulled during this admission
due to high grade bacteremia. Per renal, not imperative that pt
needs acute HD. Electrolytes monitored. Sevelamer and daily
Kayexalate continued during hospitalization.
.
#. Anemia - Thought to be chronic and likely related to her CKD.
There was concern for hemolytic anemia during this admission,
likely caused by malignant hypertension. Hct trended up during
hospitalization. Continued Epogen 4000 u three times/wk per
renal.
.
# Code - Presumed Full
.
#. Communication: Mother - [**Telephone/Fax (1) 43497**]
.
#. Dispo: Home with services.
Medications on Admission:
Valsartan 320 mg QD
Clonidine patch weekly
Hydralazine 50 mg [**Hospital1 **]
Lisinopril 40 mg [**Hospital1 **]
Nicardipine 60 mg TID
Labetalol 1000 mg TID
Prednisone 20 mg QD
Neurontin 100 mg 3x/week
Sevelemer 800 mg TID
Allergies: PCNs -> rash
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO Q8H (every 8 hours).
Disp:*90 Capsule(s)* Refills:*2*
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*450 Tablet(s)* Refills:*2*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nicardipine 30 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*2*
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive emergency
Seizures
Coagulase negative Staph bacteremia
Chronic kidney disease
Discharge Condition:
good
Discharge Instructions:
You were admitted for high blood pressure, seizures and head
bleeding.
.
Your blood pressure was controlled and you were evaluated by the
neurology, [**Location (un) **] and renal doctors. You should follow up
with all of them after you are discharged.
.
Please continue all your medications as prescribed.
.
You should continue taking your antibiotic as prescribed for 8
more days. Linezolid twice a day for 8 days.
.
If any fevers, shortness of breath, chest pain, headaches or any
other symptoms that may concern you please call your PCP or come
to the emergency department.
.
Followup Instructions:
Nephrology
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2140-9-5**] 4:00
.
Primary Care
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 44538**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-9-6**] 3:00
.
Neurology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**9-16**] 1 pm. Phone. [**Telephone/Fax (1) 40554**]
.
[**Telephone/Fax (1) 2225**]:
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2140-10-5**] 3:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2140-9-5**] |
V5861,2875,40301,5856,58281,4251,4466,7100,28521,32723,72992,V1251,3004,V4512 | 109 | 113,189 | Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
From admission note:
The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN,
history of SVC syndrome admitted with HTN and SOB in the setting
of missed HD. The patient reported missing HD yesterday because
she thinks she is being overdiuresed. She reports persistent
pain at site of rectus sheath hematoma. Denies N/V/D.
Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal
pain at the site of her known left abdominal wall hematoma,
hypertensive to 230's and hyperkalemic to 6.2 after missing her
last two dialysis sessions. At this time the pt. was dialyzed,
received a blood transfusion, and was administered her daily
antihypertensive medications. Pt. left AMA after her
transfusion despite the primary team's concerns to look for an
active area of bleeding.
In the ED, patient complain of mild dyspnea, sating well on RA.
CXR mild volume overload. KUB with no evidence of obstruction.
She was started on a labetalol gtt. ECG - RAD, LVH no change
from prior. HCT stable at 21. The renal team evaluated pt and
recommended HD, however the patient refused. She was transferred
to ICU for BP control.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
Gen: sleeping comfortably, easily awoken by verbal stimuli
HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM
Heart: S1S2 RRR, III/VI SEM throughout the precordium
Pulm: CTA b/l
Abd: NABS, midline scar well-healed, soft, mild L TTP, no
rebound/guarding
Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place
Neuro: following commands, answers appropriately, [**5-15**] motor
strength, sensation is intact.
Pertinent Results:
[**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90
MCH-29.5 MCHC-33.0 RDW-18.9*
[**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0
BASOS-0.2
[**2142-2-14**] 07:40AM PLT COUNT-101*
[**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5*
[**2142-2-14**] 07:40AM CK-MB-6
[**2142-2-14**] 07:40AM cTropnT-0.09*
[**2142-2-14**] 07:40AM LIPASE-80*
[**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK
PHOS-124* TOT BILI-0.4
[**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17
[**2142-2-14**] 07:44AM LACTATE-1.3
[**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left
pleural effusion. Left basilar air space disease which may
represent pneumonia. Clinical correlation and a follow up chest
x-ray to clearance is recommended.
[**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of
obstruction. 2. Left basilar airspace disease which may
represent pneumonia and a small left pleural effusion. Please
ensure follow-up to clearance.
Brief Hospital Course:
24 y.o female with SLE, ESRD on HD and malignant hypertension
who presents with HTN and SOB aftering missing HD.
.
# Malignant hypertension/hypertensive urgency: The patient has a
well-documented history of paroxysmal hypertension believed to
possibly be related to pain, anxiety, narcotic withdrawal and
poor medication and HD compliance. Has previously presented with
BP up to 260/160 but most often without evidence of end-organ
ischemia, as she did for this admission. Pt was treated per OMR
hypertensive protocol created by the patient's primary
providers, with a goal SBP of 160-180. With short course of IV
antihypertensives and hemodialysis, pt's BP fell appropriately
and was well maintained on oral outpt regimen of clonidine,
labetalol, aliskiren, nifedipine.
.
# ESRD: Pt was followed by the renal service and underwent HD
without any complications. Pt states she would like to
reconsider peritoneal dialysis as she is experiencing increased
fatigue since instituting HD. She will discuss this further
with the Renal team as an outpatient.
.
# SLE: Pt was continued on her home dose of prednisone with no
sign of SLE flair.
.
# Coagulopathy/history of DVT: Patient on lifetime
anticoagulation for hx of multiple thrombotic events. Pt was
continued on coumadin.
.
# Pain management: Pt was treated with PO dilaudid for her
abdominal pain, as recommended per her OMR protocol. She asked
for IV dilaudid multiple times but there was no clinical
indication. She was also continued on gabapentin.
.
# Anemia: Secondary to AOCD and renal failure. The patietns Hct
remained stable in the low 20s during admission. No PRBC
infusions were needed.
.
# Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **]
Medications on Admission:
1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for pain.
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8)
hours as needed for pain.
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Malignant Hypertension
Secondary: SLE, End stage renal disease on hemodialysis, SVC
syndrome
Discharge Condition:
Stable. SBP in 160s.
Discharge Instructions:
You were admitted with dangerously high hypertension and some
shortness of breath in the setting of missing several dialysis
sessions. You were admitted and treated with your usual regimen
of blood pressure meds and a short course of IV meds. With
dialysis, your symptoms improved.
You also had some abdominal pain, which was well controlled on
your usual pain medications.
We made no changes to your medications. Please take everything
as prescribed.
Please call your PCP or return to the hospital if you develop
any headaches, visual changes, confusion or chest pain, or any
other concerning symptoms.
Followup Instructions:
Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as
scheduled.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2142-2-21**] |
2767,78907,32723,33829,V5865,28521,7100,4251,58281,5856,40301 | 109 | 124,398 | Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
HTN, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24F with ESRD on HD, SLE, malignant HTN, history of SVC
syndrome, PRES, recently discharged on [**2142-3-18**] after admission
for abdominal pain, MSSA bacteremia, paroxysmal hypertension and
ESRD line, followed by readmission [**3-22**], now presents with usual
central crampy abdominal pain, 3 loose nonbloody stools this AM,
SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD
session, went home, states she took her PM meds, took her 8 AM
medds (hydral, labetalol), then developed these symptoms which
precluded her from taking her usual home meds (no afternoon meds
- nifedipine, labetalol, hydral). The abd pain comes and goes
and is unchanged from her baseline. While she has nausea, she is
asking for dinner.
.
In the ED, initial BP 272/148. CXR w/o evidence of volume
overload. No CT scan performed. Started on NTG gtt, given
Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1.
.
Upon arrival to the floor, her BP was 240/135. She continued to
complain of abdominal pain but was eating crackers, breathing
felt better. RR 17.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-120's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother. On disability for multiple medical problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC
Gen: pleasant, comfortable
HEENT: L eye enucleated. moon facies. Right pupil reactive
Heart: hrrr, no m/r/g
Pulm: CTA b/l
Abd: NABS, midline scar well-healed, soft, diffuse TTP, no
rebound/guarding
Ext: no c/c/e
Neuro: aox4, cn 2-12 intact grossly.
Pertinent Results:
[**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1*
[**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**11-30**]
[**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK
PHOS-192* TOT BILI-0.5
[**2142-3-24**] 02:05PM cTropnT-0.12*
[**2142-3-24**] 02:05PM CK-MB-5
[**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92
MCH-30.7 MCHC-33.4 RDW-19.8*
[**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8
EOS-3.0 BASOS-0.8
[**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL
TEARDROP-1+ ELLIPTOCY-OCCASIONAL
[**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129*
[**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2142-3-23**] 12:00PM estGFR-Using this
[**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9
[**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91
MCH-30.3 MCHC-33.3 RDW-19.4*
[**2142-3-23**] 12:00PM PLT COUNT-130*
[**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9*
Brief Hospital Course:
The patient was admitted to the MICU on a NTG gtt from the ED.
Her abdominal pain had imporved and she was eating crackers and
peanut butter. She was given her usual afternoon home
medications, and transitioned to a Nicardipine gtt, which has
worked well for her in the past. Her BP goal was for a systolic
of 180-200. The Nicardipine gtt was titrated off quickly and she
was transfered to the floor.
.
On arrival to the floor, she in fact missed her morning
medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures
requiring IV hydralazing for control. She went to dialyisis
Tuesday [**3-27**] and again had markedly elevated blood pressures
while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were
written for explicit AM administration and Nifedipine long
acting 30mg was added at night, in addition to the 90mg long
acting she was taking in the morning. She was continued on
labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and
clonidine patch 0.4mg/24 weekly patch.
.
HEr BP remained relativly stable. She established a three three
times weekly Dialysus regemin. A PAP smear was attempted due to
her history of CIN I and no PCP follow up, but was unsucesfull
due to a very small vaginal introutus and no small specuilum
available.
.
Her abdominal pain was also a chronic issue, which appeared
stable. She was not administered IV narcotics, only PO. It was
wihtout clear percipitating events or etiology. She will need GI
follow up. She was contact[**Name (NI) **] by phone several times to arrange
a GI follow up appointment but did not return messages. She has
a history of multiple missed appointments and no appoitment was
made without confirming with the patient that she would attend.
.
She was discharged to followup with her nephrologist, Dr.
[**Last Name (STitle) 4883**].
.
Medications on Admission:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4PM.
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for abdominal pain.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea for 4
days.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
[**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2*
4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
[**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2*
5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
[**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2*
6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
[**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2*
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
[**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2*
8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid ().
[**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2*
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches
Transdermal once a week: Place two patches every week on
Fridays.
[**Last Name (STitle) **]:*8 Patches* Refills:*2*
10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
[**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0*
11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for prn SBP>200: if nauseated and cannot keep down
meds, may use 1 sublingual clonidine if sbp>200. .
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
12. Kayexalate Powder Sig: Thirty (30) grams PO once a day
for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated
potassium.
[**Month/Day/Year **]:*240 grams* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Systemic Lupus Erythematosus
End Stage Renal Disease
Hypertension
Abdominal Pain
Discharge Condition:
Blood pressure stable and abdominal pain at baseline
Discharge Instructions:
You were admitted with high blood pressure. You were in the ICU
overnight for treatment. Some of your medications were changed
and you were increased to three times weekly [**Location (un) 2286**]. Your
abdominal pain is a difficult problem, as the reason for the
pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV
dilaudid is strongly discouraged and will continue to be in the
future.
You are now taking Nifedipine SR 30mg at night in addition to
90mg in the morning. Your other medications were the same.
At home, if your blood pressure is above 200, then take 100mg
hydralazine. If after 1 hour, your blood pressure does not
decrease to below 200 with this, then take another 100mg
hydralazine. If you are nauseated and cannot take in oral meds,
then take sublingual clonidine, then wait 1 hour and repeat if
BP still > 200.
Finally, your potassium has been high. Please take kayexalate
30gm tomorrow and the next day.
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**]
7:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
We will attempt to contact you on [**Name (NI) 766**] with appointment times
for you.
|
V5861,V1251,45184,2767,7100,9992,4251,5856,40301 | 109 | 124,657 | Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant
HTN admitted with mild headache, mild shortness of breath and
consistent abdominal pain at the site of her known left
abdominal wall hematoma in the setting of hypertension. Her
last HD was yesterday.
.
Upon arrival to the ED, her vitals were BP 240's systolic, HR
90's, 93% on RA. A head CT scan was done which showed no acute
process. An abdominal CT was done given her femoral line pain,
which also was normal. She was given nitropaste X2 initially,
then switched to labetalol 100mg x2, then 200mg x2, then finally
started on nicardipine drip when she showed benefit with a
decrease in her BP to 170/123 and improvement in her headache.
.
Upon arrival to the MICU, patient denies any current symptoms.
She reports that her headache, shortness of breath and abdominal
pain all resolved with blood pressure management and pain
medications.
.
Pt was transferred to the floor when blood pressure was
controlled.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: HR 96 BP 171/111 RR 12 O2 98% on RA
Physical Exam:
General in NAD
HEENT NC, AT, EOMI, PERRLA, MMM
CVS RRR, 3/6 systolic murmur in all heart fields
RESP CTA BL, no crackles or wheezes
ABD soft, hematoma raised on left anterior abdominal wall, +BS,
mildly tender over hematoma
EXT left sided femoral HD line in place, no erythema, no edema
NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye,
motor and sensory intact
Pertinent Results:
***LABS ON ADMISSION***
[**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94
MCH-30.3 MCHC-32.2 RDW-19.2*
[**2142-1-13**] 07:03AM PLT COUNT-154
[**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0*
[**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9
[**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9*
[**2142-1-14**] 12:00PM LIPASE-42
[**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT
BILI-0.4
[**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**3-15**]
[**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9*
[**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7*
.
***LABS ON DAY OF DISCHARGE***
[**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1*
MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136*
[**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137
K-5.2* Cl-101 HCO3-27 AnGap-14
[**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2*
.
IMAGING
[**2142-1-14**] EKG
Sinus rhythm. Possible left atrial abnormality. Borderline
voltage criteria
for left ventricular hypertrophy. Inferolateral ST-T wave
changes may be
related to left ventricular hypertrophy. Compared to the
previous tracing
of [**2142-1-8**] there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 190 86 368/436 13 100 24
[**2142-1-14**] CT ABD/PELV
IMPRESSION:
1. Interval decrease in size to subcutaneous anterior abdominal
wall
hematoma.
2. Infectious versus inflammatory process within the right lower
lobe of the
lung. Small right simple pleural effusion.
3. Cardiomegaly with slight decrease in size of moderate
pericardial
effusion.
4. Right lobe liver hemangioma, unchanged.
[**2142-1-14**] CT HEAD
IMPRESSION:
1. Mildly limited study given administration of small amount of
IV contrast
material. However, no evidence of hemorrhage or mass effect.
NOTE ADDED AT ATTENDING REVIEW: This patient was administered
contrast for the
abdominal CT, and the head CT was performed after part of this
dose.
Therefore, this is neither a noncontrast examination, nor a
proper contrast
CT.
[**2142-1-14**] CXR
CONCLUSION:
Persistent cardiomegaly and mild pulmonary edema.
Brief Hospital Course:
24 yo woman with hx of SLE, ERSD on HD, admitted with
hypertensive urgency.
.
# Hypertensive Urgency: Pt with extensive history of
hypertension. Patient's BP improved with nicardipine drip.
Became increased yesterday when the patient missed a dose of
oral nicardipine, but came down after a replacement dose.
Restarted all home oral antihypertensives including nicardipine
30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine
100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses.
Blood pressure remains labile and renal continues to follow
patient.
Pt was transferred to the floor as blood pressure stabilized.
BP has remained stable with systolics 140s-170s. In the MICU,
Nifedipine extended release was added in place of Nicardipine as
pt's blood pressures seemed to rise prior to Nicardipine doses.
.
# Hyperkalemia: Ocurred on the day after admission. Resolved
with administration of kayexalate. Pt continued hemodialysis on
TuThSat.
.
# Left abdominal wall hematoma: Abd CT showed a mild decrease
in the size. Pt reported that morphine did not help pain, and
was switched to dilaudid PO in the MICU. However, given pt's
recent prior admission required narcan following sensitivity to
narcotics, dilaudid was d/c'ed on the floor. Pt was continued on
gabapentin, tylenol around the clock, and low-dose Morphine as
needed for pain. Narcotics should be avoided in the future. Pain
should also resolve in the next few weeks as hematoma resolves.
.
# SLE: Pt was continued on prednisone at 4 mg PO daily.
.
#ESRD: Renal was following during her stay. She continued HD on
her T, Th, Sat schedule.
# Anemia: Hct was mildly decreased from baseline during
admission. This is likely secondary to AOCD and in the setting
of renal failure.
.
# SVC thrombus: Patient is on anticoagulation, likely lifelong.
Patient was supratherapeutic on coumadin on admission and
coumadin was subsequently held. Then INR became subtherapeutic,
so heparin gtt was used to bridge. On day of discharge, INR
became therapeutic, and pt was discharged home on Coumadin 4mg
PO daily, with INR to be checked next at hemodialysis
.
# HOCM: Pt has evidence of myocardial hypertrophy on recent
Echo. She was not symptomatic during her stay. She was continued
on her beta blocker.
.
# Depression/anxiety. She was continued on celexa and clonazepam
PRN.
.
# OSA: CPAP for sleep with 7 pressure.
.
# FEN: repleted lytes prn / regular diet
.
# PPX: coumadin, bowel regimen
.
# ACCESS: PIV/ permanent dialysis cath L fem
.
# CODE: FULL
.
# CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**]
Medications on Admission:
Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday
Hydralazine 100mg PO q8H
Labetalol 900mg PO TID
Morphine 7.5mg Q8H PRN
Nicardipine 30mg PO TID
Aliskiren 150 [**Hospital1 **]
Prednisone 4mg PO qday
Clonazepam 0.5 mg [**Hospital1 **]
Celexa 20mg PO qday
Gabapentin 300 mg [**Hospital1 **]
Acetaminophen 325 mg q6H PRN
Ergocalciferol (Vitamin D2) 50,000 unit PO once a month
Coumadin 4 mg daily
Discharge Medications:
1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8)
hours as needed for breakthrough pain for 2 weeks.
2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1*
13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
[**Hospital1 **]:*260 Tablet(s)* Refills:*1*
14. Respiratory Therapy
Please adjust settings of CPAP machine to a lower volume as it
is uncomfortable for the patient.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Discharge Condition:
Good, hemodynamically stable, afebrile, pain controlled
Discharge Instructions:
You were admitted for headaches and very high blood pressures.
You were started on an IV medication for your blood pressure
which controlled it. You were then started back on your home
medications with improvement of your blood pressure. One new
medication was added as your hypertension was difficult to
control.
You were also started on a heparin drip while restarting your
coumadin since you have a known clot in your veins. You will
need to continue your Coumadin at 4mg daily and have your INR
checked AT DIALYSIS next week.
Please take all medications as prescribed. It is important that
you do not miss doses of your medications since your blood
pressure is very sensitive to missed doses. Please keep ALL
scheduled appointments.
Medications changes include:
1. STOP NICARDIPINE
2. Start Nifedipine CR 90mg by mouth daily
3. INCREASE Labetalol to 900mg by mouth 3 times daily
4. Continue at Warfarin 4mg by mouth daily
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, chest pains,
shortness of breath, nausea, vomiting, or headaches.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up
a follow-up appointment in 1-2weeks.
Please continue your HD TuThSat.
Completed by:[**2142-1-20**] |
40301,5856,2841,7100,78900,2859,V1251,V5861 | 109 | 125,288 | Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypertensive Urgency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
(from MICU admit note)
24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and
hypertension. Pt has had work-up over recent months for abd
pain, including exploratory laparotomy, all of which essentially
(-).
Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**]
for sob with (-)CTA, dc'ed [**11-17**].
In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on
RA, rectal exam negative, guaiac(-), pelvic exam unremarkable
with no cervical motion tenderness. Renal was consulted, taken
for hemodialysis. CT abd showed large ascites, no other
pathology; CT head improved from prior with no acute ICH;
cxr(-). Given iv dilaudid for abdominal pain. BP treated with
10mg iv labetalol. Blood and urine cultures drawn, peritoneal
fluid cx sent from catheter. Admitted to MICU for hypertension
management. Access: R-HD catheter, 1 pIV in hand, 1
non-functioning peritoneal dialysis catheter.
Past Medical History:
PMH:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSH:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA
GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain
HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no
conjuctival injection, anicteric, OP clear, MMM
Neck: supple, no LAD
CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops
PULM: CTAB, no w/r/r
ABD: soft, mildly tender at PD catheter, ND, + BS, midline
incision with steri-stripes, PD catheter dressing C/I/D
EXT: warm, dry, +2 distal pulses BL, no edema
NEURO: alert & oriented, CN II-XII grossly intact (except L
eye), 5/5 strength throughout. No sensory deficits to light
touch appreciated. No asterixis
PSYCH: appropriate affect
Pertinent Results:
Admission Labs:
[**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7*
MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142*
[**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3*
[**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140
K-4.3 Cl-105 HCO3-25 AnGap-14
[**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3
[**2141-11-18**] 07:00AM BLOOD Lipase-76*
[**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9
[**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1*
Monos-2* Mesothe-11* Macroph-43*
[**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE
Epi-[**3-15**]
Discharge Labs:
[**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3*
MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182
[**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0*
[**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139
K-4.8 Cl-106 HCO3-24 AnGap-14
[**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8
[**2141-11-22**] 04:55AM BLOOD TSH-6.1*
[**2141-11-23**] 04:40AM BLOOD Free T4-1.2
Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD
Urine cx ([**11-18**]): mixed flora c/w contamination
Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth.
Imaging:
CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size
enlargement is unchanged due to known pericardial effusion.
Lungs are otherwise clear. Hilar contours are normal.
Incidentally, widening of both acromioclavicular joints is
unchanged.
CT A/P ([**11-18**]):
1. No evidence of bowel obstruction or rim-enhancing fluid
collection.
2. Large ascites, slightly increased from [**2141-11-13**], with
peritoneal dialysis catheter in place. Interval removal of
surgical skin staples along the abdomen.
3. Moderate pericardial effusion as before.
4. Symmetric heterogeneous attenuation of the kidneys could be
related to
renal failure; however, pyelonephritis could also give this
appearance.
Appearance of the kidneys is unchanged from [**2141-11-13**].
CT Head w/o contrast ([**11-18**]):
1. No evidence of acute intracranial hemorrhage.
2. Regions of hypoattenuation in the bifrontal white matter and
left
posterior temporal lobe have resolved since [**2141-6-11**]. No new
regions of
hypoattenuation seen.
Brief Hospital Course:
1) Hypertension: Patient has history of extremely labile
hypertension on an aggressive outpatient regimen. Overnight in
the MICU, patient required IV and PO labetalol for SBP > 200.
Her hydralazine was increased from 75mg to 100mg TID with mild
improvement. Her labetalol was also increased from 300mg to
400mg TID. Her blood pressure also seemed to improve when her
pain decreased and was normal in the middle of the night. TSH
was sent and elevated, although free T4 was normal. Plasma
metanephrines were sent and pending at discharge.
2) Abdominal pain: CT scan showed increasing ascites, but no
acute pathology. Peritoneal fluid was obtained and contained 544
polys. Treatment was started with metronidazole and
levofloxacin, as well as vancomycin as 1 blood culture was
growing GPC pairs/clusters. Blood cultures ended up growing 1
out of 4 bottles coag-neg Staph, likely contaminant, so
vancomycin was stopped. Since nephrology felt her peritoneal
fluid polys were inflammatory but not infectious, the
levofloxacin and metronidazole were stopped. The peritoneal
cultures remained negative. Her PD catheter was left in place as
the patient refuses HD any longer than necessitated by the
healing of her recent laparotomy (see prior d/c summaries).
3) SVC/brachiocephalic thrombosis: Patient's INR was
subtherapeutic on admission at 1.3. Due to the proximal location
of her old venous thrombi, she was started on a heparin gtt.
This was continued during her admission and her warfarin was
increased to 5mg daily. Her INR reached 2.0 at discharge
(therapeutic range 2-3). The dose was lowered to 4mg daily at
discharge to prevent overshooting the therapeutic range, but the
patient will have close follow up with coumadin clinic, with
dose titrations as needed.
4) Anxiety: Patient noted feeling short of breath and anxious
around the time of her recent admissions. Her nephrologist felt
this may be contributing to her recurrent pain and hypertension,
so psychiatry was consulted. They felt her symptoms were
suggestive of anxiety and panic attacks, recommended checking
TSH and metanephrines as above, and starting citalopram 20mg,
which was done. She was advised on breathing exercises, which
seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient
is agreeable to outpatient follow up with [**Company 191**] social work, and
potential CBT. These can be arranged by her PCP.
Medications on Admission:
1. Aliskiren 150 mg [**Hospital1 **]
2. Clonidine 0.3 mg/24 qwk
3. Prochlorperazine Maleate 10 mg prn
4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn
5. Bisacodyl 10mg [**Hospital1 **]
6. Ergocalciferol (Vitamin D2) 50,000 qmonth
7. Hydralazine 75mg tid
8. Hydralazine scale prn
9. Labetalol 300 mg tid
10. Nifedipine 90 mg qd
11. Prednisone 4mg qd
12. Warfarin 2 mg qd at 4pm
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid ().
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every [**Hospital1 766**]).
5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
[**Hospital1 **]:*180 Tablet(s)* Refills:*2*
6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMONTH ().
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
[**Hospital1 **]:*180 Tablet(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for 7 days.
[**Hospital1 **]:*15 Tablet(s)* Refills:*0*
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn
as needed for hypertension: for SBP > 180.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive urgency
Headache
Abdominal pain
Anxiety
Secondary Diagnosis:
HTN
SLE
ESRD on HD
SVC and IJ thrombosis, chronic
Anemia
Discharge Condition:
Stable, BPs improved.
Discharge Instructions:
You were admitted with elevated blood pressures, headache, and
abdominal pain. You were found to have increased amounts of
white blood cells in your abdominal cavity, but this was not
infected. Your abdominal pain resolved and you continued to have
intermittent headaches. Your blood pressure medications were
adjusted as below. You were also seen by psychiatry who
recommended starting new medications for your anxiety.
The following changes were made to your medication regimen:
- We increased your hydralazine to 100 mg three times a day.
- We also increased your labetalol to 400 mg three times a day.
- We have started a medication called celexa 20 mg daily as well
as ativan 1 mg three times a day as needed for anxiety.
- We have increased your coumadin to 4 mg daily.
- Please continue taking all other medications as previously
prescribed.
Call your doctor or return to the emergency room if you
experience any of the following: worsening abdominal pain,
nausea, vomiting, blurry vision, worsening headache, fever >
101.
Followup Instructions:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week.
Please continue to follow with your nephrologist and go to
outpatient dialysis as previously arranged.
Please discuss with your PCP the possibility of talking to a
social worker at [**Name (NI) 191**].
You will need to continue to have your INR monitored at [**Hospital 191**]
[**Hospital 2786**] clinic. Please have this level checked on
[**Hospital 766**], [**11-27**].
Completed by:[**2141-11-23**] |
V1251,V5861,4168,7821,78060,78659,51889,32723,79092,28521,56400,4010,5856,58281,4239,78959,2762,2761,78909,78906,78701,78791,7100,25200,2859,2875,53081,V4511,34590 | 109 | 126,055 | Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Nausea, Vomitting, Abdominal Pain, HTN Urgenc
Major Surgical or Invasive Procedure:
Upper GI endoscopy
Exploratory laparotomy
Tunneled hemodialysis catheter in R femoral vein
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started
peritoneal dialysis during the week of [**2141-10-8**] and presented
with a 1 day history of acute onset N/V, sharp abdominal pain on
[**2141-10-13**]. (Of note, the patient had presented to the ED on
[**10-11**] with hypotension, SBPs in the 80s off after approximately
1.5L was taken off during dialysis in the setting of taking her
PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and
was d/c'd home). On the day of admission on [**2141-10-13**], the
patient reported that the previous night, she was awoken from
sleep with severe, sharp abdominal pain, 6 episodes of frothy
emesis, 10+ yellowish BMs without melena or BRBRP.She was
admitted for further work- up of this abdminal pain.
.
In the ED here vitals were as follows: T: 97.0 HR: 101 BP:
240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV
and was subsequently placed on a labetolol drip. She also
received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg
IV q1hr and Zofran. Her abdominal CT showed multifocal areas of
small bowel wall thickening. Her peritoneal Cell count was
negtaive for SBP. She had some signs of peritonitis and thus
surgery was consulted. Her lactate was normal.
.
Upon arrival to the MICU the patient was mentating well with
complaints of diffuse sharp abdominal pain that radiated to the
back and diarrhea. She had no headache or visual changes.
Past Medical History:
- SLE DX ([**2134**] - 16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**]).
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
Placement [**5-18**]. Pt reluctant to start PD.
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome.
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN.
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
- Negative anticardiolipin antibodies IgG and IgM x4
([**2137**]-[**2140**]).
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]).
- HOCM: Last noted on echo [**8-17**].
- Anemia.
- History of left eye enucleation [**2139-4-20**] for fungal infection.
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VITALS: 98.4 HR 98 192/131 21 100%RA
GEN: Mild Distress, AOx3
HEENT: PEERLA, EOMI
NECK: Supple, No LAD, No bruit
RESP: CTAB
CARD: 2/6 systolic ejection murmur
ABD: soft, moderately tender with +/- guarding, BS+
EXTR: Warm well perfused
NEURO: Motor Grossly Intact
RECTAL: Yellow Stool
BACK: B CVAT
Pertinent Results:
[**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6*
MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176
[**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4*
[**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186*
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2141-10-26**] 06:15AM BLOOD Lipase-30
[**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9
[**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE
[**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE
Epi-21-50
Blood cultures: all negative
EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits.
Compared to the previous tracing of [**2141-10-2**] there is no
significant diagnostic change.
CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free
air under the diaphragms.
CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized
pericardial
effusion, similar in appearance from [**2141-10-13**]. The great
vessels are normal in caliber, without aneurysmal dilatation.
Evaluation of the great vessels is limited without IV contrast.
Interstitial thickening, particularly within the perihilar
regions, is
suggestive of fluid overload. There is bibasilar atelectasis
with a small
focus of consolidation in the right lower lobe (2:35) unchanged
from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered
bilateral nodules are largely stable from as far back as
[**2139-10-9**]. Specifically, there is a 5 mm nodule in the right
middle lobe (2:25), two adjacent nodules in the right lower lobe
measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule
within the left lower lobe. A nodular density seen adjacent and
anterior to the right main pulmonary artery (2:23) may reflect a
vessel. There is a small right pleural effusion.
Axillary lymphadenopathy, with axillary nodes measuring up to
approximately 10 mm in short axis, is seen. Ill- defined soft
tissue thickening within the hilus bilaterally may reflect hilar
lymphadenopathy, but assessment is limited without IV contrast.
A catheter is visualized within the visualized right upper
extremity, which may reflect a PICC line that terminates within
the right subclavian vein.
The esophagus is distended and filled with contrast, with marked
wall
thickening and edema throughout its entire length, a new
finding. There is a moderate- sized hiatal hernia.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval
development of a moderate amount of free intraperitoneal air,
that layers anteriorly and along the anterior abdominal wall.
Additional small clustered foci of extraluminal air is seen
adjacent to the proximal stomach and the gastroesophageal
junction, with a focus of air tracking into the fissure of
ligamentum venosum. Additionally, there appears to be air
tracking into the anterior subcutaneous tissues in the region of
the umbilicus. These findings are all new from the prior CT on
[**2141-10-13**], but free air was present on chest radiograph performed
[**2141-10-25**]. There is no obvious evidence of extravasation of oral
contrast into the peritoneum. Of note, a peritoneal dialysis
catheter is in place that could represent a route of entry of
intraperitoneal air.
The stomach, small bowel, and colon are filled with contrast,
without evidence of obstruction. Evaluation for wall thickening
is limited without IV contrast.
Limited non-contrast views of the liver demonstrates a rounded
1.6 cm x 1.2 cm hypodensity in the right lobe of the liver,
previously characterized as a hemangioma. The liver is otherwise
unremarkable. The gallbladder, spleen, pancreas, and adrenal
glands demonstrate no gross abnormality. Both kidneys are
atrophic. Evaluation of solid organs is limited by lack of IV
contrast.
There is a peritoneal dialysis catheter, coiled within the
pelvis, unchanged. There is a large amount of free fluid
throughout the abdomen, similar in appearance to the prior
study.
CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are
grossly
unremarkable. However, assessment of the rectal wall is limited
without IV contrast.
OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be
related to renal osteodystrophy. There is bilateral
sacroiliitis.
IMPRESSION:
1. Interval development of a moderate amount of free
intraperitoneal air, new from [**2141-10-13**]. A peritoneal
dialysis catheter is in place and could represent the route of
entry of free intraperitoneal air. However, as foci of air is
seen in the region of the proximal stomach and GE junction in
the setting of a recent endoscopy, perforation cannot be
excluded, though no frank extravasation of contrast is
identified.
2. New dilation and wall thickening of the entire esophagus, a
nonspecific finding that could relate to infectious or
inflammatory esophagitis; clinical correlation is recommended.
Esophagus is contrast-filled possibly representing reflux.
Hiatal hernia.
3. Anasarca, with moderate-sized pericardial effusion, pulmonary
edema, and small right pleural effusion.
4. Large amount of free intra-abdominal fluid in the setting of
peritoneal dialysis. Imaging cannot exclude SBP, which should be
evaluated for clinically.
5. Focus of consolidation within the right lower lobe, could
represent
aspiration or pneumonia, but unchanged from the prior study.
Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no
diagnostic abnormalities recognized. Jejunum: Small intestinal
mucosa, no diagnostic abnormalities recognized.
UE Venous U/S: No evidence of DVT of the left upper extremity,
without thrombus identified within the left subclavian vein.
Brief Hospital Course:
This is a 24 year old woman with ESRD secondary to SLE (started
peritoneal dialysis approximately one week prior to admission),
malignant HTN, h/o SVC syndrome, and multiple thrombotic events
(on warfarin) who is presenting with persistent suprapubic/lower
abdominal pain and new onset severe epigastric pain w/ nausea
and vomiting, and hypertension. Her hospital course was
complicated by multiple transfers between the MICU and the floor
secondary to hypertensive urgency.
# Abdominal Pain/Diarrhea: During the patient's admission, her
complaints of abdominal pain, nausea, diarrhea, and vomiting
progressively improved although no clear source of the symptoms
was found. Infectious causes, including viral gastroenteritis,
peritonitis or c. dif colitis, were considered. However, during
the initial part of her admission, the patient remained afebrile
with an initial relative leukocytosis which trended to within
baseline limits. The patient was empirically placed on IV
flagyl, but this was discontinued when stool samples were
negative for C.difficile. Serial abdominal exams showed no
peritoneal signs. Peritoneal dialysis fluid analysis was
negative for leukocytosis without organisms on gram stain. CT of
the abdomen on [**10-13**] showed evidence of multifocal small bowel
thickening and gastric wall edema, but no acute process. Other
etiologies of her abdomoinal pain were also considered including
mesenteric ischemia bowel secondary to SLE vasculitis, malignant
HTN, or microthrombosis and SLE enteritis. Surgery was
consulted and felt that the patient did not have an ischemic
bowel as serial lactates were negative and serial abdominal
exams showed improvement in pain. A heparin drip and warfarin
were started for treatment of possible microthrombotic ischemia,
although this was stopped when the patient had evidence of a
possible GI bleed. With regards to SLE vasculitis/enteritis,
rheumatology was consulted and they did not believe her symptoms
were related to SLE. On [**10-18**], GI performed an EGD which showed
erosion in the gastroesophageal junction yet an otherwise normal
small bowel enteroscopy to third part of the duodenum; biopsies
of stomach antrum and proximal jejunum were negative.
Approximately halfway through her hospital course, the patient
complained of severe epigastric pain in addition to her lower
abdominal pain. Both cardiac, GI, and pulmonary etiologies were
considered for the origin of her epigastric pain. Pericarditis
was considered, but her EKG was unchanged from prior studies and
there had been on interval increase in her pericardial effusion
since [**2141-10-13**]. Her lungs were also essentially unchanged from
[**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large
amount of free intra-abdominal fluid in the setting of
peritoneal dialysis. As a result, the patient underwent an
exploaratory laparotomy on [**2141-10-27**]. There were no major
findings: no evidence of perforation, obstruction, or infection.
The patient tolerated the procedure well and immediately
reported that both her epigastric and suprapubic pain were gone
after the surgery. At discharge, the patient only complained of
some mild incisional pain.
# Hypertensive urgency: The patient was initially admitted to
the MICU with a blood pressure of 240/180. Her hospital course
was complicated by extremely labile HTN and was transferred back
and forth between the MICU and the floor on three separate
occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of
SBPs > 260. Throughout all of these episodes of hypertensive
urgency, the patient remained asymptomatic from a neuro and
cardiac standpoint except for occasional headache. Her final
transfer to the floor occured [**2141-10-25**], where she remained for
the rest of her hospital course. Multiple medication regimens
were attempted and changed throughout her hospital course.
However, her blood pressures finally stabilized when she was
placed back on her oral home regimen, which includes nifedipine,
clonidine patch, labetalol, aliskiren, and hydralazine, with a
hydralazine sliding scale for SBPs > 180. At discharge, the
only change from her home regimen that was made was increasing
her nifedipine to 90 mg PO.
Her regimen as per Dr. [**Last Name (STitle) 4883**]:
Nifedipine SR 90 mg daily
Aliskiren 150 mg [**Hospital1 **]
Labetalol 300 mg TID
Hydralazine 75 mg TID
Clonidine patch 0.3 mg/24 hr patch qWed
When SBP>180, she then uses a hydralazine sliding scale. When
SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You
can
use this for up to 2-3 hours. In between PO hydral doses, can
then also use 10 IV hydralazine.
# ESRD: The etiology of the patient's ESRD is secondary to SLE.
Her Creatinine on admission was 7.9, which was near her baseline
of 8 - 9. During her admission, the patient underwent multiple
trials of peritoneal dialysis, but was unable to tolerate it on
a consistent basis secondary to abdominal pain. Prior to her
exploratory laparotomy, she was scheduled to have peritoneal
dialysis four times per day over 4hrs with 2% solution at 1.2L
per PD. After her exploratory laparotomy, surgery strongly
advised the medical team that she should not restart peritoneal
dialysis until she was at least 3 weeks out from her surgery.
Initially, the patient adamantly refused hemodialysis. However,
over several days, she became hyperkalemic and increased
swelling was noted bilaterally in her ankles and feet. As a
result, after a long coversation with her primary renal
physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled
catheter was placed in her R femoral vein on [**2141-11-1**] and she
subsequently started hemodialysis the same day, which she
tolerated well. She underwent hemodialysis two more times prior
to discharge. Upon discharge, her electrolytes were back to her
baseline. She is expected to undergo hemodialysis
(Tues/[**Last Name (un) **]/SAT) as an outpatient.
# Anemia: During her admission, the patient's HCT was monitored
daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to
have guaiac positive stools and her HCT was found to have
dropped to a low of 18.6. The patient was transfused a total of
2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was
also given on [**2141-10-17**]. She remained hemodynamically stable. GI
consulted and EGD results were as stated above. The patient's
HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] -
[**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT
drop from 26 to 20 in the setting of occult positive emesis.
She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI
was aware and planned to perform a non-urgent EGD on [**10-25**] or
[**10-26**] as the patient was hemodynamically stable and her HCT
returned to baseline. However, this did not occur as the
patient went for an exploratory laparotomy on [**2141-10-27**] and her
HCt remained stable and near baseline for the remiainder of her
hospital course.
# H/O Thrombosis: The patient was initially placed on her home
dose of warfarin 2mg qd. Her INR on admission was 1.2. She was
also started heparin drip secondary to concern for ischemic
bowel [**2-11**] microthrombotic disease. However, this was stopped
for her EGD and after she had evidence of a GI bleed. The
heparin drip was discontinued on [**10-22**]. The patient remained off
heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in
HCT and in preparation for a possible GI intervention. After her
surgery, her coumadin was held and she was off the heparin drip,
but her INR continued to drift up, getting as high as 2.6 on
[**2141-10-30**]. This was mostly attributed to nutritional deficiency
[**2-11**] poor PO intake, but there was concern for possible synthetic
dysfunction as well. As a result, she was given a test dose of
vitamin K, which she responded to well (Her INR came back down
to 1.4). As a result, her home dose of coumadin at 2 mg qday
was restarted. At discharge, her INR was still sub- therapeutic
at 1.4.
Of note, the patient has a history of SVC syndrome and had a L
subclavian venous thrombosis. During the last few days of her
hospital stay, the patient complained of increased tongue
swelling and her L face was noted to be slightly more swollen
than previously noted. As a result, she underwent upper
extremity venous ultrasound on [**2141-11-2**], which showed no
evidence of a DVT within the left upper extremity and the
previously noted thrombus within the left subclavian vein was
not seen as well.
# SLE: Rheumatology was consulted several times throughout her
hospital course, but they did not think that a lupus flare was
contributing to her presentation. Her outside rheumatologist
was also consulted. Both parties wanted to keep the patient on
her home dose of prednisone of 4 mg qday, which was continued
throughout her entire hospital course.
# Obstructive sleep apnea: The patient was noted to have OSA
based on clinical nocturnal exam during admission. Patient
attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask,
however did not tolerate as she complained of claustrophobia.
The paitent stated that she would pursue further work-up and
treatment for OSA as an outpatient. While the mask and CPAP
machine were at her bedside throughout her hospital course, the
patient rarely used it.
# Metabolic Acidosis: The patient's bicarbonate on admission
was 13. Her baseline is normally between 16-20. She received
150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief
returns to the MICU, her HC03 was 18-19, which was presumed to
be her baseline at home secondary to her CRF. At discharge,
having undergone three rounds of hemodialysis, her bicarbonate
was within normal limits at 28.
Medications on Admission:
Nifedipine 60 mg PO daily
Labetalol 900 mg PO TID
Hydralazine 50 mg PO TID
Clonidine 0.3 mg/24hr patch qWED
Lactulose 30 ml TID
Aliskiren 150 mg [**Hospital1 **]
Prednisone 4 mg daily
Warfarin 2mg PO daily
Calcitriol 1 mcg daily
Calcium carbonate 500mg QID
Dilaudid 2mg PO Q4-6hr prn pain
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
[**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2*
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
[**Hospital1 **]:*120 Tablet(s)* Refills:*2*
4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
[**Hospital1 **]:*1500 ML(s)* Refills:*0*
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily
().
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): In addition to 75 mg TID, if SBP>180, take 1 tab
every 30 min until BP decreases to 150. If no improvement after
2 hours, call your doctor.
[**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
[**Last Name (Titles) **]:*1500 ML(s)* Refills:*2*
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2*
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
[**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2*
13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
once a day.
[**Last Name (Titles) **]:*30 packets* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
end stage renal disease
malignant hypertension
abdominal free air
subclavian deep vein thrombosis
initiation of hemodialysis
Secondary:
SLE
Anemia
Discharge Condition:
stable, pain well controlled, blood pressure at baseline
Discharge Instructions:
You were admitted for abdominal pain and then subsequently had a
very long hospital course with high blood pressures, severe
abdominal pain, some free air in your abdomen resulting in an
exploratory laparotomy.
You have also been initiated on hemodialysis on
Tuesday/Thursday/Saturday schedule.
Please take all medications as prescribed in the list that you
will be given at discharge. There have been some changes to your
medications.
Please call your doctor if you have any worsening abdominal
pain, fevers, chills, nausea, vomiting, headache, palpitations,
diarrhea or any other concerning symptoms.
Followup Instructions:
You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this
appointment.
Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an
appointment in [**1-11**] weeks to have your staples removed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
4372,78039,7100,40391,4251,2859 | 109 | 128,755 | Admission Date: [**2138-4-16**] Discharge Date: [**2138-4-19**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Seizures
Elevated blood pressures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 20 year old female with h/o ESRD secondary to
SLE. She is currently on HD through a L IJ tunnelled catheter on
MWF @ [**Hospital1 1426**]. She was dialysed on the day of admission and at
the end of dialysis her her post HD BP was 230-240s and she
also experienced a bitemporal headache with blurry vision.
Also, she described transient CP sensation for 1 minute at HD.
.
In ED she was noted to have SBP to 250s and was given
phentolamine X2, clonopine PO and patch, hydralazine with
minimal effect. A CT head showed no evidence of bleed. A
nipride gtt was started with some effect with SBP falling
transiently to 190.
.
On arrival to MICU, pt was switched to labetalol gtt out of
concern for potential toxicity on nipride. Labetalol was
effective initially but pt did have SBP to 230. Pt had
witnessed, tonic clonic seizure for 30 seconds with + tongue
biting and spontaneous resolution + post-ictal state. Pt had
repeat head CT negative and neuro eval who found pt
neurologically intact and recommended holding on dilantin and
getting MR head with GAD in AM to r/o posterior
leukoencephalopathy
.
Pt had second seizure lasting 2-3 minutes and was given 2mg IV
ativan with good effect. Dilantin IV 1gm load given.
Additional labs returned with phos at 1.1 so PO and IV repletion
started.
*
Past Medical History:
ESRD [**2-12**] lupus on HD since [**11-14**] through left tunneled cath
SLE
HTN- with hx hypertensive crisis
HOCM
hx TTP
pregnancy termination in [**Month (only) **]
TTP
Social History:
lives with Mom and 14 year old brother
occasional EtOH, no tobacco, heroin, cocaine
Family History:
aunts with hypertension
grandmother died of myeloma
several men with prostate cancer
Physical Exam:
T 95.7 HR 93-110 BP 185-234/100-155 RR11-20 O2 Sat 99-100%
Gen: Sleeping in bed, NAD, easily arousable
Neck: supple, normal ROM, no thyromegaly, no bruit
CV: RRR, Nl S1 and S2, 2/6 SEM
Lung: Clear to auscultation bilaterally
aBd: +BS, soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam. Oriented
to person, place, and date. She has mild attention problems,
can
say [**Name (NI) 1841**] backwards-but takes several attempts and made one
mistake
on last try. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Registers [**3-13**], recalls
[**1-13**] at 5min. No evidence of apraxia or neglect
Fundus exam: No papilledema and no retinal hemorrhages
bilaterally.
CN II-XII symmetrical and intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout.
Reflexes:
B T Br Pa Ach
Right 2 2 2 2 2
Left 2 2 2 2 2
Grasp reflex absent
Toes were downgoing bilaterally
Coordination: normal on finger-nose-finger, heel to shin
Pertinent Results:
[**2138-4-16**] 08:44PM PT-14.8* PTT-40.3* INR(PT)-1.4
[**2138-4-16**] 05:27PM PT-14.1* PTT-150 IS HIG INR(PT)-1.3
[**2138-4-16**] 11:40AM GLUCOSE-94 UREA N-16 CREAT-3.9* SODIUM-141
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-32* ANION GAP-18
[**2138-4-16**] 11:40AM CK(CPK)-97
[**2138-4-16**] 11:40AM CK-MB-4 cTropnT-0.02*
[**2138-4-16**] 11:40AM HCG-<5
[**2138-4-16**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2138-4-16**] 11:40AM WBC-6.0 RBC-5.15 HGB-15.7 HCT-47.8 MCV-93
MCH-30.5 MCHC-32.8 RDW-17.8*
[**2138-4-16**] 11:40AM NEUTS-75.7* LYMPHS-18.0 MONOS-5.1 EOS-0.6
BASOS-0.6
[**2138-4-16**] 11:40AM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+
[**2138-4-16**] 11:40AM PLT COUNT-141*
*
Admission Head CT:
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
*
Admission chest X ray:
no abnormalities
*
ECG:
Sinus tachycardia with slowing of the rate as compared to the
previous tracing
of [**2138-4-16**]. Biatrial enlargement and new T wave inversion in lead
aVL with
dissociated ST-T wave flattening in lead I.
*
Head MRI:
Abnormal T2 and FLAIR signal within both occipital and parietal
lobes in a pattern suggestive of posterior reversible
encephalopathy syndrome
*
Knee X ray:
Normal L knee.
Brief Hospital Course:
A/p 20 yo F with ESRD on HD who p/w hypertensive crisis and has
new onset seizure
.
1) Hypertensive emergency
Her blood pressure was controlled with a labetaolol drip and she
was then transitioned to po labetalol. She was also continued on
the clonidine patch. In light of her complaints of chest pain we
were reassured by her ECG and by her flat cardiac enzymes.
.
2) New onset seizure
We thought that her new onset seizures were probably due to her
severely elevated blood pressure but other diagnoses including
lupus cerbritis were also considered.
An MRI with gadolinium was obtained. It demonstrated abnormal
T2 and FLAIR signal within both occipital and parietal lobes in
a pattern suggestive of posterior reversible encephalopathy
syndrome. We consulted the rheumatology service who thought that
her presentation was more consistent with hypertensive
encephalopathy rather lupus cerebritis. She was loaded with
dilantin. With dilantin loading and control of her blood
pressure she did not have a recurrence of her seizures.
.
3) Lupus:
She was continued on her plaquenil and prednisone.
.
4) ESRD
She continued to receive regulary scheduled hemodialysis.
.
5) Knee Pain:
On the day of discharge the patient complained of L knee pain.
On physical exam she was afebrile, the knee was slightly warm
and tender to the touch without obvious effusion. An X ray of
the knee was read as normal. She had full range of motion but it
was painful but she was able to bear weight on it. She was
instructed to use tylenol prn for pain and to return o the
clinic or emergency room should she develop worsening knee pain,
fevers or chills.
.
Communicaton:
The patient and the patient's mother were extensively counselled
about the patient's disease. She demonstrated an understanding
of the importance of good medical compliance with therapy and
keeping appointments.
Medications on Admission:
1. Clonidine TTS 1 Patch 1 PTCH TD QWED started in ED
2. Folic Acid 1 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. Prednisone 10 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Labetalol HCl 200 mg PO TID Start: In am
wean labetalol gtt as tolerated, Hold for SBP<150
7. Lisinopril 40 mg PO DAILY Start: In am Order date: [**4-16**] @
1712
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lidocaine-Aloe [**Doctor First Name **] 0.5 % Gel Sig: [**1-12**] APPL Topical every
six (6) hours as needed for pain.
Disp:*1 VIAL* Refills:*0*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*10 Patch Weekly(s)* Refills:*2*
6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Labetalol HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Protonix 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hypertensive encephalopathy and new onset seizures
Lupus Nephritis
End Stage Renal Disease on hemodialysis
Secondary:
H/o Thrombotic Thrombocytopenic Purpura.
Discharge Condition:
Good, without headaches or blurry vision, blood pressure well
controlled and at her baseline.
Discharge Instructions:
Please take all of your medications as prescribed. Please
attend all of your follow up appointments. As we discussed it is
extremely important that you take all of your blood pressure
medications as instructed.
*
Please return to the emergency room of your PCP's office if you
have severe headache, blurry or worsening vision or seizures.
*
It is CRUCIAL TO YOUR HEALTH that you attend ALL of your follow
up appointments!!!!
*
Please return to the emergency room or your PCP's office or
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44523**] office at [**Telephone/Fax (1) 44524**]
if you experience worse knee pain, swelling, fevers or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2138-5-8**] 11:20
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-6-12**] 1:45
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2138-6-25**] 10:00
Test for consideration post-discharge: Beta-2 Microglobulin.
Please call [**Telephone/Fax (1) 2100**] for a follow up appointmnt with
neurology in [**2-13**] months.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 44524**] for an appointment
in 10 days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
9596,58281,4254,7100,2875,78702,E9426,E9289,4589,2859,V1251,5856,V451,5990,2767,2762,2753,27541,58881,40301 | 109 | 131,345 | Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
right leg pain, hypertension
Major Surgical or Invasive Procedure:
blood transfusion x2
History of Present Illness:
Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple
admissions for labile hypertension who presented to the ED
complaining of about a weeks?????? worth of right leg pain. The pain
is worst when she tried to bear weight on the leg, or when she
uses it to roll over or adjust her position in bed. The pain
begins in her buttock and travels down the posterior thigh and
calf but stops before reaching the ankle. It occasionally feels
like it is coming from her low back. She denies any
parasthesias or weakness in the leg, and she denies any numbness
in her foot or groin. She denies any fevers or incontinence.
The pain was unrelieved by Vicodin that she had at home, so she
scheduled an urgent visit with her nephrologist yesterday
[**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to
250/145 and so she was referred to the ED. She ended up leaving
the ED against medical advice yesterday, but returned today
because of persistent leg pain. She reports that she took all
of her morning and noon BP meds.
She denies any fevers, headaches, visual changes, nausea (prior
to coming to the ED), or leg weakness.
Upon arrival to the ED today, she was afebrile, BP 237/146, HR
97, RR 16, Sat 100% on room air. She received a total of 90 mg
of IV labetalol and nitropaste, and was eventually put on a
labetalol drip for her hypertension. With these interventions,
her SBP dropped to the 180s, but she reported feeling nauseous
and so the drip was discontinued. She was also given 4 mg of IV
morphine and 1 mg of IV hydromorphone for her leg pain with
decent relief. Due to a urinalysis suggestive of infection, she
was given one tablet of DS TMP/SMX.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
MICU physical:
Tmax: 36.3 ??????C (97.4 ??????F)
Tcurrent: 36.3 ??????C (97.4 ??????F)
HR: 92 (92 - 94) bpm
BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg
RR: 19 (19 - 30) insp/min
SpO2: 91%
Heart rhythm: SR (Sinus Rhythm)
Height: 59 Inch
General: well-appearing young woman in no acute distress
HEENT: no scleral icterus; prosthetic right eye
Neck: supple
Chest: clear to auscultation throughout, no
wheezes/rales/ronchi
CV: regular rate/rhythm, normal s1s2, no murmurs
Abdomen: soft, nontender, nondistended, PD catheter in place in
left abdomen
Back: very mild spinal tenderness over approx L3 level of spine
Extremities: no edema, 1+ PT pulses, warm
Skin: no rashes or jaundice
Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids,
biceps, triceps, hip flexors/extensors, ankle flexors/extensors;
unable to elicit patellar reflexes bilaterally; negative
straight leg raise bilaterally
Pertinent Results:
138 111 54
-----------------< 83
5.4 14 8.2
.
WBC: 3.7
HCT: 19
PLT: 101
N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1
PT: 21.9 PTT: 48.2 INR: 2.1
.
Trends:
HCT: 19 -> 22 w 1u then received another unit.
INR 3.4 on discharge
Discharge chem:
Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18*
AnGap-17
.
[**2141-9-8**] 07:30AM BLOOD CK(CPK)-126
[**2141-9-5**] 02:50PM BLOOD HCG-<5
.
[**2141-9-8**] 1:37 pm PERITONEAL FLUID
GRAM STAIN (Final [**2141-9-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count
.
MRI L-spine:
IMPRESSION: Diffuse low-signal intensity is identified in the
bone marrow of the lumbar and lower thoracic spine as described
above, possibly related with anemic changes, please correlate
clinically. There is no evidence of spinal canal stenosis or
neural foraminal narrowing at the different intervertebral disc
spaces.
.
CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural
effusions, and pulmonary vascular prominence consistent with
pulmonary edema.
.
Hip film:
FINDINGS: No comparisons. No acute fracture or dislocation is
seen. No
lucent or sclerotic lesion is noted. There is a distal aspect of
a catheter or shunt seen in the pelvis. Soft tissues are
otherwise unremarkable. There is minimal degenerative change of
the pubic symphysis.
IMPRESSION: No acute fracture or dislocation.
.
Abdominal film:
FINDINGS: A PD catheter is seen with its tip coiled in the
pelvis. There is normal bowel gas. The underlying osseous
structures are unremarkable.
IMPRESSION: PD catheter with tip coiled in the pelvis
.
CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval
resolution of pulmonary edema.
Brief Hospital Course:
Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple
admissions for labile hypertension who presented to the ED
complaining of about a weeks?????? worth of right leg pain. She was
initially admitted to the MICU for hypertensive urgency and then
transfered to the floor after a day.
# Hypertensive urgency: had been on labetalol drip in the ED,
but this was stopped due to nausea (presumed that her BP was
coming down too fast). She was started on her home meds and
tolerated these fairly well. Transferred to the floor and noted
to have SPBs in the 90s. She required 1L IVF bolus since her
baseline SBP is thought to run in the 130-170 range. She also
had transient dizziness during this episode. BP meds were held
and later that night her SBP was in the 220s. BP meds
restarted. She remained stable thereafter with SBPs in the
130-170s. We opted to discharge her on her home regimen
(without decreasing doses) since she is more often having issues
with elevated blood pressures.
.
# Right leg pain: no evidence of avascular necrosis or fracture
on plain film. MRI and plain films were ordered and showed no
acute pathology. The pain was in the distribution of her right
hamstring and was worsened when it was stretched thus suggesting
a muscle injury. CK was normal. Pain was treated with dilaudid
initially. On day of discharge, she was able to ambulate
without gait abnormality or pain. PT saw her and rec outpt PT
followup.
.
# CKD V: PD catheter placement in place. Pt was tried on PD on a
number of occasions but did not tolerate it [**2-11**] pain. KUB
confirmed tip in place. Cx of peritoneal fluid not suggestive
of peritonitis. K remained mildly elevated. Hyperpara treated
with sevelamer (although patient refused) then tums. Pt will
reconsider PD as outpatient.
.
# Anemia: chronic. Received 2u pRBC while inhouse for Hct in
the 18-19 range. Had appropriate response. Not on Epo given
hypertension
.
# ID: Rx with cipro for ? UTI although urine cx neg. Also had
temp to 101 on evening prior to discharge. No clear source. PD
fluid cultured and NGTD. Pt remainded HD stable on day of
discharge.
.
# Prior SVC thrombus. Continued warfarin with appropriate INR
checks. INR elevated on day of discharge. Rec holding coumadin
for 2d
.
# Systemic lupus erythematosus: cont home prednisone dose
.
# Dispo status: ambulating, pain free, BP in the 150/90 range
Medications on Admission:
Nifedipine 60 mg PO qhs
Labetalol 900 mg PO tid
Hydralazine 50 mg PO tid
Clonidine 0.3 mg/hr patch qWED
Vitamin D once weekly
Vicodin prn
Aliskiren 150 mg [**Hospital1 **]
Prednisone 5 mg daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO WEEKLY ().
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid ().
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*20 Capsule(s)* Refills:*0*
9. Outpatient Physical Therapy
Please provide PT for right hamstring injury
10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
Disp:*270 Tablet(s)* Refills:*0*
11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold
dose until [**9-10**].
Disp:*30 Tablet(s)* Refills:*0*
12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a
day: goal is [**1-11**] soft bowel movements per day.
Disp:*500 ml* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- HTN urgency
- right leg pain - thought [**2-11**] hamstring injury
- chronic kidney disease - not currently on dialysis
- SLE
- anemia [**2-11**] CKD and SLE
- hx of SVC thrombosis on coumadin now
Secondary:
- hx hypertrophic obstructive cardiomyopathy
- chronic thrombocytopenia
Discharge Condition:
ambulating without difficulty. tolerating oral diet. afebrile
and SBP in the 130-150 range.
Discharge Instructions:
You came in with right leg pain and poorly controlled
hypertension. Your blood pressure was controlled initially with
IV medications then your home medications. Since your blood
pressure was occasionally low, we recommend that you hold your
labetalol if you are feeling lightheaded or have dizziness or
have blood pressure less than 110/60.
In terms of your leg pain, we performed xrays, ultrasound, and
MRI without finding a cause. We suspect a hamstring injury
given its location. Please take pain medications if needed. We
recommend followup with physical therapy.
You also had a fever which is suggestive of infection. We
treated you with cipro in case you had a UTI. Otherwise, your
cultures were unrevealing.
We attempted peritoneal dialysis but this was unsuccessful.
Please followup with your nephrologist.
Please return to the ED if you experience headache, chest pain,
shortness of breath, high fevers, or worsening leg pain.
Please hold your coumadin for two days then restart as per
previously written. Please take lactulose for constipation.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2141-9-12**] 5:00
Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**]
2:00
Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00
Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like
you to see your nephrologist within the next 1-2 weeks.
|
28529,40301,5856,58281,4254,3643,2841,78959,33829,78900,7100,2875,V1254,V1251,V5861,34590,53190,44389,32723,28521 | 109 | 131,376 | Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-8**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**Last Name (NamePattern1) 293**]
Chief Complaint:
dyspnea, Hypertension Urgency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES,
prior ICH, with frequent admission for hypertensive
urgency/emergency, with chronic abdominal pain. She was recently
admitted [**Date range (1) 43607**] after presenting for hypertensive urgency and
dyspnea for which she was started on nitroglycerin and labetalol
drips, which were weaned off in the ICU. She was also received
2U PRBCs during HD. She was discahrged home without any changes
to her medical regimen.
.
On the afternoon of [**7-4**] she notes increased dyspnea, she
therefore went to HD on Wednesday, and again on Thursday [**7-5**].
After HD, her BP remained elevated, and she took an extra dose
of labetalol 1000mg x 1. On [**7-6**] her VNA noted SBP 250s. She
took extra doses of hydralazine, but otherwise felt well. She
then woke up this morning with HA. She took all of her BP meds
this morning, but remained with HA and SOB, thus prompting her
presentation to the ED.
.
No fevers, productive cough, taking all meds, had chronic
diarrhea that is unchanged, some n/v at baseline, no coffee
ground emesis, has some abdominal pain unchanged from baseline
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Pertinent Results:
08:00a
ALK,ALT,AST,CK,CPIS,LIP,BILI,TNT ADDED 12:29PM
141 103 29 82 AGap=13
3.4 28 6.5 ∆
CK: 59 MB: Notdone Trop-T: 0.18
ALT: 21 AP: 126 Tbili: 0.4 Alb:
AST: 51 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 56
PT: 15.0 PTT: 35.5 INR: 1.3
N:69.8 L:21.9 M:5.5 E:2.5 Bas:0.3
Hypochr: 1+ Anisocy: 2+ Macrocy: 1+ Microcy: 1+ Polychr: 1+
Brief Hospital Course:
# Hypertensive Urgency - At the time of admission, the patient
denied chest pain but continued to have mild headache. She also
had resolving shortness of breath, likely secondary to
hypertension. She stated that she did take her PO meds. She
was started on a labetalol drip and continued on her home
regimen of oral labetolol, nifedipine, hydralazine, and
aliskerin. A sent of cardiac enzymes was sent and revealed a
CPK of 59 and a troponin of 0.18. The patient also underwent
dialysis in the ICU. After dialysis the labetalol drip was
weaned off. Overnight, SBP's ranged 109 to 182 mmHg. The
following day, her SBP's ranged 133 to 200. Ultimately, she was
discharged home on her normal medication regimen.
# Abdominal Pain - The patient also presented complaining of
adbominal pain. She had recently been treated for SBO; however,
at the time of admit, she was without nausea or vomiting. She
had a soft abdomen, was passing flatus, and was having daily
bowel movements. She did have hypoactive bowel sounds. She was
continued of her outpatient pain regimen of PO dilaudid,
fentanyl patch, and lidoacine patch. An ultrasound of her abd
was also performed and showed ascites in all 4 quadrants with
the largest in the left lower quadrant measuring 5.5cm.
Considering her history of thrombosis, renal recommended getting
an abdominal ultrasound with doppler flow studies. This
ultrasound showed mild to moderate ascites, a 9mm hemangioma,
and no evidence of thrombosis. After the results of this
ultrasound were reviewed, the patient was discharged home with a
plan to follow-up with liver regarding her ascites and whether
it can be attributed to her recent SBO.
# ESRD on HD - The patient gets hemodialysis on a Tu/Th/Sa
schedule. On admit, the patient was continued on her home does
of sevalemer. Renal was consulted, and the patient received
dialysis on [**7-7**] in the ICU.
# Anemia/Pancytopenia - The patient has a chronic anemia and
baseline pancytopenia that are likely secondary to her CKD and
SLE. On admit she was actually above baseline. She was
continued on her home does of epogen.
# H/o Gastric Ulcer - The patient was continued on her PPI [**Hospital1 **].
# SLE - The patient was continued on her home regimen of
prednisone 4mg po daily.
# H/o SVC Thrombosis - The patient has a goal INR of [**2-13**].
However, naticoagulation was stopped after a recent admission
secondary to a supratherapeutic INR. On admit, her INR was
sub-therapeutic. Therefore, her warfarin was restarted at 3 mg
daily.
# Seizure Disorder - The patient was continued on her home
regimen of keppra 1000 mg PO 3 times a week (Tu/Th/Sa).
# Depression - The patient was continued on her home dose of
celexa.
Medications on Admission:
1.Nifedipine 90 mg PO DAILY (Daily).
2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime).
3.Lidocaine 5 % PATCH Q24HR.
4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H
7.Prednisone 4 mg PO DAILY (Daily).
8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday).
9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday).
10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
12.Labetalol 1000 mg Tablet Tablet PO TID
13.Hydralazine 100 mg Tablet PO Q8H
14.Warfarin 3 mg Tablet PO Once Daily at 4 PM.
15.Pantoprazole 40 mg PO Q12H (every 12 hours).
16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24HR ().
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*QS Tablet(s)* Refills:*2*
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA
(TU,TH,SA).
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for abdominal pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Lupus Nephritis
End stage renal disease on hemodialysis
Ascites
Discharge Condition:
hemodynamically stable with blood pressures 130-140/70-80s.
Discharge Instructions:
You were evaluated and treated for you hypertension. You were
started on IV medications and transitioned to your home regimen
and received a session of hemodialysis.
You also had an ultrasound to evaluate the fluid in your belly.
There was no evidence of blood clot contributing to the build up
of the fluid.
Please continue to follow a low sodium diet at home and take all
of your blood pressure medications in addition to going to
dialysis.
Followup Instructions:
You have the following appointments scheduled:
Please also keep your Tuesday/Thursday/Saturday Dialysis
schedule
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-7-30**] 2:00
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
|
40301,5856,4251,7100,79902,E9352,2875,28521,78909,32723,3004,V4511,V1251,V5861,V4589 | 109 | 135,923 | Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypertensive Urgency and HA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant
HTN admitted with HA in the setting of hypertension. Upon
arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100%
on 4LNC. She was started on a nicardipine drip. She denied
shortness of breath or chest pain. She is due for HD today. She
has a left groin catheter which was recently placed [**2141-12-21**] and
is causing her pain. She was also given dilaudid IV 1 mg x 2
with some relief. CXR was performed and showed no pulmonary
edema.
.
Upon arrival to the MICU, patient denies HA, CP, SOB, fevers,
chills. Patient reports mild abdominal pain at sight of left
anterior abdominal wall hematoma and left groin pain at site of
femoral HD line. She reports that she was taking her medications
as directed, including coumadin for SVC thrombus.
Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted
for HA in the setting of HTN to 284/140 in ED. Initially, she
was treated with a nicardipine gtt to control her BP. Her
cardiac enzymes were flat, no new ECG changes. She was started
on a heparin gtt with transition to coumadin for a SVC
thrombosis. HTN secondary to med noncompliance. She was
restarted on her oral BP. She missed her PM meds yesterday, so
nicardipine was restarted, and then turned off this AM. She
received all her AM BP meds. Her BPs have been in the 160s/90s.
She had no neurological deficits.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: 176/105, 87, 18, 100% RA
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: 2/6 systolic murmur LUSB
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: left ant wall abd hematoma, TTP
Extremities: Right: Trace, Left: Trace, left fem HD line without
oozing or drainage
Skin: Warm
Neurologic: AAO x 3
Pertinent Results:
[**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2*
[**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+
BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2142-1-8**] 05:15AM cTropnT-0.08*
[**2142-1-8**] 05:15AM CK(CPK)-119
[**2142-1-8**] 04:12PM PTT-120.8*
[**2142-1-8**] 10:41PM PTT-144.8*
[**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06*
Brief Hospital Course:
24 yo woman with hx of SLE, ERSD on HD, admitted with
hypertensive urgency. Patient was initially observed in the MICU
and placed on a nicardipine drip. Patient was stablized on home
medicaitons, suggesting medication non-compliance. Additionally,
patient presented subtheraputic on coumadin for SVC thrombosis.
Patient was started on heparin ggt. After the nicardipine drip
was turned off, patient was called out to the floor. Heparin
drip was continued until INR [**2-13**]. Pressures were managed to her
baseline. Pain medications were decreased as patient has hypoxia
and altered mental status from over sedation, which was reversed
with Narcan. Patient received dialysis 3x/wk as per outpatient
schedule.
# Hypertension: Pt with extensive history of repeated admissions
for hypertension. Patient's BP improved with nicardipine drip
and after HD off drip on home PO medication regimen. Resumed
oral antihypertensives with improved BP control. HTn likely from
renal disease, possible medication noncompliance, lupus. No
evidence of MI. Continued nifedipine, aliskerin labetalol,
hydralazine, and clonidine at current doses. Renal increased
clonidine patch, and added Nicardipine with improvement of BP
control. Pt is to follow up with an appointment in the next week
to establish care at [**Company 191**], and to re-check her BP and adjust
medications further.
# SLE: Stable, continued prednisone at 4 mg PO daily.
# Left groin pain. Permanent HD line was placed on [**12-25**]. Line
and hematoma from prior peritoneal line on abdomen okay. No
leukocytosis or fevers to suggest infection. Patient was
oversedated on Dilaudid and had episode of oxygen desaturation
which was reversed with Narcan. Patient was solmolent with
morphine SR so that was d/c'ed as well, patient was given
standing tylenlol and Morphine IR PRN. Transplant surgery
removed remaining sutures today from L groin. Pt has a follow-up
appointment in the next week with Dr. [**First Name (STitle) **] (Transplant
Surgery). She will be sent home with low-dose Morphine IR and
Tylenol PRN pain. If L groin pain should become uncontrollable
on current meds, pt should return to the ED for re-evaluation.
It is anticipated that pain should resolve, as line placement
occured over 2 weeks ago.
#ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was
started for elevated calcium-phosphate product. Pt will
follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks.
# Anemia: Pt's baseline is 26. This is likely secondary to AOCD
and renal failure. Hct was stable on day of discharge at 25.9.
# SVC thrombus: Pt has a history of an SVC thrombus, and is on
coumadin. She is supposed to be on lifelong anticoagulation due
to recurrent thrombosis but INR subtherapeutic on arrival.
Heparin drip was stopped on the floor once the INR was
theraputic. INR was therapeutic on day of discharge. Pt will
need an INR check in the next week at her follow-up with her
PCP.
# HOCM: Pt has evidence of myocardial hypertrophy on Echo. She
is currently not symptomatic. Echo did not show evidence of
worsening pericardial effusion. She was continued on her
beta-blocker and other BP medications.
# Depression/anxiety: Stable. She was continued on Celexa and
Clonazepam.
# OSA: Pt as continued on CPAP for sleep with 7 pressure.
# FEN: regular diet
# PPX: heparin drip --> coumadin, bowel regimen
# ACCESS: PIV x2 / permanent dialysis cath L fem
# CODE: FULL
# CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**]
# DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR
level. Follow-up with Transplant Surgery.
Medications on Admission:
Clonidine 0.3mg / 24 hr patch weekly qwednesday
Hydralazine 100mg PO q8H
Labetalol 800mg PO TID
Hydromorphone 4mg PO q4H PRN
Nifedipine ER 90mg PO qday
Prednisone 4mg PO qday
Lorazepam 0.5mg PO qHS
Clonazepam 0.5 mg [**Hospital1 **]
Celexa 20mg PO qday
Gabapentin 300 mg [**Hospital1 **]
Acetaminophen 325 mg q6H PRN
Ergocalciferol (Vitamin D2) 50,000 unit PO once a month
Coumadin 4 mg daily
Aliskiren 150 [**Hospital1 **]
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8)
hours as needed for pain for 2 weeks.
[**Hospital1 **]:*20 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours.
13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypertensive Urgency
End Stage Renal Disease
Discharge Condition:
stable, blood pressure moderately controlled, afebrile,
tolerating POs
Discharge Instructions:
You were admitted for headaches and very high blood pressures.
You were started on an IV medication for your blood pressure
which controlled it. You were then started back on your home
medications with improvement of your blood pressure. Some of
medications were increased as your hypertension was difficult to
control.
You were also started on a heparin drip while restarting your
coumadin since you have a known clot in your veins. You will
need to take the coumadin as prescribed by your doctor, and have
your INR checked frequently per your PCP's recommendations.
Please take all medications as prescribed. It is important that
you do not miss doses of your medications since your blood
pressure is very sensitive to missed doses. Please keep all
scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, chest pains,
shortness of breath, nausea, vomiting, or headaches.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2142-1-15**] 3:00
- Will follow-up Vitamin D [**2-4**] level
Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-1-16**] 3:30
- Will re-check your INR level
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2142-1-12**] |
5856,V4512,V1251,311,34590,53190,4589,33829,78909,7100,2767,28529,4239,4254,40301,2766 | 109 | 136,572 | Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Acute Onset Dyspnea
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Please see MICU note for full details. In brief this is a 24
y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC
syndrome, h/o posterior reversible encephalopathy syndrome
(PRES) and prior intracerebral hemorrhage, frequently admitted
with hypertensive urgency/emergency who was admitted with acute
onset dyspnea after 2 weeks without dialysis given to unable to
get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange
transport for her (? refused to come). She was admitted
therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR
28 POx100 RA. She was treated with nitro gtt, labetolol gtt and
dilaudid-these gtts were stopped at 0700. In the micu she was
dialyzed with 1.7L fluid removal (though + 300cc given
tranfusion). Her SOB is improved. Her hct was also noted to be
low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent
EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in
unit, hemolysis w/u negative. BP in icu 140/106 currently but of
note was hypotensive on HD to 86/62. She notes sob improved
rapidly on arrival.
ROS: Currently she has no complaints. She notes at home her
abdominal pain is at baseline for her, felt mid epigastric, for
which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD
via right femoral catheter which is not painful, no discharge
from the sight. She denies HA, visual changes, cough, chest pain
or pressure, orthostatic changes, palpitations, nausea,
vomiting, constipation, diarrhea, melena, brbpr, dysuria,
hematuria, rash, swelling, orthopnea, pnd.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Physical Exam:
Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA
General: Sleeping comfortably but awakens easily, alert,
oriented x3
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
nonerythematous, MMM, moon facies
Neck: supple, JVP flat, no LAD, full ROM, left EJ in place
Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases
CV: S1, S2 nl, no m/r/g appreciated
Abdomen: Firm, non-tender to palpation, no masses or
organomegally
Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or
edema
Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally
Pertinent Results:
[**2142-6-18**] 05:28PM HCT-26.0*#
[**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139
POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22*
[**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2
[**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6
[**2142-6-18**] 05:04AM HAPTOGLOB-142
[**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88
MCH-30.0 MCHC-34.2 RDW-18.4*
[**2142-6-18**] 05:04AM PLT COUNT-97*
[**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136
POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20
[**2142-6-18**] 01:34AM estGFR-Using this
[**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT
BILI-0.2
[**2142-6-18**] 01:34AM LIPASE-115*
[**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8*
MAGNESIUM-1.7
[**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88
MCH-28.6 MCHC-32.5 RDW-18.6*
[**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4
BASOS-0.6
[**2142-6-18**] 01:34AM PLT COUNT-104*
[**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3*
Brief Hospital Course:
# Dyspnea: Pt's dypsnea improved on admission to the ED prior to
HD. Based on her imaging studies her dyspnea was likely related
to fluid overload (pt missed 2 weeks of dialysis) and her level
of anemia. Upon transfer to the floor she was continued on her
dialysis regimen and discharged on room air.
# Anemia: Pt's baseline 1 month ago noted to be low 30s, since
then her Hct has trended down to 22 several week prior to
admission. As she missed dialysis she was not able to reserve
her Eopgen which likely complicated her anemia. Pt underwent
hemolysis workup in the ICU which was ultimately negative. She
was given several units of PRBC and bumped her Hct
appropriately. She was noted to be guaiac negative on
examination.
# Hypertension: Pt was initially admitted with hypertension.
Following transition to the floor she was placed on her home
regimen. She was noted to be hypotensive in dialysis which is
likely due to her being on Labetalol, Nitro gtt on dialysis. Pt
was discharged on her home BP regimen with follow up with her
nephrologist.
# Chronic Abdominal Pain: Pt had noted some intermittent
abdominal pain which has been chronic. Lipases were noted to be
mildl elevated however no other concerning physical exam signs
of pancreatitis. Pt was able to tolerate a PO diet prior to her
discharge. Pt was continued on her outpatient regimen of
Dilaudid, Fentanyl patch, Neurontin.
# GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **].
# SLE: Pt was continued on her home regimen of Prednisone 4mg
daily
# History of DVT: Pt had a sub-therapeutic INR on admission. She
was discharged on Warfarin 3mg daily.
# ESRD on HD: Pt was admitted for dyspnea in the setting of
missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during
her hospitalization and she was continued on her outpatient
regimen of hemodialysis. Pt was continued on Sevelamer and
Epogen.
# Seizure D/O: Pt was continued on her home regimen of keppra.
# Depression: Pt was continued on her home regimen of Celexa.
Medications on Admission:
1. Nifedipine 90 mg Tablet Sustained Release PO QAM
2. Nifedipine 60 mg Tablet Sustained Release PO QHS
3. Lidocaine 5 % transdermal one daily
4. Aliskiren 150 mg PO BID
5. Citalopram 20 mg PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours).
7. Prednisone 4mg PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT
9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT
10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID
13. Hydralazine 100 mg PO Q8H
14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain.
15. Pantoprazole 40 mg PO Q12H
16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 H ().
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(TU,TH,SA).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Malignant HTN, ESRD on HD, Shortness of breath
Secondary: Lupus
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital after you noticed some
shortness of breath. Whilst in the hospital you were noted to
have a low blood level (anemia) and you some fluid in your
lungs. We think your blood level was low because you were not
receiving your Epo shots, we think the fluid is from not
receiving dialysis. Before you were discharged from the hospital
your breathing was better.
We recommend that you continue going to dialysis.
We made no changes to your medications.
If you notice any fevers, chills, nausea, vomiting, shortness of
breath, lightheadedness please return to the ED.
Followup Instructions:
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-6-27**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
7100,2766,4239,4254,3643,5856,40301,58381,V4512,V1581,V642,78904,V4511,2875,28529,V1251,V5861,4439,V4578,V0254 | 109 | 137,510 | Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Dyspnea, malignant hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly, 24 F with ESRD on hemodialysis, SLE, malignant
hypertension, history of SVC syndrome, PRES who presented with
abdominal pain and shortness of breath. On [**2142-4-19**] she refused
ultrafiltration at HD because she was at her dry weight. Awoke
at 3 AM feeling more short of breath. She also had worsening
abdominal pain and vomiting without hematemasis. She took all of
her medications as prescribed including two new lidocaine
patches, fentanyl patch and clonidine. She developed a slight
frontal headache but no blurry vision or neurologic symptoms.
ROS largely negative.
.
In the emergency room her initial vitals were T: 99.1 BP:
280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore
peripheral IVs placed. She received 100 mg PO hydralazine, 200
mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV,
levofloxacin 750 mg IV x 1 and was started on labetolol and
nitroglycerin drips with control of her blood pressure to the
180s systolic. She had a CXR which was concerning for volume
overload. She was admitted the MICU for further evaluation.
.
In the MICU she was stablized and transitioned to her home meds.
Nephrology gave her HD with 2L UF and subjective improvement in
SOB.
.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-120's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother. On disability for multiple medical problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
On Admission per MICU team:
Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L
General: Pleasant, comfortable, no distress
HEENT: L eye enucleated. Moon facies. Right pupil reactive
Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at
RLSB, no rubs or gallops
Respiratory: Crackles at bases bilaterally, no wheezes, rales,
ronchi
GI: soft, non-tender, non-distended, +BS
GU: no foley
Ext: Warm and well perfused, no clubbing, cyanosis or edema
.
Pertinent Results:
[**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93
MCH-29.9 MCHC-32.3 RDW-19.9*
[**2142-4-19**] 08:35AM PLT COUNT-93*
.
[**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135
POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0
.
[**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9*
.
CXR PA and LAT:
IMPRESSION:
1. Persistent cardiomegaly with prominence of pulmonary
vasculature suggesting overhydration. Minimal costophrenic angle
blunting may suggest small effusions.
2. No definite consolidation, although increased retrocardiac
density is noted, most likely due to atelectasis and vascular
congestion. Repeat imaging following diuresis could be
considered.
.
INR trend:
[**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1*
[**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9*
[**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1*
[**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5*
Brief Hospital Course:
24 F with ESRD on hemodialysis, SLE, malignant hypertension,
history of SVC syndrome, PRES who presented to the ICU for
hypertensive emergency, dyspnea, and headache, now resolved.
.
Hypertensive Emergency: Patient's blood pressure normalized with
transient nitroglycerin and labetalol drips. Likely precipitated
by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has
received [**Year/Month/Day 2286**] and her blood pressures remained at her
baseline off the drips.
- continue home blood pressure regimen
- Nifedipine 150 mg Tablet SR daily
- Hydralazine 100 mg Tablet Q8H
- Labetalol 1000 mg Tablet TID
- Aliskiren 150 mg Tablet PO BID
- Clonidine 0.2 mg/24 hr Patch Weekly
- Hydralazine 100 mg PO PRN for SBP > 200
- continue regular [**Year/Month/Day 2286**] schedule
.
Social Issues/repeated admissions: The ICU and medicine floor
addendings felt it important to express concern over her
repeated, frequent admissions for hypertensive urgency. These
episodes may be due to medication non-compliance and it may
benefit Ms. [**Known lastname **] to be evaluated by an extended care facility
to ensure proper blood pressure monitoring and health care in
general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a "home" and
declined to talk to social work at this time. Of note, she has
missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow
rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her
nephrologist. This issue was left unresolved on discharge.
.
Chronic Abdominal Pain: Currently managed with PO dilaudid,
fentanyl patch and lidocaine patch. Per MICU team, prior
authorization paperwork for fentanyl was sent during last
admission and is pending.
- continue fentanyl patch
- continue PO dilaudid
- continue lidocaine patch
.
Lupus Erythematous: Complicated by uveitis and ESRD.
- continued prednisone
.
ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue
outpatient regimen
.
Thrombocytopenia: Remained at baseline 80s to 130s.
.
Thrombotic Events: History of SVC thrombosis with negative
workup. INR drifted up and was 3.5 on discharge. She was asked
to hold her warfarin dose this PM and recheck her INR with VNA
services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**].
- continued coumadin
.
Anemia: Hematocrit 24.5 initially. Baseline 23 to 28.
.
Medications on Admission:
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H
Prednisone 1 mg Tablet
Citalopram 20 mg Tablet
Pantoprazole 40 mg Tablet,
Warfarin 3 mg daily
Gabapentin 300 mg TID
Nifedipine 90 mg Tablet SR daily
Nifedipine 60 mg Tablet SR daily
Hydralazine 100 mg Tablet Q8H
Labetalol 1000 mg Tablet TID
Aliskiren 150 mg Tablet PO BID
Clonidine 0.2 mg/24 hr Patch Weekly
Docusate Sodium 100 mg Capsule PO BID
Senna 8.6 mg Tablet
Fentanyl 25 mcg/hr Patch 72 hr
Lidocaine 5 %(700 mg/patch) daily
Hydralazine 100 mg PO:PRN for SBP > 200
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed: For systolic blood pressure > 200.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Malignant Hypertension
Systemic Lupus Erythematosus
End Stage Renal Disease
Abdominal Pain
Discharge Condition:
good, VSS, on room air, pain controlled.
Discharge Instructions:
You came to the hospital for shortness of breath and
hypertension. You were given antihypertensive drips and during
[**Location (un) 2286**] 2 liters were taken off with good improvement in your
shortness of breath. You will need to take your medications as
prescribed and follow-up with all of your doctors to prevent
coming into the hospital.
.
Medication changes:
- Please do not take your coumadin tonight because your INR is
too high. You will need to have it checked by VNA services and
adjusted.
- Please take ALL of your medications as prescribed.
.
Please call your doctor or return to the ED if you have
intractable headaches, shortness of breath, intractable pain or
other concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-4-26**] 3:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-5-25**] 9:30
Completed by:[**2142-4-23**] |
40301,58281,5855,5990,4254,7100,7243,2767,2875,79092,25200,28529,V1251 | 109 | 139,061 | Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right leg pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V
(not currently on HD or PD), and multiple admissions for
hypertensive urgency/emergency, who presented to the ED for
continued R leg pain that starts in her R buttocks and refers
down her R leg. She describes it as feeling like the pain is
deep within her bone. The pain was [**10-20**] in the AM, and she
felt like she couldn't get out of bed. Denies any swelling of
her RLE. When getting VS in [**Name (NI) **], pt noted to be very
hypertensive at 263/176. The patient reportedly has baseline
SBPs in 130-170s. She took her hydralazine, aliskirien, and
labetalol at 5 AM on day of admission. She denies any recent
recrational drug use including cocaine and amphetamines. She
denies headache, vision changes, double vision, chest pain,
shortness of breath, abdominal pain, BRBPR, dysuria. During MD
interview, the patient was nauseous and had small amount of
emesis of a recent Coolata. Pt states that flushing her PD cath
causes a large amount of stomach pain.
.
Of note, the patient was recently admitted from 08.26-29.08. The
patient initially presented to the ED after referral from her
nephrologist's office where she had complaints of right leg pain
and was found to be hypertensive to 250/145. She was admitted
after initiation of a labetalol drip and nitropaste with
improvement in sbp to 180. The patient did receive 2 U of PRBC's
during this hospitalization for baseline anemia. The patient did
have a work-up for her right leg pain complaints with plain
films of the right hip and MRI of the L-spine which did not
reveal an explanation for her symptoms and did rule out
avascular necrosis. The patient received dilaudid for pain
control and was ambulating without pain prior to discharge. In
addition, the patient completed a course of ciprofloxacin for a
positive UA with negative cultures. The patient was unable to
tolerate peritoneal dialysis for unclear reasons. Peritoneal
dialysate culture was negative for infection.
.
In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA.
BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108.
Initially given labetalol 10 mg IV x 1 and then started on
labetalol gtt for her elevated blood pressures and titrated to 3
mg/min. LENI of R leg was negative. CXR performed. Given
morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan
due to volume overload after talking with radiology. Renal c/s
initiated. A-line placed.
Past Medical History:
- Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**]).
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
placement [**5-18**]. Pt reluctant to start PD.
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome.
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN.
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]).
Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]).
- HOCM: Last noted on echo [**8-17**].
- Anemia.
- History of left eye enucleation [**2139-4-20**] for fungal infection.
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
.
PAST SURGICAL HISTORY:
- Placement of multiple catheters including dialysis.
- Tonsillectomy.
- Left eye enucleation in [**2140-4-10**].
- PD catheter placement in [**2141-5-11**].
Social History:
Single. Recently moved into her own apartment. On disability.
Denies EtOH, tobacco or recreational drug use.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA
GEN: NAD, pleasant female sitting in bed with moon facies
HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema,
MMM, no LAD
CHEST: CTAB except at R base with decreased breath sounds; no
w/r/r
CV: tachy, normal S1S2, II/VI systolic murmur accentuated with
Valsalva
ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing
c/d/i
EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally.
Negative straight leg test, no pain with internal rotation,
external rotation, extension, adduction or abduction. Some pain
on flexion at the hip.
NEURO: II - XII intact to direct testing. No deficit in light
tough sensation. Gait normal.
DERM: no rashes noted
Pertinent Results:
LABS AT ADMISSION:
[**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139
POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18
[**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6
[**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7*
[**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86
MCH-28.1 MCHC-32.8 RDW-18.0*
[**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3
BASOS-0.2
[**2141-9-11**] 07:00AM PLT COUNT-101*
UA: moderate leuk, small blood, negative nitrite, protein 100,
21-50 WBC
.
MICROBIOLOGY:
Urine culture ([**2141-9-11**]): Mixed flora
.
STUDIES:
Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM
Sinus tachycardia. The tracing is marred by baseline artifact.
There is
left atrial enlargement. Compared to the previous tracing of
[**2141-9-5**]
the rate has increased. The axis is more rightward. Otherwise,
no diagnostic interim change.
.
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM
[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral,
superficial
femoral, and popliteal veins demonstrate normal flow,
compressibility,
augmentation, waveforms. Appropriate color flow and compression
is noted
within the calf veins. No intraluminal thrombus is present.
IMPRESSION: No evidence of right lower extremity DVT.
.
TTE ([**2140-8-26**]): The left atrium is normal in size. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. The gradient increased with the
Valsalva manuever. The findings are consistent with hypertrophic
obstructive cardiomyopathy (HOCM). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
.
R HIP XR [**2141-9-6**]: No acute fracture or dislocation.
.
MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified
in the bone marrow of the lumbar and lower thoracic spine as
described above, possibly related with anemic changes, please
correlate clinically. There is no evidence of spinal canal
stenosis or neural foraminal narrowing at the different
intervertebral disc spaces.
LAB RESULTS AT DISCHARGE:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0*
100*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2141-9-14**] 06:15AM 6.8* 5.4* 1.6
CALCIUM freeCa
[**2141-9-14**] 11:30AM 0.94*
Brief Hospital Course:
ICU course:
EKG showed no change from prior, and CXR showed a suggestion of
RLL/R diaphragm haziness. IV labetalol was started, and SBPS
dropped from 200s to 130s-160s. The patient had no symptoms of
end-organ damage. The renal team was consulted, and recommended
no change to home medication regimen. The patient was found to
by hypocalcemic, and was started on calcium replacement therapy.
When stable, patient succesfully switched to PO meds and
transferred to the floor.
.
[**Hospital1 **] history:
.
1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her
SBPs ranged from 140s-160s during the day, which is her baseline
systolic blood pressure. She was maintained on her home oral
medication regimen. At night, she became more hypertensive,
with SBP to the 170s-180s, which was controlled with both IV
hydralazine and PO nifedipine. PO nifedipine was most
successful at bringing her SBP back to her baseline. SBP at
discharge was 140. Throughout her hospitalization, the patient
had no symptoms/signs of hypertensive emergency, including no
seizures, no acute worsening of renal function, no headache,
nausea, visual and mental status disturbances, chest pain,
abdominal pain, or urinary symptoms. The renal service followed
her throughout her course and did not recommend any changes to
her regimen, but will follow her closely as an outpatient.
.
2. Right leg pain: Upon arrival on the floor, the patient
complained of [**2143-4-15**] pain in R buttock and posterior thigh, much
exacerbated with standing. Of note, lumbar spine MRI and R hip
XR on most recent admission were both negative. Her pain was
intermittent, likely secondary to sciatica, and had resolved by
the time of her discharge. Her pain when she was symptomatic
was controlled well with PO dilaudid. If the pain recurs, an
MRI of the right hip can be considered to evaluate for
osteonecrosis.
.
3. UTI: The patient had a urinalysis suggestive of UTI, though
she remained asymptomatic throughout. She was treated with a
three day course of ciprofloxacin. Her urine culture showed
mixed flora consistent with skin contamination.
.
4. ESRD: The patient has end-stage renal disease due to her
lupus. The patient's creatinine remained stable at 7.9-8.4
throughout her hospitalization, which was similar to her
baseline renal function. She was followed by the renal consult
service. Her potassium remained stable. Her calcium was low
during admission, and supplemental calcium was given in addition
to starting Calcitriol. She was not dialyzed through her PD
catheter secondary to discomfort, but may reinitiate PD as an
outpatient. Her laboratories will be checked as an outpatient
in renal clinic.
.
5. Anemia: The patient's hematocrit remained near her baseline
low 20s throughout her stay. She has anemia from chronic kidney
disease and chronic disease. The patient is not on Epopoeitin
as an outpatient, likely due to her malignant hypertension.
.
6. Prior SVC thrombus: The patient has a reported history of
prior thrombus related to catheter placement in [**2139**], and was
maintained on warfarin with INR goal 2.5 to 3.0.
.
7. Systemic lupus erythematosus: No active issues. The
patient's home prednisone regimen was continued.
Medications on Admission:
- Prednisone 5 mg Daily
- Coumadin 2 mg at bedtime
- Nifedipine 60 mg Sustained Release Daily
- Hydralazine 50 mg every 8 hours
- Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday
- Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY
- Aliskiren 150 mg Twice daily
- Docusate Sodium 100 mg 2 times a day
- Labetalol 900 mg three times a day
- Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel
movements per day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Hypertensive urgency
- Right lower extremity pain
- Urinary tract infection
Secondary diagnosis:
- Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
placement [**5-18**]. Pt reluctant to start PD
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]).
Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
- HOCM: Last noted on echo [**8-17**]
- Anemia
- History of left eye enucleation [**2139-4-20**] for fungal infection
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
Discharge Condition:
Stable systolic blood pressure over past 24 hours.
Discharge Instructions:
You were admitted to the hospital for uncontrolled high blood
pressure. You spent one day in the intensive care unit, where
you were treated with intravenous medication to lower your blood
pressure. You were then transferred to a regular hospital
floor, where your blood pressure was managed with your home oral
medications. You were also treated for urinary tract infection
with antibiotics. Your right leg pain improved during
admission, and we are unsure of the cause of this pain. You
should discuss the need for an MRI of the hip if the pain
returns when you meet with your primary care doctor.
Please call your physician or return to the emergency room if
you experience fever, chills, chest pain, difficulty breathing,
abdominal pain, headache, changes in your vision, or any other
symptoms that are concerning.
Please take your medications as prescribed.
- Calcitriol was added to your medications.
- You should hold Coumadin for two days and restart Saturday,
[**2141-9-16**]. You should have your INR checked at your visit in
kidney clinic [**2141-9-18**].
- You can take Dilaudid 2-4 mg every eight hours as needed for
pain. You should be vigilant about taking lactulose if you need
to take Dilaudid.
- You should continue Lactulose as per Dr.[**Name (NI) 12913**]
instructions.
- No other changes were made.
Please keep follow up appointments as described below.
Followup Instructions:
Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at
([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed.
Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00
Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**]
[**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00
|
E8781,V5861,V5865,V1251,32723,3004,28521,2874,7100,E9426,78909,9951,4239,4251,99656,5856,40301 | 109 | 140,167 | Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Malignant hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 year old female with ESRD on HD, SLE, malignant HTN presents
with headache and abdominal pain beginning this morning. Patient
had her hemodialysis day before yesterday. She has had multiple
admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of
headache and abdominal pain. Has had extensive work-up for
abdominal pain including ex-lap on [**2141-10-27**] which was negative.
Patient states that her headache and abdominal pain are similar
in characteristics to her previous admission. Patient denies any
fever, chills, nightsweats, chest pain, shortness of breath,
abdominal pain, nausea, vomitting, diarrhea, constipation, blood
in stool, dysuria, hematuria, change in vision, hearing,
weakness or numbness.
In the ED, initial vitals were T97, BP253/170, HR100, RR24
100%RA. Was initially given 10mg IV Labetalol once and then
started on drip at 2mg/hour. She also received hydralazine IV 10
mg once and 2 inch nitropaste. She morphine 4mg once for pain
and 4mg Zofran for nausea. Her BP elevated as high as 270/174
and his labetolol was switched to nicardipine 1mg/kg/min.
On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120
RR 15 100%RA. Patient was comfortable.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
Vitals: 97.5 122/80 88 18 100%RA.
Gen: sleeping, easily arousable, appears comfortable.
HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive,
MMM.
Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3
Pulm: CTA b/l, no w/r/r.
Abd: normal bowel sounds, midline scar well-healed, soft,
nontender, prior PD site with dry dressing, patient with
tenderness to palpation over prior PD cath site, no
guarding/rebound
Ext: no edema, no clubbing, WWP. R femoral HD catheter in place.
Neuro: following commands, answers appropriately, [**5-15**] motor
strength, sensation is intact.
Pertinent Results:
Admission:
[**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3*
MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199
[**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2*
[**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103
HCO3-21* AnGap-20
[**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109
TotBili-0.4
[**2141-12-18**] 02:00AM BLOOD Lipase-73*
[**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8
[**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE
[**2141-12-18**] 03:52PM BLOOD CRP-11.5*
[**2141-12-18**] 03:52PM BLOOD C3-68* C4-19
[**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base
XS--1 Comment-GREEN TOP
[**2141-12-20**] 12:09PM BLOOD Lactate-0.9
[**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8
Cl-103
[**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3*
MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131*
[**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3*
[**2141-12-18**] 03:52PM BLOOD ESR-21*
[**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138
K-4.3 Cl-106 HCO3-23 AnGap-13
[**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109
TotBili-0.4
[**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8
[**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-12 TransE-<1
Micro:
Blood Cx- [**12-18**]: No growth
Urine Cx- [**12-18**]: No growth
[**12-18**] TTE
The left atrium and right atrium are normal in cavity size. A
possible secundum type atrial septal defect is seen by color
Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function. There is no significant resting LVOT gradient, but a
mild gradient (30mmHg peak) is seen with Valsalva manuever.
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 stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
IMPRESSION: Marked symmetric left ventricular hypertrophy with
normal regional/global systolic function and mild inducible LVOT
gradient. Mild aortic regurgitation. Mild pulmonary artery
systolic hypertension. Possible secundum type atrial septal
defect.
Compared with the prior study (images reviewed) of [**2141-10-19**], a
possible secundum type atrial septal defect is now suggested.
If clinically indicated, a follow-up study with saline contrast
and/or a TEE would be better able to characterize the possible
atrial septal defect.
CLINICAL IMPLICATIONS:
Based on [**2140**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**12-18**] CXR
IMPRESSION:
1. Cardiomegaly with findings suggestive of mild pulmonary
edema.
2. Bibasilar linear opacities suggesting atelectasis, although
developing
pneumonia cannot be excluded.
3. No evidence of free intraperitoneal air.
[**12-20**] MRV
IMPRESSION:
No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is
patent. Again seen is occlusion of the right internal jugular
and left
brachiocephalic veins. Right external jugular vein is provides
the major
venous drainage from the neck.
Brief Hospital Course:
24 year old Female with SLE, ESRD on HD and malignant
hypertension presents with abdominal pain and headache
consistent with her usual hypertensive urgency and was found to
be in hypertensive urgency in ED.
1. Malignant Hypertension: The patient had her hemodialysis two
days prior to admission. Initially in the ED her BP was 253/170.
She was given 10mg IV Labetalol and started on a labatelol drip.
She also received hydralazine IV 10 mg once and 2 inches of
nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her
BP remained elevated so she was switched to nicardipine
1mg/kg/min. The patient was transferred to the MICU. In the ICU
she was continued on the Nicardapine drip and her pressures
decreased to 175/120. Nephrology was consulted and dialysis
initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt
transferred to floor.
While on the floor the patient had question of angioedema and
markedly elevated BP. She was readmitted to the MICU on
[**2141-12-20**]. Patient's Aliskerin was also held for conern for
angioedema. The renal team removed her tunneled dialysis
catheter that had a cuff out, and replaced it with a temporary
femoral line. The patient's PD catheter was removed. The patient
was briefly on a nitro drip for hypertension. The patient's
nifedepine was increased to 120mg. The patient was transferred
to the floor with stable blood pressures, BP 124/72 on [**12-21**].
The morning of [**12-22**], the patient was noted to have a BP up to
247/120 at 0800. Hypertension persisted throughout the morning
with BPs 210s-240s systolic. HR during this time was in the 90s.
She received a total of 60 mg IV hydralazine over the course of
the morning as well as 0.1 mg PO clonidine. She was also given
her normal AM BP meds and restarted on aliskarin. Due to
persistent hypertension, she was transferred to the ICU for
further care.
On arrival to the ICU, the patient reported severe abdominal
pain over the site of recently removed PD catheter. She denied
any headache, nausea, vomiting, diarrhea, constipation, or lower
extremity swelling. She reports bilateral calf cramping but no
leg swelling. She denies any difficulty breathing or chest pain.
She took her AM BP meds without difficulty. Her blood pressure
decreased to 130s-140s/60s without further intervention. She was
transferred back to the floor on [**12-23**] and signed out AMA.
2. Angioedema:
On [**12-20**] the patietn developed facial swelling and evidence of
angioedema by ENT. The patient reported that her face is more
swollen which was confirmed by her mother on the floor. The
patient was give lasix IV as she has been unable to have any
negative filtration with HD. The patient was started on decadron
10mg q8hr, famotidine, diphenhydramine for the edema. Her
tekturna was discontinued for concern that it might be causing
angioedema. She denied difficulty with her breathing at that
time, but was very somnulent. On arrival to the MICU her vitals
were stable and oxygenating well at 100% on face mask. The
patient's airway was supported with a nasal trumpet. The patient
underwent MRV that showed no progression of her clot. Patient
was diuresed with lasix and dialysis with significant
improvement in her symptoms. She was treated with prednisone and
decadron, famotidine and benadryl for angioedema. The patient
was maintained on her heparin drip for her SVC syndrome.
3. Abdominal Pain: The patient has had extensive prior workup
that has been unrevealing. The Transplant surgery team removed
the PD cath on [**12-21**]. She continued to have abdominal pain
post-op. She was continued on PO dilaudid 2mg po prn. She
continuned to complain of abdominal pain throughout her
admission and continued to requested IV dilaudid.
4. ESRD: The patient is on a T/Th/Sat schedule. She was closely
followed by the renal team. She had dialysis on [**12-19**]. The
patient's tunneled dialysis catheter had a cuff that was out
and qas subsequently replaced with a temporary femoral line on
[**12-21**]. The patient also had her PD catheter removed on [**12-21**]
secondary to chronic abdominal pain. The patient was scheduled
to have dialysis on [**12-23**].
5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during
last admission for supratherapeutic INR. She was admitted with a
subtherpeutic INR of 1.2 She was started on a heparin drip. She
was also started on Coumadin 2mg PO qday, but was held on [**12-19**]
in prep her PD catheter removal. She was continuned on the
heparin drip and her coumadin continued to be held in
preparation for placement of a tunneled dialysis catheter by IR.
However, the patient signed out AMA and thus it was not placed.
6. Anxiety: Pt recently saw psychiatrist who started her on
Celexa. She was continued on Celexa 20mg PO daily.
7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It
trended down to 22.3 on discharge when she left AMA. There was
no evidence of active, acute bleeding. THis is likely seoncdary
to her ESRD. The patient was closely monitored.
8. Systemic Lupus Erythematosis: Rheumatology was consulted and
does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP
slightly elevated. Her Echo did not suggest worsening
pericarditis. She was continued on her home prednisone dose of
4mg daily.
9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure.
Medications on Admission:
Aliskiren 150 mg [**Hospital1 **]
Clonidine 0.3mg / 24 hr patch weekly qwednesday
Hydralazine 100mg PO q8H
Labetalol 800mg PO TID
Hydromorphone 4mg PO q4H PRN
Nifedipine ER 90mg PO qday
Prednisone 4mg PO qday
Lorazepam 0.5mg PO qHS
Clonazepam 0.5 mg [**Hospital1 **]
Celexa 20mg PO qday
Gabapentin 300 mg [**Hospital1 **]
Acetaminophen 325 mg q6H PRN
Ergocalciferol (Vitamin D2) 50,000 unit PO once a month
Warfarin held on discharge [**2141-12-14**] due to supratherap INR
Discharge Medications:
As patient signed out AMA, no medications were issued. She was
told to resume her admission medications, however no
instructions were taken by the patient.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Hypertensive urgency
2) Abdominal pain
3) End stage renal disease on hemodialysis
4) Venous thromboembolism
Discharge Condition:
Signed out AMA
Discharge Instructions:
Pt signed out AMA
Return to the hospital with any concerning symptoms. Be sure to
call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and
review your medications and discuss follow-up plan.
Followup Instructions:
Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to
arrange your hemodialysis.
Completed by:[**2141-12-26**] |
2753,5856,34839,58281,5990,2762,3643,2839,7100,V1251,V5861,7842,2767,61172,2875,27541,40301 | 109 | 147,469 | Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
arterial line
History of Present Illness:
HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile
hypertension, RUE VTE on anticoagulation, recent facial swelling
who presents with hypertensive emergency. Patient developed
severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**]
on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea
and vomiting yellow/green liquid and BP cuff again not able to
obtain BP. Patient was last seen by VNA this past Friday with BP
130/70. Patient denies any CP, shortness of breath, abd pain.
Her facial swelling is slightly worse today. She denies any
weakness, dizziness, difficulty with speach, no numbness or
tingling. She says that she is compliant with all of her
medications. She denies any GU/GI complaints despite +UA in ED.
.
In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA.
Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1,
Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written
but patient did not take due to nausea. CT head showing no
hemorrhage but hypoattenuation in frontal area, which is change
from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with
INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K
5.6 ECG with ?hyperacute T waves, otherwise no changes, given
kayexalate only.
.
Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial
swelling and hypertensive emergency requiring ICU care. She was
also admitted [**Date range (1) 43498**] with similar complaints.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA
Gen: swollen face L>R, alert and cooperative, NAD, snoring when
asleep but easily arousable
Heent: OP clear, swollen eye lids L>R, Left eye retracted with
prosthesis, anicteric, OP moist
Neck: supple, no JVD elevation, no meningismus
CV: nl S1 S2, RRR, [**1-15**] SM
Lungs: CTAB
Abd: obese, soft, NT, ND, BS+
Ext: dry, no c/c/e, diminished,
Neuro: Alert and oriented x 3, gets drowsy intermittently but
arousable, CN II-XII intact, strength 5/5 throughout, sensations
intact
Pertinent Results:
[**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis.
[**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high
bifrontal white matter, and subcortical hypoattenuation in the
left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white
differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying
focal lesion or possibly areas of new infarcts. An MRI head
without and with Iv conrast is recommended for further
characterization.
2. No evidence of intracranial hemorrhage.
[**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an
interval increase in retrocardiac opacity obscuring the left
hemidiaphragm. The right lung and the left upper lung zone are
clear. The right costophrenic angle is slightly blunted,
suggesting a very small right pleural effusion. The heart is
slightly enlarged, but the cardiomediastinal silhouette is
unchanged. There is no hilar enlargement. Soft tissue and bony
structures are unremarkable.
IMPRESSION: Interval increase in left basilar atelectasis with
pleural effusion. Superimposed pneumonia cannot be excluded.
Possible small right pleural effusion.
[**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the
head, the previously described low attenuation areas in the
parietal regions appear with hyperintensity signal on the FLAIR
sequence, mildly hyperintense on the diffusion-weighted
sequence, and also slightly hyperintense on the corresponding
ADC maps, these findings are nonspecific and may represent
posterior reversible encephalopathic changes, please correlate
clinically. There is no evidence of acute hemorrhage,
hydrocephalus, or midline shift. A low-attenuation area is
identified on the right occipital region, likely consistent with
chronic deposits of hemosiderin, please correlate with the prior
MRI dated [**2140-12-28**].
IMPRESSION: Limited examination secondary to motion artifacts.
On the FLAIR sequence, there is evidence of hyperintensity areas
in the parietal regions, left occipital lobe, which are
nonspecific and may represent possible posterior reversible
encephalopathic changes. The prior low-attenuation area of the
right occipital lobe is unchanged and may represent chronic
deposits of hemosiderin. There is no evidence of hydrocephalus
or midline shifting. Followup with MRI of the head with and
without contrast under conscious sedation is recommended if
clinically warranted.
Brief Hospital Course:
A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and
facial swelling p/w hypertensive emergency and delta MS
initially admitted to the [**Hospital Unit Name 153**].
In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home
medications. She had head imaging (MRI) with following results;
On the FLAIR sequence, there is evidence of hyperintensity areas
in the parietal regions, left occipital lobe, which are
nonspecific and may represent possible posterior reversible
encephalopathic changes. She was evaluated by neurology who
considered PRES, though she did not seize. She was started on
keppra as she has had seizures before, and will follow up with
them.
.
# HTN Emergency. She has had multiple admissions in the past
with neurological involvement, hemolysis in the past. SBP >300
in ED. Her BP was lowered slowly with a labetolol gtt in the
ICU. When it was stably below 180 she was transferred to the
medical floor on the [**Hospital Ward Name 517**]. She was continued on
clonidine TP, po labetalol, aliskiren. I/O goal was even. Her
BP remained between 120-170 before discharge, she no longer had
any headaches, or nausea. She was oriented times three.
Aliskiren was not covered by masshealth, and a prior auth was
faxed over. A supply from the pharmacy was sought but
unavailable. She was given a prescription for 5 pills to bridge
her to the time when the prior auth would have been approved in
order to facilitate her paying for the prescription. She was
also given hydralazine and instructed on how to take extra doses
when her blood pressure increased.
.
# Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive
changes on CT. AAO times three, no focal neurological signs
currently. Also likely component of OSA although this seems
chronic. No seizures although has had them in the past.
Neuro was consulted, and she was started on Keppra for question
of PRES, keppra for 6 weeks until f/u with neuro, has outpatient
MRI appointment as well. They will likely keep her on keppra
until the changes in her parietal regions have resolved.
.
#UTI-found on admission, was on Cipro-will complete course of 5
days
.
# VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o
other VTE [**2-11**] to lines in the past. Currently on coumadin. INR
2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures.
Her coumadin was restarted, has VNA set up and will be followed
by [**Hospital3 **].
.
# Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE
(brachiocephalic) vs. angioedema-pt now without swelling
.
# ESRD. Currently no on HD due to patient preference, awaiting
to start PD next week. Since patient has refused HD there was an
attempt to correct lytes and acid base with medications. Avoided
fluid overload with lasix, patient currently making urine. Lytes
- see below. She will commence PD as an outpatient (had issues
yesterday with catheter flushing)-still not working-will try
laxatives to relieve loops of bowel possibly wrapped around
catheter and she will follow up with renal on Monday. Her
ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was
administered.
.
# Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely
[**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated
in the past, likely some chronic hyerkalemia. She received
kayexalate 30 mg tid until K <5
Her electrolytes stabilized and she was continued on her home
regimen of sodium bicarb (650mg two tabs daily).
.
# SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some
point --Atovaquone to prevent hyperkalemia
Continued on prednisone 10mg (dropped from 15mg 2 weeks ago)
.
# Anemia-Hct and plts dropped on this admission but now stable
.
# HOCM. Avoid dehydration. Currently on Labetalol.
.
# PPX: systemically anticoagulated, getting kayexalate, PPI
# FEN: Electrolytes as above, no standing fluids I/Os goal even.
# Access: 2x PIV currently
# Code: Full
# Dispo: home
Medications on Admission:
Pantoprazole 40 mg daily
- Clonidine TP 0.3/24 hrs q wednesday
- Prednisone 10 mg daily (just decreased from 15 mg)
- Calcitriol 0.25 mcg daily
- Sodium bicarbonate 650 mg 2 tabs daily
- Vit D3 400 mg daily
- Vit D2 50,000 q wed, x 10 weeks
- Labetalol 300 mg po 3 tabs TID
- Nifedipine SR 90 mg [**Hospital1 **]
- Warfarin 2 mg daily
- Hydral 25 mg TID
- Lasix 40 mg [**Hospital1 **] (started friday)
- Benadryl 25 mg po prn
- Ativan 1 mg [**Hospital1 **] prn
- Colace 100 mg [**Hospital1 **] prn
- Morphine 15 mg po q 6 hrs x 14 days
- Diovan 320 mg daily
- Dilaudid prn
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
on alternating days with 15mg.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): please take as directed when blood pressure is above
180.
Disp:*90 Tablet(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
Disp:*405 Tablet(s)* Refills:*2*
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for hold for sbp < 130.
Disp:*10 Tablet(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Outpatient Lab Work
for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**]
please check INR once a week and have results faxed to
[**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**]
16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<130.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
-hypertensive emergency
-Lupus - [**2134**]. Diagnosed after she began to have swolen fingers,
a rash and painful joints.
-ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with
hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated
PTH/Metabolic Acidosis; PD Catheter placed [**5-18**]
-h/o seizures, ICU admissions; h/o two intraparenchymal
hemorrhages that were thought due to the posterior reversible
leukoencephalopathy syndrome, associated with LE paresis in [**2140**]
that resolved
-Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had
blood cleared and cataract removed as well as glaucoma.
-HOCM - per Echo in [**2137**]
-Mulitple episodes of dialysis reactions
-Anemia
-H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin
then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**],
[**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4
([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**],
[**8-/2140**])
-Facial and left breast swelling - attributed to angioedema vs
chronic L Brachiocephalic vein occlusion
-Thrombophilia ?????? likely related to SLE, h/o recurrent VTE
-Thrombocytopenia NOS
-TTP (got plasmapheresisis) versus malignant HTN
-History of left eye enucleation [**2139-4-20**] for fungal infection
Discharge Condition:
stable, afebrile, SBP 120's-170's
Discharge Instructions:
You were admitted with hypertensive emergency, your blood
pressure was extremely high. You had a head CT and MRI that
showed some changes concerning for PRES (posterior reversible
leukoencephalopathy syndrome), and neurology recommended
initiating Keppra. Your blood pressure was brought under
control in the intensive care unit and now you have a new
regimen of medications. In addition peritoneal dialysis was
attempted but there were difficulties with your catheter. This
will be further addressed by your outpatient nephrologist. You
will continue to have your INR drawn and sent to coumadin
clinic.
You should take all your medications as prescribed, you will be
taking the keppra until you follow up with a neurologist in
approximately 6 weeks. You will also be taking the Aliskiren
following discharge. You will be discharged on hydralazine
(which you will take three times daily EVERY DAY), as well as
when your blood pressure gets too high as follows;
if you blood pressure is above 180 please take an extra dose of
hydralazine, check your blood pressure in 10 minutes, if it is
still not take another dose and recheck your blood pressure in
another 10 minutes-if it is still elevated take another 25mg
hydralazine and recheck in 10 minutes-if it is still elevated
please call your doctor or go to the ER.
Continue taking your coumadin and having your INR sent to
coumadin clinic.
Please seek medication attention if you have any headaches,
chest pain, shortness of breath, dizzyness, nausea or any other
concerning symptoms.
Please follow up as outlined below.
Followup Instructions:
-Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**]
10:00
-Your renal team will contact you regarding follow up-you should
call CB for home teaching.
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2141-7-12**] 10:30
-MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building
-[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm
-Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP
for [**Name Initial (PRE) **] referral
-Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2141-6-19**] |
40301,5856,4254,4239,7100,58381,2767,78701,78791,2753,28529,78904,33829,2875,44389,V0254,V5861,V4512,V4511,V1581 | 109 | 151,240 | Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Headache, Hypertensive urgency
Major Surgical or Invasive Procedure:
Hemodialysis x 2
History of Present Illness:
24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o
SVC syndrome, h/o posterior reversible encephalopathy syndrome
(PRES) and prior intracerebral hemorrhage, recently admitted
[**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that
time with nicardipine drip for a short period and then to her
home regimen. Yesterday onset of nausea with emesis and
inability to tolerate home meds including antihypertensives.
Diarrhea mild as prior. No fever, chills, no hematemesis or
hematochezia. No melena. Today reports onset of headache
therefore to the ED.
In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was
given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium
gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium
bicarbonate, kayexalate for K 6.7 (dialysis dependent
Tues/thurs/sat) but with report of peaked T waves. Renal
dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10.
Admitted for hypertensive urgency to ICU. No gtt was started. Of
note usualy BP 160/100.
Review of sytems:
patient tearful complaining of frontal headache and nausea
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-120's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother. On disability for multiple medical problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather
Physical Exam:
Vitals: BP 240/146, 101, 98.6,
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, 3/6 SEM RUSB
Abdomen: soft, diffusely tender, no rebound or gaurding.
Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema
Pertinent Results:
[**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138
POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2142-5-15**] 05:45AM CK(CPK)-96
[**2142-5-15**] 05:45AM cTropnT-0.10*
[**2142-5-15**] 05:45AM CK-MB-NotDone
[**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91
MCH-29.6 MCHC-32.4 RDW-17.9*
[**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1*
BASOS-0.7
[**2142-5-15**] 05:45AM PLT COUNT-128*
[**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2*
[**2142-5-15**] 07:14AM K+-6.0*
[**2142-5-15**] 12:17PM K+-5.3
Images:
CXR: Persistent severe cardiomegaly.
Head CT: Normal brain CT.
Brief Hospital Course:
24 yo female with ESRD on HD, malignant hypertension with hx of
intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC
syndrome admitted due to hypertensive urgency after developing
N/V and being unable to take her po medications.
# Hypertensive urgency: The patient was admitted to the MICU the
night of admission where she was placed on a labetolol drip and
her home medications were restarted. head CT was negative for
intracranial bleed. She was continued on her home regimen of
Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly,
Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained
Release QPM and 90 mg Tablet Sustained Release QAM, and
Hydralazine 100 mg PO Q8H. During her stay her blood pressure
fluctuated, occasionally becoming relatively low due to grouping
of her medications together. Blood cultures were sent but have
been no growth to date and she remained without signs of
infection (afebrile with no leukocytosis). She was discharged
on her home regimen.
# Nausea/vomiting: The patient did not experience further
vomiting, but occasionally complained of nausea. The cause of
her nausea was unclear. She was able to tolerate po intake
prior to discharge.
# Abdominal pain/Diarrhea: The patient has chronic abdominal
pain with previous negative workups. During this hospitalization
her pain was at its baseline. Since admission she denied
diarrhea. She was continued on her outpatient regimen of [**2-14**] mg
po dilaudid q4h as needed.
# ESRD on HD: She was hyperkalemic in the emergency room and was
given kayexalate. She underwent two sessions of dialysis during
this hospitalization.
# SLE: Stable, without symptoms. She was continued on 4 mg of
prednisone daily.
# History of thrombotic events/SVC syndrome: She is
anticoagulated with warfarin as an outpatient, however her INR
was subtherapeutic on admission at 1.2. Previous documentation
in OMR states she does not need to be bridged while
subtherapeutic. She was initally continued on coumadin 4 mg po
daily, however her INR rose quickly to the therapeutic range, so
this was decreased to 3 mg po daily.
# OSA: She is on CPAP at a setting of 7 as an outpatient and was
continued on this during her hospitalization.
Medications on Admission:
Medications: as per last discharge summary
-Aliskiren 150 mg Tablet [**Hospital1 **]
-Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday)
-Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
-Labetalol 200 mg Tablet Sig 5 tab TID
-Nifedipine 60 mg Tablet Sustained Release QPM
-Nifedipine 90 mg Tablet Sustained Release QAM
-Citalopram 20 mg Tablet Sig daily
-Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN
-Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
-Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H
-Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN
-Prednisone 4 mg daily
-Coumadin 4 mg daily at 4 PM
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QPM (once a day (in the evening)).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for hypertension.
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary -
Hypertensive urgency
End-stage renal disease on dialysis
Secondary -
Systemic lupus erythematous
History of thombosis and Superior vena cava syndrome
Obstructive sleep apnea
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to dangerously elevated
blood pressure due to inability to take your medications
secondary to nausea. It is very important that you take your
blood pressure medications reguarly. Your nausea was controlled
with medication and your blood pressure decreased once back on
your home medication regimen.
You underwent two sessions of dialysis during your
hospitalization. It is extremely important that you attend
dialysis three times weekly as an outpatient.
Medication changes:
You should be taking 3 mg of coumadin daily. You will need to
have your INR checked at dialysis.
Otherwise continue your outpatient medications as prescribed.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, worsening headache, vision change,
inability to take your medications, blood in your stool, or dark
black stool.
Followup Instructions:
It is very important that you keep your previously scheduled
appointments:
You have an appointment with gynecology to evaluate an
abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30
Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-6-1**] 2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2142-5-19**] |
78900,4592,2875,78959,4254,58281,5856,40301,2841,7100,V5861,V1251,V4512,62211,44389,32723,73399,34590,28529,28521,311,53081,53190,33829,33819 | 109 | 155,726 | Admission Date: [**2142-8-13**] Discharge Date: [**2142-8-16**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Dyspnea and hypertensive emergency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 25 year old female with a history of SLE, end
stage renal disease on [**Known lastname 2286**], malignant hypertension, SVC
syndrome, PRES, prior ICH and frequent admissions for
hypertensive emergency now presenting with dyspnea and cough
productive of white sputum x 1-2 days with initial SBP 280s in
ED. Denies F/C, CP, HA, numbness, weakness, visual changes, N/V,
confusion. Reports compliance with meds but has noticed that
clonidine patches have fallen off last 24-48 hours. Her usual
crampy abdominal pain at baseline. Last BM yesterday normal. Pt
last dialyzed Saturday (day prior to admission). Most recently
admitted [**Date range (1) 43608**] with groin pain [**2-12**] HD site, [**Date range (1) 41780**] with
line infection, hypertension, last admitted to MICU [**7-12**] for
hypertensive emergency and discharged [**2142-7-23**].
.
In ED, initial VS SBP 280/140s T100.3 HR 110 RR 28 SaO2 100%.
She recieved Hydralazine 40mg IV, was maxed out on Nitro drip
and SBP 240s. Also reportedly had fever to 101, CXR with
retrocardiac opacity and received Vancomycin 1g IV and
Levofloxacin 500mg. Has 18g PIV.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD 3. Malignant hypertension with baseline SBP's
180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Home: lives with mother
Occupation: on disability, previously employed with various temp
jobs
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
No history of autoimmune disease
Physical Exam:
General: A&Ox3. NAD, oriented x3.
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
nonerythematous, MMM.
Neck: supple, no LAD, full ROM.
Lungs: CTAB, with decreased BS right base, scant crackles. No
egophony, slight dullness to percussion bases.
CV: Regular, tachy, Prominent heart sounds, S1, S2 +S3, no rubs
appreciated.
Abdomen: Soft, minimally distended, diffuse mild tenderness to
deep palpation, no rebound, guarding.
Ext: WWP, 2+ dp/pt pluses, no clubbing, cyanosis or edema.
Neuro: AAOx3. CN 2-12 intact. 5./5
Pertinent Results:
[**2142-8-13**] 02:15AM BLOOD WBC-6.1# RBC-2.66* Hgb-7.4* Hct-23.8*
MCV-90 MCH-27.9 MCHC-31.1 RDW-19.1* Plt Ct-169#
[**2142-8-13**] 07:52AM BLOOD WBC-4.9 RBC-2.45* Hgb-7.0* Hct-22.0*
MCV-90 MCH-28.7 MCHC-32.0 RDW-20.1* Plt Ct-150
[**2142-8-14**] 11:44AM BLOOD WBC-3.8* RBC-2.40* Hgb-6.9* Hct-21.7*
MCV-90 MCH-28.8 MCHC-32.0 RDW-20.0* Plt Ct-154
[**2142-8-13**] 02:15AM BLOOD Neuts-82.4* Bands-0 Lymphs-12.6*
Monos-3.2 Eos-1.6 Baso-0.3
[**2142-8-13**] 07:52AM BLOOD Neuts-80.6* Lymphs-13.6* Monos-3.9
Eos-1.7 Baso-0.3
[**2142-8-14**] 11:44AM BLOOD Neuts-81.3* Lymphs-11.5* Monos-4.4
Eos-2.4 Baso-0.4
[**2142-8-13**] 02:15AM BLOOD PT-14.1* PTT-34.0 INR(PT)-1.2*
[**2142-8-13**] 07:52AM BLOOD PT-14.2* PTT-36.1* INR(PT)-1.2*
[**2142-8-14**] 11:44AM BLOOD PT-13.7* PTT-34.7 INR(PT)-1.2*
[**2142-8-13**] 02:15AM BLOOD Glucose-80 UreaN-35* Creat-5.8* Na-137
K-4.8 Cl-100 HCO3-23 AnGap-19
[**2142-8-13**] 07:52AM BLOOD Glucose-87 UreaN-37* Creat-6.2* Na-137
K-4.0 Cl-100 HCO3-24 AnGap-17
[**2142-8-14**] 11:44AM BLOOD Glucose-131* UreaN-46* Creat-7.1* Na-136
K-5.5* Cl-102 HCO3-21* AnGap-19
[**2142-8-13**] 07:52AM BLOOD Calcium-8.5 Phos-5.6* Mg-1.7
[**2142-8-14**] 11:44AM BLOOD Calcium-8.0* Phos-6.7* Mg-1.7
[**2142-8-13**] 07:52AM BLOOD Vanco-4.9*
[**2142-8-14**] 11:44AM BLOOD Vanco-5.1*
Brief Hospital Course:
24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome
was admitted to the MICU with dyspnea and hypertensive emergency
with SBP 280s. She has frequent admissions for hypertensive
emergency. See below for specific hospital course on each
problem.
.
# HTN Urgency/Emergency: Patient was admitted directly to the
ICU with shortness of breath and hypertension. One of her
clonidine patches had fallen off and it was likely that this
could have caused some of the elevation in BP. She was started
on a nitro gtt in the ED, but in the MICU she was placed on a
labetolol drip. Lactate on admission was 0.9 and there was no
evidence of new end organ damage. She was restarted on all of
her home meds (except her qhs nifedipine) and transferred to the
floor the next day with SBP in the 160s. During her admission
renal was follwing and recommended that she be given a home
blood pressure cuff. For SBP > 200, she will have hydralazine
100mg PO. She will re-check in 30 mins with instructions to
repeat up to three times before seeking medical attention in the
Emergency room. She was also given dilaudid prn for her pain,
which is a continuation of her outpatient pain regimen. She did
not require hydralazine IV prn on the floor. Prior to discharge
her evening dose of nifedipine was restarted and she recieved
hemodialysis. She remained normotensive during the rest of her
admission and was discharged with stable vital signs.
# Dyspnea: Patient was admitted with dyspnea, which improved
with resolution of her hypertension. She required supplementary
oxygen intermitantly during the admission but was saturation >92
% on RA at discharge. There was concern for infection in the ED
and was given as above, likely secondary to pulmonary edema +/-
infection given fever, cough and infiltrate. She was started on
vancomycin in the ED, but that was discontinued and she was not
put on additional antibiotics. She remaine afebrile throughout
the rest of her stay. Blood cultures were negative at time of
discharge.
.
# Fever: Concerning for PNA given complaints of dyspnea and
cough and infiltrate on CXR. Other possible etiologies onclude
line infection given indwelling femoral HD line, however, the
femoral line had been exchanged during previous admission. See
above course in dyspnea section.
.
# Chronic abdominal pain - abdominal pain was well controlled
throughout the admission with PO dilaudid. She was moving her
bowels throughout the stay. Lidocaine patch was also
continued.ontinue neurontin per HD.
.
# ESRD on HD - HD SaTuTh. Sevelamer was continued during the
hospitalization. She recieved hemodialysis on Thursday, [**8-16**]
prior to discharge.
.
# anemia - Pt has chronic anemia, baseline pancytopenia, likely
[**2-12**] CKD and SLE, currently at/slightly below baseline, though
has h/o GIB. HCT 23 here, most recently 22 on discharge [**8-7**].
We continued EPO per renal and was administered 2 units PRBC's
prior to hemodialysis.
.
# h/o gastric ulcer - continue PPI.
.
# SLE - continue home regimen of prednisone 4mg po qdaily.
.
# h/o SVC thrombosis - Now off anticoagulation secondary to
noncompliance with coumadin
.
# seizure disorder - continue keppra 1000 mg PO 3X/WEEK
(TU,TH,SA).
.
# depression - continue celexa.
.
# FEN:
- low salt diet.
.
# Prophylaxis: heparin SC, PPI.
# Access: PIVx2.
# Code: FULL
# Communication: Patient
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
9. Sevelamer HCl 400 mg Tablet Sig: One Tablet PO TID
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
11. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID
12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H 13.
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAYS
(TU,TH,SA).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
17. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Anxiety.
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever.
19. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime).
Discharge Medications:
1. Blood pressure machine
For home blood pressure monitoring three times daily
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
6. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
10. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QT, TH
SAT ().
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
18. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
20. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
21. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO once as
needed for systolic blood pressure > 200: Take one tablet if
systolic blood pressure > 200. Re-check blood pressure in 30
mins. Repeat up to 3 times. .
Disp:*30 Tablet(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive Emergency
2. Dyspnea
3. End-Stage Renal Disease (renal failure)
Secondary Diagnosis:
- Systemic lupus erythematosus
- End Stage Renal Disease on [**Month/Year (2) 2286**]
- Malignant hypertension
- Thrombocytopenia
- Thrombotic events with negative hypercoagulability work-up
- HOCM
- Anemia
- History of left eye enucleation [**2139-4-20**] for fungal infection
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
- Thrombotic microangiopathy
- Obstructive sleep apnea on CPAP
- Left abdominal wall hematoma
- MSSA bacteremia associated with HD line [**Month (only) 956**]-[**2142-3-11**].
Discharge Condition:
Stable, Vitals stable, asymptommatic
Discharge Instructions:
You were admitted to the hospital because of high blood
pressure. You were admitted to the Intensive Care Unit for IV
medications to stabilize your blood pressure while your home
medications were restarted. You the were transferred to the
floor for continued management. You recieved hemodialysis while
in the hospital.
Changes to medication/management:
You have been given a blood pressure cuff to take your blood
presure at home. If your blood pressure is greater than 200,
take Hydralazine 100 mg by mouth. Recheck blood pressure in 30
minutes. Repeat up to 3 times.
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-8-16**]
12:00
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2142-8-22**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Last Name (NamePattern1) 8402**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-8-28**] 2:45
|
V4512,7100,33829,78659,2762,5990,78900,4251,4254,28981,7907,99662,4239,4592,58281,40301,5856,2766,2875,28521,2767,04104,E8791,04112,32723,V1251,V5861 | 109 | 158,943 | Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Abdominal Pain, Shortness of breath, Chest discomfort
Major Surgical or Invasive Procedure:
HD [**2142-3-21**] and [**2142-3-23**]
History of Present Illness:
The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN,
history of SVC syndrome, PRES, recently discharged on [**2142-3-18**]
after admission for abdominal pain, MSSA bacteremia, paroxysmal
hypertension and ESRD line, presents with central crampy
abdominal pain, chest discomfort, SOB, HTN to 230s. Pt states
that at around 11pm last night developed shortness of breath
that felt as though someone was sitting on her chest. She states
that she feels as though she cannot catch her breath. Pt also
describes chest discomfort which she states that she has not had
before. She also has her chronic abdominal pain. She states that
it comes and goes and is unchanged from her baseline.
.
In the ED, initial vitals: 98.9 [**Telephone/Fax (3) 43508**]4 100%RA. SBP as
high as 241 recorded. She received Labetalol 20 IV x 2 without
improvement. She was given hydral 20 IV without improvement, so
she was placed on a Labetalol gtt @ 4 mg/min with improvement of
SBP 220. She was given IV Zofran, IV dilaudid, Hydralazine 50mg
po, Labetolol 200mg po, Labetolol 100mg IV x 3, Levofloxacin
750mg IV, Ceftriaxone 1g IV, Vancomycin 1g IV, weregiven for
question of infiltrate on CXR prior to CT. Nitroprusside gtt
added and .5 mg/kg, pressure initially improved to 180s. Tried
to wean off the nitroprusside and pressure went back up to 208.
Chest pain has resolved, still SOB with abdominal pain. Pan-scan
w/o contrast showed interval worsening of chronic pulmonary
edema. Pleural and pericardial effusions stable. Ativan seemed
to help symptoms.
One blood culture was sent in the ED. Per report, EKG showed
LVH, ST depression in V6. Trop a little more elevated than
normal but CKs flat. [**Telephone/Fax (3) **] was discussed with renal and it
was not felt that HTN is a volume issue so no need for emergent
[**Telephone/Fax (3) 2286**].
.
Upon arrival to the floor, her SBP was 203. She continued to
complain of abdominal pain and shortness of breath though her
chest discomfort was improved. Respiratory rate up to 30.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**], getting Vanc with HD.
.
PSHx:
1. Placement of multiple catheters including [**Year (4 digits) 2286**].
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother. On disability for multiple medical problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
PE: 98.6 128/98 82 20 100% on 2L NC
vitals
Gen- NAD
HEENT- MMM
CV- Regular, nl S1, s2, + s3.
Lungs- CTA bilat
Abd- + BS, soft, ND. Tender only to deep palpation
Ext- 2+ DP bilat. trace pedal edema
Neuro- AA+Ox3.
Pertinent Results:
Admission Labs:
[**2142-3-21**] 02:20AM WBC-5.0 RBC-2.61* HGB-7.7* HCT-23.5* MCV-90
MCH-29.4 MCHC-32.6 RDW-19.3*
[**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5
EOS-1.1 BASOS-0.5
[**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168
[**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1*
[**2142-3-21**] 02:20AM cTropnT-0.12*
[**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK
PHOS-173* TOT BILI-0.4
[**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140
POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18
[**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12*
.
CT C/A/P - [**2142-3-20**] -
1. Interval worsening of pulmonary edema, now moderate to
severe. Unchanged moderate pericardial effusion. Periportal
edema persists.
2. Small right pleural effusion, unchanged.
3. Small amount of ascites.
4. No evidence of bowel obstruction. Contrast material reaches
the rectum.
5. Redemonstration of extensive mediastinal and hilar
lymphadenopathy.
The study and the report were reviewed by the staff radiologist.
Discharge labs:
[**2142-3-23**] 12:00PM BLOOD WBC-3.7* RBC-2.87* Hgb-8.7* Hct-26.1*
MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* Plt Ct-130*
[**2142-3-23**] 12:00PM BLOOD Plt Ct-130*
[**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9*
[**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137
K-4.8 Cl-104 HCO3-24 AnGap-14
[**2142-3-23**] 12:00PM BLOOD Calcium-8.4 Phos-5.7* Mg-1.9
Brief Hospital Course:
This is a 24 y.o F with SLE, ESRD on HD and malignant
hypertension
presenting with abd pain, diarrhea, and HTN.
.
# Hypertension: The patient had very high blood pressures on
presentation (200's/100's) that nevertheless are within levels
she's certainly reached during previous admissions. Initial
attempts were made to control her BP with hydralazine and
labetalol IV but after these failed to control her blood
pressure, she was started on a labetalol and nitroprusside drip
and admitted to the ICU. This was then changed to a nicardipine
drip. She was successfully transitioned to home medications of
clonidine, labetalol, aliskiren, nifedipine and hydralazine on
[**3-22**] and transferred to the medicine floor. The next day, her BP
remained within goal of 120's/80's. She was dialyzed and sent
home.
.
Tachypnea/Shortness of breath - On admission, likely due to
pulmonary edema, however, cannot rule out cardiac etiology in
setting of small enzyme leak. Has OSA. CE's were cycled and were
negative. CPAP was continued as tolerated at home settings. SOB
resolved after HD on [**2142-3-21**]
.
# abdominal pain: Consistent with patient's baseline chronic
abdominal pain. Medication effect also possible. CT prelim neg
for small bowel obstruction. LFTs doubled from [**2142-3-18**]. On
arrival to the floor, abd pain was back to baseline and well
controlled on Dilaudid 2mg PO q 4hrs
.
# ESRD: Renal followed. HD given [**3-21**] and [**3-23**]
.
# Coagulopathy: patient on lifetime anticoagulation for hx of
multiple thrombotic events. Continued coumadin
.
# HOCM: evidence of myocardial hypertrophy on Echo. Currently
not symptomatic. Continued labetalol.
Medications on Admission:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4PM.
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for abdominal pain.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea for 4
days.
14. Vancomycin at HD
Discharge Medications:
1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
6. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid () as
needed for Severe HTN.
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
10. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
11. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Discharge Disposition:
Home
Discharge Diagnosis:
SLE
ESRD on HD
Malignant hypertension
Chronic abdominal pain
Discharge Condition:
Good. Tolerating POs. BP 110's/80's
Discharge Instructions:
You were admitted with hypertension and abdominal pain. While
you were here, we treated your hypertension with medications and
dialyzed you. Your hypertension is resolved at the time of
discharge. Your belly pain partially resolved and at time of
discharge is comparable to your chronic belly pain.
.
Please follow up as below.
.
Please continue your medications as prescribed.
.
Please call your doctor or return to the ED if you have any
headaches, lightheadedness, changes in vision, vomitting, blood
in your stool, loss of consciousness or any other concerning
symptoms.
Followup Instructions:
Please follow up with your primary care doctor within 1 week.
You need to schedule an appointment with either your PCP or
OB/GYN for a pap smear as soon as possible. You should also get
a repeat urinalysis and urine culture if you have any UTI
symptoms.
.
Please continue [**Month/Year (2) 2286**] sessions as directed by the nephrology
team- your next session should be on Tuesday.
Completed by:[**2142-3-26**] |
3004,58281,45829,96509,5856,V1251,V5861,V4512,72992,40301,32723,28521,2767,E8502,4466,78097,2875,7100,2762,4254 | 109 | 158,995 | Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
altered mental status, solmolence, and relative hypotension
Major Surgical or Invasive Procedure:
none, HD per schedule on the day of discharge, transfused 1u
PRBC
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of
malignant HTN admitted with change in mental status. Patient
missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic
by mother this morning after she took some dilaudid. EMS was
called, 1 mg of narcan was administered with slight improvement
in mental status. On arrival to the ED her vitals were 112/64
62 16 99RA
she was noted to be hyperkalemic in the absence of EKG changes
and was given calcium, D5, 10U regular insulin, 30 mg po
kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat
glucose was 41 and 1amp D50 was given.
She was sent to the ICU for monitoring.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including [**Month/Year (2) 2286**].
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
HR: 80 (79 - 80) bpm
BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg
RR: 34 (21 - 34) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Physical Examination
Gen: sleeping comfortably, easily awoken by verbal stimuli
HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM
Heart: S1S2 RRR, III/VI SEM throughout the precordium
Pulm: CTA b/l
Abd: NABS, midline scar well-healed, soft, mild L TTP, no
rebound/guarding
Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place
Neuro: following commands, answers appropriately, [**5-15**] motor
strength, sensation is intact
Pertinent Results:
[**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3*
[**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94
MCH-29.1 MCHC-31.1 RDW-19.6*
[**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142
POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22*
HISTORY: Altered mental status. Evaluate underlying for
pneumonia.
UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and
[**2142-2-19**], exams.
Study is slightly limited by patient motion. In the interval,
the degree of
pulmonary edema appears improved with slightly decreased
prominence of the
pulmonary vascularity. There is unchanged extensive retrocardiac
consolidation
obscuring the majority of the left hemidiaphragm with persistent
blunting of
the left CP angle, likely related to small effusion. Exam is
otherwise
unchanged from prior with persistent cardiomegaly. A catheter is
seen
projecting over the abdomen, partially imaged.
IMPRESSION:
Slight improvement in pulmonary edema with persistent
retrocardiac opacity,
which again may represent atelectasis versus underlying
pneumonia.
Brief Hospital Course:
24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and
decreased mental status. Hypotension and altered mental status
were in the setting of excessive narcotic use. Patient's
narcotics were held, pressors returned to [**Location 213**] and patient was
mentating fine. Hct was below baseline and patient was
transfused 1u PRBC and was given HD before discharge. Patient is
to continue anti-hypertensive medications as previously
scheduled. Patient was encouraged to take less pain medications
and to use morphine (already previously written for) rather than
dilaudid for pain control.
# Change in mental status: Resolved, patient took dilaudid this
morning and was noticed to be unresponsive shortly thereafter.
Patient received 1 dose of narcan with slight improvement in BP
and mental status. patient without fevers or leuckocytosis
which argue against infection.
# Hypertension ?????? resumed outpatient regimen. Patient did not
have any hypertensive episodes requiring hydralizine 10mg IV.
# Hypotension: resolved, Patient normotensive on arrival to ICU.
Relative hypotension likely due to dilaudid. Other
considerations include sepsis, although patient without
objective signs of infection. Held pain medications and
hypotension resolved. Resumed hypertensive medications.
# Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ??????
pain under control
patient should use morphine instead of dilaudid
# Hyperkalemia: Likely due to missed HD session. She received
calcium, D5, insulin and kayexalate in ED. HD in am
ESRD: Renal following, had HD the day of discharge, transfused
while there. Will continue normal schedule as an outpatient
with HD T/Th/F this week.
# Metabolic Acidosis: likely due to renal failure and missed HD.
# SLE: continued prednisone at 4 mg PO daily.
# OSA: CPAP for sleep with 7 pressure, however patient refuses.
Continued to offer as inpatient. Should try to follow up with
sleep medicine.
Medications on Admission:
Prednisone 4mg qd
Citalopram 20 mg daily
Gabapentin 300 mg [**Hospital1 **]
Warfarin 4mg daily
Pantoprazole 40 mg qd
Clonidine 0.1 mg/24 QWED
Clonidine 0.3 mg/24 hr QWED
Labetalol 900 mg tid
Nifedipine 90 mg qd
Aliskiren 150 mg [**Hospital1 **]
Hydralazine 100 mg q8h
Morphine 7.5 mg q8h prn pain
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
narcotic overdose
relative hypotension
anemia
Secondary:
ESRD on HD [**2-12**] SLE
malignant hypertension
Discharge Condition:
stable - received HD prior to discharge
Discharge Instructions:
You were admitted for altered mental status after missing
hemodialysis. It was likely from the dilaudid you took as well
as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively
hypotensive in the setting of excessive narcotic medicaiton
usage. Narcotic medications were held and hypotension and
altered mental status resolved. Please use narcotic medications
with caution. You are recommended to use morphine for pain
control rather than dilaudid.
No medication changes were made.
Please return to the ED if you have any altered mental status or
miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or
headache from your history of malignant hypertension.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-3-20**] 3:00
HD as previously scheduled
Completed by:[**2142-2-26**] |
40301,5856,78959,4251,7100,7840,28521,30000,78659,V1251,V5861,V4511,V4578 | 109 | 161,950 | Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Headache, abdominal pain
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with
headache and abdominal pain beginning this morning, awakening
her from sleep. Had been previously discharged from [**Hospital1 **]
yesterday after being admitted for hypertension and abdominal
pain. Has had extensive work-up for abdominal pain including
ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday
she states her abdominal pain had subsided. She had HD
yesterday without complications. She awoke at 6am with a
headache and crampy, stabbing abdominal pain. Took 2mg PO
Dilaudid without relief and came to ED. No nausea/vomiting, no
changes in vision, no fevers, chills, night sweats. No chest
pain, SOB, diarrhea.
In the ED, initial vitals were T98.7, BP260/130, HR70, RR16.
Was initially given 10mg IV Labetalol X 2, 4mg Zofran for
nausea. No improvement in BP and started on Labetolol gtt. Got
1mg IV Dilaudid for pain.
Currently, patient continues to complain of headache and
abdominal pain, both [**7-17**]. No vision changes, chest pain or
shortness of breath. Has been feeling increased anxiety
recently and saw psychiatrist, was put on Celexa.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
T98.2, BP176/135, HR94, RR 22, 100% RA
Gen: well-appearing african-american woman, lying comfortably
HEENT: anicteric, L eye prosthetic non-reactive, R pupil
reactive, MMM, neck supple with submanibular LAD
CV: RRR, II/VI SEM best heard at apex
Pulm: CTA b/l
Abd: hyperactive bowel sounds, midline scar well-healed, soft,
diffusely tender to palpation, +rebound, no guarding. PD
catheter in LLQ without erythema or purulent material draining.
+dullness on percusion with evidence of clinical ascites.
Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial.
R femoral HD [**Last Name (un) **] in place without erythema, purulance
Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper
and lower extremities
Pertinent Results:
Admission labs:
CBC:
[**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5*
MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180
CHEM 10:
[**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136
K-5.2* Cl-106 HCO3-23 AnGap-12
[**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8
COAGS:
[**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3*
STUDIES:
1)Peritoneal fluid ([**11-26**]): negative for malignant cells.
Reactive mesothelial cells, macrophages, eosinophils and
lymphocytes.
2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein
thrombosis of the right or left upper extremity.
3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by
patient motion. T2/FLAIR sequences are unremarkable with
interval resolve of previously noted posterior abnormalities.
The major vessels appear patent proximally. There are stable
areas of low signal in the left frontal and right
occipetal/temporal lobes.
IMPRESSION:
1. Interval resolution of previously noted posterior white
matter
abnormalities.
2. Stable prior areas of hemorrhage within the left frontal and
right
occipital/temporal regions.
3. Very limited MRA as above.
Brief Hospital Course:
24yo F with SLE, ESRD on HD and malignant hypertension who
presented with abdominal pain and headache and was admitted for
hypertensive urgency.
[**Hospital Unit Name 153**] course:
The patient was admitted for blood pressure management and
evaluation of abd pain. An A-line was placed. EKG showed no
change from prior, and Abd x-ray showed a suggestion of RLL/R
diaphragm haziness. IV labetalol was started, and SBPS dropped
from 200s to 130s-160s. The patient had no symptoms of end-organ
damage. The renal team was consulted, and recommended no change
to home med regimen. The patient was found to be hypocalcemic,
and was started on calcium replacement therapy. When stable,
patient succesfully switched to PO meds and transferred to the
floor.
Upon transfer to the floor, the following was her course:
1. Hypertensive Urgency: Pt had had hemodialysis one day prior
to admission, so unlikely that she was volume overloaded.
Unclear what precipitated this episode of hypertensive urgency,
although suspect secondary to abdominal pain leading to an
anxiety which then precipitates hypertension. She may not have
been taking her medications secondary to pain. Negative serum
tox. On the floor, we continued hemodialysis Tu, Th, Sat. She
was initially continued on PO Labetolol 400mg TID, Hydralazine
100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she
received hydralazine 10mg IV for goal BP < 180/100. Renal team
followed patient during this hospitalization. Per renal team
recs, labetalol was increased to 800mg TID due to poor blood
pressure control. Pt discharged on clonidine 0.3mg patch,
Hydralazine 100mg three times a day, Aliskiren 150mg twice a
day, Nifedipine 90mg daily and lobatalol 800mg TID. This
regimen worked well.
2. Abdominal Pain: Extensive prior workup unrevealing. Pt had
recent CT scan during prior admission which did not show source
of abdominal pain. On admission, LFTs were normal except for
slightly low albumin, lipase was slightly elevated and KUB was
negative for free air or evidence of SBO. Peritoneal fluid was
negative for malignant cells but showed reactive mesothelial
cells, macrophages, eosinophils and lymphocytes. Negative gram
stain or peritoneal fluid cultures, excluding SBP as a cause of
the abdominal pain. PD catheter was not removed. Pt was
continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied
N/V/diarrhea or constipation.
3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal
following patient closely throughout this hospitalization. Lytes
were checked frequently and kayexalate given prn.
4. Hx of SVC/brachiocephalic DVT: Pt was initially
subtherapeutic on coumadin. Unclear if she had not been taking
Coumadin although patient reported that she has been taking all
home meds. We started heparin gtt to bridge to Coumadin. Once
therapeutic, continued Coumadin 5mg PO qday.
5. Anxiety: Likely contributing to medical problems and could
have very well been the etiology of this admission. Although pt
stated she was taking her current medications, she did report
increased anxiety which can lead to medication non-compliance
and hypertension. Pt recently saw psychiatrist who started her
on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg
PO q8hours PRN and psychiatry was re-consulted. Per psych recs,
started standing clonazepam. Pt refused psych VNA. Outpatient
PCP followup recommended.
6. Headache NOS: Pt complained of R-sided HA for several weeks,
radiating to R jaw where patient had previous tooth extraction.
Right upper extremity ultrasound was negative for DVT. She
did not have any focal neuro findings, no visual deficits. She
was initially treated with tylenol PRN Q6h; pt requested IV
dilaudid for HA, but use of this medication by IV route was
limited by team. It was felt by the pain service that her HA did
not fit migraine, tension type HA or rebound HA. They
recommended increasing dilaudid to 4-6mg Q6h PRN, continuing
tylenol and starting neurontin 300mg Qhs which was slowly
titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a
neurology consult was also obtained during this admission.
MRI/MRA showed interval resolution of previously noted posterior
white matter abnormalities and stable prior areas of hemorrhage
within the left frontal and right occipital/temporal regions,
but very limited MRA as above. Per pain recs, dilaudid was
further increased to 4mg q4h for better control of her HA.
Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**]
clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**].
7. Anemia: Likely related to ESRD. No evidence of acute
bleeding. Hct remained stable during this hospitalization.
8. SLE: no acute issues. continued Prednisone 4mg PO qday
9. FEN: tolerated regular diet, repleted lytes PRN
9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen
Medications on Admission:
(from prior discharge summary)
Bisacodyl 10mg PO qday PRN
Prednisone 4mg PO qday
Aliskiren 150mg PO BID
Clonidine 0.3mg / 24 hr patch weekly qmonday
Labetalol 400mg PO TID
Warfarin 4mg PO qday
Nifedipine 90mg PO qday
Hydralazine 100mg PO q8H
Hydromorphone 2-4mg PO q4H PRN
Lorazepam 1mg PO q8H
Celexa 20mg PO qday
Prochlorperazine 10mg PO q6H
Colace 100mg PO BID
Hydralazine 25mg PO q30min PRN for HTN
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every [**Year (4 digits) 766**]).
3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMONTH ().
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
[**Year (4 digits) **]:*100 Tablet(s)* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Year (4 digits) **]:*90 Capsule(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for headache.
[**Year (4 digits) **]:*84 Tablet(s)* Refills:*0*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*0*
11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Year (4 digits) **]:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*0*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight
(8) hours.
[**Year (4 digits) **]:*360 Tablet(s)* Refills:*2*
16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertensive Emergency
2. SLE
3. Headache, NOS
4. Abdominal pain
Discharge Condition:
BP better controlled. Headache managed on oral meds
Discharge Instructions:
You were admitted with abdominal pain, high blood pressure, and
headache. Your abdominal pain resolved - no serious cause of
this pain was found. Your blood pressure medications were
continued, and with an increased in one medication, the
labetalol. Your blood pressure improved. You should continue
the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg
three times a day, Aliskiren 150mg twice a day, and Nifedipine
90mg daily. The dose of Labetalol was increased to 800 mg three
times daily by you kidney doctor and you are given a new
prescription. Please take all medications as listed below.
For your headache, you had an MRI and MRA of the head, which did
not show a new or serious abnormality. You were seen by the
neurology and pain services. You should follow up at [**Hospital 878**]
clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in
the evening). Your pain was managed by oral dilaudid, 4mg. You
should take this medication every 4 hours as needed. You were
also started on Gabapentin (also called Neurontin) for the
headache. The dose was slowly increased to twice a day. You
may not need as much dilaudid for your headache and should wean
this medication as tolerated, given it's potential for side
effects (constipation, lethargy, dependence). Finally, you will
likely need medications for constipation while you take
dilaudid. Take colace (a stool softener), senna (a laxative),
and bisacodyl (another laxative), as needed.
It is really important that you have a primary care doctor. You
are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You
will need your INR checked since you are on coumadin.
Call your doctor if you have worsened headache, chest pain,
confusion, or any other concerning symptom.
Followup Instructions:
Please make sure you attend the following doctor appointments:
1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM.
Phone number [**Telephone/Fax (1) 60**].
2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20
3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2141-12-12**] 6:30 PM
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2141-12-2**] |
5856,40301,V4983,58381,3643,7100 | 109 | 164,029 | Admission Date: [**2140-1-19**] Discharge Date: [**2140-1-21**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 22 year old female with SLE, lupus nephritis,
ESRD on HD, malignant HTN, h/o TTP, and HOCM who presents with
HA and hypertensive urgency. Awoke this a.m. with 8/10 left
sided frontal HA - wasn't sure if it was d/t flare of uveitis
that had started on Monday or d/t HTN. Decided to skip HD and
come to ED for evaluation. No vision changes, numbness,
weakness, change in gait, chest pain, SOB. + Diarrhea x 1 day.
.
In ED patient was 217/140 but elevated to 254/152 --> received
labetolol IV 30 mg x 1 and MSO4 4mg and pressures dropped to
SBPs 208 and HA improved. Repeat labetolol with 50 mg x 1 and
repeated dose of morphine dropped pressures to 193/134 -->
labetolol gtt started, asa given, and HA resolved. Head CT
negative for intracranial bleed and CXR unremarkable.
.
ROS: cold for past week, no fevers, chills, CP, SOB, N/V, +
diarrhea.
.
Upon arrival to the floor, patient's BP was 191/126 - labetolol
gtt was not started. No sxs, no HA. She states that she is
compliant with all her meds and her mother cooks with no salt
and she has been adherent to diet.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
-No history of SLE.
-Grandfather has HTN.
-Distant history of DM.
-No history of clotting disorders
-No other history of other autoimmune diseases
Physical Exam:
Vitals: 98.0, 173/51, 86, 15, 100% RA
HEENT: L eye injected w/periorbital edema, R eye reactive w/
EOMI, anicteric sclera; MMM; OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: RRR, NL S1 and S2, + S4, III/VI systolic ejection
murmur @ LUSB radiating to apex and axilla, intensifies w/
Valsalva; no rub
Lungs: CTAB, no wheezes, rhonchi, crackles
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
GU: no CVAT
Ext: warm, 2+ DP pulses, no C/C/E; L femoral dialysis catheter
Neuro: AOx3; CN II-XII intact; strength/sensation grossly intact
Pertinent Results:
UA: mod bld, 100 protein (present on prior UAs)
.
Radiology:
CXR: No acute CP abnormality
.
EKG: NSR, nml axis, nml intervals, borderline LAE, LVH, J point
elevation in V2,V3, TWI I, aVL, V5, V6. No change when compared
to prior on [**2139-11-26**].
.
CT HEAD: No intracranial hemorrhage.
Brief Hospital Course:
A/P: Patient is a 22 year old female with SLE, lupus nephritis,
ESRD on HD who presents with hypertensive urgency.
.
# Hypertensive urgency - Unclear precipitant. Possibly
secondary to pain from worsening uveitis. Compliant with meds.
Denies illicits and tox screen negative. Patient was started on
labetolol drip in ED with good BP response and was subsequently
transitioned to PO anti-hypertensives in ICU with maintenance of
stable SBPs in 150s-170s (baseline 170s-190s). Per
nephrologist's recommendations, home lisinopril was increased to
40 mg po bid from 40 mg po qd for better baseline BP control.
No clinical evidence of end organ damage (UA difficult ro
interpret in setting of CRF). CE's x 1 negative.
.
# Headache - No evidence by CT for intracranial bleed.
Headaches were well controlled with morphine sulfate and had
resolved by time of discharge.
.
# Uveitis - Followed by outpatient optho specialist. Optho not
consulted per patient's request.
.
# ESRD - Secondary to lupus nephritis. On transplant list.
Patient received hemodialysis in house with 500 ml ultrafiltrate
without complications. At dry weight of 45 kg per patient.
Began Sevalamer 800 TID with meals. Given difficulty in
interpreting renin and aldosterone levels in acutely ill
patients, these were not drawn and will need to be drawn at
outpatient follow up.
Medications on Admission:
Lisinopril 40 mg PO QD
Labetalol 600 PO TID
Valsartan 320 mg PO QD
Clonidine 0.3 mg transdermal QW
Prednisone 40 mg PO QD
Atropine 1 % [**Hospital1 **]
Prednisolone Acetate 1 % Q1H
Moxifloxacin eye drops qid
Lorazepam 1 mg PO Q4-6H PRN
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day). Tablet(s)
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q1H (every hour).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day.
10. Blood Pressure Kit Kit Sig: One (1) Kit Miscellaneous
once a day.
Disp:*1 Kit* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Discharge Condition:
Good
Discharge Instructions:
Please take all of your blood pressure medications as
prescribed.
.
You should adhere to a low-salt diet, as increased levels of
sodium can drive your blood pressure up.
.
You are being discharged with a prescription for a home blood
pressure monitor which you can use to take daily measurements.
You should call your primary care physician for [**Name Initial (PRE) **] systolic blood
pressures greater than 180, or if you experience headaches,
nausea, vomiting, chest pain, shortness of breath, or any other
concerning symptoms.
Followup Instructions:
Please resume hemodialysis according to your regular schedule.
.
You are scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] in the Division of
Nephrology on Wednesday, [**2-3**] at 9:30 AM. Please call
[**Telephone/Fax (1) 435**] if you need to reschedule.
.
You are scheduled to follow-up with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2423**], on Tuesday, [**1-26**] at 3:30 PM. Please
call [**Telephone/Fax (1) 250**] if you need to reschedule.
.
You have been referred to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] in the Division
of Hematology for further evaluation of your anemia. This
appointment is scheduled for [**2-9**] at 3 p.m. His office
is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on the [**Hospital1 18**]
[**Hospital Ward Name 516**]. Please call Dr.[**Name (NI) 44536**] administrative assistant,
[**Doctor First Name 8982**], at [**Telephone/Fax (1) 32192**] if you need to confirm or reschedule.
|
V4569,V4589,V451,2859,2875,7100,2841,4254,58281,5856,4010 | 109 | 166,018 | Admission Date: [**2141-3-27**] Discharge Date: [**2141-3-28**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypertensive urgency.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 23 year-old woman with a history of SLE and renal
failure secondary to lupus nephritis, off HD for one year, who
presents with elevated blood pressures.
Patient was in her usual state of health when she presented to
her nephrologist today. At that time appoinment, her blood
pressure was noted to be 240/130. Other than mild nausea, the
patient did not have specific complaints. In particular, she
denied any headache, chest pains, shortness of breath,
palpatations, edema or decreased urine output. She reports
taking her blood pressure medications, as prescribed. Given the
severity of the hypertension, the patient was referred to the ED
for further evaluation.
In the ED, initial blood pressure was 221/134 with a heart rate
of 84. With use of 600mg labetolol, 40mg lisinopril, one inch of
nitropaste, 50mg PO hydralazine, then a labetolol drip, the
blood pressures improved to 160-180 systolic and 90-110s
diastolic.
Currently, the patient feels well other than some mild nausea.
She is somewhat lightheaded. Upon arrival, labetolol gtt and
nitro paste were still on with a SBP in the 140s.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
- ADAMTS 13 negative
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school and has not continued studies due to her
systemic lupus erythematosus. The patient is on disability, and
participates in focus groups. The patient does not drink alcohol
or smoke, and has never used recreational drugs.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VITALS - T 97.4, BP 148/89, HR 90, RR 25, 100% on room air.
GENERAL: Well appearing thin female, in good spirits. Sitting up
in bed in no distress.
HEENT: Prosthesis of left eye. No icteris or palor. No carotid
bruits.
CARDIAC: Regular rate/rhythm. Harsh systolic murmur. Possible
decrease with clenched fists.
LUNG: Clear bilaterally with no rales/wheeze.
ABDOMEN: Soft. Non-tender.
EXT: Warm. No edema.
NEURO: Alert. Oriented x3. Cranial nerves intact (except left
eye extraocular muscles). Sensation intact grossly.
Finger-to-nose normal. Strength 5/5 in all extremities.
SKIN: No rash noted. Nail bed changes with mild pitting noted.
Pertinent Results:
ADMISSION LABS:
===============
C3: 61
C4: 16
137 108 32 AGap=13
------------
4.4 20 6.2
Ca: 8.2 P: 5.2
ALT: 15 AP: 216 Tbili: 0.3 Alb: 3.8
AST: 41 TProt: 6.5
WBC: 3.4
PLT: 93
HCT: 26.5
N:53.8 L:38.2 M:4.5 E:3.0 Bas:0.4
STUDIES:
========
ECG ([**2141-3-27**]): NSR at 85. Normal axis. Normal intervals. LAA.
LVH. No new ST or T-wave changes.
CHEST ([**2141-3-27**]):
1. Patchy retrocardiac opacity, new, which may simply represent
atelectasis. Early pneumonic infiltrate cannot be excluded.
2. No CHF.
Brief Hospital Course:
23 y.o. F with lupus and renal failure [**2-11**] SLE, not on HD x 1
year, HTN, and cardiomyopathy admitted with elevated BPs.
# Hypertensive Urgency: This has been an ongoing issue for this
patient with prior admissions with hypertensive emergency
(seizures, intraparenchymal hemorrhages). In the ER, she was on
a labetalol drip and given nitropaste. On presentation to the
ICU, her blood pressure was below her baseline, and the
labetalol drip was stopped, and the nitropaste was removed. She
was transitioned to PO meds alone. Her labetalol was increased
to 900 mg TID. Nicardipine was increased to 60 mg [**Hospital1 **]. IV
hydralazine was used prn. Goal SBP 160-190 with DBP<110. Her
pressures remained in range during her stay, and she was
discharged on her home medications with instructions to increase
her labetalol to 900 TID.
# ESRD: Secondary to lupus nephritis. Has been off HD for almost
one year. Currently, the plan is for living related donor
(mother). The work-up for this is in progress. There are no
plans for dialysis while awaiting transplant. Renal consult
followed patient throughout hospitalization and assisted with BP
control. She was continued on Vitamin D.
# Thrombocytopenia: At baseline.
# SLE: Continued prednisone. On discharge, she was instructed to
decrease her prednisone to 10 mg daily per renal. PCP [**Name9 (PRE) **]
should be addressed as an outpatient.
# FEN: Repleted lytes prn, renal diet
# PPX: Heparin SQ, bowel regimen, PPI
# CODE: Full
# DISPO: Home with close follow up with renal.
Medications on Admission:
1. Clonidine 0.3 mg/24 hour patchy weekly
2. Hydralazine 50 mg TID
3. Labetalol 600 mg TID
4. Nicardipine SR 60 mg daily
5. Lisinopril 40 mg po BID
6. Valsartan 320 mg po daily
7. Prednisone 15 mg po daily
8. Aranesp 40 mcg/0.4 mL syringe as directed every 2 weeks
9. Vitamin D2 50,000 unit capsule by mouth, one tablet per week
x 5 weeks, then one tablet per month x 5 months
10. Lorazepam po q4 - q6 hours prn (rarely uses)
11. Hydrocortisone 2.5% ointment to affected areas (not
currently using)
12. Tacrolimus 0.1% ointment to affected areas (not currently
using)
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWEEK ().
2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Nicardipine 60 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
6. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO monthly ().
9. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1)
injection Injection every 2 weeks: as directed by your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive urgency
Secondary Diagnosis:
1. End Stage Renal Disease
2. Thrombocytopenia
3. Lupus
Discharge Condition:
Stable. Ambulating. Tolerating po's. Afebrile.
Discharge Instructions:
You were admitted for hypertension urgency. You were treated
with IV medications and then transitioned to medications by
mouth. You were seen by the kidney doctors who helped [**Name5 (PTitle) **] manage
your hypertension. Your blood pressure is now under control. It
is very important that you take your medications as prescribed.
.
The following changes have been made to your medications:
1. Please decrease your prednisone dose to 10 mg daily.
2. Please increase labetalol 900 mg three times a day.
.
Please keep all your medical appointments.
.
If you have any of the following symptoms, please contact your
physician or go to the nearest ER: fever>101, chest pain,
shortness of breath, acute change of vision, abdominal pain,
persistent nausea and vomiting, or any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2141-4-5**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2141-4-10**] 1:00
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2141-4-10**] 3:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2141-3-28**] |
E9320,2518,78909,79500,2874,78701,45829,25200,2767,28521,7100,2841,4538,5856,40301,4592,58281,4254 | 109 | 170,149 | Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Face, Left arm and breast swelling
Major Surgical or Invasive Procedure:
Intravenous Catheterization of SVC/IVC.
History of Present Illness:
23 year old woman with ESRD, SLE, recently placed PD catheter
who presents with periorbital swelling and Hypertensive urgency.
Of note she was recently admitted for tongue swelling on
[**4-7**]. At that time she was treated with Solu-Medrol,
famotidine and Benadryl in the emergency room, which was
continued for a total of three doses on the floor. The swelling
improved throughout her stay. She had been on both an ACE, [**Last Name (un) **]
and DRI at home, which she has been taking for many years.
Patient states that the tongue swelling is most likely due to a
sardine allergy. However, she had recently added Dilaudid to her
medications following PD catheter placement, so allergy to
Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on
the day of admission for ?angioedema but restarted on day of
discharge without incident so she was discharged on them.
She returned to the ED [**5-24**] with acute onset bilateral eye
swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20
Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and
pepcid. Her BP was noted to be 240's despite labetolol 900mg po,
then labetolol 20mg iv x2 so was started on labetolol gtt:
highest dose 2mg/min. This was stopped after 35 minutes, in
favor of nitro gtt. States compliant with meds at home.
Patient was comfortable on admission to the MICU. Notes pain in
abdomen 7.5/10 related to PD catheter placement (has had since
then), improves with morphine. Also notes swelling in eyes/face
since last night (has had in the past but never this severe,
always goes away on its own). She feels whole body is swollen
slightly but no more upper extremities than lower. She denies
visual changes, HA, change in hearing/tinitus, congestion, sore
throat, cough, SOB, chest pain, palpitations, nausea, vomitting,
diarrhea. Has baseline constipation (takes stool softener), last
BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria,
hematuria, change in uop, increase weight or size (clothes fit
the same), tingling, numbness, weakness, discoordination, rash,
joint pain, recent travel, ill contacts, exotic foods. She notes
episode of throat swelling over weekend resolved, seemed to be
related to sardine eating (not new for her).
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient
denies past or current alcohol, tobacco, or illicit drug use.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
ON ADMISSION:
VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA
GEN: NAD
HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival
injection, anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace
non-pitting edema
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
ON [**6-6**]:
-General: AAOx3, in NAD.
-VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on
[**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16,
O2: 98% RA.
-HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally.
-Neck: Supple, No JVD, No tracheal deviation.
-CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R
carotid. JVP not elevated. No S4.
-Lungs: CTAB, no w/r.
-Abdomen: +BS, soft, nontender.
-Extremities: Warm, no lower extremity edema. L arm appears
slightly less swollen than yesterday. Dorsalis pedis and radial
pulses strong bilaterally. No evidence of rashes, ulcers or
varicose veins.
-Breast: L breast still swollen relative to R, but diminished
from initial presentation of swelling. Skin no longer tense.
Pertinent Results:
WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4
RDW-19.7* Plt Ct-114*
- Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2
PT-20.5* PTT-89.9* INR(PT)-1.9*
Fibrino-268
Thrombn-37.4*#
AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68
Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17*
ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137*
Amylase-277* TotBili-0.4
Calcium-6.8* Phos-5.9* Mg-1.5*
Hapto-90
Homocys-37.8*
PTH-1603*
UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili
Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC
[**11-30**] Bact Few Yeast None Epi 0-2
U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet,
Mthdne Negative; UCG: Negative
STUDIES:
Portable CXR [**5-24**]: Small left pleural effusion with associated
atelectasis, although early pneumonia cannot be excluded. No
CHF.
ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change
from [**5-20**].
MRA [**5-24**]:
1. Occlusion of the right internal jugular vein below the
mandible which communicates with external jugular and subclavian
vein. Appearance suggest chronic disease.
2. Patent SVC.
3. Patent but narrowed left internal jugular vein but left
brachiocephalic
vein not visualized (possibly from technique).
4. Bibasilar atelectasis
US upper extremity [**5-26**]:
[**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ,
subclavian,
axillary, brachial, basilic, and cephalic veins were performed.
There is
normal flow, compression, and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
MRV Chest [**5-30**]:
1. Limited study which demonstrates a chronically occluded and
completely
atrophic left brachiocephalic vein.
2. Right internal jugular vein not identified, likely
chronically occluded. Left internal jugular vein is very
diminuitive as before.
3. Large right external jugular vein emptying into the
subclavian vein.
Venogram [**5-31**]:
1. Occlusion of the left brachiocephalic vein at the junction of
the subclavian and internal jugular with extensive collateral
formation consistent with chronic obstruction.
2. Patent left brachial, axillary, subclavian, and distal
internal jugular
vein.
3. Unsuccessful attempt to recanalize the left brachiocephalic
vein using a catheter and guidewire technique.
Brief Hospital Course:
Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN
who presented with acute onset bilateral facial swelling and
hypertensive urgency, which developed into L sided facial, L arm
and L breast swelling throughout her stay.
# L facial/arm and breast swelling: Initially this presented
only as facial swellingand ACE and [**Last Name (un) **] were held for possible
angioedema, however holding medications nad giving benadryl
failed to relieve symptoms. We then suspected possible venous
thrombus with occlusion leading to edema. US of upper left
extremity failed to show evidence of acute occlusion, but showed
R IJ occlusion consistent with prior studies. MRA could not
visualize the L brachiocephalic vein. Repeat MRV suggested
chronic occlusion of the L brachiocephalic vein. Venogram
performed on [**5-31**] showed extensive collateralization of the L
brachiocephalic vein with patent flow through these collaterals.
Intervention on the L brachiocephalic vein was attempted by IR,
but was unsuccessful. The primary team, renal team, [**Month/Year (2) **]
team and hematology team suspect that the most likely etiology
of her swelling is an acute-on-chronic (now occlusive) thrombus
of the L brachiocephalic vein. For this reason, the patient was
placed on Heparin IV as a bridge to coumadin anticoagulation
with goal INR [**2-12**]. Per consult with hematology the patient is to
remain on this regimen for at least 6 months, and will then
revisit as an outpatient the question of possible lifelong
anticoagulation. The patient has had extensive negative testing
for hypercoagulable states, including during this work-up with
negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein
and AT3 antibodies. Protein C and S levels were unremarkable.
Although her clots seem to have all occured in the setting of
lines, her continued thrombosis is likey due to
hypercoagulability from her lupus (in absence of lupus
anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**],
her nephrologist, and then by the coumadin clinic of [**Company 191**]. It
will be especially important that her coumadin be well titrated
given her risk of intracranial bleed with hypertension. This was
communicated tothe patient and she understands and plans to be
compliant with frequent blood draws for INR testing and varying
her coumadin dose as directed.
.
# Hypertension: The patient has chronically labile hypertension,
with frequent episodes of hypertensive urgency over systolic
200, as well as lows as far as the 80s during this admission. It
remains unclear why her blood pressure is so chronically labile.
The hope is that once she starts dialysis this will help to
stabilize her blood pressure, however in the interim various
adjustments were made to her regimen. The patient received
frequent extra doses during her stay (especially of
hydralazine), however, this occasionally causes her blood
pressure to swing too low to tolerate her subsequent standing
dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We
discharged her to home on a regimen that was reviewed with her
nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine
patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po
bid, hydralazine 35mg po tid. These medications were reviewed
extensively with the patient and she was given prescriptions for
all meds. She is discharged with home VNA for blood pressure
checks and assistance with meds. She has purchased a portable BP
cuff and will keep a BP diary to bring to subsequent
appointments as well. The importance of BP control, especially
in the setting of new anticoagulation, was discussed extensively
with the patient. Her goal SBP is 140-160 at this time.
.
# ESRD: The patient has ESRD due to lupus nephritis. PD catheter
was placed before admission and the patient received morphine
prn pain at her catheter site. The renal team followed her
closely throughout her stay. She was treated for hypocalcemia as
well as hyperkalemia. Her regimen was changed to calcitriol
0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol
400units po qday, ergocalciferol 50,000 units po qweek for ten
weeks. She plans to start HD within 1-2 weeks of discharge. She
will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment
to have her catheter flushed and to start PD. She will be
closely followed by Dr. [**Last Name (STitle) 4883**] at PD.
# SLE: The patient was maintained on her home dose of prednisone
15mg po qday throughout her stay. She has no symptoms of acute
SLE flare, so her nephrologist and outpatient physicians may
attempt to wean this down as an outpatient.
.
# abnormal pap smear: The pt is noted to have an abnormal pap
and colpo two years ago with CIN 2 and high risk HPV. This has
never been repeated, as the patient failed to schedule
appointments and DNK others. We discussed the importance of
following this up with the patient, and at her request scheduled
her for an ob/gyn appointment as an outpatient shortly after
discharge.
The patient was discharged to home with a clear plan to call
[**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an
appointment to have her PD catheter flushed later this week, as
well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**]
in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood
drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**],
subsequently this will be faxed to the [**Company 191**] coumadin clinic and
her dose will be adjusted for INR [**2-12**]. We have also given her
the phone number to call [**Company 191**] and establish care with a new PCP,
[**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management
makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**]
coumadin clinic to follow her as well.) Finally, the patient was
given an appointment with ob/gyn to have a follow up pap smear,
as her last pap and colpo two years ago showed CIN 2 with high
risk HPV and this has not been followed.
The above plan and appoitnments were reviewed with the pt and
her mother extensively. [**Name2 (NI) **] medication hcanges were also
extensively reviewed.
Medications on Admission:
Hydralazine 50 mg PO TID
Labetalol 900 mg PO TID
Nicardipine 60 mg Sustained Release PO once a day
Cinacalcet 30 mg PO DAILY: she is not sure if taking
Calcium Acetate 667 mg PO TID W/MEALS
Sodium Bicarbonate 1300 mg PO TID
Aliskiren 150 mg PO once a day (was never taking)
Pantoprazole 40 mg PO once a day
Valsartan 320mg PO DAILY
Lisinopril 40 mg PO bid
Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last
placed
Prednisone 15 mg PO DAILY
Morphine 15 mg Tablet PO Q6H as needed
Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states
not taking
Epo 4,000 units M/W/F: states not taking
colace
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once
a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO qwednesday (): for 10 weeks.
Disp:*10 Capsule(s)* Refills:*0*
8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
Disp:*270 Tablet(s)* Refills:*2*
9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose
to be adjusted by coumadin clinic.
Disp:*120 Tablet(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Disp:*50 Capsule(s)* Refills:*0*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have
result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you
to adjust your coumadin (also called warfarin) dose as needed.
17. Outpatient Lab Work
Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice
per week thereafter until told by coumadin clinic that you can
decrease lab draws. Please have result faxed to the [**Hospital1 18**]
coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust
your coumadin (also called warfarin) dose as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Malignant Hypertension (Hypertensive Urgency)
Acute Exacerbation of Chronic Left Brachiocephalic vein
occlusion
Anemia
Secondary Diagnoses:
SLE
ESRD
Hypertrophic Cardiomyopathy
Thrombocytopenia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for an acute exacerbation of a
chronic left brachiocephalic vein occlusion (a chronically
obstructed large vein closed off entirely) and hypertensive
urgency (very high blood pressure). We attempted to remove the
clot in your left brachiocephalic vein, but were unable to do
so. You have been started on long-term Coumadin (also called
warfarin) therapy to prevent future blood clots and to allow
natural dissolution of your current blood clot.
Please change your medicines to only those you are given here!
There were many changes and it is very important that you stick
to the medication list as you have large, life-threatening
swings in the blood pressure when not taking consistently.
We also treated you for high potassium levels and anemia, and
low vitamin D and calcium levels, which are related to your
kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term
treatment.
Please check your blood pressure three times per day and keep a
blood pressure diary to bring with you to all medical
appointments.
Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed
to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to
adjust your coumadin (warfarin) dose. After that, please have
your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**]
coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a
regular way to adjust your coumadin dose as needed.
MEDICINES FOR BLOOD PRESSURE:
LABETALOL 900mg three times per day (same as before)
HYDRALAZINE 25mg three times per day (lower dose than before)
CLONIDINE PATCH 0.3mg qWednesday (same as before)
NIFEDIPINE SR 90mg twice per day (new medicine!)
**stop taking your lisinopril, nicardipine, Diovan and
Aliskerin!**
MEDICINES FOR RENAL FAILURE:
ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before)
CHOLECALCIFEROL 400 units every day (new)
CALCITRIOL 0.25 mg every day (new)
SODIUM BICARBONATE 1300mg once per day (less often then before)
** stop taking your calcium acetate (phoslo), cinecalcet, and
epo injection (you'll get it at peritoneal dialysis only)**
OTHER MEDICINES:
PANTOPRAZOLE 40mg every day (same as before)
PREDNISONE 15mg every day (same as before)
MORPHINE 15mg every 6 hrs if needed for pain (same as before)
ATIVAN 1mg as needed for anxiety (same as before)
BENADRYL 25mg every 6 hrs if needed for itch (new)
COLACE 100mg twice per day if needed for constipation(same as
before)
APPOINTMENTS:
**1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on
Friday to flush your dialysis catheter and start dialysis next
week!
2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2141-6-30**] 10:00AM
3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**]
Date/Time: [**2141-6-13**] 9:30AM
**4. Please call [**Hospital3 **] next week to make an
appointment with a new primary doctor. I recommend Dr.
[**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT
IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE
FOLLOWED IN [**Hospital **] CLINIC.
**5. Please have your blood drawn as above. Your coumadin level
will be followed by the [**Hospital 197**] clinic. Their phone # is
[**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**].
If you have increased swelling, fever greater than 101,
shortness of breath, chest pain, or if you at any time become
concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to
the nearest ER.
Followup Instructions:
APPOINTMENTS:
**1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on
Friday to flush your dialysis catheter and start dialysis next
week!
2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2141-6-30**] 10:00AM
3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**]
Date/Time: [**2141-6-13**] 9:30AM
**4. Please call [**Hospital3 **] next week to make an
appointment with a new primary doctor. I recommend Dr.
[**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT
IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE
FOLLOWED IN [**Hospital **] CLINIC.
**5. Please have your blood drawn as above. Your coumadin level
will be followed by the [**Hospital 197**] clinic. Their phone # is
[**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**].
Completed by:[**2141-6-17**] |
58281,27541,28529,28521,45829,7243,2767,7100,2762,4254,5855,486,40301,2875 | 109 | 172,335 | Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24yo woman with hx SLE, CKD(not currently on HD or PD), labile
HTN here with right leg pain and HTN urgency. Patient was
recently d/ced on [**9-14**] following admission for the same
complaints.
.
Patient took her hydralazine dose on am of admission. BP at
presentation to the ER was 250/140 (The patient reportedly has
baseline SBPs in 130-170s) She was given 900 labetolol and 50
hydralazine in the ED. BP following this was 175/124. Her EKG
was unchanged. K was 5.7.
.
Patient also complaining of [**10-20**] right hip pain. Patient was
d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this
only for one day due to severe itching. Denies any
parasthesias/weakness. Her RLE/hip pain has been extensively
worked up with negative LENIs, Lumbar spine MRI and hip plain
films in the past. She was given 4mg IV morphine in the ER.
.
On admission to the floor, leg/hip pain somwhat improved with
morphine.She denies any headache, vision changes, double vision,
chest pain or SOB. Feels warm but no chills.
Past Medical History:
Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**]).
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
placement [**5-18**]. Pt reluctant to start PD.
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome.
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN.
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]).
Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]).
- HOCM: Last noted on echo [**8-17**].
- Anemia.
- History of left eye enucleation [**2139-4-20**] for fungal infection.
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
Social History:
Single. Recently moved into her own apartment. On disability.
Denies EtOH, tobacco or recreational drug use.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA
Gen:NAD, happy, pleasant female
HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial
swelling, L side>R, scerla anicteric
Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines
CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy
Pulm: CTA B/L, good inspiratory effort
Abd: +BS, soft, nontender, slightly distended and resonant to
percussion, PD catheter in place in left abdomen
ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile
without pain elicited on passive or active movement
neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4
extremities
psych: mood/affect appropriate
Pertinent Results:
MRI Right Hip ([**9-18**]): There is no signal abnormality on the
fluid-sensitive
sequences in the proximal femur, acetabulum, or other osseous
structure. On T1- weighted images, there is a focal rounded
region within the right femoral head measuring approximately 9
mm in a subchondral location, which is nonspecific but may
represent an unusual focus of red marrow. No sclerosis is seen
on the corresponding plain films. There is a small right hip
joint effusion and a small amount of fluid in the left hip joint
as well, at the upper limits of normal. There is no soft tissue
abnormality, no muscular edema, and no fluid collections.
IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow
edema in the proximal femurs or the pelvis. 3. Nonspecific small
focus of low signal on T1-weighted images in the right femoral
head is nonspecific but may represent an unusual focus of red
marrow.
TTE ([**9-21**]): The left atrium is moderately dilated. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is
identified. 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 stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Mild (1+) aortic regurgitation is seen. There is no
systolic anterior motion of the mitral valve leaflets. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
IMPRESSION: Severe symmetric left ventricular hypertrophy with
hyperdynamic systolic function and mild mid-cavitary gradient.
Mild aortic regurgitation. Moderate pulmonary hypertension.
Findings consistent with hyperrtophic cardiomyopathy.
Compared with the prior study (images reviewed) of [**2140-8-26**],
pulmonary hypertension has developed (also present on the study
from [**2140-5-20**]). Pericardial effusion is also new.
V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views demonstrate no focal defects with improved
ventilation to the posterior right basal segment. Perfusion
images in the same 8 views show improved perfusion to the
posterior right basal segement with a persistent small defect
but no new findings.
Chest x-ray shows cardiomgealy and left basilar atelectasis.
IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to
suggest acute pulmonary embolism.
B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of
the
right and left internal jugular, subclavian, axillary, brachial,
basilic and cephalic veins were performed. There is nonocclusive
focal thrombus seen in the left subclavian vein, where the vein
is not fully compressible. Flow is seen in the region,
indicating that the thrombus is nonocclusive. Elsewhere, normal
flow, augmentation, compressibility were appropriate and
waveforms are demonstrated.
IMPRESSION:
1. Focal nonocclusive thrombus in the left subclavian vein.
2. Otherwise, patent upper extremity veins as described.
[**2141-9-18**] 02:15PM POTASSIUM-5.1
[**2141-9-18**] 02:15PM HCT-21.2*
[**2141-9-18**] 08:45AM POTASSIUM-5.7*
[**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136
POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19
[**2141-9-18**] 07:30AM estGFR-Using this
[**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6
[**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87
MCH-28.1 MCHC-32.4 RDW-18.4*
[**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2
BASOS-0.3
[**2141-9-18**] 07:30AM PLT COUNT-107*
[**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0*
.
[**2141-9-21**] CXR:
There is no significant change when compared to the recent
previous
examination.
The previously described left retrocardiac opacity is unchanged
in appearance.
Cardiomegaly is also unchanged. The mediastinal contour, bony
thorax and
pulmonary vasculature are normal.
IMPRESSION: No significant change compared to study done roughly
7 hours
prior.
Brief Hospital Course:
24 yo with h/o of Lupus, HTN, and lupus nephropathy started on
peitoneal dialysis during this admissionwho was admitted
initially for R hip pain. Patient was on the floor on [**9-20**],
given morphine for the hip pain. She then had an episode of
hypotension and unresponsiveness and transferred to the MICU for
closer monitoring. The patient got 2L IVFs and narcan and
improved, in fact, found to be hypertensive upon arrival to
MICU.
.
MICU Course: On [**9-20**], the patient triggered for hypotension
(82/45), hypothermia (92.9) and altered mental status with
difficult arousability in setting of recent blood transfusion.
Concern was for sepsis, autonomic seizure, transfusion reaction,
pulmonary embolus and/or narcosis. Mental status cleared
somewhat with narcan. Renal c/s felt episode likely [**2-11**]
accumulation of morphine active metabolites. V/Q scan
demonstrated improvement since prior study. Patient's home
prednisone dose was increased from 5 to 15mg with thought that
patient may be stressed in setting of acute illness. She was
febrile on [**9-21**] and resultingly started in vancomycin,
aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was
clear. Urine culture and blood cultures are pending. Patient's
BP was in the 110s so hydralazine was stopped. Her other BP meds
were otherwise continued. Plan was/is to follow renal recs for
PD. If, in 24-48 hours (once cultures have had 48-72 hours to
grow) no source has been located, would d/c antibiotics except
for levofloxacin. Would continue levoflox for total 5 day
course for pneumonia possibly ? aspiration pneumonitis during
episode of altered mental status. If patient has leg pain
again, may consider neurogenic source such a piriformis syndrome
as suggested by neurology. Would add neurontin 100mg TID with
room to titrate up to 300mg TID. Neuro also recommended PT with
TENS unit and referral to pain clinic although patient's pain is
currently absent.
.
FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in
cardiomegaly on CXR, she got an echo yesterday. In addition to
her known HOCM, this showed (1) a small pericardial effusion,
and (2) pulmonary hypertension with an estimated tricuspid
gradient of 50 mm Hg. They probably need to be followed up over
time (particularly the pulmonary hypertension). We did
evaluated the PHTN with a VQ scan which was unremarkable, making
chronic thromboembolic disease much lower on the differential.
It would be good if we could arrange a PULMONARY CLINIC FOLLOW
UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].****
.
She underwent CT head, and V/Q scan which were unremarkable.
Her steroid dose was increased to 15mg given concern for need
for stress dose steroids. After transfer from the MICU, her
steroids were dropped back to 5mg, her home dose with the
approval of [**Last Name (un) **].
.
Her hypotensive episode was thought to be due to a delayed
clearing of the morphine due to her renal failure. Her
hydralazine was discontinued. On day 2 of her MICU stay, she
developed a fever to 102. She was pan-cultured (blood, urine,
peritoneal dialysate) without obvious source of infection.
Broad spectrum abx were started (vanco, cipro, aztreonam (pcn
allergy)) empirically. There was question of retrocardiac
opacity on CXR, though not clear. Rheum consult obtained given
hip discomfort, who felt septic joint unlikely. Neurology
consult obtained who felt autonomic seizure unlikely.
.
Pt initiated peritoneal dialysis. In this setting she has been
having some nausea, which has made taking her home labetalol
difficult, resulting in some rising BPs. She is called out to
medical service for ongoing management and workup of fever,
nausea, and hypertension. Her hip pain has resolved completely
without further intervention.
.
Floor course:
Fever: Spike fever in MICU to 102. Started on Levoquin,
Aztreonam, and Vanc. Source unclear at this point, but CXR with
question of retrocardiac opacity. There is a possibility of
aspiration pneumonitis. Other etiologies include peritoneal
fluid (PD cath), urine, and blood (though patient does not have
any indwelling lines). Hip, due to small effusion, could be
septic arthritis but no pain with movement on exam makes this
less likely. Peritoneal dialysis cultures negative so far.
Continued levo/vanco/aztreonam for 2 days empirically. Then
d/ced the Abx as no infectious etiologies were found. Steroids
back to home dosage. BCx, UCx (final neg), Peritoneal cultures
negative at discharge.
.
# Labile blood pressure: h/o of difficult to control BP with
episodes of hypertensive emergency in the past. Normal SBP runs
in 170s. Having nausea in setting of new PD, no evidence of
intracranial bleeding on clinical exam, though INR had been
supratherapeutic so remains in differential, though not
bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but
difficult for patient to tolerate due to nausea, Aliskiren *NF*
150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch,
hydralazine given hypertensive in setting of nausa.
.
# Right leg/hip pain: no evidence of avascular necrosis or
fracture on MRI though there is a small effusion. Pain resolved
without intervention. Continued to monitor
and would avoid narcotics, restart slowly if pain resumes.
Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed.
Please see consult note.
.
# Hyperkalemia: Chronic issue. Patient takes kayexalate
intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K
but patient did not need it on floor.
# CKD V: Renal following. Did well with PD on [**9-22**] but did
report some nause and cramping. She was not tolerating all 1.5L
in exchanges on discharge.
# Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct
20.1 to 21.9. Likely due to chronic hemolysis consistent with
SLE>
#. Prior SVC thrombus: Physical exam with L arm swelling
consistent with this. No flow limitations. INR 3.5 on ICU
admission. Held warfarin but restarted home 2mg daily the day
before discharge.
# Systemic lupus erythematosus: Home prednisone dose 5mg.
Currently on 15mg in setting of acute illness (day 2).
# General care: FEN: low sodium, renal diet; treatment of
hyperkalemia as above, replete other lytes prn, PD initiated,
Proph: INR therapeutic, no indication for PPI, kayexalate as
needed for hyperkalemia and lactulose prn as per home regimen.
Code: Full code, confirmed with patient Communication: with the
patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2
PIVs
Medications on Admission:
Nifedipine 60 mg PO qhs
Labetalol 900 mg PO tid
Hydralazine 50 mg PO tid
Clonidine 0.3 mg/hr patch qWED
Vitamin D once weekly
dilaudid PO prn
benadryl prn
lactulose 30 ml TID
Aliskiren 150 mg [**Hospital1 **]
Prednisone 5 mg daily
coumadin 2mg PO qday
calcitriol 1 mcg daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Hypertensive urgency
Transient Hypotension due to Narcotics
Sciatica
.
Secondary:
End stage renal disease
Systemic Lupus Erythematosus
Anemia
Discharge Condition:
Stable. Blood pressures at baseline. Hip/leg pain resolved.
Ambulating without assistance.
Discharge Instructions:
You were admitted to the hospital with high blood pressure and
right leg/hip pain. We gave you pain medications and blood
pressure lowering medications. Your blood pressure then dropped
which was caused by the pain medication, and you were
transferred to the Intensive Care Unit(ICU) where you recovered
quickly. During your stay in the ICU, you developed a fever and
were started on antibiotics. However, the cultures that were
obtained were negative, and we discontinued the Antibiotics.
During your hospitalization, your blood pressure normalized on
your home regimen, and your right leg/hip pain resolved. You had
an MRI of your hip done, which did not show an acute infection.
You were seen by the kidney doctors and they recommended
starting peritoneal dialysis. You were also given some blood for
your anemia.
Please follow up with the Peritoneal Dialysis nurse at the
scheduled day/time. Please make an appointment to meet with your
PCP in the next couple of weeks.
Your Hip pain may benefit from physical therapy or outpatient
anesthetic joint injection. Please discuss these options with
your rheumatologist.
.
Please call the number given below to schedule outpatient
physical therapy.
.
Please restart your home medications. You were also started on
Sodium Bicarb 650mg by mouth three times a day.
.
If you develop fevers, chills, trouble breathing, chest pain,
worsening of hip pain, headaches, changes in your vision or any
other symptoms that concern you please return to the emergency
room or call your doctor.
Followup Instructions:
Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on
[**Doctor First Name 766**] [**2141-9-25**]
.
Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2141-9-28**] 10:00
.
Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**]
Completed by:[**2141-9-25**] |
5589,7100,58381,5856,40301,2875,28521,45829,32723,22804,33829,78900,79092,V4511,V1251 | 109 | 173,633 | Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
abdominal pain & hypertension
Major Surgical or Invasive Procedure:
Hemodialysis
PICC Line [**12-11**]
History of Present Illness:
Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD)
from lupus nephritis, chronic intermittent abdominal pain, and
multiple prior ICU admissions for hypertensive urgency who
presented to the ED complaining of two days' of abdominal pain,
nausea, and loose stools. She was feeling well until after her
hemodialysis session on Wednesday. Thereafter, she complained of
nausea with occasional vomitting and has been unable to keep
down any of her oral medications. She also has had diffuse
abdominal pain consistent with her prior flares of pain as well
as her typical diffuse headache. The headache in particular was
worsening and, for her, this is a sign of poorly-controlled
hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the
ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room
air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste,
1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a
labetalol drip which had to be increased up to 2 mg/min. A head
CT showed no acute abnormality (including hemorrhage) and an
abdominal CT showed some possible mild colitis, though it is
unclear if this is due to her recent peritoneal dialysis.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra
Gen: mildly fatigued, but no distress
HEENT: oropharynx clear
Neck: no JVP, no LAD
Chest: clear to auscultation throughout, no w/r/r
CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard
Abdomen: soft, tender diffusely to moderate palpation without
rebound or guarding; hyperactive bowel sounds; no masses or HSM,
PD catheter in palce
Extr: no edema, 2+ PT pulses
Neuro: alert, appropriate, strength grossly intact in all four
limbs
Skin: no rashes
Pertinent Results:
[**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148*
[**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7*
[**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5
[**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138
K-5.3* Cl-105 HCO3-24 AnGap-14
[**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1
[**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3
[**2141-12-10**] 05:10AM BLOOD Lipase-72*
[**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7
[**2141-12-10**] 05:10AM BLOOD Hapto-142
[**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5
Ferritn-220* TRF-106*
ON ADMISSION:
[**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2*
MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158
[**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9
Baso-0.4
[**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3*
[**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5
[**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139
K-4.8 Cl-104 HCO3-26 AnGap-14
[**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3
[**2141-12-7**] 09:50PM BLOOD Lipase-89*
[**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9*
Mg-1.9
[**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8
Cl-101 calHCO3-23
Micro:
Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth
FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2141-12-8**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CT HEAD [**2141-12-8**]:
IMPRESSION:
1. No acute intracranial pathology including no hemorrhage.
2. The hypodensities noted in the parietal white matter are
stable. However
in the setting of the hypertension, PRES cannot be excluded. If
further
evaluation is required MR can be obtained.
CT Abdomin/Pelvis [**2141-12-8**]
IMPRESSION:
1. Moderate amount of free fluid in the pelvis is compatible
with the
patient's known peritoneal dialysis. Unchanged peritoneal
enhancement.
2. Stable liver hemangioma.
CXR [**12-11**]
IMPRESSION: Small left pleural effusion. Left lower lobe opacity
which is
either atelectasis versus pneumonia.
Brief Hospital Course:
24 year old woman with CKD V and severe hypertension due to SLE
admitted with flare of chronic abdominal pain and hypertensive
urgency.
MICU course:
Current plan on transfer
24 year old woman with CKD V and severe hypertension due to SLE
admitted with flare of chronic abdominal pain and hypertensive
urgency.
1. Hypertensive urgency:
The patient was initially maintained on a labetalol drip and
hydralazine iv prn until oral anti-hypertensives lowered her
blood pressure. Initially her blood pressure over-corrected to
SBPs in the 80s (patient was asymptomatic). Her clonidine patch
and hydralazine was held and she again became hypertensive with
SBPs 190s. The patient was restarted on a low dose clonidine
0.1 mg/24 hr patch, and hydralazine. The following dialysis the
patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic
again. Her hydralazine was stopped and continued on all her
other home medications at the advice of renal. The patient was
transferred to the floor on [**12-10**] after resolution of her
hypertensive urgency with a decreased blood pressure regimen due
to her hypotension in response to home doses of her medications.
On [**12-11**] the patient's SBP dropped to the 80's and due to her
pain medications she was extremely lethargic, but arousable. A
PICC line was placed because lack of access and she was bolused
250cc NS. The patient's pressures responded and additional
narcotics were held due to her mental status. The patient's
blood pressures continued to be labile and her clonidine patch
was increased to 0.3mg/24hr and her hydralazine was titrated
back to 100mg daily. The patient did require IV hydralazine prn
for control of her blood pressures initially, but was stablized
back on her home regimen. A possible component to the patient's
malignant hypertension is likely due to OSA. An inpatient sleep
study was performed overnight on [**12-13**] and the patient was sent
home on BiPAP for OSA. The patient was continuned on her
admission hypertensive regimen.
.
2. Abdominal pain: The etiology of her abdominal pain is
unclear, but has been a chronic issue for her. A CT scan was
performed that showed bowel wall changes that are likely
secondary to recent peritoneal dialysis and unrelated to pain.
The patient also had diarrhea, but stool studies were negative.
The patient's pain was initially treated with hydromorphone, but
because of the patient's lethargy on [**12-11**] they were initially
held. She continued to complain of severe abdominal pain. She
was slowly restarted back on her home regimen was 4mg po
hydromorphone q6 as her mental status improved. Surgery was
consulted in regards to removal of her PD catheter, but given
that she may return to PD it was deferred to the outpatient
setting.
3. CKD V from lupus nephritis: The patient was continued on HD
during her admission. She was also continued on her home
prednisone dose. She was closely followed by the renal team.
.
4. History of SVC/subclavian vein thrombus: The patient was
found to have a subtherapeutic INR on admission 1.3. She was
started on a heparin gtt and continued on coumadin. The
patient's heparin gtt was hled on [**12-10**] because of access
issues, but was restarted on [**12-11**] after her PICC line was
placed. She was therapetuic the same day and her heparin gtt
was stopped. On discharge her coumadin was supratherapeutic
(4.7) and was held. She will have her INR checked at HD.
.
5. Anemia: The patient's Hct slowly trended down. She was
guaiac negative and hemolysis labs were negative. She was
transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD.
Medications on Admission:
prednisone 4 mg daily
clonidine 0.3 mg/day patch qWeek
ergocalciferol 50,000 units qMonth
nifedipine SR 90 mg daily
hydralazine 100 mg q8h
citalopram 20 mg daily
warfarin 2 mg qhs
gabapentin 300 mg [**Hospital1 **]
hydromorphone 4 mg q4h prn
clonazepam 0.5 mg [**Hospital1 **]
alikiren 150 mg [**Hospital1 **]
docusate 100 mg [**Hospital1 **]
senna 8.6 mg [**Hospital1 **] prn
acetaminophen prn
labetalol 800 mg q8h
bisacodyl 5 mg daily prn
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
[**Hospital1 **]:*84 Tablet(s)* Refills:*0*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid ().
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed: please take as needed for anxiety prior to CPAP at
bedtime.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
14. CPAP
Home CPAP
Dx: OSA
Prefer: AutoCPAP/ Pressure setting [**5-20**]
Alt: Straight CPAP/ Pressure setting 7
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertensive Urgency
Abdominal Pain
ESRD on HD
SVC Thrombus
Secondary:
Systemic lupus erythematosus
Malignant hypertension
Thrombocytopenia
HOCM
Anemia
History of left eye enucleation
History of vaginal bleeding
Thrombotic microangiopathy
Discharge Condition:
Stable
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of elevated blood
pressure and abdominal pain. You were initially admitted to the
ICU and your blood pressure was controlled. You were stabilized
and transferred back to th floor. Your pressures remained
stable throughout the rest of your stay. Additionally, you had
abdominal pain and diarrhea. Your stool was tested for
infections and was negative. Your diarrhea resolved without
intervention. Your abdominal pain was controlled with pain
medications. You had a sleep study in the hospital which showed
that you had sleep apnea.
Please continue to take your medications as prescribed.
1. Please do not take your coumadin until your doctor tells you
to.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
You will have dialysis at [**Location (un) **] Dialysis on your normal
schedule. You need to go to dialysis on Saturday.
Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 612**]
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
Completed by:[**2141-12-16**] |
V1254,V1251,V5861,34590,53190,28529,32723,44389,28521,2875,7100,78701,33829,78900,4254,3643,58281,5856,40301 | 109 | 174,489 | Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
dyspnea, hypertension
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES,
prior ICH, with frequent admission for hypertensive
urgency/emergency, with chronic abdominal pain. She was recently
discharged on [**7-1**] after presenting for hypertensive urgency and
dyspnea for which she received iv medication in the ED, but was
otherwised managed with oral antihypertensives and CPAP.
.
She was doing well until the evening of [**7-2**] when she notes the
gradual onset of dyspnea. She denied f/c/cp/ha/abd
pain/diarrhea, or constipation. She was having regular, soft,
daily BMs.
.
On [**7-3**] she awoke, and describes n/v x 2, with increasing
dyspnea, and headache. She did not want to wait until dialysis
at 4PM and therefore presented to [**Hospital1 18**].
.
In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT
23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute
process, ECG unchanged from prior. No UA sent, though she does
make some urine. She was started on nitro gtt with modest
improvement of SBPs to 210s, then labetalol 20mg iv x1 followed
by labetalol gtt with BP 221/130 at the time of transfer. She
refused abdominal CT. Renal was consulted, but felt HD not
indicated today.
.
.
ROS: Negative for fevers, chills, chest pain, diarrhea, rash,
joint pains. +n/v as above. +abdominal pain unchanged from her
baseline. +dyspnea, +HA. denies visual changes, slurrring
speech, numbness, weeakness.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Physical Exam:
Vitals - 97.7 88 220/150 19 100%2L BC.
General: A&Ox3. NAD, oriented x3.
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
nonerythematous, MMM.
Neck: supple, no LAD, full ROM.
Lungs: CTA B, with few crackles at bases.
CV: RR, nl S1, S2 +S3, no rubs appreciated.
Abdomen: soft, minimally distended, diffuse mild tenderness to
palpation, negative [**Doctor Last Name **], no rebound, gaurding.
Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema.
Neuro: CN 2-12 intact. moving all four extremities
spontaneously.
Pertinent Results:
Lab Results on Admission:
[**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT
BILI-0.4 ALBUMIN-3.2*
WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4
RDW-18.3*
[**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5
BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2*
[**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58
[**2142-7-3**] CXR:
IMPRESSION: Unchanged moderate cardiomegaly with pulmonary
edema. Again
underlying pneumonia in the lung bases cannot be completely
excluded and
evaluation after appropriate diuresis could be performed if
pneumonia remains a clinical concern.
Brief Hospital Course:
24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome,
PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive
urgency.
.
# hypertensive urgency - On presentation she denies chest pain,
but continues to have mild headache, and resolving shortness of
breath, likely [**2-12**] hypertension. states she did take her PO
meds. Hypertensive urgency was treated as follows with nitro and
labetalol gtt which were quickly weaned as blood pressures
dropped below SBP 120. She evenutally became hypotensive to SBP
of 90 which resolved on its own. She was continued on CPAP
overnight and discontinued in the am. She was continued on her
home regimen of oral labetolol, nifedipine, hydralazine,
aliskerin. She remained normotensive the following morning and
was taken to hemodialysis after which she was discharged home on
all of her old home medications.
.
# abdominal pain - On presentation she was without n/v, soft
abdomen, passing flatus, and having daily bowel movements. She
did have hypoactive bowel sounds on admission. She was
maintained on outpt pain regimen of po dilaudid, fentanyl patch,
lidoacine patch, neurontin with HD with plan to follow BMs
closley. Her pain improved the am of discharge and she had no
further vomiting.
.
# ESRD on HD - She is currently getting HD SaTuTh, though did
not get HD on the day of presenation. As there was no acute
indication for HD on presentation, she received HD on the
following am, day of discharge. She was continued on sevelamer.
.
# anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently
above baseline, though has h/o GIB. She received 2 unit PRBCs
and epo with hemodialysis.
.
# h/o gastric ulcer - she was continued on her outpatient dose
of PPI [**Hospital1 **].
.
# SLE - continue home regimen of prednisone 4mg po qdaily.
.
# h/o SVC thrombosis - pt with goal INR [**2-13**], but this was
stopped after recent admission [**2-12**] supratherapeutic INR. INR
currently sub-therapeutic and she was resumed on warfarin at 3
mg qdaily without heparin bridge.
.
# seizure disorder - continued on keppra 1000 mg PO 3X/WEEK
(TU,TH,SA).
.
# depression - continued on celexa.
Medications on Admission:
1.Nifedipine 90 mg PO DAILY (Daily).
2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime).
3.Lidocaine 5 % PATCH Q24HR.
4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H
7.Prednisone 4 mg PO DAILY (Daily).
8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday).
9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday).
10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
12.Labetalol 1000 mg Tablet Tablet PO TID
13.Hydralazine 100 mg Tablet PO Q8H
14.Warfarin 3 mg Tablet PO Once Daily at 4 PM.
15.Pantoprazole 40 mg PO Q12H (every 12 hours).
16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours.
6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for hypertension.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day). Tablet(s)
14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA
(TU,TH,SA).
Discharge Disposition:
Home With Service
Facility:
VNA
Discharge Diagnosis:
Primary:
hypertensive emergency
anemia, erythropoetin deficiency
Secondary:
chronic renal failure on hemodialysis
lupus nephritis
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted for hypertensive urgency and treated in the
intensvie care unit with IV medications to decrease your blood
pressure. You also received 2 units of blood and hemodialysis
before you were discharged home.
It is essential that you take all of your prescribed blood
pressure medications and present regularly for your Tuesday,
Thursday, Saturday dialysis.
Please return to the emergency department or call your primary
care physician if you develop any chest pain, shortness of
breath, fevers, or any other concerning symptoms.
Followup Instructions:
You have the following appointment scheduled. Please contact
your provider if you are unable to make these appointments.
Your dialysis is scheduled for Tuesday, Thursday, Saturday.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-7-30**] 2:00
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
|
40492,5856,V451,7100,7907,99662,04119,58281,2859,V4578,3643,36019 | 109 | 175,347 | Admission Date: [**2140-5-17**] Discharge Date: [**2140-5-20**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Feeling unwell, Hypertensive urgency
Major Surgical or Invasive Procedure:
dialysis
History of Present Illness:
Pt is a 22 yo female with Lupus, end-stage renal disease on HD,
HTN, multiple other medical problems as below who presents with
feeling unwell and found to be in hypertensive urgency. Pt
states that last Thursday, five days ago, she started to feel
unwell. States that she had chills, no fever, a "weird feeling
in my stomach" with cramps, and no cough. No diarrhea. No
dysuria. Pt missed her dialysis session on Saturday because she
was feeling unwell (3 days ago). Per patient she started to feel
better that day, but today, started to feel unwell with the same
symptoms. No sick contacts.
.
In the ED, VS on arrival were: HR: 73; BP: 222/128, 100% RA. She
was given labetalol 20 mg IV, 40 mg IV, and then started on a
labetaolol gtt.She was also calcium gluconate 1 am IV,
kayexalate 30 mg po x 1, 10 units of insulin IV, and 1 amp of
d50.
.
Of note, pt was recently admitted to [**Hospital1 **] at the end of [**Month (only) 547**] for
Left uveitis/endophthalmitis. She the developed [**Female First Name (un) **]
endophthalmitis and had her L eye enucleation. She states that
she went to her appt at [**Hospital **] 5 days ago. They said
that her eye "looked good" and she was to continue on the same
amount of prednisone that she is on.
.
Her last admission she was also noted to have coag negative
staph bacteremia. She was discharged on 14 day course of
vancomycin but she somehow did not receive this at dialysis. She
has now had 4 sets bld cx + for coag negative staph and was
started on vancomycin.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
No family history of SLE. GF: HTN. No clotting disorders in
family. No history of autoimmune disease.
Physical Exam:
VS: T: 97.8; BP: 203/133; HR: 100; RR: 15; O2: 100 RA
Gen: Speaking in full sentences in NAD
HEENT: Left eye patch. Refuses to let examine/look. Right eye
reactive. Sclera anicteric. OP clear.
Neck: No LAD
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l with good air entry and flow
Abd: Soft, NT, ND.
Back: No spinal, paraspinal, or CVA tenderness
Ext: No edema. DP 2+
Neuro: A&O x 3, MS intact.
Pertinent Results:
EKG: sinus at 75. Normal axis. Normal intervals. Early
repolarization in anterior precordium. No acute changes. LVH.
.
Radiology:
CXR PA/LAT [**2140-5-17**]-
Large-bore inferior approaching right-sided dialysis catheter is
unchanged in position terminating within the right atrium. The
lungs are clear and cardiomediastinal silhouette, hilar
contours, and pleural surfaces are normal. No evidence of
pneumothorax or pulmonary edema.
.
[**2140-5-17**] 06:20AM WBC-7.4 RBC-3.85*# HGB-11.2*# HCT-35.3*#
MCV-92 MCH-29.1 MCHC-31.8 RDW-20.9*
[**2140-5-17**] 06:20AM NEUTS-91.1* LYMPHS-7.7* MONOS-1.1* EOS-0.1
BASOS-0
[**2140-5-17**] 06:20AM PLT COUNT-202
.
[**2140-5-17**] 06:20AM GLUCOSE-100 UREA N-40* CREAT-5.2* SODIUM-138
POTASSIUM-6.3* CHLORIDE-109* TOTAL CO2-18* ANION GAP-17
.
[**2140-5-17**] 04:10PM WBC-5.6 RBC-3.47* HGB-10.3* HCT-31.4* MCV-91
MCH-29.6 MCHC-32.7 RDW-20.6*
.
[**2140-5-17**] 04:10PM CALCIUM-9.1 PHOSPHATE-3.6# MAGNESIUM-2.3
[**2140-5-17**] 04:10PM LIPASE-54
[**2140-5-17**] 04:10PM ALT(SGPT)-20 AST(SGOT)-38 ALK PHOS-74
AMYLASE-267* TOT BILI-0.3
[**2140-5-17**] 04:10PM GLUCOSE-89 UREA N-40* CREAT-4.9* SODIUM-139
POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
.
[**5-17**] and [**5-18**] with blood cultures 4/4 + coag negative
staphylococcus. [**5-19**] and [**5-20**] bld cultures no growth to date.
.
Ecchocardiogram: Severe symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
Moderate resting LVOT gradient. LVOT gradient increases with
Valsalva.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. No 2D or Doppler evidence
of distal arch coarctation. AORTIC VALVE: Normal aortic valve
leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve
leaflets with trivial MR. No MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Echocardiographic results were reviewed with
the
houseofficer caring for the patient.
Conclusions:
The left atrium is elongated. The estimated right atrial
pressure is 0-5mmHg. There is severe symmetric left ventricular
hypertrophy with normal cavity size and dynamic systolic
function (LVEF>80%). Regional left ventricular wall motion is
normal. There is a moderate (25mmHg peak) resting left
ventricular outflow tract obstruction that increased (64mmHg)
with the Valsalva manuever. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. Trace
aortic regurgitation is seen. The mitral valve appears
structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Marked symmetric left ventricular hypertrophy with
dynamic
systolic function and resting LVOT gradient that increased with
Valsalva.
Compared with the prior study (images reviewed) of [**2137-12-4**],
the severity of left ventricular hypertrophy has increased and
trace aortic regurgitation is now identified. Dynamic LV
systolic function and the resting intracavitary gradient are
similar.
.
UE ultrasound
1. Abrupt occlusion of the right internal jugular vein and its
distal most aspect as it joins with the distal subclavian vein.
2. Recanalization of the left subclavian vein with some
peripheral residual clot. Recommend analysis of the SVC,
central subclavians and internal jugular veins with dedicated
magnetic resonance venography, which can be performed without
intravenous contrast for a global assessment of the venous
patency.
Brief Hospital Course:
Pt is a 22 yo female with SLE, ESRD on HD, amongst other
problems who presented with symptoms likely [**2-12**] bacteremia.
Found to be in hypertensive urgency after missing a run of
dialysis. She is now transferred to the floor for further
managment after dialysis x 1 and starting vancomycin.
.
In the MICU she was started kept briely on a labetalol gtt, and
then restarted on her home antihypertensives and dialyzed x 1
with resolution of hypertension. She was found to be bacteremic
and was started on vancomycin. She felt well and was transferred
to the floor.
.
1. Hypertensive urgency- Pt with long history of very
difficult-to-control HTN. She was initially on a labetalol gtt
as above, was dialyzed with resolution of her HTN urgency. She
was then transitioned to her her outpatient medication regimen
of valsartan, lisinopril, clonidine, labetalol, terazosin, and
nicardipine at max doses, but because of persistent HTN to the
180's she was started on hydralazine 50mg po tid on discharge.
.
2. Coag negative staph bacteremia: most likely source is line
sepsis. She was started on vancomycin and her blood cultures
cleared after 2 days in the hospital. The patient felt strongly
about keeping her HD line, which was felt to be reasonable
because her infection was coag negative staph. Ecchocardiogram
did not show any valvular vegitations. She will continue on
vancomycin for 3 weeks at hemodialysis.
.
3. ESRD on dialysis-euvolemic clinically. Had dialysis inhouse.
Continued sevelamer.
.
4. Left uveitis/endopthalmitis-Continued prednisone 30 mg po
qday. Will also continue bacitracin-polymyxin b.
.
5. Lupus- not on any other medications than above.
.
F/E/N- insists on regular diet
.
Access: Right dialysis catheter
.
Prophylaxis: Heparin sc, PPI per outpatient
.
Code Status: Full Code
Medications on Admission:
Nephrocaps 1 CAP PO DAILY
Vancomycin 1000 mg IV HD PROTOCOL
Vancomycin 1000 mg IV X1 Duration: 1 Doses
DiphenhydrAMINE 25 mg PO Q6H:PRN
Labetalol 600 mg PO TID
Heparin 5000 UNIT SC TID
Acetaminophen 325-650 mg PO Q4-6H:PRN
OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN
Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q8H
Terazosin HCl 8 mg PO BID
Gabapentin 100 mg PO QTUESDAY, THURSDAY, SATURDAY
Sevelamer 800 mg PO TID
NiCARdipine 40 mg PO Q8H
PredniSONE 30 mg PO DAILY
Sulfameth/Trimethoprim DS 1 TAB PO QMONDAY, WEDNESDAY, FRIDAY
Lorazepam 1 mg PO Q4-6H:PRN
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Clonidine TTS 3 Patch 1 PTCH TD QFRI
Lisinopril 40 mg PO BID
Valsartan 320 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
Oxycodone SR (OxyconTIN) 70 mg PO Q8H
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMONDAY, WEDNESDAY, FRIDAY ().
4. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Nicardipine 20 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Terazosin 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed.
10. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: 3.5
Tablet Sustained Release 12 hrs PO every eight (8) hours.
11. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY,
THURSDAY, SATURDAY ().
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous per hemodialysis for per hd days: per hemodialysis.
15. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY,
THURSDAY, SATURDAY ().
18. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): 1g Q dialysis.
21. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
Hypertensive urgency
Coagulase negative Staphylococcus Bacteremia
Secondary diagnosis:
Lupus
ESRD
s/p L eye enucleation
Discharge Condition:
Good. Blood pressure is in the 130s-150s systolic. Her vitals
are stable, she is ambulatory, and taking in PO
Discharge Instructions:
Please follow up as below; I have also made a new cardiology
appointment for you
.
Take all medications as prescribed; Other than giving you
vancomycin we have added hydralazine (a blood pressure
medicine), but otherwise we have not changed any of your
medicines. If you have fevers, chills, light-headedness, or
other problems then you should contact your doctor because this
may be a sign that your infection is not resolving.
You should go for hemodialysis as scheduled Saturday where they
should give you vancomycin.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2140-5-30**] 1:00
Dr. [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 60**]
Tuesday [**5-31**] at 3pm with Dr. [**Last Name (STitle) **] in Cardiology.
[**Telephone/Fax (1) 5003**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
9992,5856,40301,4251,7100,45184 | 109 | 176,760 | Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypertensive Urgency and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant
HTN admitted with hypertensive urgency, subjective fevers, and
pain.
.
Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive
urgency. Her nicardipine was changed to nifedipine in hospital
and her labetalol was increased to 900mg TID from 800mg TID.BPs
were reportedly stable in the 140's-170's on the medical floor
on nifedipine, aliskerin, labetalol, clonidine, and hydralazine
prior to discharge. Last HD was [**1-20**].
.
She reports feeling well at time of discharge [**1-20**], however woke
this evening feeling sweaty, hot, and mildly SOB. She did not
check her temperature and denies any rigors. She had total body
aching (worst in her left wrist at site of recent IV and abdomen
at site of known hematoma). +Palpitations overnight now
resolved. No CP, SOB, cough, diarrhea, dysuria,
erythema/tenderness/drainage from HD catheter. Denies recent
joint symptoms with her lupus. No sick contacts. Says she took
her BP meds.
.
Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96%
on RA. She was started on a nicardipine drip, given 1"
nitropaste with improvement in her BP. Did spike a fever while
in the ED, currently 101F 101 173/106 Given vancomycin and zoysn
for ?pna as CXR with right sided haziness. Also received 3mg IV
dilaudid for body pains. LUE ultrasound without evidence of DVT.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA
General Pleasant young woman appearing comfortable
HEENT Cushingoid faces, L eye prosthesis, MMM
Pulm Lungs clear bilaterally, no rales or wheezing
CV Regular S1 S2 ?soft systolic murmur
Abd Soft +hematoma left abdomen unchanged from prior exam
Extrem Warm full distal pulses. Left hand with slight edema ++
tender to palpation of wrist patient unable to make fist
secondary to pain, no erythema +warmth ?purulence at site of old
PIV
Skin No peripehral stigmata of endocarditis
Lines Left groin HD catheter site without erythema, purulence,
or tenderness
Neuro Alert and awake, moving all extremities
Pertinent Results:
CXR [**1-21**]:
In comparison with the earlier study of this date, the diffuse
pulmonary edema has substantially decreased, possibly following
hemodialysis. Enlargement of the cardiac silhouette persists and
there is no definite pleural effusion. Suggestion of an area of
increased opacification at the right base. This could merely
represent asymmetric edema, though the possibility of a
developing consolidation cannot be unequivocally excluded.
.
LUE US [**1-21**]:
IMPRESSION: No DVT in the left upper extremity.
.
L wrist xray [**1-21**]:
There is prominent soft tissue swelling about the wrist,
relatively diffuse, but quite prominent along the dorsum of the
wrist. No fracture, dislocation, degenerative change, focal
lytic or sclerotic lesion, or erosion is identified. No soft
tissue calcification or radiopaque foreign body is identified. A
tiny (1.7 mm) linear density is seen along the dorsum of the
wrist on the oblique view is seen only on that view and is
consistent with a small film artifact.
Brief Hospital Course:
24 yo woman with hx of SLE, ERSD on HD, admitted with
hypertensive urgency and left wrist pain.
.
1. Hypertensive urgency: Patient has an history of malignant
hypertension, with multiple recurrent admissions for
hypertensive urgency. Patient represented the evening after her
discharge from the hospital and was found to be hypertensive to
254/145. She was started on nicardipine drip and 1" nitropaste
and admitted to the ICU for further treatment. There was no
evidence of end-organ ischemia. Upon arrival to the ICU she was
given her usual home antihypertensives and the nicardipine was
quickly weaned off. It was felt that pain and anxiety were both
contributing to her elevated BPs. Her BP quickly stabilized and
she was called out to the medical floor where her SBP ranged
110-150. She was continued on nifepidine 90mg daily, aliskerin
150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and
clonidine 0.3mg + 0.1mg weekly at current doses. Given her
repeated admissions with hypertensive urgency a meeting was held
between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU
physician and her [**Name9 (PRE) **] to come up with a plan for
treatment in order to try and avoid repeated admissions to the
ICU where she quickly improves with simply continuing her home
medications. The following plan was drafted and placed in a
note in OMR titled " Care Protocol".
.
CARE PROTOCOL:
.
BLOOD PRESSURE MANAGEMENT:
.
For BP > 230/140
1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood
pressure back to baseline*.
.
2. Give daily blood pressure medications, if she has not already
taken them before arrival.
.
3. If after one hour of therapy AND/OR evidence of end organ
damage, transfer to the ICU.
.
* Note: Her usual blood pressure is ~ 160/100. Efforts should
not be made to lower blood pressure further, as this may
precipitate end organ hypoperfusion. In the absence of clear
end-organ damage, parenteral blood pressure medications (other
than
hydralazine) are generally not required.
.
PAIN MANAGEMENT:
.
As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4
PRN.This is being slowly tapered, she should not be administered
IV pain medications.
.
ANTICOAGULATION:
.
In the absence of bleeding, warfarin does not need to be stopped
on admission. Similarly, in the absence of new thrombosis,
subtherapeutic INR's do not require bridging with IV UFH.
.
2. Fever: Possible sources included line infection,
thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in
ED for possible PNA. UA without pyuria and urine culture
negative. CXR also without convinving infiltrate on repeat
PA/Lat so zosyn was discontinued. Patient was complaining of
severe pain at her IV site and was noted to have a small abscess
there which was felt to be the cause of her fever. She was
continued on IV vanco with HD for 10day course. She remained
afebrile and did not have a leukocytosis.
.
3. Left wrist pain: Began following IV placement during recent
hospitalization. Likely due to septic thrombophlebitis. Small
abscess was too small to drain. This was treated with warm
soaks and prn PO dilaudid. Vanco was continued for 10 day
course. L wrist films were enremarkable.
.
4. Left abdominal wall hematoma: Stable on exam from recent
admission. She was continued on pain management with morphine
7.5mg TID, gabapentin and tylenol as needed for pain.
.
5. SLE: Continued prednisone at 4 mg PO daily
.
6. ESRD: Continued on regularly scheduled dialysis.
.
7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from
baseline. Secondary to AOCD and renal failure. There was no
evidence of bleeding.
.
8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin.
Continued warfarin.
.
9. HOCM: evidence of myocardial hypertrophy on recent Echo.
Currently not symptomatic. Echo without evidence of worsening
pericardial effusion. Continued beta blocker
.
10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **]
.
11. OSA: Continued CPAP
Medications on Admission:
Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday
Hydralazine 100mg PO q8H
Labetalol 900mg PO TID
Morphine 7.5mg Q8H PRN
Nifedipine 90mg PO daily
Aliskiren 150 [**Hospital1 **]
Prednisone 4mg PO qday
Clonazepam 0.5 mg [**Hospital1 **]
Celexa 20mg PO qday
Gabapentin 300 mg [**Hospital1 **]
Acetaminophen 325-650 mg q6H PRN
Ergocalciferol (Vitamin D2) 50,000 unit PO once a month
Coumadin 4 mg daily
Discharge Medications:
1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
[**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2*
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
[**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2*
4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
[**Hospital1 **]:*270 Tablet(s)* Refills:*2*
5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for pain.
[**Hospital1 **]:*15 Tablet(s)* Refills:*0*
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2*
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 7 days.
[**Hospital1 **]:*4 dose* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Septic thrombophlebitis
Discharge Condition:
Stable, afebrile, BP improved.
Discharge Instructions:
You were admitted to the hospital with hypertensive urgency.
You required IV medications and were observed overnight in the
ICU. Your usual oral blood pressure medications were continued
and your blood pressure remained well-controlled.
You were found to have an infection at your prior IV site on
your left hand. For this you were given IV vancomycin. You
will need 7 days more of antibiotics which will be given with
dialysis.
Please resume your usual dialysis schedule. Your last dialysis
was [**1-23**].
Please continue to take your medications as prescribed. You
should hold your coumadin today. You can resume this on
wednesday at your normal dose. You should have your INR checked
at dialyis as usual on thursday.
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, chest pains,
shortness of breath, nausea, vomiting, or headaches.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks.
|
78659,4430,58889,E8798,58281,40301,4466,99811,5780,5849,7100 | 109 | 183,350 | Admission Date: [**2137-11-4**] Discharge Date: [**2137-11-21**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 44522**]
Chief Complaint:
blurry vision
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 20 year old female with a past medical history
significant for systemic lupus erythematosis who woke on day of
admission with blurry vision. The patient was initially
diagnosed at age 16 when her fingers swelled up and 6 months
later a kidney biopsy confirmed the lupus nephritis. She's been
medically managed on prednisone and had a trial of cytoxan which
she did not tolerate due to nausea and vomitting. Her
hypertension has been controlled with enalopril, atenolol, and
nifedipine until about 7 days prior to admission when she ran
out of medication and for that reason has been non-adherent.
On the day of admission, Ms. [**Known lastname **] called 911 and en route to
this facility developed an intense headache, localizing to the
right temporal region. In the ambulance she was discovered to
have a systolic blood pressure of about 300. Upon arrival at the
ED, she developed chest pain and shortness of breath. Morphine,
labetelol 20 IV, atenolol 50 PO, and enalapril 20 PO were
administered. She was then started on a nifedipine drip. Later,
the nifedipine was weaned for a concern of renal insufficiency
and a NTG drip was started at which point her systolic blood
pressure decreased to 180. A head CT was obtained which was
negative but she did have papilledema per the ED notes. An EKG
showed strain. The patient was admitted to the MICU overnight.
Of note, it was discovered that her creatnine was up to 5 from a
baseline of 1.5.
Past Medical History:
SLE pregnancy termination in [**Month (only) **]
CRI s/p cytoxan Q 3months 2 years ago
HTN
Social History:
lives with Mom and 14 year old brother
does not work but is considering going to college in [**Month (only) 404**]
occasional EtOH, no tobacco, heroin, cocaine
Family History:
aunts with hypertension
grandmother died of myeloma
several men with prostate cancer
Physical Exam:
Vitals: 98.6, BP 142/95, HR 88 RR 20 O2 saturation 100% on RA wt
58.3 kg
Gen: pleasant cooperative watching TV
HEENT: moon facies, PERRLA, MMM, dentition with caries, sclera
nonicteric
CV: RRR II/VI murmur heard throughout the precordium
Pulm: CTAB, no murmurs
Abd: +BS, soft, ND, NT
Ext: WWP, 2+DP bilaterally
Skin: jaws and upper extremities with coalescing annular plaques
with a pink
annular border and an atrophic hyperpigmented center consistent
with discoid
lupus.
Pertinent Results:
[**2137-11-4**] 07:50PM CK(CPK)-55
[**2137-11-4**] 07:50PM cTropnT-0.04*
[**2137-11-4**] 04:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-11-4**] 04:35PM URINE RBC-[**6-20**]* WBC-[**6-20**]* BACTERIA-OCC
YEAST-NONE EPI-[**11-30**]
[**2137-11-4**] 01:15PM GLUCOSE-129* UREA N-31* CREAT-5.2*#
SODIUM-138 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2137-11-4**] 01:15PM LD(LDH)-517* TOT BILI-0.4
[**2137-11-4**] 01:15PM HAPTOGLOB-<20*
[**2137-11-4**] 01:15PM WBC-3.8* RBC-3.32* HGB-8.5* HCT-26.8*
MCV-81*# MCH-25.7* MCHC-31.9 RDW-18.7*
[**2137-11-4**] 01:15PM PLT SMR-VERY LOW PLT COUNT-69*#
[**2137-11-4**] 01:15PM PT-12.3 PTT-28.0 INR(PT)-1.0
RENAL ULTRASOUND: IMPRESSION: Echogenic texture of both kidneys
with nonspecific ill-defined bilateral areas. The arterial and
venous flow are normal and there is no hydronephrosis.
CXR: Cardiac and mediastinal contours are normal. The lungs are
clear. Pulmonary vasculature is normal. The osseous structures
are unremarkable. No CHF
EKG: LV strain and inverted T waves in limb leads
----
ADAMTS13 (VWF Cleaving Protease)
Results Units
Reference Interval
------- -----
------------------
ADAMTS13 Inhibitor <0.4 Inhibitor Units < =
0.4
ADAMTS13 Activity 55 % (low) > =
67
[**2137-11-16**] 02:44PM BLOOD PTH-98*
[**2137-11-17**] 04:12AM BLOOD HBsAg-NEGATIVE
[**2137-11-11**] 02:17PM BLOOD HCG-<5
[**2137-11-5**] 02:31PM BLOOD dsDNA-POSITIVE A
[**2137-11-5**] 11:41AM BLOOD C3-46* C4-8*
[**2137-11-9**] 09:25AM BLOOD SCLERODERMA ANTIBODY-Test
ANTICARDIOLIPIN Ab
ANTI-CARDIOLIPIN IgG : 12.1
0 - 15 GPL
ANTI-CARDIOLIPIN IgM : 8.1
0 - 12.5 MPL
RO & [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] Result Reference
Range/Units
SSA ANTIBODY NEGATIVE NEGATIVE
SSB ANTIBODY NEGATIVE NEGATIVE
Mycophenolic Acid, Serum
Mycophenolic Acid 1.9 1.0 - 3.5
ug/mL
MPA Glucuronide 74 35 - 100
ug/mL
Brief Hospital Course:
Ms. [**Known lastname **] is a 20 year old woman with hypertensive emergency,
lupus nephritis, and TTP vs. malignant hypertension inducing
thrombocytopenia.
HTN: Ms. [**Known lastname **] had a hypertensive emergency, as evidenced by EKG
changes, papilledema, and head CT changes. This was thought
likely secondary to a lupus flare, ARF and poor medication
compliance. She was started back on metoprolol and nifedipine,
but her ACE I was held for the renal failure. The metoprolol was
changed to toprol xl and a clonidine patch were added for better
control and a simplified regimen as there was concern for
patient compliance. Titration of these medications on the
medical floor and addition of hydralazine did not result in
adequate BP control as the patient had several systolic blood
pressure readings in the 250s. She was then transferred to the
intensive care unit for uncontrolled BP accompanied by head
ache. Once there, she received IV antihypertensives and HD was
initiated. Several lbs were taken off, facilitating BP control
with oral medications. She was transferred back to the medical
floor and stabilized on a regimen of clonidine patch Qweek, TID
labetolol, and QD lisinopril.
Rheum: Ms. [**Known lastname **] has SLE with discoid rash and ARF. She was
started on a prednisone burst with calcium supplementation. She
was also started on plaquanil for 1-2 months for her discoid
rash. She will be followed by Dr. [**Last Name (STitle) **] in clinic, who will
arrange for her to see an ophthalmologist. Of note, her
complement levels were low, her DS DNA was positive and her
anti-cardiolipin IgG and IgM were within normal limits.
Renal: Ms. [**Known lastname **] presented with acute on chronic renal
insufficiency. Her rise in creatinine was dramatic, from
baseline of 1.2 in [**Month (only) 958**] to 5.2 at presentation. This was
thought to be multifactorial, from both HTN and an exacerbation
of SLE. Her ACE inhibitor was initially held, and her creatinine
continued to worsen. Of note, her UA remained somewhat bland,
without acanthocytes. Her blood pressure remained difficult to
control, requiring another trip to the MICU for administration
of IV antihypertensives. It was decided that some of this was
attributed to volume overload, so HD was initiated. A tunnel
line was placed and the patient tolerated the procedure and the
HD well. It was thought that the HD would be temporary but that
the patient would eventually progress to ESRD in the near
future. She was also started on mycophenolate mofetil in the
hopes of slowing her progression to ESRD and giving her a few
months before having to start HD as more permanent renal
replacement. She was discharged with instructions to come for HD
Mondays, Wednesdays, and Fridays.
Heme: Ms. [**Known lastname **] presented with ARF, thrombocytopenia, anemia,
and leukopenia. Her haptoglobin was low and LDH was high,
concerning for hemolysis. DIC was considered unlikely since her
coagulation studies were within normal limits but [**Doctor First Name **], TTP/HUS
were considered a possibility. A peripheral smear showed
schistocytes, so the Heme service was consulted, however this
presentation could also be secondary to a malignant hypertension
inducing shearing of erythrocytes and platelets. Her ARF could
be attributed to her hypertension as well. Given the concern for
TTP, the heme service initiated plasmapheresis with the
assistance of the blood bank. The patient had 7 plasmapheresis
treatments, one of which was complicated by symptomatic
hypocalcemia evidenced by abdominal pain. She was plasmapheresed
until her platelets reached 150. Of note, her ADAMST 13 studies
were not consistent with TTP, although these studies are still
investigational. She was also started on folate and iron for her
anemia.
GI: Ms. [**Known lastname **] had one episode of hematemesis during
plasmapheresis. This was comprised of approximately 5 cc of
clots of blood concurrently with a hematocrit drop. With this
concern for GIB, Ms. [**Known lastname **] was transferred back to the MICU
where an EGD showed diffuse linear erythema of the mucosa with
no bleeding in the stomach body. These findings were compatible
with mild gastritis but did not account for the HCT drop. She
was started on a PPI and asked to avoid NSAIDs.
Medications on Admission:
atenolol 50 [**Hospital1 **]
nefedipine and enalopril in unknown quantities
prednisone 10 QD
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: start 30 mg each day for a week after you've
finished your week of prednisone 40 mg.
Disp:*21 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days: start 20 mg each day for a week after you've finished
your week of prednisone 30 mg.
Disp:*7 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): this may turn your stool dark, be sure to take
colace if you need a stool softener.
Disp:*qs Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. 1 blood pressure cuff
please take your blood pressure once per day. Call the doctor if
your blood pressure is 160/100 or greater.
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: start 10 mg each day for a week after you've
finished your week of prednisone 20 mg.
Disp:*7 Tablet(s)* Refills:*0*
11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a month.
Disp:*4 4* Refills:*2*
13. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
16. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
17. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
malignant hypertension with hypertensive emergency
discoid lupus nephritis
acute renal failure
TTP vs. malignant hypertension induced thrombocytopenia
Discharge Condition:
good
Discharge Instructions:
Your new PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2423**]. You can reach her at [**Telephone/Fax (1) 6301**].
Take your blood pressure medications every day. Measure and
record your blood pressure every day. Since you don't yet have a
cuff at home that works, try having your pressure checked at a
pharmacy until you get your own cuff. Please bring your record
to your appointment.
Please come to the [**Location (un) **] of [**Company 191**] [**Hospital Ward Name 23**] on Monday to have
your blood drawn to check your renal function. The lab is open
starting at 7:30 AM.
You will be taking an increased dose of prednisone for now, but
it will be tapered weekly. Please also take your MMF,
nifedipine, clonodine, and labetolol. These medicines are all
available on the Mass Health Formulary and we are working with
case management to accelerate this for you.
Please come to hemodialysis at [**Hospital1 1426**] on [**2137-11-22**].
Please call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] when you get home for an appointment
to schedule the placement of your AV fistula. You should have
this placed as soon as possible. Her number is [**Telephone/Fax (1) 7207**].
Stick to a low salt renal diet as described in the materials
given to you last week. Avoid chinese food, prepared foods, TV
dinners, lunch meats etc.
Your forms have been filled out for the RIDE.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2137-12-18**] 11:00
Provider: [**First Name4 (NamePattern1) 2428**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-12-10**] 3:30
|
44389,5856,40301,58281,4232,4254,78959,4592,2841,4275,V1581,2767,7100,78900,33829,53190,53081,28521,2875,34590,V5861,V1251,2766,62211,32723 | 109 | 189,332 | Admission Date: [**2142-8-28**] Discharge Date: [**2142-8-30**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Dyspnea, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
25F with SLE since age 16, ESRD on HD, malignant HTN, and h/o
PRES, admitted with HTN urgency. Last dialyzed on Saturday [**8-25**].
Pt has had multiple recent admission over past 1 month, most
recently 2 wks ago for HTN urgency and dyspnea. During that
time, she was started on labetalol gtt, with improvement
overnight, and dialyzed on schedule. TTE showed normal EF but
severe LVH, small to mod pericardial effusion w/o tamponade.
.
Pt was feeling well until yesterday AM, when she began c/o gen
weakness and fatigue, w/ worsening DOE, orthopnea. No chest
pain, [**Location (un) **], sacral edema, fevers, cough, n/v/d, or other sx. She
was feeling so unwell that she missed her HD session yesterday
and came to the ED. Says she took all of her BP meds yesterday.
.
In ED, BP was 150s/120 with normal oxygenation on RA. CXR showed
mild pulmonary edema w/o infiltrate; she received levaquin and
vancomycin x1 dose, with labetalol 20 mg IV x1. Then transferred
to MICU.
.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD 3. Malignant hypertension with baseline SBP's
180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Home: lives with mother
Occupation: on disability, previously employed with various temp
jobs
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
No history of autoimmune disease
Physical Exam:
Vitals: 97.9 90 172/128 29 100%RA
General: Age appropriate female in NAD
HEENT: Pupil reactive on right, enucleated eye on left; OP clear
without lesions, exudate, or erythema. Neck supple, no LAD.
Lungs: Minimal bibasilar rales
CV: Nl S1+S2, no m/r/g
Abd: S/ND +bs, TTP throughout. No rebound or guarding.
Ext: No c/c/e. 1+ dp/pt bilaterally
Neuro: AAOx3. CN 2-12 intact. Strength 4/5 bilaterally upper and
lower
Pertinent Results:
[**2142-8-28**] 05:50PM PT-14.1* PTT-37.9* INR(PT)-1.2*
[**2142-8-28**] 05:47PM GLUCOSE-95 LACTATE-1.1 NA+-134* K+-5.4*
CL--102 TCO2-21
[**2142-8-28**] 05:30PM WBC-4.3 RBC-2.73* HGB-7.6* HCT-24.6* MCV-90
MCH-27.9 MCHC-31.0 RDW-18.0*
[**2142-8-28**] 05:30PM NEUTS-81.1* LYMPHS-15.2* MONOS-2.2 EOS-1.3
BASOS-0.1
[**2142-8-28**] 05:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2142-8-28**] 05:30PM PLT COUNT-93*
[**2142-8-29**] 03:48AM BLOOD WBC-4.1 RBC-2.49* Hgb-6.9* Hct-22.5*
MCV-90 MCH-27.6 MCHC-30.6* RDW-18.7* Plt Ct-101*
[**2142-8-29**] 03:48AM BLOOD Plt Ct-101*
[**2142-8-29**] 03:48AM BLOOD Glucose-91 UreaN-55* Creat-7.6* Na-132*
K-6.0* Cl-102 HCO3-22 AnGap-14
[**2142-8-29**] 03:48AM BLOOD Calcium-8.8 Phos-5.4* Mg-2.2
.
CXR: [**2142-8-28**]
AP VIEW OF THE CHEST: Severe cardiomegaly is stable. There are
bilateral hazy perihilar opacities with mild upper zone vascular
redistribution compatible with mild pulmonary edema, worse in
the interval. Small left pleural effusion is stable. There is a
retrocardiac opacity, likely representing atelectasis. No
pneumothorax is visualized. The osseous structures are
unchanged.
IMPRESSION: Mild pulmonary edema, slightly worse compared to
prior.
.
ECHO [**2142-8-29**]: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is severe symmetric left
ventricular hypertrophy with normal cavity size and
regiona/global systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a small circumferential
pericardial effusion without evidence for hemodynamic
compromise.
Compared with the prior study (images reviewed) of [**2142-8-13**], the
estimated pulmonary artery systolic pressure is higher and the
pericardial effusion is minimally larger.
.
Brief Hospital Course:
25F with SLE since age 16, ESRD on HD, malignant HTN, and h/o
PRES, admitted with HTN urgency and dyspnea, probable volume
overload.
# Dyspnea: On admission was thought secondary to volume overload
given exam and CXR consistent with increased pulmonary vascular
congestion. Less likely to be infiltrate lack of radiographic
infiltrate, leukocytosis, or increased sputum production, so
antibiotics were not continued. Pt has small cardiac effusion
likely chronic serositis?????? may be contributing to dyspnea and
resulting in a restrictive physiology. She received a repeat
ECHO showed only a mild enlargement of this effusion (no
tamponade) and there were no concerning EKG changes. She was
treated with [**Year (4 digits) 2286**] and was transferred to the floor in stable
condition.
Unfortunately on [**2142-8-30**] while in the [**Date Range 2286**] unit pt became
hypotensive with SBP in 60s. Pt was given 2L NS boluses without
significant improvement in SBP. She was drowsy but able to
converse. EKG showed sinus rhythm. During the 3rd L of fluid,
pt became unresponsive and appeared to be having respiratory
distress. A Code Blue was called at that point and when a pulse
was checked, it was absent. Resuscitation efforts for PEA
arrest were initiated. She underwent a prolonged code with
appropriate interventions for PEA arrest; due to concern for
possible PE (she had known SVC thrombosis and had not been
anticoag due to noncompliance), she even received TPA.
Unfortunately, all efforts to resuscitate the patient were
unsuccessful. Her mother who is a [**Hospital1 18**] employee was contact[**Name (NI) **]
in the beginning of the code and was able to be present with her
several times during the resuscitation. She received emotional
support from our social worker, several [**Name (NI) 10945**] nurses, as well as
her work colleagues.
Her mother did agree to an autopsy evaluation, results pending.
Her nephrologist Dr. [**Last Name (STitle) 4883**] was notified of her death by one
of his colleagues.
Medications on Admission:
Protonix 40 mg po bid
Clonidine 0.4 mg mg/24hr patch
Nifedipine SR 90 mg Daily
Aliskiren 150 mg po bid
Citalopram 20 mg daily
Prednisone 4 mg daily
Lidocaine patch daily - 12 hours on 12 hours off
Sevelamer 400 mg po tid with meals
Gabapentin 100 mg QHD
Labetalol 1000 mg po tid
Hydralazine 100 mg po Q8H
Hydromorphone 2 mg tabs, 1-2 tabs Q4H prn
Levetiracetam 1000 mg po QT,R,Sa
Senna 1 tab po bid prn
Colace 100 mg po bid
Alprazolam 0.25 po bid prn
Acetaminophen 325 mg, 1-2 tabs Q6H prn
Hydralazine 100 mg po prn for SBP>100
Discharge Medications:
none - pt deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest, respiratory failure
Dyspnea
Hypertensive urgency
Secondary Diagnoses:
- Systemic lupus erythematosus
- End Stage Renal Disease on [**Last Name (STitle) 2286**]
- Malignant hypertension
- Thrombocytopenia
- SVC thrombosis
- HOCM
- Anemia
- History of left eye enucleation [**2139-4-20**] for fungal infection
- h/o vaginal bleeding [**2139**] s/p DepoProvera injection
- Coag neg Staph bacteremia and HD line infections [**6-16**], [**5-17**]
- Thrombotic microangiopathy
- Obstructive sleep apnea on CPAP
- Left abdominal wall hematoma
- MSSA bacteremia associated with HD line [**Month (only) 956**]-[**2142-3-11**].
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2142-9-6**] |
40301,5856,7100,7907,4254,99662,99812,36001,11289,V5865,7821,28521,37900,37632,37005,36400 | 109 | 193,281 | Admission Date: [**2140-4-7**] Discharge Date: [**2140-5-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Left Eye Enucleation
History of Present Illness:
22 y/o female Lupus, ESRD, malignant HTN, who presents to the ED
with headache and hypetension after getting HD. On arrival to ED
patient's BP was 235/130. She got 10mg of hydral, 20mg of
lopressor, 0.2 of clonidine with no improvment of blood
pressure. She was started on labetolol gtt and SBP remained at
267. She was then started on nipride gtt and blood pressure
reduced to 161/104. Patient denied any chest pain, shortness of
breath, or abdominal pain. Her EKG done in the ED showed no new
changes just c/w LVH. has been using a lower dose clonidine
patch because the pharmacy did not have 0.3mg clonidine patch.
Otherwise she states no change or missed doses of her
medication. Patient HA localized to behind her L eye. She states
that this is her typical uveitis pain that she gets.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
-No family history of SLE.
-Grandfather has HTN.
-Distant history of DM.
-No history of clotting disorders
-No other history of other autoimmune diseases
Physical Exam:
PE: T 98.6 BP 190/106 HR 90 O2Sat 100% RA
Gen: Patient holding cloth on forehead
Heent: OP clear, MMM; L eye: eyelid swollen with watery
discharge, + scleral injections. no vision in left eye
Lungs: CTA B/L
Cardiac: RRR S1/S2 grade III/VI SEM
Abd: soft NT NABS
Ext: no edema; Left fem dialysis line in place
Neuro: AAOx3, normal MS, sensory intact
Pertinent Results:
[**2140-4-7**] CT HEAD: 1. No evidence of acute intracranial
hemorrhage.
2. Hyperdensity and abnormal configuration of the left globe,
most amenable to direct inspection. The appearance is changed
from [**2140-1-11**], though it appears similar to a prior scan of
[**2138-4-11**].
.
[**2140-4-7**] ECG: Sinus rhythm. Left ventricular hypertrophy.
Anterolateral T wave changes are probably due to left
ventricular hypertrophy. Compared to the previous tracing of
[**2140-2-5**] no significant change.
.
[**2140-4-11**] ECG: Normal sinus rhythm. Voltage criteria for left
ventricular hypertrophy. Non-specific T wave flattening.
Compared to the previous tracing of [**2140-4-7**] no diagnostic
interim change.
.
[**2140-4-12**] ECG: Normal sinus rhythm. Compared to tracing #1 no
diagnostic interim change.
.
[**2140-4-17**] MR BRAIN/HEAD: 1. Left globe subchoroidal and vitreous
hemorrhage with possible retinal detachment; lens not clearly
visualized, which could be due to resorption/displacement.
Patient needs ophthalmologic examination, for better evaluation.
2. No evidence of cerebral venous sinus thrombosis.
3. Hypoplastic left transverse, sigmoid, anterior-superior
sagittal sinuses, and inferior sagittal sinus.
4. Prominent ventricles, likely due to parenchymal involution
from chronic disease; no associated white matter changes.
.
[**2140-4-18**] 8:57 pm EYE Source: Superficial.
GRAM STAIN (Final [**2140-4-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH.
.
[**2140-4-7**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2140-4-7**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2140-4-7**] 03:00PM URINE RBC-[**3-14**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-[**3-14**]
[**2140-4-7**] 05:55PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
[**2140-4-7**] 03:00PM BLOOD WBC-6.2 RBC-4.82 Hgb-13.4 Hct-43.1 MCV-89
MCH-27.9 MCHC-31.2 RDW-19.0* Plt Ct-163
[**2140-4-7**] 03:00PM BLOOD Neuts-75.0* Lymphs-18.4 Monos-2.2 Eos-3.2
Baso-1.3
[**2140-4-7**] 03:00PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+
[**2140-4-7**] 03:00PM BLOOD Plt Ct-163
[**2140-4-7**] 03:00PM BLOOD Glucose-83 UreaN-11 Creat-2.6*# Na-140
K-3.9 Cl-98 HCO3-33* AnGap-13
.
[**2140-4-19**] 08:17AM BLOOD WBC-4.9 RBC-3.88* Hgb-10.7* Hct-33.1*
MCV-85 MCH-27.5 MCHC-32.2 RDW-17.9* Plt Ct-215
[**2140-4-19**] 07:30AM BLOOD WBC-5.6 RBC-4.31 Hgb-11.6* Hct-38.0
MCV-88 MCH-27.0 MCHC-30.6* RDW-17.9* Plt Ct-229
[**2140-4-19**] 08:17AM BLOOD Plt Ct-215
[**2140-4-19**] 07:30AM BLOOD Plt Ct-229
[**2140-4-19**] 08:17AM BLOOD Glucose-89 UreaN-43* Creat-4.1* Na-139
K-4.3 Cl-102 HCO3-25 AnGap-16
[**2140-4-19**] 07:30AM BLOOD Glucose-78 UreaN-47* Creat-4.5*# Na-133
K-5.2* Cl-95* HCO3-23 AnGap-20
[**2140-4-19**] 08:17AM BLOOD Calcium-10.0 Phos-4.1 Mg-1.9
[**2140-4-19**] 07:30AM BLOOD Calcium-11.5* Phos-5.2* Mg-2.1
.
[**2140-4-7**] 03:00PM BLOOD Neuts-75.0* Lymphs-18.4 Monos-2.2 Eos-3.2
Baso-1.3
[**2140-4-7**] 03:00PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+
[**2140-4-11**] 04:04PM BLOOD CK(CPK)-13*
[**2140-4-11**] 04:04PM BLOOD CK-MB-3 cTropnT-<0.01
[**2140-4-17**] 07:10PM BLOOD PTH-71*
[**2140-4-17**] 09:56PM BLOOD Type-ART pH-7.30*
[**2140-4-17**] 09:56PM BLOOD freeCa-1.35*
.
Brief Hospital Course:
1) Malignant HTN: Pt on lisinopril, valsartan, clonidine patch,
labetolol, nicardipine as an outpatient with a baseline bp
160s-180s/80s-100s. Pt was in the ICU intermittently on a
labetolol drip. Labetolol was increased and terazosin added and
titrated up. Her hypertension was exacerbated by left eye
pain/headache, which was managed as below. Plasma metanephrines,
Renin, aldosterone pending.
.
2) Left Uveitis/endophthalmitis: The patient was evaluated by
ophthomology, who noted normal OCP and felt her findings were
consistent with uveitis. She was treated with
atropine/prednisolone eye drops. Neurology was consulted to
assist with evaluation of other causes of headache; they felt
her symptoms were also most likely secondary to uveitis. She had
a MRI/MRV of her head which was without evidence of sinus
thrombosis. She required high doses of narcotics. She developed
[**Female First Name (un) **] endophthalmitis, sent for L eye enucleation [**4-20**] given
risk for autoimmune attack in contralateral eye. She is to have
daily eye dressing changes with a sterile eye patch and
bacitracin ointment. She will follow up with oculoplastics at
[**Hospital 13128**] and follow up with her ophthalmologist. She
will continue prednisone 30 mg daily for the next 3 days then
taper to 20 mg daily until her ophthalmology follow up. She was
seen by ID and will also follow up with Dr. [**First Name (STitle) **]. She was
started on bacrim ppx while on prednisone.
.
3) EXRD: Tues/Th/Sat dialysis; continue sevelamer. Follow up
with Dr. [**Last Name (STitle) 4883**].
.
4) Forearm rash: She will apply eucerin lotion and follow up
with Dr. [**Last Name (STitle) **] of dermatology [**5-30**].
.
5) SLE: Continue prednisone, mycophenolate.
.
6) code Full
Medications on Admission:
CellCept 500mg [**Hospital1 **]
Clonidine 0.3mg/24 hour
Diovan 320mg daily
Labetolol 600mg tid
Lisinopril 40mg daily
Ativan 1mg prn
Nicardipine 40mg q8
Prednisone 40mg daily
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
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. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*2*
8. Nicardipine 20 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
9. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUTHSA
(TU,TH,SA).
Disp:*30 Capsule(s)* Refills:*2*
11. Terazosin 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
12. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
Disp:*qs 1 month* Refills:*2*
13. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO three times a day: take with 3
10 mg tabs for a total of 70 mg tid.
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
14. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO once a day: Take with 40
mg tab for a total of 70 mg tid.
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
15. Eucerin Lotion Sig: One (1) app Topical twice a day.
Disp:*qs 1 month* Refills:*2*
16. EYE PAD Pad Sig: One (1) sterile pad Miscellaneous once
a day.
Disp:*30 pads* Refills:*2*
17. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*450 Tablet(s)* Refills:*2*
18. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
19. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Take 3 tabs daily for next 3 days, then take 20 mg daily
until your ophthalmology follow up.
Disp:*60 Tablet(s)* Refills:*2*
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
22. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
qHD for 12 days.
Disp:*12 g* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
[**Female First Name (un) 564**] Endophthalmitis s/p Enucleation Left Eye
Malignant Hypertension
Bacteremia
End Stage Renal Disease
Discharge Condition:
stable
Discharge Instructions:
Continue your medications as listed. Please continue to change
your eye dressing with bacitracin ointment and a sterile eye pad
daily as assisted with VNA. Please make sure you follow up with
Dr. [**Last Name (STitle) 12044**] and Dr. [**First Name (STitle) 4702**] of ophthalmology as well as your PCP
and nephrologist.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**Name12 (NameIs) 280**] Date/Time:[**2140-4-21**] 3:20. This
appointment is in your PCP's office to review your pain
medication. [**Hospital Ward Name 23**] Building, [**Location (un) **], south suite.
[**Telephone/Fax (1) 250**]
2. Please follow up with Dr. [**Last Name (STitle) 12044**] of oculoplastics as
directed.
3. Please also follow up with Dr. [**First Name (STitle) 4702**] of ophthalmology in 2
weeks.
4. Please follow up with Dr. [**Last Name (STitle) 4883**] in [**1-12**] weeks.
5. You can follow up with Dr. [**Last Name (STitle) **] of dermatology in the
[**Last Name (un) 469**] [**Location (un) **] clinic on Monday [**5-30**] at 1pm to assess
your forearm rash.
|
4254,7907,99662,78959,58281,5856,40301,4239,E9289,4592,7100,78900,33829,04119,7861,9951,2875,28521,32723,44389,28529,53190,34590,7931,E8798,V5861,V1251,V1254 | 109 | 196,721 | Admission Date: [**2142-7-12**] Discharge Date: [**2142-7-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dyspnea, hypertension
Major Surgical or Invasive Procedure:
1. Ultrasound Guided Tap
2. Venogram
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old female with a history of SLE, ESRD on
HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with
frequent admission for hypertensive urgency/emergency, with
chronic abdominal pain that presented to the ED [**7-12**] with
critically high blood pressure and dyspnea. She was recently
discharged on [**7-8**] for hypertensive urgency and dyspnea. She
was treated with labetolol gtt, [**Month/Year (2) 2286**], and her home
medications with improvement of her BP. She was discharged home
in stable condition on [**7-8**]. She had been doing well at home,
but missed her HD session on [**7-10**] due to transportation issues.
She has been taking her medications without any difficulty. On
the morning of admission, she noted increase dyspnea, and had a
dry cough, although this is not particularly new. She presented
to the ER for dyspnea. She continues to have the chronic
abdominal pain which is unchanged, and is controlled right now.
In the emergency department, VS= 98.1, 240/140, 128, 30, 96%RA.
On initial evaluation, she was noted to have SBP 70s on the
right arm, 240s on the left arm. She did not complain of any
pain. She underwent CTA torso to eval for dissection which was
negative for dissection or PE. The imaging showed persistent SVC
thrombus. There was also note of bilateral ground glass and
nodularities therefore was given levofloxacin 750 mg IV x 1. She
was given labetalol IV, then started on a labetalol gtt. Her BP
remained elevated, therefore she was transferred to the ICU for
BP control and then [**Month/Year (2) 2286**]. She was also given dilaudid 1 mg
IV x 1 as well.
Ms. [**Known lastname **] was taken to the MICU and treated for malignant
hypertension. She was given hemodialysis and her blood pressure
stabilized. She was transferred to the medical floor. She
continued to receive [**Known lastname 2286**] Tuesday, Thursday, and Saturday.
On [**7-16**], she had a paracentesis of her abdomen. She is
complaining of focal tenderness around the point of insertion.
On [**7-17**], she was transferred back to the MICU because of stridor
that was treated with Heliox. She was stabilized, and came back
to the floor on [**7-19**]. On [**7-19**], Ms. [**Known lastname **] had a venogram. On
[**7-23**], an angiography intervention for an occlusion of her left
brachiocephalic vein was discontinued because her occlusion was
not as drastic as prior imaging indicated when tested with a 22
gauge needle. Ms. [**Known lastname **] was discharged on [**7-23**] with stable
blood pressures and abdominal pain controlled.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD 3. Malignant hypertension with baseline SBP's
180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Physical Exam:
General: A&Ox3. NAD, oriented x3.
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
Neck: supple, no LAD
Lungs: CTA B, with few crackles at bases.
CV: RRR, S1, S2
Abdomen: soft, minimally distended, diffuse mild tenderness to
palpation
Ext: palpable DP/PT pulses, no clubbing, cyanosis or edema.
Neuro: CN 2-12 intact. moving all four extremities
spontaneously.
Pertinent Results:
[**2142-7-22**] 07:50AM BLOOD WBC-2.8* RBC-2.51* Hgb-7.3* Hct-23.1*
MCV-92 MCH-29.1 MCHC-31.8 RDW-21.1* Plt Ct-134*
[**2142-7-21**] 10:30AM BLOOD WBC-3.5* RBC-2.36* Hgb-6.8* Hct-21.6*
MCV-92 MCH-28.9 MCHC-31.6 RDW-20.5* Plt Ct-121*
[**2142-7-22**] 07:50AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3*
[**2142-7-22**] 07:50AM BLOOD Glucose-154* UreaN-20 Creat-4.4* Na-138
K-4.0 Cl-103 HCO3-23 AnGap-16
[**2142-7-21**] 10:30AM BLOOD Vanco-17.8
[**2142-7-20**] 09:35AM BLOOD WBC-3.8* RBC-2.39* Hgb-7.0* Hct-21.6*
MCV-90 MCH-29.2 MCHC-32.4 RDW-19.8* Plt Ct-120*
[**2142-7-19**] 12:30PM BLOOD WBC-3.6* RBC-2.49* Hgb-7.0* Hct-22.5*
MCV-90 MCH-28.3 MCHC-31.3 RDW-18.8* Plt Ct-121*
[**2142-7-20**] 09:35AM BLOOD Plt Ct-120*
[**2142-7-20**] 09:35AM BLOOD PT-19.7* PTT-38.4* INR(PT)-1.8*
[**2142-7-19**] 12:30PM BLOOD Plt Ct-121*
[**2142-7-19**] 12:30PM BLOOD PT-29.5* PTT-43.9* INR(PT)-2.9*
[**2142-7-20**] 09:35AM BLOOD Glucose-90 UreaN-19 Creat-4.2*# Na-138
K-4.2 Cl-102 HCO3-25 AnGap-15
[**2142-7-19**] 12:30PM BLOOD Glucose-72 UreaN-34* Creat-6.0*# Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2142-7-19**] 12:30PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6
[**2142-7-18**] 05:44AM BLOOD Calcium-8.9 Phos-5.1* Mg-1.7
[**2142-7-12**] 12:27PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**Last Name (un) **]
[**2142-7-12**] 12:27PM BLOOD C3-69* C4-17
[**2142-7-19**] 12:30PM BLOOD Vanco-16.7
[**2142-7-17**] 08:57AM BLOOD Vanco-15.9
[**2142-7-14**] 04:16AM BLOOD Vanco-19.2
[**2142-7-17**] 07:27AM BLOOD Type-ART pO2-66* pCO2-52* pH-7.30*
calTCO2-27 Base XS--1
[**2142-7-12**] 02:06PM BLOOD Lactate-1.0
Brief Hospital Course:
24 y/o female with h/o SLE, ESRD on HD, malignant HTN, h/o SVC
syndrome, PRES, prior ICH, and recent SBO, presented to ED on
[**7-12**] for dyspnea and hypertensive urgency.
1. hypertensive urgency - pt presented to ER with SBP in 240s
and c/o dyspnea. Her blood pressures were reported as unequal
and CTA in ER was done. This study showed no signs of
dissection. Pt's blood pressure was controlled with labetalol
gtt. At time of transfer, she denied CP and SOB. CE's were
flat. She was started on her home BP regimen of oral labetalol
on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after
admission. Pt was also continued on her HD regimen for ESRD,
for volume control.
.
2. angioedema - pt developed facial swelling and shortness of
breath while on medical floor. She was taken to ICU and
responded favorably to Heliox. Patient returned to floor and
has been comfortably breathing since. Given history of SVC,
venogram was ordered that did not indicate a complete occlusion
of the left brachiocephalic vein, as previously thought, with
help of 22 gauge needle.
3. cough: pt presented with chronic cough/dyspnea without
fevers. Chest CT revealed bilateral infiltrates and
nodularities, noted possibly infectious vs edema. Pt was started
on vanc/zosyn given recent hospitalization, brief temp spike,
and pulm infiltrates. Abx were stopped after cultures were neg.
At time of transfer, pt's dyspnea was largely resolved and these
findings were felt to be more consistent with edema given
hypertensive urgency.
.
4. chronic abdominal pain - pt has had chronic abdominal pain,
which was well controlled at time of transfer. She was continued
on her current outpt pain regimen of po dilaudid, fentanyl
patch, lidoacine patch. Her LFTs and lipase were wnl. She had no
signs of SBO.
.
5. bacteremia - GPC in pairs and clusters; started on vanco on
[**2142-7-12**].
.
6. Ascites - unclear etiology and new findings for her. Pt is
to get workup with liver team as outpatient. Her [**Date Range 2286**] seems
to have slightly improved this finding. Her coags were
unremarkable. She was seen by Hepatology in house who did not
have any specific recommendations at this time but asked to see
her in follow up as an outpatient.
.
7. ESRD on HD - HD SaTuTh,. Pt was continued on her HD regimen
while in house. Sevelamer was continued as well.
.
8. anemia/pancytopenia - chronic anemia, baseline pancytopenia,
likely [**2-12**] CKD and SLE, currently above baseline, though has h/o
GIB. Pt's pancytopenia remained stable; C3 and C4 studies were
performed and it was felt that her SLE was not active at this
time. Guiac stools were neg. EPO was continued at HD.
.
9. h/o gastric ulcer - PPI was continued throughout
hospitalization.
.
10. SLE - pt was continued on home regimen of prednisone 4mg po
qdaily.
.
11. h/o SVC thrombosis - patient's warfarin was discontinued
after discussion with Dr. [**Last Name (STitle) 4883**]. She frequently is outside
of therapeutic range on this medication and given the suspected
problems with medication compliance, it was felt it was safer to
discontinue it altogether.
.
12. seizure disorder - pt was continued on home regimen keppra
1000 mg PO 3X/WEEK (TU,TH,SA).
.
13. depression - pt was continued on her home celexa.
.
Medications on Admission:
1.Nifedipine 90 mg PO DAILY (Daily).
2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime).
3.Lidocaine 5 % PATCH Q24HR.
4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H
7.Prednisone 4 mg PO DAILY (Daily).
8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday).
9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday).
10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
12.Labetalol 1000 mg Tablet Tablet PO TID
13.Hydralazine 100 mg Tablet PO Q8H
14.Warfarin 3 mg Tablet PO Once Daily at 4 PM.
15.Pantoprazole 40 mg PO Q12H (every 12 hours).
16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QAM (once a day (in the morning)).
5. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal every Thursday.
11. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day): Please hold if systolic blood pressure < 100 or HR < 55.
14. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(TU,TH,SA).
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
17. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: do not drive or operate heavy machinery with
this medication as it can cause drowsiness.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Malignant Hypertension
Angioedema
Ascites
End Stage Renal Disease
Secondary:
Chronic Abdominal Pain
Anemia/Pancytopenia
Lupus
Gastric Ulcer
SVC Thrombosis
Seizure Disorder
Depression
Discharge Condition:
Hemodynamically stable with blood pressures 130-140 / 60-90
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2142-7-12**] because of critically high
blood pressure. While here, you were given IV antihypertensive
medications, and then you were switched to antihypertnsive
medications by mouth. You received multiple sessions of
hemodialysis. You had a distended, tender belly, and you
underwent a ultrasound guided tap to remove the fluid in your
abdomen. On [**2142-7-17**], you developed throat and facial swelling,
and you were transferred from the medical floor to the ICU. You
were given medication to help open your airway; you were
stabilized and went to hemodialysis several times. You were
transferred back to the medical floor. You had a venogram on
[**2142-7-20**], and the results at this time are still pending.
You had blood cultures drawn that were positive for bacteria.
You received IV antibiotics while at hemodialysis. You will
continue to receive these antibiotics at your appointments.
Please keep all of your medical appointments.
Please go to the nearest emergency room if you experience any of
the following:
1. Chest Pain
2. Headaches
3. Lightheadedness
4. Changes in vision
5. Nausea and Vomiting
Followup Instructions:
Please continue your regular hemodialysis schedule.
You have the following appointments scheduled. Please call if
you need to cancel or change your appointments.
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-7-21**]
12:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-7-30**] 2:00
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
Completed by:[**2142-7-24**] |
V3001,77181,07989,7761,7788,7821,V502,V053,V721 | 110 | 154,943 | Admission Date: [**2110-6-2**] Discharge Date: [**2110-6-5**]
Date of Birth: [**2110-5-29**] Sex: M
Service: NB
ID: [**First Name5 (NamePattern1) **] [**Known lastname 63430**] is a 6 day old term infant with presumed
viral sepsis being discharged from the [**Hospital1 18**] NICU.
HISTORY: [**First Name5 (NamePattern1) **] [**Known lastname 63430**] is a 3545 gram product of a term
gestation sent to the newborn intensive care unit for
evaluation of sepsis risk manifested by postnatal fever.
[**Doctor Last Name **] was born on [**5-29**] to a 35 y.o. G3 P0-1 mother whose
pregnancy was apparently uncomplicated. The mother is a
healthy woman with unremarkable prenatal screens, including
blood type 0 positive, antibody negative, hepatitis B surface
antigen negative, RPR non reactive, rubella immune, group B
strep status negative. The infant was delivered via cesarean
section for failure to progress. No sepsis risks factors.
Apgar scores were 9 at 1 minute and 9 at 5 minutes of age.
The infant was sent to the newborn nursery shortly after
delivery. The infant did well in the nursery until the
morning of [**6-2**], when the infant was noted to have a
temperature of 101.2. He had otherwise been doing well in the
newborn nursery. His weight loss at that time was [**8-2**]
percent. There was no history of maternal herpes simplex
virus or other illness.
PHYSICAL EXAMINATION ON ADMISSION: Infant pink on exam. He
was sleepy but easily awakened. Oxygen saturations were in
the low 90s in room air. A fine maculopapular rash was noted
about the face and the trunk. Initially his perfusion was
decreased, with acrocyanosis, but gradually improved over the
morning. No vesicles were noted with the rash. Head, ears,
eyes, nose and throat were normal. Heart had normal S1 and S2
without murmurs. Lungs clear to auscultation bilaterally.
Abdomen benign. No hepatosplenomegaly. Normal male genitalia.
Circumcised. Neurologic nonfocal and age appropriate. Hips
normal. Infant moving all extremities.
HOSPITAL COURSE:
1. RESPIRATORY. [**Doctor Last Name **] has been in room air throughout his
hospitalization and has not required any supplemental
oxygen. He has had a comfortable respiratory pattern
throughout.
2. [**Doctor Last Name **] blood pressure has been stable throughout his
hospitalization. He did receive one normal saline bolus after
admission to the NICU for decreased perfusion with
improvement. No murmurs have been heard.
3. FLUID, ELECTROLYTES AND NUTRITION. [**Doctor Last Name **] has been ad lib
demand feeding throughout his hospital course without
difficulty. His weight at time of discharge was 3405
grams. Electrolytes upon admission to the newborn
intensive care unit showed a sodium of 146, potassium 4.8,
chloride 106 and bicarbonate of 21. He has been voiding
and stooling without difficulty.
4. GASTROINTESTINAL. A bilirubin was drawn on day of life 4,
with a total bili of 4.8 and a direct bili of 0.4. He has
not required any phototherapy during his hospitalization.
5. HEMATOLOGY. [**Doctor Last Name **] hematocrit upon admission to the
newborn intensive care unit was 58.9, with a platelet
count of 118. His platelet count dropped over the course
of the next 48 hours, with a low of 52,000 on [**6-3**]. His
platelet count subsequently has risen, with a platelet
count of 67 on day of life 5 and a platelet count of 80 on
day of life 6, then finally a platelet count of 115 on day
of life 7. He did not require any platelets or other blood
products throughout his hospitalization. Coagulation studies
were measured on day of life 5, with a PT of 17.3 and a
PTT of 29, a fibrinogen of 336, and elevated d-dimers of
6631. Overall it was thought the thrombocytopenia was most
consistent with viral sepis.
6. INFECTIOUS DISEASE. Upon admission to the newborn
intensive care unit, a CBC with differential and blood
cultures were drawn. The CBC showed a white count of 5.3,
hematocrit of 58.9, platelet count 118, with 60 percent polys
and 3 percent bands. There were toxic granulations in the
sample. Lumbar puncture was performed, with CSF analysis
without pleocytosis. At that time, ampicillin, gentamicin and
acyclovir were initiated. Repeat CBC on day of life 4 showed a
white count of 10.7, hematocrit of 58.1, platelet count of 73,
with 48 percent polys and 1 percent bands. He received a
48 hour course of ampicillin and gentamicin. CSF HSV PCR was
sent shortly after admission to the NICU and was found to
be negative on day of life 7. The acyclovir was
discontinued at that time. Blood cultures sent upon
admission to the NICU also were negative. The rash noted upon
admission to the NICU increased over the next 24 hours,
becoming a diffuse whole-body maculopapular rash, without
petechiae or vesicles. The rash was thought to be most
consistent with enteroviral infection. Enteroviral
surface cultures and CSF PCR were sent, and these are pending
at the time of discharge. Secondary to the thrombocytopenia,
two urine samples were sent for CMV culture; these are
negative at the time of discharge. Of note, as the most
likely diagnosis was thought to be viral sepsis, liver
function tests were measured twice, and were within normal
limits.
7. NEUROLOGY. Neurologic examination remained within normal
limits throughout hospitalization. CSF analysis was benign.
8. SENSORY. A hearing screen was performed with automated
auditory brainstem responses. The infant passed in both
ears. Ophthalmology - Eye exam not indicated for this full
term infant.
9. PSYCHOSOCIAL. [**Hospital1 69**] social
worker has been involved with the family. The contact
social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: The infant is stable in room air.
Signs of infection have resolved. The infant is clinically
well.
DISPOSITION: To home with parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital 1411**] Pediatrics,
phone [**Telephone/Fax (1) 63431**].
CARE RECOMMENDATIONS:
1. Feeds at discharge are ad lib, demand bottle or breast
feeding.
2. Medications - None.
3. Car seat position screening not indicated.
4. State newborn screening status - State newborn screen was
sent on [**6-1**], and no abnormal results have been
reported.
5. Immunizations received - [**Doctor Last Name **] received his first
hepatitis B vaccine on [**6-1**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following three criteria: 1)
Born at less than 32 weeks. 2) Born between 32-35 weeks
with two of the following: day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings. 3) With chronic lung
disease. Influenza immunization is recommended annually in
the fall for all infants once they reach six months of
age. Before this age, and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
A followup appointment with Dr. [**Last Name (STitle) **] has been scheduled for
[**6-6**]. Followup platelet count is recommended at that time.
DISCHARGE DIAGNOSES:
1. Rule out sepsis.
2. Viral sepsis, likely enteroviral.
3. Thrombocytopenia, resolving..
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2110-6-5**] 16:04:30
T: [**2110-6-5**] 16:40:10
Job#: [**Job Number 63432**]
|
496,4275,99592,0389,5849,486,51881,78552,2866,27651,4019,4280 | 111 | 155,897 | Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-1**]
Date of Birth: [**2075-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
8 yo h/o COPD, HTN, HL who presented to the [**Hospital1 18**] ED the early
morning of [**2144-7-1**] with respiratory distress. T 96.8, BP 118/54,
HR 70, RR 18 on BiPAP 5/5. Found to have WBC 21 with 4%
bandemia, Cr 2.1 (baseline 0.9), lactate 3.3, trop <0.01. CXR
showed a RML pneumonia. She received vancomycin and
levofloxacin. Given her respiratory distress, she was started on
BiPAP, improved, and was taken off BiPAP. However, around 7 a.m.
on [**2144-7-1**] her respiratory status worsened with ABG 6.98/81/159.
Extremities were cool. She was intubated.
.
About 1 hour after intubation, she went into PEA arrest,
requiring epi x 2 and atropine x 2 and 4 minutes of CPR. A right
IJ sepsis line was placed. IVF, ceftriaxone, and pip-tazo were
given. She was also started on norepinephrine for hypotension,
with SBP improving to 110s. A bedside u/s showed no PTX and no
pericardial effusion. Repeat ABG was 6.75/112/227/18; tidal
volume was increased, paralytics given, a-line placed. SBP
continued to drop, and phenylephrine and then vasopressin were
started. SBP transiently improved with disconnection from the
ventilator and manual bagging. Got total of 8 L of NS. Got
methylpred 125 x 1.
.
Admitted to MICU.
.
ROS not obtained as patient was intubated.
Past Medical History:
emphysema
hypertension
hyperlipidemia
Social History:
tobacco abuse per OMR, not obtained as patient is intubated
Family History:
Mother dies of a brain tumor of unknown type in her 50's and
father died of massive MI in his 60's. No other hx of DMII, CAD,
CAD or emphysema in the family
Physical Exam:
General: intubated elderly woman
HEENT: NC/AT, sclera anicteric, ET in place
Neck: JVP not elevated
Lungs: Coarse breath sounds bilaterally from anterior
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Cool, weak pedal pulses, no edema
Pertinent Results:
[**2144-7-1**] 02:50AM WBC-21.2*# RBC-4.69 HGB-14.3 HCT-43.0 MCV-92
MCH-30.4 MCHC-33.2 RDW-12.7
[**2144-7-1**] 02:50AM NEUTS-81* BANDS-4 LYMPHS-5* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-1* PROMYELO-3*
[**2144-7-1**] 02:50AM PLT SMR-NORMAL PLT COUNT-212
[**2144-7-1**] 02:50AM CK-MB-NotDone
[**2144-7-1**] 02:50AM cTropnT-<0.01
[**2144-7-1**] 02:50AM CK(CPK)-17*
[**2144-7-1**] 02:50AM GLUCOSE-130* UREA N-46* CREAT-2.1*#
SODIUM-139 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-21* ANION
GAP-22*
[**2144-7-1**] 02:54AM LACTATE-3.3*
.
Echo [**2144-7-1**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. There is moderate global
left ventricular hypokinesis (LVEF = 30 %). Right ventricular
chamber size is normal. with moderate global free wall
hypokinesis. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2142-4-30**],
biventricular systolic dysfunction is new.
.
CXR [**2144-7-1**]: Severe emphysema with new right lower lung
consolidation since
[**2144-5-18**], likely representing pneumonia. Nodular densities also
noted, more
prominent than that seen on CT of [**2144-5-18**]; given rapid growth,
these likely are
infectious/inflammatory in etiology, however malignancy cannot
be excluded.
Given these abnormalities, CT chest is recommended to exclude
right hilar
mass.
Brief Hospital Course:
Upon arrival to MICU, patient was intubated, and despite weaning
off of sedatives, she was unresponsive with fixed, dilated
pupils. Her BP dropped and she required up to 4 pressors. The
patient expired after a few hours with family by her bedside.
Medications on Admission:
albuterol inh
atenolol 25 mg qday
fluticasone-salmeterol inh
simvastatin 40 mg qday
tiotropium inh
verapamil SR 180 mg qday
aspirin 325 mg qday
calcium + D
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
486,49121,4139,51881,41081,2762,4271,41401,4019,2724,42789 | 111 | 192,123 | Admission Date: [**2142-4-24**] Discharge Date: [**2142-5-5**]
Date of Birth: [**2075-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
cardiac catheterization
intubation
History of Present Illness:
Pt is 66 yo f with COPD, HTN, h/o recurrent PNA, who presents
with SOB. 3 days ago, pt began to experience headache, sore
throat, non-productive cough, SOB, and chills. She says 3 people
at work have been sick with headache, sore throat, and cough and
that now "she caught it." Last PM, pt had worsening SOB and
called 911 because she "couldn't catch her breath." Denies CP,
N/V/D, muscle aches.
.
In the [**Name (NI) **], pt was found to have decreased air movement and
wheezes on exam. She also had positive trop, but non-diagnostic
EKG per cardiology. She was given albuterol/atrovent nebs,
Solumedrol 125mg IV, Vanc 1g IV, Zosyn 4.5g IV, and Morphine 2mg
IV. She was also tachycardic to 150's, so was given Diltiazem
5mg IV.
.
Pt currently c/o SOB, but says her breathing has improved sincer
her presentation to the ED. Denies CP.
Past Medical History:
- COPD (last [**Name (NI) 1570**]'s [**1-17**] show FEV1 59%, FEV1/FVC 60%, seen by
Dr. [**Last Name (STitle) **] on [**2142-1-31**])
- h/o recurrent PNA (last discharged from [**Hospital1 18**] on [**2142-1-3**])
- chronic sinusitis
- HTN
- hyperlipidemia
MEDS:
Atenolol 50 mg qd
Lipitor 10 mg qd
Spiriva 1 capsule qd
Advair 100/50 1 puff [**Hospital1 **]
Fluticasone nasal spray 2 puffs qd
Social History:
Married to husband who is disabled due to stroke. Has one child.
Works as a membership saleswoman for a gym but teaches
occasional classes.
Drinks a glass of wine occassionally with meals, smoked 5
cig/day for 30 yrs, reports quitting smoking 6mo ago. No IVDU
and is sexually monogamous with her husband.
Family History:
Mother dies of a brain tumor of unknown type in her 50's and
father died of massive MI in his 60's. No other hx of DMII, CAD,
CAD or emphysema in the family
Physical Exam:
Vitals: T 96.1 BP 152/86 HR 149 RR 26 O2sat 99% on nebulizers
Gen: moderate resp distress, but able to speak [**2-13**] sentences.
Tremulous.
HEENT: OP clear, no exudate.
Neck: Supple. No JVD.
Cardio: regular, tachycardiac, no murmurs appreciated
Resp: decreased air movement throughout. Diffuse end-expiratory
wheezes.
Abd: soft, nt, nd, +BS
Ext: no c/c/e
Neuro: A&Ox3
Pertinent Results:
[**2142-4-24**] 04:15AM PT-11.7 PTT-27.7 INR(PT)-1.0
[**2142-4-24**] 04:15AM PLT COUNT-160
[**2142-4-24**] 04:15AM NEUTS-74.3* LYMPHS-17.9* MONOS-6.0 EOS-1.6
BASOS-0.3
[**2142-4-24**] 04:15AM WBC-9.1 RBC-5.20 HGB-15.9 HCT-46.0 MCV-89
MCH-30.6 MCHC-34.5 RDW-12.6
[**2142-4-24**] 04:15AM CALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2142-4-24**] 04:15AM CK-MB-7
[**2142-4-24**] 04:15AM cTropnT-0.14*
[**2142-4-24**] 04:15AM CK(CPK)-123
[**2142-4-24**] 04:15AM estGFR-Using this
[**2142-4-24**] 04:15AM GLUCOSE-144* UREA N-12 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2142-4-24**] 04:31AM LACTATE-1.1
[**2142-4-24**] 07:27AM TYPE-ART PO2-146* PCO2-51* PH-7.28* TOTAL
CO2-25 BASE XS--2
[**2142-4-24**] 12:08PM CK-MB-25* MB INDX-7.7* cTropnT-0.39*
[**2142-4-24**] 12:08PM CK(CPK)-324*
[**2142-5-4**] 04:47AM BLOOD WBC-12.8* RBC-4.82 Hgb-14.7 Hct-42.1
MCV-87 MCH-30.4 MCHC-34.8 RDW-12.3 Plt Ct-291
[**2142-5-1**] 03:04AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-4 Eos-0
Baso-0 Atyps-3* Metas-0 Myelos-1*
[**2142-5-1**] 03:04AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2142-5-4**] 04:47AM BLOOD Plt Ct-291
[**2142-5-1**] 03:04AM BLOOD PT-12.3 PTT-44.1* INR(PT)-1.1
[**2142-5-4**] 04:47AM BLOOD Glucose-119* UreaN-25* Creat-0.7 Na-143
K-3.4 Cl-104 HCO3-30 AnGap-12
[**2142-5-1**] 03:04AM BLOOD ALT-27 AST-14 LD(LDH)-281* AlkPhos-46
Amylase-31 TotBili-0.4
[**2142-4-28**] 04:00PM BLOOD CK-MB-5 cTropnT-0.11*
[**2142-4-26**] 04:56AM BLOOD CK-MB-17* MB Indx-2.6 cTropnT-0.25*
[**2142-4-25**] 02:54AM BLOOD CK-MB-34* MB Indx-7.3* cTropnT-0.51*
[**2142-4-24**] 08:00PM BLOOD CK-MB-37* MB Indx-7.2* cTropnT-0.66*
[**2142-4-24**] 12:08PM BLOOD CK-MB-25* MB Indx-7.7* cTropnT-0.39*
PATIENT/TEST INFORMATION:
Indication: Shortness of breath.
Height: (in) 67
Weight (lb): 118
BSA (m2): 1.62 m2
BP (mm Hg): 164/91
HR (bpm): 145
Status: Inpatient
Date/Time: [**2142-4-24**] at 15:22
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West CCU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 4.0 cm (nl <= 4.0 cm)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
INTERPRETATION:
Findings:
This study was compared to the report of the prior study (images
not
available) of [**2137-5-7**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter
with >50%
decrease collapse during respiration (estimated RAP 5-10 mmHg).
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion
abnormality cannot be fully excluded. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Aortic valve not well seen. Trace AR.
MITRAL VALVE: Mitral valve not well seen. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Results were
reviewed with the Cardiology Fellow involved with the patient's
care.
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is [**6-21**]
mmHg. Due to suboptimal technical quality, a focal wall motion
abnormality
cannot be fully excluded but there appears to be distal left
ventricullar and
apical akinesis. Overall left ventricular function is mildly
depressed with an
EF of ~45%. Right ventricular chamber size and free wall motion
are normal.
The aortic valve is not well seen. Trace aortic regurgitation is
seen. The
mitral valve is not well seen. No mitral regurgitation is seen.
There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2137-5-7**], the regional left ventricular dysfunction is new.
Cardiology Report C.CATH Study Date of [**2142-4-25**]
BRIEF HISTORY:
66 year old female with acute respiratory failure, elevated
cardiac
enzymes, and an anterior wall motion abnormality on
echocardiogram.
Intubated and sedated presently. No known history of CAD.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, stable.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.57 m2
HEMOGLOBIN: 12.8 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 14/14/13
RIGHT VENTRICLE {s/ed} 44/14
PULMONARY ARTERY {s/d/m} 42/21/30
PULMONARY WEDGE {a/v/m} 26/23/21
AORTA {s/d/m} 96/54/65
**CARDIAC OUTPUT
HEART RATE {beats/min} 70
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 12
CARD. OP/IND FICK {l/mn/m2} 16.4/10.4
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 254
PULMONARY VASC. RESISTANCE 44
FICK
**% SATURATION DATA (FL)
SVC HIGH 92
RA HIGH 89
IVC HIGH 97
RV INFLOW 92
PA MAIN 93
AO 99
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DISCRETE 30
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 30
6) PROXIMAL LAD DISCRETE 40
6A) SEPTAL-1 NORMAL
9) DIAGONAL-1 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 50
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 30 minutes.
Arterial time = 10 minutes.
Fluoro time = 9 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 60 ml
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Midazolam 5 mg iv
Fentanyl 75 mcg iv
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Selective coronary angiography in this right dominant system
revealed mild CAD. The LMCA had a 30% distal stenosis. The LAD
had
a 40% mid vessel stenosis. The LCx had a 50% stenosis in a
small OM
branch. The RCA had a 30% mid vessel stenosis.
2. Left ventriculography was not performed.
3. Resting hemodynamics demonstrated a RVEDP of 13 mmHg. There
was mild
pulmonary arterial hypertension with a pulmonary pressure of
42/21 mmHg.
There was elevated left sided filling pressures with a pulmonary
capillary wedge pressure of 21 mmHg. Central aortic pressure was
low at
96/54 (mean 70) mmHg. Cardiac index elevated at 11 l/min/m2
consistent
with possible sepsis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Markedly elevated cardiac index.
Cardiology Report ECHO Study Date of [**2142-4-30**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 67
Weight (lb): 118
BSA (m2): 1.62 m2
BP (mm Hg): 153/63
HR (bpm): 68
Status: Inpatient
Date/Time: [**2142-4-30**] at 14:56
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W013-1:17
Test Location: West MICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 3.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.43 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.25
Mitral Valve - E Wave Deceleration Time: 206 msec
TR Gradient (+ RA = PASP): 22 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2142-4-24**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is an
anterior space which most likely represents a fat pad.
Compared with the prior study of [**2142-4-24**], left ventricular
function appears
improved.
Brief Hospital Course:
This is a 66 yo f with COPD, h/o recurrent PNA's, HTN, and
hyperlipidemia who presented with respiratory distress. She was
admitted to the MICU and the following issues were addressed
during her hospitalization.
.
#) Resp failure: The patient was admitted to the MICU for
respiratory distress attributed to a COPD exacerbation. Although
her CXR did not show an infiltrate, she was started empirically
on nebulizer treatments and antibiotics. likely secondary to
COPD exacerbation due to infection. She was started on
ceftriaxone and azithromycin. She was also started on
methylprednisilone for her COPD flare. The patient failed
extubation on [**4-26**] and [**4-28**]. Shortly after both extubation
attempts, the patient's SBP climbed to the 200s and the patient
experienced respiratory distress. Therefore, her failure to
extubate was attributed to both her COPD exacerbation and likely
flash pulmonary edema in the setting of hypertension. After her
first extubation failure, her antibiotic coverage was broadened
to Vanc/Zosyn to cover for nosocomial PNA although no infiltrate
was seen on CXR. She was also continued on IV steroids. She
completed a 5 day course of Azithromycin and a seven day course
of Vancomycin/Pip-Tazo. Sputum cx from [**4-28**] grew 1+ GPCs,
sputum from [**4-25**] grew Aspergillus, and sputum from [**4-30**] likely
grew mold thought to be a contaminant. There was no other
evidence of fungal infection. Blood cultures, repiratory viral
antigens, and viral cx were all negative. The patient was
diuresed and her HTN was controlled on a nitro gtt. She was
succesfully extubated. She continued to have improving
oxygenation, weaning to 2L oxygen and was transferred to the
floor for 12h, after which she was discharged home on home
oxygen
.
# Elevated cardiac enzymes: The patient had ST elevations on EKG
and elevated CE with max CK 650 and Trop 0.66. She was placed on
a heparin. She underwent a cardiac catheterization which showed
mild 3 VD and markedly increased CI. ACS was thought to be
unlikely and the heparin gtt was discontinued. ECHO from [**4-30**]
showed LVEF >55% and no wall motion abnormalities. She was
started on ASA and atorvastatin. A BB was not started [**3-16**] her
severe COPD exacerbation.
.
# Arrhythmia: The patient had an episode of fascicular VT with
hypotension on [**4-27**] which lasted 10-15 minutes. It resolved with
metoprolol 12.5 po. Post-EKG showed a changed axis from prior.
Cards was consulted and recommended starting the patient on
verapamil.
.
#) HTN: The patient had a labile BP throughout her admission.
The patient's BP was controlled via an esmolol gtt initially
which was weaned once she was intubated and sedated. She was
placed on a nitro gtt prior to her successful extubation with
good effect. She was transitioned to lisinopril and verapamil
for BP control.
.
#) h/o recurrent sinusitis: She was continued on fluticasone
nasal spray.
.
Medications on Admission:
MEDS ON TRANSFER:
Insulin SC (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN
Lisinopril 40 mg PO DAILY
Aspirin 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO DAILY
PredniSONE 60 mg PO DAILY Order date: [**5-3**] @ 1118
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Fluticasone Propionate NASAL 2 SPRY NU DAILY
Tiotropium Bromide 1 CAP IH DAILY
Guaifenesin-Codeine Phosphate [**6-21**] ml PO Q4H:PRN cough
Verapamil SR 180 mg PO Q24H
.
Discharge Medications:
1. Oxygen Therapy
Patient requires 2-4 L of continuous oxygen given via nasal
canula.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
[**Month/Year (2) **]:*30 Cap(s)* Refills:*0*
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 Disk with Device(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
[**Hospital1 **]:*1 qs* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: take 6 tablets a day for 2 more days, then 5 tablets a day
for 1 week then 4 tablets a day for 1 week, then 3 tablets a day
for 1 week, then 2 tablets a day for 1 week, then 1 tablet a day
for another week. After that take 5mg a day until further
notified by your PCP.
[**Name Initial (NameIs) **]:*117 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
start after 10mg tablets are finished. continue until otherwise
noted by your PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q4H (every 4 hours) as needed for cough.
[**Name Initial (NameIs) **]:*1 qs* Refills:*0*
13. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
[**Name Initial (NameIs) **]:*30 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
COPD [**Hospital **]
Hospital acquired Pneumonia
Pulmonary edema
Elevated cardiac enzymes
Hypertension
Arrythmia
Discharge Condition:
good, tolerating pos, satting >95% on 2L, ambulating without
assistance
Discharge Instructions:
You were admitted with respiratory failure and were intubated
and treated with steroids, antibiotics, nebulizers, and diuresis
and discharged with mild oxygenation requirement
.
Please seek medical attention should your shortness of breath
worsen, or should you develop chest pain, lightheadedness,
dizziness.
.
Take all your medications exactly as prescribed, and follow up
as below.
Followup Instructions:
Please maek an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Telephone/Fax (1) 36702**]
within the next week to follow up
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2142-5-16**] 1:40
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2142-5-16**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2142-5-16**] 2:00
|
60000,41401,99592,51881,41071,5856,40391,5849,27651,20300,486,78552,0389 | 112 | 173,177 | Admission Date: [**2196-9-27**] Discharge Date: [**2196-9-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Altered MS [**First Name (Titles) **] [**Last Name (Titles) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo M w/ PMH multiple mylemoa, with Plasmacytoma of left
clavicle dx in [**6-18**] s/p xrt (last ~[**8-26**]) with recent admission
([**Date range (3) 110715**]) for dehydration and PNA presents with one day
of altered MS [**First Name (Titles) **] [**Last Name (Titles) **]. Pt recently returned home from
rehab 5 days ago after completing treatment for PNA with
Vanc/Zosyn.
.
In ED, found to be hypotensive to 90's systolic which was
responsive to fluids. Also febrile, w/ T 101. Labs notable for
Hct down to 25 (from baseline 28-30), Cr elevated to 2.4 (from
baseline 1.1-1.3), elevated trop/CKs. Pt was trace Guiac + on
exam. CXR showed improved left upper lobe opacity. In [**Name (NI) **], pt
received 2.5 L NS and one unit PRBC. Pt received one dose of
Vanc and 1 dose zosyn. His ECG showed inferolateral ST
depressions. Cardiology was called and felt that his troponin
leak was due to septic shock and not an acute MI - they
recommended treatment for [**Name (NI) **]. He was then transferred
to the floor. Shortly after arriving on the floor, his BP
dropped into the 70's systolic and MICU eval was requested. On
arrival he was found to have SBP in the 70's and to be minimally
responsive. His sats were in the low eighties. An ECG was
repeated and he again had inferolateral ST depressions. He had
one piv. NS was agressively started and a second PIV was placed
and fluids given. He was put on a NRB and Sats were in the mid
nineties, and a gas showed adequate oxygenation and
ventilation. His blood pressure did not respond to IVF so he
was started on Levophed through his lt. piv awaiting MICU
transfer.
Past Medical History:
Past Onc Hx
The patient was referred to Dr. [**Last Name (STitle) 410**] for a left clavicular
mass in [**6-18**]. The patient had a history of fx in the left
humerous. In early [**2196**], he developed a mass in his left
shoulder. At first this was thought to be a deformity
post-fracture but it continued to grow so it was decided to
biopsy it. On needle biopsy [**2196-6-23**] the mass was found to be a
plasmacytoma. An SPEP was done that showed an IgA lambda
monoclonal protein and lambda light chains in the serum, a 24
hour urine and UPEP revealed that the patient excreted about
7300 mg per day of light chains per day. He was originally
treated with decadron in [**6-18**]. He was being treated with XRT
(last ~[**8-26**]).
.
PMHx
Hypertension
Coronary artery disease s/p MI [**2179**],[**2193**]
Peptic ulcer s/p GIB
Benign prostatic hypertrophy
h/o temporal arteritis
h/o pemphigoid
h/o anemia
h/o small bowel volvulus
s/p appendectomy
s/p status post inguinal hernia repair x2
h/o colonic polyps
sigmoid diverticulosis
Rheumatoid arthritis
"sleepwalking"
h/o neck problems (?).
.
PAST SURGICAL HISTORY:
1. s/p appendectomy
2. s/p status post inguinal hernia repair x2
Social History:
The patient is married, lives in his own home. His son helps
care for both he and his wife. [**Name (NI) **] previously worked as a
psychoanalyst. He was in the army in World War II in [**Location (un) **].
He had no chemical or toxin exposure, no radiation exposure.
Family History:
Noncontributory
Physical Exam:
Vitals - T 99.1 (axillary), HR 113, BP 84/40 -> SBP 62, RR 18,
O2 94% 2L NC General - pt moaning, non-responsive to verbal
commands
HEENT -
CVS - distant heart sounds, appeared regular, tachycardic, no
noted M/R/G
Lungs - could not clearly ascultate [**3-17**] pt's moaning
Abd - soft, + palpable aortic pulse, could not assess for
tenderness, normoactive bowel sounds. G tube site with
significant purulence.
Ext - No LE edema b/l, bt. heel ulcerations, grade [**3-18**]
neuro - awake, not alert, minimally responsive
Pertinent Results:
[**2196-9-27**] 02:30PM PT-13.6* PTT-33.5 INR(PT)-1.2*
[**2196-9-27**] 02:30PM PLT SMR-NORMAL PLT COUNT-265
[**2196-9-27**] 02:30PM NEUTS-66 BANDS-4 LYMPHS-13* MONOS-6 EOS-8*
BASOS-1 ATYPS-0 METAS-1* MYELOS-1*
[**2196-9-27**] 02:30PM WBC-11.0 RBC-2.78* HGB-8.8* HCT-25.4* MCV-91
MCH-31.6 MCHC-34.5 RDW-15.5
[**2196-9-27**] 02:30PM CK-MB-10 MB INDX-2.1 cTropnT-2.67*
[**2196-9-27**] 02:30PM GLUCOSE-84 UREA N-43* CREAT-2.4*# SODIUM-125*
POTASSIUM-4.6 CHLORIDE-86* TOTAL CO2-30 ANION GAP-14
[**2196-9-27**] 02:45PM LACTATE-1.6 K+-4.7
[**2196-9-27**] 09:30PM CALCIUM-7.6* PHOSPHATE-4.5# MAGNESIUM-2.3
[**2196-9-27**] 09:30PM CK-MB-9 cTropnT-2.46*
[**2196-9-27**] 11:25PM LACTATE-2.4*
Brief Hospital Course:
Pt is a [**Age over 90 **] yo man with MMP including multiple myeloma, with
Plasmacytoma of left clavicle , s/p recent admission for
dehydration and pna (d/ced [**2196-9-8**]) who was readmitted with
[**Month/Day/Year **] and 1 day MS changes. On presentation to floor, pt
hypotensive, low grade fever, unresponsive, therefore got MICU
evaluation and pt was transferred to MICU. Upon transfer to the
MICU, patient was intubated, started on levophed, and started on
vancomycin, cefepime, and flagyl for antibiotic coverage.
Approximately 24 hours after admission, patient developed
tachycardia and [**Month/Day/Year **] with mottled and cool extremities.
[**Name (NI) **] son (his HCP) was called with initial decline in vital
signs and pt's code status was then changed from full code to do
not administer CPR. Patient then received a total of 3L NS,
levophed was increased, 3 amps bicarb were administered, patient
was started on dopamine, and patient was administered
epinephrine. Patient's BP then diminished to 0 and heart rhythm
was PEA. Time of death was called at 12:15am on [**2196-9-29**].
Medications on Admission:
Prednisone 5mg QD
Protonix 40 QD
Isosorbide mononitrate CR 30mg QD
Tramadol PRN
Aricept 10 QD
Nameda 10 [**Name2 (NI) 244**]
ASA
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Septic Shock
2. Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
53100,41071,2859,41401,725 | 112 | 174,105 | Admission Date: [**2194-6-13**] Discharge Date: [**2194-6-18**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old man
with a history of peptic ulcer disease, coronary artery
disease, status post myocardial infarction in [**2179**] as well as
[**2193**], temporal arteritis, who presented with melenas and
chest pain. The patient reported melanotic stools times 5
since 4 p.m. on the day prior to admission. No hematemesis or
hematochezia. Stools were loose. The patient had a history of
melena in [**2192-5-14**]. The patient also reported being
lightheaded, fatigued with an increase in his ch set
discomfort for which he was taking sublingual nitroglycerin
with relief. On the a.m. of presentation, the symptoms
persisted; the patient contact[**Name (NI) **] his PCP who sent him to the
[**Name (NI) **]. In the ED, the p was found to have a hematocrit of 22.9
decreased from a baseline of 32 to 38. He was given IV
Protonix, IV fluids, and transfused the first of 2 units of
packed red blood cells. Gastroenterology was consulted. The
patient initially had an EKG with slight inferior changes
while the patient was pain free. The patient then had an
episode of [**9-23**] substernal chest pain in the ED with 3 to [**Street Address(2) 94587**] changes in V3 to V4.
PAST MEDICAL HISTORY: Significant for upper gastrointestinal
bleed in [**2192-5-14**]. An esophagogastroduodenoscopy showed an
ulcer in the pylorus and chronic gastritis, coronary artery
disease, status post myocardial infarction in [**2179**] and [**2193**],
benign prostatic hypertrophy, history of temporal arteritis,
pemphigoid, history of anemia, history of small bowel
volvulus, status post appendectomies, status post inguinal
hernia repair x2, history of colonic polyps, and sigmoid
diverticulosis.
ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES.
MEDICATIONS: The patient was on:
1. Celebrex.
2. Aspirin.
3. Prednisone.
4. Atenolol.
5. Imdur.
6. Nitroglycerin p.r.n.
SOCIAL HISTORY: He is a retired physician, [**Name Initial (NameIs) 2447**].
Remote tobacco history. Social alcohol use, which is
infrequent. Married with 1 son.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION AS FOLLOWS: VITAL SIGNS:
Vital signs of 98.9 temperature, blood pressure 128/80, pulse
72, respiratory rate of 13, and oxygen 100% on 3 liters.
GENERAL: The patient appeared comfortable.
HEENT: Examination was unremarkable except for pale
conjunctiva, dry mucosa.
LABORATORY DATA: Significant for the hematocrit of 23 as
stated above, a potassium of 5.3, a BUN 78. Initial CK was
107 with an MB of 6 and a troponin of 0.02. INR was 1.0.
Urinalysis was unremarkable. As stated above, the patient had
2 EKGs and the second of which showed 2 to [**Street Address(2) 5366**] changes in
V3 to V6. Chest x-ray showed no acute cardiopulmonary
process, so the patient was admitted to the hospital.
CONCISE SUMMARY OF HOSPITAL COURSE AS FOLLOWS: GI: The
patient was felt to likely have another bleeding ulcer as the
etiology of his melanotic stools and anemia. The patient had
a history of Helicobacter pylori in the past that was
treated. The patient was felt to require EGD to evaluate for
recurrent infection as well as ongoing bleeding. The patient
was initially admitted to the ICU. Gastroenterology was
consulted. The patient was taken for EGD on [**6-13**], which
showed a deep antral ulcer, no acute bleeding. The ulcer was
injected.
The patient was initially continued on IV b.i.d. Protonix.
Hematocrits were followed and the patient was maintained on 2
peripheral IV's at all times, and aspirin was held. The
patient has another episode of melanotic stool. On [**2194-6-14**],
he was taken for another EGD, at that time which showed the
ulcer was not bleeding. As a result, the patient was felt to
be stable for discharge to home from a GI perspective with
continuation of the b.i.d. Protonix. The patient to follow up
for a repeat endoscopy in 8 weeks as an outpatient.
Cardiac: Cardiac enzymes had been significant for elevated
troponin on admission. Cardiology was contact[**Name (NI) **] who did not
recommend cardiac catheterization or coronary artery bypass
graft. The patient initially received heparin and was
restarted on aspirin, which was approved by GI as long as the
patient had serial hematocrits. The patient was transfused to
keep the hematocrit above 30. He was restarted on atenolol.
The patient was also on Imdur for a longer-acting vasodilator
effect. The patient had a couple of episodes of further chest
pain during the admission but had no further EKG changes.
Pulmonary: The patient had some desaturations to 70's and
80's with ambulation without improvement with oxygen with
ambulation, but at this time the patient was completely
asymptomatic and the patient's oxygen saturation recovered
spontaneously to the high 90's on room air with rest. As a
result, this was felt to possibly be not reflective of the
patient's pulmonary status, but reflective of some peripheral
vascular changes with ambulation. The patient was not felt to
need inpatient workup and will follow up with PCP as an
outpatient.
Hematology: The patient with acute blood loss anemia,
received a total of 4 units of packed red blood cells, had
serial hematocrits while on heparin gtt and was transfused to
keep the hematocrit above 30.
Musculoskeletal: The patient was restarted on his prednisone
for polymyalgia rheumatica and temporal arteritis.
DISCHARGE DIAGNOSES: Gastric ulcer.
Gastrointestinal bleed.
Demand ischemia, elevated troponins, and EKG changes in the
setting of acute blood loss anemia.
DISCHARGE MEDICATIONS:
1. Nitroglycerin sublingual.
2. Prednisone 5 mg p.o. daily.
3. Atenolol 25 mg p.o. q. p.m., 50 mg p.o. q. a.m.
4. Protonix 40 p.o. b.i.d.
5. Aspirin 325 mg.
6. Isosorbide mononitrate.
DISCHARGE FOLLOWUP: Follow up with Cardiology on [**Last Name (LF) 2974**], [**6-20**], at 9:15 a.m. The patient's primary cardiologist is Dr.
[**Last Name (STitle) 104122**]. Dr. [**Last Name (STitle) 104122**] was not available so the patient
followed up with Dr. [**Last Name (STitle) 11378**]. The patient also followed up with
Dr. [**Last Name (STitle) **] for outpatient endoscopy on [**8-21**] at 12:30 p.m.
and the patient was suggested to pursue cardiac
rehabilitation in 4 to 6 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**]
Dictated By:[**Last Name (NamePattern1) 8160**]
MEDQUIST36
D: [**2194-8-1**] 12:24:02
T: [**2195-5-15**] 13:09:19
Job#: [**Job Number 94529**]
|
53081,3314,1915 | 113 | 109,976 | Admission Date: [**2140-12-12**] Discharge Date: [**2140-12-27**]
Date of Birth: [**2105-2-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 35 year old
gentleman who woke up with severe headache, woke up with a
[**11-20**] frontal headache that was constant. Took Advil and
Tylenol without relief. Headache persisted. He went to an
outside hospital, where an MRI of the brain showed
hydrocephalus and a cystic mass around the pineal gland. The
patient was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] for further management.
PAST SURGICAL HISTORY: Gastric wrap.
PAST MEDICAL HISTORY: No other medical history.
PHYSICAL EXAMINATION: Heart rate 84, blood pressure 133/78,
respiratory rate 12, oxygen saturation 97 percent in room
air. The patient is lying in bed with his eyes covered. He
is alert and oriented times three. Pupils equal, round and
reactive to light, extraocular movements full with positive
photophobia and neck stiffness. Cardiovascular: Regular
rate and rhythm. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. Extremities: No
peripheral edema. Neurologic examination: Cranial nerves II
through XII intact; strength 5/5 in all muscle groups.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for close neurologic observation. He had a vent
drain placed on [**2140-12-13**] due to hydrocephalus. On
[**2140-12-14**], the patient was taken to the operating room
and had transcallosal resection of a third ventricle tumor
and continued with his vent drain in placed. The patient was
monitored in the PACU overnight, where he remained
neurologically stable.
On [**2140-12-16**], the patient was monitored on the Step-
Down Unit. He was awake, alert and oriented. Speech was
fluent. The patient complained of double vision on lateral
gaze. His strength was [**6-15**] in all muscle groups. His
dressing was clean, dry and intact. The patient had an MRI
of his entire spine that showed no evidence of metastatic
disease. The patient continued to have his vent drain in
place. Postoperatively, neurologically, the patient was
awake, alert and oriented times two, having difficulty with
short term memory postoperatively.
On [**2140-12-19**], the drain was raised to 15 cm above the
tragus. The patient continued to have difficulty with short
term memory but was otherwise intact neurologically. On
[**2140-12-20**], the patient's drain was raised to 20 cm
above the tragus. The patient continued to remain
neurologically stable. His Decadron was weaned down to 3 mg
twice a day.
On [**2140-12-24**], pathology of the mass that was removed
was consistent with ependymoma. The patient's drain was
raised to 25 cm above the tragus. The patient remained
neurologically stable and was out of bed to chair. On
[**2140-12-25**], the drain was clamped. The patient
remained neurologically stable. On [**2140-12-26**], the
patient had a head CT scan done, which showed no change in
the size of his ventricles. The drain was removed on
[**2140-12-26**] and the patient remained neurologically
stable.
DISPOSITION: The patient was discharged to home [**2140-12-27**]. Follow-up in the Brain [**Hospital 341**] Clinic in one week for
staple removal. The patient's condition was stable at the
time of discharge. Discharge medications included Percocet
one to two tablets po every four hours as needed, Decadron 2
mg po every 12 hours, pantoprazole 40 mg po once daily. His
condition was stable at the time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2141-4-25**] 11:00:30
T: [**2141-4-25**] 12:02:45
Job#: [**Job Number 34147**]
|
41401,4111,48283,2859,2720,3051 | 114 | 178,393 | Admission Date: [**2146-8-29**] Discharge Date: [**2146-9-3**]
Date of Birth: [**2098-5-9**] Sex: M
Service: Cardiothoracic Surgery
ADMITTING DIAGNOSIS: Coronary artery disease requiring
revascularization.
HISTORY OF PRESENT ILLNESS: This is a 48-year-old man in
generally good health with a new onset of dyspnea on exertion
and angina who underwent a cardiac catheterization on [**8-29**]
which revealed two vessel coronary artery disease with an
ejection fraction of 40%. There was disease in the proximal
LAD with a stenosis at D1 of 70% and 95% osteal D1 lesion,
95% distal RCA lesion with occluded PDA, mild PVB disease and
collaterals left to right. Given these findings, he was
referred to Dr. [**Last Name (STitle) 1537**] for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia.
PAST SURGICAL HISTORY: Significant for appendectomy.
MEDICATIONS: Included Gemfibrozil, Atenolol, Aspirin.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2146-8-29**] where he underwent a CABG
times three as follows: LIMA to LAD, left radial to D1
saphenous vein graft to PDA performed by Dr. [**Last Name (STitle) 1537**], assisted
by Dr. [**Last Name (STitle) 11743**]. Postoperative ejection fraction was 50-55%.
The patient was transferred to the cardiothoracic surgery
recovery unit on Nitroglycerin and Neo-Synephrine. The
patient had a temperature immediately postoperatively and
sputum cultures were sent that grew out gram negative rods
for which she was subsequently treated with Levofloxacin.
The patient otherwise did well and was transferred to the
floor by postoperative day #3. He did have another fever
spike on postoperative day #3 at which point the Levofloxacin
was begun for the gram negative rods in the sputum. He also
had one episode where he complained of epigastric pain and
EKG was obtained which demonstrated a right bundle branch
block. Enzymes were recycled and were downward trending. He
did undergo a blood transfusion on postoperative day #4 for a
hematocrit of 20 and tachycardia with mild hypotension. The
patient otherwise did very well. By postoperative day #5 was
without complaints. On physical exam, heart rate was 85,
blood pressure 116/70, clear to auscultation on the right
with bronchial breath sounds at the left base and egophony.
His sternum was stable with a regular rate and rhythm. His
abdomen was soft. His extremities were with minimal edema.
Given these findings and the fact that he was ambulating
extremely well, it was felt that he was stable for discharge.
He was discharged on Lopressor 12.5 mg po bid, potassium
chloride 20 mEq po q d for 7 days, Lasix 20 mg po bid for 7
days, Colace 100 mg po bid, Zantac 150 mg po bid, Aspirin 81
mg po q d, Motrin prn, Imdur 30 mg po q d, Niferex 150 mg po
q d and Levofloxacin 500 mg po q d for 7 days for treatment
of a potential hospital acquired pneumonia as well as
Percocet. The patient was instructed to follow-up with Dr.
[**Last Name (STitle) 1537**] in [**1-9**] weeks as well as his primary care provider [**Last Name (NamePattern4) **] [**1-9**]
weeks.
DISCHARGE DIAGNOSIS:
1. Hypercholesterolemia.
2. Coronary artery disease, status post CABG times three
performed on [**2146-8-29**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2146-9-3**] 15:21
T: [**2146-9-3**] 15:28
JOB#: [**Job Number 35153**]
|
1940,1977,2553,4240,5845,99859,6822,5119,5990,4280,34982,4019,V1000,V453,V5865,0413,2518,E9320 | 115 | 114,585 | Admission Date: [**2194-10-16**] Discharge Date: [**2194-11-13**]
Date of Birth: [**2119-1-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right adrenal tumor
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right adrenalectomy and right segment 6
resection
History of Present Illness:
The patient is a 75 y/o female who presents with a right adrenal
mass. The patient has been progressively feeling unwell since
[**Month (only) 116**]. After sustaining a fall, the patient started to have
worsening weakness and fatigue that she needed to start using a
walker to ambulate and had difficulty getting out of chairs.
She also reports increased facial hair in the past six months.
On imaging, the patient had a 10 x 7 cm right adrenal mass.
Further workup revealed that the patient had hypercortisolism.
On review of systems, the patient complains of pain and
increased difficulty in performing her activities of daily
living. The patient denies weight loss or weight gain.
Although, her obesity has become more central in nature and she
has had loss of hair on her scalp, while having increased facial
hair. She also reports increased bruising along her
extremities, some shortness of breath on exertion, thinning of
her skin, and decreased energy. The patient denies fever,
chills, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, constipation, or dysuria.
Past Medical History:
colon Ca s/p partial colectomy and adjuvant chemo - 8y ago
HTN
CCY [**2184**]
adrenal mass
mitral valve prolapse
Social History:
Lives alone in NJ, here living with daughter while undergoes
further evaluation and mgmt. Denies tobacco (<100 lifetime
cigarettes), social EtOH, no IVDU. Has 3 daughters and 2 sons
Family History:
DM in both brothers and both parents; F - prostate and liver Ca;
uncle - gastric Ca
Physical Exam:
T 96.3 P 66 BP 176/90 R 20 SaO2 95% RA
Gen - no acute distress, well-appearing, upper lip hirsutism
Heent - facial hirsutism, no scleral icterus, moist mucous
membranes
Lungs - clear to auscultation bilaterally
heart - regular rate and rhythm
abd - obese, soft, nontender, nondistended
Pertinent Results:
[**2194-10-16**] 08:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2194-10-16**] 08:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2194-10-16**] 08:08PM URINE RBC-0-2 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2194-10-16**] 08:08PM URINE AMORPH-FEW
[**2194-10-16**] 05:30PM GLUCOSE-124* UREA N-19 CREAT-0.4 SODIUM-142
POTASSIUM-2.9* CHLORIDE-98 TOTAL CO2-33* ANION GAP-14
[**2194-10-16**] 05:30PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2194-10-16**] 05:30PM WBC-7.3 RBC-3.63* HGB-11.8* HCT-33.6* MCV-93
MCH-32.5* MCHC-35.0 RDW-16.4*
[**2194-10-16**] 05:30PM PLT COUNT-231
[**2194-10-16**] 05:30PM PT-10.8 PTT-19.1* INR(PT)-0.9
Brief Hospital Course:
She was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for exploratory
laparotomy, right
adrenalectomy and right hepatic segment 6 resection. Please see
operative report for details. EBL was 3 liters. An introp U/S
revealed- liver echogenicity appeared unremarkable. Within the
posterior segment of the right lobe of the liver, there was s a
5.5 x 3.3 cm well- circumscribed, slightly hypoechoic lesion
that contained a degree of increased through transmission
suggesting at least some cystic components. The relationship of
this to the surrounding vasculature, particularly the posterior
branch of the right portal vein was demonstrated. No other
additional lesions were found.Two [**Doctor Last Name **] drains were removed by
postop day 5. Pathology returned positive for 1. Right adrenal
mass, excision (A-F):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note.
2. Liver segment six, resection (G-O):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note. Endocrinology was to follow and the plan
was to use ________ as an outpatient.
Postop she was in the SICU for fluid management and ATN.
Baseline creatinine was 0.6. Nephrology was consulted.
Creatinine trended down to 1.1 by POD 8. Renal u/s was normal.
Stress dose steroids were given preop and postop per
Endocrinology. Endocrinology preferred a slow 6 month steroid
taper. Dr. [**First Name (STitle) **] tapered prednisone after one week as she
developed an incision infection necessitating opening the
incision and using a wound vac. A CT of the abd was done on
which demonstrated Two ill-defined fluid collections
post-surgical site that were extrahepatic and could represent
postoperative seromas, bilomas, or less likely abscesses.
Multiple scattered foci of air, likely postoperative. 2.
Increased stranding about the head of the pancreas, possibly
pancreatitis. 3. Bibasilar atelectasis and small right pleural
effusion. Amylase and lipase were normal. LFTs preop were ast
1298, alt 1308, alk phos 64 and tbili 0.7. These trended down
postop with the exception of the alk phos which increased to as
high as 806 on HD 20. Subsequently, this has decreased some to
504 as of [**11-13**].
She required PICC line placement for IV antibiotics and TPN as
her kcals were insufficient. Her appetite was diminished. She
appeared apathetic on many days and expressed feelings of
sadness. Psychiatry saw her and agreed with the team that she
was experiencing intermittent delerium. There was concern that
she was experiencing the effects of less cortisol. Neurology
recommended a CT and EEG. A head CT was done for waxing/[**Doctor Last Name 688**]
mental status. This was negative for bleed/mass on [**10-29**]. An EEG
was performed which demonstrated mild encephalopathy. TSH was
3.4. Psychiatry did not recommend antidepressents or stimulants
at the time.
On CT a right pleural effusion was noted. She experienced desats
and sob. Pleuracentesis was performed on [**11-6**] (HD 20)with a
negative culture. A f/u cxr was improved and without
pneumothorax.
She developed a Klebsiella uti which was treated with Cipro and
Flagyl for the wound x 4 days. These antibiotics were switched
to Vanco and Meropenum when a wound culture identified strep
veridans, sparse yeast, Klebsiella which was pan sensitive and
staph coag positive resistent to levo/oxicillin/penicillin and
sensitive to vanco. Vanco levels were monitored. Creatinine
remained stable. She developed a 2nd UTI,yeast which was treated
with a GU Ampho bladder irrigant x3 days. This was due to finish
on [**11-13**] pm. Repeat u/a and cx were sent on [**11-13**].
A repeat abd CT revealed stable appearance of hepatic fluid
collections with some debris and air in the surgical bed.
Bibasilar atelectasis with stable right pleural effusion.
Stable appearance of right abdominal wall defect overlying
surgical site. Interval development of nonocclusive thrombus
within the intrahepatic inferior vena cava. She was started on
coumadin and IV heparin until she was therapeutic. INR Goal was
[**1-31**]. INR on [**11-13**] was 2.6
On [**11-12**] after taking off the vac and reviewing the CT, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain was inserted thru the wound into a peri-hepatic collection
and placed to bulb suction. Water soluble contrast was
administered at the bedside through this catheter. Contrast was
administered. Contrast was seen surrounding this wound and
draining along the right lateral aspect of the wound into
dressing, however, no definite communication into the abdominal
cavity noted. Midline chevron scar and multiple clips scattered
across the abdomen were seen. Remainder of abdomen was gasless.
Small amount of oral contrast seen in the rectum. She then
underwent successful drainage catheter placement in collection
in the subhepatic and hepatic areas on [**2194-11-12**].
The plan is for her to go to [**Hospital 100**] Rehab on TPN via a R picc
with a RUQ incision wound vac. She has 2 hepatic drains to
gravity drainage and meropenum/vanco will continue until next
week. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-17**] and
with endocrinology as an outpatient.
Please schedule GYN follow up of postmenopausal bleeding noted
on POD #5.Pelvic U/S (prelim report) - Study v. limited as
patient was not able to achieve proper positioning; uterus 8.0 x
4.4 x 4.5 cm; endometrium is not well visualized; ovaries not
visualized. She experienced minimal spotting while hospitalized.
Medications on Admission:
hydralazine 25q8, HCTZ 25, KCl 40"
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for sbp <140.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 doses.
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous every six (6) hours.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic DAILY
(Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): peri area.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
check INR twice weekly. goal [**1-31**].
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): check vanco level twice
weekly.
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: per picc line
protocol.
16. Outpatient Lab Work
Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin and inr. Fax to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], RN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
R adrenal mass
Hepatic collections
IVC thrombus
malnutrition
UTI,yeast
pleural effusion
ARF, resolved
post menopausal bleeding
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, incision red/bleeding or draining pus, wound drain
dislodges, foul smelling wound or increased wound drainage,
increased shortness of breath.
Followup Instructions:
weekProvider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-11-17**] 11:30
please schedule follow up with Dr [**Last Name (STitle) 574**] [**Telephone/Fax (1) 6468**]
(Endocrinology) in 1 week. Attempt Monday appointment
GYN follow up [**Telephone/Fax (1) 2664**] & schedule TVU/S as outpt prior to
apt.
Completed by:[**2194-11-13**] |
5715,07054,2875,4280,2851,2765,4019,25000,7895 | 117 | 140,784 | Admission Date: [**2133-4-7**] Discharge Date: [**2133-4-12**]
Date of Birth: [**2083-12-28**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
woman with a history of end stage liver disease secondary to
hepatitis C complicated by esophageal varices as well as a
history of encephalopathy and prior spontaneous bacterial
peritonitis who was recently discharged from [**Hospital1 18**] for
management of her ascites. On that hospitalization multiple
attempts were made to manage her fluid overload with
diuretics, but she was ultimately refractory to them. She
was referred for TIPS procedure for improved fluid
management. The patient was readmitted on the day of
admission on [**4-7**] for TIPS. The procedure was notable for
having somewhat difficult access, but no complications with
an estimated blood loss of 100 cc. At the procedure she
received 4 mg of Versed, 600 of propofol, 150 of fentanyl.
She had been hemodynamically stable for several hours post
procedure, but then her blood pressure dropped from 100/40 to
70s to 80s over 30s and her heart rate remained sinus tach.
At the time, although her urine output remained strong, she
was transferred to the medical ICU for further management.
PAST MEDICAL HISTORY: Hepatitis C genotype 1A complicated by
cirrhosis, esophageal varices, encephalopathy and presumptive
SBP. Type 2 diabetes. Obesity. Hypertension. Asthma.
Esophageal candidiasis. Gastroparesis. Depression. Status
post cholecystectomy. Status post seven spur surgeries.
Hypothyroidism. Amenorrhea. Migraines.
MEDICATIONS ON ADMISSION: Protonix 40 mg q.d., Synthroid 100
mcg q.d., Reglan 10 q.i.d., Flovent two puffs b.i.d.,
lactulose 45 ml q.i.d., Ambien 5 mg q.h.s. p.r.n., Levaquin
250 mg q.d., Lasix 60 mg b.i.d., spironolactone 100 mg
b.i.d., morphine p.r.n., albuterol one to two puffs q.six
p.r.n., Serevent one puff b.i.d.
SOCIAL HISTORY: The patient is a prior machine operator on
disability. She is not married. She lives with her son.
She has a 15 pack year tobacco history, she quit in [**Month (only) 359**].
She has a history of alcohol use, particularly heavy in the
mid-[**2109**]. She has a history of IV drug abuse, none since
the [**2109**].
FAMILY HISTORY: Noncontributory. It does not include liver
disease or bleeding disorder.
PHYSICAL EXAMINATION: The patient's temperature was 98.5,
pulse 96, BP 95/48, respiratory rate 16, sating 98 percent on
3 liters. In general, she was a pleasant, middle aged woman
lying in no acute distress. Head and neck exams showed
normocephalic, atraumatic head with pupils equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Oropharynx was slightly dry. On neck exam she had a
right central venous line with mild ooze. Heart was
tachycardiac with regular rhythm, no murmurs. Lungs were
clear to auscultation bilaterally anteriorly. Abdomen was
soft, nondistended, nontender with active bowel sounds. She
had guaiac positive stool. Extremities had 2+ edema to the
knees. On neuro exam she was alert and oriented times three.
Cranial nerves II-XII were grossly intact. Strength and
sensation were grossly intact.
LABORATORY DATA: White count 3.7, hematocrit 26.8, platelets
43. PTT 39.5, INR 1.5. Sodium 126, potassium 4.4, chloride
94, bicarb 26, BUN 31, creatinine 1.2, glucose 136. Calcium
7.5, mag 1.2, phos 3.7. AST 174, ALT 80, alka phos 126,
t-bili 3.1, LDH 255.
HOSPITAL COURSE:
1. Hypotension. The patient was admitted to the MICU for
hypotension. The underlying etiology was not initially
clear, although the differential included excess anesthesia
from the procedure, particularly given her liver disease
versus hypovolemia from a hemorrhage, either around the liver
into the abdomen or within the GI tract versus sepsis. She
was started empirically on antibiotics with levo and Flagyl.
She had an abdominal ultrasound to evaluate for ascites for
possible paracentesis. There was no ascites. She was
maintained on antibiotic prophylaxis for several days. She
was transfused one unit of packed cells and given fluids to
improve her blood pressure and it responded appropriately.
She was started on Neo-Synephrine to keep her MAPS greater
than 55. It took several days, but this was ultimately
weaned. The entire time she had excellent urine output. As
cultures continued to be negative and the patient had no
fever or white count, she was not maintained SBP antibiotic
coverage and once she was maintained on pressors, she was
able to be transferred out to the floor. She had no further
evidence of hypotension while on the medicine floor.
2. Hypoxia/congestive heart failure. The patient was given
vigorous IV fluids hydration and blood during her MICU stay.
She subsequently became progressively hypoxic with diffuse
wheezing and a chest film that was consistent with fluid
overload. She was started with diuresis once she was on the
medicine floor with rapid improvement in her hypoxia and her
lung exam. Once the pulmonary edema was improved, her
exercise tolerance improved dramatically.
3. Pulmonary. The patient does have a history of asthma and
she was wheezing significantly when she hit the floor. She
responded well to IV Lasix and frequent nebulizer treatments.
These will be continued as an outpatient per her
prehospitalization regimen.
4. Status post TIPS. The patient did not have any evidence
of encephalopathy and her abdominal distention improved
significantly over the course of her admission. She was
between 2 and 3 liters negative per day and did not have an
untoward effects with respect to her renal failure.
5. Renal. The patient's creatinine slightly increased on
admission to the ICU. However, over the course of her
admission, her creatinine went down to 1.0 by discharge which
is as good, if not better, than her typical baseline.
6. Infectious disease. When the patient was out on the
floor, she did not show any evidence of infection. She was
continued on SBP prophylaxis regimen of Levaquin q.day.
7. Endocrine. The patient was continued on her diabetes
regimen with glargine and a sliding scale.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with VNA for home safety
evaluation.
DISCHARGE DIAGNOSES:
1. End stage liver disease.
2. Hepatitis C.
3. Anasarca.
DISCHARGE MEDICATIONS:
1. Flovent two puffs b.i.d.
2. Albuterol one to two puffs q.six hours p.r.n.
3. Serevent one puff b.i.d.
4. Synthroid 100 mcg q.d.
5. Protonix 40 mg q.d.
6. Levaquin 250 mg q.d.
7. Lactulose 30 ml p.o. t.i.d.
8. Lasix 40 mg p.o. q.d.
9. Reglan 10 mg p.o. q.i.d.
10. Aldactone 25 mg p.o. b.i.d.
FOLLOWUP: The patient will call the liver center to make an
appointment with Dr. [**Last Name (STitle) 497**] in two weeks. She will contact
her PCP to make an appointment within the next one to two
weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2133-4-12**] 16:20
T: [**2133-4-12**] 16:54
JOB#: [**Job Number 50266**]
|
570,07044,5712,5849,5724,5118,2867,51882,2875,0389,486,2800,2639,2761,2767,99592,30393,4019,5723,25000,2449,1122 | 117 | 164,853 | Admission Date: [**2133-11-13**] Discharge Date: [**2133-12-1**]
Date of Birth: [**2083-12-28**] Sex: F
Service: MEDICINE
Allergies:
Cyclobenzaprine
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
End Stage Liver Disease
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49F PMH ESLD [**3-2**] Hep C, esophageal varices, history of SBP on
daily PPX, h/o hepatic encephalopathy, s/p TIPS ([**4-2**]), admitted
to OSH MICU ([**Date range (1) 50267**]) with hepatic encephalopathy. With
treatment for encephalopathy at OSH, NH3 243 -> 11, however,
worsening hyperbilirubinemia (8.1 -->16.3), xferred to [**Hospital1 18**] for
consideration of possible transplant.
Patient transfered to MICU after development of hypotension and
respiratory failure.
Past Medical History:
PmHx:
HCV genotype IA refractory to IFN x 2 ascites
grade I esophageal varices (EGD [**11-1**])
h/o esophageal candidiasis
s/p ccx
DM II
HTN
asthma
hypothyroid
depression
amenorrhea
migraines
Echo [**4-2**]: EF >65%, no WMA, trivial TR.
ETT [**5-3**]: no ischemic EKG changes, no perfusion defects at good
target HR, EF ~60%, no WMA.
Social History:
h/o ETOH abuse
h/o IVDU
quit tobacco 1 yr ago
on disability
Physical Exam:
97.9 120/50 102 22 94% 2L
Gen: lying in bed, jaundiced, obese
HEENT: no JVD
Pulm: decreased breath sounds on right side, otherwise CTA
Cardiac: RRR, S1, S2
Abd: obese, distended, diffusely tender, no rebound
Ext: anasarca
Neuro: AO x self, hospital, thinks year is "[**2103**]", otherwise
non-focal
Brief Hospital Course:
A/P: 49F ESLD [**3-2**] HCV, s/p TIPS for refractory ascites, admitted
for rising TBili who subsequently developed respiratory failure
and was transfered to the MICU.
1. Sepsis: upon initial admission to the ICU the patient was
started on a 10 day, broad spectrum course of antibx
prophylactically given an episode of hypotension. The patient
completed this course of antibx. However on HD 17 the patient
became hypotensive with elevated wbc, and lactic acidosis to 15.
She was reinitiated on broad spectrum antibx and pressors. She
was initally started on levophed but her BP's continued to
decrease and was then started on neosynephrine. Given the
patient's critically ill state at this time, the patient family
was called. The family decided to withdraw support and the
patient passed away peacefully several hours later.
2. Respiratory Failure: likely secondary to a pleural effusion
which was tapped. Pleural fluid analysis was consistent w/ a
transudate likely from ascites/liver failure. Over the course
of several weeks the patient's respiratory status improved and
was successfully extubated on HD 15. However, the patient was
reintubated on HD 17 after she developed sepsis from which she
died on HD 18.
3. ESLD: Acute on chronic liver failure. Liver (Dr. [**Last Name (STitle) 497**] and
Transplant were following. Given the patient's critically ill
state, she was not amenable to transplant during her hospital
course. Lactulose was continued for hepatic encephalopathy.
4) Coagulopathy/Thrombocytopenia - secondary to ESLD. The pt was
transfused FFP, cryroprecipitate, platelets, and pRBCs PRN.
5) ARF: Hepatorenal syndrome versus ATN (granular casts in
urine). UOP was poor. Renal was consulted and the patient was
initiated on CVVHD.
6) DM2: Insulin GTT.
7) Asthma: Cont nebs PRN.
Medications on Admission:
Aldactone
lactulose
reglan
protonix
levoxyl
lasix
magnesium
glargine
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
41401,3051,25000,4019,41011 | 123 | 195,632 | Admission Date: [**2161-10-29**] Discharge Date: [**2161-11-2**]
Date of Birth: [**2105-8-31**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
male smoker with diabetes, and hypertension, and hepatitis C,
and status post anterior myocardial infarction who presented
with anterior myocardial infarction.
At midnight on the day prior to admission, the patient
experienced substernal chest pain while sitting at rest in
his bed. The pain was radiating to his arms. It was
described as not pleuritic. It was associated with shortness
of breath. The patient took sublingual nitroglycerin without
relief. The pain lasted 10 minutes until Emergency Medical
Service arrived. He was found to be hypertensive at 210/100.
The patient was brought to [**Hospital1 188**] Emergency Department. Electrocardiogram showed sinus
rhythm at 54, normal axis, and normal intervals. ST
elevations were noted to be 1 mm to 2 mm in leads V2 through
V5 and aVL. Reciprocal ST depressions of 2 mm were seen in
leads II, III, and aVF. The patient's electrocardiogram also
showed poor R wave progression.
The patient was taken to the Catheterization Laboratory. He
was randomized to cool myocardial infarction protocol. On
catheterization, the patient was found to have left main
coronary artery without flow-limiting lesions. A 50% mid
distal lesion was seen in the left anterior descending artery
along with an occluded first diagonal that was stented. The
left circumflex, right coronary artery, and ramus intermedius
were found to be normal. Pulmonary artery saturation was
75%. Pulmonary artery pressure was 27/11. Per the protocol,
the patient was cooled to 33 degrees for five hours. He was
started on aspirin, Integrilin, and Plavix and received a
heparin bolus. He was admitted to the Coronary Care Unit for
monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of hepatitis C; on pegylated interferon and
ribavirin study. The patient quit three months ago for
unknown reasons.
3. Dyspepsia/peptic ulcer disease.
4. Diabetes; per OMR but the patient denies.
5. Depression; no prior suicide attempts with few years of
treatment.
6. Renal stones; status post renal surgery with blood
transfusions in the [**2139**].
7. History of angina.
8. Chronic back pain; status post surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Atenolol 50 mg p.o. q.d.
2. Prilosec 20 mg p.o. q.d.
3. Quinine 325 mg p.o. q.h.s. (for leg cramps).
4. Roxicet 5/325 p.o. t.i.d. as needed.
5. Univasc 15 mg p.o. b.i.d.
6. Hydrochlorothiazide 25 mg p.o. q.d.
FAMILY HISTORY: Diabetic mother. [**Name (NI) **] coronary artery
disease.
SOCIAL HISTORY: The patient reports he smoked half a pack
per day for 40 years for a total of a 20-pack-year smoking
history.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed heart rate was 48, blood pressure
was 123/55, saturating 99% on room air. The patient was
found to have dry mucous membranes. No jugular venous
distention. A regular rhythm. Normal first heart sound and
second heart sound. No murmurs. The lungs were clear. No
hematomas in the groin. Extremities had bounding dorsalis
pedis pulses.
PERTINENT LABORATORY DATA ON PRESENTATION: Complete blood
count and Chemistry-7 were within normal limits as were
coagulations. Creatine kinase was 193.
HOSPITAL COURSE BY PROBLEM: The patient was started on
aspirin, and Plavix (for a 30-day course), and Integrilin
drip (for 18 hours). The team did not start the patient on a
statin as he has a history of hepatitis C.
Liver function tests were normal with an AST of 36, ALT
was 118, alkaline phosphatase was 96, total bilirubin
was 0.5.
A cholesterol panel was as follows: Total cholesterol
was 181, low-density lipoprotein was 102, high-density
lipoprotein was 30, triglycerides were 231.
An echocardiogram was done and revealed an ejection fraction
to be normal at 55%. There was mild symmetric left
ventricular hypertrophy with normal cavity size. There was
mild regional left ventricular systolic dysfunction with
focal hypokinesis of the apex. Also of note, mild aortic
sclerosis.
A beta blocker and ACE inhibitor were titrated to blood
pressure and heart rate control. A hemoglobin A1c was found
to be 5.4. Therefore, the patient was determined not to be a
diabetic.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] as his cardiologist and with his primary care
physician (Dr. [**Last Name (STitle) 8499**].
DISCHARGE DIAGNOSES:
1. Status post anterior myocardial infarction with stent to
first diagonal.
2. Hypertension.
3. Ejection fraction of 55%.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Lisinopril 40 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. (times 30 days).
4. Atenolol 75 mg p.o. q.d.
5. Sublingual nitroglycerin as needed.
6. Statin not started; deferred to primary care physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern4) 8500**]
MEDQUIST36
D: [**2161-11-1**] 13:45
T: [**2161-11-4**] 11:45
JOB#: [**Job Number 8501**]
|
4412,486,496,07070,4478,41402,41401,4019,2720 | 124 | 112,906 | Admission Date: [**2161-12-17**] Discharge Date: [**2161-12-24**]
Date of Birth: [**2090-11-19**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Descending thoracic aortic
pseudoaneurysm.
HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman
with a history of peripheral vascular disease and COPD with
hypertension and coronary artery disease, who presented to
the Emergency Department with 10 days of cough, shortness of
breath, and chest pain. Patient had been seen earlier in the
week and started on Zithromax for presumed respiratory
infection. However, he returned on the day prior to
admission with recurrent cough. CTA done at that time showed
a partially thrombosed pseudoaneurysm or penetrating ulcer of
the aortic arch approximately 2.5 cm distal to the takeoff of
the left subclavian artery with diffuse emphysematous
changes, no pulmonary embolus.
He was started on esmolol for blood pressure control, given
an elevated pressure of 175/48 when he was admitted. He had
appropriate monitoring placed including an A line and a Foley
catheter, and admission laboratories were significant for a
hematocrit of 41.4 and a BUN and creatinine of 26 and 1.4.
His EKG did not show ischemic changes and his CK's and
troponins were negative initially. Vascular Surgery and
Cardiothoracic Surgery services were consulted and he was
admitted to the Intensive Care Unit on the Vascular Surgery
service.
PAST MEDICAL HISTORY: Right cerebrovascular accident.
Coronary artery disease.
Hypertension.
Prostate cancer.
History of hepatitis C.
Hypercholesterolemia.
Hypertension.
Asthma.
PAST SURGICAL HISTORY: Left carotid endarterectomy in [**2161-8-16**].
Right carotid endarterectomy in [**2161-6-16**].
Five vessel CABG in [**2152**].
Right upper lobectomy for lung cancer in [**2154**].
Left vertebral artery stent in [**2161-6-16**].
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Albuterol.
2. [**Doctor First Name **].
3. Lipitor 20 mg by mouth every day.
4. Cartia XT 300 mg by mouth every day.
5. Ecotrin 325 mg by mouth every day.
6. Hydrochlorothiazide 25 mg by mouth every day.
7. Protonix 40 mg by mouth every day.
8. Serevent every day.
SOCIAL HISTORY: The patient is a former smoker. He quit in
[**2160-5-15**] with a greater than 30 pack year history. Denies
ingestion of alcohol.
INITIAL PHYSICAL EXAMINATION: Temperature 96.9, heart rate
64, blood pressure initially 131/73 down to 110/57 after
institution of esmolol, 93 percent. He was alert and in no
acute distress. His heart was regular with no murmurs, rubs,
or gallops. His chest was clear to auscultation with
diminished breath sounds in the bases. His abdomen was
moderately obese with normoactive bowel sounds, soft, and
nontender. Extremities were warm without clubbing, cyanosis,
or edema. He had palpable femoral pulses bilaterally and
Dopplerable popliteal, DP and PT bilaterally with monophasic
DP and PT on the left.
STUDIES: CTA: No pulmonary embolus. A 3 cm partially
thrombosed pseudoaneurysm versus penetrating ulcer of aortic
arch 2.5 cm distal to the takeoff of the left subclavian
artery, diffuse emphysematous changes.
Chest x-ray: No new infiltrate.
BRIEF HOSPITAL COURSE: As stated above, Mr. [**Known lastname 13029**] was
admitted to the ICU for blood pressure control on an esmolol
drip. He remained without recurrent chest pain and he had a
MRI/MRA done of his chest to further delineate his anatomy.
Of note, there were two small outpouchings of contrast from
the lumen of the inferior portion of the aortic arch
surrounded by large thrombus component with some thickening
of the aortic wall and no evidence of active bleeding or free
fluid. There were additionally multiple irregularities in
the aortic wall throughout the entire thoracic and abdominal
aorta that was visualized. This was thought to represent an
unusual appearance of a penetrating ulcer with a large
thrombus component.
He additionally had a cardiac catheterization to evaluate for
any underlying coronary artery disease should he need
operative repair. This revealed 90 percent stenosis of his
right coronary artery, saphenous vein graft with patent vein
grafts to the OM and patent LIMA to the LAD with diffuse
disease in the distal LAD. A Heparin-coated stent was placed
in the vein graft to the right coronary artery.
Other findings from his catheterization revealed an 80
percent instent stenosis of the left vertebral artery and an
80 percent right brachiocephalic ostial lesion. He tolerated
the procedure well and there were no bleeding or groin
complications. He returned to the Intensive Care Unit for
continued blood pressure monitoring and his esmolol drip was
eventually weaned off.
Given the patient's multiple medical problems including his
severe pulmonary disease, underlying coronary artery disease,
and overall debilitated condition, the decision was made to
proceed with medical management as the postoperative
management of this likely penetrating ulcer. He was
transitioned to oral agents. His diltiazem dose was
increased and Lopressor was added for additional rate
control. He remained off drips for greater than 48 hours.
Decision was made to send him home with close followup. Of
note, his hematocrit remained stable. His creatinine
remained within its baseline of around 1.4 and he was
tolerating a regular diet and able to ambulate without
difficulty.
Of note, because of his complaint of cough, a sputum sample
was sent, which grew out Pseudomonas that was [**Last Name (LF) 7384**],
[**First Name3 (LF) **] he was started on ciprofloxacin on [**2161-12-22**].
Follow-up chest x-ray revealed bilateral lower lobe changes
concerning for pneumonia. He remained afebrile with normal
white count.
DISCHARGE DIAGNOSES: Penetrating ulcer versus thrombosed
pseudoaneurysm of the descending thoracic aorta.
Coronary artery disease status post right coronary artery
saphenous vein graft stent with Heparin-coated stent.
Bilateral lower lobe pneumonia.
DISCHARGE MEDICATIONS:
1. Salmeterol.
2. Flovent.
3. Lipitor 20 mg by mouth every day.
4. Tylenol as needed.
5. Aspirin 325 mg by mouth every day.
6. Hydrochlorothiazide 50 mg by mouth every day.
7. Diltiazem sustained release 360 mg by mouth every day.
8. Lopressor 12.5 mg by mouth twice a day.
9. Ciprofloxacin 500 mg by mouth every 12 hours times seven
days additional.
DISCHARGE INSTRUCTIONS: Patient is to have his blood
pressure checked 3-4 times per week and communicate these
results with Dr. [**Last Name (STitle) **] and his primary care doctor. He
should call if his systolic blood pressure is greater than
110 or less than 90. Complete a 10 day course of
ciprofloxacin to take seven additional days and to call Dr.
[**Last Name (STitle) **] should he have recurrent chest discomfort. Follow
up with Dr. [**Last Name (STitle) **] in one month with a CTA of his chest,
with Dr. [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) **], his primary care doctor in two
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2161-12-24**] 10:45:31
T: [**2161-12-24**] 11:59:21
Job#: [**Job Number 13031**]
|
44021,5849,5854,5990,9971,4400,40390,2749,496,45829,42731,V1046,V1011,V1209,V090 | 124 | 134,369 | Admission Date: [**2165-5-21**] Discharge Date: [**2165-6-6**]
Date of Birth: [**2090-11-19**] Sex: M
Service: SURGERY
Allergies:
Neurontin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
RLE Claudication
Major Surgical or Invasive Procedure:
[**2165-5-23**] Diagnostic aortic and pelvic arteriogram with left common
and external iliac stents; ultrasound-guided imaging for
[**Month/Day/Year 1106**] access; aortic catheterization.
History of Present Illness:
74M with c/o R buttock and thigh claudication who is followed by
Dr. [**Last Name (STitle) **]. He had a duplex study performed in [**Month (only) 404**] of
this year that showed a patent aortoiliac system with heavily
calcified and extensively diseased distal right common iliac
artery, right external iliac artery, and right common femoral
artery, as well as likely SFA occlusion. He has not had any
tissue loss and denies rest pain. He also has some lower back
issues, which he originally believed to be the source of his
discomfort. He recently had a R L4, L5 and S1 transforaminal
epidural and SI joint steroid injection. He denies recent
fevers, chills, or chest pain. Baseline DOE/SOB due to his COPD
and is on home O2.
He does have CRI and L renal artery stenosis with an atrophied L
kidney and is followed by Nephrology here at [**Hospital1 18**]. He also
notes bruising and bleeding easily, despite only being on
aspirin.
Past Medical History:
1. CVA x 2 s/p left vertebral artery stent in [**2161**]; s/p right
carotid endarterectomy and left carotid endarterectomy [**2161**]
2. CAD s/p 5 vessel CABG [**2152**] s/p cath in [**12/2161**] (preop) with
stent to SVG-RCA
3. HTN
4. Prostate cancer last psa 8.2, treated with watchful waiting
5. Hep C VL zero in [**2155**]
6. hyperlipidemia
7. COPD/emphysema
8. right upper lobectomy for lung CA, adenocarcinoma [**2154**]
9. s/p hernia repair
10. thrombosed pseudoaneurysm dxed [**12/2161**], medically managed
11. CRI baseline creatinine 1.5-2.0
12. Cavitary RLL abscess/PNA in [**3-20**]- treated with 4 week course
of levo/flagyl.
Social History:
Lives at home with wife. Retired salesman for Sears.
Quit smoking in [**2160**]. 30 pack year history. No etoh use.
Independent in all daily activities.
Family History:
Non-contributory
Physical Exam:
NAD. A&Ox3.
Anicteric. MMM.
No carotid bruits. B CEA scars.
RRR.
Fair aeration. Diminished bases. Scattered wheezes.
Soft. NT. ND. No palpable pulsatile masses.
Feet are warm. No ulcers or fissures. No peripheral edema.
C R F P DP PT
R 2+ 2+ 1+ dop dop dop
L 2+ 2+ 2+ 1+ dop dop
Pertinent Results:
Labs:
11.0/
9.2 ---- 266
/33.7
PT: 11.8 PTT: 26.0 INR: 1.0
142 107 72 /
------------- 90
4.7 22 3.7
estGFR: 16/20 (click for details)
Ca: 9.1 Mg: 2.3 P: 4.2
renal u/s 5/7/8
CONCLUSION: Atrophic left kidney with further shrinkage compared
to a prior study in [**2163**]. Normal size right kidney with mildly
elevated RI's but otherwise excellent flow.
No hydronephrosis.
Multiple simple cysts bilaterally.
Brief Hospital Course:
The patient was admitted to [**Year (4 digits) **] Surgery for angiogram. The
patient's procedure was cancelled on [**5-22**] secondary to concern
over his creatinine. Nephrology was consulted and renal
ultrasound performed. With Nephrology's recommendations on
optimizing the patient, the patient went for his angiogram on
[**5-23**]. He underwent a diagnostic aortic and pelvic arteriogram
with left common and external iliac stents, ultrasound-guided
imaging for [**Month/Day (4) 1106**] access, and aortic catheterization. The
patient tolerated the procedure well. For further detail of the
procedure, please refer to the operative note. Post
operatively, the patient developed hypertension to the 180's.
He was transfered to the VICU for BP management. The patient's
blood pressure normalized and Nephrology left recommendations on
BP management. The patient is discharged home with the
medication changes and with instruction to return on Wednesday
for an endarterectomy. Upon discharge, the patient is afebrile
with all vitals stable, with stable blood pressure, tolerating
po feeds, ambulating, and with pain controlled on po pain
medication.
Medications on Admission:
Albuterol 2 puffs q4-6h prn, Allopurinol 100 qod, DILTIAZEM SR
360', Advair 250/50 one puff", Lasix 40', Meclizine 25' prn,
Lopressor 50", NTG SL prn, Percocet prn, PROTONIX EC 40',
Simvastatin 40', Spiriva with HandiHaler 18mcg one puff', Ultram
50 q6h prn, Valsartan 160", ECOTRIN 325', FeSO4 325'
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary:
R buttock & thigh claudication
.
Secondary:
CAD, s/p CVA x 2, aortic arch aneurysm, HTN, prostate ca, lung
ca, h/o hepatitis C, hyperlipidemia, COPD, stage IV CKD, chronic
back pain, vitamin D deficiency, L renal artery stenosis, L
kidney atrophy, prepatellar bursitis, h/o cavitary RLL
abscess/PNA [**3-20**]
Discharge Condition:
Afebrile, vital signs stable, tolerating regular diet,
ambulating, pain well controlled on PO medication.
Discharge Instructions:
Division of [**Month/Year (2) **] and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Please note the changes we made your medications and take them
as prescribed in the sheet. We discontinued your diltiazem so
please make a note of this.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-17**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-19**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Please return on Wednesday [**5-29**] to the Surgery check-in for
your angiogram.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-7-4**] 2:10
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-7-11**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2165-10-29**] 10:30
|
4280,2639,56983,56089,49121,99859,0389,99592,99831,486,V1011,V1046,V4581,41400,5849,42731,40390,42833,5854 | 124 | 138,376 | Unit No: [**Numeric Identifier 13036**]
Admission Date: [**2165-12-2**]
Discharge Date: [**2166-2-1**]
Date of Birth: [**2090-11-19**]
Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Pneumonia.
2. Colonic pseudo-obstruction/[**Last Name (un) 3696**] syndrome
3. Cerebrovascular disease, history of cerebrovascular
accident, status post bilateral carotid
endarterectomies.
4. Coronary artery disease, status post five-vessel
coronary artery bypass grafting, status post coronary
catheterization.
5. Hypertension.
6. Prostate cancer.
7. Hepatitis C.
8. Hyperlipidemia.
9. Chronic obstructive pulmonary disease/emphysema.
10.History of adenocarcinoma of the lung, status post right
upper lobectomy.
11.Chronic renal insufficiency.
12.History of cavitating pneumonias.
DISCHARGE DIAGNOSES:
1. As above.
2. Sepsis with multisystem organ failure.
3. Respiratory failure.
4. Pneumonia.
5. Colonic perforation, status post extended right
colectomy with end ileostomy.
6. Status post tracheostomy.
7. Status post abdominal wound dehiscence, status post
fascial closure.
8. Acute on chronic renal failure.
9. Malnutrition.
ADMISSION HISTORY AND PHYSICAL: [**Known firstname **] [**Known lastname 13029**] was a 75-year-
old gentleman with multiple comorbidities who was admitted to
a referring institution with severe pneumonia and possible
COPD flare at the beginning of [**2165-12-16**]. He was managed
there with antibiotics and required some degree of steroid
therapy for his severe respiratory disease. During the
treatment of his pneumonia, he developed what was initially
was thought to be a colonic obstruction. This was evaluated
at the referring hospital by the surgical and
gastroenterology services and was found to be a colonic
pseudo-obstruction thought to be related to his pneumonia.
The patient failed to make significant progress in terms of
his colonic pseudo-obstruction. The family request transfer
to the [**Hospital1 69**] for further care.
He was initially transferred to the medical service for
management of his pneumonia and colonic pseudo-obstruction.
Gastroenterology and surgical services were consulted. Both
services concurred with nonoperative management of his
process and treating the underlying illness with correction
of any electrolyte abnormalities and minimization of any
narcotics, anticholinergic agents, which may exacerbate the
pseudo-obstruction. The patient was transferred on [**2165-12-31**].
His symptoms actually resolved on the day of transfer with
resumption of bowel function and passage of gas. This was
visible on his plain radiograph imaging. He did not require
any intervention for this. He was passing gas and having
loose stools first several days, but then began to develop
some increasing abdominal distention on [**2166-1-3**].
This was thought to be possible recurrence of his pseudo-
obstruction and again managed conservatively.
Over the course of the ensuing days, the patient was found to
have free intraperitoneal air on an abdominal x-ray from
[**1-7**] and [**1-8**]. As the patient did not initially
manifest systemic signs of sepsis, given as co-morbidities,
he was managed non operatively with antibiotics. His disease
progressed and he became progressively more ill and was taken
emergently to the operating room on [**1-9**]. Extensive
discussions were undertaken with the family and the patient
highlighting the high risk of the surgery. Given his
extensive co-morbidities and the high risk about morbidity
and mortality, they understood and wished to pursue all
treatment. On [**1-9**] he underwent an extended right
colectomy with an end-ileostomy. Please see the operative
note for further details.
His postoperative course was initially marked by prolonged
ventilator dependence and acute-on-chronic renal
insufficiency. His malnutrition and his immunosuppression
from steroids hampered his initial recovery. He did develop
some degree of pneumonia and pleural effusions and given the
high likelihood that he would require mechanical ventilation
for some period of time, tracheostomy was placed on [**1-14**].
He continued to require full ventilatory nutritional support,
as well as antibiotic therapy for his pneumonia. Nutritional
support was provided with combination of initially TPN and
subsequently enteral feedings. On [**1-20**], he began to have
increasing drainage from his abdominal incision. This was
opened at the bedside and evidenced a fascial dehiscence. He
was taken to emergently back to the operating room for
fascial closure. Notably, at this time, there was no evidence
of healing taking place since the time of operation 10 days
prior, highlighting his severe degree of immunosuppression
and malnutrition.
He was subsequently maintained in the ICU with the narcotics
for pain control and sedation. Full ventilatory support was
required. He failed multiple attempts at weaning despite
aggressive pulmonary toilet and attempts at diuresis. His
hemodynamics were relatively stable with occasional episodes
of atrial fibrillation; but otherwise no significant
hemodynamic instability. His ileostomy continued to function
and never evidenced any ischemia. His renal function
continued to deteriorate somewhat with acute-on-chronic renal
failure developing. Most concerning was the development of
fungal infections in the sputum and urine.
Over the course of the ensuing week, the patient failed to
progress despite maximal medical therapy and nutritional
support. Discussions were had with the family to decide goals
of care with the patient. After several meetings, the family
made the decision to make the patient comfort measures only,
as he was in multisystem organ failure with progressively
worsening infections and with a very low likelihood of any
meaningful recovery. The patient was made CMO on [**2166-1-29**]. He was maintained on ventilatory support per the
family's request. His sedative medications and pain
medications were continued over the course of the ensuing
days. The patient progressively went into worsening renal
failure and this was followed by cardiac arrest on [**2166-2-1**]. The family was at the bedside.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2166-2-1**] 07:16:45
T: [**2166-2-1**] 08:56:55
Job#: [**Job Number 13038**]
|
43331,99812,436,43320,4019,2720,49390,41401,V4581 | 124 | 172,461 | Admission Date: [**2160-6-24**] Discharge Date: [**2160-7-15**]
Date of Birth: [**2090-11-19**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 69-year-old man was
transferred from [**Hospital6 5016**] on the [**10-24**] to
[**Hospital1 69**]. He has a history of
coronary artery disease, hypertension, hyperlipidemia,
prostate and lung cancer with severe carotid stenosis and
transient ischemic attacks who is referred now with the
abrupt onset of speech difficulty and right-sided weakness.
The patient had been hospitalized briefly in [**Month (only) 116**] with speech
difficulty and right-sided weakness. His studies back in [**Month (only) 116**]
showed severe bilateral carotid stenosis and there was
thought to be a critical stenosis on the right, a marked
stenosis on the left. CT scan was normal and the patient had
been on aspirin and was then started on Plavix. He was
referred to [**Hospital3 **] and he was scheduled for a carotid
endarterectomy a week prior to his admission. On the day of
admission aspirin and Plavix had been stopped in anticipation
of this upcoming surgery, however, while at home patient fell
asleep, complained to his wife of not feeling well and found
him a few hours later slumped over in the bed and felt that
his speech was slurred and not very comprehensible. He
complained of double vision at the time. Paramedics reported
that he was moving his extremities, however, developed
right-sided weakness when he arrived at [**Hospital6 5016**].
MEDICATIONS PRIOR TO ADMISSION: Lipitor, Cardia,
hydrochlorothiazide, bronchodilators.
PAST MEDICAL HISTORY: Coronary artery bypass graft in [**2152**].
SOCIAL HISTORY: He had been a smoker for the majority of his
life though only smoking a few cigarettes a day. He quit in
[**2160-5-15**].
PHYSICAL EXAMINATION: He was awake and fairly alert with
fluent speech. No dysarthria. He repeats well and there is
no anomia. He follows commands. Cranial nerves: Pupils
were small and reactive to light. Fundi were not seen. He
had a fairly pronounced vertical gaze palsy. There was
suggestion of slight lateral rectus weakness. Visual fields
were full to confrontation testing. There was mild right
central facial weakness. The other cranial nerves were
intact. Motor examination showed no drift and normal
strength to confrontation. Fine finger movements were intact
but finger-to-nose testing was ataxic, especially on the
right. The patient's findings were remarkable for a vertical
gaze palsy, maybe a right VI nerve palsy which relates to his
complaint of double vision.
The patient was transferred to [**Hospital1 188**] where he was admitted to the hospital, was started on
anticoagulation and carotid duplex was performed. He was
admitted to the Vascular Service there and a stroke consult
was done.
LABORATORY ON ADMISSION: White count 13.7, hematocrit 34.6,
platelet count 209,000, PT 12.8, PTT 36.4, INR 1.1. Sodium
137, potassium 4.0, BUN 24, creatinine 1.4.
HOSPITAL COURSE: The stroke team recommended stopping
heparin on his admission day and just continuing on aspirin
and Plavix with their considering recent strokes. The MRI
showed acute stroke in the paramedian thalamus and left of
the midbrain. He also had small areas of stroke in the
cerebellum. They recommended a four vessel angiogram and a
carotid endarterectomy on the right carotid and once again
the patient was now on the 11th started on heparin. The
patient was monitored on the floor where he did continue with
double vision and he was prepped for the carotid artery
endarterectomy. His repeat carotid ultrasound was completed
which shows a narrowing of 80-99% bilaterally of the tardive
RPPCA suggest proximal disease. On the 12th the patient
continued with double vision. His blood pressure was in the
140's to 180's and no other distress. The patient was made
known to the Neurosurgery Service where he was to have an
angiogram done. On the [**5-26**] he had an angiogram
which showed greater than 85% left vertebral artery stenosis,
an occluded right vertebral artery. He had greater than 85%
of the right common carotid bifurcation stenosis, 75%
innominate origin stenosis. It was noted that patient had a
left groin hematoma after the angiogram where he was
monitored closely post-angiogram. He was also on telemetry
during this time. He did end up having an ultrasound of the
groin to rule out pseudo-aneurysm. The Stroke Team, the
Neurology Team and the Vascular Team decided that the patient
should have a right carotid endarterectomy and then have a
stenting of his left vertebral artery. On the 13th he did
have the ultrasound of his left groin which showed no
pseudo-aneurysm. The patient was kept on heparin during this
time. On the [**5-31**] the patient had a right carotid
endarterectomy done. He tolerated the procedure well. On
postoperative day one he was awake, alert and oriented.
Incision was clean, dry and intact. He was reevaluated by
the Stroke Service the same day. His blood pressure was
140/46, heart rate 74, respirations 14, temperature 97.8. At
that point he was transferred back to Neurology Service. The
patient did receive one unit of red blood cells on the 18th.
It was noted on the 19th that he had slight swelling of the
surgical scar, otherwise the patient was okay. On the 19th
it was noted that that scar had serous fluid. No pus or
edema. The site was monitored by the Vascular Service. The
patient's pain was under control with Percocet. A follow-up
ultrasound on the 20th showed a patent right carotid, small
right neck hematoma, no evidence of pseudo-aneurysm. His
left groin hematoma was small, however, improving. The
patient remained awake, alert and oriented. His neurological
status was unchanged. During the postoperative period the
patient was on aspirin and Plavix. His staples were removed
from the surgical neck site on the 21st. The site was dry
and intact. He continued to be followed by Neurology and
Neurosurgery. Labs on the 23rd showed white count of 7.5,
hematocrit of 39.2, 297,000 for platelets. On the 25th
patient did have a left vertebroangioplasty and stent.
Estimated blood loss was minimal. The patient did well with
the procedure. He woke up awake, alert and oriented. He had
no drift. Grasp was [**5-19**] bilaterally. Lower extremities were
full. He remained on heparin post stenting at 800 units an
hour and continued on aspirin and Plavix. The patient was
monitored in the Trauma Intensive Care Unit postoperatively.
He was kept on a Nipride drip to keep his blood pressure less
than 140. A Rheumatology consult was asked for on the 26th
because of right-sided knee swelling. There was no erythema,
however, there was increase in warmth. Patient was thought
to have heterotopic ossification. It was thought not to be
an infectious process. Patient was already on aspirin. They
recommended topical aspirin cream. The patient was monitored
in the Intensive Care Unit. On the 27th he continued to need
Nipride to keep his blood pressure less than 140. He
remained neurologically intact. Case Management was
following him at this time. He was moved out of the Unit on
the 28th. His groin incision was noted to be intact with no
infectious process noted. No further hematoma. He remained
neurologically intact. His blood pressure was well
controlled on oral antihypertensives. Physical Therapy and
Occupational Therapy were involved in the patient's care and
they recommended home physical therapy and also for Nursing
to follow up with the patient to check blood pressure.
Rheumatology's final recommendations were prednisone taper,
NSAIDS and some local therapy to his right knee. Patient was
treated for methicillin-resistant Staphylococcus aureus
urinary tract infection diagnosed on the [**6-10**]. He
was started on intravenous vancomycin. Infectious Disease
recommended that he start on dicloxacillin for one week after
discharge.
DISCHARGE MEDICATIONS: Include:
1. Atorvastatin 20 mg one tablet q. day.
2. __________ 110 mcg two puffs b.i.d.
3. Albuterol 90 one to two puffs every q. 4-6h.
4. Oxycodone one to two tablets q. 4-6h.
5. Aspirin 325 one tablet q. day.
6. Plavix 75 mg one tablet q. day.
7. Cardizem 240 mg SA one tablet q. day.
8. Salmeterol 50 mcg one Diskus inhalation q. 12h.
9. Lopressor 50 mg twice a day.
10. Hydrochlorothiazide 1.5 tabs q. day.
11. Doxycycline 100 mg q. 12h.
12. Rheumatology recommended a prednisone taper which was
given to the patient.
13. Motrin 600 mg p.o. t.i.d. was given for the patient's
inflammatory process of his right knee.
DISCHARGE INSTRUCTIONS: Patient is to follow up with Dr.
[**Last Name (STitle) **] in five weeks. Follow up with Dr. [**Last Name (STitle) 1132**] in one
month. He will have home visits from VNA nurses to check his
blood pressure and a home safety evaluation with Physical
Therapy.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 13027**]
MEDQUIST36
D: [**2160-7-15**] 15:08
T: [**2160-7-15**] 15:13
JOB#: [**Job Number 13028**]
|
4241,99671,42731,4168,2449 | 125 | 157,348 | Admission Date: [**2179-2-14**] Discharge Date: [**2179-2-21**]
Date of Birth: [**2128-2-29**] Sex: F
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:
Redo Aortic Valve Replacemetn (mechanical) on [**2179-2-16**]
History of Present Illness:
50 yr old female with h/o Rheumatic Heart Disease/Mitral
Stenosis/Aortic Insufficiency s/p Mitral Valve Replacement
(mechanical) and Aortic Valve Replacement (mechanical) [**2165**] who
has been c/o increasingly worsening dyspnea on exertion. An echo
revealed severe pulmonary hypertension with an increased
trans-aortic gradient with a peak gradient of 85mmHg and a mean
gradient of 49mmHG (Aortic Stenosis). She then underwent a
cardiac cath which showed clean coronary arteries and similar
disease with the prosthetic mechanical aortic valve. She was
then seen for redo-aortic valve replacement.
Past Medical History:
Redo-Aortic Valve Replacement (mechanical)
h/o Rheumatic Heart Disease/Mitral Stenosis/Aortic Insufficiency
s/p Mitral Valve Replacement (mechanical) and Aortic Valve
Replacement (mechanical) [**2165**]
Pulmonary Hypertension
Atrial Fibrillation
Aortic insufficiency
s/p Mitral commissurotomy [**2150**]
Hypothyroid
Urinary retention
h/o atrial fibrillation
Uterine Fibroids
s/p Left oophorectomy, partial left salpingectomy
Social History:
Lives with husband. [**Name (NI) **] alcohol or tobacco use.
Family History:
No diabetes, hypertension, or coronary artery disease
Physical Exam:
Neuro: A&O x 3, non-focal
Heart: RRR 4/6 SEM
Lungs: CTAB -w/r/r
Abd: Soft, NT/ND +BS
Ext: Warm, Trace edema
Pertinent Results:
Carotid U/S [**2-15**]: No evidence of carotid stenosis in the right
or left carotid arteries
Echo [**2-16**]: Pre bypass: The left atrium is markedly dilated. The
right atrium is moderately dilated. Overall left ventricular
systolic function is normal (LVEF>55%). A mechanical aortic
valve prosthesis is present. Motion of the aortic prosthesis
leaflets/discs is abnormal. Only one leaflet seen to move
normally. The transaortic gradient is higher than expected for
this type of prosthesis. There is at least moderate to severe
aortic valve stenosis ([**Location (un) 109**] 0.8, mean gradient 27). Mild (1+)
aortic regurgitation is seen. A mechanical mitral valve
prosthesis is present. The prosthetic mitral leaflets appear
normal. Mild (1+) mitral regurgitation is seen. Significant
pulmonic regurgitation is seen. Post bypass: preserved
Biventricular function LVEF > 55%. Mechanical [**First Name8 (NamePattern2) **] [**Male First Name (un) **] 21
prosthesis well seated in aortic position without perivavluar
leak. No AI. Aortic valve area 1.7-1.9 by continuity, Peak
gradient 58, Mean 29 mm Hg initally post bypass, subsuqently
peak gradient 52, mean 16 mm Hg. Mitral valve prosthesis remains
unchanged. TR and PI unchanged.
[**2179-2-14**] 10:30PM BLOOD WBC-4.4 RBC-3.53* Hgb-11.8* Hct-34.4*
MCV-97 MCH-33.4* MCHC-34.3 RDW-13.0 Plt Ct-136*
[**2179-2-16**] 02:40PM BLOOD WBC-11.9* RBC-3.48*# Hgb-10.9*#
Hct-31.0*# MCV-89 MCH-31.5 MCHC-35.3* RDW-16.3* Plt Ct-86*
[**2179-2-21**] 05:45AM BLOOD WBC-10.3 RBC-3.07* Hgb-9.4* Hct-28.5*
MCV-93 MCH-30.8 MCHC-33.1 RDW-15.5 Plt Ct-189#
[**2179-2-14**] 10:30PM BLOOD PT-14.0* PTT-27.4 INR(PT)-1.2*
[**2179-2-20**] 05:30AM BLOOD PT-20.1* PTT-97.5* INR(PT)-1.9*
[**2179-2-21**] 05:45AM BLOOD PT-24.7* INR(PT)-2.5*
[**2179-2-14**] 10:30PM BLOOD Glucose-101 UreaN-25* Creat-0.8 Na-143
K-4.4 Cl-106 HCO3-29 AnGap-12
[**2179-2-21**] 05:45AM BLOOD UreaN-25* Creat-1.0 Na-138 K-4.7 Cl-99
HCO3-28 AnGap-16
[**2179-2-20**] 05:30AM BLOOD Mg-1.9
[**2179-2-17**] 03:57AM BLOOD freeCa-1.14
[**2179-2-14**] 11:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
Brief Hospital Course:
Patient was admitted prior to her surgery secondary to being on
Coumadin for her current prosthetic mechanical valves. Her
Coumadin was stopped and she was started on Heparin. She had her
pre-operative work-up done along with a carotid u/s. On [**2-16**] her
INR was at a safe level for surgery and she was brought to the
operating room where she underwent a redo Aortic Valve
Replacement with a mehanical valve. Please see op note for
surgical details. She was then brought to the CSRU in stable
condition. Later on op day patient was weaned from sedation and
awoke neurologically intact and was then extubated. She was
weaned from all Inotropes by post op day one and was started on
B blockers and diuretics. She was gently diuresed throughout her
hospital course towards her pre-operative weight. On post-op day
two she was transferred to the cardiac surgery step-down unit.
Chest tubes and epicardial pacing wires were removed on post-op
day two. Coumadin was restarted on this day as well. Physical
therapy worked with patient during entire post-op course for
strength and mobility. She appeared to be progressing well
although on post-op day four she had some abdmonial pain, but
abdmonial x-ray was negative. By post-op day five she was
ambulating well and cleared level 5. Her INR was therapeutic and
she was discharged home with VNA services and the appropriate
follow-up appointments.
Medications on Admission:
Atenolol 25mg qd, Aldactone 50mg qd, Lasix 40mg [**Hospital1 **], Coumdin,
Digoxin 0.125mg qd, Levoxyl 100mcg qd
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: then VNA to draw INR and call results to Dr. [**First Name (STitle) **] for
continued dosing.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Redo-Aortic Valve Replacement (mechanical)
h/o Rheumatic Heart Disease/Mitral Stenosis/Aortic Insufficiency
s/p Mitral Valve Replacement (mechanical) and Aortic Valve
Replacement (mechanical) [**2165**]
Pulmonary Hypertension
Atrial Fibrillation
Hypothyroid
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no driving for 1 month
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**First Name (STitle) **] in [**1-29**] weeks
with Dr. [**Last Name (STitle) 911**] in [**1-29**] weeks
with Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 1504**] in 4 weeks
Completed by:[**2179-3-10**] |
V3101,76503,769,7793,7742,7707,76524,77081,77981,7470,7766,7726,77989,36221,V290,V053 | 126 | 176,860 | Unit No: [**Numeric Identifier 69859**]
Admission Date: [**2129-8-10**]
Discharge Date: [**2129-10-24**]
Date of Birth: [**2129-8-10**]
Sex: F
Service: NB
REASON FOR ADMISSION:
1. Prematurity (27 and [**5-1**]-week gestation).
2. Respiratory distress syndrome
MATERNAL HISTORY: Mother is a 31-year-old G1/P0-1 with [**Last Name (un) **]
[**2129-11-4**] by IVI dating, PNS: A+, antibody negative,
RPR NR, rubella immune, HBS antigen negative, GBS unknown.
Her prenatal ultrasound scan revealed an intracardiac
echogenic focus in twin A; follow-up scan showed less
prominence of this. Fetal surveys were otherwise within
normal limits. Mother developed cervical dilatation,
effacement and preterm labor at 23 weeks gestation and was
treated with bedrest and magnesium sulfate. She was treated
with betamethasone at the end of [**Month (only) 205**].
DELIVERY COURSE: Baby girl [**Known lastname 69860**] was born as twin I by C-
section for preterm labor with twin pregnancy. She was noted
to be crying after some stimulation. Bulb suction and
supplemental oxygen were given with CPAP. The baby was then
intubated because of inconsistent respiratory effort and
reduced air movement. She was transferred to the NICU in view of
prematurity and RDS.
PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature
96.2 (increased to 97.7 with warming blanket), heart rate
160, respiratory rate 45, blood pressure 45/30 (35), oxygen
saturation 91%, weight 945 grams (25th percentile), length
28.5 cm (75th percentile), head circumference 25.5 (20th
percentile). SKIN: Baby appeared bruised on the right side of
her face, entire right arm and axilla. HEENT: Anterior
fontanelle soft and flat, faces normal,
palate intact. RESPIRATORY: Breath sounds with coarse high-
pitched rhonchi initially, improved after surfactant, mild
retractions. CVS: S1/S2 normal, no murmur, perfusion fair.
ABDOMEN: Soft with no organomegaly. GU: Normal AGA female
with prominent clitoris and labia minora. NEURO: Tone good,
symmetrical exam, hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
A. RESPIRATORY: The initial respiratory course and chest x-ray
findings were consistent with respiratory distress syndrome. She
was intubated soon after birth and received 2 doses of
surfactant. She was successfully extubated to CPAP on day #2
and subsequently to nasal cannula oxygen by day of life #5.
She remained in nasal cannula oxygen for the subsequent 3 to
4 weeks and has been breathing in room air since day of life
#39. She also had apnea of prematurity needing caffeine.
Caffeine was discontinued on day of life #29. Since then she
has had no significant apnea. At the time of discharge, she
has been comfortably breathing in room air and free of
significant apnea or bradycardia for more than 1 week.
B. CARDIOVASCULAR: She was noted to have an
echocardiographically-confirmed patent ductus arteriosus, for
which she received 1 course of indomethacin. Repeat
echocardiogram on [**8-16**] showed no PDA.
C. FLUIDS, ELECTROLYTES, NUTRITION: She received parenteral
nutrition for the first 5 days of life. Breast milk was
introduced on day of life #6 and gradually advanced to a
maximum of 150 mL/kg/day of breast milk 30 calories per ounce
feed by day of life #20. The caloric supplement was weaned
in keeping with her good weight gain. At the time of
discharge, she is on ad lib p.o. feeds of breast milk
24/Similac 24 and is taking approximately 150 mL/kg/day.
Discharge weight 3000 grams, head circumference 35.5 cm, length
46 cm.
D. GI: No complications. She received phototherapy for
physiologic jaundice exaggerated by prematurity with a
maximum bilirubin of 7.3/0.3 on day of life #9.
E. HEMATOLOGY: No complications. She did not receive any blood
products during her stay.
F. INFECTIOUS DISEASE: She received an initial 48-hour course
of IV antibiotics for sepsis rule out. She did not have any
episodes of proven sepsis. She received hepatitis B immunization
on [**9-9**] and her two-month immunization course including
DTaP/IPV/HepB (pediarix), HIB, and pneumococcus.
G. NEUROLOGY: Cranial ultrasound scan [**8-17**] normal;
[**9-9**] normal.
H. AUDIOLOGY: Passed newborn hearing screen.
I. OPHTHALMOLOGY: She had stage I ROP on the right side
which has gradually resolved. At the time of discharge,
she has immature retinae zone 3 bilaterally. Follow-up
eye exam is scheduled in 3 weeks.
J. PSYCHOSOCIAL: No concerns.
CONDITION ON DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **];
telephone # ([**Telephone/Fax (1) 69861**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Ad lib p.o. feeds of breast milk
24/Similac 24.
2. Medications: Multivitamin 1 mL p.o. once
daily, ferrous sulfate 0.5 mL p.o. once daily.
3. Car seat position screening passed.
4. State newborn screening done on [**2129-8-14**]; [**8-10**], [**2128**]. The latest newborn screening is within normal
limits, and a full report awaited.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
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 OR RECOMMENDED: With
primary care pediatrician 1 to 2 days following discharge.
DISCHARGE DIAGNOSES:
1. Prematurity (27 and [**5-1**]-week gestation).
2. Respiratory distress syndrome.
3. Apnea of prematurity.
4. Hyperbilirubinemia.
5. Patent ductus arteriosus.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 69862**]
MEDQUIST36
D: [**2129-10-24**] 15:55:23
T: [**2129-10-24**] 17:06:38
Job#: [**Job Number 69863**]
|
V103,1972,19889 | 127 | 141,647 | Admission Date: [**2183-8-20**] Discharge Date: [**2183-8-24**]
Date of Birth: [**2135-2-1**] Sex: F
Service: .
CHIEF COMPLAINT: Worsening shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
female with a history of metastatic breast cancer status post
lumpectomy and radiation with a history of two recent
admissions in [**Month (only) 116**] and [**2183-7-10**], for bilateral malignant
pleural effusions and bilateral pleurodesis requiring home O2
and Bi-PAP, now presenting with one week of progressive
worsening shortness of breath. The patient noted, starting
approximately one week ago, progressively worsening shortness
of breath at rest with increasing home O2 requirements. Two
days prior to admission, the patient presented to the
Emergency Department complaining of shortness of breath,
increased heart rate, decreased O2 saturations in the low
90s. The patient was evaluated for pulmonary embolism by CT
angiogram which was negative with only slight increase in the
right pleural effusion and atelectatic changes. The patient
was discharged home with home O2 to follow-up with her
Pulmonologist, Dr. [**Name (NI) **].
On the morning of admission, the patient saw Dr.
[**Name (NI) **], reporting worsening shortness of breath,
increased O2 requirements from 1.5 to 4 liters, decreased O2
saturations from the mid-90s to the low 90s and increased
heart rate above 100. An echocardiogram of the lungs was
done showing no change in pleural effusions and the patient
was referred to the [**Hospital1 69**] for
transthoracic echocardiogram.
The echocardiogram revealed a moderate to large sized
pericardial effusion with a right atrial collapse and a right
ventricular diastolic collapse, consistent with impaired
filling and tamponade.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer diagnosed in [**2177**]: Infiltrating
ductal carcinoma status post lumpectomy and radiation with
axillary node dissection, recurrence [**2182-8-10**];
admission [**4-/2183**] and [**7-/2183**] for bilateral pleural
effusions, bilateral pleurodesis requiring home O2.
2. Cerebrovascular accident in [**2178**]: Small hemorrhagic
cerebrovascular accident from a cavernous hemangioma.
3. Seasonal allergies.
4. Right low anterior rib fracture.
MEDICATIONS ON ADMISSION:
1. Xeloda 150 mg p.o. twice a day.
2. Claritin q. day.
3. Protonix 40 mg p.o. q. day.
4. Ativan 0.4 to 1 mg p.o. q. six p.r.n.
5. Motrin p.r.n. for rib pain.
6. Home O2.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has been an Intensive Care Unit
nurse here at the [**Hospital1 69**] for 28
years. Drinks alcohol socially. She has a 20 pack year
history of tobacco and quit in [**2174**].
FAMILY HISTORY: The patient has an aunt and great-aunt with
breast cancer. Her mother died of mixed connective tissue
disorder. Her father died of hairy cell leukemia.
PHYSICAL EXAMINATION: Vital signs upon admission,
temperature maximum of 97.7 F.; heart rate of 104 to 109;
blood pressure of 121/89, nap of 102; respiratory rate of 30;
pulses 16, 128/112. The patient's O2 saturation is 92 to 97
on four liters. Generally, the patient is a thin female,
notably short of breath while speaking. HEENT examination:
No scleral icterus. Extraocular muscles are intact. Pupils
are equal, round, and reactive to light and accommodation.
Mucous membranes were moist. Neck examination: At 30
degrees with jugular venous distention approximately 10
centimeters. No carotid bruits noted. Lung examination with
decreased breath sounds bilaterally at the bases, right
greater than left, crackles half way up the right side and a
third of the way up the left side. Dullness to percussion
bilaterally, right greater than left; no wheezes.
Cardiovascular examination with increased heart rate; normal
S1, split S2. No murmurs, rubs or gallops. Pulsus paradoxus
with radial pulse decreasing with inspiration. Pulses at 16.
Her abdominal examination with normoactive bowel sounds.
Abdomen was nondistended, nontender. Spleen tip was
palpable. Extremities were warm with normal dorsalis pedis
pulses bilaterally. No peripheral edema, clubbing or
cyanosis. Neurologic examination: The patient is awake,
alert and oriented times three with no gross lesions.
LABORATORY DATA: On [**8-18**], white blood cell count 6.9,
hematocrit of 39.2, platelets of 353. Sodium 136, potassium
3.9, chloride 99, carbon dioxide 25, BUN 15, creatinine 0.4,
glucose 104, calcium 9.1. Alkaline phosphatase 91, AST 24,
ALT 14, albumin 3.4, FSH 91.
Blood cultures negative. CA antigen [**585-7-13**] and
[**900-8-7**].
CT angiogram in the Emergency [****], showed no evidence
of pulmonary embolus, slight interval increase in right
pleural effusion with left loculated atelectatic changes. A
[**8-20**] lung ultrasound showing no change in pleural
effusion.
Transthoracic echocardiogram showing left ventricular
systolic function, mildly decreased septal hypokinesis,
moderate to large pericardial effusion, right atrial
collapse, right ventricular diastolic collapse consistent
with impaired filling or tamponade.
On [**8-20**], white blood cell count 5.7, hematocrit 37.5,
platelets 329, potasium 4.1.
HOSPITAL COURSE: In brief, the patient is a 48 year old
female with a history of metastatic breast cancer status post
two recent admissions for bilateral malignant pleural
effusions, bilateral pleurodesis requiring home O2 and
bi-PAP, now presenting with progressively worsening shortness
of breath times one week and transthoracic echocardiogram
consistent with pericardial effusion.
1. Cardiovascular: The patient with an echocardiogram
consistent with pericardial effusion. The patient was taken
to the Catheterization Laboratory on [**8-21**], where the
effusion was tapped and drained for 250 cc. of serosanguinous
fluid. Right ventricular pressure of 33/15, P- a pressure of
35/17, wedge of 21. Cardiac output 5.3, cardiac index 3.2.
The drain was subsequently pulled on [**8-23**]. Miss [**Known lastname 16968**] had
an EKG upon admission which showed no evidence of electrical
alternans and EKG upon discharge which also showed no
evidence of electrical alternans.
The house officer was called to see the patient in the
evening of [**8-21**], for chest pain with inspiration. A
pericardial rub was heard. An EKG showed some elevation in
PR interval in AVR.
Throughout her hospital course, the patient remained
tachycardic, in the low 100s to 110. A follow-up
echocardiogram was done revealing normal ejection fraction 45
to 50% and no evidence of pericardial effusion.
2. Pulmonary: The patient has a history of malignant
pleural effusions likely contributing to her symptoms of
shortness of breath. Dr. [**Name (NI) **] was made aware and
recommended no further intervention at this point. The
patient was saturating well in the low 90s to 95 range on
four liters of nasal cannula which was decreased to two
liters prior to discharge. The patient reported subjectively
that her shortness of breath had improved somewhat following
the tap. She will return home on home O2 and Bi-PAP.
3. Hematology/Oncology: The patient has a history of
metastatic breast cancer and malignant bilateral pleural
effusions, now with a new pericardial effusion which is
exudative. Cytology has been sent to evaluate if this is, in
fact, a malignant pericardial effusion. Dr. [**Last Name (STitle) **] was made
aware that the patient was hospitalized and involved in her
care during her inpatient stay. She is scheduled to
follow-up with him on Tuesday, [**8-26**]. She will continue on
Xeloda and pain control with morphine, Percocet, Toradol and
Motrin p.r.n.
The patient was discharged home on [**8-24**], with the following
medications, discharge diagnoses and instructions.
DISCHARGE DIAGNOSES:
1. New pericardial effusion, cytology pending.
2. Metastatic breast carcinoma with a history of malignant
pleural effusions.
3. Cerebrovascular accident in [**2178**].
4. Seasonal allergies.
5. History of rib fracture.
MEDICATIONS UPON DISCHARGE:
1. Xeloda 1650 mg twice a day.
2. Protonix 40 mg p.o. q. day.
3. [**Doctor First Name **] 60 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. An appointment has been made for Miss [**Known lastname 16968**] to follow-up
with Dr. [**Last Name (STitle) **] in Hematology/Oncology on Tuesday, [**8-26**], at 02:30 p.m.
2. It is recommended that the patient have a follow-up
echocardiogram to evaluate any further re-accumulation of
pericardial fluid.
3. The patient is to call if she has worsening symptoms or
shortness of breath, palpitations, chest pain.
4. The patient is to resume all prior medications. No new
medications have been added upon this admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 16969**]
MEDQUIST36
D: [**2183-8-24**] 14:56
T: [**2183-8-24**] 15:13
JOB#: [**Job Number 16970**]
cc:[**Last Name (NamePattern4) 16971**] |
85300,78039,E8889 | 129 | 164,174 | Admission Date: [**2157-3-27**] Discharge Date: [**2157-4-5**]
Date of Birth: [**2120-9-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Confusion; Multiple intraparenchymal intracranial hemorrhages on
OSH CT scan
Major Surgical or Invasive Procedure:
MRI MRA brain
TEE under general anaesthesia
History of Present Illness:
36 year old with no known prior medical history presented
to [**Hospital3 15402**] ED with confusion. The outside notes do not detail
the confusion or any decline; however, [**Hospital1 **] ED physicians state
that when they spoke to the physicians there, he was apparently
alert enough to give his own history. Laboratory workup was
unremarkable. Head CT showed multifocal parenchymal hemorrhages
throughout the cerbral hemispheres, primarily at the grey-whit
ejunction aidn the largest at the right temporal lobe. He was
loaded with Dilantin 1 gram and then subsequently transferred to
[**Hospital1 **] ED.
On arrival, the ED physicians have noted that he will respond to
vigorous stimulation but seemed to be worse than reported from
[**Hospital3 15433**] ED
Past Medical History:
Episode of head [**Last Name (un) **] requiring hospitalisation 5 years ago
Social History:
Lives with an uncle named [**Name (NI) 71**]. Wife and 3 children resident
in [**Country 7192**]. Employed recently in screw production factory and
fish factory. Patient denies any IV drug use, any recent
recreational drug use, unprotected sex, or
alcohol use.
Family History:
Nil significant reported
Physical Exam:
Physical Exam:
Vitals: T 99.8 HR 81 BP 115/60 HR 16 97% on RA
General: Warm to touch but in no acute distress
HEENT: OP clear, no lymphadenopathy
Heart: RRR no murmurs
Pulm: Clear bilaterally, good areation
Extremities: Warm and well perfused, no rashes over body
MS: Arouses to gentle sternal rub and then quickly falls back
asleep. Answering only yes or no to questions. Not following
any commands - squeeze hand, show thumb, stick out tongue.
CN: Pupils 2mm bilaterally and reactive, blinks to threat
bilaterally, corneals intact, facial movements symmetric, gag
intact.
Motor: Moves all extremities equally, symmetrically, and
purposefully. Normal bulk and tone.
Sensation: Withdraws to pain in all extremities
Reflexes: 2+/4 bilaterally, no clonus, no grasp reflex, toes
upgoing bilaterally.
Gait deferred
Pertinent Results:
Labs on admission:
CBC 12.1/14.4/41.5/182
INR 1.3 PT 14.3 PTT 27.3
Lytes 145/3.6/110/26/10/0.7/111 Ca 8.7 Mg 2.1 Phos 2.9
AST 29 ALT 36 Amylase 33, AP 84, TB 0.5
Lithium 0.3
Troponin negative
UDS and SDS negative
EKG with NSR
Dilantin [**2157-4-5**] 7.4
CSF: WCC 71 RCC [**Numeric Identifier 21671**]* prot 41 gluc 71
negative for gram stain, bacterial culture, malignant cells,
cryptococcus, fungal and viral cultures, acid fast bacilli to
date
Neurocysticercosis/Toxo PND
EEG:
This is an abnormal EEG in the waking and drowsy states due
to the infrequent right frontocentral slowing. This suggests a
right
frontocentral region of subcortical dysfunction. No epileptiform
features were noted.
MRA/MRV of head
FINDINGS: There are diffuse areas of intraparenchymal
hemorrhage, the largest lesions involving the right anterior
temporal lobe and right inferior frontal lobe with smaller
hemorrhagic lesions noted scattered through the right frontal,
right parietal, right occipital lobe, and left parietal,
temporal, and frontal lobes. Additional lesions are noted
within the left corpus callosum and right basal ganglia. Many
of these lesions display mild surrounding edema; however, no
areas of abnormal enhancement are noted throughout the brain
parenchyma. There is no shift of normally midline structures or
minor or major vascular territorial infarct apparent. Mild
mucosal thickening is noted within the maxillary sinuses
bilaterally with surrounding osseous structures appearing
unremarkable. There is a probable small left parietal subgaleal
hematoma.
MRA OF THE CIRCLE OF [**Location (un) **]
The major tributaries of the circle of [**Location (un) 431**] are patent with
no areas of
significant stenosis or aneurysmal dilatation. Within the limits
of coverage of study, no sign of an AV malformation is apparent.
Caliber of the vessel lumens appears smooth and within normal
limits with no irregular stenotic areas identified.
MRV of the brain demonstrates no venous sinus thrombosis.
IMPRESSION:
1. Bilateral intraparenchymal hemorrhages many of which are at
the grey white junction with additional lesions noted within the
left corpus callosum and right basal ganglia. No abnormal areas
of enchancement to suggest underlying focal masses identified.
Mostly unremarkable MRA. Differential includes vasculitis and
septic emboli including fungal etiologies. Less likely would be
coagulopathy, hemorrhages from underlying trauma, or diffuse
metastatic disease.
TEE
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium or left atrial appendage. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Overall left ventricular systolic
function is normal (LVEF>55%). The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. 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. No vegetation/mass is seen on the
pulmonic valve.
[**2157-3-31**] Testicular USS: Bilateral simple epididymal cysts and
small left-sided hydrocele with no evidence of focal testicular
lesion.
Brief Hospital Course:
36 year old with previous episode of head trauma (details
unknown) who presents with confusion and multiple
intraparenchymal hemorrhages. The etiology of lesions remains
unclear. The initial differential included drugs such as
cocaine, CNS vasculitis, hypertensive crisis, sinus thrombosis,
or multiple mass lesions with hemorrhage. MRI demonstrated L
scalp hematoma, suggestive of trauma. We suspect he may have had
a seizure followed by fall. Thus traumatic precipitant likely
but possible other underlying predisposition for bleeding.
The patient was initially monitored in the Neurology ICU and
transferred to the floor on [**2157-3-28**]. The patient was intially
treated with antibiotics but ceased after cultures were
negative. The patient was treated with dilantin and doses
increased for low level. PLEASE CHECK DILANTIN LEVEL. EEG showed
mild right frontal slowing.
The patient remained difficult to rouse for the first several
days.
The patient became increasingly responsive but remained with
clear cognitive impairment including poor recall for events
despite repeated explanation. He was abulic, needing
significant prompting to participate in therapy. No other focal
deficits present at discharge. Formal testing of power difficult
due to variable effort but appears full.
PT OT provided.
Review of imaging studies revealed no concensus regarding
etiology of lesions. Cavernous angiomas a possibility but felt
unlikely explanatory of all lesions. MRV was negative for venous
sinus thrombosis.
Drug toxicology screens were negative, but note possible
substances not captured on screening. Echocardiogram to look for
signs of endocarditis/septic emboli was performed under GA (due
to failure to obtain without sedation) and demonstrated no
source of septic emboli. LP was performed and negative for
cryptococcus, toxoplasmosi, neurocysticercosis.
Inflammatory markers were elevated on admission and trended
down.
Question of possible bleeding metastatic lesions explored with
testicular ultrasound which was normal aside from epipidymal
cysts. CT abdomen demonstrated hypodensity in the liver likely
due to early fatty infiltration. CT chest suggested small RLL
PE. He was asymptomatic and no further action taken in view of
intracranial bleeding.
There was an episode of urethral bleeding occurred on [**2157-3-31**]
likely associated with recent catheterisation, then settled.
The social work team were involved early on to assist to
communicating with friends and family and patient. Medical team
discussed progress with wife in [**Country 7192**] and obtained phone
consent for procedures (TEE).
Follow up with neurology and PCP has been initiated. Required
further social work support to pursue free care options and
arrange PCP.
Medications on Admission:
NIL
Discharge Medications:
1. Phenytoin Sodium Extended 30 mg Capsule Sig: One (1) Capsule
PO three times a day: Take with 200mg tablet tid.
2. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule
PO three times a day: Take with 30mg tablet tid.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Multiple intracranial hemorrhages
Discharge Condition:
Stable. Remains abulic requiring encouragement to participate in
therapy.
Discharge Instructions:
Please keep all follow up appointments and seek further medical
assistance for new symptoms of confusion, weakness, abnormal
sensations or speech problems.
Please keep all follow up appointments and seek further medical
assistance for new symptoms of confusion, weakness, abnormal
sensations or speech problems.
You have been started on a medication to prevent seizures called
dilantin. Please have levels checked in the next couple of days
and at intervals thereafter as advised by your doctor.
Followup Instructions:
NEED DILANTIN LEVELS FOLLOWED AT REHAB
Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 72198**] for assistance with free
care and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72199**] [**Telephone/Fax (1) 72200**] to arrange PCP follow
up.
MRI [**Hospital Ward Name 23**] [**Location (un) 861**] Wednesday [**5-11**] 10am with Interpreter
[**Numeric Identifier 72201**]
Dr [**Last Name (STitle) **] Neurology [**Hospital Ward Name 23**] [**6-26**] 2.30pm [**Hospital1 18**] Please
call [**Numeric Identifier 72202**] to confirm the appointment; with Spanish
interpreter.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
V4581,41400,53081,25000,73028,42731,9971,5185,99831,99859 | 130 | 113,323 | Unit No: [**Numeric Identifier 56787**]
Admission Date: [**2119-11-14**]
Discharge Date: [**2119-12-1**]
Date of Birth: [**2058-6-3**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Father [**Name (NI) **] is a 61-year-old
man, with known CAD, status post coronary artery bypass graft
on [**2119-10-31**] with a LIMA to the LAD, saphenous vein graft to
OM1, saphenous vein graft to D1, and saphenous vein graft to
PDA. The patient was discharged home on [**11-5**], and returns
on the day of admission complaining of sternal drainage x
several days with increasing amounts on the day of admission.
The patient denies fever, chills, nausea, vomiting, or
malaise.
PAST MEDICAL HISTORY: CAD, status post CABG with an EF of 20
percent.
Diabetes mellitus, currently insulin dependent.
Hypercholesterolemia.
GERD.
ALLERGIES: None.
MEDS ON ADMISSION:
1. Colace 100 mg [**Hospital1 **].
2. Aspirin 81 mg once daily.
3. Plavix 75 mg once daily.
4. Carvedilol 6.25 mg [**Hospital1 **].
5. Simvastatin 40 mg once daily.
6. Lasix 40 mg [**Hospital1 **].
7. Lantus insulin 45 units q pm.
8. Percocet 5/325, 1-2 tabs q 4 h prn.
LABS ON ADMISSION: White count 18.6, hematocrit 33.9,
platelets 893, PT 17.5, PTT 24, INR 1.1, sodium 139,
potassium 4.2, chloride 101, CO2 25, BUN 14, creatinine 0.9,
glucose 246. Chest x-ray shows cardiomegaly with left-sided
effusion with atelectasis, multiple displaced wires. EKG:
Sinus rhythm with a rate of 100, Q's in III and AVF,
nonspecific ST changes with poor R wave progression.
PHYSICAL EXAM: Temperature 103, heart rate 116--sinus
tachycardia, blood pressure 100/47, respiratory rate 30, O2
sat 97 percent on 2 liters nasal prongs. Neuro: Alert and
oriented x 3, moves all extremities, follows commands,
nonfocal exam. Respiratory: Clear to auscultation with a
sucking chest wound. Cardiovascular: Regular rate and
rhythm. Sternum with surrounding erythema of about 10 cm,
with a positive click. Small draining hole in midincision
with milky serous drainage. Staples remain in place.
Abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well-perfused with no
edema. Right calf with a healing wound and minimal erythema.
Left knee with an endoscopic site that is healing, open to
air, clean and dry.
HOSPITAL COURSE: The patient was admitted to the
Cardiothoracic Intensive Care Unit. He was begun on
vancomycin 1 gm q 12 h, as well as levofloxacin 500 mg once
daily. He was typed and screened and kept NPO for
mediastinal exploration plus/minus a flap closure.
On hospital day 2, the patient was brought to the operating
room. Please see the OR report for full details. In
summary, the patient had a sternal exploration and
debridement. He tolerated the operation well and was
returned to the Cardiothoracic Intensive Care Unit intubated
and sedated with an open chest wound. Plastic surgery was
also following the patient.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. Several hours
following extubation, the patient was found to be in acute
respiratory distress and was emergently reintubated. From
that point forward, he was kept sedated and ventilated
awaiting plastics follow-up for flap closure.
On the [**11-19**], the patient returned to the operating
room. Please see the OR report for full details. In
summary, the patient was brought to the operating room by the
plastic surgery service for pectoral advancement with an
omentum flap. He tolerated the operation well and was
returned to the Cardiothoracic Intensive Care Unit. The
patient remained intubated following his surgery. However,
his sedation was minimized to allow the patient to
overbreathe the ventilator. During that period, the patient
had several episodes of coughing which led to a dehiscence of
his abdominal incision, and on the [**11-20**] the patient
again returned to the operating room for re-exploration and
closure of the fascia of his abdominal wound. He tolerated
this surgery well also and following that returned to the
Cardiothoracic Intensive Care Unit, again ventilated and
sedated. The patient remained ventilated and sedated for the
next several days in an attempt to give the wound a chance to
heal.
Ultimately, the patient was successfully extubated on the [**11-24**]. However, he stayed in the Cardiothoracic
Intensive Care Unit following extubation for close pulmonary
monitoring. It should be noted that during the patient's ICU
course, he had several intermittent episodes of atrial
fibrillation for which he was begun on amiodarone, as well as
heparin and ultimately Coumadin for anticoagulation. The
patient did well over the next several days, and ultimately
was transferred to the floor on [**11-28**], hospital day 15,
postoperative day 13. At that point, a PICC line was placed
for long-term antibiotic coverage.
Over the next several days, the patient's activity level was
increased with the assistance of the nursing and the physical
therapy staff. His antibiotic coverage was continued. His
anticoagulation was transitioned from intravenous to oral.
Finally, on the [**12-1**], the patient's final [**Location (un) 1661**]-
[**Location (un) 1662**] drain was removed from his chest, and it was decided
that he was stable and ready to be transferred to
rehabilitation for long-term antibiotic coverage, as well as
glucose control.
At that time, the patient's physical exam was as follows:
Vital signs: Temperature 98.4, heart rate 82--sinus rhythm,
blood pressure 113/66, respiratory rate 18, O2 sat 95 percent
on room air, weight day of dictation 106.6 kg, preoperatively
100 kg. Lab data: PT 17.1, INR 1.9, sodium 139, potassium
3.7, chloride 100, bicarb 27, BUN 11, creatinine 0.9, glucose
149, white count 9.1, hematocrit 28.4, platelets 830.
Physical exam - Neurologically: Alert and oriented x 3,
nonfocal exam. Pulmonary: Clear to auscultation
bilaterally. Cardiac: Regular rate and rhythm, S1, S2.
Sternum: Incision with staples, clean and dry. No erythema
or drainage. Abdomen was soft, nontender, nondistended with
normoactive bowel sounds. Abdominal incision with staples,
also clean and dry. Extremities were warm with no edema.
Right saphenous vein graft harvest site was healing well,
open to air, clean and dry.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting complicated by sternal
infection requiring sternal debridement and flap closure.
Diabetes mellitus.
Hypercholesterolemia.
Gastroesophageal reflux disease.
FOLLOW UP: Follow-up with Dr. [**Last Name (STitle) 13797**] with plastic surgery
service in 1 week. He is to call for an appointment at [**Telephone/Fax (1) 56789**]. He is also to have follow-up with Dr. [**Last Name (STitle) **] in 4
weeks. The patient is also to call for that appointment; the
number is [**Telephone/Fax (1) 170**].
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg [**Hospital1 **].
2. Simvastatin 40 mg once daily.
3. Ferrous sulfate 325 mg once daily.
4. Ascorbic acid 500 mg [**Hospital1 **].
5. Zinc sulfate 220 mg once daily.
6. Aspirin 81 mg once daily.
7. Erythromycin ophthalmic ointment [**Hospital1 **].
8. Colace 100 mg [**Hospital1 **].
9. Metoprolol XL 100 mg once daily.
10.Glargine 24 units q at bedtime.
11.Humalog insulin sliding scale q ac and at bedtime.
12.Lasix 20 mg once daily.
13.Potassium chloride 20 mEq once daily.
14.Amiodarone 400 mg [**Hospital1 **] x 1 week, then 400 mg once daily x 1
week, then 200 mg once daily.
15.Oxacillin 2 grams q 4 h through [**12-28**].
16.Warfarin as directed to maintain a target INR of 2 to 2.5.
The patient's warfarin doses starting with 4 days ago - 3 mg,
5 mg, 5 mg, 5 mg. The patient is to receive 4 mg on the [**2032-11-29**].Albuterol 2 puffs qid prn.
DISPOSITION: The patient is to be discharged to
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2119-12-1**] 13:31:57
T: [**2119-12-1**] 14:15:12
Job#: [**Job Number 56790**]
|
53081,2720,3572,25060,41401,2851,4280,41071 | 130 | 198,214 | Unit No: [**Numeric Identifier 56787**]
Admission Date: [**2119-10-29**]
Discharge Date: [**2119-11-5**]
Date of Birth: [**2058-6-3**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male with a history of diabetes type 2 x5 years complicated
by peripheral neuropathy, hyperlipidemia, and GERD, who
presented to the emergency department on [**2119-10-29**] with a
chief complaint of epigastric pain and burning. The patient
had exerted himself and had felt fatigued and lightheaded.
At that point in time, he was also short of breath and
slightly diaphoretic. He had an elevation of his ST
elevations and old Q waves inferiorly on his EKG at that
point in time. The patient was then cardiac catheterized, at
which time he had a cardiac output of 5.15 with an index of
2.26. Assessment was severe LMCA three-vessel coronary
artery disease with recent thrombotic occlusion distal RCA,
severe left ventricular diastolic heart failure, and he had a
balloon pump inserted. It was decided that the patient could
undergo CABG by Dr. [**Last Name (STitle) **]. He underwent a CABG x4, LIMA to
LAD with a jump graft, ramus, and he was diagnosed with a
PDA. He had EF preoperatively of 30 percent.
PAST MEDICAL HISTORY: His past medical history included
diabetes with peripheral neuropathy, hyperlipidemia, coronary
artery disease, and GERD.
MEDICATIONS AT HOME: His medications at home included Zocor,
Humulin insulin, aspirin 325 mg, and Lopressor b.i.d.
SOCIAL HISTORY: The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] educator, who has
difficulty ambulating at times and uses a cane to walk with
assistance. He smokes cigars once a week. He drinks an
occasional glass of wine or scotch every evening.
HOSPITAL COURSE: The patient, in the postoperative period,
did quite well within the unit for a brief period of time and
was discharged to the floor when he met criteria. He
tolerated the procedure quite well, and so he was weaned off
of his Neo immediately postoperatively. He was on the
insulin drip, and he was started on aspirin and Plavix, and
given Lasix for diuresis. [**Last Name (un) **] was called, who helped [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult to help manage his diabetes. The patient had
good pain control. He had some shortness of breath in the
postoperative period. However, he was evaluated by Physical
Therapy, and once again, he was ambulating and was able to
recruit and do quite well from a pulmonary perspective, and
by the end of discharge, he was able to ambulate
independently, was able to do stairs, and had his blood sugar
under control.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE/FOLLOW-UP INSTRUCTIONS: He was given instructions.
He is to follow up in three to four weeks with Dr. [**Last Name (STitle) **].
He was given instructions to see his cardiologist within one
week. He was given instructions to see his primary care
physician in one week and go over the medications and review
all medications that the patient was currently taking. The
patient is with an off-pump bypass and therefore should be on
Plavix for three months.
MAJOR DIAGNOSES: Coronary artery disease, status post
myocardial infarction, with a recent thrombotic occlusion,
status post coronary artery bypass graft of four vessels,
diabetes, hyperlipidemia, and blood loss anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2119-11-5**] 15:29:08
T: [**2119-11-6**] 02:04:44
Job#: [**Job Number 56788**]
|
V053,76528,76518,77214,V3001 | 131 | 171,781 | Admission Date: [**2143-12-7**] Discharge Date: [**2143-12-12**]
Date of Birth: [**2143-12-7**] Sex: M
Service: Neonatology
HISTORY: Baby boy [**Known lastname 64632**] is a 36 and 4/7 weeks gestational
age infant admitted with antenatal diagnosis of intracranial
hemorrhagic event.
MATERNAL HISTORY: Mom is a 22-year-old gravida 1, para 0,
now 1 mom with a past medial history notable for asthma, for
cigarette smoking 1 pack per day, marijuana use and alcohol
use, all prior to 7 months gestation when she became aware of
pregnancy.
PRENATAL SCREENS: Blood type B positive, antibody negative,
RPR nonreactive, group beta strep negative, hepatitis B
surface antigen negative, and rubella immune.
ANTENATAL HISTORY: Mom was a late registrant to prenatal
care, with pregnancy not diagnosed until 7 months. Estimated
date of delivery based on the 7 to 8 month ultrasound on
[**2143-10-31**].
The initial ultrasound showed ventriculomegaly and a
porencephalic cyst. Subsequent prenatal MRI showed the
following:
1. Left ventriculomegaly extended across baseline with
associated porencephalic cyst.
2. Absent corpus callosum.
3. Compression of posterior fossa and effacement of
extraaxial CSF spaces, especially those of left
cerebellar hemisphere.
4. T2 signal hyper-intensity in the right cerebral
hemisphere.
Spontaneous rupture of membranes occurred 3 hours prior to
delivery, yielding clear amniotic fluid. She proceeded to
cesarean section under spinal anesthesia due to concerns
regarding thrombophilia. There was no labor and no
interpartum fever, or other clinical evidence of
chorioamnionitis. The infant was vigorous at delivery. He was
orally and nasally bulb suctioned, and dried. Subsequently
pink and in no distress in room air. Apgar scores were 8 at 1
minute and 9 at 5 minutes of age. He was transferred
uneventfully to the newborn ICU for further observation.
PHYSICAL EXAMINATION: Birth weight 2370 grams (25th
percentile), head circumference 33.5 cm (50th to 75th
percentile), length 45.5 cm (25th to 50th percentile). HEAD,
EARS, EYES, NOSE AND THROAT: Anterior fontanel slightly full,
posteriorly fontanel prominent, sagittal sutures split
approximately 1 cm, nondysmorphic, palate is intact, no nasal
flaring. CHEST: No retractions. Good breath sounds
bilaterally. No crackles. CARDIOVASCULAR: Infant well
perfused. Regular rate and rhythm. Normal femoral pulses. S1
and S2 normal. No murmurs. Abdomen soft, nondistended. No
organomegaly. No masses. Bowel sounds active. GU: Normal
penile shaft, testes descended bilaterally. NEUROLOGIC:
Infant active, alert, responds to stimuli, axial and
appendicular tone normal and symmetrical, moving all
extremities symmetrically, no facial asymmetry, suck, root,
and gag intact, grasp symmetrical. Skin normal.
MUSCULOSKELETAL: Normal spine, limbs, hips and clavicles.
Initial blood glucose was 55.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant was admitted from labor and delivery to the newborn
intensive care unit for evaluation of this infant with
prenatal diagnosis of porencephalic cyst. He has been in room
air for the duration of his hospitalization. Of note the
infant was delivered on [**12-7**], came to the NICU for
several hours for evaluation and then transferred to the
newborn nursery several hours after delivery. He returned to
the newborn intensive care unit on [**12-9**] for head
imaging studies. He has been in room air for the duration of
his hospitalization and has not required additional oxygen
and has not had any desaturation events.
CARDIOVASCULAR: The infant has been pink and well perfused
for the duration of his hospitalization. His blood pressure
has been normal throughout his hospitalization. Heart rate is
120s to 160s and no murmurs auscultated. Normal pulses.
FLUIDS, ELECTROLYTES AND NUTRITION: Enteral feeds were
initiated within 24 hours of age. He has been taking ad lib
amounts of Enfamil 20 without difficulty and has been
tolerating feeds throughout his hospitalization. His weight
at the time of discharge is 2285 grams, and head
circumference 33 cm.
GASTROINTESTINAL: The infant's bilirubin on day of life 3
was 5.3 with direct bilirubin of 0.3. He has not required any
phototherapy.
HEMATOLOGY: The infant's blood type is not known at this
time. He has not received any blood products during his
hospitalization. His hematocrit upon admission to the newborn
intensive care unit was 53.6.
INFECTIOUS DISEASE: CBC was drawn upon admission to the NICU
mainly to look at the infant's platelet count which was 195.
There was no maternal risk for infection. The infant's CBC
had white count of 8.7, hematocrit of 53.6 with 51% poly's
and 2% bands. Blood culture was not drawn at that time and he
has not received any antibiotics. There have been no other
concerns for infection.
NEUROLOGY: As mentioned before the infant was readmitted to
the NICU on [**12-9**] for head imaging studies. He
underwent a head ultrasound on [**12-9**] which showed: 1)
porencephaly, 2) hypoplastic or absent corpus callosum, 3)
debris and/or blood products layering within the dependent
portion of the left lateral ventricle.
An MRI was done over at [**Hospital3 1810**] on [**12-10**]
which showed dysmorphic cystic dilatation of the left lateral
ventricle consistent with porencephaly. White matter volume
loss in the left cerebral hemisphere. Evidence of left
germinal matrix, subependymal and intraventricular blood
products. Foci of subacute hemorrhage in the right common
radiata. Normal MRA of the Circle of [**Location (un) 431**]. The infant's
neurologic examination has remained normal.
SENSORY: A hearing screen was performed without automated
auditory brain stem responses. The results are normal.
OPHTHALMOLOGY: Eye examination not indicated for this 36 and
[**3-28**] week infant.
GENITOURINARY: A circumcision was performed prior to the day
of discharge and circumcision site is healthy and healing
nicely.
PSYCHOSOCIAL: This is a lesbian couple both involved with the
infant's care. As mentioned earlier, mom has a history of
marijuana and alcohol use. Mom's tox screen that was done on
[**12-7**] was negative. [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] social work has been involved with the family. The
contact social worker can be reached at [**Telephone/Fax (1) **]. The parents
have both spoken with Dr. [**Last Name (STitle) 64633**] from neurology at [**Hospital3 18242**] and have been counseled on the neuro developmental
issues in this infant.
CONDITION ON DISCHARGE: Infant stable in room air. Stable
temperature in open crib, tolerating PO feeds and no evidence
of neurological compromise at this time.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 780**] and Dr. [**First Name (STitle) **] at [**Hospital3 64634**].
Phone No. [**Telephone/Fax (1) 14167**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: ad lib demand feeds of Enfamil 20.
2. Medications: None.
3. Car seat position screening: I attempted to do car seat
test in a car seat that was provided by social services
at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. Car seat was
found to be too big for the infant, so car seat position
screening deferred. Parents are stating that they do not
own a car and will not be driving and will be using
public transportation. INfant should not use the car seat
that they had brought in.
4. State newborn screen status: State newborn screen was
sent at 72 hours of age and no abnormal results have been
reported. Final results are pending.
5. Immunizations received:
The infant received his first Hepatitis B vaccine on [**2143-12-11**].
1. Immunizations Recommended:
2. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following:
3. daycare during the RSV season.
4. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
5. with chronic lung disease.
1. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointment in the neonatal neurology clinic with
Dr. [**Last Name (STitle) **] has been scheduled for [**2144-1-22**], at
10:30 a.m.
The infant has been followed by Dr. [**Last Name (STitle) 64633**] at [**Hospital3 18242**]. The baby will also be followed by care group VNA,
phone No. [**Telephone/Fax (1) 14297**]. He will also be followed by
Bay Cove Early Intervention Program. Phone Number: [**Telephone/Fax (1) 64635**].
DISCHARGE DIAGNOSES:
1. Intrauterine cerebrovascular accident.
2. Mild prematurity at 36 and 4/7 weeks gestation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 59783**]
MEDQUIST36
D: [**2143-12-12**] 01:49:32
T: [**2143-12-12**] 04:25:51
Job#: [**Job Number 64636**]
|
3051,2761,78039,430 | 132 | 160,192 | Admission Date: [**2115-5-6**] Discharge Date: [**2115-5-25**]
Date of Birth: Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
right handed lady who presents to the [**Hospital6 649**] for sudden onset of frontal occipital headache
and brief one to three minute episode of generalized
tonoclonic seizure. CT scan was consistent with subarachnoid
hemorrhage. The morning of admission at 11:30 while working
in her office talking on the phone, she put her head down
followed by shaking of bilateral upper extremities as per
colleagues. Her eyes were open and she was looking straight
ahead. She did not respond to any stimuli. No tongue
biting, no vomiting. She did not have any urinary of fecal
incontinence. EMS was activated. After approximately two to
three minutes she was back to her baseline.
PAST MEDICAL HISTORY:
1. Anemia
2. Appendectomy
ALLERGIES: PENICILLIN CAUSES A RASH. DEMEROL CAUSES
HYPERSENSITIVITY.
MEDICATIONS: The patient is on no medications on admission.
FAMILY HISTORY: Stroke, father died of stroke.
SOCIAL HISTORY: She is widowed, lives with sister. Heavy
[**Name2 (NI) 1818**], one pack per day for 20 years. Alcohol use, one
bottle of beer per day.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.3??????,
respiratory rate 20, pulse 76, blood pressure 170/87.
In general, she is a 56-year-old lady in no acute distress.
She had an O2 nonrebreather mask, appeared tired, alert,
awake and oriented to time, place and person. Followed
commands. Speech was fluent. No paraphasic events.
Repetition and naming were intact. She was attentive.
Pupils bilaterally 2 mm to 1.5 mm. Pupils equal, round and
reactive to light. Extraocular muscles were intact. Face
was symmetric, bilateral, equal and intact facial sensation.
Uvula and tongue were midline. Sternocleidomastoid and
trapezius intact. Neck supple. Normal tone and bulk. Power
and strength was [**3-24**] in all four extremities and muscle
groups. Reflexes were 2+ throughout. Toes were downgoing.
Coordination - finger nose finger was slow. Gait was
deferred.
HOSPITAL COURSE: While in the Emergency Department, the
patient became more somnolent, still was arousable, but
became sleepier. The patient was admitted to the
Neurosurgery Service on [**5-6**]. She had an angiogram
which demonstrated an anterior communicating artery aneurysm
which was clipped. The patient received triple H therapy and
Decadron while in the Surgical Intensive Care Unit. She was
observed for vasospasms, no evidence of occurred and her
intravenous fluids were slowly weaned. Her steroids were
weaned off. The patient, at this time, has a neurological
exam consisting of mental status - the patient is alert. She
is oriented in that she knows what hospital she is in. She
is oriented to person. She states that the date is [**2114**]
which has been an improvement. The patient has slight
evidence of pronator drift. She is still mildly ataxic. The
patient is being discharged to rehabilitation on [**2115-5-25**].
DISCHARGE DIAGNOSIS:
1. Subarachnoid hemorrhage secondary to anterior
communicating artery aneurysm
DISCHARGE MEDICATIONS:
1. Nimodipine 60 mg po q4 until [**2115-6-7**]
2. Heparin 5000 units subcutaneous [**Hospital1 **]
3. Dilantin 200 mg po tid
4. Zantac 150 mg po bid
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 6910**] in
three to four weeks.
DISCHARGE CONDITION: Stable
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2115-5-25**] 08:12
T: [**2115-5-25**] 08:27
JOB#: [**Job Number 30027**]
|
41071,41401,496,5990,4400,2939,2749,4439,4019,2720,V1582 | 133 | 191,817 | Admission Date: [**2165-5-6**] Discharge Date: [**2165-5-16**]
Date of Birth: [**2088-1-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
intermittent chest pain for 1-2 months, but worse in last few
days prior to admission with associated arm pain
Major Surgical or Invasive Procedure:
cabg x3 [**5-7**]
History of Present Illness:
77 yo male with 1-2 months , but worsening in past few days.
Also has associated arm pain. Admitted to [**Hospital **] Med Ctr. in
RI [**5-2**]. Ruled in for NSTEMI by exzymes. Cath performed there
revealed EF 70%, 90% LAD, CX 90-95%, 90% PDA. He has significant
COPD with reported hx of FEV1 0.6/ FVC 1.2L.
Transferred here for CABG with Dr. [**Last Name (STitle) **].
Past Medical History:
CAD
COPD
HTN
gout
depression
PVD s/p right CEA
Social History:
smoked 1 ppd for 55 years, quit 1 year ago
uses alcohol, but none in 2 months
wife died last year
Family History:
no family hx of CAD or CVA
Physical Exam:
5'6" 58.2 kg 99.3 125/91 SR 83 92% on 2L
NAD
AT/NC no JVD, lymphadenopathy, or bruits bilat. Healed Right
CEA scar.
distant heart sounds RRR no murmur
distant breath sounds without wheezes
abd. soft, NT, ND
extrems. without C/C/E, bilat erythema over medial malleoli, +
TTP
pulses: 2+ bil. carotid, radial; pops. not palpable
1+ bilat. femoral, DP and PT
Pertinent Results:
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-6**] 08:55PM BLOOD WBC-7.0 RBC-3.65* Hgb-11.6* Hct-33.7*
MCV-92 MCH-31.7 MCHC-34.3 RDW-12.2 Plt Ct-199
[**2165-5-16**] 06:35AM BLOOD Neuts-89.6* Lymphs-5.3* Monos-4.4 Eos-0.6
Baso-0.1
[**2165-5-16**] 06:35AM BLOOD Plt Ct-295
[**2165-5-6**] 08:55PM BLOOD PT-12.1 PTT-40.9* INR(PT)-1.0
[**2165-5-14**] 10:30AM BLOOD Glucose-110* UreaN-17 Creat-1.0 Na-134
K-4.2 Cl-92* HCO3-31* AnGap-15
[**2165-5-6**] 08:55PM BLOOD ALT-13 AST-21 LD(LDH)-183 AlkPhos-77
TotBili-0.4
[**2165-5-13**] 02:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9
[**2165-5-6**] 08:55PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2165-5-8**] 12:24PM BLOOD Cortsol-29.0*
Brief Hospital Course:
Carotid u/s done pre-op showed no signif. stenoses. Underwent
CABG x3 on [**5-7**] with Dr. [**Last Name (STitle) **]. Plaque was found in thoracic
aorta during intraop TEE. Transferred to CSRU on titrated
neosynephrine and propofol drips. Remained on neo on POD #1 on
ventilator for weaning. Vascular surgery ([**Doctor Last Name **])
consulted about plaque and CTA of chest was negative for
dissection. Hemodynamically stable on neo 0.3. Extubated on POD
#2 and chest tubes removed. Transferred back to CSRU after one
hour on the floor. Not reintubated, but moitored carefully for
respiratory issues/COPD. Transferred back to floor on POD #4.
Seen and eval. by PT. Beta blockade and lasix diuresis started.
Had some confusion and wheezing. Treated with haldol and
restarted on pulmonary toilet. Anxiety and confusion has
resolved. Betablockade was increased on POD #7. He continued to
increase his ambulation. UTI diagnosed on [**5-15**] with rising WBC
to 20. WBC decreased to 18 today on day 2 of a 7 day course of
cipro. Afebrile today, VS 98.5 67 SR 166/63 RR 20 92% on 2L ,
55.5 kg today ( down from pre-op weight 2.5 kg). Alert and
oriented, wounds healing well. Patient is on 2L O2 via NC at
home. Will require O2 therapy. Transferred to rehab on POD # 9.
Medications on Admission:
Combivent 2 puffs QID
Heparin IV 800 u /he
Tiotropium 1 puff qd
ECASA 81 mg qd
Advair 50/100 1 puff [**Hospital1 **]
Flomax 0.4 mg qd
NTG paste prn
Bisoprolol 2.5 mg qd
lipitor 10 mg qd
lexapro 10 mg qd
atenolol 50 mg qd
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 1 months.
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer IH
Inhalation Q4WA ().
8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
[**12-2**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
10. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Capsule, w/Inhalation Device Inhalation [**Hospital1 **] (2 times a
day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6930**] Skilled Nursing
Discharge Diagnosis:
s/p cabg x3
CAD
COPD
elev. chol
HTN
UTI
gout
depression
MI
PVD s/p Right CEA
Discharge Condition:
stable
Discharge Instructions:
may shower over wounds; pat dry
no powders, creams or lotions on incisions
may not drive for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
follow up with PCP [**Last Name (NamePattern4) **] [**12-2**] weeks post discharge
follow up with Dr. [**Last Name (STitle) **] for postop visit in 4 weeks
[**Telephone/Fax (1) 170**]
Completed by:[**2165-5-16**] |
41401,3963,4019,53081,3659,2449,4439 | 134 | 167,887 | Unit No: [**Numeric Identifier 57148**]
Admission Date: [**2127-1-14**]
Discharge Date: [**2127-1-24**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is an 80-year-old male who
reports episodes of severe fatigue in [**2124**] that resolved
spontaneously. Diagnosed with cardiomyopathy and mitral
insufficiency. He also reports an episode of chest pressure
earlier in [**2126**] that resolved with rest, with a recent
increase in episodes of fatigue recently. Therefore,
referred for cardiac catheterization in [**2126-10-9**].
Cardiac catheterization revealed an ejection fraction of 56
percent, a 100 percent RCA occlusion, a 100 percent OM
occlusion, a 70 percent ramus occlusion, a 90 percent LAD
occlusion, an 80 percent first diagonal occlusion, with 2
plus mitral regurgitation; for which he was referred for
evaluation for coronary artery bypass grafting and mitral
valve repair or replacement.
PAST MEDICAL HISTORY: Peripheral vascular disease, abdominal
aortic aneurysm, silent myocardial infarction, transient
ischemic attacks, hypothyroidism, gastroesophageal reflux
disease, psoriasis, glaucoma, hypertension, left lower
extremity varicosities, and a sodium abnormality (on steroid
treatment).
PAST SURGICAL HISTORY: Includes a left carotid
endarterectomy in [**2125**] and bilateral cataract removal.
PREOPERATIVE MEDICATIONS: Hydrocortisone 10 mg in the
morning and 5 mg in the evening, aspirin 325 mg once daily,
lisinopril 5 mg once daily, Crestor 10 mg once daily, Lasix
40 mg every other day, testosterone 200-mg injection every
three to four weeks, Levoxyl (unknown dose), atenolol
(unknown dose), and Xalatan eye drops (unknown dose).
ALLERGIES: INTRAVENOUS DYE.
PHYSICAL EXAMINATION ON PRESENTATION: Height was 6 feet 2
inches tall, weight was 186 pounds, the heart rate was 44,
the blood pressure on the right was 143/68 and on the left
131/61. In general, a tall solid elderly male. Skin
revealed no obvious disease. HEENT examination revealed the
pupils were equal, round, and reactive to light and
accommodation. The extraocular movements were intact. The
eyes were anicteric. The neck revealed a healed left carotid
endarterectomy scar. Negative jugular venous distention. No
bruits appreciated. Chest was clear to auscultation. Right
crackles at the left base. Heart revealed a regular rate and
rhythm. S1 and S2. No appreciated murmur. The abdomen was
soft, nontender, and nondistended. There was positive bowel
sounds. Negative costovertebral angle tenderness. The
extremities were warm and well perfused. There was 1 plus
edema on the left leg. Varicosities were present in the left
lower extremity with venous stasis changes. Neurologically,
cranial nerves II through XII were grossly intact; nonfocal.
Good strength in all four extremities.
RADIOLOGIC STUDIES: Preoperative carotid ultrasound in
[**2126-2-7**] showed a 60 to 80 percent right internal
carotid artery stenosis with no noted left stenosis.
A chest x-ray with no acute cardiopulmonary disease.
PERTINENT LABORATORY DATA ON PRESENTATION: Pulmonary
function tests were also obtained in [**2126-10-9**]
showing an FEV1 of 93 percent of predicted and FEV1:FVC ratio
of 97 percent of predicted. White blood cell count was 7,
the hematocrit was 39.7, the platelets were 219. PT was
12.9, PTT was 30.9, and INR was 1. Urinalysis was negative.
Glucose was 91, BUN was 22, creatinine was 1.2, sodium was
136, potassium was 4.6, chloride was 101, and bicarbonate was
27. ALT was 15, AST was 26, alkaline phosphatase was 71, and
total bilirubin was 0.4. Albumin was 4.3. Hemoglobin A1C
was 5.5.
SUMMARY OF HOSPITAL COURSE: Mr. [**Name13 (STitle) 57149**] presented on his
operative day ([**2127-1-14**]) and proceeded to the
Operating Room for coronary artery bypass grafting times four
with a LIMA to the LAD, a saphenous vein graft to the OM, a
saphenous vein graft to the ramus, and a saphenous vein graft
to the PDA. He also had a mitral valve repair with a 28-mm
[**Doctor Last Name 405**] annuloplasty band. Total coronary artery bypass
time was 184 minutes with a cross-clamp time of 155 minutes.
He was transferred to the Cardiac Surgery Recovery Unit with
a mean arterial pressure of 66, a central venous pressure of
8, in a normal sinus rhythm at a rate 86 on a Neo-Synephrine
drip. Please see the Operative Report for full details. The
patient was successfully weaned and extubated on his
operative evening.
On postoperative day one, his intravenous drip medications
were discontinued, and physical therapy was initiated. On
postoperative day two, his chest tubes were discontinued.
Electrolytes were repleted as necessary, and he was
transferred to the inpatient floor for ongoing recovery and
rehabilitation. On postoperative day three continued
uneventfully with ongoing physical therapy. Cardiac pacing
wires were discontinued. Lopressor was increased to 25 mg
p.o. twice daily for heart rate and blood pressure control.
The patient began to be screened for rehabilitation.
Postoperative days five and six also progressed well with a
significant increase in physical therapy level. It was
decided that Mr. [**Name13 (STitle) 57149**] would not need physical therapy. We
consulted Mr. [**Last Name (Titles) 57150**] endocrinologist who recommended
hydrocortisone taper, which we initiated.
On postoperative day seven, Mr. [**Name13 (STitle) 57149**] of significant right
knee swallowing and pain, for which an Orthopaedics
consultation was obtained. Orthopaedics recommended
ambulation with range of motion of the knee. They stated
there was no evidence for infection. On postoperative day
eight, Mr. [**Name13 (STitle) 57149**] reported a significant decrease in pain
with improvement in stiffness with ambulation. An x-ray of
the knee showed chronic degenerative changes only.
On postoperative day nine, Mr. [**Name13 (STitle) 57149**] was cleared by
Physical Therapy and found to be safe for discharge home. He
also had a short burst of atrial fibrillation that
spontaneously converted to a sinus rhythm with no further
episodes of atrial fibrillation. He was kept in house
overnight to monitor his heart rate. On postoperative day
ten ([**2127-1-24**]), he was found to be medically ready
for discharge home.
DISCHARGE STATUS: Home with visiting nurse.
DISCHARGE DIAGNOSES:
1. Coronary artery disease and mitral regurgitation.
2. Status post coronary artery bypass grafting times four and
mitral valve repair.
3. Peripheral vascular disease.
4. Osteoarthritis.
5. Abdominal aortic aneurysm.
6. Panhypopituitary.
7. Gastroesophageal reflux disease.
8. Psoriasis.
9. Glaucoma.
10. Hypertension.
11. Status post left carotid endarterectomy.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice daily.
2. Percocet 5/325 one to two tablets p.o. q.4h. as needed
(for pain).
3. Lipitor 20 mg p.o. once daily.
4. Latanoprost 0.005 percent drops 1 drop both eyes at
bedtime.
5. Brimonidine tartrate 0.2 percent drops 1 drop both eyes
q.8h.
6. Aspirin 81 mg p.o. once daily.
7. Lasix 20 mg p.o. once daily (for seven days).
8. Potassium chloride 20 mEq p.o. once daily (for seven
days).
9. Hydrocortisone 20 mg in the morning and 10 mg in the
evening (until otherwise instructed by Dr. [**First Name (STitle) **].
10. Levoxyl 88 mcg p.o. once daily.
11. Crestor 10 mg p.o. once daily.
DI[**Last Name (STitle) 408**]E FOLLOW-UP PLANS:
1. The patient was to follow up with Dr. [**Last Name (STitle) 57151**] in one to
two weeks; with Dr. [**First Name (STitle) **] in one week; with Dr. [**Last Name (Prefixes) **]
in three to four weeks; and with Dr. [**Last Name (STitle) 27117**] in one to two
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2127-4-1**] 15:39:55
T: [**2127-4-1**] 16:41:29
Job#: [**Job Number 57152**]
|
E9352,311,5990,34982,135 | 135 | 192,180 | Admission Date: [**2173-5-18**] Discharge Date: [**2173-5-26**]
Date of Birth: [**2123-6-9**] Sex: M
Service: Neurology
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 48749**] is a 49-year-old
man diagnosed with neurosarcoid in a previous neurologic
admission who was recently discharged to rehabilitation on
[**5-11**] after extensive workup for neurosarcoid. In
rehabilitation he was doing well and was ambulating with and
without a walker. On [**2173-5-15**], he was prematurely
changed from IV steroids to po Medrol. Since then, he has
been deteriorating rapidly to the point that he awoke on the
day of admission, and was not able to move his legs at all.
He had breakthrough pain in his lower back and exacerbation
of this allodynia in his feet and legs. When he was
initially seen in the Emergency Room, he was tearful with
feelings of hopelessness, very upset about his condition.
PHYSICAL EXAM ON ADMISSION: His vital signs were stable. He
is alert, awake, oriented and tearful. Normal name and
repetition, comprehension was intact. Months of the year
backwards and forwards were normal. Cranial nerves were
intact. Extraocular movements were full. Face is symmetric.
Tongue was midline. Palate elevates symmetrically. Shoulder
shrug was normal. He had decreased strength in his lower
extremities, 0/5 and full [**5-24**] in his upper extremities. His
sensory: Decreased sensation to C6-T1 pin prick in his upper
extremities and deep tendon reflexes were 0/4 in the upper
extremities, trace brachioradialis. Proprioception was
decreased in his fingers, wrist, and elbow at the level of
the shoulders. In his lower extremities, he had severe
decrease in sensation, decreased pin prick, light touch,
vibratory, and cold from T7 down, worse on the left side.
He was seen and admitted for acute worsening of his lower
extremity weakness. He decided to order a MRI of the spine
which is unchanged from before, and we changed the steroids
to 1 gram IV q day, Solu-Medrol x5 days, and had Rheumatology
consult to discuss these use of other immunomodulatory
agents. He had severe pain and at first we increased his
methadone and Neurontin, and started a Morphine PCA pump. We
had him on pantoprazole GI prophylaxis, and watched him
closely on the neurologic service.
Over the coming days with his movement and pain was somewhat
better controlled, Rheumatology saw him and agreed with
Solu-Medrol, and then felt that he would also benefit from
steroids after that as well. He was watched closely on the
Neurologic service, and PCA pump was working well to control
his pain.
On [**5-20**], he was found by the Neurology Service to be
minimally responsive. He was given naloxone with much
benefit. He continued to be less responsive and was not
following commands. We transferred him to the Intensive Care
Unit for further observation on [**5-20**] as well as a STAT
electroencephalogram was performed. This
electroencephalogram showed a mild encephalopathy, but was
negative for seizures. He was monitored and his respiratory
distress was watched closely. Initially, his respirations
were [**6-27**], however, in the coming hours, he improved and was
able to breathe in regular rate 12-15 breathes/minute, and
his neurologic status improved. It was felt that his acute
change in mental status was attributed to his increased pain
medications especially his PCA pump.
He was transferred back to the floor the following day. IV
steroids and Solu-Medrol were continued, and a full course
was given in five days. Again Rheumatology recommended to
continue Imuran 50 mg q day as well as continue 1.2 mg of
Medrol IV divided in [**Hospital1 **] dosages. They also recommended that
infliximab may be used 5 mg/kg IV x1, and after the IV
steroids were completed, and then two weeks later as well as
six weeks after that. I discussed this with the entire
Neurology team as well as other consulting services.
We also discussed the issue of a positive PPD with Infectious
Disease and given that we were giving him infliximab and high
dosed steroids, we may need to be more aggressive with his
anti-TB prophylactic treatment. They felt that INH was
sufficient and he would just have to be monitored closely.
He was also given a bowel regimen of Senna, Dulcolax, and
Colace, and he was able to control his bowels as well.
He was found to have a urinary tract infection with some
blood in his urine, and he was started on Levaquin 500 mg po
q day. He will continue this as an outpatient as well. His
pain was controlled on his gabapentin, nortriptyline,
Percocet, and methadone and his leg shaking was controlled on
increasing doses of primidone tapered up to 225 mg po tid.
Over the few days before his discharge, he had increasing leg
strength, and was able to abduct his legs for the first time
since admission. He remains clinically stable. We
discontinued the Foley the day prior to admission, and he
urinated nine hours later 500 cc. He continued to have
hyperesthesia in his bilateral lower extremities and his
strength was returning slowly. He was deemed stable for
discharge to rehabilitation on [**5-26**] with followup in the
[**Hospital 878**] Clinic as well as followup in the Pheresis Unit at
[**Hospital3 **] Hospital for his infliximab treatment. He was
seen and followed up with Psychiatry and his mood was better.
He stated he was hanging in there and doing well. They felt
that we should continue with Celexa 40 mg and consider using
Seroquel 25-50 mg q hs for sleep instead of Ambien.
On discharge, he was much improved. Social Work as well as
other services met with him. Social Work helped him with
[**Social Security Number 48750**]social security disability benefit forms, and relayed
information. Physical Therapy and Occupational Therapy were
.................... for rehabilitation.
DISCHARGE STATUS: Improved.
DISCHARGE DIAGNOSES:
1. Neurosarcoid.
2. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Primidone 225 mg po tid.
2. Alprazolam 0.5 mg po q am prn and 1 mg po q hs prn
anxiety.
3. Celexa 60 mg po q day.
4. Colace 100 mg po tid.
5. Seroquel 25/250 mg po q hs prn insomnia, please offer q
hs.
6. Calcium carbonate 1,000 mg po bid.
7. Methylprednisolone sodium succinate 65 mg IV bid.
8. Pantoprazole 40 mg po q24h.
9. Levaquin 500 mg po q24h x7 days.
10. Methadone 10 mg po bid.
11. Trileptal 600 mg po bid.
12. Percocet 1-2 tablets po q4-6h prn pain.
13. Atorvastatin 10 mg po q day.
14. Baclofen 5 mg po tid.
15. Bisacodyl 10 mg po/pr q day prn.
16. Vitamin D 400 units po q day.
17. Nortriptyline 75 mg po q hs.
18. Folic acid 1 mg po q day.
19. Senna two tablets po bid.
20. MVI one cap po q day.
21. Thiamine 100 mg po q day.
22. Gabapentin 1200 mg po tid.
23. Metoprolol 50 mg po bid.
24. Isoniazid 300 mg po q day.
DISCHARGE FOLLOWUP: He is to followup with Dr. [**Last Name (STitle) **] and
Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 48750**] in the [**Hospital 878**] Clinic
at [**Hospital1 **] Hospital on [**6-3**] at 2:30 pm for
a previously scheduled appointment. He will also followup
the following weak in the Plasmapheresis Unit at [**Hospital1 346**] and plans for his followup will be
conveyed to him on [**6-3**]. He will need ambulance
transport for both of these visits. He will then need
another dose of infliximab at the Pheresis Unit six weeks
after his second treatment.
[**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 11278**], M.D.
[**MD Number(1) 11279**]
Dictated By:[**Last Name (NamePattern1) 7813**]
MEDQUIST36
D: [**2173-5-26**] 11:52
T: [**2173-5-26**] 11:54
JOB#: [**Job Number 48751**]
|
496,25000,135,72141,2148,V5865,72401,53081,4019 | 135 | 199,634 | Admission Date: [**2174-5-17**] Discharge Date: [**2174-5-21**]
Date of Birth: [**2123-6-9**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: Patient is a 50-year-old male
with history of neurosarcoidosis and epidural lipomatosis
secondary to prednisone. Patient's sarcoidosis was diagnosed
in [**2173**] beginning with myelopathy secondary to epidural
lipomatosis and chronic steroid use. Patient was evaluated
and felt would benefit from a T4-T8 laminectomy.
PAST MEDICAL HISTORY: Hypertension.
Diabetes.
GERD.
Obesity.
On physical exam, he is in no acute distress. His lungs are
clear to auscultation. He does have some inspiratory
stridor. He has been on chronic steroid use since [**75**]/[**2173**].
His cardiovascular system: Regular, rate, and rhythm, no
murmurs, rubs, or gallops. Abdomen is obese. He has very
full neck and chin secondary to chronic steroid use. His
motor strength is decreased throughout. The patient has been
walking with a walker since [**2173**]. He had worsening
myelopathy.
He is admitted status post T4-T8 laminectomy without
intraoperative complications. Postoperatively, his vital
signs are stable. He was afebrile. He was following
commands x4, moving all extremities with 4 plus strength.
His lungs were clear. His abdomen was soft and nontender.
His EOMs were full. Grasp was three. His AT, [**Last Name (un) 938**], and
gastrocs were [**4-25**] bilaterally. His dressing was clean, dry,
and intact.
On postoperative day number one, he was awake, alert, and
oriented times three. His strength on the right IP is 5, 4
plus on the left. Quads 4 plus on the right and 5 on the
left. AT 5 on the right and 4 plus on the left. Gastrocs 4
plus bilaterally. He had decreased proprioception at the
ankles and decreased sensation of the lower extremities by 20
percent. He has decreased plantar reflexes. His vital signs
were stable. He was transferred to the regular floor. His
dressing was clean, dry, and intact.
He had a MRI with gadolinium of the thoracic spine, which
showed good removal of lipomatosis.
He was in stable condition, and was discharged to home on
[**2174-5-21**] with follow up with Dr. [**First Name (STitle) **] in one month. He will
follow up in 10 days for staple removal.
MEDICATIONS ON DISCHARGE:
1. Baclofen 60 p.o. q.d.
2. Citalopram hydrobromide 60 p.o. q.d.
3. Pantoprazole 40 p.o. q.d.
4. Metoprolol 100 p.o. q.d.
5. Trazodone 50 p.o. q.h.s.
6. Primidone 150 p.o. q.d.
7. Fentanyl patch 75 mcg topically q.72h.
8. Multivitamin one p.o. q.d.
9. Glipizide 5 p.o. q.d.
10. Hydrochlorothiazide 25 p.o. q.d.
11. Mirtazepine 30 mg p.o. q.h.s.
12. Alendronate sodium 70 mg p.o. q Monday.
DISCHARGE CONDITION: His condition was stable at the time of
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2174-6-16**] 16:01:21
T: [**2174-6-17**] 06:58:09
Job#: [**Job Number 48756**]
|
4375,486,2720,4019 | 136 | 184,644 | Admission Date: [**2103-5-9**] Discharge Date: [**2103-5-14**]
Date of Birth: [**2051-11-8**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with a history of bilateral supraclinoid carotid
artery occlusion (moyamoya-variant) who presented to [**Hospital1 1444**] for elective surgery.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Depression. 4. History of stroke
13 years ago. 5. History of heart murmur.
PAST SURGICAL HISTORY: 1. Hernia repair. 2. Tonsillectomy
and adenoidectomy as a child.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT HOME: 1. Vasotec. 2. Wellbutrin. 3.
Pravachol. 4. Hydrochlorothiazide. 5. Coumadin 8 mg q.d.
6. Diltiazem.
HOSPITAL COURSE: The patient underwent a pial synangiosis.
The patient tolerated the procedure well. The patient was
started on diet postoperatively, and was advanced gradually.
The patient was able to get out of bed and ambulate. His
Foley catheter was discontinued. The patient was transported
from the intensive care unit to the floor. The patient's
neurological examination was stable postoperatively. The
patient was discharged on [**5-12**] in stable condition.
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Wellbutrin 150 p.o. q.d.
3. Percocet for pain as needed.
4. Hydrochlorothiazide 25 p.o. q.d.
5. Pravachol 20 mg p.o. q.d.
6. Diltiazem 60 mg p.o. q.i.d.
7. Vasotec 5 mg p.o. q.d.
8. Dilantin 100 mg p.o. q. 8 hours.
FOLLOW UP: The patient should of with Dr. [**Last Name (STitle) 1132**], please call
Dr.[**Name (NI) 9224**] office for a follow-up appointment.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2103-5-11**] 09:25
T: [**2103-5-11**] 09:54
JOB#: [**Job Number 46869**]
|
5185,41401,V1582,42731,42732,25060,3572,24290,2720,60000,V4582 | 137 | 151,583 | Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-24**]
Date of Birth: [**2117-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Coumadin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2191-11-16**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
Diag, SVG to OM)
History of Present Illness:
74 y/o male with 1 year of dyspnea on exertion which has been
worsening over the past couple of months. Underwent cardiac cath
at OSH which revealed 50% LMCA and 3 vessel disease. He was then
tranasferred to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Cornary Artery Disease s/p PTCA/stent [**82**], Atrial Fibrillation,
Hyperthyroidism, Diabetes Mellitus, Hyperchoelsterolemia, s/p
hernia repair, eczema, neuropathy, ?TIA
Social History:
Retired. Quit smoking after 12yrs x 1ppd. Denies ETOH.
Family History:
Non-contributory
Physical Exam:
General: NAD
Skin: Bilat. soles with eczema. Neck with 1" scar secondary to
cyst removal
Lungs: CTAB -w/r/r
Heart: Irreg. rate and rhythm -murmur
Abd: Soft, NT/ND, +BS
Ext: Brown discoloration b/l LE, -varicosities
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
Vein Mapping [**11-11**]: Duplex evaluation was performed of bilateral
lower extremity veins. Greater saphenous vein is patent
bilaterally from the groin to the ankle. On the right, vein
diameters range from .24-.46 cm. On the left, vein diameters
range from .20-.5 cm to .62 cm.
Echo [**11-16**]: PRE-BYPASS: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild(1+) mitral
regurgitation is seen. There is no mitral valve prolapse. The
left atrium is normal in size. No atrial septal defect is seen
by 2D or color Doppler. There are simple atheroma in the
descending thoracic aorta. No thoracic aortic dissection is
seen. POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic function.
No evidence of aortic dissection post decannulation. The mitral
regurgitation may have been slightly improved. CXR [**11-22**]:
[**2191-11-10**] 04:44PM BLOOD WBC-9.5 RBC-4.32* Hgb-12.8* Hct-36.7*
MCV-85 MCH-29.7 MCHC-35.0 RDW-14.8 Plt Ct-250
[**2191-11-18**] 01:57AM BLOOD WBC-17.4*# RBC-3.77* Hgb-10.7* Hct-32.6*
MCV-86 MCH-28.4 MCHC-32.9 RDW-15.3 Plt Ct-205
[**2191-11-21**] 02:44AM BLOOD WBC-13.6* RBC-3.53* Hgb-10.5* Hct-30.0*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.3 Plt Ct-363
[**2191-11-10**] 04:44PM BLOOD PT-12.2 PTT-24.7 INR(PT)-1.0
[**2191-11-22**] 06:45AM BLOOD PT-16.1* PTT-28.4 INR(PT)-1.5*
[**2191-11-10**] 04:44PM BLOOD Glucose-349* UreaN-13 Creat-1.1 Na-133
K-5.1 Cl-96 HCO3-29 AnGap-13
[**2191-11-22**] 06:45AM BLOOD Glucose-114* UreaN-34* Creat-1.4* Na-137
K-4.6 Cl-97 HCO3-29 AnGap-16
[**2191-11-22**] 06:45AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.4
[**2191-11-11**] 05:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 41483**] was transferred from OSH to
[**Hospital1 18**] for surgical care. Upon admission he underwent all
pre-operative work-up, including vein mapping and carotid
ultrasound. He remained medically managed, including Heparin
gtt, for several days awaiting Plavix load from cardiac cath to
washout. On [**11-16**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 3. Please see
operative report for surgical details. He tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. He remained intubated until
post-op day one, when he was weaned from sedation, awoke
neurologically intact and was extubated. On this day attempted
cardioversion was performed d/t atrial fibrillation and was then
paced at 90. But later he then converted back to AFIB. Of note,
he was in Afib prior to surgery d/t hyperthyroidism. On post-op
day two beta blockers and diuretics were started. He was gently
diuresed towards his pre-op weight. Chest tubes were removed and
he was transferred to the SDU on post-op day two. Although later
on this day he was transferred back to the CSRU d/t respiratory
distress for aggressive pulmonary toileting. On post-op day five
his epicardial pacing wires were removed and he was started on
Coumadin for AFib. On post-op day six he was transferred to the
SDU for continued post-op care. Physical therapy followed
patient during entire post-op course for strength and mobility.
He was discharged home on post-op day 9 with VNA and the
appropriate follow-up appointments. First blood draw tomorrow
[**11-26**] with results to be called to Dr. [**Last Name (STitle) **].
Medications on Admission:
Lisinopril, Plavix, Aspirin, Atenolol, Tapazole, Glucophage,
Lipitor, Humalog, Amitryptiline, Cymbalta
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
6. Methimazole 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*1*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
13. Humalog 75/25
58 Units QAM
42 Units QPM
as prior to surgery
[**99**]. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day for 2
days: No coumadin tonight, [**11-24**], check INR [**11-26**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Cornary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: s/p PTCA/stent [**82**], Atrial Fibrillation, Hyperthyroidism,
Diabetes Mellitus, Hyperchoelsterolemia, s/p hernia repair,
eczema, neuropathy, ?TIA
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions and pat dry. Do not take bath.
Do not apply lotions, creams or ointments to incisions
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever, notice redness or drainage from
incision, please contact office immediately.
Call to schedule all follow-up appointments.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**3-11**] weeks
Dr. [**First Name (STitle) **] on Monday [**12-5**] at 10:15 AM
Completed by:[**2191-11-24**] |
1890,4254,4280,V4502,V5861,V433,412 | 138 | 105,764 | Admission Date: [**2134-3-1**] Discharge Date: [**2134-3-7**]
Date of Birth: [**2083-10-23**] Sex: M
Service: UROLOGY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Kidney mass
Major Surgical or Invasive Procedure:
Left radical nephrectomy and adrenalectomy,
regional lymphadenectomy.
History of Present Illness:
Mr [**Known lastname 39818**] is a 50-year-old male, with a long
history of multiple medical problems which include aortic
valve replacement with a mechanical valve in [**2131**] on chronic
Coumadin therapy, heparin-induced thrombocytopenia from
intravenous heparin given in [**2133**], coronary disease status
post myocardial infarction at age 35, dilated cardiomyopathy
with ejection fraction of 25 percent, who was found to have
bilateral renal masses in [**2133-12-23**]. Six weeks ago,
he underwent right partial nephrectomy in preparation for
today's left radical nephrectomy. He has a previous biopsy
of the left renal mass that was done at an outside hospital,
which was confirmatory of renal cell carcinoma. He presents
now for surgical therapy.
Past Medical History:
CAD s/p MI [**2116**]
dilated cardiomyopathy c CHF (EF 25%) and global hypokinesis
AICD [**10-26**] (prophylactic for EF, no h/o arrythmias)
AVR s/p mechanical heart valve 00'
OSA
Social History:
Tob: 1 ppd x 35y until quit 3m ago. Married, lives with wife, 1
son. [**Name (NI) **] ETOH, no drugs. Retired [**Company **] employee.
Family History:
Father had kidney cancer and prostate cancer. Mother had breast
cancer.
Physical Exam:
GEN: NAD. WD, WN.
HEENT: NCAT, EOMI
NECK: no cervical, occipital, clavicular, axillary, or inguinal
LAD.
CV: RRR 3/6 SEM at RUSB, mechanical click
PULMO: CTAB
ABD: obese, soft, NT, ND, no CVA tenderness. no palpable masses.
R sided subcostal incision well-healed.
EXT: warm, no C/C/E, 2+ DP/PT.
GU: phallus nl.
Pertinent Results:
[**2134-3-1**] 11:58PM WBC-10.4 RBC-4.08* HGB-12.0* HCT-35.8* MCV-88
MCH-29.3 MCHC-33.4 RDW-13.5
[**2134-3-1**] 11:58PM PLT COUNT-187
[**2134-3-1**] 04:48PM PT-18.5* PTT-37.4* INR(PT)-2.2
[**2134-3-1**] 04:48PM GLUCOSE-155* UREA N-14 CREAT-1.1 SODIUM-138
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-9
[**2134-3-1**] 04:48PM CALCIUM-7.6* MAGNESIUM-1.7
Brief Hospital Course:
Patient tolerated procedure well and was transferred to NSICU
d/t cardiac history. Post-op course was unremarkable. Patient
remained in NSICU for 2 days and was eventually transferred to
12Reisman. Pain was controlled with Dilaudid through
hospitalization.
On POD1, Chest tube was removed.
On POD2, NGT was removed.
On POD3, patient was transferred out of NSICU to 12R
On POD4, patient began regular diet after onset of flatus.
On POD5, patient was provided Toradol for pain. CT scan of
thorax was performed to rule out any source for pain; scan
revealed no hematoma/bleeding/fluid collection.
On POD6, patient was deemed stable and suitable for discharge.
On discharge patient remained therapeutic (INR 2.5-3.5) on
Warfarin.
Medications on Admission:
Toprol xl 50 qd
Lasix 40
Lipitor 40
Mavik 4
Coumadin 5/7.5
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: Alternate 5mg and 7.5mg qod.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal cancer
Discharge Condition:
Good.
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP. [**Name10 (NameIs) **] restarting
Mavik.
Recheck INR tomorrow.
Followup Instructions:
F/U with [**Doctor Last Name **]. Please call for appt.
F/U with PCP. [**Name10 (NameIs) **] restarting Mavik.
Completed by:[**2134-3-7**] |
78057,412,4168,41401,4254,4280,4241 | 138 | 108,120 | Admission Date: [**2131-10-31**] Discharge Date: [**2131-11-6**]
Date of Birth: [**2083-10-23**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
male with prior cardiac history significant for coronary
artery disease, history of myocardial infarction, history of
congestive heart failure, cardiomyopathy and aortic
regurgitation. The patient's aortic insufficiency has
progressed from moderate to severe over the last several
years. The patient claimed that he had a few symptoms.
However, his wife stated that he has had more dyspnea on
exertion and fatigue recently. The patient smokes
approximately one pack a day. He is overweight. The patient
denies any chest pain. The patient also has a history of
sleep apnea. A recently performed echocardiogram showed
moderate severe aortic insufficiency with ejection fraction
of approximately 25%. A repeat cardiac catheterization
performed on [**2131-9-3**] showed one vessel branch coronary artery
disease, moderate to severe aortic regurgitation, severe
global left ventricular systolic dysfunction, mild
biventricular systolic dysfunction and mild pulmonary
arterial diastolic hypertension. At the time, the left
ventricular ejection fraction was estimated to be 29%. Given
the patient's worsening symptoms, the decision was made to
proceed with an aortic valve replacement as a long term
solution.
PAST MEDICAL HISTORY:
1. [**6-24**] echocardiogram with ejection fraction of 20% to 25%
with multiple wall motion abnormalities including apical
akinesis, anteroseptal hypokinesis/akinesis, inferior
hypokinesis/akinesis as well as lateral hypokinesis/akinesis.
2. Congestive heart failure with ejection fraction of 20% to
29%. History of myocardial infarction.
3. Aortic insufficiency
4. Cardiomyopathy
5. Coronary artery disease
6. Sleep apnea
PAST SURGICAL HISTORY: No known surgical history.
MEDICATIONS:
1. Coumadin 5 mg po q day
2. Lipitor 20 mg po q day
3. Mavik 4 mg po q day
4. Lasix 40 mg po q day
5. Toprol XL 25 mg po q day
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile, heart rate 70 and sinus rhythm, blood
pressure 130/81.
GENERAL: Alert and oriented in no apparent distress, obese
white male.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits. No
evidence of jugular venous distention. No evidence of
bruits.
PULMONARY: Clear to auscultation bilaterally.
CARDIAC: Sinus rhythm, 2/6 systolic murmur and [**3-28**] diastolic
murmur.
ABDOMEN: Obese, soft, nontender.
EXTREMITIES: No edema, pulses present and are palpable
bilaterally.
LABORATORY STUDIES ON ADMISSION: Hematocrit 30.5, white
blood cell count 10.2, platelets 122. PTT 35.2, PT 12.2, INR
1.0. Glucose 119, BUN 14, creatinine 0.9. Sodium 136,
potassium 4.7.
IMAGING: Preoperative chest x-ray was within normal limits.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
cardiac surgery service. Given symptomatic aortic
insufficiency and also history of congestive heart failure,
it was decided that a surgical intervention would be
appropriate. On [**2131-10-31**], the patient underwent aortic valve
replacement with a 23 mm Carbomedics mechanical valve. The
procedure was without any complications. The patient
tolerated the procedure well. Please see the full operative
note for details. The patient remained intubated and was
transferred to the Intensive Care Unit for further management
in stable condition. The patient was extubated on the same
day. His oxygenation remained good. He was making adequate
urine.
Postoperatively, the patient's arterial blood gas was pH
7.38, PCO2 of 34, PO2 of 110. His hematocrit was stable at
30.5. The patient was further diuresed. He was transferred
to the regular floor on postoperative day 1 in good
condition. The patient continued to have excellent
oxygenation on minimal supplemental oxygen. Physical therapy
was consulted which followed the patient throughout his
hospitalization and then officially cleared him to go home.
Anticoagulation with Coumadin was restarted. Given the
presence of a mechanical valve, an INR of 2.5 to 3 was set as
the goal.
The patient remained afebrile. He remained in sinus rhythm.
His lungs were clear to auscultation bilaterally. His pacing
wires were removed on postoperative day 3. His urine
catheter was removed on postoperative day 2. The patient was
also started on intravenous heparin on postoperative day 3
given slow rise in the NR level. The patient was ambulating
without assistance. The patient was continued to be diuresed
with Lasix. He had 1+ lower extremity edema bilaterally.
His incision was clean, dry and intact throughout this
hospitalization course. On the date of discharge, his INR
was 1.9. The patient was discharged to home on postoperative
day 6.
DISCHARGE CONDITION: Stable
DISCHARGE DISPOSITION: Home
DISCHARGE DIAGNOSES:
1. Severe aortic insufficiency, status post aortic valve
replacement with a 23 mm Carbomedics mechanical valve.
2. Congestive heart failure
3. Cardiomyopathy
4. Sleep apnea
DISCHARGE MEDICATIONS;
1. Lasix 20 mg po bid x14 days
2. Lipitor 20 mg po q day
3. Lopressor 50 mg po bid
4. Coumadin 7.5 mg on [**2131-11-6**] and 7.5 mg on [**2131-11-7**] (to
follow up at the [**Hospital 197**] Clinic for further dosing).
5. Potassium chloride 20 milliequivalents po bid x14 days
6. Colace 100 mg po bid
7. Percocet 1 to 2 tablets po q 4 to 6 hours prn pain
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], in approximately for weeks.
2. The patient is to follow up with Dr. [**First Name (STitle) **] Grape, who is
his primary care physician and cardiologist, in approximately
one week.
3. The patient is to follow up at the [**Hospital 197**] Clinic in two
days to have his INR levels drawn and his Coumadin levels
adjusted.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1112**] 02-229
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2131-11-6**] 11:07
T: [**2131-11-6**] 11:03
JOB#: [**Job Number 39816**]
|
41401,9998,1890,42820,4280,2874,6823,E8798,79092,E9342,78057,5997,V4502,V433,4148 | 138 | 188,284 | Admission Date: [**2133-12-21**] Discharge Date: [**2134-1-11**]
Date of Birth: [**2083-10-23**] Sex: M
Service: UROLOGY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
BL renal masses
Major Surgical or Invasive Procedure:
Right partial nephrectomy [**1-4**].
History of Present Illness:
50yo M h/o CAD, dilated cardiomyopathy, CHF, AVR s/p mechanical
heart valve, presented to [**Hospital6 **] [**12-14**] c/o L flank
pain x1d. Abdominal CT showed bilateral renal masses: Left
kidney mass 7 cm, exocytic, lower pole and Right kidney mass 2.6
cm, w/ infarcted tissue in upper mid left kidney. A renal
ultrasound showed a solid 2.6 cm mass on right, and a complex
cystic 7 cm mass on the left. An urinalysis showed microscopic
hematuria. Pt underwent a core biopsy of Left renal mass x2.
His pain was controlled with a morphine PCA and then dilaudid IV
and his anticoagulation was switched from coumadin to heparin in
the context of his renal biopsy. He is now transferred to [**Hospital1 18**]
for continuation of care.
Past Medical History:
CAD s/p MI [**2116**]
dilated cardiomyopathy c CHF (EF 25%) and global hypokinesis
AICD [**10-26**] (prophylactic for EF, no h/o arrythmias)
AVR s/p mechanical heart valve 00'
OSA
Social History:
Tob: 1 ppd x 35y until quit 3m ago. Married, lives with wife, 1
son. [**Name (NI) **] ETOH, no drugs. Retired [**Company **] employee.
Family History:
Father had kidney cancer and prostate cancer. Mother had breast
cancer.
Physical Exam:
GEN: lying in bed, NAD. WD, WN.
HEENT: NCAT, EOMi, PERRL.
no cervical, occipital, clavicular, axillary, or inguinal LAD.
CV: RRR 3/6 SEM at RUSB, mechanical click
PULMO: CTAB
ABD: obese, soft, NT, ND, no CVA tenderness. no palpable masses
EXT: warm, no C/C/E, 2+ DP/PT.
GU: phallus nl.
Pertinent Results:
[**2134-1-10**] 04:30AM BLOOD Hct-28.4*
[**2134-1-11**] 04:31AM BLOOD PT-15.2* INR(PT)-1.5
[**2134-1-11**] 04:31AM BLOOD Creat-1.1 K-4.2
[**2133-12-23**] 06:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
[**2133-12-26**] 06:00AM BLOOD IgM HAV-NEGATIVE
[**2133-12-23**] 06:20AM BLOOD HCV Ab-NEGATIVE
[**2133-12-23**] 01:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2133-12-23**] 10:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.030
[**2133-12-23**] 10:57PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2133-12-23**] 10:57PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2133-12-22**] 06:25AM BLOOD WBC-8.9 RBC-4.19*# Hgb-12.8*# Hct-37.1*
MCV-89 MCH-30.5 MCHC-34.5 RDW-13.0 Plt Ct-96*#
[**2133-12-22**] 06:25AM BLOOD Plt Ct-96*#
[**2133-12-22**] 06:25AM BLOOD PT-12.9 PTT-52.2* INR(PT)-1.1
[**2133-12-22**] 06:25AM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-135
K-3.9 Cl-98 HCO3-29 AnGap-12
[**2133-12-22**] 06:25AM BLOOD ALT-109* AST-82* LD(LDH)-604* AlkPhos-81
TotBili-0.4
[**2133-12-22**] 06:25AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.8 Mg-2.0
Brief Hospital Course:
50yo M admitted initially to the medicine service for
work-up of his newly-dx'd BL renal masses, concerning for
malignancy. His platelet count dropped during the time of his
transfer, presumably from HIT although the one assay performed
here was negative. For this reason his anticoagulation was
switched to Argatroban and carefully titrated to effectively
anticoagulate for his mechanical valve; his platelet count
normalized. He remained as an inpatient during this complicated
work-up period.
The pathology report from [**Hospital6 **] revealed
Renal Cell Carcinoma. A metastatic work-up with Head CT, Chest
CT, Abd-Pelvic CT, and Bone scan was negative except for an
adrenal mass whose density was not consistent with benign
adenoma. (MRI could not be performed due to his AICD). Dr.
[**Last Name (STitle) **] from Urology planned a two-stage resection; first a
right-partial and then a left-total. Cardiac clearance was
obtained with a combination of studies from [**Hospital1 18**] and [**Hospital **]; an echo here showed EF 20-30% and he was maintained on
beta-blocker. He did develop LUE swelling but U/S and CT were
negative for DVT. He was maintained on therapeutic argatroban
and transitioned successfully to coumadin. EP-Cardiology was
contact[**Name (NI) **] regarding deactivating his AICD. He underwent a bowel
prep on the day prior to surgery.
A right partial nephrectomy was performed on [**1-4**] while on
coumadin. See operative report for details. He was placed in
the ICU post-operatively for close hemodynamic monitoring in
light of his complicated cardiac history; he remained intubated
with a swan-ganz catheter, chest tube, JP drain, NG tube, and
Foley catheter. He was extubated without complication on POD 1.
On POD 2 the chest tube was removed, CXR showed minimal PTX.
The NG tube was removed on POD 3. He was transfused 1 Unit
PRBCs for anemia (Hct 27). He remained in the ICU for
observation related to mobilizing fluid and concern for volume
overload given his compromised cardiac output. It was noted
that he developed a contact dermatitis, presumably from the tape
during surgical positioning; this resolved after several days
with topical cream for comfort. He remained stable and was
transferred to the regular floor on POD 4 after the swan-ganz
was changed over a wire to a triple-lumen catheter.
At this time he was passing regular flatus and given a
regular (cardiac) diet. His pain control was transitioned to PO
dilaudid. His HCT remained low and he received a 2nd Unit of
PRBCs. The JP drain was removed on POD 5. His INR was closely
checked throughout his post-operative course with dosage
decreased during immediate post-op period (Inr 2.8-3.2); it rose
to 3.8 and 3.9 with dosage decreased. After beginning PO
intake, the INR dropped significantly to 3.4 then 2.1 over 12
hours and then 1.5. His dose meanwhile had been increased to
7.5 qhs. He was resumed on his usual home medications. The
Foley was removed on POD 6 and the triple-lumen catheter on POD
7. At the time of discharge he was urinating independently,
tolerating PO diet and pain moderately controlled on PO meds.
Medications on Admission:
Lasix 40 mg PO QD
Toprol XL 50 mg PO QD
Mavik 4 mg PO QD
Lipitor 40 mg PO QD
Colace 100 mg PO BID
Dilaudid 2-4 mg IV q4h
Heparin 1100 units/hr
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed. Tablet(s)
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking dilaudid to prevent constipation.
Disp:*30 Capsule(s)* Refills:*1*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Trandolapril 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 1 doses.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal cell cancer
Heparin-Induced Thrombocytopenia
LUE cellulitis
dilated cardiomyopathy
AVR, mechanical valve
Contact dermatitis
Discharge Condition:
stable.
Discharge Instructions:
See "Nephrectomy" instruction sheet.
No baths or soaks or swimming. [**Month (only) 116**] shower, pat wound dry.
Do not drive or drink alcohol while taking dilaudid.
[**Name8 (MD) **] MD if develop fever, or if incision develops redness,
swelling, drains pus.
Heart-healthy diet.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as previously arranged. Call
[**Telephone/Fax (1) 39817**] for time and date for staple removal and post-op
check, and to discuss/schedule the L nephrectomy.
Follow-up with Primary Care Physician [**Name Initial (PRE) 176**] 2 days to discuss
INR and coumadin dosing.
Have INR checked twice daily until coumadin dose is settled with
your PCP.
|
7470,V290,V053,7766,36221,77081,76516,76524,7793,7742,769,V3101 | 139 | 195,786 | Admission Date: [**2177-9-30**] Discharge Date: [**2177-12-10**]
Date of Birth: [**2177-9-30**] Sex: F
Service: NB
HISTORY: The patient is a 1065 gram product of a 28 and 2/7
weeks gestation, born to a 28 year old primiparous mother.
Mother admitted in mid [**Month (only) 359**] with shortened cervix. She
was treated with tocolysis and betamethasone at that time.
No sepsis risk factors.
Prenatal screens - blood type O positive, antibody negative,
RPR nonreactive, rubella immune, hepatitis B surface antigen
negative, group beta strep status unknown.
On the day of delivery magnesium sulfate was discontinued at
maternal request due to side effects. Neonatology was asked
to be present at the twin delivery on the date of delivery.
The infant was vigorous at delivery. On arrival at warmer,
was noted to have umbilical clamp that had migrated off cord.
Small amount of blood loss before manual pressure applied and
replaced with clamp. Good perfusion noted. Apgar scores
were 7 at 1 minute and 8 at 5 minutes of age. She was given
blow-by oxygen, stimulation, and facial CPAP. She was
brought to the Newborn Intensive Care Unit after visiting
with parents.
PHYSICAL EXAMINATION: Birth weight 1065 grams (50th
percentile), length 35 cm (25th percentile), head
circumference 27 cm (greater than 50th percentile).
VITAL SIGNS: Temperature 98.9, heart rate 178, respiratory
rate 32, oxygen saturations 95 percent, blood pressure 41/29
with a mean arterial pressure of 34.
On examination the infant is pink, active, nondysmorphic.
Well saturated and perfused. Mild bruising about arms and
legs.
HEENT: Within normal limits.
HEART: Normal S1 and S2 without murmurs.
LUNGS: Clear. Good air entry.
ABDOMEN: Benign. Normal female preemie genitalia.
NEUROLOGIC: Nonfocal and age appropriate.
SPINE: Normal.
HIPS: Normal. Patent anus.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 59826**]
was placed on CPAP shortly after admission to the Newborn
Intensive Care Unit. She was intubated on day of life 1 for
increased work of breathing and increased oxygen requirement.
She received one dose of Survanta and was extubated to CPAP
by day of life 2. She was weaned off CPAP to room air by day
of life 10. She has remained in room air for the remainder
of her hospitalization. Caffeine citrate was started on day
of life 1 for apnea of prematurity. The caffeine was
discontinued on day of life 28. She has not had any apneic
spells in greater than 5 days.
CARDIOVASCULAR: [**Known lastname 59826**]'s blood pressure has been stable
throughout her hospitalization. No fluid boluses or pressors
were required. A soft murmur was heard on day of life 2. An
echocardiogram on day of life 7 showed a small clinically
insignificant patent ductus arteriosus. No indomethacin was
indicated. A follow up echocardiogram on day of life 29
showed no patent ductus arteriosus.
FLUIDS, ELECTROLYTES AND NUTRITION: Intravenous fluids of
D10W were started at 80 cc per kg per day upon admission to
the newborn Intensive Care Unit. A double lumen umbilical
venous catheter was placed. Enteral feedings were started on
day of life 2 at 10 cc per kg per day and enteral feeding
volume was advanced to a maximum of 150 cc per kg per day by
day of life 13. Caloric density was advanced to a maximum of
30 calories per ounce with ProMod. No feeding intolerance
noted other than frequent spits which have diminished over
time. Electrolytes have been within normal range. Last labs
on [**11-12**], showed serum calcium of 9.7, phosphorous of
6.3, and alkaline phosphatase of 313. She has been receiving
prune juice twice a day to promote stool regularity. Her
discharge weight is 3035 grams, length 48 cm, head
circumference 35.5 cm.
GASTROINTESTINAL: Phototherapy was started on day of life 1
for bilirubin of 5.4. Peak bilirubin on day of life 10 was
7.8. Phototherapy was discontinued on day of life 14 with a
rebound bilirubin of 4.6 on day of life 16.
HEMATOLOGY: The infant's hematocrit on admission was 44.9.
No blood products were given during her hospitalization.
Last hematocrit on [**11-12**], was 30 with a reticulocyte
count of 7.2 (up from hematocrit of 23 on [**10-29**]).
INFECTIOUS DISEASE: A complete blood count with different
and blood culture was drawn upon admission to the Newborn
Intensive Care Unit. CBC showed white count of 9.800,
hematocrit of 44.9, platelet count of 326 with 31 percent
polys and 0 percent bands. Blood culture at that time was
negative. She received 48 hours of ampicillin and
gentamicin. No other issues with infection during her
hospitalization.
NEUROLOGY: Head ultrasound on [**10-8**], and [**10-29**]
were both normal.
SENSORY: A hearing screen was performed without automated
auditory brain stem responses. She passed in both ears on
[**12-1**].
OPHTHALMOLOGY: [**Known lastname 59826**]'s eyes were most recently examined on
[**12-8**] ROP on the right stage 1 zone 3 with 3 clock hours and
on the left stage 1 zone 3 1 clock hour. Follow up eye
examination is recommended for the first week of [**Month (only) 956**].
PSYCHOSOCIAL: [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Social
Work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **]. The family has been
actively involved in the care of both of the twins.
CONDITION AT DISCHARGE: Stable temperature in open crib, PO
feedings well, no recent apnea of prematurity.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 45938**] in [**Hospital1 6687**],
Phone No. [**Telephone/Fax (1) 50894**] FAX [**Telephone/Fax (1) 59824**].
CARE RECOMMENDATIONS: Feeds at discharge - ad lib demand
feeds of Similac, enriched to 24 calories by concentration.
Medications - ferrous sulfate 0.25 cc daily.
CAR SEAT POSITION SCREEN: passed
THE STATE NEWBORN SCREEN: The last state Newborn Screen was
sent on [**11-2**] and [**11-16**]. Normal results
reported.
IMMUNIZATIONS RECEIVED: [**Known lastname 59826**] received her first Hepatitis
B vaccine on [**11-10**]. Her DTAP, HIV, Prevnar vaccines
were given on [**12-1**]. IPV was given on [**11-30**].
Synagis was given on [**11-30**]. Her second hepatitis B
vaccine is due on [**12-11**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria.
A. Born within 32 weeks.
B. Born between 32 and 35 weeks with two of the following:
2. daycare during the RSV season.
3. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
4. with chronic lung disease.
1. 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 Dr. [**Last Name (STitle) 45938**] is recommended
within 3 days of discharge.
Follow up with ophthalmology recommended for the first week of
[**Month (only) 956**].
Follow up ophthalmologist is Dr. [**Last Name (STitle) 59827**].
Address
23 A White's Path
[**Location 30150**], [**Numeric Identifier 59828**]
Phone [**Telephone/Fax (1) 59829**]
DISCHARGE DIAGNOSIS:
1. Prematurity at 28 and 2/7 weeks.
2. Twin gestation, twin B.
3. Respiratory distress syndrome.
4. Patent ductus arteriosus (resolved).
5. Rule out sepsis.
6. Hyperbilirubinemia.
7. Mild retinopathy of prematurity.
8. Apnea of prematurity.
9. Anemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2177-12-1**] 23:40:02
T: [**2177-12-2**] 01:31:06
Job#: [**Job Number 59830**]
|
07054,V4581,2749,41401,4019,53190,2875,5307 | 140 | 165,618 | Admission Date: [**2160-9-21**] Discharge Date: [**2160-9-23**]
Date of Birth: [**2107-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 293**]
Chief Complaint:
GI bleeding.
Major Surgical or Invasive Procedure:
Endoscopy.
History of Present Illness:
53M with hx of HepC, Hepatitis C, thrombocytopenia, and CAD s/p
CABG, with cardiac cath with stenting 1 week ago at which time
he was started on plavix. Tx'd from OSH for 2 episodes each of
black stool/BRBPR and cola colored emesis. No abd pain.
.
In the ED patient was noted to have frankly bloody guiaic with
300cc NG aspirate of cola fluid and coffee grounds; lavage was
clear, HD stable. HCT was noted to have dropped 36 to 26 over
past 8 days.
Past Medical History:
CAD s/p [**2153**] CABG with subsequent Bell's palsy, cath w stent
[**2160-9-12**]
Hypertension
Hx of Hepatitis C. Patient's primary care provider states that
the patient underwent treatment approximately 10 years ago, and
then additional "incomplete" treatment several years ago.
Unclear
re: specifics.
Thrombocytopenia. [**Month/Day/Year 7699**] have been running 60's-80's.
Gout
Hx of binge drinking
Appendectomy
Social History:
Single, works construction. Lives with son, [**Name (NI) **]
age 21. Has sister in area, [**Name (NI) 17**] [**Name (NI) 7700**] (# [**Telephone/Fax (1) 7701**].)
Patient smoked 2-3 packs a day for approximately 30 years,
quitting in [**2153**].
Family History:
Mother with an enlarged heart.
Physical Exam:
Physical Exam:
VS: Temp: AF BP: 118/57 HR: 90 RR: 20 O2sat: 100% 2 LPM
GEN: middle-aged man in NAD, pale appearing
HEENT: EOMI, PERRL
RESP: Non labored and clear anteriorly
CV: RRR no MRG
ABD: Soft, ND, NT, pos BS
EXT: No edema
Skin: No rash
Pertinent Results:
Labwork on admission:
[**2160-9-21**] 06:00AM WBC-5.6 RBC-2.48*# HGB-8.9*# HCT-26.4*#
MCV-106*# MCH-35.7* MCHC-33.6 RDW-13.8
[**2160-9-21**] 06:00AM PLT COUNT-86*
[**2160-9-21**] 06:00AM NEUTS-71.7* LYMPHS-21.8 MONOS-6.0 EOS-0.2
BASOS-0.3
[**2160-9-21**] 06:00AM PT-14.5* PTT-31.5 INR(PT)-1.3*
[**2160-9-21**] 06:00AM GLUCOSE-154* UREA N-23* CREAT-0.7 SODIUM-139
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-12
.
[**2160-9-21**] 06:00AM BLOOD cTropnT-<0.01
[**2160-9-21**] 06:00AM BLOOD CK-MB-4
.
[**2160-9-21**] 12:44PM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative
.
[**2156-4-14**] Echo: LVEF 60% with mild LVH. Mild MR, TR.
.
[**2160-9-5**] ETT ([**Hospital1 2025**]): 5 minutes 15 seconds [**Doctor First Name **] protocol, 54% max
PHR. + chest pain and EKG changes with exercise (ST elevation).
Imaging: mild inferior scar with mild inferior and inferolateral
ischemia. LVEF 68%.
FINAL DIAGNOSIS:
1. Severe native 3 vessel coronary artery disease.
2. Moderate systemic arterial hypertension.
3. Patent LIMA-LAD and radial artery-diagonal grafts.
4. SVG-RPDA with 80% stenosis; SVG-OM with 30% stenosis.
5. Successful stenting of the SVG (to RPDA) (Drug eluting)
.
ECG [**2160-9-21**]
Sinus rhythm. Normal ECG. Compared to the previous tracing of
[**2160-9-13**] no
change.
.
EGD [**2160-9-21**]
Impression: Normal mucosa in the duodenum
Ulcers in the antrum and stomach body
[**Doctor First Name **]-[**Doctor Last Name **] tear
.
Labwork on discharge:
[**2160-9-23**] 04:10AM BLOOD WBC-4.7 RBC-3.45* Hgb-11.2* Hct-32.7*
MCV-95 MCH-32.4* MCHC-34.3 RDW-16.9* Plt Ct-67*
[**2160-9-23**] 04:10AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-138
K-4.3 Cl-107 HCO3-24 AnGap-11
[**2160-9-23**] 04:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1
Brief Hospital Course:
A/P: 53 y/o man with CAD s/p recent stent ([**2160-9-12**]), history of
Hepatitis C, EtOH abuse who presented from OSH with melena,
coffee ground emesis; found to have hematocrit drop from 36 to
26 over past 8 days prior to admissin. Admitted to MICU for
monitoring prior to endoscopy.
.
1. GI bleed. The patient was transfused three units packed red
blood cells with appropriate bump in hematocrit. The hematocrit
remained stabled after transfusion with hematocrit in low 30s
hospital days [**2-29**]. The patient had two episodes of melena the
night of hospital day one; no further episodes of hematemesis or
melena during hospitalization. Hematocrit 32.7 on discharge.
Aspirin and Plavix were initially held but were restarted the
second day of admission per GI recommendations. Patient was
initially treated with Protonix 40 mg IV bid; this was changed
to po prior to discharge. EGD with results as above; no further
treatment as tear and ulcer were no longer actively bleeding. H.
pylori serum antigen was negative. The patient was taking
high-dose indomethacin for one week prior to admission for gout.
The patient is scheduled to have a repeat endoscopy in 4 weeks
as below to assess for healing of the ulcers.
.
2. CAD. Remained asymptomatic throughout hospitalization.
Aspirin and Plavix were initially held but were restarted the
second day of admission per GI recommendations.
Antihypertensives were restarted the second day of admission.
Patient to make follow-up appointment with cardiology.
.
3. Hepatitis C. No varices seen on endoscopy. Further work-up
and management deferred to the primary care doctor.
.
4. ETOH use/abuse. Patient evaluated with CIWA scale but showed
no signs of withdrawal.
.
5. Thrombocytopenia. Stable, chronic. Heparin products held as
primary care doctor [**First Name (Titles) 7702**] [**Last Name (Titles) **] have dropped in the past in
response to heparin. HIT Ab negative. [**Last Name (Titles) 7699**] in 60s on
discharge.
Medications on Admission:
Aspirin 81mg daily every morning
Lisinopril 40mg daily every morning
Folic acid 1mg daily every morning
Norvasc 5mg daily every morning
Atenolol 100mg daily every morning
Plavix
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Pantoprazole 40 mg IV Q12H
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Upper GI bleed, [**Doctor First Name **]-[**Doctor Last Name **] tear on endoscopy
2. Ulcers in stomach body and antrum
.
Secondary:
1. CAD s/p [**2153**] CABG with subsequent Bell's palsy, cath w stent
[**2160-9-12**]
2. Hypertension
3. Hepatitis C
4. Thrombocytopenia- [**Month/Day/Year 7699**] have been running 60's-80's
5. Gout
6. Hx of binge drinking
7. s/p Appendectomy
Discharge Condition:
Afebrile, vital signs stable. Hematocrit stable.
Discharge Instructions:
Please contact a physician if you vomit blood, experience black
stools, bloody stools, chest pain, shortness of breath, or any
other concerning symptoms.
.
Please take your medications as prescribed. Take Protonix 40 mg
twice a day for the rest of your life.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Follow-up endoscopy: Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 7703**] Date/Time:[**2160-11-5**] 9:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2160-11-5**] 9:00
.
Please call your primary care doctor and arrange follow-up
within the next two weeks.
.
Please make a follow-up appointment with your cardiologist.
|
51881,43491,80120,5845,25011,87342,V667,5990,E8889 | 141 | 168,006 | Admission Date: [**2140-11-6**] Discharge Date: [**2140-11-9**]
Service: Medical Intensive Care Unit [**Location (un) 2452**] team.
CHIEF COMPLAINT: Change in mental status; diabetic
ketoacidosis; status post fall.
HISTORY OF PRESENT ILLNESS: This is an 80 year old male with
a history of dementia and psychosis, nursing home resident,
status post fall this morning, found at 5:45 a.m. on the day
of admission. The patient was down for approximately 1.5
hours as noted by records from the nursing home. The patient
was noted to have a laceration at the back of his head, on
the left, with a fair amount of bleeding. Per the nursing
home, the patient was alert and oriented when found.
Initially with oxygen saturation of 87% on two liters when
sent by EMS. On arrival to the Emergency Room, the patient
was disoriented, unable to give name. The patient did not
have a cervical collar in place. The laceration on the left
forehead was noted.
Laboratory studies revealed a blood sugar in the 300's with
an anion gap of 24, with ketones in the urine. The patient
was treated with insulin 10 cc intravenous, followed by five
units per hour drip. He received one liter of normal saline,
200 cc an hour, with 40 of KCl of intravenous fluids. The
patient received 500 mg of Levaquin for a urinary tract
infection that was noted on urinalysis. Head CT was
performed and showed a left temporal hemorrhage and a left
subarachnoid hemorrhage. The patient was initially seen by
neurosurgery in the Emergency Department and was thought not
to be operable. They recommended keeping SVP's less than
140, correcting coagulopathy with platelets and limiting
intravenous fluids.
The patient also had cervical spine films, after his
laceration was repaired, but was noted to be unused. The
patient was transferred to the Medical Intensive Care Unit
for management of the DKA with a soft collar in place.
Repeat finger sticks in the Emergency Department was 230. The
patient also received 1 mg of intravenous Haldol times two in
the Emergency Room.
PAST MEDICAL HISTORY: 1.) Dementia. 2.) Psychosis. 3.)
Syndrome of inappropriate ADH secretion (SIADH). 4.) Benign
prostatic hypertrophy. 5.) Hypertension. 6.) Diabetes
mellitus. 7.) Status post lung abscess. 8.) Status post rib
resection. 9.) History of intravenous drug use. 10.)
Urinary retention. 11.) History of Methicillin resistant
Staphylococcus aureus. 12.) History of alcohol use. 13.)
Question of hepatitis B. 14.) Prior cerebrovascular
accident. 15.) Pulmonary embolus, procedure in [**2138-6-27**].
PHYSICAL EXAMINATION: Vital signs: The patient had a
temperature of 95.2; heart rate of 106; blood pressure
100p/44; saturation 96% on two liters. Generally, agitated
in a C collar. HEAD, EYES, EARS, NOSE AND THROAT: Pupils
two mms, reactive; dry blood on lips; head lags to the
posterior left. Neck: C collar in place. Lungs: Coarse
breath sounds throughout. Decreased breath sounds at the
bases. Coronary: Tachycardiac, irregular, no mitral
regurgitation. Abdomen: Soft, distended, positive bowel
sounds, nontender. Extremities: Venous stasis changes, cool
feet. Trace distal pulses. Abrasions on toes. Neurologic:
Agitated, not responding to commands; moving all extremities.
LABORATORY DATA: Pertinent white count of 15.6; hematocrit
of 30.5; platelets of 150 with a differential on the
hematocrit of 53% polys, 7 bands, 23 lymphs, 1 eosinophil, 2
metamyelocytes. Potassium of 3.4; bicarbonate of 15;
creatinine 1.6; sugar of 393. CK of 2,135; MB of 16;
troponin of .05; MB index of .7. Arterial blood gases:
Lactate of 15.3. Coagulations: INR of 1.9. Urinalysis:
Trace ketones; greater than 300 protein; white blood cell
count 6 to 10.
Chest x-ray was limited by motion; prominent upper
mediastinum; ill defined opacity in the right lung base; left
retrocardiac subtle opacity; multiple rib fractures in right ribs
four, five and six.
Head CT revealed left temporal lobe hemorrhage; left frontal
small subarachnoid hemorrhage; no mass effect; no shift.
Cervical spine films: Limited by motion; no fracture, no
dislocation. Left femoral line in place.
ELECTROCARDIOGRAM: Sinus rhythm with premature ventricular
contractions, 85, normal axis; normal intervals; peak T waves
to V2 to 3. No ST or T wave changes.
HOSPITAL COURSE: 1.) Given the concern for cerebral
hemorrhage, the patient had neurosurgery continuing to
consult on this patient and they recommended maintaining SBP
of 140, correcting INR, neurologic checks and repeating a CT.
Repeat CT on hospital day number two showed a stable bleed
with a new basilar skull fracture. Neurosurgery continued to
follow and recommended getting a magnetic resonance scan when
stable. The patient had every one hour neurologic checks and
correction of his INR coagulopathy, and assessment of his
baseline mental status.
On hospital day number three, given the concern that the
patient had changes in his neurologic examination and a
dilated fixed right pupil, a repeat head CT was performed.
This actually showed a left grossly enlarged parietal
infarct, around the area of the initial bleed that was noted.
Neurologic medicine was consulted and they recommended that
the patient be started on Mannitol, though they recognized
that the patient had a grim prognosis, given his basilar
skull fracture, as well as the questionable cervical spine
fracture.
DKA: The patient presented with elevations of finger sticks
in the 400's, with an anion gap of 25 and ketones in the
urine; all consistent with diabetic ketoacidosis. The
patient was initially hydrated and had his electrolytes
repleted. He was started on an insulin drip, with closure of
his anion gap within the first 24 hours of admission here.
The patient also presented with a severe lactic acidosis that
we continued to follow and, with hydration, his lactic
acidosis eventually resolved. This was likely on top of
acute renal failure.
The patient likely had the lactic acidosis secondary to
Metformin, which he was taking prior to admission. The
patient was maintained on the drip and then subsequently
transferred to the regular insulin on a sliding scale.
Acute renal failure: The patient presented with elevations
of his creatinine, in a setting of diabetic ketoacidosis,
lactic acidosis, infection and also appearing dry on
examination. His creatinine subsequently returned to [**Location 213**]
on the day of discharge, with improvement in his hydration
status.
Hemodynamics: The patient was maintained with SBP of 120 to
140 per neurosurgery to maintain cerebral perfusion. The
patient was maintained with minimal intravenous fluids.
Pancytopenia: On hospital day number two, the patient
presented with severe pancytopenia with a drop in his white
count from 10 to 0.7. Hematology/oncology was consulted
regarding this and it was thought that this was a
multi-factorial event, likely due to a dilutional component
since the platelet line and hematocrit were also down, but
likely felt that this was due to drug offenders, namely the
H2 blocker and PPI. He was initially placed on prophylaxis;
these were discontinued and subsequently, on repeat checks of
his white blood cell count, this actually bumped to
appropriate levels, to 3.8. The patient was also transfused
for his hematocrit as well as transfused with platelets.
Infection: The patient had a urinary tract infection and was
placed on Levofloxacin for a ten day course. Cultures showed
no growth to date. Pneumonia: The patient had a left
retrocardiac opacity, likely pneumonia, which could have
contributed to his current condition. The patient was on
Levaquin and started on Clindamycin for possible aspiration
coverage.
Rhabdomyalysis: The patient's elevation of CK and creatinine, in
the setting of a fall, troponins were flat. Likely, rhabdo
contributing to acute renal failure. The patient was
aggressively hydrated.
C spine collar: Patient status post fall and multiple films
showed questionable dense fracture. Magnetic resonance scan
was performed as per neurosurgery. This was unrevealing,
unable to rule out dense fracture. The patient was
maintained on a hard/soft collar.
Pain control: The patient was maintained on morphine prn as
his blood pressure allowed.
Code status: The patient's legal guardian, as well as grand
niece were contact[**Name (NI) **] regarding the patient's poor prognosis
after his initial insult with the basilar skull fracture,
possible dense fracture and subarachnoid hemorrhage and the
patient was initially made "Do Not Resuscitate" by the
family. After repeat head CT showed evolution of his
infarct, and neurology forecasting a grim prognosis for this
gentleman, family meeting was called and the attending of
record, this intern, and the guardian as well as the primary
care physician, [**Name10 (NameIs) 36229**] [**Name Initial (NameIs) **] meeting. The patient's grand
niece and family agreed that the most appropriate care was
comfort measures only for this patient and the patient was
made comfort measures only, with withdraw of his endotracheal
tube and placed on morphine drip with withdraw of all his
medications on the day of discharge. The patient expired on
[**2140-11-9**] at 8:36 p.m.
DISPOSITION: Deceased.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 36230**]
MEDQUIST36
D: [**2140-11-9**] 10:09
T: [**2140-11-10**] 04:15
JOB#: [**Job Number 36231**]
|
4240,2449 | 142 | 131,357 | Admission Date: [**2143-4-1**] Discharge Date: [**2143-4-5**]
Date of Birth: [**2095-2-27**] Sex: F
Service: Cardiothoracic Surgery
CHIEF COMPLAINT/REASON FOR ADMISSION: Ms. [**Known firstname **] [**Known lastname 403**] is
a postoperative admission who was admitted directly to the
operating room for mitral valve repair versus replacement.
She was seen in preadmission testing prior to surgery. At
that time, her chief complaint was occasional dyspnea on
exertion.
HISTORY OF PRESENT ILLNESS: This is a 47-year-old woman with
known mitral regurgitation followed by electrocardiogram.
Cardiac catheterization done showed 3 to 4+ mitral
regurgitation with normal coronaries and an ejection fraction
of 67%. Cardiac echocardiogram done in [**Month (only) 404**] of this year
showed an ejection fraction of 60% with mildly enlarged left
atrium. No aortic insufficiency. There was 3+ mitral
regurgitation.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse.
2. Hypothyroidism.
3. Varicosities of the lower extremities (left greater than
right).
PAST SURGICAL HISTORY: No past surgical history.
MEDICATIONS ON ADMISSION: Levoxyl 50 mcg by mouth once per
day.
ALLERGIES: The patient states no known drug allergies.
SOCIAL HISTORY: She lives with her husband and two children.
Occupation as a writer. She denies tobacco use. Occasional
alcohol use. Denies any other drug use.
FAMILY HISTORY: Her mother is alive. Her father is alive,
status post mitral valve repair.
PHYSICAL EXAMINATION ON PRESENTATION: Her height was 5 feet
3.5 inches, her weight was 130 pounds. In general, she was
well-appearing and in no acute distress. The skin was
unremarkable. Head, eyes, ears, nose, and throat examination
revealed the pupils were equal, round, and reactive to light.
The extraocular movements were intact. The sclerae were
anicteric. The neck was supple with no lymphadenopathy.
There was no jugular venous distention. There were no
bruits. The chest was clear to auscultation bilaterally.
Heart was regular in rate and rhythm. First heart sounds and
second heart sounds. There was a 3/6 systolic ejection
murmur that radiated throughout the precordium. The abdomen
was soft, nontender, and nondistended. There were positive
bowel sounds. There was no hepatosplenomegaly or
costovertebral angle tenderness. The extremities were warm
and well perfused. There was no clubbing, cyanosis, or
edema. Varicosities bilaterally (left greater than right).
Neurologically, cranial nerves II through XII were grossly
intact. A nonfocal examination. The pulses revealed 2+
femoral bilaterally, 2+ dorsalis pedis pulses bilaterally,
and 2+ posterior tibialis pulses bilaterally, and 2+ radial
pulses bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 5.7, her hematocrit was 33.2, and her
platelets were 199. Her INR was 1.1. Sodium was 136,
potassium was 3.5, chloride was 100, bicarbonate was 25,
blood urea nitrogen was 8, creatinine was 0.5, and blood
glucose was 92. Liver function tests were within normal
limits. Urinalysis was negative.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed sinus
bradycardia at a rate of 57 beats per minute.
A chest x-ray showed no active cardiopulmonary processes.
SUMMARY OF HOSPITAL COURSE: As stated previously, the
patient was a direct admission to the operating room on [**4-1**] where she underwent minimally invasive mitral valve repair
via a right mid axillary mini-anterior thoracotomy with a
28-mm [**Doctor Last Name 405**] angioplasty. Please see the Operative Report
for full details.
In summary, the patient had a minimally invasive mitral valve
repair. Her bypass time was 130 minutes with a cross-clamp
time of 110 minutes. She tolerated the operation well and
was transferred from the operating room to the Cardiothoracic
Intensive Care Unit. At the time of transfer, the patient's
mean arterial pressure was 74 with a central venous pressure
of 6. She was in a sinus rhythm at 89 beats per minute. She
had a Levophed infusion at 0.3 mcg/kg per minute and propofol
at 20 mcg/kg per minute.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was weaned from the
ventilator and successfully extubated. She had no other
events on operative day.
On postoperative day one, the patient continued to require a
Levophed infusion for blood pressure support which was
titrated as tolerated. Her Swan-Ganz catheter was removed on
postoperative day two. The patient had weaned to off the
Levophed infusion, and she was transferred to the floor for
continued postoperative care and cardiac rehabilitation.
Additionally, on postoperative day two, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 406**]
drain was removed. Over the next several days, the patient
had an uneventful hospitalization.
Once on the floor, with the assistance of the nursing staff
and the Physical Therapy staff, the patient's activity level
was advanced. She remained hemodynamically stable throughout
her hospitalization.
On postoperative day four, it was decided that the patient
was stable and ready to be discharged to home. At that time,
the patient's physical examination was as follows. Vital
signs revealed her temperature was 99, her heart rate was 92
(sinus rhythm), her blood pressure was 104/68, her
respiratory rate was 20, and her oxygen saturation was 97% on
room air. Her weight preoperatively was 59 kilograms, at
discharge was 66.7 kilograms.
Laboratory data revealed a white blood cell count of 7.7, her
hematocrit was 23.1, and her platelets were 129. Sodium was
137, potassium was 3.7, chloride was 100, bicarbonate was 31,
blood urea nitrogen was 8, creatinine was 0.5, and her blood
glucose was 99.
Physical examination revealed she was alert and oriented
times three. She moved all extremities. She followed
commands. Respiratory examination revealed the lungs were
clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. First heart
sounds and second heart sounds. The abdomen was soft,
nontender, and nondistended with normal active bowel sounds.
The extremities were warm and well perfused with no clubbing,
cyanosis, or edema. Right thoracotomy incision with
Steri-Strips, opened to air, clean and dry.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg every day.
2. Niferex 150 mg mouth once per day.
3. Vitamin C 500 mg twice per day.
4. Toprol-XL 12.5 mg once per day.
5. Levoxyl 50 mcg by mouth once per day.
6. Colace 100 mg twice per day.
7. Lasix 20 mg once per day (times two weeks).
8. Potassium chloride 20 mEq once per day (times two weeks).
9. Dilaudid 2 mg to 4 mg q.4-6h. as needed.
DISCHARGE DIAGNOSES:
1. Status post minimally invasive mitral valve repair via a
right thoracotomy.
2. Hypothyroidism.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: The patient was to be discharged home
with [**Hospital6 407**].
DI[**Last Name (STitle) 408**]E INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to have followup on the [**Hospital 409**]
Clinic in two weeks.
2. The patient was instructed to follow up with Dr. [**Last Name (STitle) 410**]
in three weeks.
3. The patient was instructed to follow up with Dr. [**Last Name (Prefixes) 411**] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2143-4-5**] 09:55
T: [**2143-4-5**] 10:23
JOB#: [**Job Number 416**]
|
1550,5715,57410,07054,30390,30401,2851,4019,5920,4168 | 143 | 143,808 | Admission Date: [**2155-1-17**] Discharge Date: [**2155-2-2**]
Date of Birth: [**2103-12-26**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: End-stage liver disease. Here for liver
transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
male with hepatitis C virus cirrhosis, right lobe
hepatocellular carcinoma, status post radiofrequency ablation
on [**2154-5-1**] who presents preop for a liver transplant in
a.m. He reports loose stools x10 per 24 hours associated
with chronic abdominal pain, no fever or chills, no nausea or
vomiting, no cough, no urinary frequency, or symptoms of UTI.
Does admit to feeling hungry and has baseline shortness of
breath.
PAST MEDICAL HISTORY:
1. Significant for hepatocellular carcinoma status post
radiofrequency ablation.
2. Hepatitis C virus.
3. Cirrhosis.
4. Hypertension.
5. Nephrolithiasis.
6. DJD.
ALLERGIES: Patient is allergic Penicillin.
MEDICATIONS AT HOME:
1. Lactulose 30 cc b.i.d.
2. Atavan 1 mg p.r.n.
3. Protonix 40 mg p.o. q. d.
4. Aldactone 100 mg p.o. b.i.d.
5. Lasix 40 mg p.o. q. d.
6. Fluoxitene 20 mg p.o. q. d.
7. Nadolol 20 mg p.o. q. d.
8. Bupropion 100 mg p.o. b.i.d.
9. Glotrimizole troche 1 five times a day.
10. Multivitamin one tab q. d.
11. Methadone 145 mg q. d.
[**Hospital 2514**] clinic is Discovery, phone number [**Telephone/Fax (1) 46538**].
SOCIAL HISTORY: Lives in [**State 1727**].
HABITS: History of alcohol abuse. Denies any cigarette
smoking.
PHYSICAL EXAMINATION: On admission, temperature 98.1, heart
rate 65, blood pressure 122/84 with a respiratory rate of 18,
98% on room air. He was alert and oriented, no acute
distress. Lungs clear to auscultation bilaterally. Heart
regular rate and rhythm. Abdomen soft, obese, positive bowel
sounds, nonfocal abdomen, tender, negative rebound, negative
hemorrhoids, positive umbilical hernia. Rectal, guaiac
negative, no hemorrhoids. Extremities, positive venous
changes and no edema.
LABORATORY DATA: On admission, the patient had a chest x-ray
that showed no acute process, no suspicious nodules. EKG on
[**2154-12-25**], sinus bradycardia, rate 49, inferior
lateral flat T-waves. On [**2154-10-1**], CT of the thorax was
stable, no lesions.
HOSPITAL COURSE: The patient was admitted to the transplant
service. He was made NPO after midnight. IV fluid was
started. Lab work was sent off to use preop for the OR.
Labs preop: White count 3.7, hematocrit 38, platelet count
38, fibrinogen 135. Coags: PT 17, PTT 37, INR 1.6.
Creatinine 1, BUN 19, sodium 139, potassium 3.9, chloride
105, CO2 26. The UA was negative.
He was taken to the OR on [**1-18**] for orthotopic liver
transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], co-surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. EBL was 2 liters. He was replaced with 5
liters of crystalloid, 6 units of FFP, 6 units of packed red
blood cells, 3 bags of platelets and 1 bag of cryoglobulin.
Please see operative report for details. The patient was
intubated and taken to the surgical intensive care unit in
critical, but stable condition.
He was given induction immunosuppression of 500 mg of Solu-
Medrol, 1 gram of CellCept intraop. In the SICU, his
hematocrits were followed closely. He was replaced with IV
fluid. Hematocrit was 30.6. He was weaned and extubated.
His LFTs trended down. Properatively, his AST was 1463, ALT
1116, alkaline phos 55, total bilirubin 3.9, and an amylase
of 279. On postoperative day 2, his AST was 476, ALT 746,
alkaline phos 56, and a total bilirubin of 1.2. A duplex
ultrasound of the liver demonstrated perihepatic ascites.
Portal veins and hepatic veins were visualized with normal
direction of flow, poorly dopplered hepatic artery waveforms
were noted, likely secondary to technical limitations. A
repeat ultrasound was done on postoperative day 2. This
demonstrated appropriate waveforms and directionality of flow
within the portal veins, hepatic veins, and hepatic arteries.
His LFTs continued to trend down. Vital signs were stable.
His preop weight was 113. On postoperative day 1, his weight
was 130.5. He began on IV Lasix and his weight trended down
and achieved a weight of 116.7 no postoperative day 14.
His hematocrit trended down to 23.5 on postoperative day 9.
He received 3 units of packed red blood cells. A repeat
hematocrit was 26.9. He received another unit of packed red
blood cells as well as 1 unit of platelets for a platelet
count of 74. Post-platelet transfusion was 114 and a post-
hematocrit was 32.1. His hematocrit remained in the range of
28 to 29 for the remainder of his hospital course. He did
undergo abdominal CT with and without contrast to evaluate
for any bleeding. The CT demonstrated no cause for drop in
hematocrit. There was moderate hepatic artery stenosis
noted. There was narrowing of the portal vein at the area of
the anastomosis as well as mild stenosis at the origin of the
right renal artery. A small amount of ascites and
perihepatic fluid was noted. There were multiple low
attenuation areas in the transplanted liver likely
representing simple cysts.
When the patient was in the SICU, as he awakened, he
complained of pain control. Patient was on Methadone 145 mg
p.o. q. d. at home and he had not been on this as of
postoperative day 2. Dilaudid 2 mg IV q. 1 hour was
ineffective in relieving the patient's pain, so the Dilaudid
was increased to 4 mg IV q. 1 to 2 hours. Methadone was
restarted. The patient was started on clear liquids. He
tolerated this without incident. His blood sugars were
elevated and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained. He was placed on
an insulin sliding scale to achieve normalization of blood
glucoses. He was hypertensive while in the SICU. He was
given Hydralazine and Lopressor. Blood pressure improved and
ranged between 130s to 140s down to 90 to 100 systolic.
Lopressor was changed to p.o. His Solu-Medrol was tapered
per protocol and he was started on 20 mg on postoperative day
7 of Prednisone and he remained on CellCept 1 gram b.i.d.
throughout this hospital course. Prograf was started on
postoperative day 2 at 2 mg p.o. b.i.d. Prograf was adjusted
and titrated to levels. Prograf level increased to 18.9 on
postoperative day 8. His dose was decreased and he was
stabilized on 2 mg p.o. b.i.d. with a Prograf level of 9 to
14 on 2 mg twice a day.
He was transferred to the medical/surgical unit where he
continued to recover slowly. Pain control continued to be an
issue. Consult was obtained. Recommendations included
continuation of Methadone 145 mg q. a.m. and adjusting
Dilaudid p.o. to 8 to 16 mg p.o. q. 2 hours p.r.n. For the
remainder of this hospital course, his pain continued to be
monitored. He complained primarily of right upper quadrant
discomfort. Towards the end of his hospital stay, his pain
was lessened and he was receiving 4 mg p.o. approximately 4
times a day.
A physical therapy consult was obtained. PT worked with him
to ambulate. Given his deconditioning, it was recommended
that he continue home PT. He has 2 [**Location (un) 1661**]-[**Location (un) 1662**] drains; #1
was discontinued on postoperative day 5 and #2 JP drain
continued to drain approximately 290 cc of serosanguineous
fluid. On postoperative day 7, he was started on IV
Vancomycin for some erythema around the incision at the left
lower quadrant. This erythema resolved towards the end of
the hospital course and Vancomycin was stopped. His white
blood cell count remained in the 4.7 to 6.6 range. The
second JP was removed. His LFTs continued to decrease. He
was tolerating a regular diet and needed a lot of
encouragement to ambulate.
On postoperative day 9, patient complained of right neck
discomfort. His right IJ site appeared mildly edematous. A
carotid ultrasound was done. This demonstrated no
pseudoaneurysm. There was also noted of a right IJ partially
occlusive clot. He was not started on Heparin or Coumadin.
The [**Last Name (un) **] consult was obtained. He was maintained on a
sliding scale insulin regimen for moderately elevated blood
sugars. He required a minimal amount of regular insulin and
this was tapered off towards the end of the hospital stay.
He was discharged home on postoperative day 15 in stable
condition. His LFTs had trended down with an AST of 49, ALT
217, alkaline phos 102, total bilirubin 0.6, albumin of 3.1.
His creatinine was 1.1, BUN 21, white blood cell count 6.6
and a hematocrit of 29.4. He was urinating independently
without any difficulty. He was tolerating p.o. well. Blood
pressure ranged between 118/72 to 135/78. He was afebrile.
He was out of bed ambulating independently. Visiting nurse
services were set up for medication management, AcuCheks and
wound assessment. The plan was for him to return to the
[**Hospital 2514**] clinic on Monday, [**2155-2-3**], for assessment for
continuation of Methadone maintenance. [**Hospital 2514**] clinic was
the Discovery House [**Hospital 2514**] Clinic. That telephone number
was 1-[**Telephone/Fax (1) 46538**]. He was discharged home in stable
condition.
DISCHARGE MEDICATIONS:
1. Fluconazole 400 mg p.o. q. d.
2. Prednisone 20 mg p.o. q. d.
3. Protonix 40 mg p.o. q. d.
4. Bactrim single strength 1 p.o. q. d.
5. CellCept 1 gram p.o. b.i.d.
6. Methadone 145 mg p.o. q. a.m. for maintenance.
7. Fluoxitene 20 mg p.o. q. d.
8. Bupropion 100 mg sustained release tab, 1 tab p.o. b.i.d.
9. Colace 100 mg p.o. b.i.d.
10. Dilaudid 2 mg tabs, 1 to 2 tabs p.o. p.r.n. q. 4 to 6
hours.
11. Balcyte 900 mg p.o. q. d.
12. Lasix 20 mg p.o. q. d.
He was scheduled to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2-6**]
at 9 a.m.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS: End-stage liver disease secondary to
hepatocellular carcinoma and hepatitis C virus.
SECONDARY DIAGNOSES:
1. Chronic pain, chronic back pain.
2. Methadone maintenance.
3. Anemia.
4.
Hypertension.
5. History of alcohol and IV drug abuse.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2155-2-3**] 15:13:39
T: [**2155-2-3**] 19:12:00
Job#: [**Job Number 46539**]
|
E8810,83900,85221 | 144 | 137,432 | Admission Date: [**2197-7-14**] Discharge Date: [**2197-7-27**]
Date of Birth: [**2143-4-10**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: The patient is a
54 year old gentleman with a history of a [**2143**]5 feet with
no loss of consciousness, complained of headache on [**7-14**],
and went to [**Hospital **] Hospital. Computerized tomography scan
of the head showed large right subdural hematoma,
longitudinally covering the whole hemisphere with about 2 cm
plus substantial midline shift and complete effacement of the
right lateral ventricle. The patient was sedated and
intubated and sent to [**Hospital6 256**]
for further management. On arrival the patient's pupils were
less than 2 mm and nonreactive. The right was 5 mm and
nonreactive. The patient was taken emergently to the
Operating Room for evacuation of acute subdural hematoma.
The patient was taken to the Operating Room and underwent
evacuation of a right frontal subdural hematoma without
intraoperative complications. Postoperatively the patient
was intubated off of Propofol and attempted to open his eyes
to voice, moving all four extremities spontaneously. After
attempts to localize the noxious stimuli, lower extremities
withdraw to pain. His blood pressure was kept less than 120
with Nipride. He continued on Propofol. His pCO2 was kept
in the 30 to 35 range. He had his thoracolumbosacral spine
cleared. His cervical spine was unable to be cleared at that
time and he has remained in a hard collar. On [**7-16**], he
had a repeat head computerized tomography scan which showed
post surgical changes and a small amount of subdural
hematoma still visible. His cervical spine showed
degenerative changes and spinal stenosis. He was extubated
also on [**7-16**]. He was following commands. He had right
drift in the upper extremity, but moving all his other
extremities spontaneously. On [**7-18**], the patient had
another repeat head computerized tomography scan which showed
stable appearance of the remaining subdural hematoma. The
patient was withdrawing all four extremities, less on the
right lower extremity, somewhat sleepy. The patient was
transferred to the regular floor on [**2197-7-20**] and remained
in stable condition. He had a swallow evaluation which he
passed, feeding tube was removed and he was able to start
taking p.o. intake. He had flexion extension films done of
the cervical spine which were inadequate and needed to be
repeated. Results of that are pending. He has been followed
by physical therapy and occupational therapy and found to
require acute rehabilitation. He is awake, alert and
following commands, moving all extremities.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. t.i.d., hold for heart rate less
than 60, blood pressure less than 110.
2. Nystatin oral suspension 5 cc p.o. q.i.d.
3. Heparin 5000 units subcutaneously q. 12 hours.
4. Famotidine 20 mg p.o. b.i.d.
5. Folic acid 1 mg p.o. q. day.
6. Thiamine 100 mg p.o. q. day.
7. Clonidine patch one patch q. day, q. Monday.
CONDITION ON DISCHARGE: Stable. Vital signs were stable at
the time of discharge.
FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) 1132**] in one month
with a repeat head computerized tomography scan.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2197-7-26**] 14:51:04
T: [**2197-7-26**] 15:21:50
Job#: [**Job Number **]
|
E8810,83900,85221 | 144 | 137,432 | Admission Date: [**2197-7-14**] Discharge Date: [**2197-8-1**]
Date of Birth: [**2143-4-10**] Sex: M
Service: NSU
ADDENDUM: On [**2197-7-28**], the patient continued to improve
neurologically. His vital signs were stable. He was awake
and alert and oriented x3. He exhibited no pronator drift.
His grip and IPs were full. His x-ray showed a C2-3
subluxation on flexion and extension films.
ASSESSMENT: He was neurologically stable and is ordered to
stay in a hard collar for now. The following day, on
[**2197-7-29**], the patient continued to show improvement. He
was to continue with physical therapy and occupational
therapy. He is to begin ambulating and is to follow up his
flexion and extension films of the cervical vertebrae in 2
weeks, and rehabilitation planning should be started. On
[**2197-8-1**], the patient was discharged to home with services.
DISCHARGE INSTRUCTIONS: He is to take all medications as
prescribed, keep all followup appointments. He is to keep
wearing the cervical collar until he has followup x-rays and
sees Dr. [**Last Name (STitle) 1132**]. He is to walk only with assistance.
FINAL DIAGNOSES: Right subdural hematoma status post
surgical evacuation of right subdural hematoma. He also has
a cervical spine subluxation with neck flexion. He is
recommended to followup. He is to get repeat cervical spine
flexion and extension x-rays in 2 weeks. He is to follow up
with Dr. [**Last Name (STitle) 1132**] in 2 weeks, [**2197-8-18**], at 9 a.m. to be preceded
by flexion and extension x-rays of his cervical spine at 8
a.m.
MAJOR SURGICAL PROCEDURE WHILE IN THE HOSPITAL: Surgical
evacuation of right subdural hematoma.
DISCHARGE CONDITION: His discharge condition is improved
though still with some gait unsteadiness requiring
supervision.
DISCHARGE MEDICATIONS:
1. Oxycodone and acetaminophen 5/325 mg tablet, 1-2 tablets
p.o. q.4-6h. as needed. He is dispensed 40 tablets with 0
refills.
2. He is also prescribed Lopressor 50 mg tablet. He is to
take 0.5 tablets p.o. b.i.d. He is to hold if his heart
rate is less than 60 or his blood pressure is less than
100. He is dispensed 30 tablets with 2 refills.
DISCHARGE CONDITION: The patient's condition at the time of
discharge is stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 55481**], M.D. [**MD Number(1) 1908**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2197-8-30**] 14:01:27
T: [**2197-8-30**] 15:45:15
Job#: [**Job Number **]
|
99662,03849,99591,2761,5859,5793,70703,7202,73342,V442,V4581,4019 | 145 | 138,459 | Admission Date: [**2145-2-15**] Discharge Date: [**2145-2-22**]
Date of Birth: [**2089-3-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Left subclavian central line - removed [**2145-2-19**]
PICC line - placed [**2145-2-19**]
History of Present Illness:
55 y/o F w/ complicated PMHx w/ known type II aortic dissection
c/b sma occlusion s/p bowel resections c/b short gut syndrome
(now on chronic TPN), s/p recent ARF, s/p recent open chole,
recent MRSA bacteremia on a long course of vancomycin, chronic
stage 4 sacral decub, now is transferred from OSH ED with fevers
to 103 at home. The pt was recently hospitalized [**Date range (1) 60533**] for
ARF felt to be due to ATN, and she was treated with Vanc/Zosyn
for fever and a Stage IV decub. Since she was discharged from
[**Hospital1 18**] off of therapy for her stage IV decubitus ulcer, she did
well until [**1-22**] when she developed fever to 101.9. She was
restarted on Zosyn and vancomycin that day. Blood cultures were
drawn at that time. 2/4 bottles from [**1-22**] grew MRSA. Of note,
her PICC line through which she receives TPN was changed on
[**1-21**], so it was felt less likely that this was the source. She
was complaining of low back and hip pain, and Dr. [**Last Name (STitle) 2716**]
recommended MRI of the pelvis to reassess the SI joint and
sacral decubitus ulcer and possibly an echocardiogram. Pt
states she thinks this was done and did not reveal a source. OMR
notes indicate that repeat blood cultures were drawn on [**1-25**] x1
and [**1-26**] x2 and as of [**2145-1-27**] these were negative. She recently
returned home with VNA from rehab facility on [**2145-2-8**] and has
been doing well until the day PTA when she developed the fevers.
In the ED at OSH, pts blood cx are growing GNR in [**2-6**] bottles.
The pt denies SOB, abdominal pain, dysuria, diarrhea, headache.
She admits to a chronic cough nonproductive of sputum and 3
minutes of L sided sharp chest pain on arrival to [**Hospital Unit Name 153**], not
associated with SOB, nausea, or radiation. She currently feels
chills.
.
In the ED, the pts BP was initially 145/77. However, the pts
SBP was noted to drop to 77/41 with pulse 99, requiring a 3 NS
and then levophed gtt. She was also noted to be febrile to 103
with WBC 11.9, lactate up to 2.4 (resolving to 1.2 s/p fluids),
and CXR was negative for acute process. In ED she was seen by
both vascular and transplant surgery who felt abd was stable and
were concerned fevers were likely [**2-4**] line infection and
recommmended removing PICC line vs. following blood cultures
before removing. The pt was seen by ID wo recommended obtaining
records of pts recent MRI, starting meropenem/levoflox,
obtaining ab imaging to eval for intrab collection, and d/c of
PICC line. She received Vancomycin 1 gm IV, Zosyn, and
Levofloxacin 500 mg IVx1.
Past Medical History:
1. Descending Aortic Dissection [**3-7**], s/p repair, c/b bowel
ischemia and resection. Briefly:
.
-[**2144-3-30**]: fenestration and SMA stent
- [**2064-4-9**]-- Pt underwent stenting of both renal arteries as the
aortic dissection had spread and had stenosed both renal
arteries.
- [**2144-4-16**]-- Abdominal aorta and bilateral pelvic runoff, aortic
dissection and fenestration, removal and replacement of right
renal stent.
- [**2144-4-22**]-- Pts. bowel ischemia worsened, went to the OR for
exploratory laparotomy, ascending aorta to superior mesenteric
artery bypass, Resection of distal ileum, right colon, and
transverse colon, Ileostomy, and subtotal colectomy and small
bowel resection.
Over the next week the pt underwent several
laparotomies/washouts and revisions of her ileostomy. Finally, a
GJ tube was placed for enteral feeding.
- [**2144-6-29**]-- Pt underwent a CT angiogram which demonstrated a
widely patent sma graft, and a stable aortic dissection.
2. Open cholecystectomy [**9-7**].
3. Stage IV sacral Decub (MRSA/VRE)
4. Short gut syndrome, on TPN
5. Bilateral Pneumothorax
6. h/o of G/J tube now removed
7. Anxiety
8. Depression
9. HTN
10. h/o hepatitis
11. h/o Pancreatitis
12. Klebsiella Bacteremia/pneumonia [**9-7**]--complicating pts
cholecystitis
13. MRCP [**1-8**]: 1. Status post cholecystectomy. Normal biliary
system. No evidence for retained stones. No explanation for
abnormal liver enzymes by MRI examination.
14. Recent Hospitalization [**Date range (1) 60534**] for sacral decub:
"dedicated hip and sacrum MRI, which showed the sacral ulcer,
infectious changes tracking up into the SI joint and fluid
around the sciatic notch. In addition, it noted AVN of the left
femoral head. No abscess was seen. The patient was continued on
Vancomycin and started on Zosyn per ID service recommendations.
Per ID recs, the patient will remain on Vanc and Zosyn
indefinitely, and will be followed in [**Hospital **] clinic."--per d/c
summary. MRI [**12-8**]: 1. Edema or minimal fluid within the left
sacroiliac joint, and edema within the adjacent soft tissues,
extending through the sciatic notch. Findings concerning for
underlying infectious etiology. No abcess is identified.
Minimal marrow edema within the left sacrum may be reactive;
while, osteomyelitis cannot be entirely excluded, it is thought
less likely.
15. h/o HIT ab
16. admssion [**Date range (1) 60535**]/05 for MRSA line infection
Social History:
40 pack year history but quit [**3-7**], occ etoh, no illicit drug
use, on disability
Family History:
mother: cad
Physical Exam:
Vs: T 97.7 BP 141/78 P 127, R29 Sat 98%RA CVP 11, SVO2 80
Gen - overweight female, having rigors
HEENT - OP clear, MM very dry, poor dentition
Neck - supple, no LAD, no JVD, no bruits
Cor - RRR, [**2-8**] HSM at LUSB
Chest - CTAB, sternal scar well healed
Abd - midline abdominal scar well healed. Illeostomy
bag with liquid output. +ttp in middle of abdomen to upper left
of colostomy bag, NABS
Ext- warm, well-perfused, no c/c/e
Back - sacral decub (stage IV) with slight erythema surrounding,
ttp. No prurulence or fluctuance.
Neuro: A&Ox3.
Pertinent Results:
[**2145-2-15**] 11:54PM GLUCOSE-102 UREA N-29* CREAT-1.4* SODIUM-139
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2145-2-15**] 11:54PM CALCIUM-8.1* PHOSPHATE-2.2* MAGNESIUM-1.8
[**2145-2-15**] 11:54PM CORTISOL-43.0*
[**2145-2-15**] 11:54PM WBC-12.2* RBC-3.54* HGB-10.5* HCT-30.6*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.8
[**2145-2-15**] 11:54PM NEUTS-90.7* LYMPHS-5.6* MONOS-3.4 EOS-0.1
BASOS-0.2
[**2145-2-15**] 11:54PM PLT COUNT-211
[**2145-2-15**] 11:53PM URINE OSMOLAL-263
[**2145-2-15**] 11:21PM CORTISOL-23.1*
[**2145-2-15**] 10:14PM TYPE-MIX
[**2145-2-15**] 10:14PM HGB-11.2* calcHCT-34 O2 SAT-95
[**2145-2-15**] 06:21PM LACTATE-1.2
[**2145-2-15**] 05:15PM GLUCOSE-92 UREA N-38* CREAT-1.6* SODIUM-132*
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16
[**2145-2-15**] 05:15PM LIPASE-16
[**2145-2-15**] 05:15PM TOT PROT-6.0* CALCIUM-9.4 PHOSPHATE-2.4*
MAGNESIUM-2.1
[**2145-2-15**] 05:15PM CORTISOL-43.4*
[**2145-2-15**] 05:15PM CRP-103.8*
[**2145-2-15**] 05:15PM WBC-11.9* RBC-3.86* HGB-11.6* HCT-33.2*
MCV-86 MCH-30.1 MCHC-34.9 RDW-15.3
[**2145-2-15**] 05:15PM NEUTS-64 BANDS-27* LYMPHS-0 MONOS-6 EOS-1
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2145-2-15**] 05:15PM PLT COUNT-232
[**2145-2-15**] 03:17PM LACTATE-2.4*.
.
CXR: no acute cardiopulm process
EKG: NSR, no ST changes, nl axis
[**2145-2-15**] 06:43AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2145-2-15**] 06:43AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2145-2-15**] 12:50AM GLUCOSE-81 UREA N-46* CREAT-1.5*# SODIUM-135
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
[**2145-2-15**] 12:50AM ALT(SGPT)-67* AST(SGOT)-57* LD(LDH)-116 ALK
PHOS-309* AMYLASE-45 TOT BILI-1.1
[**2145-2-15**] 12:50AM ALBUMIN-3.7 CALCIUM-9.3 PHOSPHATE-3.5
MAGNESIUM-1.5*
[**2145-2-15**] 12:50AM NEUTS-84.9* BANDS-0 LYMPHS-7.6* MONOS-4.5
EOS-2.5 BASOS-0.6
[**2145-2-15**] 12:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2145-2-15**] 12:50AM PLT COUNT-283
[**2145-2-15**] 12:50AM PT-13.4* PTT-31.3 INR(PT)-1.2*
[**2145-2-15**] 12:49AM COMMENTS-GREEN TOP
[**2145-2-15**] 12:49AM LACTATE-1.3
Brief Hospital Course:
Briefly, this is a 55 yo F with MMP including stage IV sacral
decub, PICC for chronic TPN, avascular necrosis with fluid in L
sacroiliac joint, recent MRSA bacteremia, and GNR in blood from
OSH, admitted with sepsis. Pt was found to have positive blood
cx for Klebsiella, now afebrile on vanc and levoflox.
.
# Sepsis/ID: Likely Klebsiella line infection. Pt was
hypotensive and febrile on admission to SBP 70s, requiring
pressors in the ICU. Her WBC was 11.9 with 27% bands on
admission. The pt has a h/o MRSA bacteremia from [**1-22**] and now
GNR in blood (now +for Klebsiella) from [**Hospital3 26615**] ED on [**2-15**].
CXR was negative for acute cardiopulm process and UA was
somewhat dirty but not grossly positive. The pt responded
appropriately to [**Last Name (un) 104**] stim test. Given it was the most likely
source of infection, the pts PICC line was pulled on admission.
Repeat RUQ US [**2-16**] was wnl. TTE on [**2-16**] was negative for
vegetations. Levophed was weaned off [**2-16**] and pts BP has been
holding. Meropenem was d/c'd [**2-16**] after blood cx from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] showed Klebsiella S to levoflox. ID was [**Last Name (NamePattern1) 4221**]
and has been following the pt. the patient was transferred to
the medical floor once stable. It was decided to continue the
levoflox for treatment of the Klebsiella line infection and
Vancomycin for h/o MRSA until she saw ID in clinic for further
f/u.
.
# Sacral Decub: Stage IV. Wound vac was discontinued PTA due to
pain. Per one of pts prior hospitalizations, plastic surgery was
considering a flap. Plastic surgery was [**Last Name (NamePattern1) 4221**] and states
decub appears to be healing well. Wound care was [**Last Name (NamePattern1) 4221**]
regarding decub care. The pt has been receiving pain meds with
oxycodone and dilaudid prn.
.
#Hyponatremia: Na 132 on admission, with baseline 136-140.
Likely hypovolemic in etiology. Na improved after fluids.
.
#URI sxs:
--r/o with influenza DFA; droplet precautions
.
# Elevated LFTs: AST, ALT and alk phos are all down compared to
discharge. These elevations have been present since [**5-7**] prior
to dissection. She had an open cholecystectomy in [**2144-9-3**]
for cholecystitis. Previous workup has included: negative
hepatitis B and C serologies x 2, nml HIDA scan [**9-7**], MRCP
showed s/p cholecystectomy: normal biliary system, no evidence
for retained stones, MRI with no explanation for abnormal liver
enzymes, negative AMA, negative HIV. Abd pain is currently at
baseline. Repeat RUQ US on [**2-16**] was negative
.
# Short gut syndrome: The pt is on chronic TPN. Abd exam seems
stable. Per PCP pt has been on TPN since [**Month (only) 216**] and is followed
by surgery. It is unclear if the pt still needs TPN, so a trial
without TPN had been initiated. However, per nutrition, the
patient needs TPN due to poor absorption given her short gut
syndrome. TPM was re-initiated and the patient had another PICC
line placed for both TPN and her antibiotics.
.
# Anemia: Hct was 32 on admission, was previously 30 on
discharge. The pt has been on epo as outpt started during last
hospitalization for ARF, but unclear if pt still needs it. Her
Epo has been discontinued this admission.
.
# h/o ARF: on last admission was felt [**2-4**] ATN in setting of
hypotension. Cr now 1.5, down from 2.6 on last discharge.
.
# Avascular necrosis with fluid within the L sacroiliac joint:
- repeat MRI here showed persistent fluid in left sacroiliac
joint. On vancomycin. To f/u with ID re: duration of vancomycin.
.
# HTN: The pts hydral and metoprolol were held in the setting of
sepsis. Her BP was normotensive without the medications, so she
was not discharged on either hydral or metoprolol.
.
# FEN: replete prn
.
# PPX: pneumoboots given h/o HIT, no bowel regimen given short
gut syndrome, PPI
.
# Full Code
,
#Communication: HCP [**Name (NI) **] [**Name (NI) 60531**] [**Telephone/Fax (1) 60536**]
.
Medications on Admission:
-zoloft 50mg po qd
-metoprolol 25mg po bid
-hydralazine 150mg po tid
-multivitamin po qd
-vitamin D 800 units po qam
-epogen 10,000 units Inj qMon
-metoclopramide 5mg po qid
-protonix 40mg po qd
-prochlorperzine 10mg po tid prn
-clonazepam 1mg po bid prn
-benefiber qam
-vancomycin 1g IV q72
-hydromorphone 2mg po tid to q4 hours prn
-oxycodone 5mg po q6hours prn
-acetominophen 650mg prn
-trazodone 50mg po qhs prn
-ambien 5mg po qhs prn
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 and HR<55.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*1 bottle* Refills:*0*
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed.
12. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
dose Intravenous Q24H (every 24 hours): Continue until you see
Dr. [**Last Name (STitle) 2716**] on [**2145-3-22**].
Disp:*35 doses* Refills:*0*
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
dose Intravenous Q 24H (Every 24 Hours).
Disp:*35 doses* Refills:*0*
14. IV care
Infusion pump and tubing
15. PICC line
PICC line care per protocol
16. Outpatient Lab Work
Needs weekly CBC, Chem 10, LFTs, Vancomycin trough starting
[**2145-2-23**] drawn - results to be faxed to Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] at
[**Telephone/Fax (1) 11959**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary - klebsiella bacteremia, sacro-iliac joint enhancement
Secondary - mesenteric ischemia s/p aortic dissection; on TPN;
stage IV sacral decub, depression, HTN, h/o hepatitis, h/o MRSA
line infection
Discharge Condition:
Stable, tolerating TPN, afebrile, walking with PT
Discharge Instructions:
-continue with medications as prescribed
-please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-4**] weeks
-continue with vancomycin and levofloxacin until you see Dr.
[**Last Name (STitle) 2716**] on [**2145-3-22**]
-please see Dr. [**Last Name (STitle) 2716**] on [**2145-3-22**] as scheduled below - it is
very important!
-please come back to the ED if you have any fevers,
dizziness/lightheadedness, shortness of breath, nausea/vomiting,
or any other concerning symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2145-3-4**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2145-3-22**] 10:00 ([**Last Name (NamePattern1) 439**])
Please see your PCP [**Last Name (NamePattern4) **] [**1-4**] weeks for follow-up - call
[**Telephone/Fax (1) 29115**] to make an appointment
Completed by:[**2145-3-25**] |
42731,9971,56962,99674,5185,44101,5570,99859,70703,5793,2874,5849,2761,5761,5571,4401,E9342 | 145 | 198,161 | Admission Date: [**2144-3-29**] Discharge Date: [**2144-7-14**]
Date of Birth: [**2089-3-31**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Abdominal aorta and bilateral pelvic run-off, aortic dissection
fenestration including transluminal balloon angioplasty,
superior mesenteric artery angiography and stenting and
intervascular ultrasound of aorta and iliac arteries. [**2144-3-30**]
Bilateral renal artery stent. [**2144-4-10**]
Abdominal aorta and bilateral pelvic runoff, aortic dissection
and fenestration, removal and replacement of right renal stent,
intravascular ultrasound of aorta. [**2144-4-16**]
Exploratory laparotomy, Ascending aorta to superior mesenteric
artery bypass, Resection of distal ileum, right colon, and
transverse
colon, Ileostomy. [**2144-4-22**]
Subtotal colectomy and small bowel resection. [**2144-4-22**]
Reexploration of abdomen with distal colon resection and distal
small-bowel resection and temporary abdominal closure. [**2144-4-24**]
Exploratory laparotomy with abdominal washout and temporary
closure.
[**2144-4-27**]
Exploratory laparotomy, small bowel resection with end-to-end
small bowel anastomosis, revision of ileostomy,
gastrojejunostomy tube placement and abdominal closure. [**2144-5-1**]
tracheostomy [**2144-5-6**]
Hickman catheter placemant, [**2144-6-4**] [**2145-6-8**]
HIT positive
postoperative sacral decubitus
postoperative fevers ?? etology
History of Present Illness:
The patient is a 54 year old female with a history of
hypertension and recent discharge from [**Hospital 1514**] hospital 14 days
ago with a Type B aortic dissection treated medically who
presented to [**Hospital **] hospital on [**3-29**] with persistent nausea and
vomiting and intensified back pain radiating down her spine. At
[**Hospital1 **], a CT-A was performed which showed no PE and a
dissection extending below the diaphragm. The patient was
transferred to [**Hospital1 18**] for further management.
The patient's symptoms began 3 weeks ago with band-like chest
pain radiating to her back with diaphoresis. She was found at
[**Location (un) 1514**] to have a Type B dissection (unknown extension) and was
admitted to the ICU and discharged 14 days ago on PO labetalol,
nifedipine, protonix and clonidine (doses unknown). Since her
discharge, the patient has been feeling increasingly weak with
intermittent nausea and bilious vomiting and has been unable to
tolerate a PO diet at home. She also noted hematemesis within
the past few days. She denies any blood in her stool recently
but notes green diarrhea x 14 days with a history of blood in
her stool at [**Location (un) 1514**]. The patient states that she has been
compliant with all her medications at home. She states her back
pain recently intensified as well.
At [**Hospital1 18**], the patient was having bilious emesis with specks of
blood with a blood pressure of 160 systolic. She was placed on a
labetalol drip at 1 mg but then developed sinus bradycardia to
the 50s. As a result, nipride was started and was at 0.1 on
exam. The blood pressure in her left arm was 100/58 and in the
right, 160/68 with a HR of 79 on nipride alone. The patient was
pain-free on exam.
A repeat CT chest and A/P was performed that showed a large,
well-perfused false lumen extending distal to the left
subclavian with the left renal artery and inferior mesenteric
artery branching from the false lumen. The superior mesenteric
artery did extend from the true lumen, however, is partially
occluded by the intimal flap. There was no bowel wall
thickening. The dissection extends inferiorly into the bilateral
external iliacs into the groin.
Vascular and cardiac surgery was consulted. Vascular surgery
decided to monitor medically for now.
Past Medical History:
Hypertension
Hepatitis ?unknown type
s/p appendectomy
h/o right shoulder surgery
Social History:
The patient works as a manager for [**State 19827**] Fried Kitchen. She
admits to smoking 1 ppd x 38 years but has not smoked since her
admission to [**Location (un) 1514**] 3 weeks ago. She admits to a history of
heavy alcohol use in the past x 1 year with 4-5 beer/hard liquor
4 x a week. She denies any history of illicit drug use. The
patient is not married and has four children and lives alone.
Family History:
No family history of aortic dissection/Marfan's.
Physical Exam:
a/o x 3,nad
ncat, perrl, eomi
neg lesions nares, oral pharnyx, auditory
supple, farom, neg lymphandopathy, supraclavicular nodes
cta b/l
rrr without murmers
soft, nttp, neg cva, pos bs
Palp DP/PT B/l
Pertinent Results:
ECHO [**2144-3-29**]
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Symmetric LVH. Mild regional LV systolic
dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal aortic arch diameter. Simple atheroma
in aortic arch. Moderately dilated descending aorta Descending
aorta intimal flap/aortic dissection. Flow in false lumen.
AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
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). Local anesthesia was provided by benzocaine topical
spray. No TEE related complications. The patient appears to be
in sinus rhythm. Results were personally reviewed with the MD
caring for the patient.
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
orthrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. There is symmetric left ventricular hypertrophy. LV
systolic function appears mildly depressed with
inferior/infero-lateral hypokinesis. There are simple atheroma
in the ascending aorta and aortic arch without evidence of
aortic dissection. The descending thoracic aorta is moderately
dilated. A mobile density is seen in descending aorta
consistent with an intimal flap/aortic dissection. There is
flow in the large false lumen. There is a
fenestration/communication between the true/false lumen at
approx. 35 cm from the incisors that may represent the point of
initial intimal tear. The dissection extends proximally and
ends at the takeoff of the left subclavian artery without
compromising subclavian flow. There is partial thombosis of the
false lumen just distal to the left subclavian artery. The
dissection extends distally to abdominal aorta and extends
beyond what was visualized (50 cm from the incisors).The true
lumen is significantly narrowed at times but distal flow is not
clearly compromised. Both coronary artery ostia were visualized
in their appropriate orientation with normal color doppler
signal (pulse wave doppler was not performed).The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
IMPRESSION: Thoracic aortic dissection limited to the descending
aorta (type B). Large false lumen that is partially thrombosed
proximally. There is no clear evidence of distal flow compromise
but clinical correlation is suggested.
RENAL U.S. [**2144-3-29**]
Reason: AORTIC DISSECTION, ASSESS RENAL FLOW
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with extensive descending dissection to
external iliacs bilaterally with left renal off of false lumen
now with decreased urine output
REASON FOR THIS EXAMINATION:Please assess renal flow
INDICATION: Assess renal vascular flow, s/p aortic dissection.
RENAL ULTRASOUND: The right kidney measures 10.3 cm. The left
kidney measures 10.3 cm. No hydronephrosis or stones. No
perinephric fluid collection identified.
DUPLEX ULTRASOUND: Color Doppler son[**Name (NI) 867**] was performed of the
renal vasculature. Normal flow is demonstrated in the right and
left renal arteries. Normal waveforms are identified within the
left and right main renal arteries.
IMPRESSION: Normal renal ultrasound. Normal flow and waveforms
are demonstrated in the main renal arteries bilaterally.
CTA CHEST W&W/O C & RECONS [**2144-3-29**]
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with Type B aortic dissection by CT from OSH
but scan did not find distal extent.
REASON FOR THIS EXAMINATION:
eval extent of dissection
INDICATION: Type B aortic dissection by CT from outside hospital
but scan did not find distal extent. Evaluate dissection.
TECHNIQUE: Contiguous axial images through the chest were
obtained without contrast. Subsequently, following the
administration of 150 cc of Optiray contrast, contiguous axial
images through the chest, abdomen, and pelvis were obtained
during opacification of the aorta and its branches. Multiplanar
reconstructions were obtained.
CTA OF THE CHEST: There is a type B aortic dissection present.
The dissection begins just distal to the left subclavian artery
origin of the aorta. There is a large false lumen seen to the
left and a smaller true lumen. There is a fenestration in the
intimal flap seen on series 3, image 18. Thus, the true and
false lumens communicate. The celiac axis arises from the true
lumen, though the intimal flap is abutting the origin of the
celiac axis. The dissection extends into the celiac axis. The
SMA similarly arises from the true lumen, though the intimal
flap is protruding into the ostium of the origin of the SMA. The
dissection extends into the SMA and the SMA is quite small. The
right renal artery arises from the true lumen, and the intimal
flap extends slightly into the ostium of the right renal artery.
This is best seen on series 4, image 295. The left renal artery
arises from the false lumen. More inferiorly, the [**Female First Name (un) 899**] arises
from the false lumen. The dissection extends into both common
iliac arteries. The dissection extends into the common external
and iliac arteries on the right side. The dissection also
extends into the external and internal iliac arteries on the
left side. The intimal flap extends through the right external
iliac artery and is seen clearly to about the level of the
acetabulum. Beyond this point, it is difficult to assess. The
intimal flap is no longer seen definitely in the mid portion of
the left external iliac artery. There is low-density material
fill to the origin of the left subclavian artery. The dissection
does not clearly extend into the left subclavian artery.
CT OF THE CHEST WITHOUT AND WITH CONTRAST: There is atelectasis
within the lungs dependently. No consolidations. There are very
small pleural effusions at the bases posteriorly. No pericardial
effusion.
CT OF THE ABDOMEN WITH CONTRAST: The liver, gallbladder, spleen,
pancreas, and adrenals are normal. The kidneys enhance
symmetrically and excrete normally, despite the left renal
artery arising from the false lumen. No free air or free fluid
within the abdomen. The noncontrast opacified loops of bowel are
containing some fluid but are otherwise unremarkable.
CT OF THE PELVIS WITH CONTRAST: The bladder, uterus, rectum, and
sigmoid are unremarkable. Within the cecum, there is a rounded
enhancing structure of unclear etiology. No pathologically
enlarged lymph nodes within the pelvis.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
Multiplanar reformatted images were essential in delineating the
anatomy and pathology in this case.
IMPRESSION: Extensive type B aortic dissection. The dissection
arises distal to the left subclavian artery. There is a
fenestration between the true and false lumen. The celiac and
SMA arise from the true lumen, though the dissection extends
into these vessels. The residual SMA is quite small. The right
renal artery arises from the true lumen and the left renal
artery from the false. The [**Female First Name (un) 899**] arises from the false lumen. The
dissection extends into the external and internal iliac arteries
bilaterally.
Brief Hospital Course:
The patient is a 54 year old female with a history of HTN, Type
B descending dissection who presents with persistent
nausea/vomiting with possible left renal and superior mesenteric
artery involvement.
1. Type B dissection
- Appreciate vascular and cardiac surgery input. The patient is
at higher risk for bowel ischemia given the nature of the near
occlusion of the SMA by the intimal flap. In addition, there is
potential renal involvement of the left renal artery as it
already extends from a large false lumen. At this time, the
patient will be medically managed with a nipride drip with a
goal SBP 100-120. Labetalol gtt was attempted in the ER without
success and was limited by sinus bradycardia to the 50s.
- We will continue to monitor for signs of renal failure or
bowel ischemia.
- On [**2144-3-29**], the patient's urine output dropped to 15-20 cc/hr
from 60-70. A stat renal ultrasound with doppler flow was
obtained to evalaute renal perfusion in the setting of a left
renal artery previously seen to be coming from the false lumen.
In addition, her lactate was checked TID which rose from 0.7 to
1.1 on [**2144-3-29**]. Vascular and cardiac surgery were called and
made aware. Then the patient developed severe left arm pain and
concern was that her dissection was extending proximally.
- On [**2144-3-30**] the pt went to the angiography suite and underwent
successful fenestration of her abdominal aortic false lumen, and
fenestration and stenting of her SMA.
- [**2064-4-9**]-- Pt underwent stenting of both renal arteries as the
aortic dissection had spread and had stenosed both renal
arteries.
[**2144-4-16**]-- Abdominal aorta and bilateral pelvic runoff, aortic
dissection and fenestration, removal and replacement of right
renal stent, intravascular ultrasound of aorta.
[**2144-4-22**]-- Pts. bowel ischemia worsened, went to the OR for
exploratory laparotomy, ascending aorta to superior mesenteric
artery bypass, Resection of distal ileum, right colon, and
transverse colon, Ileostomy, and subtotal colectomy and small
bowel resection.
Over the next week the pt underwent several
laparotomies/washouts and revisions of her ileostomy. Finally, a
GJ tube was placed for enteral feeding.
[**2144-6-29**]-- Pt underwent a CT angiogram which demonstrated a
widely patent sma graft, and a stable aortic dissection.
2. CHF, EF unknown
- The patient has 10 cm JVP on exam with no known EF. Meanwhile,
we will keep the patient euvolemic. An echo was perfomed on
[**2144-3-29**] which showed an inferior wall that was hypokinetic and
there was concern that her right coronary artery was being
affected by a dissection. As a result, a TEE was to be performed
on [**2144-3-29**] and cardiac surgery was made aware.
3. Transaminitis
- The patient reports a history of hepatitis that was contracted
from eating food in a hospital during her delivery in [**2109**]. We
will recheck a hepatitis panel and trend her LFTs. We do not
know her baseline. If her LFTs continue to climb, we may
consider a RUQ ultrasound with concern for ischemia with known
celiac involvement.
4. Coffee-ground emesis
- The patient will remain NPO for now with IV protonix [**Hospital1 **]. The
patient is hemodynamically stable at present. We will check her
Hct TID for now.
Patient [**First Name9 (NamePattern2) **] [**Last Name (un) 834**] ICU to Vicu/floor after prolonged
complicated postoperative course and trach removal [**2144-3-29**]
-[**2144-6-20**]. Patient remined on TPN for nutritional support because
of short bowel syndrome.Viedo swallow exams negative for
aspiration. PT/OT continued to work with patient.await medicade
application approval for final
dipos planning to rehabiltitaion.
[**2144-6-25**] ID consulted for persistant fevers.patient delined and
line and blood cultures sent.finalization of cultrues negative.
[**2144-7-7**] placement of hickman catheter and repositioning of GJ
tube. TPN was restarted and cycling of tube feeds began.
[**Date range (3) 60525**] patient continued to progress. [**Date range (3) 22925**] to
Rehabilitation for continued care stable.
Medications on Admission:
Protonix QD,
Labetalol 2 tablets [**Hospital1 **],
Nifedipine 1 tablet PO BID,
Clonidine 1 tablet TID
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic QHS (once a day (at bedtime)).
2. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
7. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-5**] PO Q4-6H (every 4
to 6 hours) as needed.
8. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q3DAYS ().
12. Opium 10 % Tincture Sig: Twenty (20) Drop PO ASDIR [**Hospital1 **] ().
13. Levocarnitine 330 mg Tablet Sig: 1.5 Tablets PO q500cc
tubefeeds ().
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
15. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One
(1) Appl Topical DAILY (Daily).
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for agitation.
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for PAIN.
19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN NAUSEA
20. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection every four (4) hours: glucose <60 [**1-5**] AMP D50%
glucoses 61-150/0u
glucoses 151-200/2u
glucoses 201-250/4u
glucoses 251-300/6u
glucoses >400 [**Name8 (MD) 138**] Md.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4047**] Nursing & Rehabilitation Center - [**Location (un) 4047**]
Discharge Diagnosis:
1) Aortic dissection with mesenteric ischemia, s/p aortic
fenestration and sma grafting
2) B/L renal stenosis secondary to Aortic Dissection, s/p bil.
stents
3) Bowel Ischemia, s/p multiple small bowel resections,
ileostomy
4) sacreal decubitus ulcer
5) Short gut syndrome
Discharge Condition:
stable
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] as directed, please call
[**Telephone/Fax (1) 2625**].
Completed by:[**2144-7-14**] |
412,496,4280,4271,42731,41401,41071,4275,4240 | 146 | 190,707 | Admission Date: [**2119-12-19**] Discharge Date: [**2120-1-10**]
Service: Cardiothoracic
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: The patient is
an 85 year old male with known coronary artery disease and
history of myocardial infarction in [**2089**] who presented to an
outside hospital with a complaint of shortness of breath and
dyspnea on exertion. An echocardiogram at the outside
hospital demonstrated an ejection fraction of 45% with mitral
regurgitation 2 to 3+ as well as inferior, posterior
hypokinesis. He had computerized tomographic angiography
which demonstrated no pulmonary embolus. Dobutamine stress
demonstrated large anterior apical inferior, posterior and
lateral reversible defects. Chest x-ray also done at the
outside hospital showed right middle lobe infiltrates. The
patient was transferred to [**Hospital6 2018**] for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, ischemic cardiomyopathy, right middle lobe
infiltrates, atrial fibrillation, hypercholesterolemia, gout,
noninsulin dependent diabetes mellitus, persistent elevated
CPKs, hypertension and chronic renal insufficiency.
PAST SURGICAL HISTORY: No tobacco use, social alcohol use
and previously a heavy drinker, no street drug use. Married
times 51 years, retired Army sergeant in the army for 26
years.
FAMILY HISTORY: Father died in his 70s of cancer, mother
died in her 70s. He has five children, three boys and two
girls-the three boys all live at home.
MEDICATIONS PRIOR TO ADMISSION:
1. Potassium chloride 20 mEq q.d.
2. Aspirin 81 mg q.d.
3. Tagamet 400 mg b.i.d.
4. Aldactone 12.5 mg q.d.
5. Levaquin 500 mg q.d.
6. Ditropan 2.5 mg b.i.d.
7. Lopressor 12.5 mg b.i.d.
8. Amitriptyline 30 mg q.h.s.
9. Zestril 20 mg q.d.
10. Allopurinol 100 mg q.d.
11. Amlodipine 5 mg q.d.
12. Insulin NPH 28 units b.i.d.
13. Regular insulin 14 units at 2 PM
14. Zocor, no dose stated
15. Lasix 80 mg b.i.d.
16. Coumadin 5 mg on Monday, Tuesday, Wednesday, Friday and
Saturday, 4 mg on Sunday and Thursday
ALLERGIES: He is allergic to Codeine.
PHYSICAL EXAMINATION: Physical examination at the time of
admission revealed vital signs with heartrate of 74, blood
pressure 134/67, respiratory rate 18. Head, eyes, ears, nose
and throat, pupils equally round and reactive to light.
Extraocular movements intact. Mucous membranes moist, full
benches. Neck, no lymphadenopathy and no jugulovenous
distension. Chest is clear to auscultation bilaterally.
Heartsounds, regular rate and rhythm. S1 and S2 with
systolic ejection murmur best heard in the lower sternal
border, III/VI. Abdomen is nontender, nondistended, positive
bowel sounds, obese. Groin, no bruits, no bleeding.
Extremities, positive edema. Pulses are palpable
bilaterally. Skin is ecchymotic at intravenous sites.
LABORATORY DATA: Laboratory data at the time of transfer
revealed white count 8.2, hematocrit 34.2, platelets 195,
sodium 138, potassium 4.5, chloride 101, carbon dioxide 32,
BUN 18, creatinine 1.3, glucose 118, CPK prior to admission
on [**462-12-13**], on [**413-12-14**], on [**394-12-17**]
and on [**394-12-19**]. Troponins are all less than .04
except for on [**12-13**], they were 0.05.
HOSPITAL COURSE: The patient was brought to the Cardiac
Catheterization Laboratory, please see catheterization report
or full details. In summary the catheterization report
showed normal left main with left anterior descending 80%
occlusion, circumflex 70% occlusion and right coronary artery
totally occluded. Post cardiac catheterization,
Cardiothoracic Surgery was consulted. In summary, the
patient was accepted for coronary artery bypass grafting at a
later date following a complete workup including carotid
dopplers, pulmonary function tests, and echocardiogram to
assess left ventricular function as well as his mitral
regurgitation and resolution of his right middle lobe
infiltrates as well as diuresis prior to his surgery. The
patient was maintained on the Medical Service prior to his
surgery during his preoperative testing. On [**12-20**], he
experienced an episode of nonsustained ventricular
tachycardia. At that time he was seen by the
electrophysiology service who recommended that the patient be
loaded with amiodarone and started on heparin. On [**12-23**] the patient complained of abdominal pain. Following his
complaint of abdominal pain he had decreasing level of
consciousness followed by a cardiac arrest during which he
had periods of asystole, lasting six to eight seconds.
During that time he was pulseless. He did rule in for a
non-Q wave myocardial infarction following his cardiac
arrest. A temporary pacing wire was placed and he was
transferred to the Coronary Care Unit for continued
monitoring prior to his coronary artery bypass grafting.
The [**Hospital 228**] hospital course was further complicated by an
episode of ventricular tachycardia during which the patient
was pulseless. This occurred on [**12-26**]. The patient
was shocked out of the ventricular tachycardia with 300
joules followed by ventricular pacing with the temporary wire
he had in place. The following morning, [**12-27**], the
patient was brought to the Operating Room where he underwent
an off-pump coronary artery bypass graft times one with a
left internal mammary artery to the left anterior descending,
please see the operation report for full details. The
patient tolerated the procedure well and he was transferred
from the Operating Room to the Cardiothoracic Intensive Care
Unit. At the time of transfer, the patient's mean arterial
pressure was 70, central venous pressure was 12, he was
ventricularly paced at a rate of 70. He had a propofol at 20
mcg/kg/min and Neosynephinre at 0.3 mcg/kg/min. The patient
did well in the immediately postoperative period. He
remained on his Neosynephrine infusion to keep his mean
arterial pressure greater than 70. He remained intubated
throughout postoperative day #1 in anticipation of an
angioplasty to be done on postoperative day #1.
As stated, the patient was brought to the Cardiac
Catheterization Laboratory on postoperative day #1. At that
time his coronary arteries were again studied. The
catheterization showed his left anterior descending to have
an 80% occlusion with competitive flow distally, circumflex
and obtuse marginal 1 to be 80% occluded and the right
coronary artery to be 100% occluded with proximal filling via
left to right collaterals. His left internal mammary artery
to the left anterior descending was widely patent with normal
flow. At that time he underwent an angioplasty of his obtuse
marginal 1 lesion. The lesion was crossed and stented with
no residual lesion. The patient tolerated the procedure
well, please see the catheterization report for full details.
Following the catheterization and stenting the patient was
transferred from the Catheterization Laboratory to the
Cardiothoracic Intensive Care Unit. Upon arrival the
patient's sedation was discontinued. He was weaned from his
ventilator and ultimately extubated. For the next 48 hours
the patient remained in the Cardiothoracic Intensive Care
Unit, monitoring his hemodynamic stability and his
respiratory status. On postoperative day #4 the patient was
transferred to Far 6 for continuing postoperative care and
cardiac rehabilitation. Over the next several days the
patient remained on the Cardiothoracic Step Down Floor. His
activity level was slowly increased with the aid of physical
therapy and the nursing staff. He continued to be followed
by the Electrophysiology Service and on postoperative day #10
he was brought to the Electrophysiology Suite where he
underwent electrophysiology studies and automatic implanted
cardioverter defibrillator placement. Please see
electrophysiology study report for full details. The patient
remained on Cardiothoracic Step Down Floor for two additional
days at which time he was deemed stable and ready for
transfer to rehabilitation.
At the time of transfer to rehabilitation, the patient's
physical examination is as follows: Vital signs temperature
97.7, heartrate 67, ventricularly paced, blood pressure
145/70, respiratory rate 18 and oxygen saturation 99% on 3
liters. Weight preoperatively is 125 kg, at discharge is
121.8 kg. Laboratory data on the day of discharge is white
count 9.5, hematocrit 28.7, platelets 273, PT 14, PTT 28.7,
INR 1.4. Sodium 141, potassium 4.6, chloride 102, carbon
dioxide 31, BUN 24, creatinine 1.1, glucose 100. On physical
examination he is alert and oriented times three, moves all
extremities and is conversant. Respiratory, diffuse rhonchi
bilaterally, no rales. Heartsounds, regular rate and rhythm.
Sternum is stable. Incision with steri-strips, open to air,
clean and dry. Abdomen is soft, nontender with normoactive
bowel sounds. Extremities are warm with 2 to 3+ edema and
palpable dorsalis pedis pulses. The patient does complain of
pain in the right groin including the upper leg. This pain
was noted preoperatively. He had bilateral groin ultrasounds
which were negative for pseudoaneurysm.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg b.i.d.
2. Lasix 80 mg b.i.d.
3. Potassium chloride 40 mEq q.d.
4. Enteric coated Aspirin 325 mg q.d.
5. Plavix 75 mg q.d.
6. Amitriptyline 30 mg q.h.s.
7. Percocet 5/325 one to two tablets q. 4 hours prn
8. Insulin NPH 28 units b.i.d.
9. Regular insulin sliding scale q. 6 hours
10. Ocular ophthalmic drops 1 drop OU b.i.d.
11. Amiodarone 400 mg q.d.
12. Zestril 20 mg q.d.
13. Coumadin to attain a goal INR of 2.0 to 2.5, he has
received 5 mg of Coumadin on [**1-9**] as well as will
receive 5 mg on [**1-10**]. His home medication regime for
Coumadin was 4 mg on Sunday and Thursday and 5 mg all other
days of the week.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft times one with left internal mammary artery to
the left anterior descending and status post angioplasty of
the obtuse marginal.
2. Hypercholesterolemia.
3. Atrial fibrillation status post automatic implanted
cardioverter defibrillator placement.
4. Noninsulin dependent diabetes mellitus.
5. Gout.
6. Hypertension.
7. Chronic renal insufficiency.
FOLLOW UP: The patient is to be discharged to
rehabilitation. He is to have follow up in the [**Hospital 409**] Clinic
in two weeks, follow up with Dr. [**Last Name (STitle) 1537**] in one month, follow up
with his primary care provider in one month and follow up
with Electrophysiology Service in one week.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2120-1-10**] 12:04
T: [**2120-1-10**] 12:08
JOB#: [**Job Number 37761**]
|
80111,5185,8711,9587,E8120,8024,80229,8021,8026,8470,9570 | 147 | 103,631 | Admission Date: [**2158-6-24**] Discharge Date: [**2158-7-21**]
Date of Birth: [**2133-11-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Pt is s/p MVC with multiple facial fractures, left eye injury,
and evidence of small SAH and frontal contusion
Major Surgical or Invasive Procedure:
Left Globe exploration
Facial fracture fixation, with mandibular fixation
Peg and trach placement
History of Present Illness:
PT was involved in MVC and sustained multiple injuries to his
face, Left eye and brain
Physical Exam:
On discharge:
HEENT: Pt with swollen left orbit, arch bars in place, Head
lacerations well healed, Trach removed, dressing over stoma
C/D/I
Cardiac: RRR
Chest: CTAB
Abd:soft NT/ND +BS, PEG tube inplace and without
leakage/erythema or tenderness
Ext: +2 pulses throughout, no edema
Pertinent Results:
[**2158-6-24**] 06:20PM BLOOD WBC-21.6* RBC-4.39* Hgb-13.4* Hct-37.9*
MCV-86 MCH-30.5 MCHC-35.4* RDW-12.1 Plt Ct-130*
[**2158-6-24**] 06:20PM BLOOD PT-12.8 PTT-19.4* INR(PT)-1.1
[**2158-6-24**] 06:20PM BLOOD Plt Ct-130*
[**2158-6-24**] 10:00PM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2158-6-24**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-6-24**] 06:31PM BLOOD pO2-38* pCO2-62* pH-7.30* calHCO3-32*
Base XS-1 Comment-GREEN TOP
[**2158-6-24**] 10:07PM BLOOD Type-ART Temp-38.0 Rates-14/ Tidal V-600
PEEP-5 FiO2-70 pO2-331* pCO2-52* pH-7.34* calHCO3-29 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 11:42PM BLOOD Type-ART Temp-38.0 Rates-18/ Tidal V-600
PEEP-5 FiO2-40 pO2-169* pCO2-41 pH-7.40 calHCO3-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 06:31PM BLOOD Hgb-14.0 calcHCT-42 O2 Sat-65
[**2158-6-28**] 05:03PM BLOOD Hgb-9.9* calcHCT-30
[**2158-6-29**] 01:14AM BLOOD Hgb-10.8* calcHCT-32
Brief Hospital Course:
Pt was admitted to Trauma surgery with multiple facial
fractures, as well as severe trauma to the left eye.
Neurosurgery, Opthomology and Plastics all contributed to the
patients care. The patient developed a CSF leak that was
followed by Neurosurgery that eventually subsided. Nuerosurgery
also followed the patient for a questionable C4-C6 ligamentous
injury for which he was put in a cervical collar. Opthomology
took the patient to the OR for Left globe exploration, they
found no globe rupture but significant corneal abrasion, [**Doctor First Name 2281**]
avulsion with intact lens, and retinal hemorrhages. Plastics
fixed the facial fractures and applied arch bars and was trached
and Peggged [**2158-6-28**]. Patient steadily improved over stay, he
developed some impulsiveness that slowly subsided, he was able
to maintain POs, and achieve daily caloric intake by d/c, and
was cleared by PT and OT for d/c to home with follow up.
Radiology reports:
Head CT showed:
1) Pneumocephalus from multiple facial bone fractures.
2) Subarachnoid versus subdural blood along anterior falx just
above crista
galli.
3) Likely left frontal contusion.
4) Multiple comminuted facial bone fractures. Please see the
dedicated CT
scan of the facial bones for more information.
Facial CT showed:
1. Comminuted fractures involving the outer and inner tables of
the frontal
sinuses with pneumocephalus.
2. Comminuted fractures involving the orbits and maxillary
sinuses
bilaterally. Comminuted fracture of the left zygoma.
3. Right mandibular fracture.
4. Significant subcutaneous emphysema involving the soft tissues
of the
scalp, the orbits and neck. Pansinus opacification.
MRI of spine showed:
Subtle increase in signal intensity adjacent to the spinous
processes of C4
through C6 may represent injury to the interspinous ligament.
CTA head:
IMPRESSION: 1) Slight decrease in prominence of subarachnoid
hemorrhage
anterior to the frontal lobes bilaterally, without evidence of
new mass effect
or new intracranial hemorrhage. Stable pneumocephalus associated
with
multiple comminuted skull fractures.
2) Stable appearance of extensive facial fractures.
3) No evidence of aneurysm or occlusion of the vessels of the
Circle of
[**Location (un) 431**] and its tributaries, or of the cervical portions of the
carotid and
vertebral arteries. Visualization of the small branches of the
external
carotid systems is limited, and if there is clinical interest
for evaluation
of these vessels, standard diagnostic angiography is
recommended. This
recommendation was conveyed to Dr. [**Last Name (STitle) **] at 5:00 p.m. on [**2158-6-25**].
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
QID (4 times a day): Administer to left eye.
Disp:*QS for 2wks drop* Refills:*2*
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day): Apply to Left eye.
Disp:*QS for 2wks * Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Boost Liquid Sig: One (1) PO three times a day.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Facial Fractures, with CSF leak now resolved
Left eye injury: corneal abrasion, [**Doctor First Name 2281**] avulsion, retinal
hemorrhage
small anterior SAH, left frontal contusion
cervical ligamentous injury
Discharge Condition:
stable
Discharge Instructions:
Take medications as perscribed, be sure to follow up with
plastic surgery, opthomology, orthopaedics, and trauma surgery
clinic. Wear cervical collar at all times. Follow
recommendations of Occupational therapy.
Followup Instructions:
Plastic surgery will call you to arange arch bar removal, you
also have an appointment on [**2158-7-28**] at 1pm at the [**Hospital Ward Name 23**]
Building [**Location (un) 470**] surgical specialties department, cosmetic
clinic call [**Telephone/Fax (1) 274**] with questions
Opthomology: you have an appointment for evaluation on [**2158-7-25**] at
11:15am at the [**Hospital Ward Name 23**] Building [**Location (un) 442**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
call [**Telephone/Fax (1) 253**] with questions
Neurosurgery: call [**Telephone/Fax (1) 1272**] for appointment with Dr.
[**Last Name (STitle) 62075**] in 1-2weeks
Trauma Surgery: call [**Telephone/Fax (1) 6439**] to schedule an appointment in
2 weeks
|
5121,70703,2387,5180,5119,51881,4280,42830,42731,2880,5070,4019,V1082,3659,E8799,5183 | 148 | 199,488 | Admission Date: [**2107-9-5**] Discharge Date: [**2107-10-8**]
Date of Birth: [**2029-7-11**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
SOB, anemia to 22, weakness
Major Surgical or Invasive Procedure:
Bronchoscopy x2
Bone marrow biopsy
Mechanical ventilation
History of Present Illness:
78 yo woman with MDS, presenting to [**Hospital3 **] with SOB,
hypotension, anemia (Hct = 22.1, Hbg = 7.6), leukocytosis (WBC =
31.4 with 21 bands), thrombocytopenia (Plt = 10). Pt reports
productive cough for 2 months of yellow phlegm. She describes
rhinorrhea x 1 month associated with sneezing. Over last 3
days, she reports decreased eating/drinking and feeling "funny".
Denies dysuria, fevers, hematuria, N/V/C/D/CP, hematuria, joint
or bone pain, myalgias. C/O increasing back pain and bruising
(abd bruising d/t injections). At [**Location (un) 620**], her U/A was positive
for infection. Given ceftaz, IVF's, and 1 Unit of blood. Pt
was transferred to [**Hospital1 18**] for transfusion and bone marrow biopsy
to R/O progression to AML. Last bone marrow biopsy in [**2106-11-15**]
was negative for leukemia, just c/w MDS.
Past Medical History:
1. Myelodysplasia - [**11-18**]
2. Anemia secondary to myelodysplasia
3. Right breast cyst
4. Hypertension - on 480mg Verapamil qd. SBP usually in 170's.
5. s/p hysterectomy
6. s/p cholecystectomy
7. glaucoma
8. lentigo melanoma on right face - [**9-/2103**] with wide excision.
Pathology reportedly at [**Hospital1 2025**]
9. PAN - Polyarteritis Nodosa. Biopsy of heel done at [**Hospital1 2025**].
Social History:
Widowed, active with family, minimal alcohol, nonsmoker.
Family History:
One son and brother has hemochromatosis, a sibling died of
leukemia at age 30.
Physical Exam:
T: 99.4 P: 76 BP: 112/60 RR: 22 96% on 2L NC (90% on RA)
Gen: alert and oriented, pleasant woman sitting upright in bed,
conversant, breathing comfortably
HEENT: NC/AT, pupils surgical, anicteric, MMM, OP clear
CV: RRR, no m/r/g
Lungs: No wheezing. Inspiratory crackles at L base, unchanged
from prior. O/w CTA bilaterally.
Abd: resolving ecchymoses on abdomen ([**1-17**] injections). abd is
soft, nt/nd. +bs.
Ext: no edema, brisk distal pulses.
Pertinent Results:
From [**Location (un) 620**]:
Cr: 1.3 (baseline 0.6) with BUN = 33.
Troponin: 0.3
WBC = 31.4 with 21 bands, Hct = 22.1, Hgb = 7.6, Plt = 10.
U/A: 50-100 WBC, Many bacteria
BCx x 4: 1 of 4 bottles grew coag neg staph resistant to
erythromycin and pcn.
UCx: 10-25K of each coag neg staph and diphtheroids
Admission labs at [**Hospital1 18**]:
[**2107-9-5**] 03:30PM GRAN CT-[**Numeric Identifier 6085**]*
[**2107-9-5**] 03:30PM WBC-19.9* RBC-2.57* HGB-7.8* HCT-23.9* MCV-93
MCH-30.4 MCHC-32.7 RDW-18.6*
[**2107-9-5**] 03:30PM HAPTOGLOB-332*
[**2107-9-5**] 03:30PM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-4.1
MAGNESIUM-2.2 URIC ACID-10.6*
[**2107-9-5**] 03:30PM ALT(SGPT)-24 AST(SGOT)-25 LD(LDH)-416*
CK(CPK)-43 ALK PHOS-66 TOT BILI-0.8 DIR BILI-0.3 INDIR BIL-0.5
[**2107-9-5**] 03:30PM GLUCOSE-127* UREA N-30* CREAT-1.2* SODIUM-140
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-20* ANION GAP-19
[**2107-9-5**] 03:30PM FIBRINOGE-372
[**2107-9-5**] 03:30PM RET AUT-2.2
Discharge and other relevent labs:
[**2107-10-8**] 02:00AM BLOOD WBC-1.8* RBC-2.78* Hgb-8.2* Hct-24.2*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.8 Plt Ct-39*
[**2107-10-8**] 02:00AM BLOOD Glucose-94 UreaN-15 Creat-0.2* Na-137
K-3.9 Cl-104 HCO3-24 AnGap-13
[**2107-10-3**] 12:00AM BLOOD Fibrino-204
[**2107-9-30**] 01:50AM BLOOD FDP-0-10
[**2107-10-6**] 01:20AM BLOOD Ret Aut-6.1*
[**2107-10-7**] 12:53AM BLOOD Glucose-86 UreaN-17 Creat-0.2* Na-138
K-3.7 Cl-105 HCO3-25 AnGap-12
[**2107-10-6**] 01:20AM BLOOD VitB12-472 Folate-10.4 Hapto-100
[**2107-10-1**] 12:00AM BLOOD calTIBC-164 Ferritn->[**2102**] TRF-126*
[**2107-9-26**] 12:00AM BLOOD Hapto-<20*
[**2107-9-27**] 12:00AM BLOOD Hapto-<20*
[**2107-9-29**] 12:45AM BLOOD Hapto-<20*
[**2107-9-14**] 04:19AM BLOOD TSH-0.91
[**2107-9-19**] 03:56AM BLOOD ANCA-NEGATIVE B
[**2107-9-19**] 03:56AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2107-9-12**] 04:20AM BLOOD Lactate-3.3*
[**2107-9-15**] 04:15AM BLOOD Glucose-121* Lactate-1.3
Abd CT [**9-5**]:
1. No evidence of intra or retroperitoneal hemorrhage.
2. Splenomegaly as above with increased heterogeneity and
possible focal
splenic lesions. Given the timing of the contrast [**Last Name (LF) 1868**], [**First Name3 (LF) **]
ultrasound is
recommended for further evaluation.
3. Small left pleural effusion and associated atelectatic
changes.
Brief Hospital Course:
1. Respiratory: Ms. [**Known lastname 50155**] was initially admitted to the BMT
unit but was transferred to the [**Hospital Unit Name 153**] with progressive hypoxia on
the floor on [**9-8**]. Her O2 sats dropped to 90% on a NRB. This
was originally felt to be due to a combination of causes: 1) CHF
due to large amt of fluid received via blood products (had 2
units PRBCs, 3 units platelets in prior 3 days), and 2)?
aspiration during her bone marrow biopsy [**9-6**]. She had not been
responding to Lasix on the floor. Upon admission to the [**Hospital Unit Name 153**],
she improved markedly on BiPAP. Because she was increasingly
uncomfortable with the BiPAP mask, she was changed back to a NRB
for awhile, and was eventually placed on nasal CPAP. Overnight
on [**9-8**], she began having increasing hemoptysis, first having
blood-tinged sputum and then coughing up frank blood. She also
developed worsening diffuse bilateral infiltrates on CXR. She
was intubated on [**9-9**] so that she could undergo bronchoscopy.
While it was hoped that her intubation was only for the bronch,
she instead required mechanical ventilatory support until
[**2107-9-21**]. The bronch revealed increasingly bloody fluid with
successive lavage, so it was felt she may have DAH (vs a fungal
or bacterial pna). She underwent a course of high-dose steroids
(methylprednisolone 500 mg IV bid x 6 doses) for presumed DAH.
On [**9-10**], she developed a pneumothorax on the R side that was
moderate sized (R IJ TLC was placed on evening of [**9-8**] with 2
subsequent CXRs not demonstrating a ptx, had bronch [**9-9**], then
had ptx on CXR [**9-10**], so unclear etiology.) This was treated
with 100% O2 and resolved on its own, not requiring chest tube
placement. She had another episode of bleeding and underwent
repeat bronchoscopy [**2107-9-14**]. This was also nondiagnostic. She
was very difficult to wean from the ventilator, and eventually a
family meeting was had with her primary oncologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. It was decided to extubate her and see how she did, and
her family preferred not to have her reintubated if she didn't
do well. However, she did very well. She was able to be
transferred back up to the floor on [**9-23**], and was slowly weaned
off her oxygen. By discharge, she was alternating between room
air and 2 liters O2 per nasal cannula. She has persistent
patchy alveolar and interstitial infiltrates on CXR, esp in her
LLL. The etiology of her respiratory failure was never fully
confirmed. Her [**9-9**] bronch grew out a spore called
sporobolomyces salmonicolor, which both the ID fellow and the
Microbiology lab felt was a contaminant (as it didn't grow out
until [**9-23**]). She may have had a pneumonia, as she improved on
caspofungin, ceftazidime, and vancomycin. She also may have had
DAH. She definitely had at least a superimposed component of
diastolic failure, and she was diuresed aggressively while on
the floor, approximately 1-2 liters per day. She was originally
on standing Lasix, but by time of discharge she only received
Lasix (20 mg IV) after RBC transfusions. In terms of the
etiology of her disease, there was also a question of vasculitis
(as she has a hx of polyarteritis nodosum which was reportedly
treated at [**Hospital1 2025**].) However, her ESR was 18, and house officers
here obtained her records from [**Hospital1 2025**] which consisted only of one
CBC and no notes of any sort.
2. Cardiovascular: On admission, she had an echo that showed an
EF >55%, with 1+ MR. On the evening of [**9-8**], Mrs. [**Known lastname 50155**] went
into a-fib with RVR, rates up to 170s and bp 70s/40s. She was
given Lopressor 5 mg IV x1, Diltiazem 10 mg IV x1, and placed on
a dilt gtt. She initially did not respond to any of these
measures, and the dilt gtt was maxed out at 20 mg/hr. A few
hours later, she spontaneously converted back to sinus rhythm
with rates in the 80s, and the dilt gtt was discontinued. Later
on in the ICU, she developed what was originally felt to be
atrial flutter and was evaluated by Cardiology. They felt she
had a combination of atrial tachycardia and atrial fibrillation
,and recommended control with a dilt gtt as needed, and po
verapamil. She eventually no longer required the dilt, and was
maintained on verapamil with good results. She remained in NSR
while on BMT as she was originally monitored on telemetry, which
was eventually discontinued. EKGs were unremarkable other than
a-fib.
3. ID: Given her fxnal neutropenia, she was begun on empiric
antibiotics when she originally developed diffuse opacities on
CXR. She was treated with Ceftriaxone, vancomycin, bactrim, and
clinda (initially). Her vanc was discontinued 2 days later and
she was begun on ambisome for empiric antifungal coverage. Due
to the lipid content in ambisome and its possible interaction
with surfactant in the lung, she was changed to caspofungin.
Her induced sputum was immunofluroescent negative for PCP. [**Name10 (NameIs) **]
rest of her bronch studies were negative for organisms other
than the spore mentioned above. Her antibiotics were all
eventually stopped and she remained afebrile for a while. She
also developed a sacral decubitus ulcer while in the ICU, which
was evaluated by the Wound Care nurses and dressed per their
recommendations. Twice in the week before discharge, she had
low-grade temperatures but was asymptomatic. She had a negative
urine culture and CXR showed a possible worsening of her LLL
infiltrate. The team recommended that she begin po levaquin,
but she declined this. She expressly stated that she did not
want to take any antibiotics, oral or intravenous. She
understood the consequences and stated them clearly, but wished
to not pursue the infectious workup any further. Therefore she
was not begun on any antibiotics.
4. Hematology: Her bone marrow biopsy on [**9-6**] was negative for
blasts, as was a repeat biopsy [**9-24**]. While she was in the
hospital, she required increasing frequency of transfusions.
She received packed red blood cells and platelets every other
day, to keep a hematocrit greater than 25 and platelets greater
than 20K (given the fear that she had bled into her lungs, it
was felt that a platelet transfusion threshold of 20K was more
advantageous than 10K). It was felt that her low hematocrit was
[**1-17**] to her MDS and was not the result of another process. She
had a negative DAT x 2. She did have evidence of hemolysis,
with a low haptoglobin, elevated LDH, elevated indirect
bilirubin, and a reticulocyte count of 6%. Because of her large
transfusion requirements and possible hemolysis, a super-Coombs
and an anti-platelet antibody test were sent, and were pending
at time of discharge. It was also felt likely that these
processes were all due to her myelodysplasia. On examination of
her bone marrow biopsy, the attending heme pathologist felt that
it was likely her cells were so dysplastic they did not survive
long in the periphery. Prior to d/c a conversation was had
with the patient where it was discussed and agreed upon by
everybody (including the attending Hematologist) that there was
no further treatment indicated for her MDS, and she would
continue with symptomatic transfusions. On d/c her WBC count
was also low, with an ANC of 1100. This is also felt to be [**1-17**]
MDS.
5. Liver: There was a question of whether the patient had
hemochromatosis, whether iatrogenic or otherwise. (Has son and
brother with this disease.) The hemochromatosis genetic
mutations were sent and were pending at time of discharge. Her
ferritin was greater than [**2102**]. It was decided not to chelate
her at this time.
Medications on Admission:
Danazol 100mg po bid
Procrit 20,000Units sq qd
Neupogen
Verapamil SA 480mg qd
Zestril 5mg qd
Iron 325mg qd
Fosamax 10mg qMonday
Ca++ 600mg qd
MVI qd
Potassium prn?
[**Last Name (un) 8509**] 20mg po qd
ASA 81mg qd
Colace prn
Discharge Medications:
Verapamil 120 mg po tid
Protonix 40 mg po daily
Ambien 5 mg po qhs:prn
Tylenol prn
Lasix 20 mg IV only post-RBC transfusions
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 23973**] - [**Hospital1 **]
Discharge Diagnosis:
Myelodysplastic syndrome
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications as prescribed. It is very
important to continue taking your verapamil as it keeps your
heart from beating too quickly, as it did when you were in the
ICU. You do not need to resume taking epogen, neupogen, or
danazol.
Followup Instructions:
Please f/u with your Hematologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] at [**Last Name (LF) 4068**], [**First Name3 (LF) **]
his discretion. He will receive a copy of your d/c summary.
***IMPORTANT: Pt, family, and team all had discussion regarding
her further care. She does not wish to have any antibiotics,
and wishes only to have transfusions as needed. She is DNR/DNI.
She does not have a health care proxy form, but wishes to have
her son [**Name (NI) **] [**Name (NI) 50155**] as her health care proxy and will contact her
lawyer regarding this.
|
41011,4280,3970,4240,5990,41401,2948,2859,4019,73710 | 149 | 154,869 | Admission Date: [**2135-2-18**] Discharge Date: [**2135-2-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
fatigue, dyspnea on exertion
Major Surgical or Invasive Procedure:
cardiac catheterization with stent placed at left anterior
descending artery
History of Present Illness:
[**Age over 90 **] yo woman with htn brought to ED from her [**Hospital3 **]
facility after c/o several weeks of doe after walking across the
room, fatigue. History is difficult to obtain from pt secondary
to dementia, most history is provided by nephew. [**Name (NI) **] chest
pain, dizziness, paraesthesias.
Past Medical History:
dementia
kyphosis
hypertension
Social History:
lives in [**Hospital3 **] facility
no tobacco
Physical Exam:
T 98.0 HR 80s BP 110/80 RR 14 94% RA
no acute distress, obese, oriented to person only
no JVD
cardiac exam RRR nl s1s2 no mrg
soft b/l basilar rales
abdomen soft no nd nabs
extremities with trace edema
Pertinent Results:
ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: *0.27 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 35% (nl >=55%)
Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 183 msec
TR Gradient (+ RA = PASP): *45 to 50 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately
depressed LVEF. No LV mass/thrombus.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA
systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is
moderately depressed. Anterior, distal septal, apical, distal
lateral, and
distal infeior akinesis is present.
3. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation
is seen.
4. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
5. Moderate to severe [3+] tricuspid regurgitation is seen.
6. There is moderate pulmonary artery systolic htn.
.
.
CARDIAC CATHETERIZATION
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French right [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French XBLAD 3.5 and a 6 French JR4 catheter, with manual
contrast
injections.
Visualization of the left coronary artery was repeated after the
i.c.
administration of 50 mcg of nitroglycerine.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.62 m2
HEMOGLOBIN: 10.7 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 25/26/24
RIGHT VENTRICLE {s/ed} 55/25
PULMONARY ARTERY {s/d/m} 55/30/41
PULMONARY WEDGE {a/v/m} 32/33/31
AORTA {s/d/m} 131/68/94
**CARDIAC OUTPUT
HEART RATE {beats/min} 70
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 81
CARD. OP/IND FICK {l/mn/m2} 2.5/1.5
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2240
PULMONARY VASC. RESISTANCE 320
**% SATURATION DATA (NL)
SVC LOW 42
PA MAIN 43
AO 99
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 70
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
**PTCA RESULTS
LAD
**BASELINE
STENOSIS PRE-PTCA 100
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH XBLAD 3.
GUIDEWIRES CHOICE P
INITIAL BALLOON (mm) 2.5 X 15
FINAL BALLOON (mm) 2.5 X 24
# INFLATIONS 8
MAX PRESSURE (PSI) 270
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS:
We elected to treat the totally occluded proximal LAD with
PTCA/Stenting using heparin and integrilin prophylactically. A
Choice
PTXS wire crossed into the LAD with significant difficulty (a
Wizdom SS
wire and several PT [**Name (NI) 9165**] Intermediate wires would not cross).
A 2.5
x 15 mm Voyager was used to predilate in five inflations at 8-9
atm. An
export catheter would not cross beyond the proximal LAD, but
suctioning
of this area resulted in minor improvement in flow. A 2.5 x 24
mm Taxus
DES was deployed proximally and into the mid-LAD at 12 atm, and
another
2.5 x 24 mm Taxus DES was deployed in overlapping fashion more
distally
at 12 atm. The second SDS was used to post-dilate the overlap
area at
18 atm. There was significant spasm and no-reflow in the
[**Last Name (LF) 12425**], [**First Name3 (LF) **]
intracoronary nitroglycerin and nitroprusside were adminstered
through
the guide, and more intracoronary nitroprusside was administered
through
the lumen of a 2.0 x 30 mm Maverick positioned just distal to
the second
stent.
Final angiography demonstrated no dissection, no residual
stenosis
within the stented segments with loss of a major diagonal branch
(closed
at the start of the case), and TIMI-3 flow into a diffusely
diseased
distal LAD.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 38 minutes.
Arterial time = 1 hour 34 minutes.
Fluoro time = 43.1 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 175
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Other medication:
Fentanyl 12.5 mcg IV
Furosemide 80 mg IV
Integrilin 10 cc IV bolus
Integrilin 4.5 cc/hr
Nitroprusside 550 mcg IC
Plavix 300 mg PO
Cardiac Cath Supplies Used:
.014 CORDIS, WIZDOM SS 300
.014 [**Name (NI) **], PT [**Name (NI) **], 300CM
.014 [**Name (NI) **], PT [**Name (NI) **], 300CM
2.5 GUIDANT, VOYAGER 15
2.0 [**Company **], MAVERICK, 30
6F CORDIS, XBLAD 3.5
2.5 [**Company **], TAXUS EXPRESS 2 OTW, 24
2.5 [**Company **], TAXUS EXPRESS 2 OTW, 24
3F [**Company **], EXPORT ASPIRATION CATHETER
COMMENTS:
1. Selective coronary angiography demonstrated a right dominant
system
with two [**Company 12425**] CAD. The left main had mild disease. The LAD
had a 70%
lesion at it's origin and a 100% proximal occlusion. The left
circumlfex artery had a 70% lesion in the OM1 branch. The RCA
had mild
disease.
2. Resting hemodynamics demonstrated markedly elevated right and
left
sided filling pressures with a mean RA pressure of 24 mm Hg and
mean
PCWP of 31 mm Hg. Moderate pulmonary hypertension was present.
The
cardiac index was markedly reduced, based on an assumed oxygen
consumption index. Central aortic pressure was normal.
3. Left ventriculography was not performed.
4. Successful PCI of the LAD with two overlapping Taxus DES (2.5
x 24 mm
and 2.5 x 24 mm).
FINAL DIAGNOSIS:
1. Two [**Company 12425**] coronary artery disease.
2. Markedly reduced cardiac index with elevated left and right
sided
filling pressures but normal central aortic pressure.
3. Acute anterior STEMI treated with primary PCI.
.
.
[**2135-2-18**] 10:36PM CK(CPK)-606*
[**2135-2-18**] 10:36PM CK-MB-58* MB INDX-9.6*
Brief Hospital Course:
The patient is a [**Age over 90 **] year old woman with hypertension,
hyperlipidemia, and no known CAD. She presented to the
emergency
department with dyspnea. ECG demonstrated anterior STEMI.
After a
discussion with the patient's nephew, the patient was brought to
the
catheterization laboratory where she was found to have occlusion
of the LAD with 80% stenosis at OM1. She had a cypher stent
placed to the LAD. She was found to have a low cardiac index
with low mvo2 during catheterization. She was diuresed 1 liter
over the course of her hospitalization which she tolerated well,
and resulted in marked improvement in her oxygenation.
Hospitalization was complicated by increased bleeding at access
site after catheterization, for which hemostasis was eventually
obtained but integrellin was discontinued early. Her hematocrit
remained stable. As post MI echo showed akinesis, pt was
started on coumadin for a 6 month course after determining she
was not a fall risk with physical therapy and with her PCP. [**Name10 (NameIs) **]
was also found to have a UTI for which she was treated with
Levaquin.
Medications on Admission:
zyprexa, lipitor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Sertraline HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Atorvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
acute myocardial infarction
dementia
hypertension
Discharge Condition:
stable
Discharge Instructions:
Return to the emergency department if you develop chest pain,
shortness of breath, or dizziness.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103787**] partner will see you while you are at [**Hospital 100**]
Rehab. Dr. [**Last Name (STitle) 6680**] will see you once you are back at [**Location (un) **].
.
You will follow up with a Cardiology appointment at [**Hospital1 **] out patient clinic with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2135-3-21**] 11:00
.
***** TO FOLLOW UP:
1) Patient started on lasix 40mg qd, as well as potassium.
Please monitor Cr levels and potassium levels. At time of
discharge, Cr is 1.5.
2) Patient recently started on coumadin 5mg qd. At time of
discharge, INR is 1.4 (after 2 doses of coumadin). She is being
discharged on 3mg dose qd.
Import Follow-up Instructions
Follow-up Instructions:
Completed by:[**2135-2-25**] |
4538,V1041,34690,28982,1983,4238,1961,41519,1623 | 150 | 108,732 | Admission Date: [**2161-7-9**] Discharge Date: [**2161-7-14**]
Date of Birth: [**2123-9-14**] Sex: F
Service: MED
Allergies:
Iodine; Iodine Containing / Dilantin / Percocet
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
chest discomfort and shortness of breath x 2 months
Major Surgical or Invasive Procedure:
Mediastinoscopy with lymph node biopsy - pathology pending
History of Present Illness:
The patient is a 37 year old female with PMH endometrial cancer
s/p TAH w/ R oopherectomy who presented to a [**Hospital 11074**] clinic with
two month history of shortness of breath and chest pain. She
describes the chest pain as "like an elephant standing on her
chest". She notes that it is associated with dyspnea,
diaphoresis, and lightheadedness. She was referred to a
cardiologist for a nuclear stress test about 6 weeks ago which
was normal per pt. Symptoms persisted over last three weeks with
increased fatigue and weakness. She also notes waxing and [**Doctor Last Name 688**]
feversv(Tm 100-101), productive cough and 18 pound weight loss
during this time. At the [**Hospital 11074**] clinic on [**7-8**], a chest x-ray
was done which was significant for mediastinal widening. She was
immediately taken by ambulance to Falumouth ED. At [**Hospital1 1562**], a
Chest CT showed diffuse mediastinal adenopathy and multiple
pulmonary nodules and splenomegaly. An echo showed small-
moderate pericardial effusion and increased tuerculation in RV
apex c/w RVA thrombus. NL EF/valves. Doppler US LE - Left
popliteal DVT. V/Q scan - indetermingate - 50% chance of PE.
Patient was stable during one day admission at [**Hospital1 1562**] and was
transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] for further work up of the pulmonary
nodules and lymphadenopathy. While in the [**Hospital Unit Name 153**], the patient was
seen by pulmonary and oncology. She was sent for a chest and
abdominal CT which suggested a 5x4 cm mediastinal mass with
precarinal lymph nodes, multiple smaller nodules throughout both
lungs and a small-moderate pericardial effusion. She was
hemodynamically stable in the [**Hospital Unit Name 153**] and transferred to the floors
on [**7-10**] pm.
The patient denies headaches/abdominal pain/melena/hematochezia/
change in bowel movements/dysuria.
The patient does note 10 year history of perimenopausal symptoms
- fatigue, myalgias, hot flashes, low grade temps.
Past Medical History:
1. ?Endometrial Cancer - age 25 - s/p TAH and RO, no chemo/xrt
(encapsulated tumor)
2. Migraine headaches - since age 8. Takes tylenol and motrin.
3. Cesarean Section x 3
4. History of fibrocystic breast disease - s/p multiple
mammograms and 7 negative biopsies
5. Per path report -Cervical cancer in situ [**2149**]
Social History:
The patient works as a bar manager. She has 3 children and is
separated
Tobacco -(+) [**12-19**] -3 ppd x 22 years (~40 pack-year)
Alcohol - Rare
IVDA - none
Family History:
Ancestry - scandinavian, english
Mother - [**Name (NI) 58056**]
Sister - Similar symptoms of fatigue, weakness, "perimenopausal"
on testosterone supplement
Great aunt - breast cancer
aunt - cervical cancer
"history of clotting in legs" in family
Physical Exam:
Temp max 99.6; Tcurrent 98.6, BP 109/58, HR 86-100, RR 17-21,
93-94%RA
Gen - Alert, no acute distress, anxious, thin
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - supple, no JVD, positive R shotty cervical LAD,
Chest - diffuse expiratory wheezes, some scattered crackles;
otherwise Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes; Left paraspinal (C7),
firm rubbery mass (+)tender to palpation
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally. no axillary LAD
Neuro - Alert and oriented x 3, cranial nerves [**1-29**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
[**2161-7-9**] 07:16PM WBC-7.5 RBC-3.63* HGB-10.9* HCT-33.2* MCV-92
MCH-30.1 MCHC-32.9 RDW-12.7 PLT 211 NEUTS-75* BANDS-0 LYMPHS-21
MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2161-7-9**] 07:16PM calTIBC-216* FERRITIN-142 TRF-166*IRON-17*
[**2161-7-9**] 07:16PM GLUCOSE-91 UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
[**2161-7-9**] 07:16PM ALT(SGPT)-3 AST(SGOT)-9 LD(LDH)-153 ALK
PHOS-74 TOT BILI-0.3 ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.7
MAGNESIUM-2.0
[**2161-7-9**] 07:16PM FSH-3.4 LH-4.8
[**2161-7-10**]
CT OF THE CHEST WITHOUT CONTRAST: There is no axillary
lymphadenopathy. Small
axillary lymph nodes do not meet the criteria for pathologic
enlargement and
measure up to 6 mm in size. A large mediastinal mass, which
measures up to
5.4 x 4.7 cm in axial dimension, which extends from the right
paratracheal
region at the level of the thoracic inlet to the precarinal
lesion is present
with central regions of hypodensity suggesting necrotic change.
In addition,
there is an enlarged 4.5 x 2.5 cm subcarinal lymph node.
Bulkiness in the
right hilum is present as well. Evaluation of the central
airways demonstrate
patency to the segmental bronchi bilaterally. Examination of the
lung windows
demonstrate a dominant 13 x 11 mm nodule within the right upper
lobe, with a
satellite lesion in the subpleural right apex measuring 7 mm in
size. Most of
these lesions show some characteristics of spiculation. In
addition, there is
a 5 mm nodular region in the subpleural right lower lobe, which
has well-
defined forbers. The right lower lobe demonstrates mild
atelectasis, possibly
with a smaller degree of consolidation as well. There is a trace
right-sided
pleural effusion. The left lung is essentially clear, without
evidence of
pleural effusion. There are some peripheral blebs suggestive of
paraseptal
emphysema. Note is also made of a hypodense appearance of the
blood relative
to myocardium suggestive of anemia. There is a small pericardial
effusion.
CT OF THE ABDOMEN WITHOUT CONTRAST: Allowing for the noncontrast
technique,
the liver, gallbladder, spleen, kidneys, stomach, and small
bowel appear
unremarkable. The pancreas is grossly unremarkable as well.
Adrenal glands
are not clearly visualized due to the lack of IV contrast, and
no bulky
lymphadenopathy is the retroperitoneum or mesentery is noted.
There is no
abdominal free fluid present.
CT OF THE PELVIS WITHOUT CONTRAST: The large bowel and bladder
are
unremarkable. Distal ureters are not well visualized without IV
contrast. The
uterus is not seen, and the ovaries appear unremarkable.
Examination of the osseous structures show no suspicious lytic
or blastic
lesions.
IMRESSION:
1. Large mediastinal mass with precarinal and subcarinal lymph
nodes. These
have hypodense central regions suggestive or necrosis. These
would be most
ammenable for transbronchial biopsy.
2. Multiple lung nodules, two of which are spiculated at the
right lung apex.
3. There is a small pericardial effusion.
[**2161-7-11**]
MRI BRAIN.
CLINICAL INFORMATION: Patient with history of cervical cancer
with pulmonary
nodule and mediastinal mass and patient allergic to IV contrast
for CT, for
further evaluation to exclude metastatic disease.
TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and
susceptibility axial
images of the brain were obtained before gadolinium. T1 axial,
sagittal and
coronal images were obtained following the administration of
gadolinium.
FINDINGS: In the right posterofrontal lobe, there are two small
areas of
signal abnormality seen within on the FLAIR images, one
laterally along the
anterior aspect of the central sulcus and the second superiorly
to the
posterior frontal lobe near the midline. Both of these foci
demonstrate
enhancement following the administration of gadolinium. No other
focal
abnormalities are identified. Specifically, no evidence of
periventricular
signal abnormalities are seen. No other areas of enhancement are
noted. The
ventricles and extraaxial spaces are normal in size. No evidence
for midline
shift, mass effect or hydrocephalus is seen.
IMPRESSION: Foci of signal abnormalities in the right frontal
lobe with
enhancement. The differential diagnosis includes metastatic
disease and
demyelinating process, given patient's age. However, given the
clinical
history and the location of the lesions, metastatic disease is
considered more
likely.
Brief Hospital Course:
37 year old female with h/o cervical cancer s/p TAH transferred
from outside hospital with progressive chest discomfort, SOB,
and weight loss with Left popliteal DVT, possible PE and chest
xray/ CT evidence of mediastinal mass and multiple bilateral
nodules with mediastinal lymphadenopathy.
1. Pulmonary nodules - On admission a chest xray suggested a
small focal opacity in right upper lobe and right paratracheal
opacity. A chest CT the following day suggested a large
mediastinal mass with precarinal and subcarinal lymph nodes with
hypodense central regions suggestive of necrosis. It also showed
multiple nodules, two spiculated lung nodules at right lung
apex. These lesions were most consistent with lung cancer versus
lymphoma so a mediastinoscopy was planned. Other things
originally on the differential were: TB -PPD negative,
histoplasmosis -antigen still pending, coccidoiomycoses,
nocardia, sarcoidosis (scandinavian) - ACE-normal. On [**7-11**] she
had a MRI-brain, which showed two foci of signal abnormalities
in the right frontal lobe with enhancement. No edema or mass
effect was seen secondary to the brain lesions. On [**7-13**], she had
a mediastinoscopy. The frozen section was positive for non-small
cell lung cancer; paratracheal lymph nodes were sent for
pathology (still pending).
2. Non-small cell lung cancer - Multiple necrotic lymph nodes
radiographically and grossly, MRI of the brain with focal right
frontal brain mets; and a 1 by 1 inch paraspinal hard, rubbery
lesion on her Left upper back; presentation consistent with
metastatic NSCLC. Patient was told her diagnosis with her mother
and grandfather in the room. She seemed to take the news well,
appropriately becoming teary eyed. She was then seen by a social
worker and told the social worker that she was coping well and
did not need to be seen anymore. She was seen by oncology
consult and set up for
an outpatient follow up with multidisciplinary oncology team on
thursday [**7-16**]. During that time she will discuss chemo vs
biologic therapies vs palliation.
She will also have a bone scan to evaluate for bone mets also on
thursday as an o/p. On the last day of admission, the patient
noted blurriness in left periphery; no deficit on visual fields
or neuro exam; the patient was advised to have a head ct to
reevaluate for mass effect or bleeding in the brain lesions, but
she refused and wanted to go home with no further treatment. She
was counseled to go to the ED if she had worsening vision
deficits, headaches. The patient's shortness of breath was
stable during the admission; she required 2L oxygen especially
during long conversations; the patient will be sent home on home
oxygen.
2. Hypercoagulable state - DVT/PE/?RV thrombus - echo at outside
hospital also with possible thrombus in RV; pt obviously
hypercoagulable most likely secondary to primary lung
malignancy; she was maintained on heparin throughout the
admission and was switched to Lovenox and underwent Lovenox
administration teaching prior to discharge
3. Pericardial effusion - found on echo at [**Hospital1 **]; stable on
chest CT at [**Hospital1 18**].Most likely secondary to the primary lung
malignancy; patient did not experience any decreases in blood
pressure, increased shortness of breath, or increased chest pain
during the admission. SHe was monitored throughout the admission
for tamponade physiology and did not present with any.
4. Fevers - low grade throughout admission; most likely
secondary to the malignancy; fungal, blood cultures were
negative; lyme antibody was negative; patient never mounted an
increased white blood cell count.
5. Pain/Nausea - The patient had back and chest (pleural) pain
throughout the admission well controlled PRN dilaudid q 3-4
hours. She was started on a fentanyl patch for pain on [**2161-7-13**]
with dilaudid for breakthrough. SHe also noted increased nausea
with the dilaudid which was well controlled with phenergan.
After the mediastinoscopy, she had increased throat pain which
was relieved with viscous lidocaine.
6. 10 year hisory of perimenopausal symptoms - FSH, LH within
normal limits; no further work-up during the admission
7. PPX - She was maintained on a multivitamin and zantac during
the admission with colace and senna to releive constipation in
the setting of narcotics.)
8. Code Status - Full Code
Medications on Admission:
Tylenol
(Heparin gtt from outside hospital)
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): please place new patch on
Thursday [**7-16**].
Disp:*10 Patch 72HR(s)* Refills:*2*
4. Promethazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q3-4H ()
as needed.
Disp:*84 Tablet(s)* Refills:*0*
5. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
Q3-4H () as needed for throat pain.
Disp:*112 ML(s)* Refills:*0*
6. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
Disp:*30 subcutaneous injection* Refills:*2*
7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*60 Tablet(s)* Refills:*2*
8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
9. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-small cell lung cancer
Left popliteal deep vein thrombosis/pulmonary embolus
Discharge Condition:
stable
Discharge Instructions:
Please go the the emergency department if you have increasing
shortness of breath or chest pain or if you have worsening
blurry vision or headaches.
Followup Instructions:
Please go for bone scan on Thursday, [**7-16**] at 9:30 am. Main
entrance [**Hospital Ward Name **] - by [**Hospital Ward Name 2104**] elevators.
Please follow up with Dr. [**Last Name (STitle) **] in the Thoracic Oncology Center
this Thursday, [**7-16**] at 10:30 am.
|
41071,42830,4280,4240,4160,5121,42731,41401,4019 | 151 | 151,029 | Admission Date: [**2145-5-6**] Discharge Date: [**2145-5-15**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with a history of gastritis, hypertension and
hypercholesterolemia who was admitted to the [**Hospital Unit Name 196**] Service on
[**2145-5-6**] for the complaint of progressive chest pain.
The patient described a two to three month history of
progressive shortness of breath and substernal chest pain.
The patient stated that the chest pain originally occurred at
rest and reported that her episodes had become more severe
over the ensuing time. The patient's episodes were
characterized by pain radiating to both arms that would
occasionally wake her up at night and lasted approximately 30
minutes in duration. The patient was reportedly evaluated by
her primary care physician and was presumptively diagnosed
with gastritis; an esophagogastroduodenoscopy conducted on
[**2145-4-13**] demonstrated mild gastritis which resulted in
outpatient treatment with Maalox and Protonix prn. The
patient continued to demonstrate worsening symptoms,
resulting eventually in a MIBI stress test on [**5-5**] which
demonstrated severe lateral wall reversible defects. The
patient was subsequently advised to come immediately to the
Emergency Department at [**Hospital6 256**],
where she was noted to have ST depressions in leads 2, AVF,
V5 and 6 and an old T wave inversion in leads 1 and AVL. The
patient was subsequently started on heparin and nitroglycerin
drip which brought immediate relief of her chest pain
symptoms and she was subsequently admitted to the Medicine
Service on [**5-6**] for further evaluation and treatment.
PAST MEDICAL HISTORY: Hypertension; hypercholesterolemia;
colon cancer; status post colectomy; breast cancer;
peripheral vascular disease; gastritis; status post right
total hip repair; status post thyronodular excision.
HOME MEDICATIONS: Sinemet; Levo Carbidopa; Lipitor;
Atenolol; Norvasc; Hydrochlorothiazide; Protonix; Benicar;
Timolol; Maalox; Tylenol; Multivitamin; calcium; fish oil.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Widowed and lives in [**Location 1439**] [**State 350**]
with daughter, formerly worked as a secretary and is now
retired. No smoking and no alcohol history.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2145-5-6**]. Initial inpatient therapy
included Aspirin, statins, heparin, and Nitroglycerin drip,
on which regimen the patient was noted to have significant
relief of her chest pain. Cardiac catheterization performed
on [**2145-5-7**] demonstrated three vessel coronary artery
disease, moderate mitral regurgitation, moderate diastolic
ventricular dysfunction, and mild systolic ventricular
dysfunction. A 30 cc intra-aortic balloon pump was inserted
without complication through the course of the procedure.
The patient's ejection fraction was noted to be approximately
50%. Following catheterization, the patient was admitted to
the Cardiac Care Unit for further evaluation and management.
The patient was subsequently evaluated by the Cardiothoracic
Surgery Service and scheduled for urgent coronary artery
bypass graft on [**2145-5-10**]. On [**5-10**], the patient
underwent an off pump coronary artery bypass graft times one
with anastomosis of the left internal mammary artery to the
left anterior descending with a plan for postoperative
stenting. The patient tolerated the procedure well without
complications. The patient's pericardium was left open;
lines placed including an arterial line, Swan-Ganz catheter,
and intra-aortic balloon pump; wires placed included
ventricular pacer wires; two slits including mediastinal,
right and left pleural tubes. On transfer to the
Cardiothoracic Surgery Recovery Unit, the patient
demonstrated a mean arterial pressure of 92, central venous
pressure of 0, PAD of 8 and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1052**] of 18. The patient
demonstrated a heartrate of 84 in normal sinus rhythm. Drips
on transfer included Neo 0.7 and Propofol at 10. In the
Cardiothoracic Surgery Recovery Unit, the patient progressed
well clinically and was successfully extubated on
postoperative day #1, [**5-11**]. The patient was returned to
the Catheterization Laboratory on postoperative day #1, where
stents were placed both to the circumflex and ramus. On
postoperative day #2, the patient was cleared for transfer to
the floor, at which point her IABP was removed and her cordis
was changed to a triple lumen catheter without complication.
The patient was subsequently admitted to the Cardiothoracic
Service on direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. Postoperatively
the patient progressed well clinically. Physical therapy
evaluation recommended the patient for [**Hospital 5735**]
rehabilitation following discharge, after which point the
patient was successfully screened for placement. On
postoperative day #4, the patient's chest tubes were removed
without complication; subsequent chest x-ray demonstrated no
evidence of pneuomothorax. The patient was successfully
advanced to a regular p.o. diet and was noted to have
adequate pain control via oral pain medications. On
postoperative day #5, [**2145-5-15**], the patient was cleared
for discharge to a rehabilitation facility with instructions
for follow up.
CONDITION ON DISCHARGE: The patient is to be discharged to
an extended care facility with instructions for follow up.
STATUS ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. 12 hours
2. Pantoprazole 40 mg p.o. q. 12 hours
3. Potassium chloride 20 mEq p.o. q. 12 hours
4. Docusate sodium 100 mg p.o. b.i.d.
5. Aspirin 325 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d.
7. Carbidopa Levodopa 20/100 mg tablets one tablet p.o.
t.i.d.
8. Carbidopa levodopa 25/100 mg tablets one tablet p.o.
b.i.d.
9. Atorvastatin 20 mg p.o. q. day
10. Timolol Maleate 0.25% eye drops one drop ophthalmic
q.h.s.
11. Losartan 25 mg p.o. q.d.
12. 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 should pat dry incisions afterwards; no bathing or
swimming. The patient may resume a regular diet. The
patient has been advised to limit physical activities, no
heavy exertion, no driving while taking prescription pain
medications. Follow up with primary care provider within one
to two weeks following discharge. Follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] within four weeks of discharge. The patient has been
advised to call to schedule both appointments.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2145-5-15**] 13:25
T: [**2145-5-15**] 15:41
JOB#: [**Job Number 5736**]
|
41401,9971,42731,9975,78820,4019,2720,412,60000,4414,V1301 | 152 | 117,181 | Admission Date: [**2145-7-22**] Discharge Date: [**2145-8-3**]
Date of Birth: [**2065-11-11**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 60889**] is a 79-year-old male
who was recently discharged from [**Hospital1 18**] preoperatively after
being referred to Dr. [**Last Name (STitle) **] for coronary artery bypass
grafting. He has a history of hypertension, angina, abdominal
aortic aneurysm, hypercholesterolemia and was recently
discharged from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1281**] Hospital prior to his admission
last week at [**Hospital3 **] for lithotripsy and bladder calculi.
He presented with an episode of nausea and vomiting, weakness
and chest discomfort. He had known renal and bladder calculi
as well as an incidental finding of a 4.4-cm abdominal aortic
aneurysm by report from his outside hospital. He developed
hematuria and was transferred from [**Hospital **] hospital to [**Hospital1 **] the week prior to this admission. Please
refer to the discharge summary dated [**2145-7-18**]. On the way
home from the hospital in [**Location (un) **], he had developed vertigo,
nausea and vomiting. He was then transferred in to our
institution for work-up for cardiac disease preoperatively to
his abdominal aortic aneurysm repair or possible stenting.
PAST MEDICAL HISTORY:
1. Myocardial infarction [**2120**].
2. Hypertension.
3. Angina.
4. BPH.
5. Bladder calculi and renal calculi.
6. Abdominal aortic aneurysm.
7. Hypercholesterolemia.
PAST SURGICAL HISTORY: Includes open cholecystectomy. He was
evaluated by cardiology and was allowed to return home to get
urology clearance from his primary care physician and the
urologist who had treated him the week prior in [**Hospital **] hospital
and to return for surgery on [**2145-7-22**] with Dr. [**Last Name (STitle) **].
LABORATORY DATA: EKG showed normal sinus rhythm with
occasional PVCs, normal PR and Q-waves in leads II, AVR and
AVF and question of Q-wave inversion in lead III. Persantine
MIBI was performed which showed a moderate, partially-
reversible inferior wall perfusion defect and ejection
fraction of 55%. Echocardiogram performed prior to this
admission showed an ejection fraction of 55% or greater, 1+
MR and no pericardial effusion. Please refer to the echo
report. A CT of the abdomen done on [**7-13**] prior to this
admission also showed extensive atherosclerotic changes with
associated 5.4-cm infrarenal abdominal aortic aneurysm with
no evidence of rupture. The left common iliac was also
aneurysmal and total occlusion of the right common iliac with
reconstitution of the right internal iliac and femoral
arteries. It also showed massive prostatic enlargement and a
right-sided posterior diaphragmatic hernia containing
mesenteric and omental fat. Repeat CT of the abdomen was done
the following day which also showed a simple, multiple renal
cyst bilaterally. Chest x-ray done on [**7-15**] showed no
evidence of free intraperitoneal air and small bilateral
pleural effusions with some mild pulmonary vascular
congestion. Cardiac catheterization performed also showed a
right dominant system with a left main 30% lesion, a
diffusely-diseased LAD with a 90% mid-vessel stenosis, a 99%
OM1 lesion and a totally-occluded proximal RCA. EF was 60% at
catheterization with no mitral regurgitation. Carotid
Dopplers also performed showed less than 40% stenosis on both
the right and left internal carotid arteries. The patient was
allowed to return to home for urology clearance and was
readmitted to the hospital on [**7-22**] for coronary artery
bypass grafting. He also had been treated for urinary tract
infection over the weekend. He was seen by urology who
recommended continuous bladder irrigation which we were
unable to perform in the OR so the decision was made to keep
the patient in-house for several days to wait until his gross
hematuria cleared. He was admitted on the 7th and followed by
our service.
On hospital day 2, he had some supraventricular tachycardia
with activity. His EKG showed no ischemic changes and he had
no chest pain. His hematuria continued to resolve.
Preop labs were as follows: White count 7.1, hematocrit 34.8,
platelet count 272,000, sodium 140, K 3.9, chloride 103,
bicarbonate 29, BUN 18, creatinine 1.1, blood sugar of 117,
PT 13.8, PTT 27.8, ALT 52, AST 32, alkaline phosphatase 59,
amylase 35, total bilirubin 0.8, lipase 34. He was started on
ciprofloxacin 500 mg p.o. twice a day and continued with
Lopressor beta blockade and continue also with aspirin and
Finasteride.
His pressure was 152/74 that morning. He was in sinus
tachycardia at 52 with respiratory rate of 20 and saturating
99% on room air. IV nitroglycerin was started briefly for
blood pressure control and the plan was to continue to
irrigate him over the weekend for his hematuria, and bring
him back to the OR on Monday.
On [**7-26**], he underwent coronary artery bypass grafting x3
by Dr. [**Last Name (STitle) **] with a LIMA to the LAD, a vein graft to the
PDA and a vein graft to the OM. He was transferred to
cardiothoracic ICU in stable condition on titrated Propofol
and phenylephrine drips. He was also seen by urology who
cleared him for CABG prior to the procedure. On postop day 1,
his index was 2.6. He remained stable in the cardiothoracic
ICU.
Postop labs were as follows. White count 12.7, hematocrit 32,
K 4.4, BUN 12, creatinine 1.0.
His sugars were covered by sliding scale insulin. He was seen
by Dr. [**Last Name (STitle) **], his cardiologist. He was on insulin drip at 3
units an hour and lidocaine drip at 2 mg per minute.
On postoperative day 2, he went into atrial fibrillation with
a ventricular response rate of 129. He maintained good blood
pressure of 114/52. His chest tubes were pulled. His atrial
fibrillation was treated. He received magnesium repletion
also. His creatinine remained stable at 1.2 and his exam was
unremarkable. When he was weaned from his drips, he was
transferred out to the floor and was seen and evaluated by
urology and by physical therapy to start working on
ambulation with the nurses and the therapists. On the 13th,
his urine was clear. He was managing his pain control with
p.o. medications. He was in sinus rhythm with some PVCs. He
was restarted on his cholesterol medicines. He was continued
with IV diuresis with Lasix. His blood pressure was 145/69 so
his blood pressure was titrated up. He did have some
complaints of nausea but this was not overwhelming. His
pacing wires were discontinued.
On postoperative day 4, he had another event of atrial
fibrillation overnight with a blood pressure of 132/68. His
Foley was discontinued per urology. His exam was
unremarkable. Incisions were clean, dry and intact. He was
alert and oriented with a nonfocal neurological exam. His
lungs were clear bilaterally. He was also seen by social
work. The following morning he was back in sinus rhythm again
with a good blood pressure. He continued his diuresis with
Lasix and continued to increase his ambulation and his
activity tolerance level.
On the 17th, he went back into atrial fibrillation and
heparin was started as a possible bridge to Coumadin. His
exam was unremarkable. He was saturating well on 2 liters
nasal cannula. His heparin was discontinued per Dr. [**Last Name (STitle) **].
His pressure came down to 101/54.
On the 19th, amiodarone was started for his atrial
fibrillation at 400 mg p.o. twice a day. He was doing very
well, ambulating with minimal support. His creatinine was
stable at 1.2. His exam was unremarkable, clean, dry and
intact incisions. The central venous line had been removed.
He continued on Proscar 5 mg p.o. once a day for his enlarged
and somewhat raw prostate. His urine was clear. His beta
blockade had been increased to 75 mg p.o. three times a day
and he was discharged to home in stable condition with VNA
services, with the following discharge diagnoses.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass grafting x3.
3. Hypertension.
4. Status post myocardial infarction [**2120**].
5. Abdominal aortic aneurysm.
6. Hyperlipidemia.
7. Renal and bladder calculi, status post lithotripsy [**Month (only) **]
[**2145**].
It was recommended that he followup with Dr.[**Name (NI) 5572**]
service for postop surgical visit in the office at 4 weeks,
to see Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 64178**], his primary care physician, [**Last Name (NamePattern4) **] 2
weeks, to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his cardiologist, in 2 weeks,
and to see Dr. [**Last Name (STitle) **], his urologist at the outside
hospital, after his discharge.
DISCHARGE MEDICATIONS:
1. Proscar 5 mg p.o. once daily
2. Colace 100 mg p.o. twice a day
3. Zantac 150 mg p.o. twice a day
4. Enteric-coated aspirin 81 mg p.o. once a day
5. Crestor 5 mg p.o. once daily
6. Metoprolol 75 mg p.o. three times a day
7. Amiodarone 200 mg p.o. once a day
8. Coumadin 1 mg p.o. with no dose to be taken on the evening
of [**8-3**]. INR check was scheduled with blood draws on
[**8-4**], the day after discharge, with results to go to
Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 64178**], his primary care physician, [**Name10 (NameIs) **]
therapeutic INR dosing with Coumadin. The patient had been
started on Coumadin the evening prior to discharge.
Again, the patient was discharged to home in stable condition
on [**2145-8-3**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2145-8-18**] 11:47:57
T: [**2145-8-18**] 12:49:09
Job#: [**Job Number 64184**]
|
41081,41401,4019,2724,412,V4581,V4582 | 154 | 102,354 | Admission Date: [**2127-12-23**] Discharge Date: [**2127-12-26**]
Date of Birth: [**2073-7-26**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Erythromycin Base
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, STEMI
Major Surgical or Invasive Procedure:
left heart catheterization and balloon angioplasty
History of Present Illness:
54yo male with past medical history significant for coronary
artery disease s/p multiple interventions including CABG in
[**2118**], htn, hld who is presenting with STEMI. The patient reports
that he was standing in his kitchen at rest this afternoon
around 4pm and he had sudden onset of chest pressure, which is
how his angina always presents. He took nitroglycerin x4 and the
chest pain did not improve, so he called EMS.
.
Upon arrival of EMS, the patient was given nitro and aspirin. He
was taken to OSH, where EKGs were done and the decision was made
to transfer to [**Hospital1 18**]. On arrival to the cath lab, he reported
his pain as [**4-13**]. In the cath lab, the patient had balloon
angioplasty of the TCA but no placement of stent. There was
thrombosis of the distal RCA that was refractory to balloon
angioplasty, despite IV heparin, IV integrillin and prasugrel.
The final injection showed TIMI 1 flow into the distal vessel
and ST segment elevation consistent with continued inferior wall
STEMI. His CP was [**6-13**].
.
The patient reports that he has been in his baseline state of
health since [**Month (only) 116**], when he was experiencing increasing anginal
symptoms and so he had repeat coronary angiography, done as an
outpatient, where he was found to have severe in stent
restenosis of the RCA and had DES placed. Since that time, he
has had much improved symptoms and has been able to keep up with
his exercise regimen of walking 2miles 5 days a week at a speed
of [**3-7**] miles per hour. On Friday, 4 days prior to presentation,
the patient noted that he was "at the edge of his exertion"
while he was doing his 2 mile walk. By this he means that if he
had increased his speed, he would have had angina, but since he
maintained his speed, he was not having angina. On Sunday, 2
days prior to presentation, the patient had acute onset of chest
pain and realized he had forgotten to take his am meds, so he
took them and he took one nitroglycerin and felt resolution of
the pain.
.
In the CCU, the patient reports 2/10 chest pain, denies dyspnea.
.
On review of systems, he denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: [**2118-4-6**]: LIMA -> LAD, SVG -> rPDA, SVG -> diagonal, SVG
-> ramus, left radial -> OM
[**2118-9-16**] PTCA and beta-brachytherapy of VG -> PDA
[**2-6**] s/p PTCA/beta-brachytherapy of the SVG->PDA
- PERCUTANEOUS CORONARY INTERVENTIONS:
-[**2117**]: IMI treated with retavase and overlapping proximal RCA
stents and distal RCA stent
-[**6-/2120**] s/p rotational atherectomy of the mid RCA and stenting
with two Taxus DES 3.0 x 12mm in the distal RCA with an
overlapping
3.0 x 24mm Taxus.
- [**5-/2127**] focal severe in-stent restenosis in the right coronary;
Drug-eluting stent (3.5 x 12 mm dilated to 3.75 mm).
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anxiety/depression
Low back pain (resolved)
Left ankle fracture with surgery
Elbow fracture with surgery
? TIA word finding difficulty, micrographia after receiving
retavase.
Social History:
Divorced, has 3 kids- son, 22 has substance abuse issues;
daughter, 20, is at [**Hospital1 498**] [**Location (un) 5169**]; son, 17 is honors high school
student.
Occupation: Electrical Engineer; went out on disability several
years ago.
Tobacco: Quit [**2100**] (smoked 1-2ppd x7 years)
ETOH: quit 20 yrs
Recreational drug use: denies
Family History:
mother died at age 85 [**2-5**] Parkinson's disease. Dad died in his
40's from liver disease. Brother- died in his 60s from chronic
inflammatory demyelinating polyneuropathy. Sister- breast
cancer, obesity. Sister-depression.
3 children healthy.
Physical Exam:
ADMISSION EXAM:
.
VS: T=AF BP= 92/54 HR=65 RR=14 O2 sat= 98% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2127-12-23**] 07:50PM BLOOD WBC-8.7# RBC-3.86* Hgb-11.6* Hct-34.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-12.8 Plt Ct-187
[**2127-12-23**] 07:50PM BLOOD PT-12.3 INR(PT)-1.1
[**2127-12-23**] 07:50PM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-110* HCO3-21* AnGap-11
.
PERTINENT LABS AND STUDIES:
.
[**2127-12-23**] 07:50PM BLOOD CK(CPK)-84
[**2127-12-24**] 03:07AM BLOOD CK(CPK)-364*
[**2127-12-24**] 04:45PM BLOOD CK(CPK)-1084*
[**2127-12-24**] 03:07AM BLOOD CK-MB-44* MB Indx-12.1* cTropnT-0.27*
[**2127-12-24**] 08:50AM BLOOD CK-MB-90* cTropnT-0.68*
[**2127-12-24**] 04:45PM BLOOD CK-MB-105* MB Indx-9.7* cTropnT-1.28*
.
[**2127-12-24**] ECHOCARDIOGRAM The left atrium is elongated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the basal to mid
inferior wall. The remaining segments contract normally (LVEF =
55 %). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic function
with preserved left ventricular ejection fraction. Mild mitral
regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
This is a 53 year-old Male with past medical history significant
for CAD s/p CABG and multiple PCIs, p/w STEMI s/p DES to RCA
with poor flow after stenting ho presented with ST-elevation
myocardial infarction and underwent cardiac catheterization.
.
ACUTE CARE:
.
# CORONARY ARTERY DISEASE - The patient has had multiple PCIs
and is s/p CABG. He had a left heart catheterization with
balloon angioplasty of the RCA at the time of admission without
placement of stent, he was medically managed. He was treated
with Heparin gtt, Integrillin gtt, Pprasugrel and Aspirin. His
integrillin and heparin infusions were discontinued following
his catheterization. A 2D-Echo showed mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal to mid inferior wall (LVEF 55%). We did decreased his
Lisinopril from home dose of 40 mg to 10 mg this admission and
stopped his Plavix and decided to utilize Prasugrel.
.
CHRONIC CARE:
.
# HYEPRTENSION - We continued home Lisinopril but at 10 mg daily
and resumed his Metoprolol medication.
.
# HYPERLIPIDEMIA - Continued Atorvastatin 80 mg PO daily.
.
ISSUES OF TRANSITIONS IN CARE:
1. Exchanged Plavix for Prasugrel for anti-platelet therapy.
2. Will follow-up with outpatient Cardiologist and primary care
physician.
3. At the time of discharge, the patient had no pending
radiologic studies, labroatory studies, or microbiologic data.
Medications on Admission:
1. NTG 0.4mg tablet SL prn chest pain
2. aspirin 325mg daily,
3. Plavix 75 mg daily,
4. lisinopril 40 mg daily,
5. Atorvastatin 80mg daily
6. Toprol-XL 200 mg daily.
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed as needed for chest pain: Take 1 capsule
x3, separated by 5 minutes.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Acute ST-elevation myocardial infarction
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] for a heart attack that was caused by
a blockage in your right coronary artery. As you know, you did
not have placement of another stent in your coronary artery but
the artery was opened with a balloon. Your chest pain improved
with medical management and you will continue to follow with
your cardiologist and to take medications for your heart.
Please note the following changes to your medications:
1. STOP taking plavix, take prasugrel instead to prevent
blockages in your heart arteries
2. Decrease lisinopril to 10 mg daily instead of 40 mg.
Please be sure to follow up with your physicians.
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2128-3-15**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) 28295**], [**First Name3 (LF) **] PA.
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 25161**]
When: Tuesday, [**2126-1-6**]:15 AM
*[**Doctor First Name **] is covering for Dr. [**Last Name (STitle) **].
Department: CARDIAC SERVICES
When: MONDAY [**2128-2-9**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
99672,41401,4111,2720,4019,412,V4582,V1582 | 154 | 162,891 | Admission Date: [**2118-4-5**] Discharge Date: [**2118-4-11**]
Date of Birth: [**2073-7-26**] Sex: M
Service: CARDIOTHOR
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
male with known coronary artery disease status post inferior
myocardial infarction and status post stenting of the right
coronary artery in [**2117-12-4**]. The catheterization at
that time also demonstrated multiple lesions of the left
anterior descending and left circumflex. Subsequently he was
stable and underwent a second catheterization in [**2118-12-4**] because of more recurrent chest pain, which showed good
result in the right coronary artery, no change in the left
coronary artery lesion. Since then he continued on a stable
course until the past week when he developed progressive
episodes of chest pain. The pain began to occur at rest and
it was not relieved with Nitroglycerin sublingual. He was
promptly brought to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Decreased HDL.
4. Coronary artery disease; myocardial infarction in
12/[**2117**].
PAST SURGICAL HISTORY:
1. Status post right coronary artery stenting in [**2117-12-4**].
2. Status post left ankle surgery.
ALLERGIES: Include Vicodin and question of an intravenous
antibiotics, unknown name.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day.
2. Toprol XL 100 mg p.o. q. day.
3. Lisinopril 5 mg p.o. q. day.
4. Lipitor 10 mg p.o. q. day.
5. Multivitamin one p.o. q. day.
6. Calcium supplement q. day.
SOCIAL HISTORY: The patient is married with three children,
exercises on a regular basis. He is a past smoker who quit
in [**2100**]. Denies any ETOH.
PHYSICAL EXAMINATION: On admission, the patient has vital
signs which are stable. HEENT is within normal limits. Neck
shows no lymphadenopathy, no bruits. Chest is clear to
auscultation. Heart is regular rate and rhythm with no
murmur. Abdomen is soft, nontender. Extremities with normal
pulses; no edema.
LABORATORY: On admission, white blood cell count of 6.0,
hematocrit of 39, platelets of 216. Sodium of 143, potassium
of 4.5, BUN of 14, creatinine of 1.2, glucose of 69, INR 1.0.
EKG was significant for normal sinus rhythm with normal axis.
No evidence of ischemia.
HOSPITAL COURSE: On the day of admission, the patient
underwent cardiac catheterization. This revealed 90%
stenosis of the right coronary artery, 70% stenosis of the
proximal left anterior descending, mid-LAD, and 70% stenosis
of the diagonal 1, 70% stenosis of the proximal circumflex
and 90% stenosis of the obtuse marginal 1.
On hospital day two, the patient went to the Operating Room
where he underwent coronary artery bypass graft times five.
He had left internal mammary artery to the left anterior
descending, saphenous vein graft to diagonal, saphenous vein
graft ramus; saphenous vein graft to right coronary artery
and left radial artery to the obtuse marginal. He tolerated
this procedure well; was transferred to the Intensive Care
Unit, intubated and on a Nitroglycerin drip.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2118-4-10**] 14:39
T: [**2118-4-11**] 14:01
JOB#: [**Job Number 12115**]
|
86401,8028,8054,E9689,87349 | 155 | 147,148 | Admission Date: [**2125-9-8**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2093-3-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 32 year old man,
admitted on [**2125-9-8**] when he was assaulted by his roommate,
early in the morning. There was positive loss of
consciousness. When he regained consciousness, he crawled to
a phone and called 911. On the scene, he had a GCS of 15 and
a large amount of blood as described by EMS. He was taken to
an outside hospital. There, he had a head CT which was
negative. Besides the facial trauma he had sustained, he
began to complain of abdominal pain and was transferred at
that time to [**Hospital1 69**] trauma bay.
He was hemodynamically stable en route and complaining only
of left sided chest pain and abdominal pain. There was no
previous medical history of surgical history. He is not
taking any medications and denies having any allergies. The
patient smokes and drinks.
PHYSICAL EXAMINATION: Initial vital signs reveal a
temperature of 99.4; 81; 110 by palpable; 100% on room air;
GCS of 15; pupils are equal, round, and reactive to light and
accommodation. Extraocular movements intact, without pain.
Significant amount of facial edema as well as several
lacerations. Mandible was intact. There were no missing
teeth. The mid face was stable. The neck revealed a midline
trachea without any obvious crepitus or deformities. The
left side of the chest was tender without crepitus. There
was a regular rate with equal breath sounds bilaterally. The
abdomen was diffusely tender, had bowel sounds. There was
guarding but there was no rebound. The rectum had normal
tone, guaiac positive. Brown stool. Prostate in the normal
spot. The back was without step-off and was nontender. There
was no edema or gross deformity in any of the extremities,
which the patient was able to move without pain.
LABORATORY DATA: Significant for a urinalysis with large
blood, greater than 50 red blood cells, lactate of 234,
normal amylase.
RADIOLOGIC DATA: CXR and PXR without fracture, pneumothorax
or other acute disease.
CT of the head, repeated, revealed no bleed, mass or shift,
although there was a right maxillary sinus fracture. CT of
the C spine was negative. CT of the abdomen revealed a grade
I to II liver laceration and contusion, without free fluid in
the abdomen. A cystogram was negative for extravasation,
although there was no contrast noted in the left ureter,
raising the question of a ureteral injury but again, there
was no free fluid noted in the abdomen. The spleen and
kidneys were otherwise unremarkable. Facial cuts of the head
revealed a non displaced fracture of the left lateral orbital
wall and fracture of the nasal bones and septum. There was
no right maxillary fracture noticed on the facial cut CT.
TLS films revealed transverse process fractures on the right
sided L2 and L3.
HOSPITAL COURSE: The patient was admitted to the T-SICU for
serial hematocrits and abdominal examination. His hematocrit
remained stable and his abdominal examination improved
progressively. Ophthalmology and plastic surgery were both
consulted regarding the patient's facial fracture. It is
likely that the patient will be able to enjoy non operative
management of his injuries, although he will be following up
with plastic surgery in a week as an outpatient. An
orthopedic spine consult was also obtained and again, no
brace or operation was felt to be needed to manage this
patient's injuries. His urinalysis gradually cleared of the
red cells and as his abdominal examination remained so
benign, it was felt that a ureteral injury was extremely
unlikely and no further work-up was obtained for that
possible injury. The patient is discharged home with the
aforementioned follow-up.
FINAL DIAGNOSES:
Status post assault.
Liver contusion.
Left orbital wall fracture.
L2 and L3 transverse process fracture on the right.
Facial lacerations.
The patient will have his sutures out when he returns to the
Emergency Department within two days and he will be seen in
trauma clinic within two weeks as well. Dr. [**Last Name (STitle) 363**] will be
following his spine.
DISCHARGE MEDICATIONS:
Bacitracin to the various facial abrasions he sustained.
Erythromycin ointment to the eye four times a day for a week
prophylactically.
Docusate.
Percocet prn with 30 dispense.
Ibuprofen 600 mg three times a day with food.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36/D: [**2125-9-10**] 07:01/T: [**2125-9-10**] 18:07
JOB#: [**Job Number **]
|
44103,48241,51881,4280,5849,5070,4019,56400,V090 | 156 | 168,847 | Admission Date: [**2120-5-20**] Discharge Date: [**2120-6-10**]
Date of Birth: [**2057-11-11**] Sex: M
Service: BLOOMGART INTERNAL MEDICINE
HISTORY OF PRESENT ILLNESS: A 62 male, status post abdominal
aortic aneurysm repair with known thoracic aneurysm presents
with sudden onset of back pain described as tearing, brought
to the emergency department with vital signs of heart rate of
60, blood pressure of 164/80. CTA showed a type B dissection
from the distal aorta to the left subclavian to
aorto-[**Hospital1 **]-femoral graft with a true celiac lumen, half FMA
true lumen and half false lumen and left renal true lumen but
with right renal false lumen. Transferred to the Intensive
Care Unit on labetalol and Nipride.
REVIEW OF SYSTEMS: Positive for nausea and emesis times one
at home, one episode of loose stool at home, positive
shortness of breath, no jaw or arm pain, no palpitations, no
fevers or chills, no confusion and no weakness, numbness or
tingling.
PAST MEDICAL HISTORY: Deep venous thrombosis,
osteoarthritis.
PAST SURGICAL HISTORY: Status post 8 cm abdominal aortic
aneurysm repair, status post wound dehiscence.
SOCIAL HISTORY: History of tobacco use. One pack per day
tobacco history. Quit [**12-11**]. Lives in [**Location 4310**] with his wife.
Two to three alcoholic beverages per week.
MEDICATIONS ON ADMISSION: Lopressor 25 mg p.o. b.i.d.,
aspirin 81 mg p.o. q.d. No known drug allergies.
PHYSICAL EXAMINATION: Patient was afebrile with heart rate
of 60, blood pressure 120/53, respiratory rate 18, 94 percent
on 4 liters. In general he is alert, oriented times three
lying flat on a stretcher in moderate distress. HEENT: NPAT,
pupils equal, round, reactive to light, extraocular movements
intact. Oropharynx moist mucous membranes without erythema
or exudate. Neck supple, full range of motion, no
lymphadenopathy, no bruits. CV: Regular rate and rhythm,
normal S1 and S2 without murmurs, rubs or gallops. Chest
clear to auscultation throughout. Abdomen obese, positive
bowel sounds, midline scar, nontender, no masses, no audible
bruits. Extremities: 1+ pretibial edema, no cyanosis, no
clubbing. Pulses: 2+ dorsalis pedis and posterior tibial,
femoral, radial. Neurologic: Sensation intact 5 out of 5
strength, 2+ refluxes upper extremity and lower extremity
bilaterally.
LABORATORY VALUES: On admission WBC 13.8, hematocrit 45,
platelets 237 with a normal differential. Chemistries:
sodium 142, potassium 4.6, chloride 103, bicarb 28, BUN 30,
creatinine 1.0, glucose 111, coagulation profile normal. CK
was 129, troponin was less than .01. CTA showed an acute
aortic dissection beginning distal to the left subclavian and
extending down to the aorto-[**Hospital1 **]-femoral graft. Celiac showed
a two lumen SMA half true, half false with contrast to
arcades. Left renal true lumen, right renal false lumen with
decreased enhancement with contrast.
ASSESSMENT: A 62 year-old male status post abdominal aortic
aneurysm repair and aorto-[**Hospital1 **]-femoral graft now with acute
type B dissection with SMA and right renal artery
involvement. No evidence of compromise to viscera. Patient
was admitted for medical management.
HOSPITAL COURSE BY PROBLEM:
1. Aortic dissection: Patient was started on a labetalol
and Nipride drip with a goal of systolic blood pressure of
less than 120. He was continued on those drips with
titration for the first four days of his hospitalization. At
that time other antihypertensives were added including an ACE
inhibitor, hydralazine and spironolactone. At the time of
dictation the patient has been weaned off his Lebatolol and
Nipride drip. He has also been weaned off most of his
antihypertensive medications and is currently on a regimen
that includes an ACE inhibitor, hydrochlorothiazide, beta
blocker and Clonidine. His Clonidine is slowly being
titrated off as the ACE inhibitor is titrated up. Eventually
he will only a regimen of an ACE inhibitor beta blocker and
hydrochlorothiazide. His blood pressure currently is 120/80.
2. MRSA pneumonia. The patient developed acute hypoxia
during this hospitalization and has sputum cultures positive
for MRSA. He was treated with a ten day course of Vancomycin
and a 14 day course of levofloxacin. He was intubated for
six days during the course of his hospitalization for acute
mental status changes and in the setting of benzodiazepine
use and hypoxia thought to be secondary to his pneumonia. At
the time of dictation the patient has an oxygen requirement
of three liters, is saturating in the high 90s and the goal
of care is to wean oxygen as tolerated in the rehabilitation
setting.
3. Constipation: The patient was continued on a bowel
regimen including Colace, Senna, Dulcolax, enemas and
lactulose.
4. Acute mental status changes: Probably secondary to
benzodiazepine use. During the subsequent course of his
hospitalization patient was taken off benzodiazepines and for
the remainder he should avoid benzodiazepines as they clear
cause mental status changes.
5. Fluid, electrolytes and nutrition: The patient after
intubation was maintained on a low sodium diet. He was
diuresed after extubation.
6. Prophylaxis: Patient is on a proton pump inhibitor and
received subcutaneous heparin while he was immobile.
Currently the patient is ambulating for deep venous
thrombosis prophylaxis.
CONDITION AT DISCHARGE: Stable.
CONDITION STATUS: To rehabilitation.
DISCHARGE MEDICATIONS: Tylenol 325 to 650 p.o. q 4 to 6
p.r.n., albuterol nebs 1 q three hours p.r.n., Captopril 37.5
mg p.o. t.i.d., hydrochlorothiazide 25 mg p.o. q.d., Atrovent
MDI 2 puffs q 4 hours p.r.n., Clonidine .1 mg p.o. q 6 hours
times four doses, folic acid 1 mg p.o. q.d., Guaifenesin 5 to
10 ml p.o. q 6 p.r.n., heparin 5,000 units subcutaneous q 12
hours while immobilized, Lopressor 25 mg p.o. b.i.d.,
Protonix 40 mg p.o. q.d., Senna 2 tabs p.o. b.i.d., p.r.n.
FOLLOW UP: Patient will follow up with his primary care
physician and vascular surgeon, Dr. [**Last Name (STitle) 1391**] after his
rehabilitation stay.
[**Doctor Last Name **], [**Doctor Last Name **] R. M.D. [**MD Number(1) 19181**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2120-6-7**] 15:50
T: [**2120-6-7**] 16:59
JOB#: [**Job Number 19182**]
|
44103,48241,51881,4280,5849,5070,4019,56400,V090 | 156 | 168,847 | Admission Date: [**2120-5-20**] Discharge Date: [**2120-6-10**]
Date of Birth: [**2057-11-11**] Sex: M
Service: MED
ADDENDUM: See previous dictation for hospital course
summary. The patient remained in the hospital for an
additional four days, awaiting placement in rehabilitation
center. All medications and discharge information remained
the same from previous dictation for [**2120-6-7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**]
Dictated By:[**Last Name (NamePattern1) 19183**]
MEDQUIST36
D: [**2120-7-27**] 16:05:22
T: [**2120-7-27**] 17:55:28
Job#: [**Job Number 19184**]
|
47829,78057,2930,5191,486,5180,5845,4280,2869,42731,99811,5109,5185,44103 | 156 | 199,280 | Admission Date: [**2120-12-31**] Discharge Date: [**2121-1-27**]
Date of Birth: [**2057-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lorazepam / Benzodiazepines
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
63 yo male with h/o 8cm AAA resection
with aortobifemoral graft in [**12-11**], who was diagnosed in [**5-12**]
with type B dissection from distal aorta to L subclavian to
aortobifem graft. Pt admitted [**2120-12-31**] elective thoracoabdominal
aortic aneurysm repair with reimplant SMA/celiac/L renal/R renal
fem-fem bypass on [**12-31**]. Bronchoscopy on [**1-2**] notable for mod
thin secretions and several blood clots. Pt was reintubated due
to mucus plugs, requiring several bronchs while intubated. Pt
also developed acute renal failure, volume overload. Pt was
extubated on [**2121-1-15**], is currently NPO with NG TFs, and we were
consulted to evaluate pt for swallow. PMH / PSH: CAD, DVT, OA
both knees, MRSA pneumonia, s/p knee/ankle/elbow sx, gum sx,
deviated septum, emphysema, (+) h/o smoking, depression
Major Surgical or Invasive Procedure:
PROCEDURE: Repair of thoracoabdominal aneurysm,
reimplantation intercostal arteries, and reimplantation of
the superior mesenteric artery, celiac access, and the right
and left renal arteries.
PREOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following
type B dissection, medically managed. Surgery was indicated
due to increase in size of the aneurysm to about 8 cm. The
patient was essentially asymptomatic.
POSTOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following
type B dissection, medically managed. Surgery was indicated
due to increase in size of the aneurysm to about 8 cm. The
patient is essentially asymptomatic.
PREOPERATIVE DIAGNOSIS: Thoracoabdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSES: Thoracoabdominal aortic aneurysm.
PROCEDURE:
1. Repair of thoracoabdominal aortic aneurysm.
2. Reimplantation of the left renal artery, superior
mesenteric artery and celiac artery.
3. Reimplantation of the right renal artery.
4. Left femoral artery, left femoral vein bypass.
PROCEDURE INDICATIONS:
1. Respiratory failure.
2. Assessment of airways patency.
SCOPE: Number 6.
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Severe mucous plugging in the left
main stem.
PROCEDURE:
1. Flexible bronchoscopy.
2. Therapeutic aspiration of thick mucous plugging in the
left main stem.
ice: CSU Date: [**2121-1-14**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
FIRST ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Patent airways.
PROCEDURE: Flexible bronchoscopy.
[**2121-1-18**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD
PROCEDURE: Flexible bronchoscopy and therapeutic aspiration.
Service: CSU Date: [**2121-1-22**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367
PREOPERATIVE DIAGNOSIS: Loculated left pleural effusion with
pulmonary collapse.
Postoperative respiratory insufficiency and
tracheobronchitis.
POSTOPERATIVE DIAGNOSIS: Loculated left pleural effusion
with pulmonary collapse.
Postoperative respiratory insufficiency and
tracheobronchitis.
PROCEDURE:
1. Left thoracoscopy with partial lung decortication.
2. Percutaneous tracheostomy tube placement.
3. Flexible bronchoscopy with aspiration of tracheobronchial
tree.
History of Present Illness:
63 year old man with h/o 8cm AAA
resection with aortobifemerol graft in [**12-11**], who was diagnosed
in [**5-12**] with type B dissection from distal aorta to L subcalvian
to aortobifem graft. Pt admited [**2120-12-31**] for elective
thoracoabdominal aortic aneurysm repair with reimplant
SMA/celiac/L renal/R renal fem-fem bypass on [**2120-12-31**].
Bronchoscopy on [**1-2**] notable for mod thin secretions and
several blood clots. Pt was reintubated due to mucus plugs,
requiring several bronchs while intubated. Pt also developed
acute renal failure, volume overload. Pt was extubated on
[**2121-1-15**]. Chest CT on [**2121-1-20**] showed bilateral effusions with
near total collapse of R lung and on [**1-22**] pt was
bronched and trached. We were consulted to assess his ability to
tolerated wearing a Passy-Muir Speaking Valve.
HPI / Subjective Complaint: 63 y/o male with 8cm AAA resection
with aortobifemoral graft in [**12-11**], but then presented to [**Hospital1 **] in
[**5-12**] with back pain. Found to have type B dissection from distal
aorta to L subclavian to aortobifem graft. Underwent
thoracoabdominal aortic aneurysm repair with reimplant
SMA/celiac/L renal/R renal fem-fem bypass on [**12-31**]. Bronchoscopy
on [**1-2**] notable for mod thin secretions and several blood
clots.
Past Medical History:
PMH / PSH: DVT, OA both knees, MRSA pneumonia, ankle sx, knee
sx,
elbow sx, gum sx, deviated septum, emphysema
PAST MEDICAL HISTORY: Deep venous thrombosis,
osteoarthritis.
PAST SURGICAL HISTORY: Status post 8 cm abdominal aortic
aneurysm repair, status post wound dehiscence.
Social History:
SOCIAL HISTORY: History of tobacco use. One pack per day
tobacco history. Quit [**12-11**]. Lives in [**Location 4310**] with his wife.
Two to three alcoholic beverages per week
Family History:
NC
Physical Exam:
On admit
Axo x3 NAD well developed
CTA/Bl
S-NT/ND no RT/no guarding
EXT good distal pulses warm well perfused extremities
Pertinent Results:
Admission labs
[**2120-12-31**] 10:14PM WBC-4.5 RBC-3.62*# HGB-11.0*# HCT-30.0*#
MCV-83 MCH-30.4 MCHC-36.7* RDW-13.8
[**2120-12-31**] 10:14PM WBC-4.5 RBC-3.62*# HGB-11.0*# HCT-30.0*#
MCV-83 MCH-30.4 MCHC-36.7* RDW-13.8
[**2120-12-31**] 10:36PM TYPE-ART RATES-8/ TIDAL VOL-800 O2-100
PO2-193* PCO2-41 PH-7.34* TOTAL CO2-23 BASE XS--3 AADO2-489 REQ
O2-81 INTUBATED-INTUBATED VENT-CONTROLLED
[**2120-12-31**] 10:28PM PT-17.9* PTT-42.0* INR(PT)-2.0
Discharge labs
[**2121-1-27**] 03:57AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.0* Hct-27.0*
MCV-92 MCH-30.8 MCHC-33.4 RDW-17.6* Plt Ct-319
[**2121-1-26**] 03:50AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.2* Hct-28.0*
MCV-91 MCH-30.1 MCHC-33.0 RDW-17.5* Plt Ct-314
[**2121-1-27**] 03:57AM BLOOD Plt Ct-319
[**2121-1-27**] 03:57AM BLOOD Glucose-112* UreaN-29* Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-32* AnGap-8
[**2121-1-26**] 03:50AM BLOOD Glucose-104 UreaN-27* Creat-1.0 Na-140
K-3.8 Cl-104 HCO3-30* AnGap-10
[**2121-1-12**] 12:04AM BLOOD ALT-44* AST-33 AlkPhos-175* Amylase-23
TotBili-2.4*
[**2121-1-27**] 03:57AM BLOOD Mg-2.2
[**2121-1-27**] 12:53AM BLOOD Type-ART pO2-84* pCO2-55* pH-7.42
calHCO3-37* Base XS-8
[**2121-1-26**] 05:03AM BLOOD O2 Sat-97
Brief Hospital Course:
The following procedures are earmarks of the events that have
occured t mark the hospital course:
PROCEDURE: Repair of thoracoabdominal aneurysm,
reimplantation intercostal arteries, and reimplantation of
the superior mesenteric artery, celiac access, and the right
and left renal arteries.
PREOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following
type B dissection, medically managed. Surgery was indicated
due to increase in size of the aneurysm to about 8 cm. The
patient was essentially asymptomatic.
POSTOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following
type B dissection, medically managed. Surgery was indicated
due to increase in size of the aneurysm to about 8 cm. The
patient is essentially asymptomatic.
PREOPERATIVE DIAGNOSIS: Thoracoabdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSES: Thoracoabdominal aortic aneurysm.
PROCEDURE:
1. Repair of thoracoabdominal aortic aneurysm.
2. Reimplantation of the left renal artery, superior
mesenteric artery and celiac artery.
3. Reimplantation of the right renal artery.
4. Left femoral artery, left femoral vein bypass.
PROCEDURE INDICATIONS:
1. Respiratory failure.
2. Assessment of airways patency.
SCOPE: Number 6.
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Severe mucous plugging in the left
main stem.
PROCEDURE:
1. Flexible bronchoscopy.
2. Therapeutic aspiration of thick mucous plugging in the
left main stem.
ice: CSU Date: [**2121-1-14**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
FIRST ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Patent airways.
PROCEDURE: Flexible bronchoscopy.
[**2121-1-18**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD
PROCEDURE: Flexible bronchoscopy and therapeutic aspiration.
Service: CSU Date: [**2121-1-22**]
Date of Birth: [**2057-11-11**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367
PREOPERATIVE DIAGNOSIS: Loculated left pleural effusion with
pulmonary collapse.
Postoperative respiratory insufficiency and
tracheobronchitis.
POSTOPERATIVE DIAGNOSIS: Loculated left pleural effusion
with pulmonary collapse.
Postoperative respiratory insufficiency and
tracheobronchitis.
PROCEDURE:
1. Left thoracoscopy with partial lung decortication.
2. Percutaneous tracheostomy tube placement.
3. Flexible bronchoscopy with aspiration of tracheobronchial
tree.
Major issues are below which have been resolved prior to D/C
Neuro: Pt was intubated and sedated for some time and had a
waxing and [**Doctor Last Name 688**] course with regards to confusion, he at times
was floridly confused but after resolution of electrolye and
pulmonary issues his nerologic issues resolved, was evaluated by
neurologic team and cleared from their prospective
CV: pt has had stable course from cardiovascular propspective,
was supported initially with pressors and then was given agents
for control
Pulm:
Pt was admitted postoperativly from his thoracoabdominal repair
his renal funtion was marginal in the first several days
postoperatively he with he had emphysema with difficulty weening
from the vent and was extubated and re-intubated early in his
post -op course, he was finally extubated and needed several
subsequent bronchoscopy evalutations and finally his pulmonary
issues led him to a tracheostomy from which he has been stable
from a pulmonary function.
Renal: pt was followed by renal service for ATN in post op
period which resolve overtime to normal creatinine prior to D/C
FEN: all electorlyte abnormalities were corrected prior to D/C,
free water was used to correct dehydration and increased NA
Dispo to rehab because of chronic debilitation and trach mask
Medications on Admission:
FLUOXETINE HCL 10MG--One every day - increase to 2 every day as
needed
Discharge Medications:
1. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) ml PO Q4H
(every 4 hours) as needed for fever or pain.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) for 5 days.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**]
Puffs Inhalation Q6H (every 6 hours).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
10. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Ascorbic Acid 100 mg/mL Drops Sig: Five (5) ml PO DAILY
(Daily).
13. Heparin Sodium Lock Flush 100 unit/mL Solution Sig: One (1)
ML Intravenous DAILY (Daily) as needed: for PICC catheter .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Thoraco-abdominal aneurysm
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing for 1 month
no creams, lotions, ointments to incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] upon discharge from rehab
with Dr. [**Last Name (STitle) **] in [**3-12**] weeeks
Completed by:[**2121-1-27**] |
2554,2762,V0980,43811,4380,43889,78079,V5843,25000,7310,2768,7872,4019,2859,V090,4280,48241,5990,5070,51881,78552,99592,0389 | 157 | 107,880 | Admission Date: [**2106-6-17**] Discharge Date: [**2106-6-24**]
Date of Birth: [**2025-12-3**] Sex: M
Service: MEDICINE
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Sepsis, respiratory failure
Major Surgical or Invasive Procedure:
Intubation, extubation, central line/PICC placement
History of Present Illness:
80y M, NH resident s/p recent subdural hematoma evacuation who
was in his USOH until 3.30am today when (per NH records) he
suddenly became hypotensive and hypoxic. A STAT ABG at the time
was 7.48/25/66/18.7, his SBP was in 70s and was treated with IV
NS, x2 bld cx were drawn and the pt was started on empiric Vanc
for presumed UTI. His labs were significant for: WBC 25.7 and Na
133. The pt was transferred to [**Hospital1 18**] to r/o sepsis and PE.
.
Per ED notes, this morning pt was also noted to have increasing
confusion, decreased urine output, fever and elevated white cell
count. He was tachycardiac, and had fever to 103, lactate 5 and
SBP to 80s. He was treated w/ IVF w/ inc in BP to 111/49, 1 dose
Vanc/levo/flagyl.
.
Recent admission ([**Date range (1) 61538**]) to ED for mental status changes and
hypotension in setting of UTI (pan-sensitive P.aeruginosa)
treated w/ 7d course PO Cipro.
.
On arrival to the [**Hospital Unit Name 153**], the pt was deep suctioned by the
Respiratory therapist and his secretions were significant for
food particles and bloody secretions.
Past Medical History:
DM- not on meds on diet control
Paget's disease
subdural hematoma s/p L craniotomy w/ hematoma evacuation ([**5-18**]
and [**5-21**]. Has some residual right sided weakness, aphasic,
cognitive impairment)
recent admission for UTI
h/o MSSA
acute infarct noted on MRI [**5-15**] (left posterior frontal region
indicative of an acute infarct).
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
VS: T: 98.4, HR: 115, BP: 109/82, RR:30, O2 sats: 88% on 15L
high-flow
GEN: Elderly male, awake, sitting up in bed, in obvious
respiratory distress, audible wheezing.
HEENT: OP clear but very dry, no LAD, PERRLA
CV: (difficult to auscultate [**2-11**] diffuse, loud ronchi) RRR,
S1+S2, no obvious m/r/g
PULM: Diffuse rhonchi and wheezing throughout both lung fields.
ABD: soft, NT, ND, +BS, no HSM
EXTREM: no c/c/e. Warm periphery.
Neuro: Pt thinks he is in [**Hospital1 392**]. Once oriented to place, he can
recall it after 10 minutes, recalls DOB. Not oriented to time or
date. Tone LUE>RUE. Downgoing left plantar, equivocal right
plantar. Decreased bulk throughout.
Pertinent Results:
lactate 5->3
Phenytoin: 9.0
CHEM7: (83% N with 1 Band), Occ bacteria, occ yeast
CBC: WBC 52, HCT 31.7->29.8
UA: WBC [**10-29**]
.
Radiology:
CXR: RLL opacity-> PNA vs aspiration, extensive Paget's disease
of the right humerus, scapula and clavicle
.
ETT placement: 6cm above carina. It's below the clavicles.
.
[**2106-6-17**] 5:30 pm URINE Site: CATHETER
**FINAL REPORT [**2106-6-20**]**
URINE CULTURE (Final [**2106-6-20**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
[**2106-6-17**] 11:05 pm BRONCHOALVEOLAR LAVAGE
SPECIMEN COLLECTED VIA LAVAGE WITH STERILE WATER.
**FINAL REPORT [**2106-6-20**]**
GRAM STAIN (Final [**2106-6-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2106-6-20**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2406**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2106-6-18**] 12:00 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2106-6-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2106-6-20**]): NO GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Brief Hospital Course:
80 year old male with DM, recurrent UTI, Paget's, s/p recent
subdural hematoma evacuation admitted to [**Hospital Unit Name 153**] w/ respiratory
failure found to have MRSA pna VRE urosepsis, now improved,
called out of [**Hospital Unit Name 153**] to medicine.
.
# Respiratory distress: Patient was in acute respiratory
distress on admission to the [**Hospital Unit Name 153**]. He was noted to have thick
bloody secretions on deep suctioning with visible food
particles. He was intubated and a bronchoscopy was performed on
[**6-18**] which showed inflamed friable mucosa with moderately thick
mucous in the LLL bronchus. No foreign body was visualized and
a BAL was sent for culture.
His acute respiratory distress was attributed to aspiration PNA
and urosepsis, however, his CXR on [**6-19**] was concerning for
possible ARDS. He was started on protective ARDS vent settings.
He was extubated successfully on [**6-20**]. His sputum culture
eventually grew MRSA and patient was continued on Linezolid for
coverage of MRSA PNA and VRE UTI. Pt also developed pulmonary
edema from fluids that were received, and received lasix for
diuresis with good effects. Pt's O2 was weaned as tolerated. At
the time of dicharge, pt was satting at 95% on RA.
.
# VRE urosepsis/aspiration, MRSA pneumonia: Patient was admitted
to the [**Hospital Unit Name 153**] for sepsis given hypotension, hypoxia, tachycardia,
fever and leukocytosis. The pt was noted to have a UTI. A
culture sent from the ED grew out enterococcus and patient was
noted to have bibasilar consolidations R > L accompanied by
small-to-moderate pleural effusions concerning for PNA. Patient
was started on Vancomycin, Levofloxacin, and Zosyn.
Blood cultures were sent from the ED remained NGTD. However,
urine cx returned positive for VRE, and patient was started on
Linezolid IV for coverage of his MRSA PNA and VRE UTI. The BAL
also came back + for MRSA which is covered by linezolid.
Attempted to d/c foley and pt unable to void after trial and
foley was replaced. Will need another voiding trial after
treatment of UTI.
.
# Hypotension: Patient arrived from the ED on Levophed. He was
aggressively fluid resuscitated and he was weaned off the
levophed on [**6-19**]. It was noted that the patient was developing
a non-gap hyperchloremic acidosis from the normal saline which
had been used for volume resusciation so his IVF was changed to
lactated ringers with good resolution. On [**6-18**] he failed his
[**Last Name (un) 104**] stim test and was started on stress-dose steroids. His
blood pressure stablized and his steroids were continued. IV
steroid was switched to po and po steroids tapered to off on
[**6-24**].
.
# Mental status changes: Patient is s/p subdural hematoma
evacuation. It is unclear what his baseline mental status is
although per report, he is able to follow commands, and there
was a notable decline which in part tiggered this admission.
Likely etiology of new decline in mental status is infection.
Given his past history of CVA, heparin SC was withheld. Patient
was continued on his seizure prophylaxis with Phenytoin
(currently 9.0; goal [**10-29**]) for his history of subdural
hematoma. He should be continued on this for an additional 2
weeks.
.
# DM: Patient was maintained on an ISS.
.
FEN: Patient was NPO while intubated. Nutrition was consulted
and tube feeding was initiated on [**6-18**]. Pt self discontinued his
NGT and a swallow study was performed. The video swallow showed
no aspiration but pt should have pills crushed for pocketing. In
addition, he does not have teeth and therefore should cont on
pureed solids. Pt was taking poor PO and had another family
discussion about PEG tube placement. Family does not want a PEG
tube but this should be readdressed with family if pt continues
to take poor PO. Daughter will address with her family. Pt was
started on Megace on [**6-24**].
*
PPx: Hepain SC, PPI, bowel regimen
*
Access: PICC
*
Code status: Full code (discussed with son, [**Name (NI) **], who lives in
[**Name (NI) 33977**])
*
Communication: son (W:[**Telephone/Fax (1) 66904**], C:[**Telephone/Fax (1) 66905**])
Medications on Admission:
Phenytoin for sz ppx
SC Heparin 5000U TID
Pantoprazole 40mg QD
Thiamine 100mg QD
MVI
Folic acid 1mg QD
Phenytoin 500mg QD (200mg [**Hospital1 **] and 100mg at noon)
Senna 1 Tab [**Hospital1 **] PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Lopressor 25 mg [**Hospital1 **]
ISS
recently completed course Ciprofloxacin 500 mg Tablet Q12H on
[**2106-6-6**]
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
2. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
QAM AND QPM () for 2 weeks.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulatory then stop.
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO
AT NOON ().
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed for constipation.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Please see sliding
scale. .
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
15. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY
(Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) Flush Intravenous DAILY (Daily) as needed: 10 ml NS
followed by 2 ml of 100 Units/ml heparin (200 units heparin)
each lumen Daily and PRN. Inspect site every shift.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 100 U/ML.
17. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 3 days.
18. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
Aspiration/MRSA pneumonia
Sepsis
VRE urosepsis
.
Secondary diagnoses:
Hypertension
Discharge Condition:
Stable, afebrile
Discharge Instructions:
Call your doctor or come to emergency department if you develop
fevers, chills, nausea, vomiting, worsening cough, shortness of
breath, or any other worrisome symptoms.
Please call your PCP to make an appointment in [**1-11**] weeks after
you leave the rehab facility.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks.
Follow up with Dr. [**Last Name (STitle) 739**] with head CT on [**2106-7-1**].
PROVIDER: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-1**] 2:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
79001,7850,7310,2939,E8859,2859,79092,7843,4321,25082,27651,99811,85222 | 157 | 110,545 | Admission Date: [**2106-5-17**] Discharge Date: [**2106-5-26**]
Date of Birth: [**2025-12-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Found down with subdural hematoma on CT
Major Surgical or Invasive Procedure:
Left sided craniotomy for subdural hematoma evacuation X2
History of Present Illness:
80 y/o male transferred from outside hospital with subdural
hematoma. Mr [**Known lastname 30119**] is a 80 y/o gentleman who was found down
by a friend this morning,? tripped over rug. However friend of
patient reports change in mental status the last 24 hours
driving
was off while driving to Foxwoods. His friend asked him to call
him when he got home but he didn't so friend went and checked on
him and found him down on the floor. He was found to have an INR
of 1.6 at outside hospital. Mr [**Known lastname 30119**] relates a fall
approximately 1 month ago when he hit his head on the corner of
the stove and had a LOC.
Past Medical History:
Diabetes not being treated, Paget Disease
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
T:98.0 BP:143/75 HR:80 R18 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-11**] EOMs full
Neck: in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Bruise on right leg, poor toe nails, Warm and
well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: To name and hospital, date [**2077-3-9**]
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming impaired. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Right sided drift
UE [**5-14**] (Bicep/Tricep) hands are arthritic lower extremities IP
[**5-14**] AT [**Last Name (un) 938**] 3+/5 G [**4-14**] bilaterally
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+ 2+
Left 2+ 2+
Pertinent Results:
[**2106-5-17**] 08:20AM PT-14.3* PTT-30.5 INR(PT)-1.3*
[**2106-5-17**] 08:20AM PLT SMR-NORMAL PLT COUNT-169
[**2106-5-17**] 08:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2106-5-17**] 08:20AM NEUTS-48* BANDS-1 LYMPHS-12* MONOS-38* EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2106-5-17**] 08:20AM WBC-5.1 RBC-4.10* HGB-12.8* HCT-36.2* MCV-88
MCH-31.2 MCHC-35.4* RDW-16.3*
[**2106-5-17**] 08:20AM CK-MB-13* MB INDX-3.7 cTropnT-0.06*
[**2106-5-17**] 08:20AM CK(CPK)-348*
[**2106-5-17**] 08:20AM GLUCOSE-102 UREA N-14 CREAT-0.5 SODIUM-142
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
Brief Hospital Course:
Mr [**Known lastname 30119**] was admitted to the Trauma ICU on the Trauma
service. After discussion with the patient and his nephew it
was felt having a craniotomy to evacuate his large left sided
subdural would be in his best interest.
On [**5-18**] he went to the OR and had left sided craniotomy, he was
extubated post operatively and had a subdural drain in place.
He was moving all extremities with good strength however less
strenght on the right sided he continued to be disorientated at
time.
On POD#1 He has a CT which showed evacuation of the chronic
portion with some reaccumulation of the acute blood but overall
improved. He received 1 unit of blood for crit 27. He was
transferred to the step down unit, he had some agitation after
transfer however, a second CT was stable, repeat crit was 31.
On POD#3 he was noted have some increase lethargy, a repeat CT
showed an interval increase of acute subdural blood he was
brought to the OR for a repeat subdural evacuation of
craniotomy. He spent overnight in the PACU, his exam he was
having difficulty speaking (which was similar post his first
surgery) slightly weaker on the right side though moving all
extremities. He had an MRI Slow diffusion in the left posterior
frontal region indicative of an acute infarct. He continued to
follow one step commands, slightly weaker on the right.
On [**5-26**] his drain was removed and a repeat head CT showed
continued evidence for a mixture of acute and chronic blood
products, as well as gas within the left frontal-temporal
subdural hemorrhage. Additionally, there is slight widening and
a somewhat biconvex contour to what may be an epidural
collection of gas subjacent to the craniotomy flap.
Neurologically he was awake alert, following commands but
continued with some aphasia though had no difficulty swallowing
or eating. His right side appeared weaker than the left.
On [**5-27**] he appeared brighter following commands trying to speak
a few words. He continues to move the right arm less than the
left. He does have motor strength in that arm. His appetite is
excellent.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision clean and dry. Have staples removed on [**2106-6-3**]
Watch incision for redness, drainage, swelling, bleeding or
fever greater than 101.5 call Dr[**Name (NI) 4674**] office
Also call for any mental status changes such as lethargy
Followup Instructions:
Have staples out on [**2106-6-3**] at Dr[**Name (NI) 4674**] office or at
nursing facility
Have sutures on left side of head removed [**2106-5-28**]
Follow up with Dr [**Last Name (STitle) 739**] in 4 weeks with head CT at that
time
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2106-5-26**] |
53240,49320,V4581,412,4019 | 158 | 169,433 | Admission Date: [**2170-2-3**] Discharge Date: [**2170-2-6**]
Date of Birth: [**2102-2-26**] Sex: M
Service: MED-BLUMGA
For content of this Discharge Summary, please refer to the
Discharge Summary dictated by myself, with Discharge Date of
[**2170-2-3**], for content.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-419
Dictated By:[**Last Name (NamePattern1) 14783**]
MEDQUIST36
D: [**2170-4-19**] 13:56
T: [**2170-4-19**] 14:03
JOB#: [**Job Number 19220**]
|
V3001,76503,6823,769,7756,7450,76527,77981,81220 | 159 | 156,461 | Admission Date: [**2152-6-9**] Discharge Date: [**2152-8-30**]
Date of Birth: [**2152-6-9**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 43153**] [**Known lastname **] is the former 864
gram product of a 34 week gestation pregnancy born to a 25
year-old G2 P0 woman. Prenatal screens: blood type 0
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
abortion at seven months. This pregnancy was notable for an
abnormal alpha fetoprotein and triple screen, which was
followed with serial ultrasounds. They showed normal
biophysical profiles and structurally normal fetus. There
was a lag in prenatal care. The mother presented to her [**Name (NI) **]
office on the day of delivery showing poor fetal growth and
reported leaking of amniotic fluid for two months. On
oligohydramnios were noted. No kidneys or lungs were
visualized. She was transferred from [**Hospital6 2561**]
to the [**Hospital1 69**]. She underwent a
cesarean section for concern for fetal heart rate
decelerations. Apgars were 8 at one minute and 8 at five
minutes. The baby required blow by O2, drying and bulb
suctioning. He was admitted to the Neonatal Intensive Care
Unit for management of his prematurity.
HOSPITAL COURSE/PERTINENT LABORATORY DATA:
Respiratory: [**Known lastname 43153**] was intubated shortly after admission and
given one dose of Surfactant. He was extubated to nasal cannula
O2 on day of life number one. He remained on nasal cannula O2
until day of life number twenty five when due to increased
work of breathing he was placed on nasopharyngeal CPAP. He
remained on the nasopharyngeal continuous positive airway
pressure through day of life number forty nine. Since that
time he has remained on high flow nasal cannula O2 400 to 500
cc of flow, 45 to 65% fraction of inspired oxygen. His
evolving chronic lung disease is treated with Diuril. A
trial of bronchodilators showed no added benefit. On three
occasions within a week he has had respiratory arrest
events marked by profound bradycardia. The etiology of these is
unclear, and a bronchoscopic examination is planned at [**Hospital3 18242**] for [**2152-8-30**].
Cardiovascular: Heart size on chest x-ray was noted to be
large. An echocardiogram was performed on day of life number
two and showed moderate to severe biventricular dysfunction.
A small pericardial effusion was noted. The heart
was otherwise structurally normal with a small
atrial septal defect. The echocardiograms were repeated
several times, which showed gradual improvement in the
cardiomyopathy. Most recent echocardiogram was on [**2152-8-3**]
showing a moderate atrial septal defect, mild right
ventricular overload and left peripheral pulmonic stenosis.
He required treatment with Dopamine through day of life
number nine. At the time of discharge his heart rates are in
the 140 to 160 range with mean pressures 50 to 60s.
Fluids, electrolytes and nutrition: [**Known lastname 43153**] was initially NPO
and maintained on intravenous fluids. He required monitoring
with an umbilical arterial catheter for the first two weeks
of life. Enteral feeds were started on day of life number
ten and gradually advanced to full volume. Feedings have
always been well tolerated. At the time of discharge he is
on mother's breast milk fortified to 34 calories per ounce, 4
with human milk fortifier, 6 by calories by medium chain
triglyceride oil and 4 calories by Polycose. On a 32
calorie per ounce regimen, he had only gained 9 gms/kg/d.
The etiology of the poor growth is also unknown. Weight on the
day of discharge is 2.56 kilograms. Serum electrolytes have
been closely monitored due to the diuretic treatment. Most
recent electrolytes were on [**2152-8-22**] with a serum sodium of
137, serum potassium of 3.9, chloride 97, PCO2 of 29. He is
on sodium, potassium, chloride and potassium phosphate
supplements.
Infectious disease: [**Known lastname 43153**] had a sepsis evaluation at the
time of birth. A white blood cell count was 4200 with 34%
polys, 9% bands, 49% lymphocytes. Blood culture was obtained
prior to starting antibiotics. The culture was no growth.
He received a seven day course of Ampicillin and Gentamycin.
On [**2152-7-10**] an abscess was noted over the left wrist. The
abscess was unroofed and Citrobacter koseri was cultured.
Due to prior concern for sepsis [**Known lastname 43153**] was being treated with
Vancomycin and Gentamycin. His coverage was changed to
include Ceftazidime to provide better coverage. A second
incision and drainage was performed on [**2152-7-28**] and again
the same Citrobacter koseri was cultured. He received a
total of fourteen days of the Vancomycin, Gentamycin and
Ceftazidime with resolution of the abscess. Also of concern
with infectious disease with his hepatic workup he was found
to be hepatitis A antibody positive. Further testing showed
him to have the hepatitis A immunoglobulin negative.
Gastrointestinal: [**Known lastname 43153**] has presented with some
unidentified liver dysfunction. An extensive metabolic and
gastrointestinal workup has been undertaken and multiple
metabolic tests sent. A HIDA scan showed a normal
gallbladder and ruled out biliary atresia, alpha one
antitrypsin level had MM typing. The only metabolic test
found to be abnormal was the carnitine panel with his level
slightly low, carnitine replacement therapy was started and
his most recent carnitine levels were on [**2152-8-15**]. Free
carnitine is 90 with a range of 27 to 49. Total is 104 with
a rate of 38 to 68. The axo carnitine is 14 with a range 7
to 19 and the aso to free carnitine ratio was 0.2 with a
normal of 0.2 to 0.5. The free and total carnitine levels
being slightly higher then normal range represent the change
on the increased carnitine supplementation. [**Known lastname 43153**] has also
had an elevated direct bilirubin, which peaked at 8.3 on day
of life 45. He has been treated with both Phenobarbital and
Actigall. The Phenobarbital was discontinued [**2152-8-19**].
Most recent direct bilirubin was 6.4 mg per deciliter on
[**2152-8-22**]. PT and PTT were normal on [**8-29**].
Hematologic: [**Known lastname 43153**] is blood type O positive antibody
negative. His hematocrit at birth was 36.8%. He has
received multiple transfusions of packed red blood cells.
Most recent transfusion was on [**2152-7-24**]. Most recent
hematocrit was 31.4% on [**2152-8-22**] with a reticulocyte count
of 3.6%. He is receiving supplemental iron.
Endocrine: [**Known lastname 43153**] has had persistent problems with
hypoglycemia despite multiple attempts to wean him from
continuous feeds. He responds with intermittent blood
glucoses less then 40. Serum insulin growth hormone and
Cortisol levels have been drawn on numerous occasions with
the episodes of hypoglycemia and all levels have been within
the normal range. Endocrine consult from [**Hospital3 1810**]
is involved in following. The etiology of his glucose
requirement is unclear. It does not appear to be a result of
hyperinsulism and may explain his poor growth. Endocrine does
not have suggestions at present for further evaluation. We have
consulted the metabolism team.
Neurology: Head ultrasound has been performed on two
occasions during his admission. Both were within normal
limits.
Musculoskeletal: A fracture of the right humerus was noted
incidentally on a chest x-ray. This was likely a result of
severe metabolic bone disease.
Sensory: Audiology screening has not yet been performed.
Ophthalmology, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2281**] defect later described as a coloboma
was noted shortly after birth. Serial retinal examinations
have been performed and showed mature retinas on [**2152-7-12**].
CONDITION ON DISCHARGE: Fair.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**]. The
primary pediatrician has not yet been identified.
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: NPO in
preparation for the Operating Room. When feeding expressed
breast milk 45 to 34 calories per ounce, 4 calories by human
milk fortifier, 6 calories by medium chain triglyceride oil,
4 calories by Polycose. One half teaspoon ProMod powder per
100 cc of the breast milk.
MEDICATIONS: Ranitidine 4.8 mg po q 8 hours, Carnitine 100
mg po b.i.d., potassium phosphate 2.3 millimoles po b.i.d.,
vitamin D 300 international units po q day, calcium
glubionate 46 mg as elemental calcium po b.i.d., Reglan 0.2
mg po q 8 hours administered one half hour prior to feeds.
Fer-In-[**Male First Name (un) **] 25 mg per ml dilution 0.25 cc po q.d., Diuril 43
mg po pg b.i.d., sodium chloride supplement 1 milliequivalent
po b.i.d., potassium chloride supplement 1 milliequivalent po
b.i.d., Actigall 30 mg po b.i.d., vitamin E 5 international
units po q day.
Car seat positioning screening not yet performed. State
newborn screening have been sent on multiple occasions with
only the carnitine abnormality detected.
Immunizations were administered between [**8-8**] and [**2152-8-12**]
and included hepatitis B vaccine, diptheria, cellular
pertussis, hemophilus influenza, the injectable polio vaccine
and the pneumococcal seven valent conjugate vaccine.
Immunizations recommended, Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria - born at less then 32
weeks gestation, 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 with chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and
other care givers should be considered for immunization
against influenza to protect the infant.
FOLLOW UP: Follow up with Consult Services at [**Hospital3 18242**] to include endocrine, cardiology, genetics, metabolism,
gastrointestinal and otorhinolaryngology.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Severe intrauterine growth restriction.
3. Respiratory distress syndrome.
4. Chronic lung disease.
5. Atrial septal defect.
6. Global cardiac dysfunction.
7. Suspicion for sepsis ruled out.
8. Citrobacter koseri cellulitis of the left wrist.
9. Congenital carnitine deficiency.
10. Conjugated hyperbilirubinemia.
11. Right humeral fracture.
12. Coloboma of the right eye.
13. Hypoglycemia.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2152-8-30**] 02:55
T: [**2152-8-30**] 06:22
JOB#: [**Job Number **]
|
V3001,76503,6823,769,7756,7450,76527,77981,81220 | 159 | 156,461 | Admission Date: [**2152-6-9**] Discharge Date: [**2152-9-7**]
Date of Birth: [**2152-6-9**] Sex: M
Service: NEONATOLOGY
This is an addendum discharge summary covering the period [**2152-8-30**]
to [**2152-9-7**].
HISTORY OF PRESENT ILLNESS: Please see previously-dictated
summary. Briefly, [**Known lastname 43153**] [**Known lastname **] is a former 864 gram product
hospitalized in the Neonatal Intensive Care Unit at [**Hospital1 1444**] since birth. He underwent a
rigid bronchoscopy at [**Hospital3 1810**] on [**2152-8-30**]. He
returned postoperatively to the Neonatal Intensive Care Unit
at [**Hospital1 69**].
HOSPITAL COURSE BY SYSTEM:
ventilatory settings of peak inspiratory pressure of 23 over
positive end expiratory pressure of 5, intermittent mandatory
ventilatory rate of 30, 36% oxygen. He was extubated within
several hours of his return to nasal cannula oxygen. He has
had several episodes of laryngospasm with respiratory arrest
and accompanying profound bradycardia. The bronchoscopy
performed on [**2152-8-30**] showed findings of normal vocal cords
with normal motion, a moderately inflamed larynx with
frequent laryngospasm, a normal subglottis, normal trachea,
mild left bronchomalacia, and a normal right bronchus. There
were three severe episodes of laryngospasm during the
procedure. It was felt that this the most likely cause of his
episodes.
In view of those findings, optimization of his anti-GE reflux
regimen, and the repeated episodes in the week postoperatively,
the decision has been made to move forward with a tracheostomy.
The procedure is scheduled for [**2152-8-30**] at 10:30 A.M. Since the
initial bronchoscopy, [**Known lastname 43153**] has remained in nasal cannula oxygen
500 cc flow, 35-40% fraction of inspired oxygen. He remains on
Diuril for treatment of his chronic lung disease. He has also
been treated with Atrovent and albuterol nebulizers in an attempt
to treat his laryngospasms.
2. Cardiovascular: As previously noted, [**Known lastname 43153**] has a large
atrioseptal defect. Most recent echocardiogram was on
[**2152-8-24**]. A murmur remains present at the time of transfer.
3. Fluids, electrolytes and nutrition: [**Known lastname 43153**] continues to
have problems with hypoglycemia. At the time of transfer, he
is nothing by mouth on intravenous fluids. When feeding, he
is on 150 cc/kg/day of preemie Enfamil 34 calories/ounce with
additional ProMod protein supplement. He receives a four
hour volume infused over three hours, i.e., three hours on,
one hour off. Weight at the time of transfer is 2.77 kg.
Most recent electrolytes were on [**2152-9-4**], with a serum sodium
of 139, potassium 5.6, chloride 99, total carbon dioxide 33,
BUN 15, creatinine 0.2.
4. Infectious Disease: There have been no new infectious
disease issues over the last week of hospitalization.
5. Gastrointestinal: As previously noted, [**Known lastname 43153**] receives
treatment for conjugated hyperbilirubinemia with Actigall.
His most recent serum bilirubin was a total of 7.7, a direct
of 5.5. A right inguinal hernia has been noted, and is soft
and reducible.
6. Hematology: Postoperative hematocrit was 35.4% on
[**2152-9-4**]. A preoperative CBC has been drawn, with results
pending at the time of this dictation.
7. Sensory: Audiology screening has still not yet been
performed.
CONDITION AT DISCHARGE: Fair.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 1810**]
for elective tracheostomy and gastrostomy tube placement with an
ultimate plan for discharge or transfer to rehabilitative care.
No primary pediatrician has yet been identified.
CARE RECOMMENDATIONS:
1. Feedings: Nothing by mouth in preparation for the
operating room. Intravenous fluids of 10% dextrose with 2
mEq of sodium chloride and 1 mEq of potassium chloride per
100 cc at 120 cc/kg/day. The patient has been nothing by
mouth since 7 A.M.
2. Medications: Ranitidine 5 mg by mouth every eight hours,
carnitine 100 mg by mouth twice a day, potassium phosphate
2.3 millimoles by mouth twice a day, vitamin D 300 IU by
mouth once daily, calcium glubionate 46 mg as elemental
calcium by mouth twice a day, Reglan 0.2 mg by mouth every
eight hours one-half hour prior to feeds, Fer-in-[**Male First Name (un) **] 25 mg/ml
dilution 0.25 cc by mouth once daily, Diuril 50 mg by mouth
twice a day, potassium chloride supplement 1 mEq by mouth
twice a day, Actigall 30 mg by mouth twice a day, vitamin E 5
IU by mouth once daily.
3. Immunizations: His second hepatitis B vaccine is due
[**2152-9-7**], previously administered on [**2152-8-8**]. All other
immunizations are up to date. He has not received Synagis.
DISCHARGE DIAGNOSIS:
1. Prematurity at 34 weeks gestation
2. Severe intrauterine growth restriction
3. Respiratory distress syndrome
4. Chronic lung disease
5. Atrioseptal defect
6. Global cardiac dysfunction
7. Suspicion for sepsis ruled out
8. C ellulitis of the left wrist
9. Congenital carnitine deficiency
10. Conjugated hyperbilirubinemia
11. Right humeral fracture
12. of the right eye
13. Hypoglycemia
14. Laryngospasms
15. Right inguinal hernia
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (Titles) 37585**]
MEDQUIST36
D: [**2152-9-7**] 01:31
T: [**2152-9-7**] 02:31
JOB#: [**Job Number 43154**]
|
41041,41401,7291,2720,3051 | 160 | 161,672 | Admission Date: [**2174-11-6**] Discharge Date: [**2174-11-8**]
Date of Birth: [**2124-11-22**] Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Morphine
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from OSH with STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with percutaneous balloon angioplasty
and stening.
History of Present Illness:
49 yo female with past medical history significant for
fibromyalgia was transferred from an OSH with three weeks of
intermittent chest pain and STE in II, III, and aVF. The patient
describes the chest pain as burning, diffuse left-sided chest
pain, radiating to jaw and left shoulder, lasting anywhere from
5-20 minutes, and with no relationship to activity or food.
Patient reports pain improves somewhat with leaning forward.
Associated symptoms include shortness of breath. One day prior
to admission, patient had a severe episode of this chest pain
while driving and was brought into [**Hospital3 **] from home.
ECG at OSH demonstrated 1mm STE in II, III, and aVF with TWI in
V1-V2, I, and avL. Patient received plavix 600mg, aspirin 325mg,
integrilin bolus and drip, and heparin bolus and drip. Patient
also received 1x nitroglycerine at OSH with SBP decrease to the
70s, per report.
.
In the cath lab, patient with 95% thrombotic lesion in the mid
RCA and had a 3 x 18 Vision stent placed with subsequent TIMI 3
flow.
Past Medical History:
Hypercholesterolemia
Fibromyalgia
Social History:
Tobacco - 1 PPD; 40 PPY history
EtOH - social drinker at the holidays
Illicit Drugs - Denies
Not currently employed, takes care of grandchildren
Family History:
No cardiac disease
Diabetes Mellitus
Physical Exam:
T 96.8 / HR 74 / BP 115/60 / RR 16 / PO2 100% on 2L NC
Gen: lying comfortably in bed, no acute distress
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: (limited anterior exam) CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. palpable 2+ DP/PT pulses bilaterally; 2+ femoral
pulses bilaterally with mild oozing at right femoral site but no
hematoma; right femoral bruit
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities equally
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2174-11-6**] 08:30AM PT-13.5* PTT-150* INR(PT)-1.2*
[**2174-11-6**] 08:30AM PLT COUNT-257
[**2174-11-6**] 08:30AM NEUTS-80.6* LYMPHS-14.4* MONOS-3.9 EOS-0.8
BASOS-0.3
[**2174-11-6**] 08:30AM WBC-13.9* RBC-4.18* HGB-14.6 HCT-41.5 MCV-99*
MCH-34.9* MCHC-35.1* RDW-12.9
[**2174-11-6**] 08:30AM CALCIUM-7.8* PHOSPHATE-1.9* MAGNESIUM-1.9
[**2174-11-6**] 08:30AM CK-MB-13* MB INDX-10.3* cTropnT-0.11*
[**2174-11-6**] 08:30AM CK(CPK)-126
[**2174-11-6**] 08:30AM GLUCOSE-119* UREA N-13 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-24 ANION GAP-10
[**2174-11-6**] 11:34AM PLT COUNT-240
[**2174-11-6**] 11:34AM WBC-11.1* RBC-3.94* HGB-13.0 HCT-39.5
MCV-100* MCH-33.0* MCHC-32.9 RDW-12.6
[**2174-11-6**] 11:34AM CK-MB-28* MB INDX-10.1* cTropnT-0.49*
[**2174-11-6**] 11:34AM CK(CPK)-276*
[**2174-11-6**] 11:34AM GLUCOSE-107* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-20* ANION GAP-12
[**2174-11-6**] 06:30PM CK(CPK)-412*
[**2174-11-6**] 06:30PM CK-MB-46* MB INDX-11.2* cTropnT-1.32*
[**2174-11-6**] 08:23PM CK(CPK)-327*
[**2174-11-6**] 08:23PM CK-MB-39* MB INDX-11.9* cTropnT-1.18*
[**2174-11-6**] 06:30PM GLUCOSE-88 UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-22 ANION GAP-13
[**2174-11-6**] 08:23PM GLUCOSE-140* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-10
[**2174-11-6**] 11:34PM CK(CPK)-270*
[**2174-11-6**] 11:34PM CK-MB-31* MB INDX-11.5* cTropnT-0.96*
[**2174-11-6**] - CARDIAC CATH
COMMENTS:
1. Selective coronary angiography of this right dominant
dominant system
revealed single vessel disease. The LMCA, LAD, and LCx all had
mild
diffuse disease but no angiographically significant stenoses.
The RCA
had a 95% thrombotic lesion in the mid-vessel.
2. Limited resting hemodynamics revealed elevated right and left
sided
filling pressures with a mean RA 14mmHg and PCWP 18mmHg. The
cardiac
index was preserved at 2.86 l/min/m2.
3. Left ventriculography was deferred.
4. Successful PCI of the mid RCA using a 3.0x18mm Vision bare
metal
stent deployed at 14atm.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Successful PCI of the mid RCA using a bare metal stent.
TTE - [**2174-11-7**]
Cardiology Report ECHO Study Date of [**2174-11-7**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Right ventricular
function. S/P stent mid RCA.
Height: (in) 67
Weight (lb): 129
BSA (m2): 1.68 m2
BP (mm Hg): 115/63
HR (bpm): 67
Status: Inpatient
Date/Time: [**2174-11-7**] at 08:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W056-0:00
Test Location: West CCU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.41 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 141 msec
Pulmonic Valve - Peak Velocity: 0.8 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mildly
depressed LVEF. [Intrinsic LV systolic function likely depressed
given the
severity of valvular regurgitation.]
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferoseptal - akinetic; mid inferoseptal - akinetic; basal
inferior -
akinetic; mid inferior - akinetic; inferior apex - hypo;
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
aortic arch diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
mildly
depressed. [Intrinsic left ventricular systolic function is
likely more
depressed given the severity of valvular regurgitation.] Resting
regional wall
motion abnormalities include basal and mid inferior and
inferoseptal akinesis
with apical inferior hypokinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6.There is no pericardial effusion.
Brief Hospital Course:
49 yo male with past medical history significant for
hyperlipidemia transferred from OSH with inferior STEMI, found
to have mid-RCA lesion, and now s/p BMS and chest pain free.
.
1. Coronary artery disease
At cardiac catheterization, patient found to have a 95%
thrombotic lesion of mid-RCA with BMS placed. Patient was chest
pain free for the duration of her hospitalization after cardiac
cath. Her course was complicated by formation of large
ecchymoses at the site of cardiac cath. She was noted to have a
right femoral bruit both before her catheterization and remained
stable after her catheterizations. She was started on aspirin
325mg, plavix 75mg, atorvastatin 80mg, and was converted to
Toprol XL 25mg PO daily. Given that patient's EF was not
diminished, patient was not started on ACE inhibitor. Patient
was evaluated by physical therapy during this admission who
cleared patient to be discharged home. Patient was discharged
home with cardiology follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
.
2. Hyperlipidemia
Patient reports a history of hyperlipidemia and was started on
high dose atorvastatin during this admisison.
Medications on Admission:
TRANSFER MEDS:
Aspirin 325mg PO daily
Integrilin Drip
Heparin Drip
Plavix 75mg PO daily
.
HOME MEDS:
Occasional Advil or Ibuprofen
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST elevation myocardial infarction
.
Secondary:
Hypercholesterolemia
Tobacco Abuse
Discharge Condition:
good. chest pain free. ambulating unassisted. tolerating oral
medications and nutrition.
Discharge Instructions:
You were evaluated and treated for chest pain. You were found
to have a heart attack which was caused by a blockage in one of
your coronary arteries.
Followup Instructions:
1) Primary Care Physician: [**Name Initial (NameIs) **] spoke to Dr. [**Last Name (STitle) 40510**] office and
have given him information regarding your hospital stay. You
should expect a call from his office by Thursday [**11-10**]
to schedule an appointment. If you do not hear from his office,
please give his office at [**Hospital1 3597**] Family Practice a phone call to
follow-up. The phone number at [**Hospital1 3597**] Family Practice is
[**Telephone/Fax (1) 70303**].
.
2) Cardiology: You also have an appointment scheduled with your
new cardiologist, [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D., for [**2174-12-16**] 1:00.
His phone number is [**Telephone/Fax (1) 2934**].
.
3) Echocardiogram: We also recommend that you have an
echocardiogram (an ultrasound of your heart) within the next [**2-23**]
weeks to assess your heart function. Your appointment is
Thursday [**12-8**] at 11am. If you need to reschedule
[**Telephone/Fax (1) **]. Your appointment will be in the [**Location (un) 436**] of the
[**Hospital Ward Name 23**] Clinical Center on the [**Hospital Ward Name 516**].
|
1562,78039,5119,99859,7907,56722,3320,43330,4019,2724,78791,11289,04104,V1259 | 161 | 121,804 | Admission Date: [**2173-5-26**] Discharge Date: [**2173-7-1**]
Date of Birth: [**2101-5-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Bleeding Ampullary Mass
Major Surgical or Invasive Procedure:
Endoscopic Retrograde Cholangiopancreatography (ERCP)
[**6-3**] Transduodenal ampullary resection with CCY
[**6-17**] IP did Thorocentesis of pleural fluid on the right.
[**6-18**] US guided aspiration of fluid collection around liver
[**6-24**] CT guided drainage of subcapsular liver fluid
Endoscopic Retrograde Cholangiopancreatography (ERCP)
History of Present Illness:
This is a 72 year old male that presents from [**Hospital 40074**]Hospital after having one week of symptoms of dizziness and
syncope secondary to an upper GI bleed. He noted bright red
blood per rectum on the day prior to presentation. He was also
having headaches. He was rescucitated at the [**Hospital **] Hospital with 5
Units of PRBCs for a Hct of 23, which improved to Hct 35. An
endoscopy showed a bleeding ampullary lesion. He was transferred
to [**Hospital1 18**] for ERCP and work-up of mass. He denies weight loss
prior to symptoms. He did have decreased appetite, chronic
constipation, but denies prior episodes of blood per rectum.
Past Medical History:
Carotid Disease - attempted stent placement [**4-1**]. Started on ASA
and plavix.
TIA's
Parkinsons
HTN
Seizure disorder
Hyperlipidemia
Chronic constipation
Social History:
Lives alone
Retired
Family History:
Noncontributory
Physical Exam:
VS: 98.1, 48, 103/68, 20, 98% RA, weight 152lbs
Gen: NAD, A+O x 3
Head: no scleral icterus, no jaundice, no LAD, no thyroidmegaly
CV: RRR
Chest: CTAB
Abd: soft, nontender, nodistended, no masses, no hernia, no
organomegaly
Ext: PT, DP, radial pulses +2 bilat., no edema
Pertinent Results:
CAROTID SERIES COMPLETE [**2173-5-27**] 8:59 AM
CAROTID SERIES COMPLETE
Reason: TIA
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with TIA
REASON FOR THIS EXAMINATION:
Eval for carotid stenosis
CAROTID STUDY
HISTORY: TIA.
FINDINGS: No prior studies for comparison. There is complete
occlusion of the left ICA and associated internalization of the
external carotid artery on the left. There is also absent flow
involving the left vertebral artery. There is a significant
focal hypoechoic plaque involving the right ICA. Similar plaque
involving the right ECA. The peak systolic velocities on the
right are 264, 56, and 15 cm per second for the ICA, CCA, and
ECA respectively. The ICA to CCA ratio is 5.3. There is
antegrade flow involving the right vertebral artery.
IMPRESSION:
1. Occluded left-sided ICA and left-sided vertebral artery.
2. 70-79% right ICA stenosis.
3. Near occlusion of the right external carotid artery.
SPECIMEN SUBMITTED: GI BX 1 AMPULLA.
Procedure date Tissue received Report Date Diagnosed
by
[**2173-5-26**] [**2173-5-26**] [**2173-5-28**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf
DIAGNOSIS:
Ampulla, mucosal biopsy:
Fragments of adenoma.
CT ABDOMEN W/CONTRAST [**2173-5-27**] 4:32 PM
CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST
Reason: eval pancreas for ductal dilation, vessels, a mass, per
panc
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with ampullary mass
REASON FOR THIS EXAMINATION:
eval pancreas for ductal dilation, vessels, a mass, per pancreas
protocol
CONTRAINDICATIONS for IV CONTRAST: None.
CT ANGIOGRAM
TECHNIQUE: Multidetector CT through the abdomen and pelvis with
angiogram protocol. Nonenhanced, arterial, and venous phase were
obtained. Coronal, sagittal, volume rendering, and MIP
reconstructions are provided.
There are no prior studies available for comparison.
HISTORY: 72-year-old man with ampullary mass.
ABDOMEN CT:
Dependent changes are seen in the bases of the lungs.
There are no enhancing focal lesions in the liver. There is no
biliary duct dilatation. In segment IVb, there is a 6-mm
hypoenhancing area, too small to be characterized. There is a
10-mm stone within the gallbladder lumen. The gallbladder wall
is not thickened. The pancreas, adrenal glands, and spleen are
unremarkable. Few splenules are seen near the spleen measuring
up to 11 mm.
Both kidneys have few hypoenhancing cortical and exophytic
lesions, too small to be characterized, likely cysts.
In the ampullary region, there is an enhancing well-defined
round lesion measuring 10 x 10 mm. Otherwise, the small bowel
loops are unremarkable.
There is no free air or free fluid in the abdomen. Few
non-pathologically enlarge lymph nodes are seen within the
mesentery.
PELVIC CT:
The bladder, distal ureters, prostate gland, rectum, and sigmoid
colon are unremarkable.
There is no free fluid or lymphadenopathy within the pelvis.
BONE WINDOWS: There are no concerning bone lesions.
CT ANGIOGRAM:
The aorta is normal in caliber. The celiac, SMA, bilateral
duplicated renal arteries, and [**Female First Name (un) 899**] are patent.
There is conventional vascular distribution.
There is a short segment of moderate stenosis in the origin of
the inferior left renal artery and in the proximal portion of
the superior right renal artery.
The hepatic, portal, superior mesenteric, and splenic veins are
patent.
CT reconstructions were essential in delineating the anatomy and
pathology.
IMPRESSION: Ampullary mass. There is no biliary duct dilatation
or dilatation of the main pancreatic duct.
Bilateral renal cysts.
Cholelithiasis.
Sinus bradycardia. No diagnostic abnormality. No previous
tracing available for
comparison.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
51 162 90 [**Telephone/Fax (2) 67344**] 29 52
MR CONTRAST GADOLIN [**2173-5-29**] 1:58 PM
MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST
Reason: Please eval for prior evidence of stroke. Eval cerebral
[**Last Name (un) **]
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with [**Doctor First Name 3098**] occlusion and [**Country **] stenosis.
REASON FOR THIS EXAMINATION:
Please eval for prior evidence of stroke. Eval cerebral vessels
EXAM: MRI of the brain and MRA of the head and neck.
CLINICAL INFORMATION: Patient with left internal carotid artery
occlusion and right ICA stenosis, for further evaluation to
exclude stroke and also to evaluate the cerebral blood vessels.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and
diffusion axial images of the brain were obtained. 2D
time-of-flight MRA of the neck vessels and 3D time-of-flight MRA
of the circle of [**Location (un) 431**] was obtained. Gadolinium- enhanced MRA
of the neck was acquired. The gadolinium-enhanced MRA is
somewhat limited possibly related to delay in timing and venous
contamination. Source images were evaluated to obtain maximum
information.
FINDINGS:
BRAIN MRI:
The diffusion images demonstrate no evidence of acute infarct.
Mild-to- moderate brain atrophy seen. No evidence of territorial
infarcts noted. Minimal changes of small vessel disease are
noted in the white matter. No evidence of acute or chronic blood
products seen.
IMPRESSION: No evidence of acute infarct. Mild-to-moderate brain
atrophy.
MRA OF THE NECK:
The neck MRA demonstrates normal flow signal in the right
vertebral artery. The right internal carotid demonstrates
high-grade approximately 70% stenosis at the bifurcation. The
evaluation of the right carotid stenosis on the post- gadolinium
MRA is limited secondary to venous contamination.
The left internal carotid is occluded at the bifurcation. No
flow is visualized in the distal cervical left internal carotid
artery. No flow is seen in the left petrous carotid artery.
The evaluation of the left vertebral artery on source images
demonstrate flow signal in a markedly narrowed left vertebral
artery in the proximal portion. Subtle flow signal is also seen
in the left V3 segment of the vertebral artery. This finding is
indicative of diffuse atherosclerotic disease involving the left
vertebral artery. The visualized great vessels of the thoracic
inlet demonstrate no evidence of high-grade stenosis.
IMPRESSION: 1. Occlusion of the left internal carotid artery at
the bifurcation. 2. High-grade stenosis of the right internal
carotid bifurcation. Normal right vertebral artery. 3. Diffuse
atherosclerotic disease involving left vertebral artery with
partial visualization in the proximal and distal portions.
MRA OF THE HEAD:
The head MRA demonstrates absence of flow signal in the distal
left internal carotid artery. The supraclinoid internal carotid
artery is minimally visualized with flow visualized from the
left PCA to the left middle cerebral artery. On the right side
normal flow signal is seen in the supraclinoid internal carotid,
right MCA and both anterior cerebral arteries. The posterior
communicating artery is also visualized on the right side.
In the posterior circulation, diffuse narrowing of the basilar
artery is visualized with absence of flow signal in the distal
basilar artery indicative of diffuse atherosclerotic disease
with high-grade stenosis or occlusion of the distal basilar
artery. Both distal vertebral arteries demonstrate narrowed flow
signal caliber.
IMPRESSION:
1. Occlusion of the left internal carotid with collateral flow
to the left MCA through the left posterior communicating artery.
Normal flow signal in the right supraclinoid internal carotid,
right MCA and both anterior cerebral arteries. Diffuse
atherosclerotic disease of the basilar artery with probable
occlusion or high-grade stenosis in the distal basilar artery.
EXERCISE MIBI [**2173-6-1**]
EXERCISE MIBI
Reason: PT WITH H/O CAROTID ARTERY DISEASE, SCHEDULED FOR
SURGERY THIS WEEK FOR BLEEDING AMPULLARY MASS, CARDIOLOGY
REGUESTS
RADIOPHARMECEUTICAL DATA:
3.2 mCi Tl-201 Thallous Chloride;
22.0 mCi Tc-[**Age over 90 **]m Sestamibi;
HISTORY: 72 y/o male with carotid artery disease and
pre-operative for a
bleeding ampullary mass, for pre-op risk stratification.
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
milligram/kilogram/min. Two minutes after the cessation of
infusion, Tc-[**Age over 90 **]m
sestamibi was administered IV.
INTERPRETATION:
Image Protocol: Gated SPECT
Resting perfusion images were obtained with thallium.
Tracer was injected 15 minutes prior to obtaining the resting
images.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is adequate.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 69%.
IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left
ventricular cavity
size and function.
RADIOLOGY Final Report
UGI SGL CONTRAST W/ KUB [**2173-6-7**] 9:18 AM
UGI SGL CONTRAST W/ KUB
Reason: Please do thin barium study by injecting contrast via
NGT, a
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with duod./ampullary mass s/p resection and
reanast. POD#5.
REASON FOR THIS EXAMINATION:
Please do thin barium study by injecting contrast via NGT, and
doing a SBFT. The patient had a duodenal resection, so the
purpose of the study is to eval. integrity of anastomosis.
INDICATION: Duodenal and ampullary mass status post resection
and reanastomosis. Query leak.
DUODENAL/SMALL BOWEL BARIUM STUDY: A scout was performed showing
a midline horizontal staple line, with a nasogastric tube in the
stomach and a right- sided JP drain. Phleboliths are also seen
in the pelvis and a bone island in the right iliac.
After instillation of approximately 100 cc of Gastrografin
through the nasogastric tube, spot fluoroscopic images were
obtained, which showed the contrast collecting first in the
stomach and then promptly emptying into the duodenal sweep. No
evidence of leak is seen. Contrast promptly enters the jejunum.
There is no evidence of obstruction.
IMPRESSION: No evidence of leak at the duodenal anastomosis.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: concern for abcess/leak. gastrographin contrast
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
72 year old man POD 7 s/p transduodenal ampullectomy and CCY
with fevers, hypotension
REASON FOR THIS EXAMINATION:
concern for abcess/leak. gastrographin contrast
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Post op day 7 after transduodenal ampullectomy and
cholecystectomy with fevers and hypotension, assess for abscess
or leak.
COMPARISON: CTA of the abdomen from [**2173-5-27**].
TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis
was performed through the administration of Gastrografin oral
contrast and Optiray intravenous contrast. Coronal and sagittal
reformations were obtained.
CT OF THE ABDOMEN: There are small bilateral pleural effusions,
right greater than left with associated atelectasis at the lung
bases. The heart and pericardium appear unremarkable. The liver
parenchyma appears unremarkable. There is pneumobilia
identified, primarily in the left lobe. The patient is status
post cholecystectomy. The adrenal glands, spleen, and pancreas
appear unremarkable. The kidneys enhance and excrete contrast
symmetrically. Again seen are hypodensities which are
incompletely characterized on the current study in both kidneys.
The loops of small and large bowel appear normal in caliber. A
nasogastric tube terminates in the antrum of the stomach.
Contrast has reached the distal small bowel. There is no
evidence of extraluminal contrast. A surgical drain is seen in
the right upper quadrant. There is ascites fluid in the right
upper quadrant, tracking down the right pericolic gutter, there
is higher density posteriorly suggesting some blood. There are
also foci of free intraperitoneal air consistent with the recent
surgery. Skin staples are seen across the anterior abdomen, and
there is mild subcutaneous soft tissue stranding. No fluid
collections are identified within the abdomen. There is some
stranding in the right upper quadrant in the region of the
recent surgery. Vascular structures demonstrate atherosclerosis
of the abdominal aorta. The major arteries and veins are patent.
CT OF THE PELVIS: A Foley catheter is seen within the bladder,
and there is nondependent air in the bladder lumen. The
prostate, seminal vesicles and rectum appear unremarkable. There
is small amounts of free fluid in the pelvis. Note of a small
left-sided fat-containing inguinal hernia.
Osseous structures demonstrate no concerning lytic or sclerotic
lesions.
IMPRESSION:
1. No evidence of anastomotic leak or drainable fluid
collection.
2. Postoperative appearance in the right upper quadrant with
foci of pneumoperitoneum, small amount of ascites, pneumobilia,
and nonspecific fat stranding.
3. Small bilateral pleural effusions, right greater than left
with associated atelectasis.
Reason: US guided aspiration of fluid collection around liver
[**Hospital 93**] MEDICAL CONDITION:
72 year old man s/p tranduodenal ampullary resection with
elevated WBC and fever.
REASON FOR THIS EXAMINATION:
US guided aspiration of fluid collection around liver
ULTRASOUND-GUIDED PERIHEPATIC FLUID COLLECTION DRAINAGE.
HISTORY: 72-year-old male s/p transduodenal ampullary resection
with elevated while blood count and fever and fluid collection
around the liver
PROCEDURE: The risks and benefits of the procedure were
explained to the patient. Written informed consent was obtained.
Preprocedure timeout was called to confirm the identity of the
patient and the procedure to be performed. The patient was
prepped and draped in the usual sterile fashion. Lidocaine 1%
was used for local anesthesia.
Moderate sedation was provided, by a nurse, by administering
divided doses of 25 mcg of fentanyl and 0.5 mg of Versed,
throughout the total intraservice time of 20 minutes during
which the patient's hemodynamic parameters were continuously
monitored.
Under direct ultrasound guidance with freehand technique, a
suitable spot in the right upper quadrant was chosen and after
administration of lidocaine, an 8-French [**Last Name (un) 2823**] catheter was
placed into the perihepatic fluid collection.
110 cc of greenish fluid were aspirated. A sample was sent for
microbiology.
The patient tolerated well the procedure.
There were no complications.
The attending radiologist, Dr. [**Last Name (STitle) **] was present during the
entire procedure.
The patient tolerated well the procedure.
IMPRESSION: Successful ultrasound-guided placement of drainage
catheter in the perihepatic fluid collection.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Compare to CT Abdomen on [**6-10**] to make sure that
everything h
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
72 year old man POD 7 s/p transduodenal ampullectomy and CCY
with fevers, hypotension
REASON FOR THIS EXAMINATION:
Compare to CT Abdomen on [**6-10**] to make sure that everything has
imprvoved
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 72-year-old man postoperative day 16, status post
transit duodenal ampullectomy for ampullary mass, also
cholecystectomy with fevers and leukocytosis on antibiotics.
TECHNIQUE: Multidetector CT images were obtained through the
abdomen and pelvis with oral and intravenous contrast. Coronal
and sagittal reformatted images were obtained.
COMPARISON: CT abdomen and pelvis [**2173-6-13**].
CT OF THE ABDOMEN WITH CONTRAST: The lung bases show right lower
lobe atelectasis with a moderate-sized right pleural effusion
and small left pleural effusion. The size of the pleural
effusions have not significantly changed since the prior scan.
The heart and pericardium are unremarkable. Within the abdomen,
there has been interval placement of a pigtail drainage catheter
within the lateral perihepatic collection, and there is less
fluid and air within this collection. There has been interval
development of a new fluid collection posterior to the right
lobe of the liver measuring 4.0 (anterior to posterior) by 6.7
(transverse) by 6.8 (superior to inferior) cm. The fluid within
this collection is of low density and there is no surrounding,
enhancing rim. There are no focal liver lesions. The previously
identified air within the biliary system has resolved. There is
no biliary ductal dilatation. The patient is status post
cholecystectomy. The pancreas, spleen, and adrenal glands are
normal in appearance. Again seen are tiny hypodensities within
the bilateral kidneys, the largest of which is within the mid
pole of the left kidney, and measures 13 mm, and is most
consistent with a simple renal cyst. The remaining low-density
foci within the kidneys are too small to characterize. The
kidneys enhance symmetrically and excrete contrast normally.
There is no evidence of hydronephrosis or hydroureter. There is
an unchanged amount of intraabdominal ascites. Again seen is a
surgical drain coursing from the second portion of the duodenum
posterior to the liver and exiting the abdomen through the right
lower abdominal wall. This drain does not appear to communicate
with the newly identified liver subcapsular fluid collection.
The stomach and intra-abdominal loops of small and large bowel
are unremarkable in appearance. There is no bowel dilatation,
bowel wall thickening, or inflammatory fat stranding within the
mesenteric fat. There is no pathologically enlarged mesenteric
or retroperitoneal lymphadenopathy. There is no free air.
CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon,
seminal vesicles, prostate, distal ureters, and bladder are
normal in appearance. There is no pathologically enlarged
inguinal or pelvic lymphadenopathy. There is an unchanged
small-to-moderate amount of intrapelvic free fluid. There is a
small fat-containing left inguinal hernia, which is unchanged.
There is edema in the subcutaneous tissues consistent with
anasarca.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. New, approximately 4 x 6 cm subcapsular fluid collection
posterior to the right lobe of the liver. .
2. Interval placement of a percutaneous pigtail catheter within
the previously identified fluid- and air-containing collection
lateral to the right lobe of the liver. Interval decreased in
size of this collection from the prior scan of [**2173-6-13**].
3. Unchanged small amount of intraabdominal ascites.
4. Left lower lung lobe atelectasis, stable, with stable size of
bilateral pleural effusions, right greater than left.
These findings were discussed with the clinical team and
infectious disease team caring for the patient at the time of
interpretation at 3:00 p.m. on [**2173-6-22**].
Reason: Please drain hepatic fluid collection. Do not leave
drain un
[**Hospital 93**] MEDICAL CONDITION:
72 year old man w/p Whipple, CCY on [**6-3**] for a bleeding ampulary
mass.
REASON FOR THIS EXAMINATION:
Please drain hepatic fluid collection. Do not leave drain unless
puss. Please send fluid for Gram stain, culture, and amylase.
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL DETAILS: Post-op. Loculated posterior perihepatic fluid
collection. Existing catheter in situ.
PROCEDURE:
Pre-procedure written consent and confirmation of patient
identity and nature of procedure performed. The patient was
placed in a lateral position to allow accfess to the loculated
6.7 cm x 4.1 cm fluid density collection along the right
posterior superior aspect of the liver. Following usual aseptic
technique, local and intravenous analgesia using a right
posterior intercostal approach, a 10 French [**Last Name (un) 2823**] multipurpose
pigtail catheter was inserted into this fluid collection.
Initial aspiration yielded 10-15 cc of serous fluid samples, of
which have been sent for microbiological culture, Gram stain,
and amylase. No immediate complications. Dr. [**First Name (STitle) **] (attending
Radiologist) was present.
CT-GUIDED MANIPULATION OF EXISTING PIGTAIL CATHETER
The non-contrast CT scan confirms the existing pigtail catheter
in good position along the lateral aspect of the right lobe of
the liver. Minimal residual rim of fluid density measuring up to
1.6 cm in depth. The existing 8-French pigtail catheter was
flushed and aspirated. Minimal (less than 5 cc) amount of serous
fluid aspirated.
NON-CONTRAST CT SCAN OF THE ABDOMEN:
Minimal right basal pleural effusion, consolidation in the
posteromedial aspect of the right lower lobe. On the unenhanced
CT, no liver lesions or intrahepatic biliary dilatation. No
upper abdominal collections or lymphadenopathy.
CONCLUSION:
1. Successful placement of 10-French pigtail catheter into the
loculated right posterior perihepatic fluid collection,
2. The existing multipurpose pigtail catheter line was flushed
and aspirated and remains in good position along the lateral
aspect of the right lobe of liver. Minimal (less than 1.6 cm)
rim of fluid at that level.
CHEST (PA & LAT)
Reason: Lung exam worsened. Crackles in lungs increased in lungs
[**Hospital1 **]
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with ampullary mass
REASON FOR THIS EXAMINATION:
Lung exam worsened. Crackles in lungs increased in lungs
bilateral.
HISTORY: Ampullary mass and increased crackles in the lungs.
COMPARISON: [**2173-6-17**].
CHEST: PA and lateral views. There is a moderate right pleural
effusion and right lower lobe atelectasis has increased compared
to 4:17 p.m. on [**2173-6-17**], but appears similar to 8:35 a.m. on
[**2173-6-17**]. Small left effusion is unchanged. There is no pulmonary
edema. Left subclavian central venous catheter remains in
unchanged position. A pigtail catheter is present within the
right pleural effusion.
IMPRESSION:
1. Moderate right pleural effusion, increased since the
post-thoracentesis radiograph of [**2173-6-17**], but similar to the
pre-thoracentesis radiograph.
2. Unchanged small left pleural effusion.
[**2173-6-27**] 05:04AM
COMPLETE BLOOD COUNT
White Blood Cells 11.3* K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.43* m/uL 4.6 - 6.2
PERFORMED AT WEST STAT LAB
Hemoglobin 9.9* g/dL 14.0 - 18.0
PERFORMED AT WEST STAT LAB
Hematocrit 29.3* % 40 - 52
PERFORMED AT WEST STAT LAB
MCV 85 fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 28.7 pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 33.6 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 16.1* % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 644* K/uL 150 - 440
PERFORMED AT WEST STAT LAB
FLUID,OTHER PERIHEPATIC.
GRAM STAIN (Final [**2173-6-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2173-6-27**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ABSCESS Site: PERITONEAL
**FINAL REPORT [**2173-6-24**]**
GRAM STAIN (Final [**2173-6-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2173-6-21**]):
REPORTED BY PHONE TO [**Doctor Last Name **] OVERLAND FA9A [**1-/9167**] 3P [**2173-6-20**].
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
ANAEROBIC CULTURE (Final [**2173-6-24**]): NO ANAEROBES ISOLATED.
[**2173-6-17**] 3:35 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2173-6-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2173-6-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2173-6-23**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2173-6-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 67345**],[**Known firstname **] [**2101-5-26**] 72 Male [**-5/2247**] [**Numeric Identifier 67346**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: GALLBLADDER, RT. LATERAL MARGIN AND
AMPULLARY ADENOMA.
Procedure date Tissue received Report Date Diagnosed
by
[**2173-6-3**] [**2173-6-3**] [**2173-6-11**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/lo??????
Previous biopsies: [**-5/2118**] GI BX 1 AMPULLA.
************This report contains an addendum***********
DIAGNOSIS:
1. Gallbladder (A1-B1):
Unremarkable gallbladder mucosa and cholelithiasis, pigmented
type.
2. Right lateral margin (C1):
Duodenal mucosa with marked cautery artifact, no malignancy
identified.
3. Ampullary mass, resection (A-E):
Invasive adenocarcinoma. See synoptic report.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] reviewed slides B-D.
Small intestine: Polypectomy; Segmental Resection; Whipple
procedure (Pancreaticoduodenectomy, partial or complete, with or
without partial Gastrectomy Synopsis
MACROSCOPIC
Specimen Type: Polypectomy.
Tumor Site: Duodenum, ampulla.
Tumor configuration: Exophytic (polypoid).
Tumor Size
Greatest dimension: 2.3 cm. Additional dimensions: 1.3 cm
x 0.8 cm.
Other organs Received: None.
MICROSCOPIC
Histologic Type: Adenocarcinoma (not otherwise characterized).
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor invades lamina propria or submucosa.
Regional Lymph Nodes: pNX: Cannot be assessed.
Lymph Nodes
Number examined: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Mucosal margin:
Uninvolved by carcinoma.
Deep margin:
Uninvolved by carcinoma.
ADDENDUM:
The original frozen sections were reviewed retrospectively by
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]. It is felt that the invasive
carcinoma seen on the permanent sections is not present on the
original frozen section slides.
Addendum added by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/jg????????????
Date: [**2173-6-16**]
Clinical: Pancreatic mass.
Gross:
The specimen is received in fresh in three, each labeled with
the patient's name, "[**Known lastname **], [**Known firstname **]" and the medical record
number.
Part 1 is additionally labeled "gallbladder". The specimen
consists of a single intact distended gallbladder measuring 11.3
x 4.6 x 4.4 cm. The serosa is tan-pink and focally red and the
specimen is opened longitudinally to reveal approximately 30 cc
of dark brown honey-colored viscus fluid. There is a single
green gallstone measuring 0.9 x 0.9 x 0.9 cm which is bisected
to reveal a green crystalline interior. The mucosa is tan-pink
and notable for multiple small yellow flecks. The wall thickness
measures up to 0.2 cm. The specimen is sectioned and represented
as follows: cystic duct margin and body in A1, fundus in B1.
Part 2 is additionally labeled "right lateral margin". The
specimen consists of a single piece of soft pink red tissue
measuring 1.2 x 0.8 x 0.3 cm. One side of the specimen has
either been previously inked in black or darkened by cautery.
This side is inked over in black. There is a single suture
demarcating one side of the specimen which is inked in yellow
and the specimen is submitted entirely with the black ink side
face down, in cassette labeled C1.
Part 3 additionally labeled "ampullary adenoma" consists of a
2.3 x 1.3 x 0.8 cm polypoid fragment of tan pink mucosa
containing a 0.4 cm stalk. The stalk has been identified by the
surgeon with a blue stitch and contains the pancreatic and
biliary duct margins. There is a 0.3 cm area of mucosal
ulceration at one end of the polyp. The resection margin is
inked black, shaved off and submitted for frozen section
diagnosis en face. A representative cross section of the polyp
is also submitted for frozen section diagnosis. Frozen section
diagnosis by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] is "ampullary adenoma with
focal high grade dysplasia. No invasion seen on sampled
sections. The adenoma focally extends to the side margin. The
shaved common bile duct and pancreatic duct margin are free of
dysplasia." The stalk margin frozen section remnant is entirely
submitted in A and the polyp frozen section remnant is entirely
submitted in B. The remainder of the specimen is serially
sectioned and entirely submitted in C-E, with the ulcerated area
in D.
Brief Hospital Course:
The patient was admitted on [**2173-5-26**]. An ERCP with biopsy showed
adenocarcinoma. A CT confirmed the presence of an Ampullary
Mass.
#Carotid Disease
A noninvasive carotid study showed complete occlusion of the
left ICA and the right ICA with 70-79% narrowing.
#Vascular consult
An Angio obtained form an OSH ([**Doctor Last Name **], [**3-1**]) showed the
right ICA to be 35% occluded. A neuro consult was requested to
work up his TIA's vs. Parkinsonism. A MRI Brain/ MRA carotids
revealed mild-to-moderate brain atrophy and occlusion of the
left internal carotid artery at the bifurcation, high-grade
stenosis of the right internal carotid bifurcation. Normal right
vertebral artery, normal flow signal in the right supraclinoid
internal carotid, right MCA and both anterior cerebral arteries.
Dr. [**Last Name (STitle) **] felt that there was no intervention needed prior to
abdominal surgery.
#Neuro consult
Neuro found no evidence of symptomatic right brain lesion on
exam, but there may be a small stroke not detected clinically.
#Cardiology Consult
Cardiology recommended an Echo and Stress Mibi which were
negative for ST changes and showed normal myocardial perfusion,
and normal left ventricular cavity
size and function.
He was then cleared to go to the OR on [**2173-6-3**] and had an Open
Cholecystectomy and Transduodenal Ampullary Resection. He
tolerated the procedure well. He was NPO, had a NGT and IV
fluids. He was started on a PCA for pain control. He needed
further teaching on the use of his PCA before he was able to
have pain control.He had a JP drain in place and staples to his
abdominal incision.
#Pain Consult
A pain consult was obtained after the patient required Narcan
for sedation, a respiratory rate of 8, and pinpoint pupils. APS
recommended that he continue with subcutaneous Dilaudid until he
is able to take PO meds. He was then changed to PO Dilaudid on
POD 6.
#Seizure
POD 3, the patient had a 30 second episode of
non-responsiveness, blank downward gaze and increase fine
tremors of the bilateral upper extremities, right>left.
Afterwards, he was unable to remember the names of his
daughters, or remember the event. The family states that the
last seizure was 5 years ago. Neurology was consulted and
recommended Ativan IV for any further seizure activity and to
restart Tegretal 200mg TID once he is able to take POs. He was
restarted on Tegretal on POD 4, and has had no further seizure
activity.
POD 4, a UGI SGL CONTRAST W/ KUB showed no evidence of leak at
the duodenal anastomosis. The NGT was D/C'd and he was started
on sips. His diet was advanced as bowel function returned. Stool
was sent for C.diff due to a frequent loose stool which was
negative.
POD 6, he was found down on the floor, obtund ed. He denies
hitting his head, he was reportedly confused and talking, but
thought it was [**2146**]. Neurology was called immediately. Labs were
sent and a Tegretol level was adequate at 7.6, WBC 28.4 and temp
of 101.9 axillary. He then became diaphoretic and was not
responding to questions and was not opening his eyes. It seems
likely that the patient was confused due to sepsis and
hypotension as opposed to a seizure related event. He was
transfered to the SICU. He was given IV fluids and started on
Vancomycin, Levo, Flagyl. A head CT showed no evidence of
intracranial hemorrhage or mass effect.
On [**2173-6-13**] he spiked a fever to 102F. An Abdominal CT on [**2173-6-13**]
showed no evidence of drainable fluid collection or abscess, but
increased bilateral pleural effusions. He was started on Zosyn
(Levo/Flagyl D/C'd) and continued the Vancomycin.
A JP amylase on [**2173-6-14**] was [**Numeric Identifier 67347**]. On POD 12 a UGI/Air with KUB
showed no evidence of a leak.
His JP revealed [**Female First Name (un) 564**] and he was started on Fluconazole. His
WBC continued to be elevated 28.4, 33.5, 29.6, 23.5, 15.8, 20.6,
17.3, up to 33.7 on POD 13.
Infectious Disease was consulted and they suggested broad
spectrum antibiotics and that we should sample the pleural
effusion.
POD 13, A PICC line was placed and he was started on TPN.
POD 14, Urine cultures were negative. he continued to spike a
temperatures, up to 102.4 and he had increased work of
breathing. Interventional Pulmonology was contact to perform a
thoracentesis for the right sided pleural effusion and they
removed 1.2 liters of fluid. The pleural effusion was negative.
Occupational and physical therapy was consulted and he was
started on aggressive pulmonary toilet.
POD 15 a left subdiaphragmatic collection was drained by US
guidance seen on the [**6-13**] CT. The drain was negative for
bacteria and positive for [**Female First Name (un) 564**] albicans.
POD 19 on an interval CT scan there was a subcapsular fluid
collection. Unclear the etiology.
POD 22 The Subscapular fluid collection was drained by CT
guidance. The cultures have been negative for bacteria.
POD 24: The subscapular pigtail was d/c'd
POD 25: The pigtail drain the fluid around the liver was d/c'd
Medications on Admission:
Lipitor 20
Tegretol 200 tid
HCTZ
Colace
Protonix 40 [**Hospital1 **]
Atenolol 25
Lisinopril
ASA 81 for 2 yrs and Plavix for 2 months, but both stopped 10
days ago
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
Disp:*90 One injection* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. TPN
Day 3 and/or thereafter: Central Standard 2-in-1 (no fat) For
Date: [**2173-6-28**] **Order marked as pumped Feeding Weight(kg)
TPN Volume Amino Acid(g/d) Dextrose(g/d) Fat(g/d) Kcal/day
70 1750 [**Telephone/Fax (1) 67348**]
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc
90 0 25 40 15 20 12 18
Insulin(units) Zinc(mg)
30 10
Total volume of solution per 24 hours.
Rate of continous infusion determined by pharmacy-See Label
14. Outpatient Lab Work
Chem 10 Every Wednesday
15. Outpatient Physical Therapy
Ambulation with assistance once a day and aggressive chest
therapy of a pulmonary toilet every day.
16. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] nursing
Discharge Diagnosis:
Bleeding Ampullary Mass
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain or persistent pain
* Fever (>101.5 F) or Vomiting
* Bleeding
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
No driving while taking strong pain medication.
No lifting > 10 lbs for 6 weeks.
Take antibiotics for only 10 more days.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **]. Call ([**Telephone/Fax (1) 2363**] to
schedule an appointment.
2. Please follow up with Dr. [**Last Name (STitle) 67349**] from Vascular Surgery to
have a repeat Carotid U/s. Please call to schedule this
appointment.
Completed by:[**2173-6-30**] |
6961,5533,71590,2765,53140 | 162 | 195,893 | Admission Date: [**2142-3-25**] Discharge Date: [**2142-3-28**]
Service: Internal Medicine
CHIEF COMPLAINT:
Upper gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
woman with a history of osteoarthritis and psoriasis who
presents with hematemesis. She noticed this on [**2142-3-22**] but it resolved spontaneously. She then experienced
melena and hematemesis of significant amount, one to two cups
of bright red blood on the morning of admission. She also
felt lightheaded, although she did not experience chest pain,
shortness of breath or abdominal pain. This has never
occurred to her before. The patient has a history of
ibuprofen use, 300 mg three times a day for months, for her
osteoarthritis pain.
On admission, the patient was tachycardiac to the 110s but
blood pressure was stable in the 120s systolic. Nasogastric
lavage was performed, showing coffee-grounds and clots, which
did not clear with 1.5 liters normal saline.
Gastroenterology was consulted and an
esophagogastroduodenoscopy was performed, showing a 15 mm
crated ulcer with large blood clot overlying the base. They
were unable to dislodge. Epinephrine was injected with
success. The patient received one unit of packed red blood
cells on presentation for a hematocrit of 24.
PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Psoriasis.
MEDICATIONS ON ADMISSION: Ibuprofen 300 mg p.o.t.i.d.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone. She has never been
married and has no children. She has a niece and nephew who
visit her often and help her out. She drinks one brandy with
lemonade four to five times per week and denies smoking. She
has not seen a doctor in three years and is not sure who her
primary care physician [**Last Name (NamePattern4) **].
CODE STATUS: "Do Not Resuscitate"/"Do Not Intubate".
PHYSICAL EXAMINATION: On physical examination, the patient
had a blood pressure of 119/56, pulse 100, respiratory rate
17 and oxygen saturation 100% on two liters. General:
Awake, alert, in no acute distress, pale. Head, eyes, ears,
nose and throat: Pupils equal, round, and reactive to light
and accommodation, extraocular movements intact, anicteric
sclerae, oropharynx clear. Neck: Supple, no bruits. Chest:
Clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm, S1 and S2, II/VI soft systolic ejection
murmur at right upper sternal border. Abdomen: Soft,
nontender, nondistended, positive bowel sounds. Extremities:
No cyanosis, clubbing or edema. Neurologic examination:
Alert and oriented times three, cranial nerves II through XII
intact, musculoskeletal [**4-15**] in all four extremities.
LABORATORY DATA: Admission white blood cell count was 8.5
with 80% neutrophils, 15% lymphocytes and 3% monocytes,
hematocrit 24.5, platelet count 243,000, prothrombin time
12.8, partial thromboplastin time 23.9, INR 1.1, sodium 138,
potassium 3.7, chloride 104, bicarbonate 25, BUN 65,
creatinine 0.7, and glucose 225. Urinalysis was negative.
HOSPITAL COURSE: The patient is an 88 year old woman with a
history of osteoarthritis, on ibuprofen, who presents with
hematemesis and melena, esophagogastroduodenoscopy showing
gastric body ulcer.
1. Gastrointestinal: The patient had hematemesis secondary
to a gastric ulcer, likely secondary to non-steroidal
anti-inflammatory drug overuse. The patient received a total
of four units of packed red blood cell transfusions and her
hematocrit stabilized in the 30s. She was admitted to the
Medical Intensive Care Unit for one night and then
transferred to the floor in stable condition.
The patient had no more hematemesis or evidence of active
bleeding. She was on a Protonix drip and kept on nothing by
mouth for the first 24 hours. It was thought to perhaps to
repeat an esophagogastroduodenoscopy, however, because she
was stable, it was thought to best defer this to the
operating table setting. Helicobacter pylori antibody was
checked and was negative.
The patient's hematocrit continued to remain stable. Once
she was on the floor, her diet was advanced and she tolerated
this well, without any symptoms. She will follow up with
gastroenterology in two to three weeks and have a repeat
esophagogastroduodenoscopy in eight weeks. The patient was
told to strictly avoid any non-steroidal anti-inflammatory
drugs, e.g., Motrin, Advil, ibuprofen, and to use Tylenol for
pain instead. She was also placed on iron supplementation
once a day.
2. Osteoarthritis: The patient was told to use Tylenol for
this. She did not complain of any severe pain while in the
hospital.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE MEDICATIONS:
Tylenol p.r.n. pain.
Protonix 40 mg p.o.b.i.d.
Iron sulfate 325 mg p.o.q.d.
Colace 100 mg p.o.t.i.d.
DISCHARGE DIAGNOSES:
1. Osteoarthritis.
2. Upper gastrointestinal bleed secondary to stomach ulcer.
3. Psoriasis.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with nurse practitioner, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], for a hematocrit
check on [**2142-4-5**] at 1:20 p.m. She is to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of the gastroenterology department, on [**2142-4-23**] at 1:00 p.m. and with me, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**], as her
new primary care physician, [**Name10 (NameIs) **] an initial visit appointment
on [**2142-4-18**] at 1:30 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2142-3-28**] 18:20
T: [**2142-3-29**] 14:26
JOB#: [**Job Number **]
|
41071,4280,42840,5180,501,V4502,4940,5771 | 163 | 138,528 | Admission Date: [**2146-6-20**] Discharge Date: [**2146-6-22**]
Service: [**Hospital Unit Name 196**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
SOB at OSH, [**Location (un) **] to [**Hospital1 18**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo male w/PMH significant for CAD s/p MI in [**2131**] with 4v CABG
and redo in [**2141**], Pacemaker/ICD, DM, HTN, asbestosis on home O2
who experienced sudden SOB after his dinner. No associated CP.
He did report orthopnea and palpitations. No fever, chills, or
cough. He went to [**Hospital3 **] ED and was found to have a BP
of 204/101 and HR of 140 in sinus rhythm, RR=34, and O2 sat of
88% on RA in respiraotry distress. He was given a heparin drip,
nitroglycerin drip, 40 mg IV Lasix, ASA, nebs, 5 mg Lopressor
x3, SLNTG x3, Morphine, and 125 mg solumedrol. His BP then
dropped and he was flown to [**Hospital1 18**]. Here, his BP was 75/53, and
his nitro drip was D/Ced. He was started on dopamine ad his BP
stabilized. BNP at OSH was >6000, and initial enzymes were
negative. Given lasix and diuresed 800 cc. Currently feels
"much better", no CP, but still not at baseline. His anginal
equivalent is SOB, not CP.
Past Medical History:
1.CAD with MI and 4v CABG in [**2131**]. CABG redo in [**2141**].
2. Asbestosis with O2 requirement at home.
3.Pacer/ICD placed after syncopal episode in the airport.
4.NIDDM
5.CHF--EF~20% by report and confirmed by echo here.
6.HTN
Social History:
Libes in [**Location (un) **] with his wife. Daughter lives in FL.
Used to work in a shipyard.
No Drugs, occ EtOH, Past history of smoking, not currently.
Family History:
Non-contributory
Physical Exam:
T=96.6, HR=90, BP=94/49, RR=22, O2 sat=96% on 8LNRB, 800 cc
urine at OSH, 400 cc in ED
Gen: Pleasant, mild dyspnea, but speaking in complete sentences;
abdominal breathing; lying flat
HEENT:EOMI, PERRLA, MMM, JVD on expiration to the angle of the
jaw. CArotid bruit on R, none on L.
CV:RRR, Nl S1,S2, no S3,S4, I/VI SEM at R 2nd ICS.
Pulm:Rales 1/3 up bilaterally, bronchial sounds over Right
mid-lung zone.
Skin:Diaphoretic, No rashes
Abd: Soft, NT/ND, decreased bowel sounds, no rebound or
guarding. No organomegaly
Ext:No edema, 1+ DP pulses Bilaterally, no femoral bruits.
Neuro:A&Ox3
Pertinent Results:
[**2146-6-20**] 03:49AM BLOOD WBC-25.2* RBC-3.98* Hgb-9.3* Hct-29.9*
MCV-75* MCH-23.3* MCHC-31.2 RDW-16.8* Plt Ct-425
[**2146-6-21**] 05:00AM BLOOD WBC-19.9* RBC-3.57* Hgb-8.4* Hct-26.3*
MCV-74* MCH-23.5* MCHC-31.9 RDW-17.4* Plt Ct-381
[**2146-6-21**] 10:00PM BLOOD Hct-31.0*
[**2146-6-22**] 06:00AM BLOOD WBC-12.9* RBC-4.39* Hgb-10.8*# Hct-33.5*
MCV-76* MCH-24.7* MCHC-32.4 RDW-17.8* Plt Ct-397
[**2146-6-20**] 03:49AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3*
Monos-1.5* Eos-0.3 Baso-0.1
[**2146-6-20**] 03:49AM BLOOD PT-14.7* PTT-110.8* INR(PT)-1.4
[**2146-6-21**] 05:00AM BLOOD PT-13.9* PTT-57.8* INR(PT)-1.3
[**2146-6-22**] 06:00AM BLOOD PT-12.6 PTT-27.4 INR(PT)-1.1
[**2146-6-22**] 06:00AM BLOOD Plt Ct-397
[**2146-6-20**] 03:49AM BLOOD Glucose-247* UreaN-42* Creat-2.2* Na-140
K-5.3* Cl-104 HCO3-20* AnGap-21*
[**2146-6-21**] 05:00AM BLOOD Glucose-98 UreaN-49* Creat-2.0* Na-141
K-5.0 Cl-106 HCO3-21* AnGap-19
[**2146-6-22**] 06:00AM BLOOD Glucose-47* UreaN-45* Creat-1.7* Na-142
K-4.5 Cl-105 HCO3-23 AnGap-19
[**2146-6-20**] 03:49AM BLOOD ALT-6 AST-27 CK(CPK)-195* AlkPhos-90
[**2146-6-20**] 01:23PM BLOOD CK(CPK)-244*
[**2146-6-20**] 08:06PM BLOOD CK(CPK)-190*
[**2146-6-21**] 05:00AM BLOOD CK(CPK)-120
[**2146-6-20**] 03:49AM BLOOD CK-MB-25* MB Indx-12.8*
[**2146-6-20**] 03:49AM BLOOD cTropnT-0.52*
[**2146-6-20**] 01:23PM BLOOD CK-MB-27* MB Indx-11.1*
[**2146-6-20**] 08:06PM BLOOD CK-MB-16* MB Indx-8.4*
[**2146-6-21**] 05:00AM BLOOD CK-MB-10 MB Indx-8.3* cTropnT-0.44*
[**2146-6-20**] 03:49AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.4* Iron-36*
[**2146-6-22**] 06:00AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6
[**2146-6-20**] 03:49AM BLOOD calTIBC-309 Ferritn-631* TRF-238
[**2146-6-20**] 03:49AM BLOOD Triglyc-58 HDL-41 CHOL/HD-3.0 LDLcalc-68
[**2146-6-20**] 04:58AM BLOOD Lactate-2.2* K-4.8
[**2146-6-20**] 07:03AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-6-20**] 07:03AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2146-6-20**] 07:03AM URINE RBC-[**1-28**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2146-6-20**] 01:26PM URINE Hours-RANDOM UreaN-448 Creat-48
Echo:
Conclusions:
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The
left ventricular cavity is dilated. Overall left ventricular
systolic function
is severely depressed (ejection fraction approximately 20
percent). Right
ventricular chamber size is normal. Right ventricular systolic
function
appears depressed. The aortic root is mildly dilated. The aortic
valve
leaflets (3) are mildly thickened but not stenotic. Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is no mitral valve prolapse. Moderate (2+) mitral regurgitation
is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but
cannot be quantified.
Chest CT:
IMPRESSION: 1) Extensive calcified pleural plaques consistent
with prior history of asbestos exposure. Right pleural effusion
with equivocal smooth enhancement of the right posterior lateral
pleural surface but without nodularity or other findings to
suggest mesothelioma. Correlation with pleural aspirate should
be considered.
2) Cardiomegaly and extensive coronary artery calcifications.
3) Borderline enlargement of the main pulmonary arteries suggest
a possible pulmonary artery hypertension.
4) Atelectasis at the left lung base and bronchiectasiss.
5) Extensive calcifications throughout the pancreas consistent
with chronic pancreatitis.
6) Small nodule in the left adrenal gland which possibly
represents an adenoma. However, this cannot be fully
characterized due to the lack of non- contrast series.
CXR:
IMPRESSION:
1) CHF
2) Calcified pleural plaques with a large right effusion or
pleural thickening. Further evaluation with CT scan is
reccommended to exclude malignant mesothelioma.
Brief Hospital Course:
This 80 y/o male with h/o CAD, DM, HTN, asbestosis was admitted
in fairly stable condition after a modest diuresis at the OSH
and the ED. He was managed for an NSTEMI and acute CHF
exacerbation. We spoke with his PCP and pulmonologist while he
was here, and obtained records from his cardiologist.
1.CHF: This exacerbation was likely due to a combination of
ischemia(NSTEMI), severe HTN, and chronic systolic/diastolic
dysfunction. We started him on Natrecor due to his underlying
CRI and he diuresed well with daily goals of 1L negative fluid
balance. Also got an echo which confirmed an EF of approx 20%,
and 2+MR. His SOB rapidly improved, but he was still using
minimal O2 upon D/C. He is on 2LNC at home chronically. He was
able to walk without O2 in the hospital though without dropping
his O2 sats. Patient was instructed to not eat salty foods and
wife confirmed they have seen nutritionist before and have
handouts at home of appropriate and inappropriate foods. He was
transitioned to Lasix on D/C at 20 mg/day, with instructions to
weigh himself and take extra Lasix iof his weight increases by 2
lbs in 1 day. Hopefully this will keep him from slowly entering
CHF again. He was on Lasix in the past, then Bumex, but for
now, we will try Lasix with the above instructions. His
cardiologist or PCP may elect to alter this regimen depending on
his stability as an outpatient.
2.CAD:Known h/o coronary issues. His EKG showed a new
incomplete LBBB and his cardiac enzymes were positive for MI.
No ST elevations seen. His anginal equivalent is also SOB,
which was his primary complaint. Initially started on ASA,
heparin, statin. His Coreg was held due to initially tenuous
BP. He was briefly on dopamine, but was quickly weaned from
this. His CKs peaked in 200s and began trending down. There
was question of whether this was result of demand ischemia or
not. It was decided that he did not need a cath due to quick
improvement and no further symptoms. The heparin was stopped
and his Coreg was restarted when his BP could tolerate it. He
was sent home on coreg, but his diovan was not restarted as his
BP was in normal range without it. Will need this monitored.
3.EP:He has a pacemaker that was placed after syncopal episode.
There were no issues with abnormal rhythms as an inpt. Repeat
EKGs showed QRS narrowing to more normal value.
4.Renal: Initial creatinine was elevated and was reported that
he had CRI since a hospital admission last year. Records
obtained showed a Cr baseline close to 3 after that admission,
but latest labs in records showed Cr of 2.0 on [**2146-6-6**]. He was
in this range throughout admission, with last value being 2.0.
He had good urine output on Natrecor here and no other issues
with his kidneys.
5.Asbestosis: CXR done which showed pleural plaque and effusion.
CT of chest again showed plaques and effusion. His
pulmonologist reported that he has had this effusion 3 times in
the past and fluid analysis was negative for malig mesothelioma.
It was not retapped here due to this information. We scheduled
a f/u appointment for him with Dr [**Last Name (STitle) **]. Also instructed him to
continue using his oxygen at home as before.
6. Initially had elevated WBC ct. Possibly due to solumedrol,
but believed to be elevated before this as well. No evidence of
infection was found. COunt was followed, and gradually returned
to nL.
7.He was discharged stable and at his baseline respiratory
status, with close follow-up stressed to him and his family with
cardiologist, PCP, [**Name10 (NameIs) **] pulmonologist. Plan for daily weights
and Lasix adjustment as appropriate will hopefully help keep him
from redeveloping volume overload.
Medications on Admission:
1.Coreg 6.125 mg [**Hospital1 **]
2.Diovan 40 mg qd
3.Lipitor 10 mg qd
4.Amaryl 1 mg qd
5.[**Doctor First Name **]
6.Nexium 40 qd
7.Celebrex 200 qd
8.Bumex?
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*40 Tablet(s)* Refills:*2*
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1.CHF
2.CAD
3.CRI (baseline Cr~2.0)
4.asbestosis
5.NIDDM
Discharge Condition:
Pt was stable. He was eating well.Shortness of breath was
resolved and he is at his baseline. [**Month (only) 116**] still require O2 at
night as before.No chest pain.
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience chest pain or increasing shortness of breath.
Please weigh yourself every day. If your weight increases by 2
lbs or more in one day, take an extra 20 mg of Lasix (in
addition to your daily dose of 20 mg Lasix that we started you
on). If your weight remains up the next day, then call your
doctor to report this.
Please STOP your Diovan.
Your Lipitor dose was INCREASED from 10 mg/day to 40 mg/day.
We STARTED you on aspirin, Plavix, and Lasix (furosemide).
Please take each of these daily.
All of your other medications have stayed the same.
Followup Instructions:
Pulmonology appointment with Dr [**First Name (STitle) **]: [**2146-7-19**] at 5:20
pm
Please call your PCP to arrange an appointment in 1 week.
Cardiology appointment with Dr [**Last Name (STitle) 174**] on [**7-25**] at 2:15 pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|