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E8150,8822,85220,5185,99889,5070,2859,9579,87342 | 248 | 175,353 | Admission Date: [**2142-10-19**] Discharge Date: [**2142-11-6**]
Date of Birth: [**2124-7-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Rollover motor crash
Major Surgical or Invasive Procedure:
[**2142-10-20**] Repair of left hand extensor tendon/STSG
History of Present Illness:
18 yo female unrestrained driver, s/p rollover MVC; ejected from
vehicle. Was found ~50 ft from vehicle with obvious left hand
deformity. She was intubated at scene secondary to
combativeness. She was transferred to [**Hospital1 18**] for continued care.
Past Medical History:
None
Family History:
Noncontributory
Pertinent Results:
[**2142-10-19**] 03:25PM GLUCOSE-132* LACTATE-2.0 NA+-138 K+-4.6
CL--107 TCO2-21
[**2142-10-19**] 03:15PM GLUCOSE-146* UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-20* ANION GAP-14
[**2142-10-19**] 03:15PM AMYLASE-87
[**2142-10-19**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2142-10-19**] 03:15PM WBC-19.8* RBC-4.11* HGB-12.9 HCT-35.1* MCV-86
MCH-31.4 MCHC-36.8* RDW-13.0
[**2142-10-19**] 03:15PM PLT COUNT-154
CT HEAD W/O CONTRAST
Reason: ?ICH
[**Hospital 93**] MEDICAL CONDITION:
18 year old woman with AMS on scene s/p rollover
REASON FOR THIS EXAMINATION:
?ICH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 18-year-old woman status post motor vehicle
collision.
COMPARISONS: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is a small left-sided acute subdural hematoma
along the anterior left frontal convexity, up to 3 mm in
thickness. There is also a suspected thin subdural along the
posterior aspect of the falx cerebri up to 4 mm in diameter. A
punctate 2 mm density in the subcortical white matter, within
the right frontal lobe, is suggestive of a hemorrhagic
contusion.
Additional punctate densities along the medial periventricular
white matter adjacent to the right lateral ventricle, and within
the right side of the corpus callosum, are suspicious for
diffuse axonal injury with hemorrhage, based on their locations.
There is no mass effect, hydrocephalus or shift of the normally
midline structures. The ventricles, cisterns, and sulci are
unremarkable without effacement. The [**Doctor Last Name 352**]-white matter
differentiation appears preserved.
There is a small air-fluid level in the left maxillary sinus
which can be seen in intubation. There is slight mucosal
thickening in the sphenoid sinus. The mastoid air cells are
clear. The osseous structures are unremarkable. There is
bilateral soft tissue swelling above the orbits anteriorly.
IMPRESSION:
1. Small left frontal subdural hematoma, with suspected small
subdural along the posterior falx cerebri as well.
2. Small right frontal hemorrhagic contusion.
3. Dense foci along the right lateral ventricle, and within the
corpus callosum, suspicious for diffuse axonal injury with
hemorrhage.
The findings were discussed shortly after the study with Dr.
[**Last Name (STitle) **] and posted to the ER dashboard. When clinically
appropriate, an MR is suggested in order to better evaluate the
extent of injury, as MRI is more sensitive, in particular, for
detection diffuse axonal injury, particularly for foci not
associated with hemorrhage.
CT C-SPINE W/O CONTRAST
Reason: ?fx
[**Hospital 93**] MEDICAL CONDITION:
18 year old woman with AMS on scene s/p rollover
REASON FOR THIS EXAMINATION:
?fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 18-year-old woman with altered mental status after
motor vehicle accident.
COMPARISONS: None.
TECHNIQUE: Axial non-contrast CT images of the cervical spine
were obtained, and sagittal and coronal reconstructions were
also performed.
FINDINGS: The alignment of the cervical spine is normal, without
listhesis. There is no evidence of fracture, dislocation, bony
destruction, or prevertebral soft tissue swelling. The osseous
structures appear normal.
The patient is intubated, and there is a nasogastric tube
passing through the esophagus. In the left upper lobe, there is
a peripheral 4-mm nodular density which may represent a lung
nodule, or perhaps a small contusion, although there is no
evidence of surrounding injury to suggest chest injury. There is
mild dependent change in the visualized right apex.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Small density in the left upper lobe, which could represent a
small contusion or nodule. Follow-up after three months is
suggested to ensure resolution.
CHEST (PORTABLE AP)
Reason: CP processes
[**Hospital 93**] MEDICAL CONDITION:
18 year old woman with fever
REASON FOR THIS EXAMINATION:
CP processes
IMPRESSION: 18-year-old with fever, status post motor vehicle
accident.
COMPARISON: [**2142-10-31**].
FINDINGS: Lungs are clear except some residual opacity in the
right apex, not significantly changed from the previous
examination. There are no pleural effusions. Cardiomediastinal
silhouette is unremarkable. No evidence of central
lymphadenopathy.
Right PICC terminates in the distal SVC. A feeding tube
terminates in the expected location of distal stomach.
IMPRESSION: Unchanged appearance of residual right apical
opacity, otherwise clear lungs
Blood Urine CSF Other Fluid Microbiology
Recent
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2142-11-6**] 07:00AM 9.5 3.81* 11.6* 32.4* 85 30.4 35.8* 13.9
543*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2142-11-1**] 02:02AM 80.4* 12.7* 5.8 0.5 0.7
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2142-10-20**] 02:20AM NORMAL1 NORMAL NORMAL NORMAL NORMAL
NORMAL
1 NORMAL
MANUAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2142-11-6**] 07:00AM 543*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2142-11-6**] 07:00AM 101 34* 0.8 134 3.7 98 24 16
[**2142-11-5**] 11:20AM 120* 37* 0.9 137 3.7 100 25 16
[**2142-11-3**] 07:15AM 106* 37* 1.2* 144 4.5 106 26 17
[**2142-11-2**] 06:51AM 125* 37* 1.2* 149* 4.2 112* 26 15
[**2142-11-1**] 02:02AM 143* 36* 1.4* 146* 3.7 110* 25 15
[**2142-10-31**] 12:37PM 129* 37* 1.3* 142 3.8 106 27 13
[**2142-10-31**] 03:03AM 159* 31* 1.4* 141 3.6 104 26 15
[**2142-10-30**] 12:45AM 104 9 0.6 138 3.9 99 26 17
[**2142-10-29**] 01:17PM 110* 138 3.8 101 27 14
Source: Line-art
[**2142-10-29**] 03:46AM 83 12 0.5 136 3.9 101 28 11
[**2142-10-28**] 03:05AM 140* 9 0.5 139 4.2 106 25 12
[**2142-10-27**] 02:38AM 101 9 0.4 140 3.5 104 29 11
[**2142-10-26**] 02:01AM 89 10 0.5 142 4.1 108 27 11
[**2142-10-25**] 02:20AM 115* 8 0.4 141 4.1 109* 25 11
[**2142-10-24**] 11:36AM 3.7
Source: Line-a-line
[**2142-10-24**] 04:01AM 115* 5* 0.5 142 3.6 110* 25 11
[**2142-10-23**] 02:23PM 3.7
Source: Line-aline
[**2142-10-23**] 03:13AM 128* 3* 0.5 140 3.8 108 24 12
[**2142-10-22**] 02:31AM 109* 3* 0.6 139 3.8 111* 20* 12
ADDED ALB [**2142-10-22**] 8:35AM
[**2142-10-21**] 11:34AM 94 2*1 0.5 137 3.7 112* 20* 9
1 VERIFIED - CONSISTENT WITH OTHER DATA
[**2142-10-21**] 02:55AM 92 3* 0.6 138 3.7 114* 17* 11
[**2142-10-20**] 04:55PM 81 0.6 140 3.5 112* 20* 12
Source: Line-art
[**2142-10-20**] 02:20AM 91 10 0.6 139 3.4 110* 21* 11
[**2142-10-19**] 03:15PM 146* 10 0.8 141 3.6 111* 20* 14
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2142-10-19**] 03:15PM 87
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2142-11-6**] 07:00AM 9.8 4.4 2.0
ANTIBIOTICS Vanco
[**2142-11-2**] 06:52AM 6.2*1
Vancomycin @ Trough
1 UPDATED REFERENCE RANGE AS OF [**2142-9-5**] == REPRESENTS
THERAPEUTIC TROUGH
NEUROPSYCHIATRIC Phenyto
[**2142-10-28**] 03:05AM 3.2*
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2142-10-19**] 03:15PM NEG NEG1 NEG NEG NEG NEG
1 NEG
80 (THESE UNITS) = 0.08 (% BY WEIGHT)
LAB USE ONLY HoldBLu RedHold
[**2142-10-24**] 04:12AM HOLD1
1 HOLD
DISCARD GREATER THAN 24 HRS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Vent Comment
[**2142-10-29**] 01:30PM ART 82* 41 7.44 29 3
[**2142-10-29**] 09:52AM ART 37.9 50 187* 38 7.47* 28 4
[**2142-10-29**] 03:57AM ART [**10-12**] 400 5 50 200* 48* 7.40 31* 4
INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2142-10-29**] 01:30PM 112* 3.8
[**2142-10-29**] 09:52AM 121* 0.8
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
[**2142-10-21**] 06:30PM 85
CALCIUM freeCa
[**2142-10-29**] 01:30PM 1.23
Brief Hospital Course:
She was admitted to the trauma service. Neurosurgery and Plastic
Surgery were consulted because of her injuries. Her
neurosurgical issues were nonoperative; she was loaded with
Dilantin and continued on a scheduled dose for 10 days; serial
head CT scans were followed and were stable. She will follow up
in [**Hospital 4695**] clinic in 5 weeks for repeat head CT scan.
Plastic Surgery was consulted for her left hand degloving
injury. She was taken to the operating room for repair of her
extensor tendon and STSG. She will follow up with Plastic
surgery in [**1-8**] weeks after discharge.
Because of her [**Doctor First Name **] Behavioral Neurology was consulted as patient
was having behavior issues; periods of extreme restlessness and
agitation. During her ICU stay she was receiving Haldol and
Ativan and required 1:1 sitters. It was recommended that these
agents be placed on hold as could have been contributing to her
delirium. Her behavior dramatically improved, mental status such
that she knew the date and place.
During her ICU stay she was initially difficult to wean;
discussions took place with family as to possibility of
tracheostomy. She eventually was able to wean and then was
extubated. She was transferred to the step-down unit [**Unit Number **] days
following her extubation.
Speech and Swallow were evaluated early on during her hospital
stay; initially she did not pass her bedside swallow; a Dobhoff
tube was placed and tube feedings were initiated. She was
re-evaluated by Speech several days later once her mental status
improved; her diet was upgraded to nectar thick liquids and soft
solids. Her tube feedings were cycled; she was also placed on
calorie counts. Because of the dramatic improvement in her
mental status it is expected that the Dobhoff will be very short
term and she will eventually have her diet upgraded with
continued evaluation by SLP once at rehab.
On the morning of her discharge she was in the bathroom and
while sitting on the toilet slipped hitting her right foot, on
examination there was no point tenderness or swelling. No other
injuries were identified.
Physical and Occupational therapy were also consulted and have
recommended [**Hospital **] rehab stay. Case management initiated this
process and she was accepted by [**Hospital1 **].
Social work was closely involved with patient and family for
coping and support.
Medications on Admission:
OCP
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day as needed for per sliding scale.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection [**Hospital1 **] (2 times a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) ML's 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.
5. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ML's PO BID (2
times a day).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
REHAB HOSP OF CAPE AND ISLANDS
Discharge Diagnosis:
s/p Rollover motor vehicle crash
Degloving injury left hand
Small subdural hematoma
Diffuse axonal injury
Discharge Condition:
Good
Discharge Instructions:
No procedures left arm because of the injury that was sustained.
Followup Instructions:
Follow up with Plastic Surgery clinic in 1 week, call
[**Telephone/Fax (1) 5343**] for an appointment.
Follow up with Neurosurgery, Dr. [**Last Name (STitle) 548**] in 5 weeks. Call
[**Telephone/Fax (1) 2992**] and inform the office that you will need a repeat
head CT scan for this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2142-11-6**] |
42841,2859,53081,25000,7921,2449,41402,41401,4589,4660,42731,5849,99812,41071,51882,49322 | 249 | 116,935 | Admission Date: [**2149-12-17**] Discharge Date: [**2149-12-31**]
Date of Birth: [**2075-3-13**] Sex: F
Service: MEDICINE
Allergies:
Altace
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath, increased angina
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Ms. [**Known lastname **] is a 74 year-old woman with a history of CAD s/p
CABG in 10/84 with redo in 11/84, stent to left subclavian in
[**6-17**] and repeat dx cath without intervention in [**10-18**], EF of 35%
on echo in [**2145**], atrial fibrillation diagnosed in [**2146**] managed
with rate control and anti-coagulation, hypertension, lipids and
asthma/possible COPD (no PFT's noted in record/no smoking
history) admitted now with SOB/unstable angina. The patient's
current symptomatology began last friday [**12-12**] when she
developed URI symptoms including nasal congestion and cough.
Since then she has noted increased dyspnea, increased episodes
of her anginal pain including at rest and cough productive of
yellow/celery colored sputum. Dyspnea has increased to point
where she has trouble with stairs now where recently she has
not. Has dry cough at baseline attributed to Mavik, but her
current cough is different. Has also had significantly
increased fatigue over this time. Takes combivent or albuterol
with some relief of shortness of breath. Her SOB brought her to
see her PCP [**Name Initial (PRE) 1262**]. CXR was obtained and revealed no acute
process. Other history from that visit is unobtainable.
Last night she had palpitations and her shortness of breath
subsequently worsened which ultimately brought her to [**Hospital1 18**]
today.
Reports taking all her medications. Has had some dietary
indiscretion recently including salted fish last friday and
dining out recnetly.
Also reports increased stress and exposure to dogs at family
members house.
Denies fever or chills. Denies feeling dizzy, syncope. NO
weight loss. Appetite has been good.
Past Medical History:
CAD as above
atrial fibrillation
htn
increased lipids
asthma
?COPD(non-smoker)
GERD
Anemia
Social History:
No history of smoking. Occasional alcohol and no IVDU. Lives in
[**Location 86**] area with excellent support from family.
Family History:
non-contributory
Physical Exam:
VS: T: 97.5 BP 124/63 HR: 90's RR 18 95% 3l (on nitro)
general: No distress but mildly increased work breathing resting
pleasant,
HEENT: PERLLA, EOMI, MMM, no pharyngeal exudate, no conj
injection, sclarae anicteric, no lymphadneopathy. JVP to about
12cm. No carotid bruits. Neck is supple
lung: wheezing throughout the lung fields
heart: tachy, irregular, S1 and S2 wnl, no murmurs/rubs or
gallops
abd; +b/s, soft, non-tender, non-distended, no masses
extr: +2 pitting edema bilaterally,swelling is symmetric in
lower extremities. non-tender. DP and femoral pulses are 1+.
no femoral bruits.
neuro; Alert and oriented x 3. no focal deficits
appreciated--strength appropriate for age, normal cerebellar and
reflexes. CNII-XII intact
Pertinent Results:
[**12-17**] chest x-ray:
PA AND LATERAL VIEWS OF THE CHEST: The patient is S/P CABG.
There is a
vascular stent projecting above the aorta again demonstrated and
unchanged.
The cardiac and mediastinal contours are stable. No evidence of
failure. The
lungs are clear. There is no pleural effusion.
IMPRESSION: No evidence of pneumonia. No evidence of CHF.
(pulmonary vascular congestion, cardiomegaly)
Admit labs:
[**2149-12-17**] 12:10PM WBC-8.8 RBC-3.84* HGB-11.7* HCT-34.6* MCV-90
MCH-30.3 MCHC-33.6 RDW-14.4
[**2149-12-17**] 12:10PM NEUTS-83.9* LYMPHS-9.4* MONOS-5.6 EOS-1.1
BASOS-0.1
[**2149-12-17**] 12:10PM PLT COUNT-237
[**2149-12-17**] 12:10PM GLUCOSE-180* UREA N-15 CREAT-1.1 SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16
[**2149-12-17**] 01:45PM PT-21.3* PTT-31.7 INR(PT)-2.9
Ischemia labs:
[**2149-12-17**] 12:10PM CK(CPK)-95
[**2149-12-17**] 12:10PM cTropnT-<0.01
[**2149-12-17**] 06:00PM CK(CPK)-147*
[**2149-12-17**] 06:00PM CK-MB-6 cTropnT-0.06*
Last cath:
PROCEDURE DATE: [**2147-11-15**]
INDICATIONS FOR CATHETERIZATION:
Chest pain. Prior CABG. S/P subclavian stent.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease with extensive
bridging
collaterals of the RCA.
2. Known occluded saphenous vein grafts.
3. Patent LIMA to LAD.
4. Patent left subclavian stent.
5. Mild mitral regurgitation.
6. Mild systolic ventricular dysfunction.
7. Mild right common-femoral vascular disease.
COMMENTS:
1. Coronary arteriography in this right dominant system showed
native
three-vessel coronary artery disease. The LMCA had mild luminal
irregularities. The LAD artery was occluded in the mid-vessel.
The left
circumflex artery was proximally occluded with two distal OMs
with a
"jump" segment filling via left to left collaterals. The RCA was
proximally occluded with many bridging collaterals supplying the
distal
RCA and posterior LV branches.
2. Saphenous vein grafts were known to be occluded from a prior
catheterization dated [**6-17**] and were therefore not visualized.
3. Graft angiography showed a widely patent LIMA to LAD,
supplying the
distal [**1-18**] of the LAD and large collaterals to the RCA and
r-PDA.
4. Left subclavian angiography showed a widely patent left
subclavian
stent.
5. Resting hemodynamics showed normal left-sided filling
pressure.
6. Left ventriculography showed mild global hypokinesis with
more
pronounced hypokinesis of the inferior wall. There was trace
mitral
regurgitation. The calculated LVEF was 45%.
7. Limited left ilio-femoral peripheral angiography showed a
mild 30%
stenosis of the common femoral artery.
EKG: afib, left axis deviation, ST depression and TWI in V2-V6.
[**12-19**] Echo:
Study continues from Tape [**2149**] W487 to tape [**2149**] W 509, starting
at 0:15 for an additional seven minutes of recording.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Depressed LVEF. Cannot assess LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. LV systolic function appears depressed. Overall
left ventricular systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension.
[**12-26**] cath:
PROCEDURE DATE: [**2149-12-26**]
INDICATIONS FOR CATHETERIZATION:
EKG changes.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed three vessel disease. The LMCA was diffusely
disease.
The LAD was occluded mid-vessel and filled distally via the
LIMA. The
LCX was occluded proximally, and filled distally from
collaterals from
the LCX. The RCA was occluded proximally and filled distally via
bridging collaterals.
2. Graft angiography revealed a patent LIMA-LAD. The SVGs were
not
imaged as they were known to be occluded.
3. Left ventriculography was not performed.
4. The left subclavian stent was widely patent.
LIVER OR GALLBLADDER ULTRASOUND.
INDICATION: 74 year old female with abdominal pain, increased
LFTs. Evaluate
for gallstones, or liver disease.
There are no prior studies for comparison.
The patient is status post cholecystectomy. The common bile duct
measures 5
mm, and is within normal limits status post cholecystectomy. The
liver shows
no focal abnormalities. The liver parenchyma is mildly
hyperechoic in
echotexture, consistent with fatty infiltration. The right
kidney measures
8.3 cm. There is a mild hyperechoic focus within the interpolar
right kidney,
with no evidence of posterior shadowing, possibly representing a
small
parenchymal calcification Within the lateral aspect of the right
kidney, in
the interpolar region, there is a 1.2-cm anechoic focus, most
likely
representing a simple cyst. The left kidney measures 8.1 cm,
with no focal
abnormalities.
IMPRESSION:
1) Patient is status post cholecystectomy.
2) The liver is echogenic, consistent with fatty liver. However,
other forms
of liver disease, and more advanced liver disease, including
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
[**12-24**] chest x-ray:
INDICATION: Shortness of breath, s/p extubation. Check status.
FINDINGS: A single AP semi-upright image. Comparison study dated
[**2149-12-21**]. The heart shows slight left ventricular enlargement. There
is evidence of
a prior CABG procedure. A vascular stent is noted in the left
brachiocephalic
vessel. The pulmonary vessels are normal. No pulmonary
infiltrates are seen.
There is slight blunting of the right costophrenic angle and
slight widening
of the minor fissure consistent with a small effusion. The hila
and
mediastinum are otherwise unremarkable. The ETT and the NG line
remain well
positioned.
IMPRESSION: Possible small right pleural effusion. No other
acute
cardiopulmonary abnormality. Prior CABG surgery noted and prior
left
brachiocephalic stent in place.
Brief Hospital Course:
72 year-old woman with CAD s/p CABG in [**2129**], stent to left
subclavian in [**6-17**], re-cath in 02 as above, history of CHF,
depressed EF, hypertension, afib astham/COPD who presents now
with increasing SOB and anginal episodes after URI last Friday.
Cardiovascular:
a)ischemia: Concerning past history, very high risk and now with
good story for unstable angina [**Female First Name (un) **] admit. Patient was ruled out
for MI on admission. After stabilization of her pulmonary
issues, given her history and an echo which could not fully
assess LVEF and could not rule out RWMA, she went for cardiac
catherterization and found to have no new lesions, patent LIMA
to LAD.
Patient maintained on ACE, beta-blocker, statin, aspirin, imdur.
Imdur and beta-blocker titrated up. D/ced calcium channel
blocker with likely systolic dysfunction and definite diastolic
CHF. Sublingual nitro as needed. Had been on Mavik for unclear
reason, tolerating ACE here--would titrate up for heart failure
as below.
Continues to have seom angina with stress.
b)pump: Patient noted to have depressed EF in past-35%? but no
recent echo on admission. Echo here showed: 1. The left atrium
is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. LV systolic function appears depressed. Overall
left ventricular systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension. On
admission, the patient was felt to be euvolemic to slightly
volume overloaded and gently diuresed but her SOB was primarily
due to astham/copd exacerbation. AFter transfer to ICU(see
below) patient received lots of fluids and needed to be
diuresed. Diuresed adequately for discharge--felt to be dry for
discharge by exam and labs. Given that she was acutely
decompensated from pulmonary perspective and volume overloaded
when echo was done, it was not felt to be fully accurate of
baseline status. Maintained on beta-blocker, ACE for ischemia
and HF. Should titrate ACE/beta to HF goals based on repeat
echo (lisinopril 20/toprol 150).
c)rhythm; afib: has always been rate controlled, never
cardioverted. POor control now and had sensation of
palpitations on night PTA. Unclear if ratelead to CHF or CHF
lead to increased rate and component of ischemia?--Increaed
demand leading to ischemia vs. ischemia leading to tachy--
Patient maintained on metoprolol for rate control with good
affect. Had been on dilt but with ? heart failure, systolic-held
and went up on beta-blocker for control.
Concerning anti-coagulation, we are holding coumadin until
patient has outpatient colonoscopy-had guiac positive stools and
crit drop (also with neck hematoma after central line
placement.) Scheduled for outpatient colonoscopy and then to
re-start coumadin then.
Shortness of breath/hypoxemia: CHF vs. post URI Reactive airways
disease vs. COPD vs. PE vs. pneumonia--ON admission, SOB felt
secondary to astham exacerbation-Patient acutely decompensated,
wheezy on exam, sent to unit on day 2 of admission for
intubation. Treated with predniesone, flovent, azithromycin
then levaquin as well as nebs/inhalers. HAd 5 day ICU stay and
then was transferred out. By discharge, not wheezy satting well
on room air. Felt to be RAD post bronchitis. Was not fluid
overloaded on admit--was diuresed after ICU stay with lots of
fluids. On discharge satting well on room air.
Anemia at baseline/Crit drop/guiaic positive: Patient had crit
drop while in ICU. She had a hematoma after central line
placement as well as guiac positive stools. Was on heparin
during this time for her afib, stopped at this time. She
stabilized after transfusion in ICU, and needed no further
transfusions. Neck hematoma is resolving. Guiac positive
stools-she is scheduled for outpatient colonoscopy. Re-address
anti-coagulation for afib after this. Do not want her on iron
until after colonoscopy.
Elevated LFT's, tbili and PTT: After being off heparin (on it
for afib), stopped for crit drop in [**Name (NI) 102488**] PTT remained
elevated. WAs on subcu heparin, lft's obtained which showed
mild transaminase elevation and t bili elevation. Subcu heparin
stopped, RUQ U/S obtained showed fatty liver/h/o
cholecystectomy. Lft's, t. bili and PTT trended down on
discharge. Patient will need follow -up of these studies as an
outpatient. ? MEd affect. Lipitor was increased from 10 to 40
given significant coronary disease--although unlikely to cause
acute elevations.
Hsitory of DM: Not on meds prior to admission. Needs primary
care follow-up.
Hypothyroidism: Levoxyl continued, TSH normal
GERD: PRotonix continued, no acute issues.
General care: VIT D, calcium, multi-vitamins
FULL CODE
Medications on Admission:
cardizem 120
levoxyl 75
warfarin 1/2/2 3 day rotation
protonix 40
lipitor 10
HCTZ 25
Imdur 45
metoprolol 12.5 [**Hospital1 **]
Mavick O.5
multi-vitmain
citrate
ferrous gluconate
aspirin 81
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
newly depressed EF- systolic Heart failure
acute renal failure
hypercoagulability
neck hematoma
cad
diabetes
reactive airway disease s/p bronchitis
transaminitis
Discharge Condition:
stable, ambulating with assistance
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2l
Call your doctor if you experience any further chest pain,
shortness of breath.
All medications as prescribed.
You will need to follow up with Dr. [**Last Name (STitle) 14069**] and Dr. [**Last Name (STitle) 120**] this
week. Please call to make appointments.
They will decide about re-starting coumadin after you [**1-7**]
colonscopy. Will also need to have [**Name (NI) 53324**], PT/PTT checked at
that time.
Please check ast, alt, alk phos and total bilirubin every few
days and trend results. If increasing dramatically then [**Name8 (MD) 138**] MD
for further work up.
Outpatient doctor to re-institute coumadin over next few weeks.
Followup Instructions:
Dr. [**Last Name (STitle) 14069**] within one week. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 37171**]
Follow-up appointment should be in 1 week
Call Dr. [**Last Name (STitle) 120**] this week to set up appointment.
Need to repeat echo in 3 monthsProvider: RADIOLOGY Where: [**Hospital 4054**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-1-2**]
4:00
Date/Time:[**2150-1-7**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2150-1-7**] 10:30
You are scheduled for colonscopy on [**1-7**].
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS
Date/Time:[**2150-1-7**] 10:30
|
53081,34280,2449,49320,2724,5859,25000,78451,40390,4280,42731,41402,2851,5849,43411,41071,56985 | 249 | 149,546 | Admission Date: [**2155-2-3**] Discharge Date: [**2155-2-14**]
Date of Birth: [**2075-3-13**] Sex: F
Service: NEUROLOGY
Allergies:
Altace / Bactrim
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
chest pain, hematochezia
Major Surgical or Invasive Procedure:
IA TPA, MERCI clot retrieval
History of Present Illness:
79 yo female with CAD s/p CABG in [**2129**], recent cath with only
LIMA-LAD patent, HTN, HLP, COPD, and afib who presents with 5
day history of red/maroon stools. Patient was at her PCP's
office earlier last week and was found to be anemic (HCT not in
system) and was planned for a colonscopy this week. She was at
home, and earlier today developed substernal chest pressure that
was persistent. She describes this pressure as a squeezing
sensation, different and worse than her usual anginal symptoms
for which she takes nitro. Usually her pain occurs with exertion
or at night when she's not wearing her oxygen and is limited to
her arm, but today it was also in her chest as well. She
described the pain as [**2155-9-26**] initially, and nitro at home did
not help, nor did increasing her O2 from 2-> 3L.
.
In the ED, initial VS: 97.8, 99, 116/, 24, 100%RA. Initially,
the patient was noted to have bright red blood on rectal exam.
She was tachycardic to the low 100s, but BP remained stable. She
received nitro SL and morphine which improved her CP to [**2155-3-20**].
Cardiology was consulted for the STD seen in the lateral leads,
but they felt this was likely c/w demand ischemia given her
significant anemia and severe coronary disease. She was given 2
units of PRBCs and 2 units of FFP prior to transfer. GI was
called, and felt the patient should have reversal of her INR
(4.5). She was given 5 mg IV vitamin K as well. Her BP remained
stable, and her HR improved to the 80s. She had a 20 and 16G PIV
placed. Her vitals prior to transfer to the MICu were 110/65,
89, 20, 98% 3L. She did complain of some dyspnea/tachypnea prior
to transfer, but her O2 sats remained 98% with 3L of O2.
Past Medical History:
- Coronary artery disease, s/p 3V CABG EF 50%
- Left subclavian stent [**51**]/[**2146**].
- Atrial fibrillation.
- Hypertension.
- Hyperlipidemia.
- COPD (FEV1/FVC 53, FEV1 0.63)
- GERD
- Anemia.
- Hypothyroidism
Social History:
denies tobacco, ETOH, or drugs.
Family History:
Mother with myocardial infarction in her 60s. No diabetes
mellitus. Grandfather with chronic obstructive pulmonary
disease.
Physical Exam:
VS - Temp 99.0F, BP 102/56, HR 72, R 28, O2-sat 96 2L% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD up to ears, no carotid bruits
LUNGS - bibasilar crackles, 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, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-21**] throughout, sensation grossly intact throughout,
Pertinent Results:
[**2155-2-3**] 06:20PM BLOOD WBC-9.9# RBC-2.45*# Hgb-7.0*# Hct-22.5*#
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.1 Plt Ct-251
[**2155-2-3**] 11:26PM BLOOD Hct-26.6*
[**2155-2-4**] 11:35AM BLOOD Hct-31.6*
[**2155-2-5**] 04:54AM BLOOD WBC-13.0* RBC-3.47* Hgb-10.1* Hct-31.0*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.4* Plt Ct-201
[**2155-2-6**] 06:55AM BLOOD WBC-11.4* RBC-3.58* Hgb-10.6* Hct-32.1*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.4 Plt Ct-187
[**2155-2-7**] 06:58AM BLOOD WBC-10.4 RBC-3.28* Hgb-10.0* Hct-28.7*
MCV-88 MCH-30.4 MCHC-34.8 RDW-15.2 Plt Ct-173
[**2155-2-7**] 12:25PM BLOOD Hct-31.7*
.
Echo:The left atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 20-30 %) with regional variation. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with severe global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**1-18**]+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2153-12-5**], the left
ventricular ejection fraction is markedly reduced.
.
CXR [**2-3**]:Findings suggesting mild congestive heart failure.
CT head, CTA head/neck, CTP [**2155-2-7**]
NON-CONTRAST CT: There is no evidence of acute intracranial or
parenchymal
hemorrhage. There is mild bihemispheric hypoattenuation of the
periventricular
and subcortical white matter consistent with sequelae of small
vessel ischemic
disease. The bilateral basal ganglia show small hypoattenuations
consistent
with old lacunar infarcts. There is calcification of the
intracranial carotid
artery. Also noted is a left maxillary sinus mucosal thickening.
The other
paranasal sinuses and mastoid air cells are well aerated.
CTA OF THE NECK AND HEAD: There is abrupt cutoff of the right
MCA at the
junction of the M1 and M2 segments. This represents a thrombus
within the
right MCA . Also noted is calcification of the bilateral carotid
bulbs. The
remaining intracranial and cervical vessels are unremarkable.
The vertebral
and carotid ostia are unremarkable. A stent is noted in the left
subclavian
artery which is patent.
Also noted are sternotomy wires, bibasilar atelectatic changes
in the
visualized lung apices and a hypoplastic or absent thyroid
gland. Clinical
correlation is recommended.
There are several enlarged mediastinal lymph nodes, the largest
of which is
precarinal and measures 14.3 mm.
CT PERFUSION: There is increased mean transit time in a large
right MCA
territory distribution in the right frontoparietal region. This
is associated
with decreased cerebral blood flow but normal cerebral blood
volume. This
likely represents an acute large infarct with some mismatch
possibly
representing an area of penumbra.
Rotation of the C1 over C2 vertebra is likely positional in
nature.
IMPRESSION: Acute right MCA vascular territory infarct as
described above.
CT head [**2155-2-8**]
IMPRESSION: No intracranial hemorrhage or edema.
HbA1c 5.5
LDL 33
Brief Hospital Course:
79 yo female with CAD s/p CABG with only patent LIMA-LAD, COPD,
HTN, afib who presents with hematochezia, anemia, and angina,
sent to MICU initally where she was transfused with HCT back up
to 31, c/b NSTEMI with CHF.
.
# Stroke: has h/o Afib but her anticoagulation was held in the
setting of acute GIB complicated by NSTEMI. It was felt she
would restart ASA 325mg upon discharge. The pt was intact
neurologically throughout admission until [**2-7**] when she was
found to have acute onset dysarthria, L facial droop, L
hemiparesis. Code stroke was called and pt was found to have R
MCA embolic infarct on CT head. She was sent emergently to neuro
IR for IA TPA and MERCI clot retrieval. She was initially
transferred to the neuro ICU and has been continuing to improve
clinically. Her coumadin has been re-started and her hematocrit
has remained stable. Her LDL was 33 and HbA1c was 5.5. Her INR
on day of transfer ([**2-14**]) was 3.1 and today's dose will be held.
Please monitor daily for goal [**2-19**].
.
# Hematochezia: likely due to angiodysplasia vs diverticulosis
as pt had colonoscopy in [**2152**] with only polyps. on transfer out
of the MICU her HCT was up to 31 (was initially 22.5 on
admission) after 3U pRBC. While on the floor she was transfused
1 more unit of blood and her HCT was maintained around 30
without any evidence of GI bleeding (stools were without blood).
She was continued on [**Hospital1 **] po pantoprazole. Her hematocrit has
remained stable in the low 30s. Gastroenterology plans to
perform a colonoscopy as an outpatient in [**6-24**] weeks. Given her
other comorbidities and stable hematocrit it was decided to
defer this procedure at this immediate time.
.
# NSTEMI: Patient has known bad coronary disease with diseased
grafts as well taking up to 3 NTG daily for anginal pain.
patient's initial ECG with afib with RVR and lateral STD and
TWI; most likely due to demand ischemia. Pt had CP and 1st set
CE was neg, but then subsequent had Trp peak up to 1.8 (CK 556,
CKMB 10.4) c/w NSTEMI in setting of acute lower GI bleed.
Cardiology was consulted and recommended holding anticoagulation
until she was stable from her GIB. Her chest pain improved with
transfusions, nitro, and morphine, and now pt has been CP free
while on the floor. she was started on metoprolol 25 tid,
atorvastatin 80mg. her lisinopril and imdur were held to avoid
hypotension in the setting of GIB. Her lisinopril has been
resumed and her blood pressure has been well-controlled.
.
# Dyspnea/tachypnea: Patient has COPD at baseline, and uses O2
(2L) at night for comfort and angina with exertion. During the
day, she should be using her O2 but she has not been using it
due to difficulty with portability. Now with EF 20-30% severely
dropped form 50% in [**2153**], likely due to NSTEMI. Also likely
worsened initially in MICU in the setting of volume (blood, FFP,
and IVFs). Diuresed well with IV lasix in the MICU and on the
floor. She was started on po 20mg lasix daily and maintained on
her fluticasone and ipratropium nebs. She is currently doing
well on her home requirements of 2L O2 via nasal cannula.
.
# Afib: patient on metoprolol and coumadin as an outpatient.
Given her above h/o GIB complicated by NSTEMI, cardiology/GI
consults recommended that due to her CHADS2 score of 3 she
should be restarted on ASA 325mg once her GIB was stabilized. It
was felt that the pt would have this started upon d/c. Despite
these efforts the pt suffered from an embolic stroke entailed
above and therefore will be continued on coumadin with goal INR
[**2-19**].
.
# Hypothyroidism: cont levothyroxine
.
# DM2: RISS. Glipizide may be resumed at the time of transfer.
.
# CKD: creat 1.3-1.5 at the time of presentation, now trending
down to 0.9-1.
.
Medications on Admission:
Albuterol
Coumadin 1 mg daily
Fluticasone 220 mcg 1 puff [**Hospital1 **]
Glipizide 5 mg daily
Imiquimond 5% packet apply twice a week
Imdur 90 mg daily
Lisinopril 2.5 mg daily
Levothyroxine 75 mcg daily (150 mcg on sunday)
Atorvastatin 40 mg daily
Macrobid 50 mg QHS
Pantoprazole 40 mg daily
HCTZ 50 mg daily
Spiriva 1 puff daily
Metoprolol succinate 100 mg daily
Aspirin 81 mg daily
Ferrous gluconate 325 mg daily
Coenzyme Q10 100 mg daily
Calcium/Vitamin D daily
MVI daily
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
4. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM: Adjust as needed for goal INR [**2-19**].
7. Levothyroxine 75 mcg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily): Q Mon, Tues, Wed, Thurs, Fri, Sat.
8. Levothyroxine 75 mcg Tablet [**Month/Day (3) **]: Two (2) Tablet PO DAILY
(Daily): on Sunday only.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Glipizide 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
NSTEMI
Right MCA stroke
Lower GI bleed
Discharge Condition:
A&Ox3, dysarthric. R gaze preference, surgical pupil (left
eye). L facial droop. Extinction to L on DSS. Antigravity
strength in all extremities.
Discharge Instructions:
You were initially admitted with a gastrointestinal bleed and
chest pain. During your hospital course you had a stroke which
was treated with intraarterial TPA and MERCI clot retrieval.
Your hematocrit has remained stable and you will be transferred
to a rehabilitation facility for further care.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2155-2-14**] 8:40
Provider: [**Name10 (NameIs) 9977**] IN [**Location (un) 2788**] Phone:[**0-0-**]
Date/Time:[**2155-2-14**] 1:15
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2155-2-18**]
1:00
Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurology) to schedule a follow up
appointment in two months. His office can be reached at ([**Telephone/Fax (1) 76682**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
E9342,59971,45829,2800,E8788,V4986,V1254,V4581,412,49320,2449,1534,42821,1982,2639,5849,5601,99811,99813,42731,4280,40390,5853,4139,25000,53081 | 249 | 158,975 | Admission Date: [**2156-4-27**] Discharge Date: [**2156-5-14**]
Date of Birth: [**2075-3-13**] Sex: F
Service: SURGERY
Allergies:
Altace / Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Occult positive stools, h/o stroke while off of anticoagulation
for GIB.
Major Surgical or Invasive Procedure:
Laparoscopy and open right ileocolectomy, [**2156-4-30**]
History of Present Illness:
81 yo F with pmh of CVA, stage III CKD, CAD s/p LIMA to LAD,
Afib on dabigatran who presents for a colonoscopy planned for
guiaic positive stools and a recent admission for GIB. The
patient denies any current complaints and has not noted any
recent bloody stools. She does complain of some right upper
quadrant "heaviness" that does not radiate. It is [**4-25**] in
intensity. Denies any relieving or exacerbating factors. She
notices it most at night time when she is trying to fall asleep.
She denies any change with diet. She denies any n/v, diarrhea,
constipation. She otherwise feels at her baseline with respect
to her health.
.
Review of Systems: Pain assessment on arrival to the floor: 0/10
(no pain). No recent illnesses. No fevers, chills, or night
sweats. Appetite is good and weight is stable. No SOB, new
cough. She has chronic angina that typically occurs when she
wakes up or sometimes at night time after a busy day, relieved
with 1 SLNG, this is stable but frequent (sometimes takes SLNG
daily). No PND or orthopnea. No urinary symptoms. No LE edema.
No skin changes. No arthralgias or joint swelling. Other systems
reviewed in detail and all otherwise negative.
Past Medical History:
- Coronary artery disease, s/p 3V CABG EF 50%
- Left subclavian stent [**51**]/[**2146**].
- Atrial fibrillation.
- Hypertension.
- Hyperlipidemia.
- COPD (FEV1/FVC 53, FEV1 0.63)
- GERD
- Anemia.
- Hypothyroidism
- Stage III CKD
- CVA
- fractured pelvis in fall several months ago
Social History:
She lives alone. She has extensive support from her daughters.
She denies tobacco, ETOH, or drugs
Family History:
Mother with myocardial infarction in her 60s. No diabetes
mellitus. Grandfather with chronic obstructive pulmonary
disease.
Physical Exam:
Vital Signs:
T 97.9 BP 101/66 P 77 RR 18 SpO2 100% on 2L
Physical examination:
- Gen: Well-appearing in NAD.
- HEENT: Conj/sclera/lids normal, left surgical pupil, right
pupil reactive. EOM full, and no nystagmus. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Irregularly irregular. Normal S1, S2. II/VI systolic
murmur at left sternal border. JVP <5 cm.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver not enlarged. Neg [**Doctor Last Name 515**] sign.
- Extremities: No ankle edema.
- Skin: No lesions, bruises, rashes with exception of stasis
dermatitis bilateral shins
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**5-20**] in
upper and lower extremities bilaterally. Sensation to light
touch intact in upper and lower extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Pertinent Results:
[**2156-4-27**] 04:40PM WBC-8.3 RBC-3.44* HGB-9.5* HCT-29.5* MCV-86
MCH-27.5 MCHC-32.1 RDW-16.5*
[**2156-4-27**] 04:40PM NEUTS-74.6* LYMPHS-13.7* MONOS-8.9 EOS-2.4
BASOS-0.4
[**2156-4-27**] 04:40PM PT-20.0* PTT-47.3* INR(PT)-1.8*
[**2156-4-27**] 04:40PM GLUCOSE-72 UREA N-27* CREAT-1.4* SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12
[**2156-4-27**] 04:40PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-1.7
.
EKG - AFib, LAD, unchanged c/w prior with exception that TW is
upright in I instead of inverted. No acute ST/TW changes.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the medical service and started on
a colonoscopy preparation, her pradexa was held and she was
started on a heparin drip. She was taken to the GI suite on
[**2156-4-28**] for endoscopy which showed an "ulcerated mass with
necrotic base highly suggestive of carcinoma" in the cecum. She
had a CT scan of the chest/abdomen/pelvis to assess for
metastasis and further define the tumor. It confirmed
colonoscopy findings and did not show evidence of metastasis.
She was taken to the operating room for a right colectomy with
Dr. [**Last Name (STitle) 1120**] of colorectal surgery on [**2156-4-30**]. There was 500 cc of
estimated blood loss.Please refer to Dr.[**Name (NI) 3377**] operative note
for further details. She was started on cipro/flagyl
prophylactically after the procedure. After a brief stay in the
PACU she was transferred to the floor but over the course of the
night had low urine output, her blood pressure dropped to the
systolic 80s/40s and her atrial fibrillation frequently took her
heart rate to the 120s-130s. She was transferred to the ICU
given her extensive cardiac history and unclear etiology of her
hypotension -- cardiogenic vs. septic. She was continued on
antibiotic coverage and the plan was for volume resuscitation
with close monitoring of other aspects of her clinical picture.
She was asymptomatic and felt well throughout the process,
though somewhat tired.
She was transfused one unit of PRBCs, volume resuscitated with
crystalloid and albumin and eventually her systolic pressures
returned to the 90s-100s systolic. She was deemed stable for
transfer to the floor. On POD 5 she reported passing flatus,
she was advanced in diet progressive to a low-residue regular
diet on POD 8.
Remaining aspects of her hospitalization, by systems:
Neuro: No issues. Pain controlled on a regimen of IV and PO
medications when tolerating. Mental status appropriate
throughout hospitalization.
Cardiac: Multiple cardiac issues assessed by cardiology service
preoperatively and which recommended continuing current care.
Multiple episodes of anginal chest pain relieved with sublingual
nitroglycerin. No EKG changes until POD 7 when chest pain was
accompanied by questionable ischemic changes on EKG. Cardiology
recommended nitroglycerin PRN as well as cycling enzymes which
returned at 0.05->0.05->0.04. Her afib was monitored on
telemetry and she was treated with 5 mg IV lopressor q6 hours
when NPO and transitioned to 25 mg PO BID.
Respiratory: Baseline used oxygen at home was kept on 2L oxygen
in the hospital and maintained good saturations in the high 90
percents. She did have some respiratory difficulty and
increased oxygen requirement while in the ICU but this resolved
after effective diuresis. At time of discharge satting 90s on
room air.
Heme: Once the patient's hematocrit was stable, a heparin drip
was started to bridge her to coumadin therapy. However, patient
developed melenic stools and hematuria when heparin drip
restarted. All anticoagulation except aspirin was held and no
further episodes of bleeding occured. Patient's coumadin will
need to be restarted when her nutritional status is more
improved.
ID: Cipro/Flagyl initially post-operatively and dc'd on POD 7.
Afebrile throughout course. Complained of vaginal itching, given
single dose of oral diflucan.
[**Name (NI) 153**] Course
Pt was transferred to the [**Hospital Unit Name 153**] on [**5-1**] for management of
hypotension and low urine output in setting of recent colectomy.
.
# Hypotension: Noted to be progressively hypotensive through
today (POD1) with concern for hypovolemia however could also be
related to evolving sepsis picture she is currently on
cipro/flagyl since last night. Given extensive cards history
could also be cardiogenic shock related to missed event given
her 500cc blood loss intraoperatively and prior hx of ischemic
event in setting of blood loss in 01/[**2155**]. Lower concern for
this given current clinical and exam status. Given hx of
recurrent UTIs (on home macrobid suppressive tx) could also be
related to urosepsis. Currently mentating at baseline. Plan to
volume resuscitate until increase in O2 requirement. She
received 1u pRBC on arrival to floor with 500cc LR IVF boluses x
2. Her BP improved to 90-110 wo pressors. She did not require a
CVL and declined this on her ICU consent form as well. NICOM was
placed which showed 33% change in CI, indicating likely fluid
responsiveness. Her UO improved to 20cc/hr but remained there
with crystalloid boluses. Per surgery recs, she was changed to
albumin 5% IVF hydration. She was given lasix for volume
overload XXXX.
She was broadened to vancomycin, zosyn and ciprofloxacin for
double GNR coverage overnight given higher likelihood of GI
etiology related to recent surgery and instrumentation. Given
her remarkable hemodynamic improvement overnight she was changed
back to cipro/flagyl. She was recultured for urine and blood.
Her EKG was checked and at baseline. Cardiac enzymes were cycled
and mildly elevated trop attributed to underlying CKD and
possible demand ischemia [**2-18**] tachycardia on presentation.
.
# CAD: Extensive cardiac hx including recent NSTEMI [**1-/2156**] in
setting of GIB and CVA at same time. Has been on home
dabigatran. Follows as outpt w Dr. [**Last Name (STitle) 120**]. Increasing NSL use
for her anginal equivalent altho per cards notes, outpt cards is
not concerned for ischemic etiology. Last TTE 8/[**2156**]. She was
continued on Heparin SQ, 81mg asa and pneumoboots. Her
transfusion goals were for Hct<30 per cardiology recs
pre-operatively. EKG in the ICU was rechecked and at baseline.
Cardiac enzymes were cycled (see above).
.
# Afib: On dabigatran at home for other comorbidities, CHADS2
score is 6. Currently in afib. Her home betablocker was held for
hemodynamic monitoring. She was noted to be in 100-130s afib
with mild SOB but otherwise comfortable. Her betablocker was
restarted on [**5-2**] and XXXX.
.
# CHF: Systolic EF 35% on TTE [**8-/2155**] and global LV hypokinesis.
Cards consulted pre-op w recommendation to gently diurese for
vol overload on presentation - last given 20mg IV lasix [**4-29**].
Pleural effusion on AM chest xray and crackles on exam on
transfer to the ICU. Home diuretic was held on admission to the
ICU for BP stabilization and restarted XXX.
.
# Cecal Mass: necrotic appearance on colonoscopy concerning for
malignancy. S/p colectomy [**4-30**]. Pathology is pending.
.
# CKD: unclear baseline but likely 0.9-1.1. On outpt procrit.
Creatinine elevated on admission. FENA this AM 1%, concern for
possible ATN related to hypovolemia. Repeat urine lytes notable
for FeNA = 0.1% indicating prerenal hypovolemic picture. Urine
output was monitored and responded to IVF boluses w increase to
20cc/hour.
.
# COPD/ASthma: On home O2 via nasal cannula at baseline. Unclear
pulmonary disease hx. She was continued on home dose
fluticasone, and spiriva. Albuterol held for tachycardia and
restarted on XXX.
.
# HTN: on home ace, and bblocker. Holding now for hemodynamic
monitoring.
.
# HL: cont home lipitor
.
# Hypothyroidism: continued on home dose levothyroxine
.
# DM: on home glipizide. Holding oral meds, cont ISS.
.
FEN: IVF to MAP>60, replete electrolytes, NPO for now
Prophylaxis: Subcutaneous heparin, pantoprazole IV q24
Access: peripherals
Code: DNR, ok to intubate, no CVL
Communication: Patient, HCP [**Name (NI) 16883**] [**Name (NI) **] [**Telephone/Fax (1) 102489**]
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA four times daily PRN
ASPIRIN - 81MG Tablet - ONE EVERY DAY
Pradexa 75 mg [**Hospital1 **]
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol twice daily
GLIPIZIDE - 1.25 mg Tablet daily
LEVOXYL - 75MCG Tablet - ONE EVERY DAY; 150 mcg on Sunday
LIPITOR - 40MG Tablet - ONE EVERY DAY
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth daily
NITROFURANTOIN [MACROBID] - 50 mg nightly
PROTONIX - 40MG Tablet, Delayed Release (E.C.) - ONE EVERY DAY
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg daily
TOPROL XL - 25 mg daily
OTC:
CALCIUM CARBONATE-VITAMIN D3 600 mg-400 unit Tablet - twice a
day
COENZYME Q10 - 100 mg Capsule by mouth daily
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - 1 Tablet(s) by
mouth daily
Discharge Medications:
1. levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ML PO BID (2
times a day).
5. atorvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. hydromorphone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day): hold for loose stool.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-18**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
11. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours).
12. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Day (2) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
13. nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Day (2) **]: One (1) Tablet,
Sublingual Sublingual PRN as needed for chest pain.
14. metoclopramide 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every
eight (8) hours for 3 doses: For three doses only once patient
is at rehab. Afterwards, this medication should be
discontinued.
Disp:*3 Tablet(s)* Refills:*0*
15. Blood Draw [**Month/Day (2) **]: One (1) blood draw once, [**2156-5-10**]: Please
check INR value for coumadin dosing.
Disp:*1 blood draw* Refills:*0*
16. metoprolol tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
twice a day.
17. fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. pramoxine-mineral oil-zinc 1-12.5 % Ointment [**Hospital1 **]: One (1)
Appl Rectal [**Hospital1 **] (2 times a day) as needed for anal itching.
19. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for puritis r/t dry skin on back.
20. insulin lispro 100 unit/mL Solution [**Hospital1 **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
21. lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Renaisance gardens
Discharge Diagnosis:
cecal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of a bleed from your
gastrointestinal tract. It was discovered that you had a
colonic mass upon further investigation and you then had a
surgical procedure called a right colectomy.
Regarding your anticoagulation, you have been very mal nourished
and when our surgical team attempted to anticoagulate you you
developed further GI bleeding and some blood in your urine. Your
anticoagulation has been on hold for the time being. The
rehabilitation facility should restart this anticoagulation at a
time they see as appropriate when you nutrtional status has
improved some.
In the coming days as you continue to recover, please keep in
mind the following:
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-25**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
While taking narcotic pain medication, please emember to take
colace (to avoid constipation) and please do not drive or
operate heavy machinery.
Please follow-up with your primary care physician (in addition
to your surgeon) in the coming weeks to reconcile all of your
medications and to touch base regarding other medical issues or
concerns after the surgery.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Please call your doctor if you experience the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Patient needs to have her INR checked on Monday, [**2156-5-10**], and
have her coumadin dosing readjusted per results. Primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3315**] at [**Location (un) **], [**Apartment Address(1) 8308**], [**Location (un) **],[**Numeric Identifier 1700**] and phone [**Telephone/Fax (1) 37171**] to arrange for appointment
on Monday.
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks. Call ([**Telephone/Fax (1) 6316**] to schedule the appointment. Please call on Monday,
[**5-10**].
Completed by:[**2156-5-14**] |
0382,78552,51881,481,5849,78551,9982,1970,19889,99592,4239,2859 | 250 | 124,271 | Admission Date: [**2188-11-12**] Discharge Date: [**2188-11-22**]
Date of Birth: [**2164-12-27**] Sex: F
Service: CSU
BRIEF CLINICAL HISTORY: Ms. [**Known lastname 59870**] is a 23 year old Haitian
woman who presented originally to the Medical Intensive Care
Unit on [**2188-11-12**], with approximately two to three
week history of mid sternal chest discomfort which had been
treated with codeine. Circumstances surrounding the
patient's presentation were somewhat confusion and
contradicted at various times by the patient and various
family members. What is known is that within three to four
days of the patient's presentation to [**Hospital6 649**] she had arrived from [**Country 2045**] on apparently a
legal visa. Soon after arriving she began experiencing
shortness of breath, dyspnea and intermittent fever and
chills. What is unclear is how long she had been having
these problems. She had had a prescription for codeine which
she had taken with her. While she did endorse that the
symptoms became worse during her flight, it was generally
agreed that there was a prodrome that superceded her flight.
Upon her presentation to the Emergency Department on the
afternoon of the 17th the patient was complaining of
shortness of breath, dyspnea and increasing bilateral lower
extremity swelling. She had had a productive cough for at
least the last 48 hours, being described as yellow to green
sputum. She did describe fevers and denied any night sweats.
PRIOR MEDICAL HISTORY: Asthma.
Unclear history of a resection of the neck mass, apparently
in the [**Country 13622**] Republic although this was never entirely
clear.
ALLERGIES: Aspirin causes eye swelling in eyes.
MEDICATIONS: Codeine exact prescription unknown.
FAMILY HISTORY: The patient has a sister with [**Name2 (NI) 14165**] cell
disease and is thought to have [**Name2 (NI) 14165**] cell trait.
SOCIAL HISTORY: The patient was endorsed that she had been
sexually active in the past but denies unprotected
intercourse. Denies intravenous drug use, alcohol or
tobacco. As previously mentioned, the patient is a recently
emigrated Haitian. She joined her brother and sister here in
the United States and leaves a mother in [**Country 2045**].
PHYSICAL EXAMINATION: Upon presentation to the Emergency
Department, the patient is described as a somewhat frail-
appearing Haitian woman in some distress. She had a
temperature maximum and temperature currently of 97.8
degrees. She was extremely tachycardiac at 170 beats per
minute. Blood pressure was 142/100. Respirations 30s,
sating 100 percent on a nonrebreather mask but 91 percent on
room air. In general, she was pale and cachectic using
accessory muscles for breathing. Head, eyes, ears, nose and
throat examination showed dry mucous membranes and unable to
visualize posterior discs. Neck is supple, there is,
however, a small 1 cm scar seen on the left side, no evidence
of any thyromegaly or anterior or posterior lymph node chain
adenopathy. Chest shows decreased breath sounds bilaterally
but in particular on the left side. There are coarse
crackles throughout bilaterally. Cardiac examination is
tachycardiac, no evidence of any murmurs, rubs or gallops.
Abdomen is soft, nontender, nondistended with positive bowel
sounds. Extremities, show 2 plus lower extremity edema.
LABORATORY RESULTS ON PRESENTATION: Sodium 135, potassium
8.8, chloride 100, carbon dioxide 23, BUN 10, creatinine 0.5,
glucose 92, white blood cell count 14.4, hematocrit 26.9,
platelets 720, lactate 1.2, liver function tests pending at
the time of admission.
Radiology: The patient had a patchy interstitial
infiltrates, left side greater than right with left pleural
effusions as well as some poorly differentiated pleural
thickening throughout.
BRIEF HOSPITAL COURSE: Based on the patient's initial
presentation, it was thought that her presentation was a most
likely acute and chronic etiology. Scenarios considered were
pneumonia, pulmonary embolism secondary to recent air travel,
severe asthma. Given the tachypnea and poor oxygenation, the
patient was admitted directly to the Cardiac Intensive Care
Unit. There she was made a full code. Shortly after
arrival, therapeutic thoracentesis was performed. This
removed greater than 250 mm of serosanguinous fluid from the
left side. There was some improvement in her pulmonary
function thereafter. Within two hours of presentation to the
Medical Intensive Care Unit the patient became tachypneic and
arterial blood gases showed increasing difficulty with
oxygenation. She was shortly intubated thereafter with
confirmation of placement of an endotracheal tube via chest x-
ray. Bronchoscopy performed soon thereafter likewise showed
good placement of her endotracheal tube. Aspiration showed a
large amount of purulent, sometimes bloody material within
the lung parenchyma.
Thereafter the patient's presentation became increasingly
consistent with aseptic etiology. She was started on Zigress
per the sepsis protocol. By morning, her respiratory status
had worsened and again there became increasing problems with
oxygenation. Initial consultation by Cardiac Surgery for
possible extracorporeal membrane oxygenation was obtained and
Cardiac Surgery deemed the patient an appropriate candidate
and emphasized their readiness to perform procedure as
necessary. This initial extracorporeal membrane oxygenation
evaluation took place on [**2188-11-13**]. However, the
decision was made to delay extracorporeal membrane
oxygenation over night and to reassess in the morning.
By hospital day Number 2, the patient's presentation had
evolved to florid sepsis. Human immunodeficiency virus tests
as well as critical stem tests had all come back negative.
By mid morning, the patient had been maxing out all of her
ventilation possibilities and oxygenation was still extremely
challenged. Bedside echocardiogram showed evidence of a
large pericardial effusion. It was not clear if this was
secondary to the pneumonia, pulmonary embolism or other
etiology. Cardiology was consulted and the decision was made
to do a pericardiocentesis. The procedure was performed at
the bedside under ultrasound guidance. During this maneuver,
there was some damage noted to the right ventricle, most
likely secondary to a large dilated ventricle in the setting
of high right-sided pressures. The patient was taken
emergently to the Operating Room. In the Operating Room a
midline sternotomy was performed and a pericardial tamponade
was repaired. During the course of this repair, several
lesions in the surface of the heart and lungs were noted.
These were biopsied intraoperatively. Initial intraoperative
pathology showed pathology consistent with neuroendocrine
carcinoma, again highly unusual for a woman of this age and
this presentation. Given the unclear etiology of these
lesions and the patient's overall presentation, decision was
made to continue aggressive treatment and while in the
Operating Room the patient was catheterized per the right
femoral vein and artery and extracorporeal membrane
oxygenation was started.
The patient at that time was transferred to the
Cardiothoracic Surgery Unit and her care team was transferred
from the Medical Service to the Cardiac Surgery Service under
the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. Over the next 48 hours, the
patient remained reasonably stable on extracorporeal membrane
oxygenation. Her oxygenation was maintained. A chest x-ray
showed a gradually improving lung field, although the
starting point from this was complete whiteout of both
fields. A single sputum culture did show Streptococcus
pneumonia. The patient was started empirically on
Vancomycin, Ceftriaxone and Levofloxacin. While on
extracorporeal membrane oxygenation, the patient's sedation
was lightened intermittently and she was confirmed to be able
to move all four extremities. She likewise underwent daily
bronchoscopy and several mucous plugs and purulent material
was removed from her lungs.
On hospital day 5 through 7, intense review of the surgical
samples was undergone by the Pathology Department in concert
with the Oncology Group. Initial staining of the tissue
likewise was thought to be neuroendocrine tumor, however,
subsequent specialized staining with amino peroxidase showed
this tumor to, in fact, to be consistent with a poorly
differentiated large cell carcinoma. In further reviewing
the patient's history, both by record and in discussion with
her siblings and her mother in [**Country 2045**], it appears that the
patient had a small lesion removed from her neck somewhere in
the [**Country 13622**] Republic. The exact nature of this mass, its
size, pathology and follow up was never obtained although it
was thought to be quite suspicious.
By hospital day 9 or postoperative day 6, final evaluation by
Oncology had been completed and in discussion with the
primary team, Oncology and the patient's family decision was
made that attempt would be made to wean her from the
extracorporeal membrane oxygenation machine, given that there
was no clear interventions to be directed towards the cancer
itself. On [**11-21**], [**2187**], after intensive optimization
of her ventilator settings, fluid status and introduction of
nitric oxide, attempt was made to wean the patient from
extracorporeal membrane oxygenation. This was tried
unsuccessfully during the course of the day and by late in
the afternoon, the patient ultimately had to be returned to
full extracorporeal membrane oxygenation support. By the
following day after an additional review by the Cardiac
Surgery Service, opinion rendered by the Ethics Support
Service, Dr. [**Last Name (STitle) 59871**] [**Name (STitle) 59872**], and position taken by the [**Hospital6 1760**] Legal Department, decision
was made for a final wean of the extracorporeal membrane
oxygenation machine. Prior to this maneuver, the patient's
brother and sister were intensively consulted, and indeed
spent much of [**Holiday 1451**] Day in the patient's room.
Several conference calls were initiated both directly and
through a Creole translator to the patient's mother in [**Country 2045**].
Pastoral services as well as Ethics Committee were consulted
throughout this and the patient's family was fully aware and
in agreement of what was happening with the patient.
At approximately 2 PM in the afternoon of [**2188-11-22**],
the patient's ventilator settings were once again optimized.
A surgical team was brought into her Intensive Care Room and
after complete wean of the extracorporeal membrane
oxygenation machine, Vascular Surgery Service decannulated
intake and output catheters and closed the enterotomies in
both vessels. Over the next two to three hours, the patient
required increasing pressure support, maxing out Levophed,
epinephrine, Natrecor, Neo-Synephrine and ventilator
settings, none of which were to maintain a blood pressure
compatible with life. Lactaid increasingly increased.
Likewise pH dropped consistently to 7.1 despite several
cycles of bicarbonate. At approximately 7 PM the patient
became asystolic and unresponsive to further chemical
interventions.
There were several long discussions at that time with the
patient's brother and sister as well as various members of
the Creole community. Several hours later, a conference call
was set up and in the company of the Intensive Care Unit
staff, the patient's brother and sister informed the mother
of the sister's passing. The patient's mother did appear
willing and anxious to have an autopsy performed and this was
arranged. The patient's case was presented to the medical
examiners office and likewise was declined.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2188-11-23**] 01:23:31
T: [**2188-11-23**] 08:13:21
Job#: [**Job Number 59873**]
|
85300,9130,9100,30500,E8889 | 251 | 117,937 | Admission Date: [**2110-7-27**] Discharge Date: [**2110-7-29**]
Date of Birth: [**2090-3-15**] Sex: M
Service: TRAUMA [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Briefly, this is a 20 year old
male status post assault versus fall. He was found down at a
party and brought to an outside hospital by his friends. [**Name (NI) **]
was found to be stable and responsive. Head CT scan there
showed a right temporal bleed. The patient was transferred
to [**Hospital1 69**] for further
management.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
PHYSICAL EXAMINATION: The patient was alert and oriented
times one, [**Location (un) 2611**] Coma Scale of 13, moving all extremities
and following commands. Pupils are equally reactive. Clear
to auscultation. Trachea midline. Regular rate and rhythm.
Abdomen was soft, nontender. Rectal is guaiac negative and
no gross deformities on back.
LABORATORY: White blood cell count was 15, hematocrit 39,
platelets 276. Electrolytes were within normal limits.
Toxicology screen positive for ethanol at a level of 38.
Head CT scan showed an acute intraparenchymal hemorrhage,
possibly small right frontal subdural hematoma. Pelvic x-ray
was read as negative.
CT scan of the cervical spine was read as no fracture. CT
scan of the abdomen and pelvis was read as negative. TLS was
also read as negative.
HOSPITAL COURSE: Neurosurgery was consulted. According to
their recommendations, an MRI was done as was a follow-up
head CT scan on hospital day number two. Repeat head CT scan
showed no change from previous and MRI showed no organic
cause for the bleed and confirmed likely traumatic cause.
The patient was transferred to the Floor and felt to be
ready for discharge on hospital day number three, as he was
tolerating a regular diet, ambulating well and with no
complaints of pain. Rehabilitation Services came by and
spoke with the patient. The refused alcohol counseling and
was discharged to home.
DISCHARGE INSTRUCTIONS:
1. The patient to follow-up with Dr. [**Last Name (STitle) 1132**] of Neurosurgery
in one month with an outpatient CT scan.
2. Also to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 49211**] in [**Hospital **]
Rehabilitation in one to two weeks.
3. To follow-up with the Trauma Clinic in one to two weeks.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg capsule three times a day.
2. Tylenol for pain.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post closed head injury with intraparenchymal
hemorrhage, right frontal and bitemporal.
2. Small foci parenchymal hemorrhage; thin subdural right
temporal.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2110-8-1**] 16:38
T: [**2110-8-7**] 21:29
JOB#: [**Job Number 49212**]
|
2875,78559,5722,7895,51881,5780,45620,5712,45341,E8796,V1301,3051,0701,5798,2738,34831,5723,2851,2639,8670,5997,486,2761,2867,30500,5849,5990 | 252 | 190,159 | Admission Date: [**2133-3-31**] Discharge Date: [**2133-4-23**]
Date of Birth: [**2078-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Esophageal Variceal Hemorrhage
Major Surgical or Invasive Procedure:
Intubation, Mechanical Ventilation, EGD Without Intervention,
IVC Filter Placement.
History of Present Illness:
55 yo man with hx of alcoholism, admitted with GI bleed to OSH,
with gelatinous bright red blood emesis, and weakness, found to
be unresponsive, BP 68/38, HR 130s, HCT 19 at [**Hospital3 7569**].
He was then was intubated for airway protection, given 2uPRBC
and 2-3L NS, SBP came up to 100. Pt transferred here to [**Hospital1 18**]
for further evaluation. In the MICU, he received 9 units pRBC,
4 units FFP (for coagulopathy that has since resolved). He was
seen by GI who did multiple EGDs; these showed no active
bleeding, grade 2 esophageal varices, and portal gastropathy.
No intevention was performed. He was also seen by neuro for
some ?myoclonic jerks that were thought to be [**2-25**] etoh
withdrawal vs. anoxic brain injury vs. hepatic encephalopathy.
His hct stabilized and he had no more episodes of active
bleeding. He was extubated on [**4-9**], but his MS continues to wax
and wane. He is currently completing a 10 day course of
Vancomycin for ?GPC in sputum. He also completed an 8 day course
of Levo/flagyl for SBP ppx given his ascites.
Also during the MICU course, abdominal US showed diffusely
coarsened and heterogeneous hepatic echotexture, consistent with
cirrhosis. No focal lesions identified. Small amount of
perihepatic ascites. Patent portal veins, with flow in the
appropriate direction. He had a TTE that showed only mild MR.
[**Name13 (STitle) **] jad a swam placed; numbers did not implicate a primary
cardiac cause for his initial hypotension. Abd CT showed showed
mesenteric edema, some diverticuli. MRI of head showed mild to
mod age-inappropriate brain atrophy.
He was transferred to the floor when hct was stable; MS is still
waxing and [**Doctor Last Name 688**], and he is still not able to adequately take
PO's.
Past Medical History:
Alcoholism, Kidney Stones, ETOH Cirrhosis.
Social History:
1 ppd smoking hx and known alcoholic- unclear when last drink,
lives alone with no known family
Family History:
NC
Physical Exam:
VS: 99.5 110/78 75 20 104
Gen: not completely clear speech, A&O x 2 (knows year, knows in
hospital, ?knows president), mild distress, tearful at times
HEENT: PERRL, some yellow saliva/exudate on roof of mouth
Neck: with right IJ, no lad, no JVD appreciated
Lungs: CTA from anterior exam
CV: distant heart sounds, nl s1/s2, no m/r/g
Abd: soft, distended, ?fluid wave, no HSM, nt, no reb/guard
Extr: 2+ pitting edema in LE (with pneumoboots), DP 1+
bilaterally
Neuro: MS as above, [**5-28**] grip, can lift legs off bed, 3-4/5
strength LE
Pertinent Results:
ABD U/S ([**2133-3-31**]): IMPRESSION: 1) Diffusely coarsened and
heterogeneous hepatic echotexture, consistent with cirrhosis. No
focal lesions identified. Small amount of perihepatic ascites.
2) Patent portal veins, with flow in the appropriate direction.
EGD ([**2133-3-31**]): Impression: Grade II varices were noted in the
lower esophagus but last 4 cm of esophagus appeared fibrotic
with no varices, consistent with possible prior endoscopic
therapy. No bleeding noted from the esophagus. Mostly old, and
some fresh blood in the stomach - ?bleeding from proximal
stomach. Erythema and congestion in the whole stomach compatible
with portal gastropathy and hypoalbuminemia. Otherwise normal
egd to second part of the duodenum.
L LE U/S ([**2133-4-19**]): IMPRESSION: There is a crescenteric-shaped
thrombus within the left common femoral vein, which is only
partially occlusive. Acuity of this can not be determined, and
this may be an acute thrombus. These correspond to the findings
on recent CT scan.
CT TORSO/PELVIS ([**2133-4-18**]): IMPRESSION: 1) 3.4-cm aneurysm
arising from the proximal left common iliac artery. 2) Apparent
peripheral filling defect within the left superficial femoral
vein. While this could represent artifact, an ultrasound could
be performed to evaluate for the presence of thrombus in this
patient with history of left femoral vein catheterization. 3)
Diverticulosis with no CT evidence of diverticulitis. 4) Sludge
and stones within a nondistended gallbladder. 5) Moderate amount
of intra-abdominal ascites with a nodular liver contour,
findings suggestive of cirrhosis. 6) Small bilateral pleural
effusions with associated atelectasis. 7) Emphysema. 8)
Bilateral low-attenuation lesions within both kidneys, likely
representative of simple cysts. A focal area of dense
calcification is also present adjacent to a cystic area of low
attenuatiuon within the posterior right kidney.
[**2133-3-31**] 04:38AM BLOOD freeCa-1.03*
[**2133-4-2**] 05:36AM BLOOD freeCa-1.19
[**2133-3-31**] 04:38AM BLOOD Glucose-127* Lactate-9.0* Na-144 K-4.9
Cl-115* calHCO3-17*
[**2133-3-31**] 09:48AM BLOOD Lactate-3.0*
[**2133-3-31**] 04:05PM BLOOD Lactate-1.8
[**2133-4-5**] 08:11AM BLOOD Lactate-1.3
[**2133-3-31**] 07:37AM BLOOD Type-ART Temp-35.3 Rates-12/ PEEP-5
FiO2-100 pO2-303* pCO2-45 pH-7.23* calHCO3-20* Base XS--8
AADO2-364 REQ O2-65 Intubat-INTUBATED
[**2133-3-31**] 09:48AM BLOOD Type-ART Temp-36.4 pO2-107* pCO2-37
pH-7.35 calHCO3-21 Base XS--4 Intubat-INTUBATED
[**2133-3-31**] 04:05PM BLOOD Type-[**Last Name (un) **] Temp-38.2 Tidal V-50 PEEP-5
pO2-104 pCO2-36 pH-7.35 calHCO3-21 Base XS--4 Intubat-INTUBATED
Vent-CONTROLLED
[**2133-4-1**] 04:45PM BLOOD Type-ART Temp-36.4 Rates-18/2 Tidal V-500
PEEP-5 FiO2-50 pO2-82* pCO2-35 pH-7.34* calHCO3-20* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2133-4-8**] 08:03AM BLOOD Type-ART Temp-36.7 Rates-14/3 Tidal V-500
PEEP-5 FiO2-50 pO2-89 pCO2-38 pH-7.48* calHCO3-29 Base XS-4
-ASSIST/CON Intubat-INTUBATED
[**2133-4-8**] 02:30PM BLOOD Type-ART Temp-35.8 Rates-0/9 Tidal V-500
PEEP-5 FiO2-50 pO2-93 pCO2-36 pH-7.47* calHCO3-27 Base XS-2
Intubat-INTUBATED
[**2133-4-1**] 03:17AM BLOOD HCV Ab-NEGATIVE
[**2133-3-31**] 04:10AM BLOOD ASA-NEG Ethanol-19* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-3-31**] 04:33AM BLOOD ASA-NEG Ethanol-10 Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-4-1**] 03:17AM BLOOD AFP-6.2
[**2133-4-12**] 05:36AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **]
[**2133-4-1**] 03:17AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2133-3-31**] 07:21PM BLOOD Cortsol-14.0
[**2133-3-31**] 09:38PM BLOOD Cortsol-13.5
[**2133-3-31**] 10:01PM BLOOD Cortsol-14.2
[**2133-3-31**] 07:21PM BLOOD TSH-0.85
[**2133-4-11**] 05:09AM BLOOD calTIBC-130* Ferritn-816* TRF-100*
[**2133-3-31**] 06:33AM BLOOD Albumin-3.0* Calcium-7.0* Phos-5.2*
Mg-1.2*
[**2133-3-31**] 02:02PM BLOOD Calcium-8.1* Phos-3.1# Mg-1.8
[**2133-3-31**] 07:21PM BLOOD Calcium-7.5* Phos-2.6* Mg-1.6
[**2133-4-10**] 05:26AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7
[**2133-4-16**] 05:48AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.7
[**2133-4-23**] 05:46AM BLOOD Calcium-7.7* Phos-4.5 Mg-1.9
[**2133-4-1**] 03:17AM BLOOD Lipase-12
[**2133-4-17**] 06:04AM BLOOD Lipase-224*
[**2133-4-18**] 05:55AM BLOOD Lipase-219*
[**2133-4-19**] 06:24AM BLOOD Lipase-235*
[**2133-4-20**] 05:50AM BLOOD Lipase-191*
[**2133-4-21**] 05:50AM BLOOD Lipase-147*
[**2133-3-31**] 04:10AM BLOOD Amylase-23
[**2133-3-31**] 04:33AM BLOOD Amylase-21
[**2133-3-31**] 06:33AM BLOOD ALT-16 AST-47* AlkPhos-93 TotBili-2.2*
[**2133-3-31**] 07:21PM BLOOD ALT-15 AST-46* AlkPhos-62 TotBili-1.9*
[**2133-4-1**] 03:17AM BLOOD ALT-16 AST-61* AlkPhos-68 Amylase-14
TotBili-1.4 DirBili-0.8* IndBili-0.6
[**2133-4-21**] 05:50AM BLOOD ALT-22 AST-47* AlkPhos-128* Amylase-115*
TotBili-1.5
[**2133-4-22**] 06:19AM BLOOD ALT-20 AST-41* LD(LDH)-266* AlkPhos-120*
TotBili-1.6*
[**2133-3-31**] 04:10AM BLOOD UreaN-25* Creat-1.2 Na-145 K-4.2 Cl-115*
HCO3-14* AnGap-20
[**2133-3-31**] 04:33AM BLOOD UreaN-26* Creat-1.2
[**2133-3-31**] 06:33AM BLOOD Glucose-127* UreaN-24* Creat-1.1 Na-143
K-5.3* Cl-111* HCO3-18* AnGap-19
[**2133-3-31**] 09:03AM BLOOD Glucose-124* UreaN-27* Creat-1.1 Na-144
K-4.4 Cl-114* HCO3-21* AnGap-13
[**2133-3-31**] 02:02PM BLOOD Glucose-109* UreaN-34* Creat-1.3* Na-146*
K-4.2 Cl-117* HCO3-20* AnGap-13
[**2133-4-4**] 04:10AM BLOOD Glucose-127* UreaN-28* Creat-1.0 Na-146*
K-3.6 Cl-119* HCO3-24 AnGap-7*
[**2133-4-5**] 05:06AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-146*
K-3.7 Cl-119* HCO3-24 AnGap-7*
[**2133-4-6**] 06:21PM BLOOD Glucose-107* UreaN-28* Creat-1.1 Na-146*
K-3.4 Cl-113* HCO3-26 AnGap-10
[**2133-4-7**] 04:14AM BLOOD Glucose-131* UreaN-29* Creat-1.1 Na-145
K-2.9* Cl-115* HCO3-25 AnGap-8
[**2133-4-13**] 05:00AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-143
K-2.3* Cl-109* HCO3-29 AnGap-7*
[**2133-4-14**] 05:18AM BLOOD Glucose-110* UreaN-16 Creat-1.4* Na-144
K-3.4 Cl-111* HCO3-28 AnGap-8
[**2133-4-15**] 06:02AM BLOOD Glucose-104 UreaN-15 Creat-1.5* Na-144
K-4.0 Cl-111* HCO3-26 AnGap-11
[**2133-4-21**] 05:50AM BLOOD Glucose-85 UreaN-22* Creat-1.9* Na-138
K-4.3 Cl-106 HCO3-27 AnGap-9
[**2133-4-22**] 06:19AM BLOOD Glucose-89 UreaN-20 Creat-1.8* Na-138
K-3.8 Cl-106 HCO3-25 AnGap-11
[**2133-4-23**] 05:46AM BLOOD UreaN-15 Creat-1.7* K-3.9
[**2133-3-31**] 04:10AM BLOOD Fibrino-150
[**2133-3-31**] 04:33AM BLOOD Fibrino-140*
[**2133-3-31**] 06:33AM BLOOD Fibrino-213#
[**2133-4-2**] 05:26AM BLOOD Fibrino-304
[**2133-3-31**] 04:10AM BLOOD PT-19.0* PTT-36.7* INR(PT)-2.3
[**2133-3-31**] 04:10AM BLOOD Plt Ct-113*
[**2133-3-31**] 04:33AM BLOOD PT-19.3* PTT-46.2* INR(PT)-2.4
[**2133-3-31**] 04:33AM BLOOD Plt Ct-110*
[**2133-4-4**] 04:10AM BLOOD PT-14.8* PTT-31.4 INR(PT)-1.4
[**2133-4-4**] 04:10AM BLOOD Plt Ct-92*
[**2133-4-5**] 05:06AM BLOOD PT-15.4* PTT-30.6 INR(PT)-1.5
[**2133-4-22**] 06:19AM BLOOD PT-14.8* INR(PT)-1.4
[**2133-4-22**] 06:19AM BLOOD Plt Ct-180
[**2133-4-14**] 05:18AM BLOOD Neuts-79.8* Lymphs-12.1* Monos-6.0
Eos-1.8 Baso-0.3
[**2133-4-15**] 06:02AM BLOOD Neuts-78.2* Bands-0 Lymphs-12.6*
Monos-6.7 Eos-2.1 Baso-0.3
[**2133-4-16**] 05:48AM BLOOD Neuts-75.6* Lymphs-15.5* Monos-6.3
Eos-2.4 Baso-0.2
[**2133-4-20**] 05:50AM BLOOD Neuts-66.6 Lymphs-22.4 Monos-5.6 Eos-4.6*
Baso-0.7
[**2133-3-31**] 04:10AM BLOOD WBC-28.5* RBC-2.51* Hgb-8.1* Hct-25.6*
MCV-102* MCH-32.2* MCHC-31.5 RDW-21.2* Plt Ct-113*
[**2133-3-31**] 04:33AM BLOOD WBC-27.1* RBC-2.54* Hgb-8.3* Hct-25.7*
MCV-101* MCH-32.7* MCHC-32.4 RDW-20.8* Plt Ct-110*
[**2133-3-31**] 06:33AM BLOOD WBC-20.5* RBC-4.42*# Hgb-13.4*# Hct-40.4#
MCV-92# MCH-30.3 MCHC-33.1 RDW-18.6* Plt Ct-76*
[**2133-4-1**] 06:00PM BLOOD WBC-9.4 RBC-3.77* Hgb-11.4* Hct-32.9*
MCV-87 MCH-30.3 MCHC-34.7 RDW-19.5* Plt Ct-95*
[**2133-4-1**] 11:31PM BLOOD WBC-9.7 RBC-3.73* Hgb-11.5* Hct-32.9*
MCV-88 MCH-30.7 MCHC-34.9 RDW-19.3* Plt Ct-104*
[**2133-4-2**] 05:26AM BLOOD WBC-9.1 RBC-3.76* Hgb-11.2* Hct-33.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-19.3* Plt Ct-106*
[**2133-4-6**] 08:12PM BLOOD Hct-35.7*
[**2133-4-11**] 07:14PM BLOOD Hct-36.2*
[**2133-4-14**] 05:18AM BLOOD WBC-16.2* RBC-3.40* Hgb-10.7* Hct-31.3*
MCV-92 MCH-31.5 MCHC-34.2 RDW-19.0* Plt Ct-93*
[**2133-4-15**] 06:02AM BLOOD WBC-14.1* RBC-3.44* Hgb-10.9* Hct-32.2*
MCV-94 MCH-31.8 MCHC-34.0 RDW-19.2* Plt Ct-99*
[**2133-4-20**] 05:50AM BLOOD WBC-8.6 RBC-3.10* Hgb-9.5* Hct-29.0*
MCV-94 MCH-30.7 MCHC-32.8 RDW-19.1* Plt Ct-138*
[**2133-4-21**] 05:50AM BLOOD WBC-8.0 RBC-3.07* Hgb-9.6* Hct-29.3*
MCV-95 MCH-31.2 MCHC-32.8 RDW-18.7* Plt Ct-148*
[**2133-4-22**] 06:19AM BLOOD WBC-8.3 RBC-2.99* Hgb-9.5* Hct-28.2*
MCV-94 MCH-31.7 MCHC-33.6 RDW-19.0* Plt Ct-180
[**2133-4-23**] 05:46AM BLOOD Hct-28.7*
Brief Hospital Course:
1. UGIB/Cirrhosis: The patient presented from and an outside
hospital after suffering a severe upper GI bleed, hypotension,
and hypovolemia. He was resuscitated with PRBC and IVF, and sent
to the [**Hospital1 18**] MICU. The etiology was considered likely variceal
in nature, given the briskness of his bleed, and history of
heavy ETOH use. He had had multiple EGD's at [**Hospital1 18**] showing
varices, portal gastropathy, but required no EGD-interventions
(ie. cautery or clipping). Of note, Hepatitis A titers were
positive. He was started on Lactulose, PPI, Nadolol,
Spironolactone and Lasix. The latter two were discontinued given
declining renal function. His HCT remained stable on the floor
thereafter, with levels in the high 20's to low 30's. He was
completd on a course of Levofloxain and Flagyl for SBP PPx in
the setting of an UGIB. He was discharged with [**Hospital1 18**] Liver
follow-up.
2. Confusion: He was seen by neurology while in the MICU who
felt that the differential diagnosis for this patient included,
alcoholic encephalopathy, anoxic brain injury, or hepatic
encephalopathy. His EEG, Head MRI and Head CT were negative. His
mental status improved, with sedation avoidal and treatment of
his liver disease, as noted above.
4. Fevers (UTI and LE DVT): While in the MICU, he was treated
with a course of vancomycin for gram positive cocci in his
sputum, and he received a course of levo/flagyl for SBP
prophylaxis. Once on the floor, he continued to have persistent
low grade fevers. Multiple urine/blood/peritoneal fluid
cultures were negative. A CT of the torso did not show any
source. However, a clot in the left common femoral vein, which
was confirmed by ultrasound, was seen. Further, his urine
cultures later grew out VRE. Regrading the clot, an IVC filter
was placed (given the fact he was not a anticoagulate candidate
and the high probability of the acuity of the clot because of
recent femoral line placement). He was started on a short course
of Linezolid for the UTI. It was unclear if the clot or the UTI
were the cause of his fevers.
5. ARF: The patient had normal renal function at baseline. He
evidenced an acute decline in his GFR after a CT contrast dye
exposure and his creatinine peaked in the low 2.0's. It improved
thereafter. He had a possible ATN (with FENa at 6%) and was
managed with gentle hydration.
6. Alcoholism: He had nos signs of withdrawal over his course.
He was seen by the Addiction service, social work and was
advised to enter a detoxification center upon discharge from his
rehab facility.
Medications on Admission:
Meds on Transfer:
Nadolol 20
Vanco 1 [**Hospital1 **]
Haldol
Protonix
Ativan
Dulcolax
SSI
Meds on Admission:
Ativan 0.5 PRN, Lasix 40 QDay, Remeron 15 QDay, Aldactone 25
QDay, Naprosyn PRN
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis:
1) Variceal Hemorrhage.
2) Alcoholic Cirrhosis.
Secondary Diagnosis:
3) Vancomycin-Resistant Enterococcal Urinary Tract Infection.
4) Common Femoral Vein Thrombosis.
Discharge Condition:
Fair/Stable.
Discharge Instructions:
1) Please call your doctor or return to the ER if you have any
nausea, vomiting, fevers, chills, dizziness, dark stools,
diarrhea, bleeding, or any other concerning symptoms.
2) Take your medications as instructed.
Followup Instructions:
1) Please arrive on the following date to see your new liver
doctor. Your liver doctor will restart your Aldactone and Lasix
when your kidney function returns to normal:
Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2133-6-3**] 9:00
2) Please see your primary doctor (MAURUKAS,RIMAS J.
[**Telephone/Fax (1) 28582**]) in the next 2-3 weeks. Your hematocrit (blood
level) should be checked at least weekly for a month after you
leave your rehab, to ensure it is stable.
3) We recommend you enter an alchohol detoxification center once
you leave the physical rehab facility. The social workers at the
rehab facility can help you with this.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
45620,3575,2851,7895,5712 | 252 | 193,470 | Admission Date: [**2133-8-15**] Discharge Date: [**2133-8-19**]
Date of Birth: [**2078-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
vomiting blood
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy with banding of varices
History of Present Illness:
55 y/o M w/hx of alcoholic cirrhosis and grade II esophageal
varices, w/recent MICU admission [**3-28**] for UGIB, who presented to
OSH with hematemesis. He reports that he was in his USOH and
feeling well until this evening. He was drinking iced coffee
with his daughter and began to feel vaguely nauseous. He was at
his daughter's house, and so he went home. When he stood up, he
felt very "hot", and then he vomited approximately [**1-25**] cup of
bright red blood. He called EMS and was taken to [**Hospital3 18201**]. For other review of systems, he occasionally
has a mild increase in his abdominal girth with some associated
tenderness, but none recently. He denies any fevers or chills.
He has some occasional lower extremity edema in the RLE
*
At [**Location (un) **], he was afebrile, tachycardic to 123, bp 95/49. His
labs there were significant for a Hct of 19.4 (from 29 2 days
ago in liver clinic), platelets 150, WBC 14. His creatinine was
1.4 (1.0 on recent check in Liver clinic). His INR was 2.1. He
also had a lipase of 243. He received Vit K 10 mg SQ, protonix
40 mg IV, octreotide bolus and gtt, 3.5 L NS. He was transfused
2 U PRBCs. He had several episodes of vomiting black emesis
with clots and was subsequently medflighted to [**Hospital1 18**].
*
In our ED, he remained tachycardic but has a stable bp in the
120s. Labs were drawn and revealed a Hct of 25, INR 1.5, Plt
117. Creatinine was 1.0. He had an NG lavage which did not
clear after 2L. He was admitted to the MICU.
.
MICU course:
UGIB - EGD done [**8-15**] showing non bleeding varices, 3 bands
placed. Resuscitated with fluid but still tachycardic; TSH
checked, .77, 2.5. Received 4 units RBC in [**Hospital1 18**] (+2 at
[**Location (un) **]) c HCT on txf (28.2-30.9), 1 unit FFP. Tx c PPI IV,
octreotide drip, levofloxacin for sepsis prophylaxis in
cirrhotics with variceal bleed
.
Cirrhosis - Nadolol, lactulose held in setting of low BP and
acute bleed. Lactulose started once hct stable. RUQ u/s c
dopplers done to assess portal flow. Pt. creatinine stable
0.9-1.0; not likely hepatorenal in MICU.
.
On questioning, pt. denies any abdominal pain, nausea, vomiting,
hematemesis, only has had 1 BM since arrival to hospital. Has
appetite, drinking clear fluids currently.
Past Medical History:
Past Med Hx:
1. Alcoholic cirrhosis: had 3 week hospital stay here in [**Month (only) 958**]
[**2133**], where he presented with hematemesis. Was intubated in
MICU, had EGD x3 which showed grade II esophageal varices (not
bleeding, had scarring in [**3-27**] cm of distal esophagus which were
felt consistent with prior endoscopic therapy), and portal
gastropathy. Actual source of bleeding never found, pt never
had endoscopic intervention here. Had abd u/s at that time
which showed patent portal vein. Also had a Swan at the time
which per report did not reveal a cardiac cause of his
hypotension. TTE normal.
2. left Femoral DVT, rx w/IVC filter (clot was felt to be due to
femoral cordis)
3. VRE UTI during [**3-28**] hosp
Social History:
Soc Hx: Was a heavy drinker until prior hospitalization in
[**2133-3-24**]. Smoked 2 ppd x 20 yrs, now smokes 10 cigs/day.
Lives at home alone, daughter lives one mile away.
Family History:
no history of liver disease
Physical Exam:
T: 98.4 BP: 129/72 P: 104 R: 12 O2 sat: 98% RA
Gen: awake, alert and oriented male in no acute distress
HEENT: NC, AT. NGT in place. Sclerae mildly icteric. PERRL.
MMM.
Neck: supple, no LAD.
Lungs: Mild inspiratory crackles at R base, o/w CTA
bilaterally.
CV: tachycardic, regular, no m/r/g.
Abd: mildly distended, nontender, no fluid wave. + bs.
Ext: trace R ankle edema, o/w no peripheral edema, good distal
pulses bilaterally
Skin: warm and dry. Erythema over superior chest, no palmar
erythema.
Neuro: moving all extremities well. No asterixis.
PE on txf from MICU:
VS - 98.8, 82, 119/52, 17, 98% RA
HEENT - sclerae anicteric, conjunc. pink, EOMI
Lungs - CTA at apices, bases
Abd - soft, NT, + hepatmegaly (8-9 cm in length by percussion),
+ spider angiomas over sternum, spleen not palpable
Heart - RRR, S1, S2
Ext - +palmar erythema, trace edema to ankles b/l, pneumoboots
on
Neuro - A* O * 3, no asterixis
Pertinent Results:
Labs at [**Location (un) **]:
WBC 14 (67 polys/2 bands), Hct 19 (MCV 100), Plt 150
Na 142, K 5.1, Cl 108, Bicarb 25, BUN 28, Creat 1.4, Glc 104
Calcium 8.2, albumin 2.1, total protein 5.4
Tot bili 0.8, alk phos 134, ALT 26, AST 25, amylase 29, lipase
243
.
[**2133-8-15**] 02:25AM BLOOD WBC-15.1*# RBC-2.80* Hgb-8.9* Hct-25.9*
MCV-93 MCH-31.8 MCHC-34.4 RDW-17.4* Plt Ct-117*
[**2133-8-15**] 06:00AM BLOOD WBC-13.0* RBC-2.50* Hgb-8.0* Hct-23.8*
MCV-95 MCH-31.9 MCHC-33.6 RDW-18.0* Plt Ct-105*
[**2133-8-18**] 05:53AM BLOOD WBC-9.7 RBC-3.31* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.3 MCHC-34.4 RDW-17.0* Plt Ct-91*
[**2133-8-18**] 08:00PM BLOOD Hct-32.2*
[**2133-8-19**] 06:00AM BLOOD WBC-7.9 RBC-3.36* Hgb-10.8* Hct-30.4*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.7* Plt Ct-96*
.
[**2133-8-15**] 02:25AM BLOOD PT-15.0* PTT-29.4 INR(PT)-1.5
[**2133-8-15**] 02:25AM BLOOD Plt Ct-117*
[**2133-8-19**] 06:00AM BLOOD PT-13.6* PTT-28.8 INR(PT)-1.2
[**2133-8-19**] 06:00AM BLOOD Plt Ct-96*
.
[**2133-8-15**] 02:25AM BLOOD Glucose-98 UreaN-29* Creat-1.0 Na-143
K-5.6* Cl-114* HCO3-22 AnGap-13
[**2133-8-15**] 06:00AM BLOOD Glucose-109* UreaN-30* Creat-1.0 Na-144
K-4.6 Cl-113* HCO3-24 AnGap-12
[**2133-8-19**] 06:00AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-138
K-3.7 Cl-108 HCO3-23 AnGap-11
.
[**2133-8-15**] 02:25AM BLOOD Albumin-2.6*
[**2133-8-15**] 06:00AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.6
.
[**2133-8-18**] 05:53AM BLOOD Free T4-0.7*
[**2133-8-15**] 06:00AM BLOOD TSH-0.77
.
RUQ U/S c Doppler:
The liver has a heterogenous echotexture and nodular surface
contour suggestive of underlying cirrhotic change. No focal mass
lesion demonstrated.
Doppler assessment of the hepatic vasculature shows patent left,
right and main portal veins with normal directional flow. The
left middle and right hepatic veins and inferior vena cava are
patent with normal spectral waveform on Doppler. Right, left,
and main hepatic arteries are demonstrated with a good systolic
upstroke.
There is a moderate amount of intra-abdominal ascites, which
appears simple on [**Month/Day/Year 950**]. The common bile duct is prominent
in diameter at 7 mm but there is no intrahepatic biliary
dilatation. A number of small echogenic gallstones are noted in
the dependent portion of the gallbladder, which is nondistended
and non-thickened.
The splenic and superior mesenteric veins are patent on color
Doppler flow.
Brief Hospital Course:
UGIB - this was thought likely [**2-25**] to portal
gastropathy/esophageal varices. He has not been banded in the
past. Since his NG lavage did not clear after 2 L, persistent
coffee grounds, dark brown liquids, he was transferred to the
MICU. He received IVF, 4 units of pRBCs and he remained HD
stable. He underwent EGD in the morning after admission to the
MICU as described above under HPI. He was transferred to the
floor after he had been HD stable c no further episodes
hematemesis, BRBPR, and c a stable hematocrit. On the floor, he
had one episode of BRBPR but remained HD stable c a stable crit.
He was continued on his levaquin regimen started in the MICU
for a 7 day course (day [**7-30**], [**8-21**]). He was taken off the
octreotide drip and switched to PO protonix. He was discharged
with a plan for EGD with banding on Monday, [**2133-8-24**], c Dr.
[**Last Name (STitle) **].
.
Cirrhosis: According to discharge summary from [**2133-3-24**], pt
was supposed to be on Nadolol, lactulose, protonix but pt
reported that he is only taking nortriptyline. He was started
on nadolol on transfer to the floor. He was maintained on
lactulose. An abdominal U/S c Dopplers was done (see above).
He did not become hepatorenal. He was discharged with
prescriptions for lactulose and nadolol.
.
TCA use: The pt. came in using nortryp.; this was d/w his PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 28583**]. He was started on this for peripheral neuropathy
[**2-25**] Etoh use. He reported minimal paresthesias in his feet and
no recent Etoh use; it was thought better to stop this
medication in this context.
.
Thyroid studies: In the MICU, the question was raised that he
may be hyperthyroid given his elevated HR despite fluid
resuscitation. A TSH and free T4 were checked. One TSH level
was low, another normal. A free T4 level was low. His HR came
down on transfer to the floor and we did not pursue further
workup for hyperthyroidism given his low T4.
.
IVC filter: A discussion was had c the IR resident who was
involved in the placement of his IVC filter; a trapease filter
as he has is usually a permanant filter.
Medications on Admission:
Nortriptyline
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Upper Gastrointestinal Bleed
2. Alcoholic Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
You should contact your PCP or go to the Emergency Room if you
continue to have any more episodes of bloody vomiting, bloody
stools, bright red blood in the stool, light headedness,
dizziness, chest pain, shortness of breath. You should take all
your medications as prescribed and keep all your appointments
with health care providers.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Monday, [**2133-8-24**] at
10:00 AM for an EGD with banding. You should not eat anything
after midnight the night before the procedure. You will need to
arrange for a ride home after the procedure on [**2133-8-24**]. The
appointment is listed below:
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2133-8-24**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2133-8-24**] 10:00
You also have the following other appointments listed below:
Provider: [**Name10 (NameIs) **] Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2133-10-12**] 8:30
|
4019,2720,4168,29410,3310,2449,4240,486,4260 | 253 | 176,189 | Admission Date: [**2174-1-21**] Discharge Date: [**2174-1-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
CC:[**CC Contact Info 46956**]
Major Surgical or Invasive Procedure:
Pacemaker placement DDD
History of Present Illness:
HPI: 84 year old female with HTN, hypercholesterolemia, dementia
presents from nursing home after they noted that her heart rate
was in the 30's. She was noted to be in complete heart block, on
arrival to hospital, sbp decreased to 80's systolic and she was
started on Dopamine gtt at 13 cc/hr.
Past Medical History:
HTN
Hypercholesterolemia
dementia with agitation
Hypothyroidism
depression
syncope
Social History:
Soc Hx:
lives in nursing home. (+) Tobacco 1ppd x 50 yrs, quit > 15 [**Last Name (un) **]
Family History:
FAMILY HISTORY: Sister CVA in her 60s. Father CVA in his
70s.
Physical Exam:
Phys Exam:
98.1F HR 60 BP 151/64 RR 14 100%/intubated
Gen: sedated, intubated, responsive to pain
HEENT: PERRL, intubated
CV: distant S1, S2, ?systolic murmur
Chest: external pacer in place with dsg C/D/I
Pulm: diffuse rhonchi and occasional wheeze bilaterally
Abd: (+) BS, soft, obese, nontender
Ext: WWP, faint DP pulses b/l, 2+ pitting LE edema b/l
Pertinent Results:
[**2174-1-21**] 09:36PM BLOOD WBC-13.5*# RBC-3.89* Hgb-11.3* Hct-32.5*
MCV-84 MCH-29.1 MCHC-34.8 RDW-15.6* Plt Ct-222
[**2174-1-26**] 07:35AM BLOOD WBC-10.4 RBC-3.81* Hgb-11.4* Hct-31.7*
MCV-83 MCH-30.0 MCHC-36.0* RDW-15.6* Plt Ct-222
[**2174-1-23**] 05:18AM BLOOD Neuts-79.2* Lymphs-14.0* Monos-3.0
Eos-3.7 Baso-0.1
[**2174-1-21**] 09:36PM BLOOD PT-12.6 PTT-24.9 INR(PT)-1.1
[**2174-1-22**] 05:42AM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.2
[**2174-1-24**] 07:15AM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1
[**2174-1-21**] 09:36PM BLOOD Glucose-148* UreaN-22* Creat-1.0 Na-136
K-4.5 Cl-101 HCO3-24 AnGap-16
[**2174-1-26**] 07:35AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
[**2174-1-21**] 09:36PM BLOOD ALT-28 AST-28 CK(CPK)-57 AlkPhos-77
TotBili-1.0
[**2174-1-22**] 05:42AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2174-1-22**] 05:42AM BLOOD TSH-6.6*
[**2174-1-22**] 05:42AM BLOOD Free T4-0.8*
[**2174-1-21**] 09:41PM BLOOD Type-ART pO2-428* pCO2-38 pH-7.43
calHCO3-26 Base XS-1
[**2174-1-22**] 12:13PM BLOOD Type-ART Temp-37.2 FiO2-40 pO2-94 pCO2-36
pH-7.48* calHCO3-28 Base XS-3 Intubat-NOT INTUBA
Echo [**2173-1-24**]
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. 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. There is moderate aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification with a
moderate inflow gradient (in part due to significant
regurgitation). Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly thickened. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
chest X ray: [**2173-1-21**]
Chest: A single semi-upright AP view at 9:30 p.m. is compared to
previous examination earlier from the same day. Since the
previous exam the interstitial edema has decreased. There is an
endotracheal tube with the tip approximately 4.5 cm proximal to
the carina. There is a new single lead pacemaker with the lead
overlying the right ventricle. There is no evidence of
pneumothorax. There are probable pleural calcifications in left
lower lung. There is focal opacity in right upper lobe which may
represent pneumonia.
Brief Hospital Course:
A/P: 84 year old female with HTN, hyperlipidemia, recently
diagnosed pneumonia treated with antibiotics, found by nursing
home to have HR 30's, found to be in complete heart block.
.
1. CV: Rhythm: Patient was taken to the cath lab, intubated for
agitation, and a external screw-in pacemaker was placed. Unclear
source of complete heart block, given she r/o for ischemia, more
likely worsening conduction system with age.
A permanent DDD pacemaker was placed on [**2173-1-25**] with no
complications. Patient should have a follow up appointment with
device clinic in 1 week.
Pump: Patient on admission appeared volume overloaded, and her
lasix dose was increased from 40 po day to 40 IV q day. Patient
responded well, and later on was transitioned back to her home
dose40 PO/day
ECho on Echo on [**1-24**].EF >55%Mod AS, MOd MR [**First Name (Titles) **] [**Last Name (Titles) **] and severe
pulmonary artery systolic HTN on ECHO.
Ischemia: Patient rule out for MI, enzymes negative.
BP: patient was initially hypotensive on admission, and was
started on Dopamine. After procedure, she was transfer to CCU
and Dopamine was weaned off over the following 12 hours.
CAD: Patient was continued on Aspirin, Statin, and Ace was
re-started once patient was transfer to the floor.
2. Pulm: patient was extubated succesfully in the morning of
[**2173-1-24**]. Patient did well after extubation.
.
3. ID: Pneumonia, was treated at NH with Erythromycin. Chest X
ray on admission compatible with Right upper lobe pneumonia.
Patient was switched to Azytromycin- Ceftriaxone. Sputum final
showed sparse oropharingeal flora. Per ID recomendation, and
given good clinical conditions, antibiotics were stopped on
[**2173-1-25**].
Per electrophisiology recs, she received Vancomycin for 48 hours
after procedure, since patient will be d/c after 24h, she will
receive 1 more day of keflex.
.
4. Hypothyroidism: Patient with high tsh and low free t4 on
admission. levothyroxine dose was increased from 75 to
100mcg/day.
.
5. Dementia: Continue Namenda.
.
6. FEN: Cardiac heart diet monitor electrolytes and replete prn.
.
Medications on Admission:
Lipitor 20 qhs
Lasix 40 po qday
lisinopril 2.5 po qday
MVI
Os-Cal 500mg qday
ASA 81 qday
Namenda 10 qday
Levoxyl 75 mcg qday
tylenol prn
Erythromycin 333 TID (for PNA)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qday ().
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-17**]
Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
8. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 days.
9. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Compleat Heart Block
Community Acquired Pneumonia
Hypothyroidism
Discharge Condition:
good
Discharge Instructions:
Please take your medications as prescribed.
Please follow up your appointments as schedule.
A pacemaker device was implanted durint this hospitalization.
Your levothyroxine dose was increased during your hospital stay.
If shortness of breath, chest pain, or any other symptoms that
may concern you please call your pcp or come to the Emergency
department.
Followup Instructions:
Please call your PCP for [**Name Initial (PRE) **] follow up appointment in about 2
weeks.
Please call Pacemaker and Device clinic at ([**Telephone/Fax (1) 2361**] to
make an appointment in 1 week.
Please recheck TSh in 1 month.
Completed by:[**2174-1-26**] |
60000,99811,2851,42789 | 255 | 112,013 | Admission Date: [**2187-2-12**] Discharge Date: [**2187-2-15**]
Date of Birth: [**2109-8-5**] Sex: M
Service: GU
ADMISSION DIAGNOSIS: Benign prostatic hypertrophy.
POSTOPERATIVE DIAGNOSES: Benign prostatic hypertrophy,
postoperative anemia.
ADMISSION HISTORY AND PHYSICAL: Patient is a 77-year-old
male with a history of BPH and no other medical history who
presented for surgical resection after complaining of weak
stream.
PAST MEDICAL HISTORY: Includes BPH and mild exercise
intolerance.
PAST SURGICAL HISTORY: Of renal cyst aspiration, hernia
repair, cataract surgery, and colonoscopy and biopsy.
MEDICATIONS: Include aspirin 81 mg every day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Includes no tobacco use and [**2-16**] alcoholic
drinks a day with no drug use.
REVIEW OF SYMPTOMS: Otherwise noncontributory.
PHYSICAL EXAM: Revealed a 71 inch, 157 pound male with a
pulse of 68, blood pressure of 147/92 in no apparent distress
with clear lungs with a [**2-19**] murmur in left sternal border
with abdomen that is soft and nontender. No extremity edema.
HOSPITAL COURSE: Patient presented as above and underwent a
transurethral resection of the prostate for BPH on [**2187-2-12**]. This was a large resection, and postoperatively was
noted to have a great deal of hematuria requiring brisk CBI
immediately postoperatively. Because of the brisk CBI and
requiring bag changes approximately every 30 minutes, patient
was monitored overnight for 1-to-1 nursing care in the ICU.
Medically, however, patient remained stable throughout the
hospital course, and patient's hematocrit postoperatively was
in the 30s (stable at 30 at discharge). Patient did not
require any transfusions.
The patient's Foley was removed on postoperative day #2 after
urine was noted to be fruit punch color off of CBI. Patient
was then observed for another day of hospitalization, and
reported urinating well. But initially urinated several
clots. The urine color then became much lighter in color
after urination of clots. Patient reported sensation of
complete emptying upon discharge, and also reported a very
strong stream and good satisfaction of his urination.
Therefore, upon discharge on postoperative day #3, patient
was ambulating, voiding, without significant pain, and
tolerating POs without difficulty.
DISCHARGE CONDITION: Good.
DISCHARGE DIET: Regular.
DISCHARGE MEDICATIONS: Tylenol 650 mg p.o. q.4h. p.r.n.
pain, Colace 100 mg p.o. b.i.d. No antibiotics were given
upon discharge because 3 days of ciprofloxacin had been given
in the hospital.
FOLLOWUP: Will be with Dr. [**Last Name (STitle) 365**] in [**1-15**] weeks.
DISCHARGE ACTIVITIES: No restrictions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 27469**]
Dictated By:[**Name8 (MD) 20918**]
MEDQUIST36
D: [**2187-2-15**] 07:27:56
T: [**2187-2-15**] 08:49:15
Job#: [**Job Number 27470**]
|
53240,41071,53560,40390,5859,04186,41401,2724,496,42731,V4581 | 256 | 108,811 | Admission Date: [**2170-8-16**] Discharge Date: [**2170-8-22**]
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
Vomiting & Dark Diarrhea
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
This is a 84 year old male with a history of CAD (s/p cypher to
RCA in [**2166**]), recent AAA repair in [**6-14**], HTN, hyperlipidemia,
COPD, PUD who presents from his NH on [**8-16**] with vomitting,
abdominal pain and dark stools. He notes that several days ago,
he began to have nausea, vomitting, loose stools and abdominal
pain. Due to these symptoms he has had limited PO intake. He was
brought to the ED due to persistent loose stools and abdominal
pain.
.
In the ED: VS 97.2 102 101/66 20 100% RA. He had a CTA that
showed a duodenitis and absence of dissection. He was given
Cipro 400mg IV x1, Flagyl 500mg IV x1 given for duodenitis. He
was initially admitted with a hct to 30, and then the following
AM noted to have hct to 22. He was given 1 unit pRBC for this
and transfered to the MICU, though he was hemodynamically stable
throughout. Plan was for patient to undergo an EGD, but this
procedure was held due to a coagulopathy with an INR to 2.3. He
was given 5mg PO vitamin K and 2 units of FFP (INR down to 1.6).
During his blood product transfusion, he developed chest pain
that was left sided, and associated with mild SOB. His ECG
revealed inferolateral ST depressions. His chest pain
self-resolved. Troponins trended from 0.04 to peak of 0.11, most
recently down to 0.1 so no longer being followed. CKs and CK-MB
have been flat throughout. Thought to be consistent with demand
ischemia. Cardiology was consulted and recommended conservative
management with holding ASA and continuing BB.
.
In the MICU, patient received a total of 6 units prbcs, and
eventually hematocrit began to stabilize and increase over the
last 24 hours. Additionally became hypertensive, currently on
BB, started on hydralazine for easy on/off if he develops
hemodynamically significant re-bleed. At this time, patient is
transfered to the medicine floor with plan for EGD in the
morning pending stable INR (1.4 yesterday).
.
At this time, patient is feeling well. No BM for several days,
feels he has more energy. No nausea or vomiting. His only
complaint is his chronic arthritis for which he requests
tylenol. No fevers, chills, abdominal pain, chest pain,
shortness of breath.
Past Medical History:
Past Medical History:
1. Coronary artery disease, status post MI in [**2166**]. 2 vessel
disease s/p successful PCI to mid-RCA, EHCO: EF 45% with no
significant valvular disease ([**2169**])
2. Hypertension.
3. Hyperlipidemia.
4. Paroxysmal atrial fibrillation.
5. History of abdominal aortic aneurysm.
6. History of deep venous thrombosis.
7. Chronic obstructive pulmonary disease: FEV1 70%, FEV/FVC 79%
[**2166**]
8. Peptic ulcer disease.
9. History of esophagitis.
10. History of gastrointestinal bleeding.
11. Diverticulosis.
12. Renal insufficiency.
13. Lumbosacral radiculopathy.
14. Depression.
15. History of hip fracture.
.
PAST SURGICAL HISTORY:
1. Status post stent graft surgery for abdominal aortic
aneurysm.
2. Status post [**Location (un) 260**] filter placement for history of DVT.
3. Status post hip replacement.
4. Status post AAA repair.
Social History:
Lived with wife of 60 years at home, but currently at rehab.
Supportive family with 1 daughter, 2 granddaughter and
great-granddaughters. Retired [**Name2 (NI) **] professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 532**]. Denies
tobacco, etoh, drugs. At home, he uses a walker for ambulation.
Family History:
noncontributory
Physical Exam:
VS 98.1 134/82 72 18 100%@RA
Gen: Awake, reluctantly converstant, admits being confused
HEENT: Dry oropharynx, CNII-XII otherwise intact
Pulm: B CTA
CV: S1& S2 appreciated without murmur
Abd: Non tender to palpation, non distended, BS present. Old
bruising on left abdomen. Several surgical scars.
Ext: No edema, 2+ distal pulses
Pertinent Results:
[**2170-8-16**] 10:15AM PT-20.5* PTT-30.3 INR(PT)-1.9*
[**2170-8-16**] 10:15AM PLT COUNT-521*
[**2170-8-16**] 10:15AM NEUTS-63.4 LYMPHS-30.4 MONOS-4.1 EOS-0.8
BASOS-1.3
[**2170-8-16**] 10:15AM WBC-10.7 RBC-3.40* HGB-10.1* HCT-30.6* MCV-90
MCH-29.7 MCHC-33.0 RDW-16.6*
[**2170-8-16**] 10:15AM ALBUMIN-3.1* CALCIUM-8.9 PHOSPHATE-2.8
MAGNESIUM-2.2
[**2170-8-16**] 10:15AM CK-MB-NotDone
[**2170-8-16**] 10:15AM cTropnT-0.04*
[**2170-8-16**] 10:15AM LIPASE-16
[**2170-8-16**] 10:15AM ALT(SGPT)-11 AST(SGOT)-24 CK(CPK)-90 ALK
PHOS-51 TOT BILI-0.3
[**2170-8-16**] 10:15AM estGFR-Using this
[**2170-8-16**] 10:15AM GLUCOSE-93 UREA N-53* CREAT-1.7* SODIUM-143
POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2170-8-16**] 10:22AM HGB-10.5* calcHCT-32
[**2170-8-16**] 10:22AM LACTATE-2.1* K+-5.2
[**2170-8-16**] 02:48PM LACTATE-1.3
ECHO:
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. There is infero-lateral hypokinesis. The remaining LV
segments appear hyperdynamic and therefore the overall left
ventricular systolic function is preserved (LVEF = 55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2169-10-18**],
the LVEF has improved.
CTA CAP:
IMPRESSION:
1. No evidence of aortic dissection or endograft leak s/p aortic
aneurysm
endograft repair.
2. Focal thickening in the duodenum with some adjacent fat
stranding,
suggestive of duodenitis.
3. Interval improvement in the left lower lobe consolidation.
4. Air in the bladder. Correlate for recent catheterization.
Otherwise, may represent infection. Correlate with urinalysis.
EGD findings:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Diffuse continuous moderate inflammation of the mucosa
with no bleeding was noted in the antrum.
Duodenum:
Mucosa: Diffuse continuous marked inflammation of the mucosa
with no bleeding was noted throughout the duodenum.
Excavated Lesions A single cratered non-bleeding 20mm ulcer was
found in the proximal bulb. A small visible vessel was present
in the center of the ulcer. Clipping was attempted, but three
endoquick clips were non-adherent. Some oozing was noted after
the clipping attempt, 4cc of epinephire were injected at the
ulcer border at three separate sites.
Impression: Moderate inflammation in the antrum
Marked inflammation in the duodenum
Ulcer in the proximal bulb
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
# GI Bleed: Patient presented with 4 day history of vomiting
and melena without any PO intake and abdominal pain. On his
first night he displayed no symptoms. The following morning,
pt's INR was found to be 2.3. Hematocrit dropped to 22 from 30.2
EGD Cancelled. 2 U FFP transfused followed by 2 units PRBCs in
preparation for EGD. During administration of 1st unit of blood,
called to bedside for a trigger: Patient had chest pain with ST
Depression in I, II, aVF, V3-6. Resolved with SL Nitroglycerin.
Lipitor 80mg, Lopressor 25mg PO TID restarted. After discussion
with Cardiology & Geriatrics (Primary) 325mg ASA started.
Intermediate Hct drawn after 1.5 Units PRBC administered showing
21.2. At this point the unit was consulted. No blood per rectum,
no hemtatemesis. Patient has no new complaints at this time.
During his ICU admission, the patient received 5 units pRBCs.
Initially, he did not have an appropriate HCT bump, but then he
began to bump appropriately and was hemodynamically stable for
transfer to the floor. He had no further episodes of melena or
chest pain. His cardiac enzymes began to trend downwards. His
HCT goal was greater than 30 given dynamic ECG changes and
likely ischemia. He was then transferred back to the floor
since he remained hemodynamically stable and bumping
appropriately to pRBCs with no further transfusions. EGD done
which showed non-bleeding ulcer in duodenal bulb with visible
vessel that was not able to be clipped. It was injected with
epinephrine. No further bleeding while admitted. H. pylori IgG
was checked and was found to be positive prior to discharge.
Patient was discharged on 2 week course of triple therapy for H.
pylori.
# Pneumonia: Patient admitted with PICC line in place from MSSA
Pneumonia. Nafcillin course completed on [**8-16**], no signs or
symptoms of pneumonia on this admission. PICC line was
discontinued prior to discharge.
# Hypertension: The patient was initially maintained on home
regimen of Amlodipine, Hydralazine and Lopressor until transfer
to the MICU. His lopressor was decreased to 12.5 mg TID given
HR in the 50s on telemetry. His hydralazine was ultimately
decreased to 50mg TID. He was started on Lisinopril for BP
control in the setting of recent MI. BP well-controlled at the
time of discharge.
# Anxiety: The patient was initially maintained on home regimen
of Effexor & Xanax.
# AAA Repair: Assessed and cleared by [**Month/Year (2) **] surgery that
examined the CT and felt there were no issues with the graft.
# Chronic Back pain: The patient continued home Oxycodone 5mg
PO Q4hrs PRN pain and Neurontin 100mg PO BID.
# Stage [**Month/Year (2) 1105**] CKD: The patient's Cr was below baseline of 1.7-2
during admission after fluid administration and low PO intake
over the last few weeks. His baseline Cr 1.7-2, secondary to
hypertension.
# CAD: Patient maintained on home beta blocker and
anti-hypertensives. Home Aspirin was held during the acute
bleed. Otherwise as above. It was also held at the time of
discharge per primary attending until seen by GI given how large
the patient's bleed had been. Restarting this medication should
be discussed with the patiet's primary care physician as an
outpatient.
# Coagulopathy: INR was 2.3 at the time of admission. Improved
with vitamin K, FFP and increased nutrition. Was likely due to
malnutrition and was stable and improved prior to discharge.
# Code Status: Patient request DNR/DNI status with Dr. [**Last Name (STitle) **].
Ordered entered and confirmed [**2170-8-17**].
Medications on Admission:
Simvastatin 20 mg PO Qday
Aspirin 325 mg PO Qday
Pantoprazole 40 mg PO BID
Albuterol 90 mcg/Actuation Aerosol 2 Puff IH Q6H PRN Dyspnea
Alprazolam 1 mg PO QHS
Venlafaxine 225 mg PO Qday
Ferrous Sulfate 325 mg PO Qday
Gabapentin 100 mg PO TID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Bisacodyl 10 mg PR QHS:PRN Constipation
Hydralazine 50 mg PO Q6H
Metoprolol Tartrate 25 mg PO TID
Amlodipine 10mg PO Qday
Furosemide 20 mg PO Qday
Oxycodone 5 mg PO Q4h PRN Pain
Nafcillin 2g IV Q6h, completed [**8-16**]
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. 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*
4. Outpatient Lab Work
Please draw CBC and Chemistry panel including Na, K, HCO3, Cl,
BUN, Cr and call into Dr. [**Last Name (STitle) 65810**] at [**Telephone/Fax (1) 719**].
5. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO QPM (once a day (in the
evening)).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO QAM (once a day (in the
morning)).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): please take this while you are taking
oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
12. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
13. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Upper GI bleed
Duodenal ulcer
H. Pylori positive
NSTEMI
Coronary artery disease
Hypertension
Chronic kidney disease
Discharge Condition:
Hemodynamically stable with stable hematocrit
Discharge Instructions:
You were admitted with a GI bleed. You were given blood and had
an upper endoscopy that showed ulcers in your stomach. You were
also found to be H. pylori positive as below. You should take
protonix twice a day to help heal your ulcer and to prevent
additional ulcers from forming. You are also being prescribed
two weeks of two antibiotics to erradicate the H. Pylori. Please
take these as directed.
It is very important that you follow up with the
Gastroenterologist for further evaluation and management.
If you notice an increase in the number of dark stools you are
having, if you notice blood in your stools, or if you develop
chest pain, shortness of breath, abdominal pain, change in your
urinary habits, or any other symptom that is concerning to you,
please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room
immediately.
Several of your medications have been changed:
1. Simvastain: Please take 80mg daily
2. Hydralazine: Please take this three times daily
3. Please do not take aspirin, ibuprofen or other non-steroidal
anti-inflammatory medications until you discuss this with your
gastroenterologist given that these medicines can predispose you
to GI bleeding.
4. You have been started on a medication called Lisinopril for
your hypertension. Please take this as directed.
5. Your Metoprolol dose has changed from 25 mg three times daily
to 12.5 mg three times daily.
6. You are also positive for H. Pylori which is likely causing
your ulcers. You will be treated with two weeks of antibiotics
(amoxicillin and clarithromycin). Please take these as directed.
7. We are holding your Lasix for now. Please discuss restarting
this with your primary care physician.
You should have lab work done this upcoming [**Last Name (Titles) 2974**] which should
be called into your primary care doctor's office.
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2170-8-30**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-8-30**] 12:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-10-22**]
3:20
Gastroenterology:
Provider: [**Name10 (NameIs) 16385**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2170-9-12**] 2:00
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2170-8-24**] 10:30
|
V4582,4414,7847,2762,42731,496,5990,5780,00845 | 256 | 153,771 | Admission Date: [**2166-7-21**] Discharge Date: [**2166-7-23**]
Service: MED
The patient was in the Fenard ICU.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of coronary artery disease status post right
coronary stent, deep venous thrombosis, paroxysmal atrial
fibrillation, chronic obstructive pulmonary disease,
abdominal aortic aneurysm, peptic ulcer disease, hypertension
presenting from [**Hospital3 2558**] with confusion, hematemesis,
and high white count. The patient was recently admitted from
[**2166-2-6**] to [**2166-2-14**] for a right hip open reduction
internal fixation status post a fall. He was also treated
with Levofloxacin from [**2166-7-15**] to [**2166-7-22**] for presumed
urinary tract infection. On admit he complained of several
bouts of diarrhea over the past few days prior to admission
as well as fevers and chills. He has a history of recurrent
aspiration pneumonia but did not complain of a cough.
The day prior to admit he complained of abdominal pain
diffusely with bloody emesis times one concurrent with a
nosebleed. The morning of admission he was found to be
diaphoretic, pale, and his white count was elevated to 34.
In the Emergency Department he received vancomycin,
ceftriaxone, and Flagyl empiric. His hematocrit was found to
be 29 and decreased to 17. After one unit of packed red
cells it was improved to 26. He was guaiac negative and
trace guaiac positive brown stool. Nasogastric lavage was
clear with flecks of blood. Chest x-ray was negative.
Abdominal CT showed no acute process. His systolic blood
pressure in the Emergency Department dropped to the 80s which
was responsive to intravenous fluid boluses. His heart rate
also transiently decreased to the 40s with an atrial
arrhythmia. He was given two liters of normal saline as well
as two units of packed red cells.
PAST MEDICAL HISTORY: Coronary artery disease status post
non-ST elevation myocardial infarction
Status post right coronary artery stent in [**2-/2166**] with two-
vessel disease, diastolic dysfunction, ejection fraction 60
percent
Deep venous thrombosis [**3-/2166**] on Coumadin
Status post right hip open reduction internal fixation in
[**7-/2166**]
Paroxysmal atrial fibrillation
Mild chronic obstructive pulmonary disease
Abdominal aortic aneurysm repair
Diverticulosis
Peptic ulcer disease/gastroesophageal reflux disease
Hypertension
Hyperlipidemia
Depression
Carotid stenosis
Osteoarthritis
Benign prostatic hypertrophy status post transurethral
resection of the prostate
Chronic renal insufficiency with baseline creatinine of 1.6
to 1.8
MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Atorvastatin 10 mg q.d.
3. Venlafaxine 150 mg q. a.m., 225 mg q. p.m.
4. Aspirin 325 mg q.d.
5. Protonix 40 mg q.d.
6. Colace 100 mg b.i.d.
7. Atrovent nebulizer and Albuterol nebulizer p.r.n.
8. Calcium carbonate 500 mg p.o. t.i.d.
9. Vitamin D 400 units q.d.
10. Alprazolam 1 to 2 mg q. h.s. p.r.n.
11. Trazodone 25 mg q. h.s. p.r.n.
12. Senna
13. Percocet one to two tabs p.o. q. 4 to 6 hours p.r.n.
14. Coumadin 3 mg q. h.s.
15. Levofloxacin 250 mg q.d. Finish course [**2166-7-22**].
ALLERGIES: No known drug allergies.
PERTINENT LABORATORY DATA ON ADMIT: His white count was
34.5, hematocrit 29, 17, and then 26, INR 1.3, BUN 67,
creatinine 1.8, anion gap 15, cardiac enzymes negative times
three, haptoglobin normal. Urinalysis showed positive
nitrites, moderate bacteria, trace leukocyte esterase, 11 to
20 white blood cells, 0 red blood cells, lactate 6 and on
repeat 2.2.
CT of the abdomen and pelvis showed bibasilar atelectasis
with relative sparing of subpleural region. Abdominal aortic
aneurysm unchanged to prior study.
Chest x-ray: No acute cardiopulmonary process.
EKG in Emergency Department during a bout of hypotension
showed [**Street Address(2) **] depressions anterolaterally with resolution
of depressions on the floor.
HOSPITAL COURSE BY PROBLEM: Hematemesis: The patient was
transfused a total of four units of packed red blood cells
and continued to have a stable hematocrit checked every six
hours. EGD was done by Gastroenterology which showed no
active bleeding and was consistent with erosive esophagitis.
He was continued on Protonix 40 mg q.d. Likely, his
hematemesis was secondary to his episode of epistaxis the day
prior to admit. H. pylori is pending.
Infectious Disease: Patient's white count was 34 on admit.
He had low-grade temperatures to 99 and 100 degrees
Fahrenheit. He was started empirically on a course of p.o.
Flagyl to cover for Clostridium difficile as the patient was
recently on Levofloxacin and complained of diarrhea prior to
admit. His urinalysis was also a positive. On admit he was
started on ceftriaxone as well as vancomycin. This was
switched to Bactrim before discharge. Cultures are pending.
Deep venous thrombosis: The patient has a history of a deep
venous thrombosis in [**3-/2166**] on Coumadin with a goal INR of 2
to 3. He was given two doses of vitamin K at [**Hospital3 2558**]
before transfer. His INR on admit was 1.3. As the patient
could not be anticoagulated on the first night, inferior vena
cava filter was placed and after the normal EGD, his Coumadin
was resumed.
Pulmonary: The patient is on Albuterol and Atrovent
nebulizers. He was 7 to 8 liters positive during the course
of this stay and mildly fluid overloaded. He required two
liters oxygen by nasal cannula and responded well to Lasix
during his diastolic cardiac dysfunction. He will be
discharged on 20 mg p.o. q.d.
Renal: Patient's creatinine improved to baseline and anion
gap resolved, likely from a non-gap metabolic acidosis from
his prior diarrhea.
Coronary artery disease status post stent: He was continued
on his aspirin and Plavix.
Fluids, electrolytes, and nutrition: The patient's diet was
advanced and he tolerated it well before discharge.
Contact: Wife.
Full Code.
DISPOSITION: The patient will be discharged back to [**Hospital3 7511**] for continued rehabilitation after his open reduction
internal fixation.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Coumadin 3 mg p.o. q. h.s.
2. Protonix 40 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Percocet one to two tabs p.o. q. 4 to 6 hours p.r.n.
6. Flagyl 500 mg p.o. t.i.d. times 12 days
7. Bactrim one tablet p.o. b.i.d. times seven days
8. Trazodone 12.5 mg p.o. q. h.s. p.r.n.
9. Albuterol and Atrovent nebulizers q. 6 hours p.r.n.
10. Venlafaxine 150 mg p.o. q. a.m., 225 mg q. p.m.
11. Lipitor 10 mg p.o. q.d.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 35922**]
MEDQUIST36
D: [**2166-7-23**] 11:26:52
T: [**2166-7-23**] 15:31:50
Job#: [**Job Number 94092**]
|
4414,4422,78820,496,2720,4019 | 256 | 155,415 | Admission Date: [**2163-7-26**] Discharge Date: [**2163-7-29**]
Service: Vascular
HISTORY OF PRESENT ILLNESS: The patient was initially
evaluated in Dr.[**Name (NI) 82589**] office on [**2162-7-6**]. He has a
known aneurysm. He underwent aortogram with coil
embolization to the right internal iliac artery which he
tolerated well. He now returns for an endovascular aneurysm
repair.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Chronic obstructive pulmonary disease.
3. Hepatitis.
4. Chronic low back pain.
5. Right hip pain.
6. Echocardiogram in [**2161**] showed left atrial dilatation,
left ventricular hypertrophy, with normal systolic function.
7. Electrocardiogram and stress in [**2161**] was without
electrocardiogram changes.
8. He has a history of peptic ulcer disease with symptoms
over six to eight years.
PAST SURGICAL HISTORY:
1. Transurethral resection of prostate in [**2158**].
2. A cystoscopy in [**2158**] and [**2155**].
3. Hemorrhoidectomy in [**2154**].
4. Appendectomy in [**2130**].
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: Darvon, Effexor 2.25 mg p.o. q.d.,
Xanax 1 mg p.o. p.r.n., Cardura 4 mg p.o. at bedtime.
PHYSICAL EXAMINATION: Blood pressure 166/86, pulse 75,
respirations 20. The general appearance revealed an
overweight Russian-speaking gentleman in no acute distress.
His HEENT examination was unremarkable. His heart had a
regular rate and rhythm, distant heart sounds. No extra
murmur, rubs or gallops. Chest revealed distant lungs sounds
bilaterally in all lung fields. No adventitious sounds.
Abdomen was round, soft, and nontender. No bruits were
noted. No organomegaly was noted. The abdominal aorta was
not prominent. The extremities showed edema bilaterally with
palpable posterior tibialis pulses.
PREOPERATIVE LABORATORY: Hematocrit of 41.5, creatinine 1.5,
PT and INR were normal.
RADIOLOGY/IMAGING: Electrocardiogram showed inverted T
waves in I, aVL, V5, and V6; unchanged from [**2158**].
HOSPITAL COURSE: The patient is now admitted endovascular
abdominal aortic repair. The patient was admitted to the
preoperative holding area. On [**2163-7-26**], he underwent an
endovascular abdominal aortic aneurysm repair without
incident. He was transferred to the Postanesthesia Care Unit
in stable condition with dopplerable dorsalis pedis and
posterior tibialis bilaterally.
Postoperatively, he remained hemodynamically stable. His
postoperative hematocrit was 34.6. His BUN was 16,
creatinine 1.5, potassium 4.2, magnesium 2.2. He had a
palpable dorsalis pedis bilaterally. Bowel sounds were
present. Lungs were clear to auscultation. He continued to
do well and was transferred to the Surgical Intensive Care
Unit for continued monitoring and care.
Vascular on call was called to see the patient at 3:30 a.m.
on postoperative day one for complaints of chest pain. Vital
signs were blood pressure of 121/51, pulse 72, respiratory
rate 19, oxygen saturation 96% on room air. Lung examination
and cardiac examination were unremarkable. Abdomen remained
soft and nontender. Pulse examination remained unchanged.
An electrocardiogram was obtained. There were no acute
ischemic electrocardiogram changes. Serial creatine kinase,
MB, and electrocardiogram were obtained. Electrolytes were
obtained. Hematocrit was obtained. Results revealed
hematocrit was stable at 31.8. Electrolytes showed a
potassium of 5.1, BUN 19, creatinine 1.5, ionized
calcium 1.12. Creatine kinase total was 1400. MBs were 16,
10, and 7. Troponin was less than 0.3. Serial
electrocardiograms returned to baseline. The patient
remained hemodynamically stable with a temperature maximum
of 101.2. Incentive spirometry was begun. Perioperative
Kefzol was continued. He remained in the Vascular Intensive
Care Unit.
On postoperative day two he defervesced. He ruled out for
myocardial infarction and was delined and transferred to the
regular nursing floor. His Foley was discontinued, but the
patient failed to void and required the Foley to be replaced.
On the day of transfer he had a temperature maximum of 100.4
to 98.7. Groin dressings were clean, dry and intact.
Abdomen was soft, nontender, and nondistended. Foley was in
place. Culture and sensitivity and urinalysis were sent for
evaluation. The patient was continued on Kefzol. Urology
was consulted with regard to failure to void in a patient
with known transurethral resection of prostate.
DISCHARGE DISPOSITION: The patient was evaluated by Physical
Therapy and felt that he would benefit from a short stay in
rehabilitation for increasing endurance and mobility. The
patient was requested to be screened by Transitional Care
Unit.
MEDICATIONS ON DISCHARGE:
1. Cardura 4 mg p.o. q.d.
2. Ancef 1 g intravenous q.8.h.
3. Percocet tablets one to two tablets q.4h. p.r.n. for
pain.
4. Heparin 5000 units subcutaneous b.i.d.
5. Ocean Spray to both nostrils p.r.n.
6. Xanax 0.5 mg p.o. q.h.s.
7. Flexeril 10 mg p.o. q.d.
8. Dulcolax suppository p.r.n.
9. Colace 100 mg p.o. b.i.d.
10. Dulcolax tablets 5 mg to 10 mg p.o. p.r.n.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Status post endovascular stent.
3. Fever secondary to unclear etiology; urine and culture
and sensitivity pending at the time of dictation.
4. Failure to void with a history of transurethral resection
of prostate; Genitourinary consulted.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18836**], M.D. [**MD Number(1) 18837**]
Dictated By:[**Last Name (NamePattern1) 17652**]
MEDQUIST36
D: [**2163-7-29**] 11:47
T: [**2163-7-29**] 12:23
JOB#: [**Job Number 94085**]
|
5939,9975,5990,5849,9961,5185,4413,496,4019,2724,V1507,2859,V1251,412 | 256 | 188,869 | Admission Date: [**2170-6-15**] Discharge Date: [**2170-6-27**]
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
intermittant abdominal and back pain for 10 days
Major Surgical or Invasive Procedure:
Abdominal Aortic Aneurysm S/p repair [**2170-6-14**]
History of Present Illness:
83 yo M s/p EVAR in [**7-/2163**] by Dr. [**Last Name (STitle) 18835**] for an infrarenal
AAA. He has been lost to follow up since that time. He has been
c/o intermittant abdominal and back pain for the last 10 days,
with an acute increase in pain at around 6PM this evening. He
was
seen by his PCP [**Last Name (NamePattern4) **] [**6-11**] and a NC CT was obtained, showing
enlargement of the AAA from ~ 5x5 to ~ 7x7. His symptoms were
thought to be due to constipation and he was sent home
recommendations to see Dr. [**Last Name (STitle) 22426**] in [**Hospital **] clinic ASAP.
A
repeat NC CT was done this evening, due to his CRI, which showed
the enlarged AAA with extravasation of high-density fluid
anteriorly. The AAA also appears to now involve the renal
arteries B. He arrived in the ED hypertensive with SBP >200. We
have since given him Labetalol and he is now on a Nitro gtt for
BP control, goal SBP <100. He is currently mentating. We have
discussed the gravity of this situation and he wishes us to
proceed with an attempt at operative repair.
Past Medical History:
1. Coronary artery disease, status post MI in [**2166**]. 2 vessel
disease s/p successful PCI to mid-RCA
2. Hypertension.
3. Hyperlipidemia.
4. Paroxysmal atrial fibrillation.
5. History of abdominal aortic aneurysm.
6. History of deep venous thrombosis.
7. Chronic obstructive pulmonary disease.
8. Peptic ulcer disease.
9. History of esophagitis.
10. History of gastrointestinal bleeding.
11. Diverticulosis.
12. Renal insufficiency.
13. Lumbosacral radiculopathy.
14. Depression.
15. History of hip fracture.
PAST SURGICAL HISTORY:
1. Status post stent graft surgery for abdominal aortic
aneurysm.
2. Status post [**Location (un) 260**] filter placement for history of DVT.
3. Status post hip replacement.
Social History:
Home: lives with wife of 60 years at home; supportive family
with 1 daughter, 2 granddaughter and great-granddaughters
[**Name (NI) **]: retired math professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 532**]
Denies tobacco, etoh, drugs
Family History:
noncontributory
Physical Exam:
VS: T 98.8 HR 56 BP 100/56
Gen: NAD. A&Ox3.
Heart: [**Last Name (un) **], [**Last Name (un) **]. Now brady in the 50's.
Lungs: Diminshed bases b/l.
Abdomen: + Guarding. TTP diffusely. + Palpable mass mid-abdomen.
Pulses: Palpable femoral pulses B. No peripheral edema.
Labs:
Trop-T: <0.01 CK: 35 MB: Notdone
144 109 23 /
------------- 109
4.5 26 1.7
Ca: 9.8 Mg: 2.2 P: 2.6
ALT: 5 AP: 62 Tbili: 0.5 Alb: 3.9 AST: 12 Lip: 17
143 103/
------- 100
4.2 27
freeCa:1.18
Lactate:1.3
pH:7.42
Hgb:13.4
CalcHCT:40
PT: 13.4 PTT: 30.6 INR: 1.1
Abd./Pelvis CT: New stranding and high-attenuation fluid
surrounding large abdominal aortic aneurysm, which is slightly
increased in size since very recent exam of [**2170-6-11**]. Of note,
the stent endograft has migrated significantly inferiorly since
previous contrast-enhanced scan of [**2167-2-25**]. While no evidence of
intramural hemorrhage, active endoleak or extravasation of
contrast is seen, these findings are concerning, and may
represent impending leak or rupture. Alternatively, the
inflammation surrounding the aortic aneurysm could represent a
process such as aortitis (though no evidence of such was seen as
recently as three days before).
Pertinent Results:
[**2170-6-25**] 07:20AM BLOOD WBC-7.9 RBC-3.51* Hgb-9.8* Hct-30.8*
MCV-88 MCH-28.1 MCHC-32.0 RDW-15.1 Plt Ct-257
[**2170-6-24**] 04:51AM BLOOD WBC-8.0 RBC-3.31* Hgb-9.6* Hct-28.6*
MCV-86 MCH-29.0 MCHC-33.5 RDW-15.3 Plt Ct-251
[**2170-6-23**] 04:52AM BLOOD WBC-6.8 RBC-3.43* Hgb-9.8* Hct-29.7*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.0 Plt Ct-222
[**2170-6-22**] 02:10AM BLOOD WBC-7.5 RBC-3.69* Hgb-10.5* Hct-31.7*
MCV-86 MCH-28.4 MCHC-33.0 RDW-14.8 Plt Ct-235
[**2170-6-21**] 03:00AM BLOOD WBC-8.6 RBC-3.56* Hgb-10.3* Hct-30.7*
MCV-86 MCH-28.8 MCHC-33.4 RDW-14.9 Plt Ct-219
[**2170-6-20**] 02:42AM BLOOD WBC-9.4 RBC-3.60* Hgb-10.7* Hct-31.0*
MCV-86 MCH-29.8 MCHC-34.5 RDW-14.9 Plt Ct-206
[**2170-6-19**] 03:11AM BLOOD WBC-8.3 RBC-3.41* Hgb-9.9* Hct-29.4*
MCV-86 MCH-29.1 MCHC-33.8 RDW-15.1 Plt Ct-168
[**2170-6-18**] 01:08AM BLOOD WBC-8.6 RBC-3.21* Hgb-9.1* Hct-28.2*
MCV-88 MCH-28.4 MCHC-32.3 RDW-14.8 Plt Ct-126*
[**2170-6-17**] 04:24AM BLOOD WBC-10.4 RBC-2.97* Hgb-8.6* Hct-26.7*
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.3 Plt Ct-124*
[**2170-6-16**] 02:05AM BLOOD WBC-10.7 RBC-3.43* Hgb-10.0* Hct-29.6*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.3 Plt Ct-155
[**2170-6-15**] 08:30AM BLOOD WBC-12.1* RBC-3.63* Hgb-10.6* Hct-31.3*
MCV-86 MCH-29.3 MCHC-34.0 RDW-13.6 Plt Ct-197
[**2170-6-15**] 03:18AM BLOOD Hgb-9.4*# Hct-27.9*#
[**2170-6-15**] 12:50AM BLOOD WBC-9.8 RBC-4.42* Hgb-12.6* Hct-37.7*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.3 Plt Ct-229
[**2170-6-15**] 12:50AM BLOOD Neuts-69.3 Lymphs-23.6 Monos-4.8 Eos-1.4
Baso-0.8
[**2170-6-25**] 07:20AM BLOOD Plt Ct-257
[**2170-6-25**] 07:20AM BLOOD PT-13.2 PTT-28.6 INR(PT)-1.1
[**2170-6-24**] 04:51AM BLOOD Plt Ct-251
[**2170-6-23**] 04:52AM BLOOD Plt Ct-222
[**2170-6-22**] 02:10AM BLOOD Plt Ct-235
[**2170-6-21**] 03:00AM BLOOD Plt Ct-219
[**2170-6-20**] 02:42AM BLOOD Plt Ct-206
[**2170-6-20**] 02:42AM BLOOD PT-12.7 PTT-31.1 INR(PT)-1.1
[**2170-6-19**] 03:11AM BLOOD Plt Ct-168
[**2170-6-19**] 03:11AM BLOOD PT-12.1 PTT-34.3 INR(PT)-1.0
[**2170-6-18**] 09:45AM BLOOD PT-12.2 INR(PT)-1.0
[**2170-6-18**] 01:08AM BLOOD Plt Ct-126*
[**2170-6-17**] 04:24AM BLOOD Plt Ct-124*
[**2170-6-17**] 04:24AM BLOOD PT-14.7* PTT-38.8* INR(PT)-1.3*
[**2170-6-17**] 04:24AM BLOOD PT-14.7* PTT-38.8* INR(PT)-1.3*
[**2170-6-16**] 02:05AM BLOOD Plt Ct-155
[**2170-6-16**] 02:05AM BLOOD PT-15.7* PTT-41.1* INR(PT)-1.4*
[**2170-6-15**] 08:30AM BLOOD Plt Ct-197
[**2170-6-15**] 08:30AM BLOOD PT-16.1* PTT-35.8* INR(PT)-1.4*
[**2170-6-15**] 03:18AM BLOOD PT-15.1* PTT-40.9* INR(PT)-1.3*
[**2170-6-15**] 12:50AM BLOOD Plt Ct-229
[**2170-6-26**] 10:05AM BLOOD Glucose-125* UreaN-34* Creat-1.8* Na-141
K-4.1 Cl-104 HCO3-32 AnGap-9
[**2170-6-25**] 07:20AM BLOOD Glucose-112* UreaN-38* Creat-2.0* Na-141
K-4.0 Cl-105 HCO3-30 AnGap-10
[**2170-6-24**] 04:51AM BLOOD Glucose-124* UreaN-45* Creat-2.2* Na-141
K-3.5 Cl-106 HCO3-29 AnGap-10
[**2170-6-23**] 04:52AM BLOOD Glucose-92 UreaN-47* Creat-2.3* Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
[**2170-6-22**] 02:10AM BLOOD Glucose-104 UreaN-49* Creat-2.5* Na-142
K-3.9 Cl-111* HCO3-25 AnGap-10
[**2170-6-21**] 03:00AM BLOOD Glucose-98 UreaN-49* Creat-2.6* Na-142
K-4.2 Cl-112* HCO3-21* AnGap-13
[**2170-6-20**] 04:38PM BLOOD Creat-2.7*
[**2170-6-20**] 02:42AM BLOOD Glucose-141* UreaN-45* Creat-2.8* Na-141
K-4.6 Cl-111* HCO3-22 AnGap-13
[**2170-6-19**] 03:11AM BLOOD Glucose-116* UreaN-40* Creat-2.6* Na-140
K-4.2 Cl-113* HCO3-21* AnGap-10
[**2170-6-18**] 01:08AM BLOOD Glucose-79 UreaN-34* Creat-2.6* Na-139
K-4.1 Cl-112* HCO3-19* AnGap-12
[**2170-6-17**] 04:24AM BLOOD Glucose-76 UreaN-32* Creat-2.2* Na-140
K-4.5 Cl-115* HCO3-20* AnGap-10
[**2170-6-16**] 02:05AM BLOOD Glucose-91 UreaN-28* Creat-2.2* Na-142
K-4.4 Cl-116* HCO3-22 AnGap-8
[**2170-6-15**] 08:30AM BLOOD Glucose-198* UreaN-22* Creat-1.6* Na-142
K-4.7 Cl-114* HCO3-23 AnGap-10
[**2170-6-15**] 12:50AM BLOOD Glucose-109* UreaN-23* Creat-1.7* Na-144
K-4.5 Cl-109* HCO3-26 AnGap-14
[**2170-6-18**] 09:45AM BLOOD ALT-4 AST-20 LD(LDH)-229 AlkPhos-37*
TotBili-0.6
[**2170-6-15**] 08:30AM BLOOD CK(CPK)-65
[**2170-6-15**] 12:50AM BLOOD ALT-5 AST-12 CK(CPK)-35* AlkPhos-62
TotBili-0.5
[**2170-6-15**] 12:50AM BLOOD Lipase-17
[**2170-6-15**] 08:30AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2170-6-15**] 12:50AM BLOOD cTropnT-<0.01
[**2170-6-15**] 12:50AM BLOOD CK-MB-NotDone
[**2170-6-26**] 10:05AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
[**2170-6-25**] 07:20AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0
[**2170-6-24**] 04:51AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.2
[**2170-6-23**] 04:52AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2170-6-22**] 02:10AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.2
[**2170-6-21**] 04:32PM BLOOD Mg-2.2
[**2170-6-21**] 03:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3
[**2170-6-20**] 02:42AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
[**2170-6-19**] 03:11AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.9
[**2170-6-18**] 09:45AM BLOOD Albumin-2.2*
[**2170-6-18**] 01:08AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
[**2170-6-17**] 04:24AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.7
CHEST (PORTABLE AP) [**2170-6-15**] 12:47 AM
FINDINGS: Single portable upright chest radiograph is reviewed
without comparison. Cardiomediastinal silhouette is unchanged,
with lobulated contour to the descending thoracic aorta which
appears to correlate to thoracic saccular aneurysm seen on prior
CT from [**2166-10-29**]. Minimal scarring in the right mid lung is
unchanged. Emphysema is unchanged. There is no new airspace
opacity. There is no pleural effusion or pneumothorax, though
note, a portion of the left hemithorax and costophrenic sulcus
is excluded.
IMPRESSION:
1. Increased prominence of lobulated contour of the descending
aorta, suggestive of interval growth of known saccular aneurysm
at this site.
2. No evidence of pneumonia.
CT PELVIS W&W/O C [**2170-6-15**] 1:04 AM
COMPARISON: [**2170-6-11**] and [**2167-2-25**].
CT ABDOMEN: Bullous emphysematous changes at the lung bases,
right greater than left are unchanged. Right basilar atelectasis
has increased.
Liver and gallbladder are normal. There is mild dilatation of
the extrahepatic common bile duct, measuring up to 13 mm. No
sign of stone or other obstructing lesion is seen. Pancreas is
fatty replaced, and atrophic. Spleen is normal. The stomach and
intra-abdominal loops of bowel are normal. There is no sign of
bowel obstruction. Kidneys are atrophic bilaterally, with
unchanged small cystic lesions too small to definitively
characterize. Contrast is excreted symmetrically. There is no
hydronephrosis.
Large infrarenal abdominal aortic aneurysm is again seen. The
aneurysm has slightly increased in size, measuring 7.3 x 6.9 cm.
The endovascular stent graft is again identified below the renal
arteries, with limbs extending into both common iliac arteries.
Stent graft is unchanged in position from [**2170-6-11**]. However,
note is made that when compared to previous contrast- enhanced
study of [**2167-2-25**], the stent has shifted significantly in
position, at least 3 cm inferiorly. While there is no definite
evidence of leak or extravasation of contrast from the stent,
and there is no increased density seen within the aneurysm sac,
there is now a moderate amount of inflammatory stranding seen
around the aneurysm sac. There is also dense fluid (48 [**Doctor Last Name **] on
non-contrast imaging) seen tracking along the left aspect of the
aneurysm sac (2:47).
There is no free intraperitoneal air, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Pelvic loops of large and small bowel are normal,
though lower pelvis evaluation is limited by streak artifact
from right hip prosthesis. There is no free pelvic fluid or
abnormal pelvic or inguinal lymphadenopathy. Aneurysm coil in
the right internal iliac artery is unchanged.
OSSEOUS STRUCTURES: Right hip prosthesis is unchanged.
Ill-defined sclerotic lesion in the right iliac bone is
unchanged. Mild degenerative changes in the lumbar spine are
stable.
IMPRESSION: New stranding and high-attenuation fluid surrounding
large abdominal aortic aneurysm, which is slightly increased in
size since very recent exam of [**2170-6-11**]. Of note, the stent
endograft has migrated significantly inferiorly since previous
contrast-enhanced scan of [**2167-2-25**]. While no evidence of
intramural hemorrhage, active endoleak or extravasation of
contrast is seen, these findings are concerning, and may
represent impending leak or rupture. Alternatively, the
inflammation surrounding the aortic aneurysm could represent a
process such as aortitis (though no evidence of such was seen as
recently as three days before).
ECG Study Date of [**2170-6-18**] 9:22:24 AM
Artifact is present. Sinus rhythm. There are non-diagnostic Q
waves in the
inferior leads. Diffuse non-specific ST-T wave changes. Compared
to the
previous tracing early transition is no longer present.
CHEST (PORTABLE AP) [**2170-6-20**] 3:46 PM
INDICATION: Dobbhoff placement.
COMPARISON: [**2170-6-15**].
FRONTAL CHEST RADIOGRAPH: There has been interval removal of the
endotracheal tube. The Dobbhoff tube is seen with tip projecting
over the proximal duodenum. Right-sided central venous line is
in unchanged position. Otherwise, no significant change seen
compared to prior study with persistent bibasilar opacities and
small bilateral pleural effusions.
IMPRESSION: Dobbhoff tube seen with tip projecting over the
proximal duodenum. Otherwise, no significant change from prior.
ECG Study Date of [**2170-6-20**] 11:45:24 AM
Sinus rhythm. Non-specific inferolateral T wave flattening.
Compared to the previous tracing of [**2170-6-18**] the Q wave is absent
in lead III and less
pronounced in lead aVF. T wave flattening is new.
Brief Hospital Course:
83 yo M s/p EVAR in [**7-/2163**] by Dr. [**Last Name (STitle) 18835**] for an infrarenal
AAA. He has been lost to follow up since that time. He has been
c/o intermittant abdominal and back pain for the last 10 days,
with an acute increase in pain at around 6PM this evening. He
was
seen by his PCP [**Last Name (NamePattern4) **] [**6-11**] and a NC CT was obtained, showing
enlargement of the AAA from ~ 5x5 to ~ 7x7. His symptoms were
thought to be due to constipation and he was sent home
recommendations to see Dr. [**Last Name (STitle) 22426**] in [**Hospital **] clinic ASAP.
A
repeat NC CT was done this evening, due to his CRI, which showed
the enlarged AAA with extravasation of high-density fluid
anteriorly. The AAA also appears to now involve the renal
arteries B. He arrived in the ED hypertensive with SBP >200. We
have since given him Labetalol and he is now on a Nitro gtt for
BP control, goal SBP <100. He is currently mentating. We have
discussed the gravity of this situation and he wishes us to
proceed with an attempt at operative repair. Patient was
admitted for open AAA repair and further management.
HD1 [**2170-6-15**] Patient was taken to OR by Dr. [**Last Name (STitle) 14533**] for repair
of ruptured AAA. Patient tolerated procedure well.
Post-operatively patient was transfered to the ICU for recovery.
Patient sedated and intubated. Patient rousable and responsive.
Patient placed on levo and cipro for antibiotics. NPO. On RISS
for blood sugar control. Vitals signs stable on pressors
(Levophed gtt.), low dose beta blocker. Labs stable.
POD1 [**6-16**] Remains in ICU, intubated, sedated on Propofol and
Fentanyl drips. Antibiotics switched to Ancef and cipro.
Afebrile. Remains NPO. Poor urine output- hydrated. Plans to
wean to extubate, wean off drips.
POD2 [**6-17**] Remains in ICU, intubated but weaning, sedated.
Continues to require IVF. Given 1 unit of PRBC. Afebrile. NPO.
POD3 [**6-18**] Remains in ICU, intubated-continues to wean, minimally
sedated. Diuresed with Lasix. Remains on Cipro. Transfused 1
unit PRBC. Adequate UOP. Afebrile. RISS.
POD4 [**6-19**] Remains in ICU. Vent weaned and extubated. Reamins on
Fentanyl drip for pain management. Hypertensive- increased beta
blocker.Good UOP. Continues on Cipro.
POD5 [**6-20**] Remains in ICU. Awake, extubated, afebrile. Diuresed
with Lasix-adequate uop. Resumed some home meds. Tube feeds via
NGT. Cipro d/c'd. RISS.
POD6 [**6-21**] Remains in ICU, hypertensive- started on Nitro gtt,
increased antihypertensives. Afebrile. Dob off placed, tube
feeds increased- well tolerated. Gentle diuresis. Plan to
transfer to stepdown. Resumed most home meds. RISS.
POD7 [**6-22**] Speech and swallow eval-OK to start POs as tolerated,
thickened liquids. Remains in ICU. Nitro gtt for hypertension.
Diuresed with lasix. Afberile. Physical therapy referral.
Transferred to VICU [**Hospital Ward Name 121**] 5.
POD8 [**6-23**] VICU status, VSS, afebrile. Diuresed. Pulmonary
toilet. No acute events.
POD9 [**6-24**] VICU status, VSS, afberile. Increasing diet. No acute
events.
POD10 [**6-25**] VICU staus, VSS, afberile. DAT. PT re-consult,
ambulate. Diuresed. Dispo planning.
POD11 [**6-26**] Floor status, VSS, afebrile. D/c foley. Rehab screen
for dispo.Afebrile. no acute events. Restarted Cipro for
CITROBACTER FREUNDII COMPLEX that grew from urine Cx on [**6-22**].
POD12 [**6-27**] Discharged to Rehab ([**Hospital1 599**] of [**Location (un) 55**]) in good
condition. Will D/c on Cipro for 2 wks. FU for Dr. [**Last Name (STitle) 14533**]
already set up.
Medications on Admission:
oxycodone 5mg q4prn
amlopidine 5mg QD
lisinopril 25 (20 + 5) mg QD
metoprolol 12.5 mg [**Hospital1 **]
alprazolam 1 mg QHS
gabapentin 300/200 mg
omeprazole 20 mg QD
simvastatin 20 mg QD
venlafaxine xr 225 mg qhs
senokot [**2-7**] tab QHS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q AM ().
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Abdominal Aortic Aneurysm S/p repair [**2170-6-14**]
CAD
HTN
hyperlipidemia
pAF
h/o DVT with IVC filter
COPD
PUD with GIB
esophagitis
diverticulosis
renal insufficiency
lumbosacral radiculopathy
depression
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-15**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-11**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-7-11**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2170-10-22**]
3:20
Completed by:[**2170-6-27**] |
4019,V5861,V1259,E8859,85221 | 257 | 179,006 | Admission Date: [**2112-12-20**] Discharge Date: [**2112-12-23**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
woman with a history of meningioma removal in [**2091**], stroke in
[**2105**], pulmonary embolism in [**2102**]. She is on Coumadin. She
had a fall five days ago, hitting her head. Yesterday, she
was standing by the bed when she again fell. This time, she
hit the back of her head around 8:30 p.m. She was lying on
the floor for ten hours before being found by her son in the
morning. She could not stand up. She was taken to an outside
hospital, which showed a subdural hematoma. She was
transferred to [**Hospital1 69**]. She had
no loss of consciousness the morning of the fall.
PHYSICAL EXAMINATION: On physical examination, her
temperature was 97.9; blood pressure was 221/74, heart rate
63; respiratory rate 14; saturation 98% on room air. In
general, she was in no acute distress. Cardiac: Regular
rate and rhythm, no murmur. Chest was clear to auscultation.
Neurologically, she was alert and attentive, oriented times
three, fluent speech. Extraocular movements full. Face:
Sensation was intact. She had no facial droop; question of a
left old one from her old stroke. Tongue was midline. Palate
was gross symmetrically. Strength was [**5-16**] in all muscle
groups. Sensation was intact to light touch. Finger to nose
and coordination were intact. Her gait was deferred secondary
to her critical condition on admission. She also had a left
ptosis and history of right leg weakness and left ptosis from
previous stroke and surgery.
HOSPITAL COURSE: She was admitted to the Intensive Care
Unit. She was monitored in the Intensive Care Unit. She had
a repeat CAT scan which showed stable appearance of a left
subdural hematoma. She also has a right subdural hematoma
which was found to be stable as well. The patient was
monitored in the Intensive Care Unit. Her blood pressure was
kept under 150. She was restarted on her p.o. medications
although she still continued to have some episodes of
hypertension, requiring some intravenous medication. She did
remain stable and was transferred to the floor on [**2112-12-21**].
She remains neurologically stable. Repeat head CT today is
stable. She was offered surgery (craniotomy) to decompress the
Left Subdural hematoma, but the patient refused.
She was seen by physical therapy and occupational therapy and
found to be safe for discharge to home with a walker and home
safety evaluation. Her condition was stable at the time of
discharge.
MEDICATIONS:
Metoprolol XL 250 mg p.o. q h.s.; hold for systolic less than
100 and heart rate less than 50.
Heparin 5000 subcutaneous which will be discontinued before
discharge.
Manoxapril 15 mg p.o. q. day.
Diltiazem extended release 80 mg p.o. q. day.
Atorvastatin 10 mg p.o. q. day.
CONDITION: Stable at the time of discharge.
She will follow-up with DR. [**First Name (STitle) 742**] [**Name (STitle) **], M.D. in
two weeks with a repeat head CT at that time.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2112-12-23**] 10:52
T: [**2112-12-23**] 10:56
JOB#: [**Job Number 53954**]
|
V3001,77081,76519,76528,77981,7706,V290,V053 | 260 | 190,363 | Unit No: [**Numeric Identifier 71985**]
Admission Date: [**2105-3-23**]
Discharge Date: [**2105-3-30**]
Date of Birth: [**2105-3-23**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name9 (NamePattern2) 71986**] [**Known lastname **] is the former 3
kg product of a 36 and 6/7 weeks gestation pregnancy, born to
a 40 year-old, G3, P1 now 2 woman. Prenatal screens: Blood
type 0 positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown. The mother's obstetrical history is
notable for an intrauterine fetal demise at 32 weeks
gestation which occurred in [**2102**]. This pregnancy was
uncomplicated with planned early delivery secondary to
concern with the prior intrauterine fetal demise. The mother
was taken to elective Cesarean section on [**2105-3-23**]. The
infant emerged with spontaneous respirations. She required
oxygen, bulb suctioning as part of her resuscitation. Apgars
were 7 at 1 minute and 8 at 5 minutes. She was admitted to
the NICU due to respiratory distress.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 3000 grams; length was 49 cm;
head circumference was 34 cm. General: Non dysmorphic, near
term female in moderate respiratory distress. HEENT:
Anterior fontanel soft and flat; non dysmorphic facies;
palate intact. Neck and mouth normal. Mild nasal flaring.
Chest: Mild subcostal retractions. Good breath sounds
bilaterally. No adventitious sounds. Cardiovascular: Well
perfused. Regular rate and rhythm. Femoral pulses normal.
Normal S1 and S2. No murmur. Abdomen soft, nondistended, no
organomegaly, no masses. Bowel sounds active. Anus patent.
Genitourinary: Normal female genitalia. Spine straight,
normal sacrum. Skin normal. No rashes. Extremities: Moving
all, hips stable. Neurologic: Active, alert, reactive to
stimuli. Tone normal and symmetric, moving all extremities.
Suck, root, gag intact. Facies symmetric.
HOSPITAL COURSE:
1. Respiratory: [**Year (4 digits) 71986**] had respiratory distress consistent
with retained fetal lung fluid. She did require 400 cc of
nasal cannula oxygen flow for the first few hours after
birth. By day of life 1, she was in room air and she
continued in room air for the rest of her Neonatal
Intensive Care Unit admission. She had an episode of
spontaneous apnea and bradycardia associated with a
feeding on day of life 2. Therefore, she remained for an
additional 5 day observation. During that time, she has
not had any further episodes of apnea and bradycardia. At
the time of discharge, she is breathing comfortably in
room air with a respiratory rate of 30 to 50 breaths per
minute.
1. Cardiovascular: [**Year (4 digits) 71986**] has maintained normal blood
pressure and heart rates. No murmurs have been noted.
Baseline heart rate is 130 to 160 beats per minute with a
recent blood pressure of 71/42 mmHg, mean arterial
pressure of 52 mmHg.
1. Fluids, electrolytes and nutrition: [**Year (4 digits) 71986**] was initially
n.p.o. and maintained on IV fluids. Enteral feeds were
started on day of life 1 and were advanced to full
volumes. At the time of discharge, she is breast feeding
or taking Similac 20 formula ad lib. Weight on the day of
discharge is 2.755 kg with a corresponding head
circumference of 34 cm and a length of 49.5 cm.
1. Infectious disease: Due to the unknown etiology of the
respiratory distress and the unknown group beta strep
status of the mother, [**Name (NI) 71986**] was evaluated for sepsis
upon admission to the NICU. A complete blood count was
within normal limits and a blood culture was obtained
prior to starting IV ampicillin and gentamycin. The blood
culture was no growth at 48 hours and the antibiotics
were discontinued.
1. Hematology: [**Name (NI) 71986**] is blood type 0 positive and is
direct antibody test negative. Hematocrit at birth was
44.3%. She did not receive any transfusions of blood
products.
1. Gastrointestinal: [**Name (NI) 71986**] had a peak serum bilirubin
occur on day of life 4 with a total of 13.4 mg/dl. Her
repeat bilirubin on day of life 5 was down to 12.3 mg/day
of life total. A serum bilirubin obtained on the day of
discharge is 10.6/0.3.
1. Neurologic: [**Name (NI) 71986**] has maintained a normal neurologic
exam during admission. There are no concerns at the time
of discharge.
1. Sensory:
Audiology: Hearing screening was performed with automated
auditory brain stem responses. [**Name (NI) 71986**] passed in both ears on
[**2105-3-29**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7610**], [**Location (un) 42044**].,
[**Hospital1 2436**], [**Numeric Identifier 42046**], telephone number [**Telephone/Fax (1) 42047**].
CARE AND RECOMMENDATIONS:
1. Ad lib p.o. feeding; breast feeding or Similac 20
formula.
2. No medications.
3. Car seat position screening was performed. [**Telephone/Fax (1) 71986**] was
observed in her car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screen was sent on [**2105-3-26**]. There has been
no notification of abnormal results to date.
5. Immunizations: Hepatitis B vaccine was administered on
[**2105-3-26**].
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 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP:
1. Appointment with Dr. [**Last Name (STitle) 7610**] within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 36 and 3/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis, ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2105-3-30**] 01:50:53
T: [**2105-3-30**] 04:39:30
Job#: [**Job Number 71987**]
|
25000,1508,2765,03849,2639,42732,42731,4280,4210 | 261 | 118,523 | Admission Date: [**2101-12-27**] Discharge Date: [**2102-1-12**]
Date of Birth: [**2025-8-4**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
male with a history of esophageal cancer, type 2 diabetes,
who presented to the Emergency Department with a chief
complaint of weakness. The patient has been in declining
health since [**2101-8-24**] secondary to his esophageal
cancer and has noted decreasing po intake secondary to
mucositis over the last few months. The patient has also
complained of increasing bilateral lower extremity edema over
the last month and has been seen by his primary care
physician in the past for intravenous fluid administration.
On the day of presentation the patient once again presented
originally to his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34867**] [**Name (STitle) 32412**],
requesting intravenous fluid administration. The patient was
thought to be significantly dehydrated on examination and was
therefore referred to the Emergency Department for
evaluation.
In the Emergency Department the patient was noted to have a
heart rate in the 140s with progressive hypoxia to as low as
77% on a nonrebreather. The patient was subsequently
immediately admitted to the Intensive Care Unit for
progressive hypoxia.
REVIEW OF SYSTEMS: Positive for a cough for the last three
to four weeks, which was worse when he attempted to eat or
drink anything, as well as a low grade temperature and chills
for the last two days. The patient also has noted
significantly increasing leg edema over the last few weeks.
At the time of admission to the Emergency Department, the
patient tripped and fell and hit his head on his way into the
Emergency Department.
PAST MEDICAL HISTORY: 1. Esophageal cancer treated with
local radiation therapy, 5FU, Cisplatin diagnosed in [**2101-8-24**]. 2. Status post Billroth 2 in the [**2060**] secondary
to peptic ulcer disease. 3. Type 2 diabetes mellitus times
ten years. 4. Polio as a child. 5. Questionable abruption
of many deep venous thrombosis. 6. Recurrent bladder
infections.
ALLERGIES: Penicillin causes a rash.
MEDICATIONS: NPH.
SOCIAL HISTORY: Tobacco use in the past, but quit in the
[**2050**] and reports a three pack per day history times twenty
years prior to this. The patient denies any alcohol use.
FAMILY HISTORY: The patient has a son who has been diagnosed
with renal cell carcinoma. The patient's primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34867**] [**Name (STitle) 32412**] and he is followed by
oncologist Dr. [**First Name (STitle) **].
PHYSICAL EXAMINATION: Vital signs, temperature 99.4. Heart
rate 140. Blood pressure 122/75. Respiratory rate 16.
Sating 98% on room air and then subsequently 77% on 100% face
mask. General, ill appearing, elderly thin male. HEENT
right temple with ecchymosis, pupils are equal, round and
reactive to light. Extraocular movements intact. Poor
dentition. Cardiovascular tachycardic, no murmurs.
Pulmonary diffuse rales. Abdomen soft, midline surgical
scar. Rectal examination guaiac negative. Extremities 3+
bilateral lower extremity edema to the knees.
LABORATORY: White blood cell count 7.7, hematocrit 29.7,
platelets 225, sodium 127, potassium 4.4, chloride 94, bicarb
27, BUN 18, creatinine 0.7, glucose 288. Free calcium 1.05.
Arterial blood gas 7.48/30/67/lactate equals 1.8. Chest
x-ray bibasilar infiltrates in the dependent regions. CT of
the head no evidence of bleed or mass, but low attenuation
left cerebellar area. CT of the chest, diffuse infiltrate
consistent with congestive heart failure, but no evidence of
PE. Electrocardiogram, atrial flutter at 150 beats per
minute.
HOSPITAL COURSE: The patient was noted to have marked
hypoxia at the time of admission, which was originally
thought to be secondary to a PE, however, his CT angiogram
was negative. The CT scan also demonstrated evidence of an
alveolar process, which was felt to be congestive heart
failure versus pneumonia. Given the lack of fever, sputum or
increased white blood cell counts and given the patient's
symptoms of increasing lower extremity edema, it was felt to
be most likely secondary to congestive heart failure.
However, the patient was also noted to have a
supraventricular tachycardia versus atrial flutter of unclear
etiology. The patient was treated with intravenous Diltiazem
push without change in his pulse, however, his systolic blood
pressure did drop to the 70s. Therefore an emergent
cardiology consult was obtained and cardioversion was
attempted with conscious sedation. Further diuresis was put
on hold pending potential cardioversion. However,
cardioversion was attempted with 200 jewels and then 300 and
360 jewels without success resulting in a rhythm of
multifocal atrial tachycardia. Cardiology consult
subsequently recommended attempting rate control with an
Esmolol drip, initiating gentle diuresis and obtaining a
portable echocardiogram to assess function and valvular
disease.
The patient was placed on an Esmolol and a neo-synephrine
drip, which were titrated as needed to keep a mean blood
pressure of greater then 60 and a rate less then 100. The
patient was treated with Lasix for gentle diuresis and
cardiac enzymes were cycled to evaluate for the potential of
myocardial ischemia as an initiating event. The patient's
multifocal atrial tachycardia persisted and an echocardiogram
was obtained. The echocardiogram demonstrated 4+ MR with a
flail mitral leaflet and a normal end systolic dimensions. A
vegetation could not be definitively ruled out. Given that
blood cultures obtained at the time of admission were
subsequently demonstrating gram positive coxae in pairs and
chains it was felt the patient was most likely suffering from
endocarditis. By this time the patient was hemodynamically
stable, however, with persistent MAT. Given the acute onset
of mitral regurgitation vasodilator therapy such as ace
inhibitor and nitroglycerin were initiated as tolerated. The
possibility of surgical correction was discussed with the
patient and his family who stated that they did not want
surgery under any circumstances. Therefore it was determined
to attempt medical management of the patient's acute mitral
regurgitation and endocarditis.
As the patient underwent gentle diuresis his oxygen
saturations began to improve and his supplemental oxygen
needs were slowly titrated down. The patient's
neo-synephrine drip was titrated off and the patient was
started on Captopril [**Company 34868**].i.d.
An infectious disease consult was obtained to help in the
management of endocarditis. The infectious disease consult
recommended removing the patient's Port-A-Cath so that the
infection would be easier to cure with antibiotics. They
felt the most likely bug responsive was staph aureus versus
enterococcus versus strep viridans versus a coag negative
staph and therefore requested treatment with Penicillin.
Given the patient's history of a Penicillin allergy
desensitization to the drug was initiated per protocol. The
patient's blood culture results demonstrated enterococcus,
which was Ampicillin sensitive and therefore the patient was
placed on Penicillin therapy intravenously with Gentamycin
for synergy for two weeks after therapy.
Over the next few hospital days the patient's Captopril dose
was titrated up as tolerated and his supplemental oxygen
requirement was titrated down. The patient's heart rate
remained tachycardic, which is felt to be likely a
compensatory response given the patient's poor forward flow
secondary to acute mitral regurgitation.
On [**12-30**] the patient was felt to be stable enough to be
transferred to the floor. The patient had been off of
pressor therapy for the last 48 hours and was tolerating low
doses of ace inhibitor for afterload reduction.
However, on the evening following transfer to the flor the
patient became suddenly tachycardic and hypotensive with a
blood pressure in the 70s and a heart rate in the 150s. The
patient was treated with 5 mg intravenous Lopressor times
three with some decrease in his heart rate, but little change
in the blood pressure. The patient was subsequently given a
normal saline bolus of 250 cc times three and then loaded on
Digoxin therapy. The patient appeared to respond well to the
beta blocker with a decrease in his heart rate, however,
additional fluid therapy did little to help the patient's
blood pressure and resulting in a significantly worsened
oxygen requirement. Therefore the patient was treated once
again with Lasix and over the next few hospital days a
careful balance was maintained between controlling the
patient's heart rate and not dropping his blood pressure too
low. The patient was therefore continued on standing doses
of Captopril, Lopressor and Digoxin as well as prn Lasix
doses, which were titrated up as tolerated over the next few
hospital days. The patient maintained a systolic blood
pressure in the high 80s to low 90s, however, he tolerated
this blood pressure well with adequate urine output and
normal mentation. A PICC line was placed for long term
administration of antibiotic therapy.
Given the length (two weeks) of Gentamycin therapy for
synergy against enterococcus the concern for ototoxicity was
raised and an audiology consult was obtained. Audiology
recommended that the patient already had some hearing loss
prior to admission for which he was seeking amplification
therapies and recommended as little Gentamycin as possible
with follow up audiology testing following release from the
hospital.
Following transfer to the floor the patient's rhythm
converted from a multifocal atrial tachycardia to atrial
fibrillation. The patient was currently on Digoxin and
Lopressor for rate control and the patient's heart rate was
maintained in the 90s to low 100s. The possibility of
cardioversion as a potential therapeutic option was discussed
with cardiology who recommended that it was possible that his
hemodynamics may improve with cardioversion to normal sinus
rhythm. Given the state of the patient's mitral valve
endocarditis it was unlikely that the patient would be able
to maintain his heart rate and normal sinus rhythm
successfully. In addition, cardiology recommended that
consideration be given to starting the patient on Coumadin
therapy and this was echoed by the patient's primary
oncologist. Therefore the patient was started on low dose
Coumadin therapy with a goal INR of 2.0 to 2.5.
At this point given the difficulty of maintaining the patient
with adequate blood pressure and heart rate a family meeting
was obtained in order to evaluate the patient and families
goals in the setting of the [**Hospital 228**] medical problems. The
results of the family meeting suggested that the family and
the patient were hoping that the patient would improve enough
to go to a rehab and they did want to complete antibiotic
therapy for the current endocarditis. However, the family
and the patient all understood the tenuous state of the
patient's current health and that while our current medical
therapies might provide the patient some degree of
improvement. They were incapable of curing the patient's
primary problem and would likely only help with short term
benefits. However, the patient and his family once again
reiterated their desire not to undergo surgical correction of
his valvular disease.
Over the next few hospital days the patient continued to
improve very slowly with mild decreases in his lower
extremity edema and subjective decreases in shortness of
breath and fatigue. However, the patient continued to
demonstrate mild setbacks such as on [**4-5**] when the
patient was transferring from bed to chair and became acutely
short of breath with a subsequent heart rate in the 150s,
systolic blood pressure in the 60s and a drop in his oxygen
saturations to 80 to 85%. At this point, however, the
patient was treated with intravenous Lopressor 5 mg times two
doses with a subsequent drop in his heart rate to the 100s
and a bump in his systolic blood pressure to the 190s.
Therefore it was demonstrated that the patient did well when
his Lopressor was administered despite low blood pressures,
because his blood pressure acutely responsive to his heart
rate. Therefore his Captopril was increased to a dose of 50
mg t.i.d., his beta blocker was increased to a dose of 37.5
mg t.i.d. and Digoxin was continued on a q.o.d. basis. In
addition, the patient was started on a daily dose of Lasix at
20 mg po q day and was monitored for the appropriateness of
that dose for continued effective gentle diuresis.
Over the next few hospital days the patient's medications
were titrated as needed while the patient was screened for
rehabilitation. The patient was seen by physical therapy and
was able to transfer from bed to chair and even improved well
enough to walk a few steps.
At the time of discharge the patient's Lopressor had been
titrated up to 62.5 mg t.i.d., which his blood pressure was
able to tolerate. In addition, the patient was continued on
Captopril 50 mg t.i.d., Digoxin every other day and Lasix 40
mg po b.i.d. A therapeutic INR was obtained on Coumadin at 1
mg po q day. Although the patient consistently demonstrated
a blood pressure with a systolic in the low 80s, the patient
maintained adequate urine output and excellent mentation.
Therefore it was felt that the most important therapeutic
intervention was to maintain the patient's heart rate at
approximately 100 and therefore the patient's beta blocker
should not be held unless his blood pressure was low enough
to cause low urine output or mental status changes. The
patient was transferred to rehabilitation on the 20th with
thirty more days of antibiotic therapy remaining via his PICC
line and a stable cardiac regimen obtained for management of
his acute mitral regurgitation.
CONDITION ON DISCHARGE: The patient was discharged to rehab
in guarded, but stable condition.
DISCHARGE MEDICATIONS: Lopressor 62.5 mg po t.i.d. hold for
systolic blood pressure less then 70, Coumadin 1 mg po q day,
NPH 6 units subQ b.i.d., Digoxin 0.125 mg po q o day,
Captopril 15 mg po t.i.d., Ampicillin 2 grams intravenous q 4
hours times thirty days, Gentamycin 60 mg intravenous q 12
hours times thirty days, Protonix 40 mg po q day, Nutra
shakes one po t.i.d. with meals, Tylenol 650 mg po q 4 to 6
hours prn, regular insulin sliding scale, Lasix 30 mg po
b.i.d.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2102-4-10**] 11:47
T: [**2102-4-12**] 12:23
JOB#: [**Job Number 34869**]
|
4254,496,28249,4019,42731 | 262 | 106,019 | Admission Date: [**2153-9-25**] Discharge Date: [**2153-9-28**]
Date of Birth: [**2090-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p EtOH ablation of interventricular septum for Hypertrophic
obstructive cardiomyopathy
Major Surgical or Invasive Procedure:
Ethanol ablation of Myocardial interventricular septum
History of Present Illness:
Patient is a 63 yo male with PMH significant for hypertrophic
cardiomyopathy, COPD, hypertension and recently diagnosed Afib
admitted after undergoing EtOH ablation of the interventricular
septum. The patient has had DOE with chest pressure since 1
year. Says that he used to get SOB and CP while walking up only
a slight incline. He denies symptoms at rest. He does have
periodic leg edema which he treats with diuretics. He sleeps on
two pillows for comfort. Denies claudication, PND,
lightheadedness. Gives h/o occasional palpitations of about few
seconds since 1 year. In early [**2153-8-19**], pt had CP and
diaphoresis at rest which subsided after some time. Next day he
went to play golf but soon developed SOB and CP and had to be
admitted to [**Hospital3 **]. Troponin was borderline positive/CK's
negative and he was transferred to [**Hospital1 18**] for cardiac
catheterization which revealed a significant subaortic valve
pressure gradient that increased with Valsalva. He was found in
atrial fibrillation during the admission and discharged on
Coumadin which he stopped taking on [**9-18**]. He now came in
for ethanol ablation of the myocardial interventricular septum.
Past Medical History:
1)Hypertrophic cardiomyopathy (diagnosed 3 years ago)
2)Hypertension
3)COPD
4)Low back pain secondary to herniated disc
5)Atrial fibrillation (newly diagnosed)
6)s/p Cataract surgery
7)Remote knee surgeries
8)Thalasemia minor
Social History:
Patient is single and lives alone. He has two chdilren.
Pt smoked 1ppd x 40-50yrs and quit 10 yrs ago.
1-2 beers/day
Family History:
Mother w/MI
Physical Exam:
vitals BP 142/73 HR 40-50 (irregular) RR 14 O2 Sat ??
Gen: Conscious and cooperative, in NAD
HEENT: JVD elevated to about 10cm, PERRL, EOMI, neck supple
Chest: CTA bilaterally
CVS: S1 S2 muffled. ?Systolic murmur at LSB.
Abd: Soft, non-tender, non-distended, BS+
Neuro: A&Ox3, No FND
Ext: Cath wound on Rt groin. No hematoma or bruit. Peripheral
pulses+
Pertinent Results:
Labs
[**2153-9-25**] 07:22PM BLOOD WBC-6.0 RBC-5.12 Hgb-10.8* Hct-31.7*
MCV-62* MCH-21.1* MCHC-34.1 RDW-15.7* Plt Ct-107*
[**2153-9-25**] 07:22PM BLOOD WBC-6.0 RBC-5.12 Hgb-10.8* Hct-31.7*
MCV-62* MCH-
[**2153-9-25**] 07:22PM BLOOD CK(CPK)-338*
21.1* MCHC-34.1 RDW-15.7* Plt Ct-107*
[**2153-9-25**] 07:22PM BLOOD CK-MB-61* MB Indx-18.0* cTropnT-0.54*
[**2153-9-26**] 06:08AM BLOOD CK(CPK)-743*
[**2153-9-26**] 06:08AM BLOOD CK-MB-128* MB Indx-17.2* cTropnT-3.48*
[**2153-9-28**] 06:30AM BLOOD WBC-8.2 RBC-4.81 Hgb-10.1* Hct-29.7*
MCV-62* MCH-21.0* MCHC-34.0 RDW-15.6* Plt Ct-96*
[**2153-9-28**] 06:30AM BLOOD Glucose-86 UreaN-14 Creat-1.0 Na-141
K-3.5 Cl-104 HCO3-30 AnGap-11
.
ECHO ([**2153-9-25**]) - Pre septal ablation
The left atrium is markedly dilated. There is symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is systolic anterior motion of the mitral
valve leaflets with a severe (peak 60-70mmHg) resting left
ventricular outflow tract obstruction.
Following administration of 0.5ml Definity (diluted 1.5ml to
8.5ml saline), there was prominent enhancement of the basal
septum abutting the mitral valve [**Male First Name (un) **]. The right ventricular free
wall did not appear to enhance
.
ECHO ([**2153-9-25**]) - Post septal ablation
Following administration of alcohol (total 2.7ml), there was
intense enhancement of the basal interventricular septum in the
area abutting the [**Male First Name (un) **] of the mitral valve. [**Male First Name (un) **] persisted, but
the LVOT gradient declined to <30mmHg peak. Overall left
ventricular systolic function remained intact.There was no
pericardial effusion
.
Brief Hospital Course:
Mr. [**Known lastname 5422**] [**Last Name (Titles) 1834**] ethanol ablation of myocardial
interventricular septum on [**2153-5-29**] after which he was
transferred to the CCU for monitering for development of heart
block.
.
1. Hypertrophic obstructive cardiomyopathy
Patient's initial heart rate was in the 40's and irregular
(Atrial fibrillation). A temporary pacing line was put in at the
time of the procedure so that he could be paced if he developed
complete heart block and became symptomatic. On the second day
his HR picked up and by the 3rd day his temporary pacing line
was removed. Pt was also started on Toprol XL 100mg twice daily
and Verapamil SR 240 twice daily. He also experienced an episode
of chest pain [**2-26**] on the 2nd day. Given his recent cardiac cath
with normal coronoray arteries and unchanged EKG the pain was
most likely due to his HOCM and he was given morphine.
He also experienced 3-4 episodes of groin bleeding at the site
of his cath wound. Each time manual pressure was applied for
about 10 min followed by a pressure dressing. Later his heparin
was discontinued. Pt was transferred to the Step down unit for
where he did fine. There were no more episodes of groin bleeding
and the area was soft without any audible bruit.
.
2) Atrial fibrillation
He was started on heparin drip given his high CHADS score for
risk of stroke due to his atrial fibrillation. However due to
repeated groin bleeding at the site of his cath wound heparin
was stopped. He was started on Coumadin 2.5mg daily. His Toprol
and Verapamil given for HOCM also helped in rate control.
.
3) Hypertension
Patient was continued on Diovan 160mg twice daily. His Toprol XL
and Verapamil were also adjusted to control his BP. Lasix which
had been stopped on admission was continued on day 4.
.
4)FEN
Potassium was continued as his K on admission was 3.1. He was
continued on potassium chloride and slowly his potassium
improved. He was given healthy cardial diet with low sodium.
.
5)Disposition
The patient is being discharged home. He needs to follow up with
his primary care physician, [**Name Initial (NameIs) 2085**] (Dr. [**Last Name (STitle) **] and with
the coumadin clinic. If he develops syncope, palpitations or
persistent chest pain he should immediately contact his
cardiologist.
Medications on Admission:
1)Toprol XL 100mg twice a day
2)Diovan 160mg twice a day
3)Verapamil SR 240mg twice a day
4)Furosemide 80mg daily every morning (sometimes takes up to
160mg
depending on weight)
5)Doxazosin 8mg daily every evening
6)Klor-con 10meq ER, 2 tablets twice a day
7)Aspirin 81mg daily every morning
8)Coenzyme Q 10, 150mg daily every morning
9)Vitamin C 1000mg daily every morning
10)Vitamin D 1000 IU daily every morning
11)Folic acid 400mcg daily every morning
12)MVI
13)Glucosamine/Chondroiton one daily every morning
14)Coumadin 2.5mg daily every morning, last dose [**2153-9-18**]
15)Albuterol prn
16)Advair diskus prn
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Doxazosin 8 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhale Inhalation twice a day.
9. Outpatient [**Name (NI) **] Work
PT, PTT, INR
please send results to [**Last Name (LF) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5424**].
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ethanol ablation of Myocardial interventricular septum for
Hypertrophic Obstructive Cardiomyopathy
Atrial Fibrillation, new onset
Secondary:
Hypertension
COPD
Discharge Condition:
Stable
Discharge Instructions:
If you experience syncope, shortness of breath, chest pain or
any other symptoms that concern you, please call your PCP or
return to the ER.
.
Please take all medications as prescribed. Please follow up with
all appointments.
Followup Instructions:
please make a follow up appointment with Dr. [**Last Name (STitle) **] in 3 months.
You will also need a repeat echo at that time.
.
Please get your blood drawn and have the results sent to your
PCP [**Name9 (PRE) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5424**].
.
You have an appointment with your PCP [**Name9 (PRE) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 5424**] on [**10-3**] Wed at 1:30. Please get your labs drawn
prior to your appointment.
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital **] clinic ([**Telephone/Fax (1) 5425**] in one month.
Completed by:[**2153-10-1**] |
25073,25063,25043,25053,40391,7854,5180,3572,58381 | 263 | 120,845 | Admission Date: [**2160-1-9**] Discharge Date: [**2160-1-21**]
Date of Birth: [**2104-6-18**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Right third toe ischemic changes.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old male with
a past medical history significant for diabetes,
hypertension, hypercholesterolemia, neuropathy, chronic renal
insufficiency, coronary artery disease, who underwent a left
BKA and a right [**Doctor Last Name **]-DP bypass graft and CABG. Three days
prior to admission, he presented with right third toe
discoloration. This has become progressive over the past
three days. He denies rest pain secondary to severe
neuropathy. He has recently developed linear changes between
the toes, as well. He has not been able to move forefoot and
toes for years. This is not an acute change. Denies
constitutional symptoms.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Hypercholesterolemia.
4. Neuropathy.
5. Chronic renal insufficiency.
6. Coronary artery disease.
PAST SURGICAL HISTORY:
1. Left BKA which was done in [**2153**].
2. A right [**Doctor Last Name **]-DP done in [**2143**].
3. Coronary artery bypass done in [**2149**].
SOCIAL HISTORY: The patient is a former smoker, rare tobacco
use. He is married and lives with his wife.
ALLERGIES: Denies any known drug allergies.
MEDICATIONS ON ADMISSION:
1. Enteric-coated aspirin 81 mg qd.
2. Lasix 20 mg [**Hospital1 **].
3. Lipitor 40 mg qd.
4. Cartia XL 240 mg qd.
5. Avapro 150 mg qd.
6. Alphagan eyedrops.
7. Cosopt eyedrops.
8. Insulin - 30 U of NPH + 8 of R in the morning; [**7-12**] of N +
[**6-16**] of R q pm.
PHYSICAL EXAM - VITAL SIGNS: 99.8, 78, 176/66, 18, 95% on
room air.
GENERAL APPEARANCE: Alert, in no acute distress.
CHEST EXAM: Lungs are clear to auscultation.
HEART: Regular rate and rhythm. There are no murmurs.
ABDOMINAL EXAM: Unremarkable.
RECTAL: Without masses or prolapse
EXTREMITY EXAM: Shows left BKA. The right forefoot is
mottled, with the first toe and tips of the second, third toe
blue. The carotids are palpable bilaterally without bruits.
The femorals are palpable bilaterally, 2+. The right
popliteal is biphasic, dopplerable signal. The graft at the
ankle is monophasic. The right DP is monophasic signal. PT
is monophasic signal.
HOSPITAL COURSE: The patient was initially evaluated in the
Emergency Room and admitted to the vascular service for
continued care. The patient was continued on heparinization.
Venous mappings were obtained of the upper extremities and
lower extremities for potential consideration of
revascularization. Rehydration and Mucomyst protocol were
initiated. The patient underwent arteriogram with attempted
lytic therapy of the graft thrombosis without success.
Psychiatry was consulted for second opinion regarding
surgical intervention for foot salvage versus amputation.
They were in agreement that the patient would require an
amputation. The patient underwent a right BKA on [**2160-1-15**].
He tolerated the procedure well and was transferred to the
PACU in stable condition.
The patient was followed perioperative by Dr. [**Last Name (STitle) **] of the
cardiology service. The patient had EKG without ischemic
changes. Serial CKs were 163, 159 and 160. There were no
CK-MBs or troponin levels drawn since total CKs were flat.
The remaining hospital course was unremarkable. Physical
therapy was requested to see the patient. He will require
rehab. Prior to discharge to home, the patient was followed
by [**Last Name (un) **] service. He did require adjustment in his Insulin
regime for episodes of hyperglycemia.
Cardiology recommended that the patient needs to consider
starting an ACE inhibitor, and Zestril 5 mg was started. On
postoperative day #3, the patient ran a T-max of 100.8.
Duplex of the right extremities was obtained. There was no
DVT. Chest x-ray did show some left lower lobe atelectasis
and cardiomegaly, but no definite pneumonia.
The patient's hyperglycemia improved. The patient was
pancultured at the time of the temperature elevation, and
these cultures were all negative. The patient was seen by
infectious disease, and recommendations regarding antibiotic
therapy and length of therapy. They felt there was no
obvious source of infection for the fever. They felt that
the suspected cause of the fever was related to his
atelectasis. Recommended DC antibiotics. Reculture patient
if he respikes.
The patient continued to show improvement. The patient was
discharged to rehab in stable condition. Antibiotics were
restarted on [**1-18**] for a short course of 7 days, and then
they should be discontinued. Vancomycin, Levofloxacin and
Flagyl were begun. At the time of discharge, the patient was
on no antibiotics.
The patient should follow-up with Dr. [**Last Name (STitle) **] in 2 weeks
after discharge. Skin clips will remain in place in the
amputated stump until seen in follow-up. Wound care is dry
sterile dressing with Ace wrap qd. The patient should be
cultured if he spikes again.
DISCHARGE MEDICATIONS:
1. Aspirin, enteric-coated, 81 mg qd.
2. Atorvastatin 40 mg qd.
3. Brimonidine tartrate ophthalmic 0.15% 1 drop left eye qd.
4. Dorzolamide 2% and Timolol 0.5% combined ophthalmic drop 1
OU [**Hospital1 **].
5. Diltiazem ER 240 mg qd.
6. Pentamidine 20 mg [**Hospital1 **].
7. Metoprolol 2.5 mg [**Hospital1 **].
8. Aspirin 325-650 mg q 4-6 h prn fever.
9. Oxycodone/acetaminophen tablets [**2-8**] q 4-6 prn pain.
10.Insulin, sliding and fixed scale as follows: NPH - 46 U
at breakfast and 8 U at bedtime.
Regular Insulin sliding scales before meals and at bedtime as
follows: Breakfast Insulin sliding scale: Glucose less than
100 - no Insulin; 101-150 - 4 U; 151-200 - 6 U; 201-250 - 8
U; 251-300 - 10 U; 301-350 - 10 U; 351-400 - 12 U; greater
than 400 - 12 U.
Lunch sliding scale: Glucose less than 100 - no Insulin;
101-150 - 4 U; 151-200 - 6 U; 201-250 - 8 U; 251-300 - 9 U;
301-350 - 9 U; 351-400 - 11 U; greater than 400 - 13 U.
Dinner time sliding scale: Glucose less than 100 - no
Insulin; 101-150 - 4 U; 151-200 - 6 U; 201-250 - 8 U; 251-300
- 11 U; 301-350 - 13 U; 351-400 - 13 U; greater than 400 - 13
U.
Bedtime sliding scale: Glucose less than 250 - no Insulin;
251-300 - 2 U; 301-350 - 4 U; 351-400 - 6 U; greater than 400
- 8 U.
DISCHARGE DIAGNOSES:
1. Right foot ischemia, nonreconstructable, status post right
below-knee amputation.
2. Diabetes, Insulin dependent, uncontrolled, corrected.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], M.D .02.914
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2160-1-21**] 11:10
T: [**2160-1-21**] 11:19
JOB#: [**Job Number 24231**]
|
4240,4139,41401,4019 | 265 | 101,608 | Admission Date: [**2149-2-20**] Discharge Date: [**2149-2-25**]
Date of Birth: [**2093-8-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE x 2 months
Major Surgical or Invasive Procedure:
[**2-20**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->Diag), MVRepair (28mm
band)
History of Present Illness:
55 y/o with known CAD, cypher stent to LCx [**3-3**], now with
recurrent angina.
Past Medical History:
CAD s/p LCx cypher stent
h/o rheumatic fever
HTN
lipids
Physical Exam:
NAD HR 70, B/P 128/68
Admission exam unremarkable.
Pertinent Results:
[**2149-2-25**] 06:10AM BLOOD Hct-25.4*
[**2149-2-24**] 06:05AM BLOOD WBC-5.6 RBC-3.48* Hgb-7.9* Hct-24.0*
MCV-69* MCH-22.7* MCHC-32.9 RDW-18.3* Plt Ct-144*
[**2149-2-24**] 06:05AM BLOOD Plt Ct-144*
[**2149-2-23**] 05:16AM BLOOD PT-13.4* PTT-27.0 INR(PT)-1.2*
[**2149-2-25**] 06:10AM BLOOD K-4.2
[**2149-2-24**] 06:05AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-135
K-3.8 Cl-99 HCO3-30 AnGap-10
Brief Hospital Course:
He was taken to the operating room on [**2149-2-20**] where he
underwent a CABG x 3 and MVRepair. He was transferred to the
SICU in critical but stable condition. He was extubated later
that same day. He was found to be in SVT and started on an
esmolol drip. His SVT resolved and he was weaned from his
vasoactive drips. He was transferred to the floor on POD #3. He
continued to do well post operatively and was ready for
discharge home on POD #5.
Medications on Admission:
toprol, quinapril, HCTZ, lipitor, plavix, tricor, asa
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
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:*0*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
10. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD s/p LCx cypher stent
h/o rheumatic fever
HTN
lipids
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pound sin one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 14522**] 2 weeks
Completed by:[**2149-2-25**] |
34550,34830,42832,49390,4280,27401,4373,412 | 266 | 186,251 | Admission Date: [**2168-7-10**] Discharge Date: [**2168-7-14**]
Date of Birth: [**2090-12-17**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
called to evaluate for altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation, now extubated
History of Present Illness:
77 year-old woman with PMH of L internal carotid aneurysm,
complex partial seizures, currently weaning off dilantin who
presented with disorientation, not following commands or
recognizing people and wandering around; now s/p intubation.
Family reports that pt has a hx of seizures for about 15 years,
on dilantin. She has never had GTC seizures. Her seizures are
characterized by confusion, not following commands. Because she
has been seizure-free for the last 7 years she was started on a
dilantin wean recently and family thinks she might not be taking
her meds any more.
Pt was well until around 3:30 am; she was working as a nurse [**First Name (Titles) **]
[**Hospital3 2558**] when she suddenly became disoriented, wondering
around, would not respond to questions or recognize her
colleagues. There is no hx of weakness. Family reports that her
seizures in the past have had similar presentations.
She was brought to ED where she was moving all extremities
symmetrically with eyes open, not following commands. As she was
too agitated for brain imaging, she was intubated and started on
propofol. Family thinks it was about an hour between initiation
of symptoms and intubation. She received zosyn and vancomycin. A
head CT showed previous aneurysm but no acute process. Family
denies any recent illness.
ROS:
Family denies that pt had visual difficulty, hearing changes,
difficulty speaking, language problems, memory difficulty,
difficulty swallowing, vertigo, unsteady gait, paresthesias,
sensory loss,weakness, or falls.
The patient denied fever, wt loss, appetite changes, cp,
palpitations, DOE, sob, cough, wheeze, nausea, vomiting,
diarrhea, constipation, abd pain, fecal incont, dysuria,
nocturia, urinary incontinence, muscle or joint pain, hot/cold
intolerance, polyuria, polydipsia, easy bruising, depression,
anxiety, stress, or psychotic sx.
Past Medical History:
-L internal carotid aneurysm
-lung ressection many years ago found not to be malignant
-Asthma
-heart attack in her 70's
-?CHF
-complex partial seizures as above
-arthritis
Social History:
NP, works at [**Company **] Corner, widowed, 5 children, denies
tobbaco, occasional alcohol use
Family History:
asthma; sons think her father could have had seizures
Physical Exam:
Per admitting resident
T-89 BP-173/110 HR-100 RR-21 100O2Sat intubated
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple, normal ROM, supple, no carotid or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: intubated on propofol, could follow commands such
as open your eyes
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Corneal +; normal Doll's. Facial movement
symmetric. Tongue midline
Motor:
She moves all extremities symmetrically spontaneously
Sensation: She retracts to noxious stimuli symmetrically in all
extremities
Reflexes: B T Br Pa Pl
Right 1 1 1 1 0
Left 1 1 1 1 0
Toes were mute bilaterally.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: unable to examine
Pertinent Results:
[**2168-7-12**] 06:05AM BLOOD WBC-10.5 RBC-4.09* Hgb-12.1 Hct-38.5
MCV-94 MCH-29.6 MCHC-31.5 RDW-15.3 Plt Ct-165
[**2168-7-11**] 09:19PM BLOOD WBC-10.7 RBC-4.17* Hgb-12.4 Hct-38.6
MCV-93 MCH-29.8 MCHC-32.2 RDW-15.6* Plt Ct-183
[**2168-7-11**] 02:14AM BLOOD WBC-10.2# RBC-4.12* Hgb-12.4 Hct-38.2
MCV-93 MCH-30.1 MCHC-32.5 RDW-15.8* Plt Ct-189
[**2168-7-10**] 05:10AM BLOOD WBC-3.8* RBC-4.28 Hgb-13.0 Hct-39.3
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.6* Plt Ct-194
[**2168-7-11**] 09:19PM BLOOD Neuts-68.3 Lymphs-23.6 Monos-3.7 Eos-3.9
Baso-0.6
[**2168-7-11**] 02:14AM BLOOD Neuts-70.0 Lymphs-24.1 Monos-3.3 Eos-1.9
Baso-0.6
[**2168-7-12**] 06:05AM BLOOD Plt Ct-165
[**2168-7-12**] 06:05AM BLOOD PT-12.1 PTT-28.6 INR(PT)-1.0
[**2168-7-11**] 02:14AM BLOOD Plt Ct-189
[**2168-7-10**] 05:10AM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1
[**2168-7-10**] 05:10AM BLOOD Fibrino-285
[**2168-7-11**] 09:19PM BLOOD ESR-36*
[**2168-7-12**] 06:05AM BLOOD Glucose-114* UreaN-14 Creat-0.7 Na-139
K-3.4 Cl-109* HCO3-21* AnGap-12
[**2168-7-11**] 02:14AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-142
K-4.0 Cl-109* HCO3-20* AnGap-17
[**2168-7-10**] 05:59PM BLOOD Glucose-135* Na-142 K-3.6 Cl-107
[**2168-7-10**] 05:10AM BLOOD UreaN-18 Creat-0.7
[**2168-7-11**] 02:14AM BLOOD ALT-36 AST-43* CK(CPK)-146 AlkPhos-103
TotBili-0.8
[**2168-7-10**] 05:59PM BLOOD CK(CPK)-158
[**2168-7-11**] 02:14AM BLOOD CK-MB-2
[**2168-7-10**] 05:59PM BLOOD CK-MB-2 cTropnT-0.01
[**2168-7-12**] 06:05AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0
[**2168-7-11**] 02:14AM BLOOD Albumin-3.5 Calcium-8.3* Phos-2.4*#
Mg-1.4*
[**2168-7-10**] 05:59PM BLOOD Mg-1.4*
[**2168-7-11**] 09:19PM BLOOD CRP-145.7*
[**2168-7-10**] 05:10AM BLOOD Digoxin-1.3
[**2168-7-11**] 02:14AM BLOOD Phenyto-16.6
[**2168-7-10**] 05:10AM BLOOD Phenyto-1.4*
[**2168-7-10**] 05:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-7-10**] 05:22PM BLOOD Type-ART pO2-194* pCO2-29* pH-7.50*
calTCO2-23 Base XS-0
[**2168-7-10**] 10:55AM BLOOD Type-ART Temp-37.1 Tidal V-500 PEEP-5
FiO2-100 pO2-556* pCO2-34* pH-7.47* calTCO2-25 Base XS-2
AADO2-131 REQ O2-32 -ASSIST/CON Intubat-INTUBATED
[**2168-7-10**] 05:22PM BLOOD Lactate-2.6* K-3.4*
[**2168-7-10**] 10:55AM BLOOD Glucose-176* Lactate-3.7* Na-145 K-3.1*
[**2168-7-10**] 06:46AM BLOOD Lactate-3.9*
[**2168-7-10**] 05:17AM BLOOD Glucose-122* Lactate-4.8* Na-146 K-4.4
Cl-106 calHCO3-22
[**2168-7-10**] 05:22PM BLOOD freeCa-1.19
[**2168-7-10**] 10:55AM BLOOD freeCa-1.10*
Urine
[**2168-7-10**] 05:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2168-7-10**] 05:45AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2168-7-10**] 05:45AM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2168-7-10**] 07:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Joint Fluid
[**2168-7-12**] 02:27AM JOINT FLUID WBC-[**Numeric Identifier 101684**]* RBC-[**Numeric Identifier **]* Polys-87*
Lymphs-6 Monos-7
[**2168-7-12**] 02:27AM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calciu
EEG [**2168-7-10**]
IMPRESSION: This 24-hour video EEG telemetry captured no
pushbutton
activations. No electrographic seizures or interictal
epileptiform
discharges were seen. The background was slow and disorganized
throughout the recording, suggestive of a moderate
encephalopathy, and
some superimposed leftsided slowing suggested subcortical
dysfunction in
that region.
EEG [**2168-7-11**]
IMPRESSION: This is an abnormal non-continuous extended routine
EEG due
to slowing and disorganization of the background with brief
bursts of
generalized slowing suggestive of a mild to moderate
encephalopathy.
Medications, toxic/metabolic disturbances, and infections are
common
causes. No epileptiform discharges or electrographic seizures
were seen
in this study. This study captured no pushbutton activations.
Wrist (left) x-ray [**2168-7-11**]
There is abnormal widening of the scapholunate interval
measuring 7 mm
consistent with SL ligament rupture. There are also degenerative
changes
involving the radioscaphoid joint and of the first CMC joint.
There is mild generalized demineralization. No acute fractures
or dislocations are seen. There is mild swelling about the soft
tissues of the wrist.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to neurology ICU for evaluation and
management of seizures. She was closely monitered and underwent
frequent neuro checks.
Hospital Course;
Neuro
She was intubated in ED for airway protection. The most likey
cause of seizure in this patient was medication taper of
dilantin as outpatient recently. She was not febrile and had no
signs of infectious precipitant. She underwent CT scan of head
with CTA which did not show evidence of acute pathology, however
did show aneurysm of size 3mm in left ICA in caverous sinus
area. This was thought to be incidental and did not correlate
with the clinical presentation. She was loaded with dilantin and
continued on 100 mg TID with no further clinical events. She
was monitored on continuous EEG with results as described above.
Pulm
She was rapidly extubated on [**7-10**] night and closely monitered.
Her respiratory status was stable after extubation. However she
complained of throat pain and some tenderness. It was thought to
be related to recent intubation. She underwent Neck X ray which
showed prominent soft tissue swelling about the neck, however,
this may be partially due to the patient's body habitus. The
epiglottis was not enlarged and there was no prevertebral soft
tissue swelling.
Rheum
She complained of left wrist pain, shortly after transfer out of
ICU. The wrist appeared swollen and tender. She was seen by
hand surgery and underwent joint tap which showed positive
birifringent rhomboid crystals consistent with a diagnosis of
pseudo-gout. She received a short course of unasyn which was
discontinued after a gram stain of the fluid was negative and a
fluid culture has shown no growth to date. She was treated with
colchicine and ibuprofen 800 mg tid with good relief of her
symptoms. An x-ray of her wrist revealed a widening of the
scapholunate interval consistent with ligament rupture. This
was reviewed with the hand surgery team who believed this was a
chronic finding and unlikely to be related to her presentation.
ID
She was afebrile and did not show signs of infection. She had
an elevated ESR and CRP which was believed to be related to her
pseudogout.
Medications on Admission:
-IC albuterol 4mg [**Hospital1 **]
-omeprazole 20mg daily
-allopurinol 200mg daily
-IC digoxin 0.25g daily
-metoprolol 50mg daily
-IC tramadol 50mg daily
-diclofenac 50mg TID
-dilantin 100mg daily (currently on taper)
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Diclofenac Potassium 50 mg Tablet Sig: One (1) Tablet PO
three times a day.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Pseudogout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after an episode of confusion and
disorientation which was likely a seizure. It is likely this
occurred due to the recent discontinuation of your
anti-epileptic medication. Phenytoin was resumed and you should
continue this medication as prescribed. Also, you were found to
have pseudogout in your left wrist. Please take NSAIDs as
needed for pain control (such as ibuprofen 600-800 mg three
times daily for the next 3-5 days as needed) and follow up with
your PCP [**Last Name (NamePattern4) **] [**2-6**] weeks.
Followup Instructions:
Please follow up with your neurologist, Dr. [**First Name (STitle) 437**] as scheduled;
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2168-7-25**] 8:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2168-8-16**] 10:15
|
9974,5770,5990,07032,56789,9982,E8788,E8490,5778,7850 | 267 | 163,714 | Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-15**]
Date of Birth: [**2131-9-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Acute pancreatitis.
Presumed pancreatic injury from percutaneous biopsy.
Major Surgical or Invasive Procedure:
Exploratory Laparotomy,
Wide drainage of pancreatic leak
Placement of a combined gastrostomy/jejunostomy tube (MIC tube).
History of Present Illness:
This unfortunate 24-year-old lady had hepatitis B and was being
worked up for this with a biopsy of her liver. It is uncertain
to my why she required
this biopsy. The patient had this done in the midline
position 2 days prior to this procedure. In the interim, she
became very sick and was treated at another hospital.
She developed abdominal and went to NSMC-[**Hospital1 1281**] ED where workup
was significant for lipase of [**2110**] and amylase of 1351. CT
showed diffuse hypoattenuation of the liver, suggestive of
infiltration, and small amount of ascites. She was admitted with
a diagnosis of acute pancreatitits. On evening of [**6-3**], she
became febrile and tachycardic. Repeat laboratories showed WBC
29.3 (from 20.0), amylase 3894 (from 1351), and lipase >2400
(from [**2110**]). Repeat CT showed increase in intraperitoneal fluid,
pelvic fluid, and bilateral pleural effusions
She was transferred to our facility the day of this operation.
In the
interim, she developed clear-cut acute pancreatitis and was
gravely ill. We found her to be profoundly dehydrated with
all the sequelae of raging acute pancreatitis. What was
worrisome, however, was her abdominal exam which showed
peritonitis. In reviewing the reports, there was apparently a
percutaneous biopsy attempt of the left lateral sector of the
liver. It was pretty clear that there was a traumatic injury
to the pancreas through this biopsy precipitating acute
pancreatitis. I was very concerned that there was a ductal
leak injury given her clinical state with a rigid abdomen
with peritoneal signs.
Past Medical History:
HBV x 5 years
Social History:
Has 2 young children. No EtOH or tobacco
Physical Exam:
Vitals - T 100.3, BP 139/64, HR 121, RR 18, O2 sat 98% 2L NC
General - well-appearing female, speaking full sentences, no
acute distress
HEENT - PERRL, EOMI, OP clr, MMM, no LAD
CV - RRR, [**3-16**] syst flow mur
Chest - CTAB
Abdomen - subxiphoid biopsy set dressed, c/d/i; abdomen
diffusely tender with voluntary guarding
Extremities - no edema
Pertinent Results:
[**6-6**] BCx-p [**6-5**] S/BCx-p; UCx-neg [**6-4**] UCx -> neg; Bld Cx ->
pending; Bld fungal Cx -> pend; OR swab-GPC (broth only)-[**Last Name (un) **]
pending
.
[**2156-6-4**] 07:24AM BLOOD WBC-28.1* RBC-3.91* Hgb-11.5* Hct-33.6*
MCV-86 MCH-29.5 MCHC-34.3 RDW-14.8 Plt Ct-293
[**2156-6-9**] 06:30AM BLOOD WBC-13.3* RBC-3.41* Hgb-9.7* Hct-29.8*
MCV-87 MCH-28.4 MCHC-32.5 RDW-14.8 Plt Ct-413
[**2156-6-9**] 06:30AM BLOOD Glucose-102 UreaN-5* Creat-0.4 Na-138
K-4.0 Cl-103 HCO3-28 AnGap-11
[**2156-6-9**] 06:30AM BLOOD ALT-25 AST-32 LD(LDH)-379* Amylase-170*
TotBili-0.4
[**2156-6-4**] 07:24AM BLOOD ALT-35 AST-25 AlkPhos-49 Amylase-2045*
TotBili-1.1
[**2156-6-4**] 07:24AM BLOOD Lipase-2662*
[**2156-6-9**] 06:30AM BLOOD Lipase-190*
[**2156-6-9**] 06:30AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.6
.
[**2156-6-15**] 05:50AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.3* Hct-28.3*
MCV-87 MCH-28.5 MCHC-32.9 RDW-15.3 Plt Ct-673*
[**2156-6-14**] 05:05AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-137
K-4.5 Cl-101 HCO3-26 AnGap-15
[**2156-6-15**] 05:50AM BLOOD ALT-72* AST-34 LD(LDH)-303* AlkPhos-99
Amylase-223* TotBili-0.4
[**2156-6-15**] 05:50AM BLOOD Lipase-286*
[**2156-6-14**] 05:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.7*
[**2156-6-11**] 06:50AM BLOOD Albumin-3.0*
.
CT ABDOMEN W/CONTRAST [**2156-6-11**] 1:12 PM
IMPRESSION: Marked improvement post-drainage of fluid collection
in the abdomen. Decrease in amount of fluid seen in the pelvis
as well. Tiny amount of fluid is seen near the pancreatic tail
and lesser sac. The celiac, superior mesenteric, and inferior
mesenteric arteries are patent. The portal vein, and superior
mesenteric veins and splenic veins are patent.
.
[**2156-6-14**] ERCP
Procedures: A plastic pancreatic stent was removed from the
ampulla with a snare.
Impression: PEG
Stent in the major papilla
A plastic pancreatic stent was removed from the ampulla with a
snare.
Otherwise normal ercp to second part of the duodenum
.
Brief Hospital Course:
She was admitted on [**6-4**]//07 with a presumed pancreatic leak and
peritoneal signs, fever, elevated WBC, tachycardic.
# pancreatitis:
She was NPO and started on IVF resuscitation. She was receiving
Morphine for pain control.
She went to the OR later that evening for Exploratory
laparotomy; Wide drainage of pancreatic bed for pancreatic leak;
Placement of a combined gastrostomy/jejunostomy tube (MIC tube).
On POD 2, she was extubated. She continued to have fevers for
several days post-op, with a Tm 103.4. Blood cultures were
negative.
She was found to be MRSA+, likely colonized. C.diff was
negative. Urine grew out E.coli and she was started on Cipro for
a UTI. She continued to have a WBC and intermittent fevers. She
went for a ERCP for stent removal on [**2156-6-14**]. Her WBC trended
down, she was not having fevers and clinically was stable.
Her LFTs, Amylase and Lipase continued to trend down and did not
bump with PO intake. Her pancreatitis seemed to resolve.
#Abd/GI: She had 2 JP drains in place and a GJ feeding tube. Her
midlin incision was C/D/I. The staples were removed on POD 11
and steri strips placed. The other drains will remain in place
for now.
# Tachycardia: Normal response to acute pancreatitis, improved
with IVF resuscitation and as fevers trended down.
.
# Chronic HBV
- monitor clinically
.
# FEN:
She was NPO, IVF. She was started on trophic tubefeedings on POD
4 and started on clear liquids on POD 5. Her lytes were repleted
PRN. Her diet was advanced over the next few days. She was able
to tolerate food and her tubefeedings were discontined.
.
Proph
- SQ heparin
- PPI while NPO
.
Medications on Admission:
none
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Pancreatic leak
Tachycardia
Peritonitis
Fever
UTI
Discharge Condition:
Good
Tolerating diet
Abdomen soft
Pain Controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
=
=
=
=
=
================================================================
Please resume all regular home medications and take any new meds
as ordered. You are being discharged on Cipro for a UTI. Please
complete the full course of antibiotics.
.
Continue to ambulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Completed by:[**2156-6-15**] |
48241,4280,51881,5845,4275,0389,49322,2761,4271 | 268 | 110,404 | Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-18**]
Date of Birth: [**2132-2-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with a past medical history notable for diabetes mellitus,
hypertension, coronary artery disease status post myocardial
infarction and coronary artery bypass graft, right lower
lobectomy, asthma and congestive heart failure, who presents
complaining of cough times one week, malaise and fatigue.
The patient had a low grade temperature of 99.6 F., at home.
The patient denied any lower extremity edema or weight gain.
The patient's peak flows at home were in the 150 range.
The patient was recently admitted to the hospital [**1-28**]
until [**2-5**] for similar complaints of shortness of
breath and cough. At that time, she was treated with
steroids, Azithromycin and nebulizers for a presumed
bronchitis exacerbation.
In the Emergency Room, the patient was treated with a
Combivent nebulizer, Solu-Medrol intravenously, Levaquin and
Lasix.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Neuropathy.
3. Hypertension.
4. Coronary artery disease status post inferior myocardial
infarction in [**2182**]; status post coronary artery bypass graft
in [**2190**]; most recent catheterization in [**2196-8-1**] with an
ejection fraction of 40%; left internal mammary artery with
40% disease and right coronary artery with 90% disease.
5. Status post right lower lobectomy for question of
tuberculosis disease at age 16.
6. Asthma.
7. Congestive heart failure.
8. Fibromyalgia.
9. Osteoarthritis.
10. Low back pain secondary to spinal stenosis.
ALLERGIES: Penicillin and tetracycline.
MEDICATIONS AT TIME OF ADMISSION:
1. Aspirin 325 mg a day.
2. Prednisone taper.
3. Protonix 40 mg a day.
4. Trandolapril 2 mg a day.
5. NPH 34 units in the morning and 26 units at night.
6. Subcutaneous insulin.
7. Albuterol inhaler.
8. Fluticasone inhaler.
9. Valium p.r.n.
10. Sotalol 80 mg twice a day.
11. Nystatin swish and swallow.
SOCIAL HISTORY: The patient lives at home independently.
She has around 12 siblings. She has a 30 pack history of
tobacco but quit in [**2182**]. She does not use any alcohol.
PHYSICAL EXAMINATION: Temperature 99.5 F.; pulse 96; blood
pressure 110/60; respiratory rate 24; pulse oximetry 95% on
two liters. In general, a sad tearful female with a flat
affect. HEENT: Pupils are equal, round and reactive to
light. Mucous membranes were moist. Neck is supple without
any jugular venous distention. Chest: Crackles at the lung
bases about [**2-3**] of the way up. Cardiovascular: Regular
rate, no murmurs. Abdomen is soft. Extremities are warm
without edema with good pulses. Neurological is alert and
oriented times three.
LABORATORY: Data at the time of admission is white blood
cell count of 10.3 with 70% neutrophils, hematocrit of 39.7,
platelets of 226. Sodium 134, potassium 4.4 hemolyzed,
chloride 95, bicarbonate 29, BUN 24, creatinine 1.4 with
baseline of 1.0, and glucose of 120.
Chest x-ray shows blunting of the left costophrenic angle,
right middle and lower lobe pneumonia.
EKG with normal sinus rhythm at a rate of 95, old Q waves in
the inferior leads with no acute ST changes.
HOSPITAL COURSE:
1. Hypoxic hypercarbic respiratory failure: The patient was
initially admitted to the Medical Floor for treatment of her
multi-lobar pneumonia. She initially maintained an oxygen
saturation of greater than 95% on three liters of nasal
cannula, however, developed hypoxia to 80% with saturation of
90% on non-rebreather, in the setting of a narrow complex
tachycardia while she was on the floor. However, the patient
remained hypoxic at about 96% on a nonrebreather; therefore
she was transferred to the Fenard Intensive Care Unit.
In the Intensive Care Unit her arterial blood gas revealed a
pH of 7.16, a pCO2 of 74 and pO2 of 94 with abnormal mental
status. The patient's culture data revealed a Methicillin
resistant Staphylococcus aureus pneumonia and the patient's
antibiotic regimen was changed to Vancomycin. There was also
a question of aspiration.
The patient was initially tried on a trial of Bi-PAP,
however, she did not tolerate this very well and her mental
status decreased to the point of requiring intubation.
Initially there was significant confusion regarding her code
status, as on a previous admission it was documented that she
wanted to be resuscitated but did not want to be intubated.
So, after discussion with various of her attendings and given
her clinical status, the decision was made to intubate the
patient as she was in acute respiratory distress.
The patient continued to require high ventilatory support and
had adult respiratory distress syndrome physiology.
2. Tachycardia: The patient, just prior to her transfer to
the Intensive Care Unit, had a tachycardia that was presumed
to be either an atrial tachycardia versus an NRT. She
decreased her rate from the mid 200s to 100 after receiving
diltiazem 20 mg intravenously and was followed closely in the
Intensive Care Unit. She had multiple episodes of
tachycardia and the Electrophysiology Service was consulted
as well as the Electrophysiology physician, [**Name10 (NameIs) **],
occasionally her rhythm would break with Idenosine and
occasionally with Diltiazem and eventually she was on a
diltiazem drip. There was a question of amiodarone loading
as well.
Of note, her Sotalol, which she had been maintained on as an
outpatient, had been discontinued during her hospital course
as she had started to develop renal failure.
3. Hypotension: The patient remained hypotensive after she
was intubated and was not fluid responsive. Her MAPs were
around 50. She was started on norepinephrine and vasopressin
and the etiology was thought to be sepsis although it then
also became cardiogenic later in her hospital course.
4. Acid Base: The patient had a mixed respiratory and
metabolic acidosis. She was given intravenous fluids and her
respiratory status was maintained with a ventilator, although
it was very difficult to correct her acid base status given
her overwhelming sepsis as well as her worsening renal
failure.
5. Acute Renal Failure: The patient had worsening renal
failure likely secondary to acute tubular necrosis with
anuria. CVH was debated upon, however, ultimately a change
in the patient's code status did not require use of this node
of volume removal.
DISPOSITION: After extensive discussion with the family,
initially the patient was clearly full code as she was
intubated, ventilated and on pressors, however, after two to
three family meetings and multi-system organ failure
including cardiovascular, pulmonary, renal with overwhelming
sepsis, Methicillin resistant Staphylococcus aureus pneumonia
and progressive overall worsening, it was decided that goal
for care would change from "Do Not Resuscitate" "Do Not
Intubate" followed by COMFORT MEASURES ONLY status. The
patient had multiple family members who came to see her prior
to her demise.
The patient expired at 03:55 a.m. on [**2198-2-18**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2198-4-5**] 13:13
T: [**2198-4-6**] 22:25
JOB#: [**Job Number 9246**]
|
V08,99592,V090,5119,73008,48241,41519,78552,03811 | 269 | 106,296 | Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-27**]
Date of Birth: [**2130-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Bactrim Ds
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
right IJ placement
History of Present Illness:
40 M with HIV (CD 4=664 in [**2169**] and 189 on [**2170-11-5**]) but no
history of opportunistic infections who presents with 2 days of
fevers to 102 for which he took tylenol. He had a cough
productive of clear sputum and back pain secondary to a deep
cutaneous abscess. He presented to the ED on [**2170-11-5**] with fever
and abscess. The abscess was I&D'd and he was given fluids for
tachycardia and oxacillin for abscess. He then abruptly dropped
his BP to 60's, a sepsis protocol was initiated and a total of 5
L fluid were given. A central line was placed, vanc, ceftriaxone
and dilaudid were given in the ED. Admitted to the [**Hospital Unit Name 153**] for
closer monitoring of hypotension and tachycardia. Blood cultures
from [**2170-11-5**] grew MRSA x 2. Surgery following. ID consulted for
antibiotic therapy and ?indications for propylaxis given low
CD4.
Past Medical History:
1. HIV: diagnosed in [**2158**], on ZDV/3TC/nevirapine (per OMR note
but patient denies ever being on HAART), currently no meds,
followed by Dr [**Last Name (STitle) 4844**]
2. Seasonal allergies
3. Right hand tendonitis
4. s/p T and A
5. Right knee cellulitis (MSSA, [**3-21**])
6. H/o strep pharyngitis, HSV, skin abscesses (per OMR)
Social History:
Lives alone, currently single, smokes 1 ppd x 12 years, past
ecstacy and Ketamine use
Family History:
Non-contributory
Physical Exam:
Tm=102.1 Tc=98.6 P=95 (92-104) BP=110/65 (110/65-124/59)
RR=21 100% RA
Gen - Alert, no acute distress, lying on R side, unable to move
secondary to vac dressing
HEENT - PERRL, extraocular motions intact, anicteric, moist
mucous membranes, poor dentition
Neck - 10 cm JVD, no cervical lymphadenopathy, submandibular
lymphadenopathy
Chest - Right upper lobe crackles, decreased breath sounds at
the bases bilaterally R>L
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tenderness; lower back with vac
dressing draining 2 cm incised lesion
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-1**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
MRI [**11-19**]: Essentially stable appearance of soft tissue
edema/inflammation
without evidence of osteomyelitis or drainable abscess
collection. Slightly
heterogeneous signal within the dependent portions of the iliac
bones is non-
specific, and most likely represents hematopoietic marrow.
CT abdomen [**11-18**]: No intra-abdominal fluid collections.
CT chest [**11-14**]: Multiple nodular and focal patchy opacities
bilaterally of different sizes, many of which show evidence of
cavitation. The largest of these within the
right upper lobe although all lobes are affected. These findings
are
consistent with septic emboli. 2. Elevation of the right
hemidiaphragm. Tiny right-sided pleural effusion which is
layering posteriorly. 3. Gastric varices.
MRI Pelvis [**2170-11-7**]: No evidence of intraosseous infection.
CXR [**2170-11-7**] AP: Increased right pleural effusion with right
lower lobe atelectasis vs. PNA. Increased pulmonary edema vs.
diffuse infection.
CXR [**2170-11-6**] AP: Left upper lobe, right upper lobe infiltrates
suggestive of PMA. Diffuse intersitital opacities suggestive of
pulmonary edema vs. infxn
[**2170-11-5**] 07:35AM WBC-12.9* LYMPH-8* ABS LYMPH-1032 CD3-82
ABS CD3-845 CD4-18 ABS CD4-189* CD8-59 ABS CD8-613 CD4/CD8-0.3*
[**2170-11-5**] 07:35AM PLT COUNT-240
[**2170-11-5**] 07:35AM WBC-12.9* RBC-5.24 HGB-14.6 HCT-42.8 MCV-82
MCH-27.9 MCHC-34.1 RDW-12.1
[**2170-11-5**] 07:35AM NEUTS-84.4* LYMPHS-8.3* MONOS-6.6 EOS-0.4
BASOS-0.4
[**2170-11-5**] 07:35AM CORTISOL-25.6*
[**2170-11-5**] 07:35AM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-2.9
MAGNESIUM-1.5* URIC ACID-3.8
[**2170-11-5**] 07:35AM LIPASE-12
[**2170-11-5**] 07:35AM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-147 ALK
PHOS-102 AMYLASE-28 TOT BILI-0.9
[**2170-11-5**] 07:35AM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15
[**2170-11-5**] 08:06AM LACTATE-2.3*
[**2170-11-26**] 10:31AM BLOOD WBC-4.1 RBC-4.34* Hgb-11.5* Hct-35.3*
MCV-81* MCH-26.5* MCHC-32.7 RDW-14.6 Plt Ct-419
[**2170-11-5**] 07:35AM BLOOD WBC-12.9* Lymph-8* Abs [**Last Name (un) **]-1032 CD3%-82
Abs CD3-845 CD4%-18 Abs CD4-189* CD8%-59 Abs CD8-613
CD4/CD8-0.3*
[**2170-11-21**] 05:00AM BLOOD WBC-3.7* Lymph-42 Abs [**Last Name (un) **]-1554 CD3%-91
Abs CD3-1408 CD4%-29 Abs CD4-454 CD8%-57 Abs CD8-888*
CD4/CD8-0.5*
[**2170-11-22**] 05:50AM BLOOD ALT-46* AST-30 CK(CPK)-20* AlkPhos-131*
TotBili-0.2
[**2170-11-19**] 10:06AM BLOOD ALT-57* AST-41* LD(LDH)-174 AlkPhos-127*
Amylase-39 TotBili-0.2
[**2170-11-25**] 03:28AM BLOOD Vanco-14.5*
Brief Hospital Course:
1. sacral abscess - Abscess was incised and drained in the ED.
Surgery consult obtained, and this was felt to be subcutaneous
abscess rather than pilonidal cyst. Wound cultures grew out
MRSA. Pt placed on vancomycin, ultimately for a 4-week course.
Wound vac was placed, with surgery following and doing dressing
changes. Wound vac discontinued prior to discharge per surgery
team; wet-to-dry dressings were performed, and eventually dry
gauze dressings. No evidence of further infection, with abscess
appearing to be healing well by discharge. Pt will follow up
with Dr. [**Last Name (STitle) **] in surgery in 4 weeks.
2. MRSA sepsis - Pt was admitted to the [**Hospital Unit Name 153**] from the ED on a
non-rebreather mask, hypotensive on a levophed drip which was
weaned off and the patient remained stable, transferred from
[**Hospital Unit Name 153**] to the floor on [**2170-11-8**]. On arrival, pt's CVP continued
to be low ([**4-23**]), with further fluid resuscitation resulting in
adequate BP. Levophed drip was stopped 48 hours later, and BP
remained stable throughout rest of course. Pt had multiple
further blood cultures for surveillance purposes, which were
negative. Last positive blood culture was on [**11-5**]. Pt on
vanco for 4 week course after first negative blood culture.
Vancomycin trough levels were persistently low, with continual
uptitrating of the dose, up to 1750mg IV q12, and then
ultimately was 1000mg IV q8h with a therapeutic trough level.
3. pneumonia - Pt noted to have multiple patchy opacities on
CXR and chest CT, some of these lesions were noted to be
cavitating. ID was involved early in the course of [**Hospital **]
hospital stay. 3 AFB smears were negative, PCP via sputum
induction was negative, Legionella urinary antigen was negative,
Cryptococcus negative. A PPD was placed, which was negative, as
well. CXR showed right pleural effusion with right lower lobe
atelectasis vs. pneumonia. This was evaluated with U/S probe and
it was determined that the fluid collection was too small to be
tapped. Findings on CT scan were consistent with septic emboli,
so a TTE and then TEE were performed, both of which were
negative for any vegetations. Per ID, it is thought that these
are septic emboli, likely of MRSA, from some intravascular
source but not valvular vegetations. The appearance of these
nodules, in their cavitations is consistent with Staph
pneumonia, possibly from hematogenous spread. Pt was placed on
4 week course of vanco, and he continued to improve overall,
feeling well by the time of discharge. He maintained good O2
sats and showed no respiratory distress. A followup CT scan was
arranged prior to discharge, and pt will follow up in [**Hospital **] clinic
to determine if the vancomycin may be discontinued.
4. fevers - fevers persisted even with the vancomycin on board.
Pt's cultures were consistently negative and no changes noted
on repeat chest imaging. Pt clinically was well-appearing in
the last week or so before discharge, but was still having
fevers. Other sources of fever were searched for: an abdominal
CT showed no fluid collections or occult abscesses; an MRI of
the sacral area near the abscess ruled out osteomyelitis. It
was thought that perhaps his subtherapeutic vanco dose might be
responsible for this. However, no further causes of infection
were found, and pt was clinically well. Pt remained afebrile
for > 4 days prior to discharge.
5. HIV - CD4 count low 189, but pt had an acute infectious
process going on. Repeat CD4 count when pt more stable was 454.
Bactrim prophylaxis was stopped. Pt will follow up with Dr.
[**Last Name (STitle) 4844**] in [**Month (only) 404**] of next year. No HAART while in house.
6. HSV - pt had some oral HSV and completed a 7-day course of
famciclovir with resolution of symptoms.
7. gastric varices - varices were found incidentally on CT
scan. LFTs were mildly elevated. Pt asymptomatic. Abd CT scan
did not comment on any liver abnormalities. An outpatient EGD
appointment was arranged to better assess these varices, as well
as a subsequent liver clinic appointment.
8. PPX: H2 blocker, SQ heparin
9. FULL CODE.
10. Dispo: Patient will be discharged to home with VNA for PICC
care, as well as help with dressing changes.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
6. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg
Intravenous Q12H (every 12 hours) for 11 days: Last day of
treatment in [**12-6**]. Patient may need longer duration of therapy
to be determined by outpatient infectious disease doctor.
[**Last Name (Titles) **]:*22 doses* Refills:*0*
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous QD () as needed: to PICC.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. saline heparin flushes per VNS protocol
11. PICC line care
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] HOME THERAPIES
Discharge Diagnosis:
Primary diagnoses:
MRSA sacral abscess
MRSA bacteremia
Septic Pulmonary Emboli
HIV
Secondary diagnoses:
Gastric Varices, seen on CT scan
Seasonal allergies
Right hand tendonitis
s/p T and A
Right knee cellulitis (MSSA, [**3-21**])
h/o strep pharyngitis, HSV, skin abscesses (per OMR)
Discharge Condition:
stable. pain well controlled. wound healing well.
Discharge Instructions:
Please call your doctor and return to the hospital for
fever/chills, increasing warmth, pain, redness, or swelling from
the abscess, general malaise, diarrhea, or any other concerns
you may have.
Please go to all of your appointments.
Followup Instructions:
You have the following appointments:
1) Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-12-1**] 10:15
This is on the [**Hospital Ward Name 517**]. Please do not eat any solid food 3
hours beforehand. ***Before this appointment, please call ([**Telephone/Fax (1) 26760**] to update your information.
2) MD Where: LM [**Hospital Unit Name 4337**] DISEASE
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30
3) Dr. [**Last Name (STitle) **] - surgery - to take a look at your abscess
[**2170-12-24**], 1:00PM; in [**Hospital Ward Name 23**] building (Surgical
Subspecialties); phone number ([**Telephone/Fax (1) 26761**]
4) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**], Dr.[**Name (NI) 4864**] nurse practitioner
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-12-25**]
11:00
5) Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-2-7**] 9:50
6)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2170-12-20**] 10:00
***You need to arrive at 9 am.
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS
Date/Time:[**2170-12-20**] 10:00
This is for evaluation of your liver
7) Liver Clinic appointment: to follow up with liver scan
[**2171-2-26**] at 9 am [**Location (un) **] Dr. [**Last Name (STitle) 10924**]
|
25000,501,412,4019,43310,4139,4271,99604,4280 | 270 | 188,028 | Admission Date: [**2128-6-23**] Discharge Date: [**2128-6-27**]
Service: [**Hospital Unit Name 196**]
Allergies:
20/20 / Iodine; Iodine Containing / Keflex
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Symptomatic carotid stenoses.
Major Surgical or Invasive Procedure:
L internal carotid artery stenosis s/p angioplasty and stenting
Pacemaker and ICD lead revision
History of Present Illness:
80 year old with significant carotid artery stenoses revealed by
MRA. Noted to have significant L-ICA stenoses beyond the
bifurcation with mild stenosis at the bifurcation. On the right
hand side, moderate to severe stenosis at the bifurcation and in
the proximal R-ICA. These stenoses have become symptomatic with
recent ?TIA. Obstructions: Left 90%, right 60-70%.
Past Medical History:
1. ICD: Biventricular ICD placed for VT indication.
2. CAD: last cath [**10/2124**]: D1 ostial 30%, LCx 30% ISRS, totally
occluded RCA. 3 prior MI's. Stent to LCx in [**2118**], PTCA of LAD in
[**2121**], stent to RCA in early [**2113**] (now occluded).
3. h/o LBBB
4. Desc aortic aneurysm (2.3 x 1.5 cm [**2-21**])
5. CHF, syst and diast (EF 30%)
6. Asbestosis on home O2
7. DJD s/p R TKR
8. Mild CRI
9. s/p appy
Social History:
Pt is a Jehovah's witness
no etoh /tob
Lives with his wife in an apartment in [**Name (NI) 1474**]
Family History:
HTN, CAD, DM
Physical Exam:
V/S: afeb, 75, 108/59, 14, comfortable on RA
I/O: 1738/1040 (+698), overnight -1340.
Tele: No events.
Gen: A/Ox3, pleasant, NAD.
CV: RRR, nl s1/s2, no m/r/g. No carotid bruit.
Pulm: CTAB
Abd: +BS, S/NT/ND
Extr: No c/c/e.
Neuro: CNII-XII intact
Pertinent Results:
[**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**]
INDICATIONS: 80 year old man with carotid artery stenosis.
Evaluation of the
vasculature requested.
TECHNIQUE: Multiplanar T1, T2, and susceptibility images of the
brain were
obtained. No contrast was administered. MR angiography of the
circle of [**Location (un) 431**] was performed with acquisition of two- and
three- dimensional time-of-flight images. MR angiography of the
neck was also performed with two- and three-dimensional
time- of- flight images of the major arteries.
FINDINGS: On the brain images, there is no evidence of
hydrocephalus, mass
effect, or shift of the normally midline structures. The
ventricles,
cisterns, and sulci are unremarkable. There are patchy areas of
increased T2
signal in the pons. There are also widespread patchy areas of
increased T2
signal in the subcortical white matter of both cerebral
hemispheres. These
signal abnormalities are consistent with chronic small vessel
ischemic
infarcts. Also, in the posterosuperior right frontal cortex,
there is a small
area of increased T2 signal in the cortex consistent with a
chronic
infarction. A similar small infarct in the head of the left
caudate nucleus
is also observed. No susceptibility artifact is seen. The
visualized
vascular flow voids are present. The osseous structures, soft
tissues, and
sinuses are unremarkable. MR angiography of the circle of [**Location (un) 431**]
shows no evidence of stenosis in the major vessels. Along the
proximal right posterior cerebral artery, there is a tiny focus
of increased signal intensity on the two-dimensional
time-of-flight images. In the source images, there is no
suggestion of an aneurysm at that site. This small focus appears
to be an artifact. There is no definite
evidence of an aneurysm. MR angiography of the carotid and
vertebral arteries in the neck is significant for a severe
stenosis beyond the bifurcation in the left proximal internal
carotid artery. Only mild carotid narrowing is seen at the left
carotid bifurcation. The left carotid bifurcation is more
superiorly located
than the right, and accordingly, three-dimensional time-
of-flight images
understandably did not entirely cover this area. The severe left
proximal
internal carotid stenosis is best visualized on the
two-dimensional time- of-
flight images. On the right side, on both the two- and
three-dimensional
time-of- flight images, a probable moderate to severe right
carotid stenosis
at the bifurcation, and moderate to severe right proximal
internal carotid
stenosis is also seen.
IMPRESSION: The head MRI shows evidence of widespread patchy
increased T2
signal. These are are consistent with chronic small vessel
ischemic infarcts. The MR angiogram of the circle of [**Location (un) 431**]
shows no definite evidence of stenosis or aneurysm. The MR
angiogram of the neck is significant for a severe left internal
carotid artery stenosis beyond the bifurcation, with mild
stenosis at the bifurcation. On the right, there is evidence of
moderate to severe stenosis at the
bifurcation and in the proximal internal carotid artery.
Procedure Date:[**2128-6-11**]
[**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**]
HISTORY: 80 y/o man s/p bivalve ICD placement. R/O RV lead
dislodgement.
COMPARISON: [**2128-6-12**].
CHEST AP: The tip of the right ventricular lead appears to have
rotated into
the right atrium. The right atrial and coronary sinus leads are
in unchanged
position. Cardiac and mediastinal and hilar contours are stable
in appearance.
Pulmonary vasculature is normal. The lungs are clear. There are
no pleural
effusions. Osseous and soft tissue structures are unremarkable.
IMPRESSION: Displacement of right ventricular ICD lead into the
right atrium.
Procedure Date:[**2128-6-24**]
[**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**]
History: Defibrillator lead change.
Chest, PA and Lateral: The heart is normal in size. A
difibrillator is
present on the left anterior chest wall, and there are two RV
leads and a
single RA lead. There is no pneumothorax. There are no signs of
failure and
there are no focal infiltrates. Nodular calcifications in the
left mid lung
zone are likely related to previous granulomatous disease. There
is no
mediastinal adenopathy. There is no effusion or bone
destruction.
Procedure Date:[**2128-6-26**]
Brief Hospital Course:
Admitted for stent placement in the left ICA. Pt. returned from
cath with 1.5 mcg/kg/min of phenylephrine, successfully weaned.
Pt. experienced brief bouts of non-specific bilateral radiating
numbness but with consistently normal CNII-XII exam; likely
transient vagal depression nature. The patient also has a
biventricular ICD implanted, which was interrogated prior to the
stent procedure. It was determined that the RV lead/ICD had
become dislodged. The defibrillator function was disabled,
leaving the device operating as an RA/LV DDD pacer. CXR
indicated that the RV lead had ascended into the RA. The pacer
function began to be impaired by erroneous sensing, with pacing
occuring on the ST segment leading to brief aberrant NSVT runs.
EP put the ICD into [**Last Name (un) **] (sense-only) mode, and the patients
leads were then percutaneously resited satisfactorily as
confirmed by repeat CXR. ICD function was tested and found to be
satisfactory. The patient did well after carotid stenting and
ICD lead revision and was subsequently discharged home with
assistance in stable and improved condition.
Medications on Admission:
1. Lasix 20mg po qd
2. Glucophage 500mg po bid
3. Glyburide 5mg po qd
4. Prevacid 30mg po qd
5. Lisinopril 20mg po qd
6. ASA 325mg po qd
7. Oxycodone 5mg po q4-6h:PRN pain
8. Plavix 75mg po qd
9. Simvastatin 40mg po qd
10. Digoxin 0.125mg po qd
11. Setraline 50mg po qd
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day): Do not stop this medicine until speaking with Dr.
[**First Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**2-24**]
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. L internal carotid artery stenosis s/p angioplasty and
stenting
2. Dislodged pacemaker and ICD lead s/p revision
3. Congestive Heart Failure
4. Diabetes Mellitus
Discharge Condition:
stable and improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
-Contact your primary care physician should you experience any
lightheadedness, dizziness, shortness of breath or chest pain.
-Do Not restart your lisinopril without checking with Dr.
[**First Name (STitle) **]. The visiting nurse will call his office next week after
checking your blood pressure.
Followup Instructions:
1. Please call to schedule an appointment NEXT WEEK with Dr.
[**Last Name (STitle) 284**] at ([**Telephone/Fax (1) 5862**] to follow up for your pacemaker.
2. Contact Dr.[**Name2 (NI) 3101**] office to schedule an appointment at
([**Telephone/Fax (1) 7236**] to be seen the same day as Dr. [**Last Name (STitle) 284**].
Completed by:[**2128-7-12**] |
5770,5772,57400,57410,25001 | 271 | 173,727 | Admission Date: [**2120-8-7**] Discharge Date: [**2120-8-20**]
Date of Birth: [**2074-11-30**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
gallstone pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 45 year old female transferred from [**Hospital3 **]
on [**2120-8-7**] for treatment of pancreatitis. Patient
presented to [**Hospital1 **] after a syncopal episode. Postive reports of
R abdominal and back pain after eating fatty meals in the past.
At [**Hospital1 **], lipase 7474m antkase 2,490, ALT 402, AST 463, bili
1.5, Alk Phos 130, WBC 17. CT demonstrated cholecystitis,
cholelithiasis, intrahepatic ductal dilatation and pacreatitis
with surrounding phlegmon. She improved on cefotetan, imopenem
and hydration. On [**8-6**], patient symptoms became acutely
worse and developed grey-[**Doctor Last Name **] sign. Repeat CT demonstrated
increase in abdominal fluid, increase in pancreatic inflamation,
increase [**Last Name (un) **] of phlegman, new pleural effusions. Patient
arrived to [**Hospital1 18**] intensive care unit [**2120-8-7**].
Past Medical History:
none
Social History:
Denies EtOH, Tobacco or IDU
Family History:
Denies CAD, cancer, or gallstones
Physical Exam:
99.2 158/70 89 24 94% 5L
diaphoretic
dry MMM
tachy regular
dull @ bases bilaterally, poor inspiratory effort
tense echymosis over flanks bilaterally, tender, distended, no
rebound
mild lowere extremity edema
Pertinent Results:
[**2120-8-7**] 08:06PM LACTATE-1.0
[**2120-8-7**] 07:12PM GLUCOSE-155* UREA N-19 CREAT-0.5 SODIUM-153*
POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-30* ANION GAP-14
[**2120-8-7**] 07:12PM ALT(SGPT)-42* AST(SGOT)-21 ALK PHOS-90
AMYLASE-80 TOT BILI-0.4
[**2120-8-7**] 07:12PM LIPASE-33
[**2120-8-7**] 07:12PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.5
[**2120-8-7**] 07:12PM WBC-14.9* RBC-3.35* HGB-8.4* HCT-27.3*
MCV-81* MCH-25.1* MCHC-30.8* RDW-16.8*
[**2120-8-7**] 07:12PM NEUTS-75* BANDS-0 LYMPHS-15* MONOS-8 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2120-8-7**] 07:12PM PT-14.2* PTT-19.7* INR(PT)-1.3
Brief Hospital Course:
On arrival to medical intensive care unit, patient was stable
and supportive measures were continued. Imipenan was continued.
Patient remained stable and was started on TPN and transferred
to the surgical intensive care unit on [**8-8**]. Patient
continue to improve in both clinical appearance and in lab
values and was transferred to the floor [**8-10**]. Sugars
were monitored and patient required insulin. Patient was
advanced low fat diet on [**8-16**] which she tolerated well. A
[**Last Name (un) 387**] consult was obtained for patients new onset of diabetes.
A cholecystectomy was planned during the hospital admission was
but then cancelled secondary to a large pseudocyst demonstrated
on CT. Patient was discharged on [**8-20**] with surgical and
[**Last Name (un) 387**] follow upl
Medications on Admission:
none
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
Disp:*30 * Refills:*2*
2. Humalog 100 unit/mL Solution Sig: per sliding scale unit
Subcutaneous with meals.
Disp:*100 * Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
insulin dependent diabetes
gallstone necrotizing pancreatitis
cholelithiasis
Discharge Condition:
good
Discharge Instructions:
Take medications as perscribed.
Call doctor or report to emergency if develop abdominal pain,
naseau or vomiting
Followup Instructions:
Patient to call and make appointment with Dr.[**Name (NI) 2829**] office
in one month. Office will arrange for patient to have repeat CT
scan that AM.
[**Hospital **] Clinic- [**2120-9-11**] 10 am with Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 55107**]
Patient to follow up with Dr.[**Name (NI) 56952**] office regarding diabetic
nutrition education classes.
|
41519,4538,41091,5997,4019,2859,2967 | 272 | 164,716 | Admission Date: [**2186-12-25**] Discharge Date: [**2187-1-2**]
Date of Birth: [**2119-11-21**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 67-year-old gentleman
with a history of hypertension and hyperlipidemia who was
transferred from an outside hospital to [**Hospital1 190**] for acute management of a submassive pulmonary
embolism. Three [**Known lastname **] prior to admission the patient
developed increasing right calf pain that was sudden in onset
while walking that increased with weight bearing. The
patient also noticed a right lower extremity edema below the
knee. On the [**Known lastname **] of admission he experienced a sudden onset
of shortness of breath with minor exertion and associated
cough that occasionally produced a yellow sputum. He denied
any chest pain, chest discomfort, hemoptysis, nausea,
vomiting, diarrhea, diaphoresis, syncope. He also denied any
recent trauma. The patient drove himself to the [**Hospital 1474**]
Hospital for further treatment of his shortness of breath.
While at [**Hospital1 1474**] it was noted his temperature was 100.2
Fahrenheit. An arterial blood gas showed 7.49/35/67 while he
was saturating at 92% on room air. A right lower extremity
ultrasound revealed an extensive DVT from the popliteal vein
cephalad to include the common femoral vein. A stat chest CT
showed a massive pulmonary embolism with a saddle embolus
extending across the bifurcation of both the right and left
pulmonary artery with extensive emboli throughout both lower
lobes. The was started on a heparin drip and emergently
transferred to [**Hospital1 69**] for
further evaluation.
REVIEW OF SYSTEMS: The patient denies any prior history of
cancer. He has no history of blood clots. He also has no
history of cerebrovascular accident, myocardial infarction or
diabetes mellitus. It should be noted that the patient
states that recently he has been extremely depressed and he
has been lying in bed for lengthy period of time because he
has not been able to get the energy or motivation to do
things.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia.
3. Bipolar disorder for which he has received treatment for
the past five to six years. 4. Cholecystitis two years ago.
5. Acute renal failure two years ago secondary to a decreased
p.o. intake.
PAST SURGICAL HISTORY: 1. Tonsillectomy as a child. 2.
Right cartilage excision secondary to leg swelling 10-12
years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: 1. Aspirin 325 q.d. 2. Lisinopril
10 mg q.d. 3. Lovastatin 20 mg q.d. 4. Tegretol 200 mg
t.i.d. 5. Olanzapine 5-15 mg q.h.s. p.r.n.
FAMILY HISTORY: Father has a history of Alzheimer's. He
died from pneumonia and stroke. His mother has a history of
atherosclerosis and died at the age of 75. No known history
of cancer or clotting disorders in the family.
SOCIAL HISTORY: The patient denies smoking. He also denies
intravenous drug use. In the past he abused alcohol. He is
married living with his second wife. [**Name (NI) **] has five children
from his first marriage and three children from his current
spouse. [**Name (NI) **] is a former military veteran and he receives most
of his care at the Veteran's Hospital.
PHYSICAL EXAMINATION: His blood pressure was 117/72, pulse
98, respiratory rate 28, temperature 99.2, oxygen saturation
99% on three liters. In general he is a fatigued elderly
gentleman in minor respiratory distress. He was alert and
oriented to person, place and situation. Heart: Regular
rate and rhythm with distant heart sounds secondary to
hyperexpansion of the lungs. There were no murmurs, gallops,
or rubs appreciated. Lungs: He had decreased breath sounds
at the right base with an occasional expiratory wheeze.
Abdomen: Soft, nontender, normal active bowel sounds. There
was no hepatosplenomegaly. He had bilateral bulging flanks.
Extremities: Right lower extremity edema from the knee
distal. His right lower extremity was slightly erythematous
and warm. No cords could be appreciated. There was no
cyanosis or clubbing and he had +2 dorsalis pedis pulses
bilaterally.
LABORATORY DATA: Sodium 138, potassium 4.0, chloride 102,
bicarbonate 25, BUN 20, creatinine 1.4, glucose 113. His
white blood cell count was 8.9. His hematocrit was 37.9,
platelet count 244, PT 13.1, PTT 22.3 and an INR was 1.2.
His initial cardiac enzymes showed a CK of 256, a CK MB of
4.4, a troponin of 2.9.
EKG on presentation showed sinus tachycardia with a slight PR
prolongation. There was a normal axis. There was T wave
inversion and Q wave in lead 3. There were no other ST or T
wave inversions noted.
HOSPITAL COURSE: This is a 67-year-old gentleman with a
history of hypertension, hyperlipidemia, no past history of
DVT, who presented to an outside hospital and was found to
have a submassive pulmonary embolism. He was transferred to
[**Hospital1 69**] for further management.
1. Pulmonary embolism: Upon admission the patient was given
a bedside echocardiogram which revealed the left ventricular
cavity was mildly dilated. Overall left ventricular systolic
function was unable to be assessed. The right ventricular
cavity was moderately dilated and the right ventricular
systolic function appeared to be depressed. A repeat
echocardiogram was performed which showed that the left
atrium was mildly dilated. There was mild symmetrical left
ventricular hypertrophy. The left ventricular cavity size
was normal. Overall left ventricular systolic function was
normal with an ejection fraction of approximately 70%. The
right ventricular cavity was moderately dilated. There was
global right ventricular free wall hypokinesis. The aortic
root was mildly dilated. The aortic valve leaflets were
mildly thickened but not stenotic. Mild aortic regurgitation
was seen. The mitral valve leaflets were mildly thickened.
There was no mitral valve prolapse. Trivial mitral
regurgitation was seen. The left ventricular pattern
suggests impaired relaxation. There was no pericardial
effusion. Multiple laboratory studies were drawn to
determine the patient's coagulation status. Protein C was
slightly elevated with a value of 132. Protein S was normal
with a value of 91. Homocystine was slightly elevated with a
value of 14.6. Anticardiolipin antibody studies were normal.
The prothrombin mutation analysis showed no mutations and the
factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**] analysis showed no genetic mutations also.
The patient remained on a heparin drip and he was seen by the
pulmonary team for evaluation of whether thrombolysis therapy
should be initiated. The pulmonary team recommended
conservative management with intravenous heparin. They
recommended no thrombolytics unless the patient were to
become hemodynamically unstable. The patient was monitored
in the coronary care unit on a telemetry bed. His O2
saturations remained above 92% on two liters. He showed no
symptoms of hemodynamic instability and after 48 hours he was
started on Coumadin. He was then transferred to the floor
until his INR became therapeutic. The patient was then set
up with the outpatient [**Hospital 197**] clinic at the VA who will
manage his Coumadin and INR with a goal INR between 2 and 3.
He should remain on Coumadin for a minimum of six months.
2. Bipolar disorder: The patient was mildly depressed during
his stay in the hospital. He remained on his home
psychiatric medication regimen. The patient was released in
stable condition.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lisinopril 10 mg q.d.
3. Lovastatin 20 mg q.d.
4. Tegretol 200 mg t.i.d.
5. Olanzapine 5-15 mg q.h.s. p.r.n.
6. Coumadin 7.5 mg q.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. Follow up at the [**Hospital **] clinic in two [**Known lastname **] for an INR check
and for further management of his Coumadin.
2. Follow up with his primary care physician [**Name Initial (PRE) 176**] 1-2
weeks. The patient know to return to the emergency room if
he develops any shortness of breath, chest pain, chest
tightness, dyspnea on exertion or lower extremity pain. He
should also return to the emergency room if while on Coumadin
he falls and hits his head or has red, bloody or dark stools.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2187-1-25**] 10:37
T: [**2187-1-25**] 10:50
JOB#: [**Job Number 46151**]
|
E8543,96501,30421,07070,E8541,E8498,3051,07030,51881,4280,2920,30431,9708,9696,E8500,30401 | 273 | 158,689 | Admission Date: [**2141-4-19**] Discharge Date: [**2141-4-20**]
Date of Birth: [**2107-8-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Cocaine and heroine overdose
Major Surgical or Invasive Procedure:
Right internal jugular vein central line placement
Intubation and extubation on [**2141-4-19**]
History of Present Illness:
The patient is a 33 year old African-American male with a
history of polysubstance abuse who was found by the police in
his car with a needle in his antecubital vein, incoherent and
combative. He was subsequently brought to [**Hospital1 18**] where he
admitted to cocaine, heroin and marajuana use but denied ETOH.
The patient was initially extremely combative and required up to
20 mg IV haldol and 4 + mg ativan for sedation. After receiving
sedation, he then became somnolent with an inability to manage
his own secretions and was intubated for airway protection. His
serum tox in the ED was negative with a urine tox positive for
cocaine and opiates.
Past Medical History:
L meniscal tear
chylamydia
heroin/cocaineHCV
gential herpes
anxiety
eczema
Social History:
The patient smokes 1.5 packs of cigarettes per day. He recently
has used 30 to 50 bags of heroine in the past. Low alcohol.
Positive cocaine use. Positive crack use. Positive heroine drug
abuse. The patient claims about 3 g a
day for cocaine use in past history.
Family History:
The patient claims mother and father are
alive and healthy. The patient has no siblings.
Physical Exam:
Tc=97.9 P=100 BP=170/100 RR=18 100% O2 on RA
Gen - Intubated, sedated
HEENT - PERLA
Heart - RRR, No M/R/G
Lungs - CTAB (anteriorly)
Abdomen - Soft, NT, ND, + BS, no hepatosplenomegaly
Ext - No C/C/E, + 2 d. pedis bilaterally
Skin - Tattoos, needle marks evident throughout upper
extremities
Pertinent Results:
[**2141-4-19**] 03:29PM CK(CPK)-663*
[**2141-4-19**] 03:29PM WBC-8.1 RBC-4.80 HGB-12.2* HCT-37.3* MCV-78*
MCH-25.4* MCHC-32.7 RDW-13.0
[**2141-4-19**] 03:29PM PLT COUNT-204
[**2141-4-19**] 02:43PM TYPE-ART PO2-131* PCO2-49* PH-7.38 TOTAL
CO2-30 BASE XS-3 INTUBATED-NOT INTUBA
[**2141-4-19**] 01:13PM TYPE-ART PO2-71* PCO2-52* PH-7.34* TOTAL
CO2-29 BASE XS-0
[**2141-4-19**] 01:00PM TYPE-ART RATES-[**11-13**] TIDAL VOL-600 O2-50
PO2-179* PCO2-55* PH-7.34* TOTAL CO2-31* BASE XS-2 -ASSIST/CON
INTUBATED-INTUBATED
[**2141-4-19**] 06:26AM TYPE-ART PO2-347* PCO2-57* PH-7.32* TOTAL
CO2-31* BASE XS-1
[**2141-4-19**] 05:00AM URINE HOURS-RANDOM
[**2141-4-19**] 05:00AM URINE HOURS-RANDOM
[**2141-4-19**] 05:00AM URINE GR HOLD-HOLD
[**2141-4-19**] 05:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2141-4-19**] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2141-4-19**] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2141-4-19**] 02:30AM GLUCOSE-93 UREA N-10 CREAT-1.0 SODIUM-144
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-20
[**2141-4-19**] 02:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
ECG Study Date of [**2141-4-19**] 10:01:34 AM
Sinus rhythm. Since the previous tracing of [**2141-4-19**] the rate has
decreased. The
mild J point and ST segment elevation are now back to a pattern
similar to that
of [**2138**].
CHEST (PORTABLE AP) [**2141-4-19**] 3:15 AM
IMPRESSION: No definite acute cardiopulmonary process.
Brief Hospital Course:
Impression: The patient is a 33 year old male with h/o PSA who
presented after cocaine/heroine intoxication s/p intubation post
sedation now extubated and AOX3.
1. Polysubstance abuse:
- The patient clearly overdosed on heroine and cocaine. On
further questioning, the patient was unable to provide more
details regarding the event.
- Addiction consult was placed but patient did not want to
participate in referral.
- The patient exhibited no further symptoms of withdrawal
throughout his stay.
2. Respiratory status:
- As mentioned, the patinet required intubation secondary to
sedation and inability to clear his secretions.
- The patient was given lasix in the ED for what they thought
was flash pulmonary edema. His CXR showed ?RL infiltrate but was
felt not to be significant given his clinical picture.
- He self-extubated himself and continued to sat well off of O2.
3. ID- ?RL infiltrate
- Patient did not spike fevers with no WBC with questionable RL
infiltrate on CXR. There was no evidence to support a pneumonia
and thus the patient was not treated with antibiotics.
4. Hepatitis C:
- The patient has received no prior treatment and his LFTs were
within normal limits.
5. Mental status change:
- The patient arrived to the FICY very sedated. This was most
likely due to the 20 mg IV haldol and 4 mg Ativan the patient
received in the ED. The patient was not fully cooperative on
physical exam but alert and oriented times three.
The patient was discharged from the [**Hospital Unit Name 153**] with no further events
once he remained stable and was able to tolerate PO intake and
asked to follow up with his primary care physician.
Medications on Admission:
None.
Discharge Medications:
None.
Discharge Disposition:
Home
Discharge Diagnosis:
Heroin and cocaine overdose.
Discharge Condition:
Stable.
Discharge Instructions:
Please return to the ER if you feel more confused or develop
more shortness of breath.
Followup Instructions:
Please call ([**Telephone/Fax (1) 1300**] to schedule an appointment with your
primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**].
|
430,5070,2720,4019,43320 | 274 | 130,546 | Admission Date: [**2114-6-28**] Discharge Date: [**2114-7-12**]
Date of Birth: [**2048-5-18**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male with a history of a cerebrovascular accident with
residual right-sided weakness who presented after having
severe acute onset of headache the night before admission.
The patient's wife stated he had no trauma or precipitating
factors. The patient vomited three times overnight. Denied
any fever, chills, nausea, chest pain, shortness of breath or
visual changes. The patient awoke this morning with
increased right leg weakness and continuous headache and now
new onset of neck pain notably with flexing. The patient
currently states that he only has a headache.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Cerebrovascular accident in [**2112**].
MEDICATIONS:
1. Lisinopril 40 q. day.
2. Lipitor 40 q. day.
3. Minoxidil 2.5 q. day.
4. Atenolol 10 q. day.
5. Triamterene hydrochlorothiazide 37.5/25 one q. day.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: He was afebrile. Heart rate in the
60's. Blood pressure 235/97. Sats 97 percent on room air.
Generally, in no acute distress, pleasant. HEENT: No
lymphadenopathy. Positive tenderness to paraspinal area.
Positive pain on flexion. Cardiovascular: Regular rate and
rhythm. Pulmonary: Chest clear to auscultation bilaterally.
Abdomen soft, non-tender, non-distended. Extremities: No
clubbing, cyanosis or edema. Neurological: Awake, alert and
oriented times three. Long and short term memory intact.
Recalls two out of three and three out of three with
prompting. Following three step commands. Finger-to-nose
normal bilaterally. Rapid alternating movements intact
bilaterally. His strength was [**6-13**] in all muscle groups. His
reflexes were 2 plus throughout and his toes were upgoing.
RADIOLOGY: CT shows likely a caudally positioned
subarachnoid hemorrhage, the causes of which could be a
ruptured aneurysm, arteriovenous malformation or tumor. The
patient had several scans, MRI's of the brain and neck and a
conventional angiogram, all of which were negative for any
arteriovenous malformation or aneurysm or more atypical
source of hemorrhage such as a vascular malformation. The
patient had his angiogram on [**2114-6-28**], which showed an
occluded left vertebral artery and showed no evidence of an
aneurysm. The right vertebral artery ended in the PICA
distribution and provided multiple dural/muscular collaterals
to the left vertebral artery.
HOSPITAL COURSE: On [**6-29**] the patient was awake, alert and
oriented times three. Extraocular movements were full. No
nystagmus. The face was symmetric. No pronator drift. IP's
were full. Wiggles toes bilaterally. It was stable. Diet
was advanced and he remained stable. The patient had a
repeat head CT on [**2114-6-30**], that showed no new hemorrhage
and no extension of his existing hemorrhage. Neurologically
he was stable. He had a repeat MRI of the cervical spine
that was negative for any vascular malformation. His head CT
remained stable. He had a chest x-ray that showed no
pneumonia. On [**7-2**] he was opening his eyes, sleepy,
preferred to keep his eyes closed. Knew his name, following
commands, moving all extremities with good strength. The
patient spiked a temperature on [**7-4**] to 102. Fully
cultured. Continued on day two of levofloxacin and Flagyl
for question of aspiration pneumonia. The patient had repeat
chest x-ray on [**2114-7-5**], that showed improvement of the
left lower lobe opacity. The patient had a non-contrast head
CT on [**2114-7-8**], that showed a right internal capsule
infarct likely due to small vessel disease. The patient was
assessed by Speech and Swallow and must remain NPO. Patient
was unable to cooperate with swallow evaluation due to his
mental status. His vital signs remained stable. He had been
afebrile. He was sleepy but easily arousable, oriented times
one to two. Motor strength: His grasp on the left was [**6-13**];
on the right he was 4 plus out of 5. His IP's were 5 out of
5. He remained sleepy but arousable. He had a PEG tube
placed on [**2114-7-11**], without any complications and will
restart on his tube feedings. His sodium level has been
steadily climbing with a high level 156. Today, [**7-11**], it
is 163. He is receiving 700 cc of free water down his
feeding tube four times a day with repeat sodium pending for
[**2114-7-12**].
DISCHARGE MEDICATIONS: Include:
1. Metoprolol 50 p.o. b.i.d.
2. Lisinopril 20 p.o. q. day.
3. Minoxidil 10 p.o. b.i.d.
4. Albuterol nebs one inhaler q. 6h. p.r.n.
5. Lansoprazole oral suspension 300 mg per NG q. day.
6. Heparin 5000 subcu q. 12h.
7. Atorvastatin 40 q. day.
8. The patient also had Dyazide one p.o. q. day which was
discontinued due to his high sodium. When his sodium
levels return to normal level, that should be restarted
for blood pressure control.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1132**] in one month with a
repeat head CT.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2114-7-11**] 14:45:13
T: [**2114-7-11**] 15:29:14
Job#: [**Job Number 103176**]
|
0389,51881,78552,5849,4538,2869,85221,5990,99592,3320,V667,33182,29410,4019,E8889,V1582 | 275 | 129,886 | Admission Date: [**2170-10-6**] Discharge Date: [**2170-10-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
Lethargy x 2 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo M w/ h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] body dementia, Parkinson's dz, htn, and h/o
falls who p/w increasing lethargy x 2 days. Moved to [**Hospital 7137**] on [**2170-9-18**] due to progressive dementia s/p multiple falls.
Was stable at [**Hospital3 2558**] until the past 2 days when note was
made of increasing difficulty w/ ambulation and difficulty
swallowing. Had swallow training today and kept coughing, per
daughter. [**Name (NI) **] daughter and wife, no diarrhea. Incontinent of
urine at baseline but no foul smell recently. Last fall
approximately 5 days ago per wife. [**Name (NI) **] is nonverbal at
baseline. However, family noticed he was very sleepy on arrival
to ED and had an absent look about him but is now interacting
with them more through touch since initial resuscitation. In ED,
O2 sats dropped into 80s, and he initially required 100% NRB.
SBP dropped from 120's to 90s. The patient was evaluated by the
MICU and placed on sepsis protocol. He received 4L NS. After
receiving IVF, his BP stabilized. O2 sat eventually stabilized
at 98% on 5L NC. The MICU team felt that he did not require ICU
level of care so he was admitted to the medicine service for
further observation
Past Medical History:
HTN
[**Last Name (un) 309**] body dementia
h/o falls
Parkinson's disease
Social History:
Lives at [**Hospital3 2558**]. Dependent of all ADLs and incontinent
of stool/urine at baseline. Married and has daughter who visits
him regularly. No significant h/o tob and only occasional Etoh
(none currently).
Family History:
M w/ h/o alzheimer's disease
Physical Exam:
T 103.0 (rectal) hr 84 bp 119/82 rr 25 O2 98% 5L NC
gen: elderly, in nad
heent: perrla (3->2mm), sclera anicteric
cv: rrr, no m/r/g, soft s1/s2
pulm: diminished BS at both bases, no wheeze/ronchi/rhales
abd: nabs, soft, nt/nd, no masses/hsm
extr: no LE edema, warm/dry
neuro: awake, alert, non-conversant
Pertinent Results:
CXR: tortuous Aorta, no infiltrates
.
Head CT: right subdural hemorrhage, primary isodense, suggesting
subacute/chronic. no shift of midline structures. brain atrophy
and areas of chronic lacunar infarction.
[**10-15**] Head CT:
HEAD CT WITHOUT IV CONTRAST: Again demonstrated within the right
subdural space is a heterogeneous fluid collection, which is
predominantly hypodense in attenuation with small foci of
hyperattenuation noted. The appearance of this subdural hematoma
is not significantly changed since the prior examination. There
is associated mass effect upon the adjacent right cerebral
cortex, which is unchanged since the prior examination, and only
minimal right to left midline shift is again demonstrated, which
also is unchanged since the prior examination. There are no new
areas of intra- or extra-axial hemorrhage noted. The ventricles
and sulci are stable in size, and there is no evidence of
hydrocephalus. Periventricular white matter hypodensities are
again noted along with focal hypodensities within the basal
ganglia, findings consistent with chronic microvascular and
lacunar infarction.
Visualized paranasal sinuses and left mastoid air cells are
clear. Post- surgical changes within the right mastoid air cells
are again demonstrated with an air fluid level, unchanged in the
interval.
IMPRESSION: Overall, stable appearance of subacute/chronic right
subdural hematoma. No new areas of hemorrhage identified.
.
Admission Labs:
[**2170-10-5**] 06:00PM URINE RBC-[**2-24**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2170-10-5**] 06:00PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.5 LEUK-SM
[**2170-10-5**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]->1.030
[**2170-10-5**] 06:21PM LACTATE-2.8* K+-4.7
[**2170-10-5**] 06:30PM PT-15.4* PTT-27.7 INR(PT)-1.6
[**2170-10-5**] 06:30PM PLT SMR-NORMAL PLT COUNT-143*
[**2170-10-5**] 06:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2170-10-5**] 06:30PM NEUTS-90.0* BANDS-0 LYMPHS-7.8* MONOS-2.1
EOS-0 BASOS-0.1
[**2170-10-5**] 06:30PM WBC-21.1*# RBC-5.52 HGB-17.0 HCT-48.1 MCV-87
MCH-30.9 MCHC-35.4* RDW-13.6
[**2170-10-5**] 06:30PM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-2.2
[**2170-10-5**] 06:30PM CK-MB-6 cTropnT-<0.01
[**2170-10-5**] 06:30PM ALT(SGPT)-22 AST(SGOT)-73* CK(CPK)-799* ALK
PHOS-81 AMYLASE-23 TOT BILI-1.8*
[**2170-10-5**] 06:30PM GLUCOSE-131* UREA N-49* CREAT-1.4* SODIUM-142
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-20* ANION GAP-22*
Brief Hospital Course:
He was initially stable on the floor, without fever or
hypotension. Then, in AM of [**2170-10-7**], he decompensated with
temp to 101.6, rigors, and hypotension with SBP of 80's.
Additionally, his oxygen dropped to 78% on RA -> 97% on 100% NRB
-> 97% on 3L NC. He was initially stabilized with 4L of NS
boluses, but hypotension persisted to 70's systolic. Dopamine
was started. Hypoxia persisted with sats in 80's on 100% NRB. A
respiratory code was called, and he was intubated by Anesthesia.
ABG done at codewhile on 100% NRB was 7.43/31/132, lactate of
2.0. He was transferred to the CCU for further treatment.
.
In the CCU he required one pressor for less than 24 hours. His
hypotension was felt to be due to vasodilation from sepsis in
combination with hypovolemia. His culture data only revealed
gram negative rods in his urine, and Vanc, Levo and Flagyl were
continued. He was intubated for hypoxic respiratory failure. The
etiology of his hypoxemia was unclear. [**Name2 (NI) 227**] his rapidly
deteriorating neurolgic function from Parkinsons' he may have
aspirated, although, he did not have radiologic evidence of a
pneumonia. His hypoxemia may have been due to acidosis and v/q
mismatching. LENIs did not reveal evidence of DVT. He was
extubated successfully on [**10-11**]. He had moderate secretions and
received aggressive chest PT, but maintained adequate O2 sats on
shovel mask. Additionally, he was started on low dose
beta-blocker for hypertension and treated with free water
boluses for hypernatremia. During his ICU stay he was less
responsive to stimuli and a repeat CT scan revealed unchanged
size and mass effect from subdural hematoma. His mental status
improved to baseline according to family after weaning sedation.
He developed LUE edema and on [**10-13**] a LUE doppler was performed
which showed occlusive thrombosis of both brachial veins and the
axillary vein, and nearly completely occlusive thrombosis of the
subclavian vein. Pt. had not been receiving SC Heparin because
of his known subdural hematoma and risk for increased bleeding
and mass effect, and a decision was made not to anti-coagulate
him, even given the doppler results. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] stim test was
performed, with decreased Cortisol response, and pt. was pulsed
with 7 days of fludrocortisone and hydrocortisone. During his
CCU stay, he was started on tube feeds. A discussion was begun
with the family regarding long-term nutrition and possible peg
placement. He was about 8 L positive on day of transfer, and had
been receiving Lasix QD. Pt was transfered from CCU to the floor
on [**2170-10-15**] with resolved urosepsis. Pt remained afebrile but
un-responsive. He finished Vanc/Levo/Flagyl x 10 days. His WBC
continued to be elevated. Family discussion was held and
patient was made CMO. Pt was started on Morphine drip titrated
to comfort. Pt's breathing became more agonal over next few
days and he peacefully expired on [**2170-10-19**] @ 10:18 am. Family
was notified and were able to say their final goodbyes while
patient was still in the hospital.
.
# SDH: - Appears to be subacute to chronic. Stable. Repeat CT
last: unchanged subdural hematoma/hypodense collection,
unchanged/persistent mass effect on right cerebelar cortex,
minimal right to left midline shift. No hydrocephalus, no new
hemorrhages. Chronic lacunar and microvascular infarcts.
Neurosurg was re- consulted but unable to say whether burr hole
procedure will reverse mental status changes, drainage in ~ 4
weeks is still recommended, once acute events stabilized.
.
# UE DVT - hold off on anticoagulation for now given SDH
.
# Failed [**Last Name (un) 104**] stim - initially Tx with 7 d steroids; stable
electrolytes/BP.
.
# PPX: pneumoboots, ppi
.
# FEN: NGT, tube feeds were continued until pt was made CMO;
supplemented with IVFs D5 1/2NS with 20 K.
# Full Code: Family met with the providers and decided to make
CMO. .
# Communication: [**First Name5 (NamePattern1) **] [**Known lastname 30376**] (daughter): cell [**Telephone/Fax (1) 30377**] (no
messages), home [**Telephone/Fax (1) 30378**], work [**Telephone/Fax (1) 30379**]
Medications on Admission:
MVI
sinemet 25/100 1 tab po bid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Urosepsis
2. End stage Parkinson's Disease
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2170-10-29**] |
56212,2851,53020,53081,2720 | 276 | 135,156 | Admission Date: [**2147-11-19**] Discharge Date: [**2147-11-22**]
Date of Birth: [**2112-1-16**] Sex:
Service: Medicine, [**Hospital1 **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old
gentleman with no past medical history who recently taking
aspirin 81 mg by mouth once per day three weeks prior to
presentation to decrease potential cardiac risks.
The patient reports that two weeks ago he had scant bright
red blood on his toilet paper after a soft bowel movement.
None again until the day of admission when he had ten soft
bowel movements; all brown and streaked with blood. The
patient denies lightheadedness or syncope. He denies nausea
or vomiting. Her reports that he was consuming alcohol at a
social event last night, and he ate out at a fast food
location this past week. The patient denies any history of
anal trauma. He denies abdominal pain, dizziness, or
weakness. He reports some fatigue. No chest pain. No
palpitations. No shortness of breath. No known history of
hemorrhoids. No history of easy bruising or bleeding
disorders. The patient reports that he occasionally has back
pain.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia; under no treatment.
2. Gastroesophageal reflux disease; for which he
occasionally uses Prilosec.
MEDICATIONS ON ADMISSION: Aspirin 81 mg by mouth once per
day (started two weeks ago as stated).
ALLERGIES: The patient denies any known drug allergies.
FAMILY HISTORY: No family history of colon cancer.
SOCIAL HISTORY: The patient lives with his wife [**Doctor First Name **] who
is a nurse [**First Name (Titles) **] [**Hospital1 69**]. The
patient denies any use of illicit substances. The patient
denies any use of tobacco and reports occasional use of
alcohol (a few drinks on the evening prior to admission).
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed the patient's temperature was 95 degrees
Fahrenheit, his heart rate was 105, his blood pressure was
150/82, his respiratory rate was 12, and his oxygen
saturation was 100% on room air. In general, the patient was
alert sitting up on the gurney with an athletic build and
good coloring. Head, eyes, ears, nose, and throat
examination revealed the sclerae were anicteric. The mucous
membranes were moist. The patient's neck was supple. No
carotid bruits. Cardiovascular examination revealed the
patient had a regular rate. There was 1/6 systolic murmur at
the left sternal border. No rubs or gallops. Radial and
dorsalis pedis pulses were 2+ bilaterally and equal. The
patient's lungs were clear to auscultation. The abdomen was
soft and distended. There were positive bowel sounds. No
bruits. No masses. There was a soft tissue 0.5-cm in
diameter mass at one o'clock above the umbilicus. The
patient's extremities were warm with some varicose veins
present on the leg. No clubbing, cyanosis, or edema.
Neurologic examination revealed cranial nerves II through XII
were grossly intact. His gait was not assessed. Rectal
examination revealed normal tone and guaiac-positive stool.
Orthostatics were not assessed prior to intravenous fluid
hydration.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories on admission revealed the patient had a normal
white blood cell count, normal platelets, and his hematocrit
was 40%. His prothrombin time, partial thromboplastin time,
and INR were all within normal limits. Electrolytes were all
within normal limits.
PERTINENT RADIOLOGY/IMAGING: In the Emergency Department,
the patient had a nasogastric lavage which was negative, and
gastric contents were of food.
Electrocardiogram revealed a normal sinus rhythm with normal
axis and normal intervals. There was a single T wave
inversion in V1 and biphasic T waves in V3. There was a Q
wave in III. No ST elevations or depressions. No known
previous electrocardiogram for comparison.
CONCISE SUMMARY OF HOSPITAL COURSE: Our impression was that
this was a 35-year-old otherwise healthy gentleman with
bright red blood per rectum multiple times in one day and a
history of significant blood on toilet paper two weeks ago
with recent use of aspirin.
The differential was a lower gastrointestinal bleed, most
likely diverticulosis or hemorrhoids, given the clinical
history and lack of crampy pain or support for colitis or
irritable bowel disease.
The patient has no history to support the idea of ulceration
or upper gastrointestinal bleeding. No family history of
colon cancer.
The patient was initially managed with fluid resuscitation.
Serial hematocrit levels were monitored, and all stools were
guaiaced. The patient was kept nothing by mouth for an
esophagogastroduodenoscopy and colonoscopy. The patient was
not orthostatic or symptomatic. The patient was initially
admitted to the floor and the Gastroenterology Service was
following him closely.
On the night of admission, the patient persistently had
bright red blood per rectum every hour. He became
orthostatic and lightheaded. The patient's hematocrit
decreased into the 20s, and he was transferred to the Medical
Intensive Care Unit for further monitoring. He was
transfused 2 units of packed red blood cells and given 3
liters of normal saline, and his blood pressure normalized to
120/84. Subsequent nasogastric lavages were all negative.
Esophagogastroduodenoscopy revealed a short segment of
[**Doctor Last Name 15532**] esophagus, Schatzki ring. A tagged red blood cell
scan revealed no active gastrointestinal bleed. A
colonoscopy revealed diverticulosis of the cecum and
ascending colon as likely source of bleeding. No active
bleeding site was found, but his hematocrit remained stable
over 48 hours. The patient denied any complaints. The
patient had no abdominal pain.
On the day of discharge, it was presumed that diverticular
disease was the source of his bleeding with no subsequent
bleeds. The patient was maintained on a high-fiber diet. He
was continued on Protonix 40 mg by mouth once per day. The
patient was recommended to have a follow-up
esophagogastroduodenoscopy for esophageal biopsies given the
short segment of [**Doctor Last Name 15532**] esophagus seen on the
esophagogastroduodenoscopy during his admission.
DISCHARGE DISPOSITION: All electrolytes were within normal
limits, and he was discharged to home hemodynamically stable.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Anemia secondary to blood loss.
3. Diverticulosis.
4. [**Doctor Last Name 15532**] esophagus.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to call for an appointment to
follow up with a gastroenterologist in six months for a
repeat esophagogastroduodenoscopy with Dr. [**Last Name (STitle) **] and/or Dr.
[**Last Name (STitle) 10689**].
2. The patient was instructed to follow up with his primary
care physician.
MEDICATIONS ON DISCHARGE: Protonix 40 mg by mouth once per
day.
CONDITION AT DISCHARGE: The patient was hemodynamically
stable with a normal blood pressure (130 systolic) without
lightheadedness or evidence of gastrointestinal bleeding.
His hematocrit was stable at 32%.
DISCHARGE STATUS: Discharge status was to home.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2148-1-8**] 12:50
T: [**2148-1-11**] 10:57
JOB#: [**Job Number 54031**]
|
1561,7895,2767,2762,5761,591,5715,5845,0389 | 279 | 192,224 | Admission Date: [**2164-6-14**] Discharge Date: [**2164-6-18**]
Date of Birth: [**2090-2-27**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of type 2 diabetes, coronary artery
disease (status post myocardial infarction), and
cerebrovascular accident who originally presented on [**6-11**]
from [**Hospital 1562**] Hospital with painless jaundice and a 55-pounds
weight over the past year here for endoscopic retrograde
cholangiopancreatography.
The patient noticed gradual jaundice since [**2164-5-25**]. No
abdominal pain, nausea, vomiting, fevers, or chills.
Positive dark urine, and light stools, pruritus, and fatigue.
An abdominal computed tomography on [**2164-5-31**] from the
outside hospital was reported to have shown moderate ascites,
a large liver and spleen, and dilation of the biliary tree,
with a question of intrahepatic malignancy.
An abdominal ultrasound at the outside hospital on [**2164-6-1**] showed splenomegaly, ascites, gallbladder wall
thickening, and dilated ducts in the liver.
A magnetic resonance imaging on [**2164-6-2**] at the outside
hospital showed dilation of the biliary tree and a 4-cm
lesion in the left lobe of the liver.
Endoscopic retrograde cholangiopancreatography on [**6-11**]
performed at [**Hospital1 69**] showed an
intraductal mass, and plastic stent placed. The mass was
brushed and cells were sent to cytology which were positive
for adenocarcinoma.
Additionally, the patient was found to have an increased
creatinine while admitted. Creatinine in [**2163-12-24**]
was noted to be 0.9. Then on [**6-5**], creatinine was noted
to be 2 after a computed tomography scan at the outside
hospital. On admission to the hospital on [**6-11**],
creatinine was noted to be 8.1. The patient was treated
multiple times with Kayexalate for a high potassium. A
paracentesis was performed on [**6-13**] which showed no
evidence of spontaneous bacterial peritonitis.
On [**6-14**], a Quinton catheter was placed in the right
femoral vein, and the patient underwent hemodialysis. During
the course of hemodialysis the patient became hypotensive in
the 80s/40s, and was subsequently volume resuscitated with
2.2 liters of fluids. His blood pressure did not increase,
and the patient began to experience shortness of breath. The
patient was originally saturating 96% on room air but then
desaturated to 93% on 2 liters of oxygen and then 95% on 4
liters of oxygen. Additionally, the patient was wheezing.
Thus, the patient was transferred to the Medical Intensive
Care Unit.
An arterial blood gas was taken and showed a pH of 7.41, a
PCO2 of 28, and a PO2 of 72. Once the patient was
transferred to the Medical Intensive Care Unit, his blood
pressures dropped to the 60s. A right internal jugular was
placed, and the patient was started on Levophed. Fresh
frozen plasma was given prior to line placement as the
patient's INR was 1.7. Additionally, the patient was started
on ampicillin, gentamicin, and Flagyl for presume
cholangitis.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease; status post myocardial
infarction. A catheterization performed in [**2162-5-23**]
showed no significant coronary artery disease.
2. An echocardiogram performed in [**2162-5-23**] showed
diastolic dysfunction without systolic dysfunction and left
atrial enlargement.
3. Non-insulin-dependent diabetes mellitus.
4. Cerebrovascular accident with a right facial droop.
5. Left hydronephrosis; chronic ?
6. Mild spinal stenosis at L4-L5.
7. Left anterior temporal lobe small arachnoid cyst.
MEDICATIONS ON ADMISSION: Spironolactone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Alcohol once per month. Tobacco times 20
years; quit four years ago. No intravenous drug abuse. One
to two cups of coffee once per day. A retired truck driver.
FAMILY HISTORY: Family history was not significant for
gastrointestinal problems or [**Name2 (NI) 499**] cancer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Medical Intensive Care Unit revealed
vital signs of 93/29, heart rate was 83, respiratory rate was
10, and oxygen saturation was 96% oxygen saturation on 4
liters nasal cannula. Temperature was 95.8 (hypothermic).
In general, the patient was markedly jaundiced and
appropriately conversational. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. Scleral
icterus. A jaundiced oropharynx. Spider angiomas on the
face. Chest examination revealed crackles at the bases
bilaterally/anteriorly. Mild expiratory wheezes.
Cardiovascular examination revealed a regular rate and
rhythm. A [**1-26**] holosystolic murmur heard at the left fifth
intercostal space midclavicular line. The abdomen was soft
and nontender. Distended. Positive fluid wave. Unable to
assess organ size. A right femoral Quinton catheter.
Extremity examination revealed no edema. Dorsalis pedis
pulses were 2+ bilaterally. Positive asterixis bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission to the Medical Intensive Care Unit revealed white
blood cell count was 7 (down from 10.2), hematocrit was 28.6,
and platelets were 90. Prothrombin time was 15.9, partial
thromboplastin time was 37.1, and INR was 1.7. Urinalysis
revealed brown/cloudy. Specific gravity was 1.016, large
blood, 100 protein, moderate bilirubin, trace leukocytes,
greater than 50 red blood cells, 6 to 10 white blood cells,
few bacteria, and amorphous crystals. Sodium was 137,
potassium was 4.5, chloride was 100, bicarbonate was 16,
blood urea nitrogen was 86, creatinine was 7.9, and blood
glucose was 105. Lipase was 72 and amylase was 25. Calcium
was 7.8, phosphate was 6.9, and magnesium was 2.1. Albumin
was 3. ALT was 47, AST was 82, total bilirubin was 27.2, and
alkaline phosphatase was 145. Microscopic examination from
ascites taken from [**6-13**] revealed no growth, no
polymorphonuclear leukocytes, no organisms seen on Gram
stain, 55 white blood cells, and 3045 red blood cells.
Cytology from ascites taken from [**6-13**] was negative for
malignant cells. Brush on endoscopic retrograde
cholangiopancreatography taken from [**6-11**] was positive for
malignancy cells adenocarcinoma. Urine cultures from [**6-12**]
and [**6-13**] revealed no growth.
PERTINENT RADIOLOGY/IMAGING PERFORMED AT [**Hospital1 **]:
1. Endoscopic retrograde cholangiopancreatography performed
on [**6-11**] revealed intraductal mass, stent placed.
2. Abdominal ultrasound on [**6-12**] revealed sludge in the
gallbladder, negative [**Doctor Last Name **] sign, liver shrunken with
increased echogenicity, enlarged spleen, and portal vein was
patent.
3. Magnetic resonance imaging of the abdomen performed on
[**6-11**] (although limited by the patient's claustrophobia),
revealed massive ascites, left greater than right small
bilateral pleural effusions, liver nodularity (consistent
with cirrhosis), 3.6-cm X 4.8-cm mass with increased signal
in segment 4A liver, spleen mildly enlarged, varices along
the stomach (portal hypertension), gallbladder with no stones
and no ductal dilatation.
4. A chest x-ray on [**6-14**] revealed right internal jugular
in place and pulmonary edema. No infiltrate. No
pneumothorax.
HOSPITAL COURSE BY ISSUE/SYSTEM: In summary, the patient is
a 74-year-old gentleman with diabetes, coronary artery
disease, and cerebrovascular accident who presented with
painless jaundice and a 55-pound weight loss, status post
endoscopic retrograde cholangiopancreatography with stent,
now with cirrhosis and acute renal failure and probable
cholangiocarcinoma. The patient was transferred to the
Medical Intensive Care Unit with hypotension and shortness of
breath.
1. HYPOTENSION ISSUES: Hypotension was treated with
pressors (Levophed). The patient was weaned off Levophed
with gentle fluid boluses. Mean arterial pressure remained
in the 50s to 60s, and the patient mentated well throughout
his hospital course in the Medical Intensive Care Unit.
Hypotension was most likely secondary to sepsis.
2. PULMONARY ISSUES: The patient remained stable on 4
liters nasal cannula and was saturating well. The patient's
pulmonary status was monitored closely while receiving fluid
boluses for blood pressure so as to prevent a flare of
pulmonary edema. Albuterol nebulizers were given for
wheezing.
Shortness of breath differential diagnoses included
cirrhosis, renal failure, ascites (atelectasis), possible
congestive heart failure or fluid overload.
3. CORONARY ARTERY DISEASE/CONGESTIVE HEART FAILURE ISSUES:
No aspirin was given at this time as the patient was
coagulopathic with an increased INR. No beta blocker were
given during this time as the patient was hypotensive. Mild
congestive heart failure was seen on chest x-ray on [**6-11**].
The patient received an echocardiogram on [**6-15**] which
revealed an ejection fraction of 75% to 80%; although the
patient was on Levophed at the time of this echocardiogram.
Findings included left atrium was mildly dilated, left
ventricular wall thickness and cavity size were normal,
hyperdynamic, right ventricular size and motion were normal,
aortic valve leaflets were thickened, no regurgitation,
trivial tricuspid regurgitation, and borderline pulmonary
artery systolic hypertension. No effusions.
4. GASTROENTEROLOGY ISSUES: Intraductal mass was positive
for adenocarcinoma by cytology. Palliative care for this
patient. The patient's treatment options and prognosis were
discussed at length with the patient and his family.
Total bilirubin and liver function tests were checked daily
to assess for obstruction. If these values were to increase
significantly, could possibly replace stent with a more
permanent stent via endoscopic retrograde
cholangiopancreatography to relieve obstruction. Total
bilirubin tended to decrease throughout his hospital stay.
The patient also has cirrhosis of unclear etiology.
5. RENAL ISSUES: Acute renal failure; question as to
etiology - acute tubular necrosis; status post contrast for
computed tomography versus hepatorenal syndrome.
The patient received three days of hemodialysis. No fluid
was removed in hemodialysis. Renal consultation team is
following the patient. Fractional excretion of sodium was
1%.
6. INFECTIOUS DISEASE ISSUES: The patient was originally
started on ampicillin, gentamicin, and Flagyl for presumed
cholangitis causing a septic picture with increased white
blood cells, hypotension, and hypothermia. This antibiotic
regimen was changed to vancomycin, ceftazidime, and Flagyl so
as to provide more protection for the kidneys.
Cultures were negative or pending to date. Blood cultures
from [**6-15**] were pending. Urine cultures from [**6-12**] and
[**6-13**] showed no growth. Ascites from [**6-13**] showed no
growth.
7. HEMATOLOGIC ISSUES: The patient remained coagulopathic
secondary to liver disease. The patient was oozing from
intravenous site. Thus, the patient was given three days of
subcutaneous vitamin K to correct for the increased INR.
The patient received two units of packed red blood cells
while in the Medical Intensive Care Unit for a hematocrit of
less than 30. The patient also received one unit of fresh
frozen plasma prior to internal jugular central vein line
placement on [**6-14**].
8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
received fluid boluses for a decreased blood pressure; yet
remained saturating well on 4 liters nasal cannula oxygen and
had no complaints of chest discomfort. Electrolytes were
repleted as needed. The patient was given a full diet upon
his request.
9. ACCESS ISSUES: The patient has a right internal jugular
central line which was placed on [**6-15**], and a right femoral
Quinton catheter which was placed on [**6-14**], as well as two
peripheral intravenous lines.
10. CODE STATUS: The patient's code status was changed from
full code to do not resuscitate/do not intubate. The patient
and the patient's family expressed a wish to not be started
on pressors if the patient's blood pressure were to fall.
11. SOCIAL ISSUES: Multiple family meetings were held with
the patient and his family. His son [**Doctor Last Name **] is the main
contact person. Additionally, the patient's brother flew in
from [**Name (NI) **] and was able to meet with the patient and spend
time with him.
DISCHARGE DISPOSITION: Currently, the patient is in the
Medical Intensive Care Unit awaiting a private bed on the
floor. The patient will most likely either be discharged to
the floor in a private bed or go home soon with some kind of
hospice care or visiting nurse assistance; pending Social
Work evaluation and discussions with the family and the
patient.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: The patient was to be discharged pending a
private room on the floor, or the patient and his family wish
for care at home.
DISCHARGE DIAGNOSES:
1. Cirrhosis.
2. Probably cholangiocarcinoma.
3. Acute renal failure.
4. Diabetes.
5. Coronary artery disease/congestive heart failure.
MEDICATIONS ON DISCHARGE: Have yet to be decided. The
patient will most likely go home with antibiotics for
presumed cholangitis and other comfort medications.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with his primary care doctor
if needed.
2. The patient was also to follow up with Social Work for
home hospice care if desired.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 21075**]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2164-6-17**] 22:36
T: [**2164-6-17**] 22:51
JOB#: [**Job Number 51753**]
cc:[**Last Name (NamePattern4) 51754**] |
77081,76526,76514,7793,7742,V3001,V290 | 280 | 123,506 | Admission Date: [**2155-12-8**] Transfer Date: [**2155-12-22**]
Date of Birth: [**2155-12-8**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname **] is a 31-1/7 week gestational age
male delivered via cesarean section secondary to maternal
HELLP Syndrome. Mother is a 19-year-old, G2, P1, estimated
date of confinement of [**2155-2-7**] with the following prenatal
labs. Blood type B positive, antibody negative, Hepatitis B
surface antigen negative. RPR nonreactive. Rubella immune.
GBS unknown.
Prior medical history notable for an ovarian cyst. During
this pregnancy it was noted that this infant was growth
restricted. In addition, mother was diagnosed with pregnancy
induced hypertension. Mother's platelets were 96, ALT was
159. Mother received betamethasone times one prior to
delivery. She had rupture of membranes at time of delivery.
Baby cried spontaneously with vigorous respirations, required
blow-by oxygen times several minutes with resolution of
cyanosis. Apgar's 7 and 8 at 1 and 5 minutes. [**Hospital **]
transferred to the MICU for further management.
PHYSICAL EXAMINATION: On presentation birth weight 1108
grams, length 40 cm, head circumference 27.5 cm. Vital signs:
Temperature 98.7, pulse 130 to 160, mean blood pressure is
42, sating 98 percent on room air.
General: Preterm male in radiant warmer. No apparent
distress.
Head, eyes, ears, nose and throat: No dysmorphic features,
AFOF, red reflex present bilaterally. OP clear, palate
intact. Neck supple, no retractions.
Respiratory: Clear to auscultation bilaterally, good air
entry, mild intercostal retractions.
Cardiac: Regular rate and rhythm. S1 and S2 normal, no
murmurs.
Abdomen: Soft, nondistended, hypoactive bowel sounds, no
hepatosplenomegaly.
Extremities: Well perfused, no cyanosis or edema. Femoral
pulses two plus bilaterally. Spine intact, no dimpling, anus
patent. No Ortolani or Barlow sign present.
Neurologic: Spontaneous MAE, Morrow/suck/palmar/plantar
grasp intact.
HOSPITAL COURSE:
1. Respiratory: The patient received blow by oxygen times
several minutes for mild cyanosis at birth with prompt
resolution. The patient remained stable on room air
throughout the remainder of his hospital course. The
patient exhibited signs of apnea of prematurity on day of
life three and was started on caffeine citrate. The
patient remained on caffeine citrate until [**12-17**] when it was
discontinued. Last spell noted on [**12-15**].
2. Cardiovascular: The patient remained cardiovascularly
stable throughout hospital course. No murmurs were heard
on cardiac auscultation.
3. Hematology: The patient had a maximum bilirubin of 6.1 on DOL
#2, which resolved with single phototherapy. Phototherapy was
discontinued on DOL #6 for bili=3.1/0.7 with rebound bili of
2.8 on DOl #8.
4. Infectious disease: The patient was placed on Ampicillin
and Gentamicin to rule out sepsis for 48 hours. Blood
cultures: No growth to date. Antibiotics were
discontinued at 48 hours. Initial CBC was benign with a
white count of 4.6, platelets 144, hematocrit 56, white
count differential: 39 polys, 0 bands, 50 lymphocytes.
5. Neurologic: The patient had a head ultrasound (HUS) on
[**2155-12-15**] which noted right choroid plexus cysts and one left
choroid plexus cyst vs germinal matrix, repeat HUS on [**2155-12-22**]
was read as normal. IN setting of first HUS findings, a urine
CMV was sent and pending at time of this summary.
6. Fluid, Electrolytes and Nutrition: Maternal feeds were
started on day of life two of breast milk/Special Care 20
kilo counts per ounce and have been gradually increased to
full feed volume of 150 cc's per kilo per day at [**2155-11-16**].
The patient has shown no signs of feed intolerance. Currently,
the patient is on SC 30 with Promod with total fluids of
150cc/kg/d. birth weight of 1180g and current weight is
1225g. Infant is currently on Vitamin E and iron.
CARE RECOMMENDATIONS AT TIME OF SUMMARY:
MEDICATIONS: Vitamin E and iron
OTHER: Car seat testing has not been performed.
No immunizations have been administered.
State newborn screen sent repeat on [**2155-12-19**]
OF NOTE, family is interested in circumcision prior to d/c
home.
urine CMV pending
PEDI: Dr. [**Last Name (STitle) 14936**] in [**Location (un) 1475**]
DISCHARGE DIAGNOSIS:
1. Prematurity at 31-1/7 weeks gestational age.
2. Hyperbilirubinemia, resolved.
3. Apnea of prematurity, resolving
4. Immature feeding.
5. s/p r/o sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern4) 57175**]
MEDQUIST36
D: [**2155-12-17**] 10:40:07
T: [**2155-12-17**] 11:52:50
Job#: [**Job Number 59542**]
|
51881,1628,1970,1977,515,4254,4280,5849,7140,4019,2356,4439,485 | 281 | 111,199 | Admission Date: [**2101-10-18**] Discharge Date: [**2101-10-25**]
Date of Birth: [**2041-10-12**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo F with RA (only on plaquenil), HTN, pulm fibrosis, PVD,
OA, tobacco use presents to ED with 2-3 wk h/o malaise, dry
cough, and progressive SOB. Denies any F/C/NS. Nearly
intubated in the ED for hypoxic respiratory failure (O2 sats
80s, RR 40s), with significant wheeze. However, with IV
steroids and continuous albuterol nebs, improved and
stablilized, though still tachypnic with wheeze. CTA
demonstrated no PE, though large mass (taking up much of RUL,
some of RML that compresses the RUL and RML bronchi, with
?extension into the pretrachial/subcarinial space vs associated
lymphadenopathy, innumerable bilateral nodules and thick
interstitial markings. In addition, hypodensities were
visualized in the liver. Started on empiric levo/azithro in the
ED.
ED course also notable for MAT as high as 170 bpm, in part
exacerbated by albuterol, with rate-related lateral ischemic
changes (st dep V3-V6, lateral TWI). ruling out for MI with
serial neg cardiac enzymes.
Past Medical History:
RA
pulmonary fibrosis
PVD
tobacco use (>20 years)
OA
HTN
prior Cardiomyopathy, with EF now 55% (was 30-40% [**2095**], etiology
unknown)
Recent p-mibi, with no perfusion defects, no [**Last Name (LF) **], [**First Name3 (LF) **] 58%
s/p appy
s/p cervical fusion [**2095**]
s/p lumbar fusion
OA
Social History:
Very relgious, former heavy smoker.
Family History:
N.C.
Physical Exam:
T 97.9 HR 127 BP 138/63 RR 25 98% NRB
Gen: Female, sitting up, tachypnic, w/ acc muscle use
HEENT/Neck: +JVD, +cervical LAD, EOMI, MM dry,
CV: irregular, tachy, no m/r/g
Pul: diffuse wheezes, poor a/m b/l
abd: soft, nt, nd.
Ext: no edema, from
Pertinent Results:
[**2101-10-18**] 02:22PM TYPE-ART TEMP-37.0 RATES-/30 O2-60 PO2-118*
PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA
[**2101-10-25**] 03:02AM BLOOD WBC-17.2* RBC-3.61* Hgb-9.9* Hct-31.9*
MCV-88 MCH-27.5 MCHC-31.1 RDW-15.0 Plt Ct-95*
[**2101-10-25**] 03:02AM BLOOD Glucose-150* UreaN-56* Creat-1.2* Na-145
K-4.5 Cl-111* HCO3-25 AnGap-14
[**2101-10-25**] 09:40AM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-70*
pCO2-51* pH-7.26* calHCO3-24 Base XS--4 Intubat-NOT INTUBA
Brief Hospital Course:
Pt was admitted to the [**Hospital Unit Name 153**] in respiratory distress.
CT/angiogram results showed a large right lung mass, likely to
be lung cancer, with metastasis to the left lung and liver. The
prognosis of this cancer was discussed with the patient and her
sister, [**Name (NI) **], her healthcare proxy. [**Name (NI) **] the patient's
respiratory distress seemed to improve, her blood gases
demonstrated that she was tiring out. On [**10-24**] and [**10-25**] family
meetings were held to discuss the patient's progress and dismal
prognosis. At this time the patient was made DNR/DNI but
treatment was continued. Later on in the night, the patient
became hypotensive and increasingly short of breath. After
speaking with [**Doctor Last Name **], her healthcare proxy, comfort measures
were started with morphine. Shortly thereafter, she became more
hypoxic and bradycardic. The patient had no corneal reflexes,
and had no heart sounds or breath sounds for one minute. Time
of death was 7:10pm. The family was present. Autopsy consent
was granted.
Medications on Admission:
lopressor
oxycontin
vioxx
plaquenil
fosamax
mvi
Discharge Medications:
expired
Discharge Disposition:
Home
Facility:
expired
Discharge Diagnosis:
pneumonia
metastatic lung cancer
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
|
99644,78039,5859,5990,E8859,4019,73300,2449,3004,4389,V4364,V4365 | 282 | 119,013 | Admission Date: [**2175-2-1**] Discharge Date: [**2175-2-8**]
Date of Birth: [**2101-4-6**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Bilateral femoral periprosthetic shaft fractures
Major Surgical or Invasive Procedure:
1. Open reduction, internal fixation with percutaneous
plating and reduction of right periprosthetic fracture.
2. Open reduction, internal fixation with percutaneous
plating technique, minimally invasive technique of left
femoral periprosthetic fracture.
History of Present Illness:
Ms. [**Known lastname 70391**] is a 73-year-old female patient who fell from
standing resulting in bilateral femur fractures which were
periprosthetic. On the left side, she has a hip hemiarthroplasty
and total knee, and on the right side she has a hip
hemiarthroplasty. The presence of implants precludes the
performance of intramedullary nailing. The procedure of choice
at this point is plating which we will perform through a
percutaneous technique in order to minimize the morbidity to
this elderly and very frail patient.
Past Medical History:
CVA 2.5yrs ago
Seizure disorder
h/o Urosepsis/UTI
Hypertension
Osteoporosis
Pancreatic insufficiency
h/o Depression/anxiety
h/o alcoholic liver disease
Hypothyroidism
Chronic renal insufficiency - baseline CRE 1.4-1.8
h/o Hyperkalemia
h/o Amenia
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
On discharge:
Afebrile, All vital signs stable
Gen: Alert and oriented, No acute distress
Lungs: Clear to auscultation bilaterally
Cardiac: regular rate and rhythm
Abd: +bowel sounds, benign
Extremities: bilateral lower
Weight bearing: non weight bearing x8wks
Incision: no swelling/erythema/drainage
Dressing: clean/dry/intact
+[**Last Name (un) 938**]/FHL/AT
+SILT
2+ pulse, wiggles toes
Capillary refill brisk
Brief Hospital Course:
Ms. [**Known lastname 70391**] presented to the Emergency Department from [**Hospital3 **]
Hospital with bilateral leg pain. She was evaluated by the
Orthopaedics department and found to have bilateral
periprostetic femur fractures. She is s/p Bilateral total hip
replacements. Reduction was attempted, but unsucessful. She was
placed in bilateral leg braces for stabilization. She was
admitted to the medicine service and cleared for surgery. On
[**2175-2-2**], she was prepped and brought down to the operating room
for surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication. Post-operatively,
she was extubated and transferred to the PACU for further
stabilization and monitoring. She was then transferred to the
floor for further recovery. On POD #1, she was transfused 2
units of PRBC for postoperative anemia. She then remained
hemodynamically stable and her pain was controlled. She
progressed with physical therapy to improve her strength and
mobility. She continues to make steady progress without any
incidents. She was discharged to a rehabilitation facility in
stable condition. She was instructed to call Dr.[**Name (NI) 4016**]
office at [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks
after hospital discharge.
Medications on Admission:
Buspirone
Aspirin
Fosamax
Synthroid
Darvocet
Keppra
MVI
Effexor XR
Prevacid
Norvasc
Pancrease
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 4 weeks.
13. Insulin Regular Human 100 unit/mL Solution Sig: SSIR
Injection ASDIR (AS DIRECTED).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
15. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for Anxiety.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
Bilateral periprosthetic femur shaft fractures
Discharge Condition:
Stable
Discharge Instructions:
Keep the incision clean and dry. You may apply a dry sterile
dressing as needed for drainage or comfort.
If you are experiencing any increased redness, swelling, pain,
or have a temperature >101.5, please call your doctor or go to
the emergency room for evaluation.
You may not bear weight on either leg.
Your skin staples/sutures may be removed 2 weeks after surgery.
Resume all of your home medication and take all medication as
prescribed by your doctor.
Continue your Lovenox injections as prescribed for preventing
blood clots.
Please call Dr.[**Name (NI) 4016**] office @ [**Telephone/Fax (1) 1228**] for a follow
up appointment in 2 weeks after hospital discharge.
Feel free to call our office with any questions or concerns.
Physical Therapy:
Activity: Out of bed w/ assist
Right lower extremity: Non weight bearing x8wks
Left lower extremity: Non weight bearing x8wks
Treatments Frequency:
As stated above
Followup Instructions:
Please call Dr.[**Name (NI) 4016**] office for a follow-up appointment 2
week after hospital discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2175-2-8**] |
5569,37272,00845,2875,2765,4280,5780,5070 | 283 | 109,185 | Admission Date: [**2166-8-12**] Discharge Date: [**2166-9-12**]
Date of Birth: [**2090-9-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
gentleman presenting to [**Hospital1 69**]
emergency department on [**2166-8-12**] complaining of 24 hours of
dizziness, shortness of breath, cough, fever and respiratory
distress. Patient was noted to have a significant past
medical history of upper GI bleed and was status post one
episode of coffee ground emesis the night prior to admission.
Patient was found to be in mild respiratory distress with
bilateral rhonchi, hypoxia and hypercapnia. Patient became
significantly more hypoxic and hypercapnic and anesthesia was
called for potential difficult airway and patient was
successfully intubated. Patient remained hemodynamically
stable. In the emergency department patient was noted to
have a temperature of 101.9, blood pressure 118/50, heart
rate 119, O2 sat 77%, respiratory rate between 30 and 35.
Patient received sublingual nitroglycerin times one, noted
drop in blood pressure to systolic of 77 over diastolic of
54. Given 5 liters IV fluids. Subsequent ABG of 7.48, 38,
39 in room air. Given 100% nonrebreather and increased O2
sat to 85%. Patient was then electively intubated. Chest
x-ray showed predominantly CHF with bilateral pneumonia
consistent with aspiration pneumonia. Subsequent ABG was
7.36, 45, 96. Patient was put on assist control 14/400, PEEP
12, 100%. Patient was noted to have bloody sputum with
suctioning. No acute GI bleed. Patient received CAT scan of
head which showed no bleed. Patient was subsequently
admitted to the medical ICU. Patient subsequently received
FFP times two units and one bag of platelets.
PAST MEDICAL HISTORY: Head and neck squamous cell cancer in
[**2158**] status post XRT and radical neck dissection. CVA in
[**10-10**]. Recent admission for GI bleed and hemoptysis.
Thrombocytopenia. Ulcerative colitis. Basal cell cancer of
the scalp. Status post head injury in the [**2103**] status post
metal plate insertion.
ALLERGIES: No known drug allergies.
MEDICATIONS: Prednisone taper which ended [**2166-8-3**], Protonix
40 q.day, Fioricet p.r.n., hydrocortisone enema 100 q.h.s.
p.r.n., Colace 100 b.i.d., sulfasalazine 1000 mg t.i.d.
SOCIAL HISTORY: Distant tobacco history. Patient currently
nonsmoker. Nondrinker. Past history of ETOH abuse. No
illicit drugs. Patient recently widowed.
FAMILY HISTORY: Significant for prostate cancer in father
and uterine cancer in sister.
PHYSICAL EXAMINATION: On presentation to medical ICU
temperature was 101.9, pulse 101, blood pressure 116/69,
respiratory rate 12, 96%. Patient was intubated, sedated and
unresponsive. Pupils equal, round, and reactive to light.
Mucous membranes moist. Right IJ placed in E.D. in place.
Regular rate S1, S2, 2/6 systolic ejection murmur. Lungs
showed diffuse crackles with occasional rhonchi. ET tube in
place with some diffuse bloody secretions. Abdomen distended
with decreased bowel sounds. Extremities were warm, 1+
distal pulses, 1+ pitting edema [**1-12**] way up patient's calves.
LABORATORY DATA: Subsequent EKG showed sinus tach at 110, 0
axis, right bundle branch block, slight [**Street Address(2) 4793**] depression in
4 and 5.
HOSPITAL COURSE: The patient was admitted to MICU with the
diagnoses of severe hypoxia, bilateral pneumonia, CHF versus
aspiration pneumonia, resolving hemoptysis, fever and
elevated white count at 21.0. Patient was started on
levofloxacin and Flagyl, pan cultured. Was given propofol
for sedation. Patient's chest x-ray day subsequent to
admission was consistent with aspiration pneumonia. Gram
positive cocci. Was continued on Levaquin and Flagyl.
Vancomycin was added for coverage.
Pulmonary. Bilateral pneumonia persisted right worse than
left. He was continued on Levaquin, Flagyl and vancomycin.
Medical ICU team had difficulty oxygenating patient further
contributing to patient's respiratory failure from aggressive
volume depletion in the emergency department and early ICU
course. Patient was in excess of 18 liters positive.
Patient was placed on assist control, tidal volume 500, PEEP
16, pressure support 25, FIO2 50%. Patient slowly making
gradual decrease in FIO2 to 40%. Patient had decrease in
PEEP to 14. Patient continued on course of antibiotics for
aspiration pneumonia. Patient was noting to continually
desat with decrease in PEEP requiring increase in ventilatory
support. Patient received moderate benefit from aggressive
chest P.T. and recruitment maneuvers. At or around hospital
day 16 patient was switched from assist control to pressure
support of 10, PEEP 16, FIO2 40%. Patient continued to have
thick yellow secretions, coarse breath sounds bilaterally.
Chest x-ray slowly improving. Right interstitial
consolidations. Patient eventually tolerated decrease of
pressure support to 12, PEEP 12, continuing to wean. Patient
was deemed slow to wean from vent settings and ENT was
consulted to do an O.R. trach for patient secondary to
patient's neck dissection and XRT for skin cancer. On or
around [**9-4**] patient was at pressure support of 12,
PEEP 7 [**12-11**], FIO2 40%, remaining extremely sensitive to
changes in pressure support. Drops from pressure support of
14 to 13 would make patient tachypneic pulling low tidal
volumes. Patient remained slow to wean. Patient was
decreased on his sedation of Ativan and fentanyl drips and
slowly began to wean from pressure support of 12 to eventual
goal of pressure support of 8 over a period of 12 days. On
[**2166-9-10**] patient was decreased to pressure support of 8.5 and
40% and was started on trach collar trial for one hour.
Patient continued at pressure support of 8.5 and 40% for
multiple hours without previous tachypnea episodes. Patient
was gotten out of bed to chair and had multiple successful
trach collar trials ranging from 15 minutes to 1 1/2 hours.
Patient was aggressively diuresed with Lasix with a goal of
0.5 to 1 liter net negative on fluid balance per day.
Diuresis was somewhat limited secondary to recurrent bouts of
hypotension with systolic in the 90s, thus delaying diuresis.
Over the course of the hospital stay from [**8-12**] to
today, [**9-12**], patient is now net only 1.5 liters positive
in fluids and responding to Lasix.
Infectious disease. Throughout his hospital course patient
continued to have low grade fevers in the range from 100 to
101.0. Patient occasionally spiked fevers as high as 102.8.
Patient was put on ceftriaxone and vancomycin. Patient's
white counts were in the high teens and subsequently
decreased. All cultures, blood and urine, were negative.
Further all cath tips sent for culture were negative.
Patient was given abdominal CT and sinus CT to look for
source. Sinus CT was positive for right maxillary sinusitis.
Abdominal CT was negative for infectious source. Patient was
continued on antibiotics. ENT was consulted for sinusitis
and suggested increase head of bed, intranasal spray, no
acute management necessary at this time. On or around
[**9-2**] patient was found to be C.diff positive in the
stool. Patient was started on Flagyl. All blood cultures,
wound cultures and sputum cultures remained negative.
Patient without any new elevations in white count or
temperature spikes for the 10 days prior to discharge.
Patient's hematocrit ranged from the high 20s in the
beginning of his hospital stay and began to very slowly drift
down throughout the hospital course. Patient had no source
of obvious bleeding, although he was noted to have OB
positive stool. Patient was transfused two units of blood
with an inappropriate bump in patient's hematocrit.
Patient's hematocrit only increased from 23 to 25 status post
two units. Patient's hematocrit tended to be stable with
slight decrease. Patient eventually trended down from
hematocrit of 26 to a slow decrease over subsequent days to
hematocrit of 23. Patient was transfused two additional
units of blood, bringing patient's hematocrit to an
appropriate bump. Patient's hematocrit was noted to be 31.
From [**2166-9-3**] patient's hematocrit has remained around 31 and
remained stable. No active bleeding prior or since noted.
Neurologically despite negative head CT in the emergency
department, throughout patient's course with decreasing
sedation, patient continued to not move any extremities. Did
appear to track and somewhat understand responses, although
he was nonvocal in response. ICU staff remained concerned
while sedation was completely turned off for a period of four
days on or about [**9-1**]. Patient was given repeat head CT
which was negative for bleed. Approximately four days after
shutting off sedation patient was noted to move all
extremities, although was noted to be weak. Subsequent day
patient was found to be able to follow simple commands,
squeezing hands, blinking eyes, etc.
Trach done in O.R. was done on [**9-1**]. Patient was
also sent to interventional radiology on [**9-5**] to receive a
PEJ, percutaneous jejunal tube, for nutritional support.
Prior patient had been on a combination of TPN and tube
feeds. At time of discharge on [**2166-9-12**] patient currently has
a left subclavian day seven and previously described PEJ tube
also day seven. Both insertion sites are clean, dry and
intact and devoid of any signs of infection. Throughout
patient's course he was kept on prophylaxis including
pneumoboots, subcu heparin and Prevacid. Patient currently
taking Colace, erythromycin eyedrops, Reglan, Gas-X, Flagyl
day seven, lactulose, miconazole cream, Ativan, fentanyl
patch and Ambien.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 39096**]
Dictated By:[**Last Name (NamePattern1) 43678**]
MEDQUIST36
D: [**2166-9-12**] 11:43
T: [**2166-9-12**] 12:24
JOB#: [**Job Number **]
|
78039,2875,51881,2859,V440 | 283 | 144,156 | Admission Date: [**2166-10-2**] Discharge Date: [**2166-10-7**]
Date of Birth: [**2090-9-5**] Sex: M
Service: NEURO/ICU
HISTORY OF PRESENT ILLNESS: This is a 76 year-old man with a
history of prior strokes, anxiety disorder, cranial plate
after trauma in World War II, head and neck cancer and recent
respiratory failure secondary to aspiration pneumonia with
difficulty being weaned from the ventilator. He presents
from [**Hospital **] rehab as he is in pulmonary rehab at this time.
While he was in a rehab facility he was noted by an employee
to have an episode of unresponsiveness unclear how long. His
eyes "back as well." At 7:30 a.m. his eyes rolled back again
and he was brought to [**Hospital1 69**].
On arrival he had a thirty second generalized tonic clonic
seizure observed with post ictal confusion. He received
Dilantin one gram and prepped for an LP and then LP was
tried, however, unobtainable. He was then noted to be waking
up and doing better and with no further seizure activity. We
admitted him to the Intensive Care Unit at that point. After
CT scan showed several attenuations consistent with a stroke
of an undetermined age, but no hemorrhage. On admission we
also performed a CT scan with contrast as the original CT was
without contrast. This CT was negative. We also performed
an electroencephalogram, which showed occasional generalized
single spikes with no focal abnormalities. We continued his
Dilantin at 150 mg intravenous t.i.d. and continued to check
levels. His Dilantin level on discharge was 4.7, however,
this is corrected for his albumin at 11.8. At that point we
decided to increase his Dilantin to 200 mg t.i.d. Throughout
his hospital admission he had no further seizure episodes.
He was noted to have persistent thrombocytopenia and
hematology/oncology was consulted. He was noted to have
numerous episodes of thrombocytopenia in his last three
hospital visits and each time his platelets were increased
over the hospital stay. His differential per
hematology/oncology included drug induced and ITP. ITP was
unlikley given the smear and he had normal fibrinogen, lack
of fever and no change in kidney function. In [**2166-7-10**]
the patient appeared to improve due to discontinuing numerous
medications including Zantac and Clonidine. In [**2166-7-10**] the platelet count was also low, but came out nicely.
Heparin induced thrombocytopenia and ITP were still in the
differential. He was on heparin 5000 units subQ t.i.d. on
admission and we stopped that. His platelets rose to 77 on
discharge and remained stable.
The patient was tapped on Saturday after platelet
transfusion. His LP had an opening pressure of 16, white
cells of 2, reds of 120, 85 glucose and 65 protein, gram
stain was negative. He had no other signs of meningitis on
examination. His pulmonary status remained stable throughout
his admission. At first he was somewhat agitated and he
necessitated low dose Ativan and Propofol overnight for the
first night, however, he did not have any other problems and
was sating well. Arterial blood gas on discharge was pH
7.46, PO2 50, O2 82.
LABORATORIES ON DISCHARGE: White blood cell count 7.6,
hemoglobin 8.9, hematocrit 27.5, platelets 78, sodium 140,
potassium 3.5, chloride 100, CO2 31, BUN 18, creatinine .7,
glucose of 134, calcium was 8.3, phosphorus 3.1, magnesium
was 1.8. Dilantin level was 4.7, but corrected to 8 for his
albumin, which was 2.6.
On discharge his neurological examination he was alert and
answering questions and following commands. Pupils are
equal, round and reactive to light. Extraocular movements
showed slight decrease in abduction left greater then right.
Motor examination he moved all extremities symmetrically,
full strength. No drift. Reflexes were symmetric. Tone was
normal. From a neurological perspective he was seizure free.
We increased his Dilantin and this should be followed in a
few days at rehab. From a gastrointestinal perspective he is
on prophylaxis. When admitted he had hematest positive
stools. Hematocrit on admission was 32 and on discharge was
27.5. As an outpatient he should have further evaluation for
this, but otherwise he is clinically stable. We discussed
this with the SICU team and they felt that outpatient workup
was in order being that he was clinically stable. His renal
function had good output, normal BUN and creatinine. In
regard to his hematology/oncology, he was on heparin and his
platelets have increased.
The patient will be ready for discharge today to [**Hospital **]
Rehab. Prior to discharge we will assure intravenous access
and possible PICC placement.
DISCHARGE MEDICATIONS: Dilantin 200 mg nasogastric t.i.d.,
Metoprolol 25 mg nasogastric b.i.d., Lansoprazole 30 mg
nasogastric q day, sliding scale insulin, Lasix 40 mg q day
nasogastric, MVI one per nasogastric q day, Salsalate 500 mg
nasogastric b.i.d., Colace 100 mg nasogastric q day,
Ipratropium bromide nebulizers q 12 hours, albuterol one
treatment q twelve hours, Senna one tab nasogastric q.h.s.,
Trazodone 50 mg po q.h.s. prn sleep, _______________ .5 mg
intravenous q 4 to 6 hours prn.
His diet is Promote with fiber full strength, 95 milliliters
per hour, check residuals q 4 hours and hold if greater then
100 milliliter residual. His anticipated goals is to wean
off vent.
FINAL DIAGNOSES:
1. Seizure.
2. Respiratory failure.
3. Thrombocytopenia.
4. Anemia.
He is to follow up with his physician at [**Name9 (PRE) **] or Dr.
[**First Name (STitle) **] as well as nurse [**First Name (Titles) 3639**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43679**] I spoke with
on the phone prior to discharge. Further questions regarding
any medical issues should be referred to the CICU team here,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He was also followed by Dr. [**First Name (STitle) 7818**]
hematology/oncology and neurology Dr. [**Last Name (STitle) **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279
Dictated By:[**Last Name (NamePattern1) 30849**]
MEDQUIST36
D: [**2166-10-6**] 13:16
T: [**2166-10-6**] 12:28
JOB#: [**Job Number 43680**]
|
53140,4280,42731,4019,V5861,2851 | 284 | 112,354 | Admission Date: [**2149-11-29**] Discharge Date: [**2149-12-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
black stools and weakness x 7 days.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
87 yo f w/ h/o CHF, htn, afib, and h/o recent fall resulting in
a compression [**Hospital **] transferred from [**Hospital3 **] for c/o black
stools w/ hct 16.3 and INR 32.3 due to no available ICU beds at
[**Hospital1 392**]. Patient was AF, bp 130/44 and hr 87. She received 2 U
PRBC, 40 IV protonix, and 10 mg IV vit K for this. On arrival to
[**Hospital1 18**] ER, hct 25.2 and INR 2.1. BP 150/54 and hr 70. Patient
received additional 5 mg SQ vit K, in addition to 2 U FFP. NG
lavage was done and yielded coffee ground emesis w/ the first
250 cc, followed by a pink-tinged fluid with the second 250 cc.
On hx patient reports no po x 2 weeks due to nausea w/o c/o pain
w/ eating. She has never had black stools in the past. She is on
coumadin and her level was low 3 weeks ago (per her report) and
thus her coumadin was increased. Patient denies any diarrhea w/
the black stool. She is N but no V, and she denies abd pain. No
h/o NSAIDs and no h/o PUD. No BRBPR or hematemesis. She also
denies c/o LH, COP, or SOB. However, she has been completely
exhausted for the past week.
Past Medical History:
## CHF
## HTN
## afib on coumadin
## h/o compression fx due to fall
## s/p recent fall (2 wks ago)
Social History:
+ h/o tob: [**11-20**] pk yr hx, quit 25 yrs ago.
No Etoh x 4 yrs, occasional in the past.
Married and has 1 daughter. Contact for emergencies: [**Name (NI) **] [**Name (NI) **]
(sister).
Family History:
NC
Physical Exam:
T 99.1 hr 71 bp 155/65 rr 18 O2 92% RA (100% on 4L NC)
genrl: in nad, pleasant
heent: perrla (3->2 mm), MMM, OP clear, NGT in place (120 cc
lavage continues to produce coffee grounds)
neck: no JVD
cv: rrr, no m/r/g
pulm: cta bilaterally
abd: nabs, soft, nt/nd, no masses/hsm
rectal: black, guiac positive stool surrounding anus
extr: no [**Location (un) **]
neuro: a, o x 3, strength and soft touch sensation [**6-5**] grossly
in UE/LE
Pertinent Results:
[**2149-11-29**] 02:42PM WBC-16.8* RBC-2.81* HGB-9.0* HCT-25.2* MCV-90
MCH-31.9 MCHC-35.6* RDW-16.0* PLT COUNT-281
[**2149-11-29**] 02:42PM NEUTS-82.8* LYMPHS-13.3* MONOS-3.5 EOS-0.3
BASOS-0.2
[**2149-11-29**] 02:42PM PT-17.5* PTT-26.8 INR(PT)-2.1
[**2149-11-29**] 02:42PM GLUCOSE-115* UREA N-45* CREAT-1.0 SODIUM-141
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
.
[**2149-12-3**] 05:03AM BLOOD WBC-11.7* RBC-3.53* Hgb-11.4* Hct-32.7*
MCV-93 MCH-32.2* MCHC-34.8 RDW-15.5 Plt Ct-325
[**2149-12-3**] 05:03AM BLOOD Plt Ct-325
[**2149-12-3**] 05:03AM BLOOD Glucose-91 UreaN-21* Creat-1.0 Na-139
K-4.2 Cl-99 HCO3-31 AnGap-13
[**2149-12-3**] 05:03AM BLOOD Mg-1.8
.
CXR [**2149-11-29**]:
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with bibasilar crackles w/ h/o chf
REASON FOR THIS EXAMINATION:
r/o CHF
HISTORY: Bibasilar crackles, rule out CHF.
CHEST, SINGLE AP VIEW. No previous chest x-rays on PACS record
for comparison.
The lungs are hyperinflated. There is moderate to moderately
severe cardiomegaly. There is subsegmental atelectasis and/or
scarring at both bases. There is minimal blunting of both
costophrenic angles. There is no CHF or frank consolidation. I
doubt the presence of an infectious infiltrate. There is right
upper hilar peribronchial cuffing. Linear atelectasis or
scarring noted in the right mid zone. An NG tube is present, tip
over proximal stomach. There is osteopenia and an old ununited
left clavicle fracture.
IMPRESSION: Hyperinflation and cardiomegaly. Right upper hilar
peribronchial cuffing. No CHF. Doubt acute infectious
infiltrate.
.
CT HEAD W/O CONTRAST [**2149-11-29**] 4:59 PM
CT HEAD W/O CONTRAST
Reason: r/o ich
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with recent head trauma, INR 35
REASON FOR THIS EXAMINATION:
r/o ich
CONTRAINDICATIONS for IV CONTRAST: None.
CT HEAD
INDICATION: Recent head trauma, INR 35.
No prior studies are available for comparison.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intraparenchymal or extra-axial
hemorrhage. There is no shift of normally midline structures,
mass effect or hydrocephalus. There is mild prominence of the
ventricles and sulci consistent with age-related involutional
change. Encephalomalacic changes are demonstrated in the
anterior and medial portions of the frontal lobes bilaterally.
There is also encephalomalacic change demonstrated in the left
occipital lobe. Periventricular white matter hypodensities are
also noted consistent with chronic small vessel ischemic change.
The visualized paranasal sinuses and osseous structures are
within normal limits.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Encephalomalacic changes in the bifrontal lobes and left
occipital lobe.
.
CXR [**2149-11-29**]:
Atrial fibrillation
Modest nonspecific intraventricular conduction delay
Modest ST-T wave changes with probable QT interval prolonged
although is
difficult to measure - are nonspecific but clinical correlation
is suggested for possible in part metabolc/drug effect.
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 0 118 446/479 0 -21 107
.
Patient: [**Known firstname 2127**] [**Known lastname 780**]
Ref.Phys.:
Birth Date: [**2062-8-14**] (87 years) Instrument: GIF XQ140
gastroscope
ID#: [**Numeric Identifier 62551**] ASA Class: P2
Medications: Cetacaine topical spray
Meperidine 25mg
Midazolam 1mg
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings: Esophagus:
Lumen: A small size hiatal hernia was seen.
Excavated Lesions A single non-bleeding 6mm ulcer was found in
the gastroesophageal junction.
Stomach:
Contents: Old blood was seen in the stomach. No sites of active
bleeding were identified.
Duodenum: Normal duodenum.
Impression: Blood in the stomach
Ulcer in the gastroesophageal junction
Small hiatal hernia
Brief Hospital Course:
87 yo f w/ h/o CHF, HTN, fib, and h/o recent fall transferred
from OSH w/ likely UGI in setting of elevated INRX (on
Coumadin).
.
## UGI: The patient's HCT was 16.3 with INR 32.3 at OSH. The
patient received 2 units of PR BC, Protonix 40 mg iv, and 10 mg
IV Vit K at the OSH. Due to no ICU availability, the patient
was transferred to [**Hospital1 18**]. On arrival to [**Hospital1 18**], her HCT was 25.2
with INR 2.1. She received additional mg sc Vit K and 2 u FFP.
NG lavage showed coffee ground emesis followed by a pink-tinged
fluid. CT of head was neg for bleeds. The patient was started
on Protonix 40 mg iv bid and observed overnight in the MICU, and
GI did not feel that urgent EGD was necessary as the patient was
hemodynamically stable with stable HCT after blood transfusion.
The patient was transferred to the floor in a hemodynamically
stable and hct was stable at 33.2. EGD was performed on [**12-1**]
which showed an ulcer at GE junction and old blood in the
stomach without signs of active bleeding. The patient was
switched to po Protonix [**Hospital1 **] after the procedure and hct
continued to remain stable at the time of discharge. The
patient is to follow up with Dr. [**First Name (STitle) 1356**], her PCP, [**Name10 (NameIs) **] decide on
when to restart coumadin and close monitor of INR when she gets
placed on coumadin again.
.
## CHF: After a total of 4 units of PRBC transfusion, the
patient became hypoxemic and required supplemental O2 to keep O2
sat above 92. Her lung exam was consistent with pulmonary
edema. She was given IV lasix and her hypoxemia resolved. Once
satting 95-97% on RA, she was restarted on her outpatient po
lasix regimen.
.
## Afib: Held beta blocker initially given UGIB. Once stable
hemodynamically, outpatient atenolol 100mg qday and amlodipine
5mg qday were restarted for rate control. No coumadin was given
during this hospitalization. GI felt that she can be restarted
on coumadin but with close monitor of INR with goal of [**3-6**].
.
## HTN: No antihypertensives given while in the MICU. Received
lasix iv for pulmonary edema and gradually added her outpatient
antihypertensives, atenolol, amlodipine, and lasix.
.
## S/p recent fall: Head CT w/o bleed or shift. The patient did
not have other musculoskeletal pain anywhere.
.
## Leukocytosis: No clear sources and the patient remained
afebrile. WBC continued to trend down and at the time of
discharge, wbc was 11.7. Ua/ucx and bcx and CXR were negative
for infection.
.
## PPX: pneumoboots, ppi
- PT recommended outpatient PT as the patient became
deconditioned during this hospitalization. The patient was
discharged home with PT services.
.
## FEN: Cardiac diet. Repleted 'lytes/prn.
.
## Full code (confirmed w/ patient)
Medications on Admission:
coumadin 1 mg po qd
lasix 40 mg po qam, 20 mg po qpm
atenolol 100 mg po qd
amlodipine 5 mg po qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Ativan 0.5 mg Tablet Sig: [**2-2**] Tablet PO once a day as needed
for anxiety for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Principal:
1. Upper GI bleed.
2. Gastric Ulcer.
3. Blood Loss Anemia.
Secondary:
1. Atrial Fibrillation.
2. Heart Failure (EF unknown)
3. Hypertension.
4. Vertebral Compression Fracture.
Discharge Condition:
Stable. Hematocrit stable at 32.7.
Discharge Instructions:
Return to the emergency department or call your primary care
physician if you develop chest pain, shortness of breath, blood
in your stools, abdominal pain, nausea, vomiting, bloody sputum,
or any other worrisome symptoms.
Do not take coumadin until you see you primary care physician
tells you so. You may resume all your blood pressure
medications as previously prescribed. We've added Protonix 40mg
twice a day for your stomach ulcer. You have a follow-up
appointment with Dr. [**First Name (STitle) 1356**] on [**2149-12-4**], Thursday at 10:50 am.
Discuss with your primary care physician about starting calcium,
vitamin D, and possibly bisphophonates for osteoporosis.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1356**], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone number: [**Telephone/Fax (1) 17465**].
Date/Time: [**2149-12-4**] at 10:50am.
2. Outpatient H. Pylori antibody assay - to be performed by Dr.
[**First Name (STitle) 1356**].
3. Please ask Dr. [**First Name (STitle) 1356**] to start you on calcium and vitamin D
supplementation for osteoporosis. She may also add another
medication callled a Bisphosphonate for this as well.
|
30390,7907,99662,E882,99813,48283,9584,5185,80605,80621,81341,80625,8730,1270,83961,36840,71941,5711 | 285 | 165,312 | Admission Date: [**2152-9-21**] Discharge Date: [**2152-10-20**]
Date of Birth: [**2107-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
1. status post fall from roof at work.
2. T3 burst fracture with evidence of complete spinal cord
injury and spinal instability.
3. C6, C7 spinous process fracture, T1 spinous process
fracture,
T2 spinous process fracture and T4 spinous process
fracture.
4. Left displaced distal radius fracture.
5. sternal manubrial fx. dissociation
Major Surgical or Invasive Procedure:
1. Anterior fusion T2 to T4 with application of interbody
cage and morselized autograft [**9-22**].
2. Posterior C5 to T9 arthrodesis [**9-22**].
3. Posterior C5 to T9 nonsegmental instrumentation [**9-22**] .
4. Corpectomy of T3 with from the posterior approach
decompression from T2-3 to T3-T4 [**9-22**].
5. Posterior decompression laminectomy, medial facetectomy
T1-2 to T3-4 [**9-22**].
6. Right posterior iliac crest bone graft with application
of morselized autograft [**9-22**].
7. Application of morselized allograft [**9-22**].
8. Closed reduction of left distal radius fracture [**2152-9-21**].
9. Tracheostomy [**10-3**].
10. Percutaneous endoscopic gastrostomy [**10-3**]
11. [**Location (un) 260**] inferior vena caval filter [**10-3**]
12. Transesophageal echocardiogram
13. Percutaneous drainage of fluid collection by Interventional
Radiology [**10-17**].
History of Present Illness:
45year old, Spanish speaking male s/p fall from roof while
working. Fell 15-20 feet. Landed on head. No LOC. Unable to feel
or move LE, [**Month (only) **] sensation below nipples on arrival. Given 2.5g
salumedrol in field by EMS.
Past Medical History:
none
Social History:
From [**Country 149**]. In United States for work. Living with cousin and
her husband. Wife and children live in [**Country 149**].
Family History:
noncontributory
Pertinent Results:
[**2152-9-21**] 05:25PM GLUCOSE-114* LACTATE-1.5 NA+-143 K+-3.9
CL--107 TCO2-24
[**2152-9-21**] 05:22PM WBC-11.3* RBC-4.47* HGB-14.0 HCT-38.0* MCV-85
MCH-31.3 MCHC-36.8* RDW-13.1
[**2152-9-21**] 05:22PM FIBRINOGE-226
[**2152-9-21**] 05:22PM FIBRINOGE-226
[**2152-9-23**] 01:04AM BLOOD WBC-25.2* RBC-3.71* Hgb-11.3* Hct-31.8*
MCV-86 MCH-30.6 MCHC-35.6* RDW-14.8 Plt Ct-143*
[**2152-10-4**] 02:01AM BLOOD WBC-26.5*# RBC-3.02* Hgb-9.0* Hct-25.9*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.0 Plt Ct-637*
[**2152-10-5**] 02:20AM BLOOD WBC-10.8# RBC-2.84* Hgb-8.2* Hct-25.0*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.0 Plt Ct-686*
[**2152-10-17**] 03:32AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.6* Hct-26.9*
MCV-87 MCH-30.9 MCHC-35.7* RDW-15.3 Plt Ct-341
[**2152-10-17**] 03:32AM BLOOD Plt Ct-341
[**2152-10-17**] 03:32AM BLOOD Glucose-101 UreaN-21* Creat-0.6 Na-136
K-3.7 Cl-105 HCO3-23 AnGap-12
[**2152-10-11**] 03:30AM BLOOD ALT-126* AST-54* CK(CPK)-304*
AlkPhos-187* TotBili-0.6
[**2152-10-8**] 04:32AM BLOOD Lipase-60
[**2152-9-21**] 05:22PM BLOOD CK-MB-15* MB Indx-2.1
[**2152-9-21**] 05:22PM BLOOD cTropnT-<0.01
[**2152-9-22**] 01:11AM BLOOD CK-MB-31* MB Indx-1.7 cTropnT-<0.01
[**2152-10-17**] 03:32AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0
[**2152-10-8**] 10:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2152-10-10**] 09:17PM BLOOD HIV Ab-NEGATIVE
[**2152-9-21**] 05:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-10-8**] 10:10AM BLOOD HCV Ab-NEGATIVE
[**9-22**]: MRSA screen
[**9-24**]: Bl Cx -> MR S. Aureus Coag Neg
[**9-26**]: Sputum: P. AERUGINOSA, K. PNEUMONIAE, M. CATARRHALIS
[**9-30**]: Acinetobacter pansens.
[**10-1**]: C. diff neg, BL/[**Last Name (un) **]/Sputum neg, VANCO trough 5.8
[**10-3**]: LFTs elevated, WBC 14.6, Hct 28, VANCO trough 6.9
[**10-4**]: WBC 26.5, NA 132, BAL GS -/cx P
[**10-5**]: CL tip cx P., Vanco trough 15.4
[**10-7**]: vanco 9.9
[**10-8**] BAL: g+ cocci pairs/clusters, g- rods. ID P
[**2071-10-10**]: acinetobacter in sputum
[**2074-10-11**]: AFB neg x 3
[**10-12**]: Leg. Urine neg
[**10-13**]: O&P: neg
[**10-16**]: MRSA neg (nasal)
[**10-17**] Back cx: GS - , Cx-
Radiology:
[**9-21**] CT Head: No evidence of intracranial hemorrhage or mass
effect.
[**9-21**] CT C-Spine: Burst fracture of the T3 vertebral body.
Multiple fractures of the posterior elements of C6, C7, T1, and
T2. No impingement on the bony cervical spinal canal.
[**9-21**] CT Thorax: burst fracture of T3, retropulsion of fragments
into canal. multiple fractures of the distal cervical and upper
thoracic posterior elements. no aortic injury seen, sternal
dislocation.
no abd/pel injury. old fx in the inferior ribs bilaterlly.
[**9-21**] CT Pelvis: No fractures of the lumbar spine, sacrum, or
pelvis are identified.
[**9-21**] MRI C/T Spine: T2-T3 Fx-Disloc c intraspin/PLL disrupt. c
txn of cord. Intraspinal hematoma.
[**9-21**] R Wrist/Elbow/Shoulder: 1. R Colles Fx. 2. R ulnar styloid
pr.
[**9-28**]: CT thorax: Bilat Pl. Eff., pneumonia
[**10-4**]: L lung atelectasis improved; new opacification R lung ?
lg aspiration; incr small R pleural effusion
[**10-4**] R wrist post-cast
[**10-6**] port CXR: Worsening Llung air space opacity, ?asp PNA
[**10-7**]: RUQ US neg
[**10-9**] CT torso: Diffuse ground glass opacities, ? PNA, wedge
shaped kidney infarcts
[**10-11**]: TEE >55%, nl.
[**10-16**] MRI: demonstrating no definite discitis/osteomyelitis.
Small irregularly enhancing region in what appears to be right
sided
epidural space at T2/T3 level, as described above, which could
be
postoperative scar or a phelgmon.
Two additional peripherally enhancing fluid collections, one in
the
posterior epidural space at T2 level; the larger one in the
posterior
paraspinal soft tissues at approximately the same level, as
described above, which may represent postoperative seromas
versus abscess.
[**10-17**]: IR percutaneous drainage of subcutaneousx tissue
Brief Hospital Course:
45 year old Spanish speaking male admitted to T/SICU status post
fall from 15-20 feet at work. Landed on head with resultant
injuries including, traumatic burst fracture of the T3 vertebral
body with retropulsion of multiple fragments posteriorly as well
as angulation of the spinal canal at this level, fracture of the
posterior elements of T1 and T2 -> s/p Fusion, Right transverse
distal radial fracture, sternal manubrial fracture dissociation,
and a head laceration. Patient underwent C5-T10 posterior spinal
fusion with L1-L4 posterior decompression as well as open
reduction and internal fixation of his right wrist fracture
[**2152-9-22**]. He was given 7 liters of crystalloid and 1200 cc of
red blood cells in the operating room during the spinal fusion.
See operative reports for procedure details. Patient tolerated
both procedures reasonably well but was found to be hypotensive
after spinal fusion and was transfused 2 additional units of
packed red blood cells when transported back to the Trauma/SICU
after surgery. He was placed on spinal precautions and given a
[**Location (un) 36323**] brace to wear after extubation. The patient's
respiratory status was managed on a ventilator.
On [**9-24**], patient was transfrused 2 units of packed red blood
cells and was febrile to 104 with a whit blood cell count to
16.4 He was started on Vancomycin and ZIsyn for broad spectrum
coverage. Physical and Occupational therapy were consulted on
[**9-25**] and followed patient throughout hospital course with
satisfactory results.
On [**9-26**], patient was taken to operating room for ORIF of right
distal radius fracture without event. See operative reports for
procedure details. Infectious Disease was consulted for
continued fevers and recommended standard fever workup including
pan culture, d/c lines fpr 2 days with central line exchange,
stool studies, sputum cultures (patient underwent multiple
bronchial alveolar lavages for sputum collection), and
strongyloides. Please see microbiology results above for
details. An ascaris worm was removed from patient's nostril in
entirety and sent to pathology for identification. ID followed
patient throughout hospital stay and recommendations were
followed. Levoquin was added to antibiotic regimen on [**10-2**].
Vanco/Zosyn discontinued on [**10-14**]. Patient is to continue
Levaquin until [**10-23**] for sputum culture positive for Acintobacter
10/24 per ID recommendations.
On [**9-28**], arterial line was reinserted and received 2 untis PRBC
for hematocrit of 23 and CT of spine was performed to eval for
abscesses. Please see results section for details. Nutrition
followed patient throughout course and recommendations followed
regarding tube feeds/TPN. On [**9-29**] social work wrote letter to
Mexican Vice Consul in [**Location (un) 86**] regarding patient's status and was
instrumental in obtaining family contact and visas. Social work
was actively involved in patient's care throughout stay. On
[**9-29**] had spontaneous breathing trail but tired after 4 hours
and was placed back on mechanical ventilation.
Please note patient had multiple fever spikes throughout course,
was pan cultured with each spike > 102. Please see above culture
data for details. On the final spike before discharge, he
underwent an interventional radiology drainage of a superficial
fluid collection over T2 and T3. Fluid was cultured and found to
be without infection. He was also tested for tuberculosis,
Hepatitis A/B/C, CMV, HIV, Legionella, which were all negative.
AFB was negative x 3.
On [**10-3**] he underwent tracheostomy, PEG, and IVC filter
placement for spinal cord injury with prolonged respiratory
dependency, malnutrition and right risk for venous embolic
disease. See operative reports for details. He tolerated that
procedure without complication. Initially after tracheostomy,
the patient's respiratory status was managed with assist control
ventilation. However, as he recovered and gained muscle
strength, he was weaned over to CPAP with pressure support and
remained stable throughout the rest of his hospital stay. His
pressure support was slowly weaned to 5.
Forehead staples removed on [**10-5**] and arterial line was removed.
On [**12-10**], a fiberoptic endoscopic evaluation of swallowing was
performed which showed mild oral pharyngeal dysphagia with
minimal aspiration. With recommendation to repeat swallowing
evaluation at rehab facility. On [**10-11**] patient underwent a TEE
which showed no evidence of subacute bacterial endocardiditis.
On [**10-12**], patient complained of a visual field defect and
Ophthalmology was consulted with no recommendations for
intervention. Thoughts were consistent with traumatic
maculopathy which should slowly improve. Patient should follow
up in [**Hospital 68264**] clinic as an outpatient in [**1-21**] weeks.
Patient remained stable, cooperative, and cordial throught
duration of hospital stay. He was afebrile for > 48 hours before
discharge.
Medications on Admission:
None
Discharge Medications:
1. [**Location (un) 36323**] brace Sig: One (1) at all times.
Disp:*1 * Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a
day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Acetaminophen 160 mg/5 mL Solution Sig: [**12-20**] PO Q4H (every 4
hours) as needed for fever>101.5.
9. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever>101.5.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q
24H (Every 24 Hours).
12. Potassium Chloride Oral
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Through [**2152-10-23**].
Disp:*4 Tablet(s)* Refills:*0*
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Calcium Gluconate 2 gm / 100 ml D5W IV PRN
please administer for ionized calcium less than 1.12
18. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg<2.0
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Traumatic burst fracture of the T3 vertebral body with
retropulsion of multiple fragments posteriorly as well as
angulation of the spinal canal at this level. Status post
fusion.
2) Fracture of the posterior elements of T1 and T2 . Status post
Fusion
3) Right transverse distal radial fracture. Status post ORIF.
4) sternal manubrial fracture. dissociation
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
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.
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.
Be sure to take your complete course of antibiotics.
You may resume your regular diet as tolerated.
You may resume all of your previously prescribed medications.
You may take showers.
You should wear your [**Location (un) 36323**] back brace at all times.
Followup Instructions:
With Dr. [**Last Name (STitle) 1352**] in Orthopedic Spine Clinic in 1 month. Please
call [**Telephone/Fax (1) 1228**] to make that appointment. Location [**Hospital Ward Name 23**] 2,
[**Hospital Ward Name 516**] [**Hospital3 **] Deaconness.
With Dr. [**Last Name (STitle) **] in General Orthopedic Surgery for right
radial fracture and shoulder pain in 2 weeks. Call [**Telephone/Fax (1) 1228**]
to make that appointment.
With [**Hospital 8183**] Clinic for visual field defect in [**2-19**] weeks.
Call [**Telephone/Fax (1) 253**] to make that appointment.
|
V5865,51884,5070,5100,44024,70703,5118,4280,5121,27652,42731,5990,24290,486,V4975,0414,1121,99881,4920,V5867,3572,25060 | 286 | 106,909 | Admission Date: [**2175-12-31**] Discharge Date: [**2176-2-24**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Increased SOB
Major Surgical or Invasive Procedure:
Tracheal intubation
Mechanical ventilation
Chest tube placement x 2
Arterial cannulation
Central venous cannulation
Bronchoscopy
Tracheostomy
PEG tube placement
Pleurodesis
History of Present Illness:
85 year old woman admitted with a chief complaint of hypoxia.
She was admitted to [**Hospital1 **] [**2175-12-27**] after 10 day
hospitalization at [**Hospital1 18**] for left below the knee amputation. She
has a history of steroid use for oxygen dependent COPD. On
arrival at [**Hospital1 **], her O2 sat was 97% on 2L. She has had a
steadily increasing oxygen requirement since, progressing to the
point on the day of admission of being on BiPap 14/8 15L. When
her mask is removed for even a few seconds, she desaturates to
the low 70s. She has been evaluated for her hypoxia by various
coverage physicians over the weekend and was treated with
nebulizer treatments and lasix with little improvement. She also
had a CXR on [**12-28**] which showed a left lower lobe pneumonia for
which she is on ceftriaxone, flagyl, and vancomycin. On the day
of admission, she was tachypneic, more hypoxic, with decreased
responsiveness, and was sent in for evaluation. On exam in the
ED, she was noted to have decreased air movement with rhonchi
and faint wheezes which improved with nebulizer treatments. Her
CXR was not impressive. An EKG showed multifocal atrial
tachycardia and mild lateral ST depressions. She was initially
placed on Bipap in the ED; after nebulizer treatments, she
improved and was put back on nasal cannula. She then again got
worse in the ED, and an ABG was 7.25/94/66. The patient was thus
intubated in the ED for worsening respiratory failure and sent
to the [**Hospital Unit Name 153**].
Past Medical History:
type 2 diabetes
hypertension
gout
osteoporosis
chronic obstructive pulmonary disease, steroid dependent,
oxygen-dependent, (FVC 1.89,FEV1 0.83, FEV1/FVC 44, DLCO:
Severely reduced)
paroxysmal atrial fibrillation
anemia
peripheral neuropathy secondary to diabetes
gastroesophageal reflux disease
history of MRSA
hyperthyroidism
PAST SURGICAL HISTORY:
right below knee popliteal bypass graft with nonreversed
saphenous vein and a left popliteal bypass graft with saphenous
vein angiogram on [**2175-9-30**].
mastectomy in [**2150**].
PICC line placement [**2175-9-30**].
left BKA
Social History:
The patient is a resident at [**Hospital **] rehabilitation. There is
no smoking or alcohol history.
Family History:
Noncontributory
Physical Exam:
T 100.8 HR 106 BP 163/69 O2Sat 90% AC Tv 400 x 20 PEEP 5 FiO2
0.5
Gen: Patient intubated, responsive and sedated
Heent: PERRL, sclera anicteric, OP with ulcers, MMM
Lungs: Diffuse tubular sounds ant/lat
Cardiac: Irregularly Irregular no murmurs
Abdomen: soft NT NABS
Ext: Left BKA, surgical wound intact, staples in place; Right LE
no edema, black necrotic right big toe. Right DP +2 at ankle
Neuro: sedated
Pertinent Results:
Admission labs:
CBC: WBC-21.1*# RBC-3.64* Hgb-10.2* Hct-33.3* MCV-91 MCH-27.9
MCHC-30.6* RDW-17.9* Plt Ct-646*
Diff: BLOOD Neuts-81.8* Lymphs-13.3* Monos-3.5 Eos-0.8 Baso-0.6
Coags: PT-13.3 PTT-37.1* INR(PT)-1.2
Chem 10: Glucose-86 UreaN-28* Creat-1.0 Na-147* K-4.2 Cl-103
HCO3-38* Calcium-7.9* Phos-2.6* Mg-2.0
ABG: Type-ART Temp-37.0 Rates-40/ FiO2-50 pO2-66* pCO2-94*
pH-7.25* calHCO3-43* Base XS-9 Intubat-NOT INTUBA
Comment-VENTIMASK
Other: Lactate-1.1
Cardiac enzymes: CK(CPK)-14* CK-MB-NotDone cTropnT-0.06* ->
CK(CPK)-14* CK-MB-1 cTropnT-0.04*
Thyroid tests: TSH-0.10* Free T4-0.7* T4-3.3*
Discharge labs:
Imaging:
Admission CXR:
1. Worsening of right upper lobe opacity near the future, which
are somewhat linear. Although it could represent subsegmental
atelectasis, cannot rule out the presence of pneumonia.
2. Background emphysema and pulmonary fibrosis as well as
pulmonary artery hypertension.
3. Bilateral small pleural effusions are stable.
Admission CTA Chest:
1. No evidence of central pulmonary embolism.
2. Right lower lobe consolidation/atelectasis; this likely
represents
pneumonia in the correct clinical setting.
3. Stable mediastinal lymphadenopathy, most prominent in the AP
window and precarinal distribution.
4. Severe fibrotic, bronchiectatic, and cystic changes
consistent with the known history of COPD. No pneumothorax as
was demonstrated on the prior CT.
5. Several smaller focal areas of consolidation bilaterally, the
most prominent of which in the left lower lobe, just superior
and anterior to the dominant area of consolidation. While these
may represent multifocal areas of infection or fibrotic change,
followup should be obtained to exclude malignancy.
6. Small left-sided pleural effusion.
7. Mild prominence of the central main pulmonary artery, likely
consistent with the given history of pulmonary arterial
hypertension.
Head CT [**2176-1-5**]: There is no evidence for hemorrhage. The
ventricles, sulci, and cisterns demonstrate no effacement. The
[**Doctor Last Name 352**] white matter junction is preserved. There are multiple
hypodensities seen in the subcortical and deep white matter as
well as both thalami that are the sequelae of chronic small
arterial ischemia. There is a frothy fluid within both maxillary
sinuses, sphenoid sinuses, and right mastoid air cells that may
indicate sinusitis. The osseous structures are unremarkable.
CXR [**2176-1-5**]: Very large left-sided pneumothorax with signs of
tension.
Chest CT [**2176-1-5**]:
FINDINGS: The large left hydropneumothorax, mostly air filled
was also shown on plain chest radiographs earlier today. Since
it shifts the mediastinum rightward and everts the left
hemidiaphragm, it may be causing hemodynamic tension as well.
The left lung is tethered to the chest cage by many pleural
adhesions.
Right lower lobe consolidation is improving and edema has
resolved. Emphysema is severe. A 6- cm bulla marginates the left
major fissure and smaller bullae are seen elsewhere . The
airways are patent up to the segmental bronchi. There is no
right pleural or any pericardial effusion.
Subcentimeter mediastinal nodes not meet CT size criteria for
lymphadenopathy. Extensive atherosclerotic coronary artery
calcifications are noted, along with substantial aortic valvular
calcification. There is no pericardial effusion.
In the upper abdomen, the imaged liver, spleen, adrenals, and
kidneys are unremarkable. A 24-mm gallstone is noted without
evidence of cholecystitis.
There are no suspicious bone findings.
ET tube and NG tube are in good position with the NG tube
terminating in the body of the stomach and the ET tube well
above the carina.
IMPRESSION:
1. Large left hydropneumothorax could be under tension and
hemodynamically significant.
2. Severe emphysema including a 6 cm bulla along the left major
fissure.
3. Improving right lower lobe consolidation.
4. Decreasing pulmonary edema.
CXR [**2176-1-5**] pm: Compared with the examination obtained
approximately 6 1/2 hours earlier, a left chest tube has been
inserted, with its tip ending in the apex. The left pneumothorax
has markedly diminished and is now small, best seen at the left
lateral costophrenic angle. The mediastinum is now midline. The
endotracheal tube is in satisfactory position. A nasogastric
tube descends into the abdomen. There is a background of chronic
lung disease and emphysema. Scattered nonspecific opacities are
present bilaterally.
CXR [**2176-1-8**]: Left lung appears to be completely re-expanded. The
left apical pleural tube is relatively short intrathoracic and
the tip of the basal tube is not its entire course is
extrathoracic. Little if any left pleural effusion or pleural
air. Mild pulmonary edema is unchanged. Heart size is normal,
although larger than it was prior to chest tube insertion. Tip
of the ET tube is in standard placement and a nasogastric tube
passes into the stomach and out of view. Dr. [**First Name (STitle) **] was paged to
discuss these findings at the time of dictation.
CXR [**2176-2-5**]: One of the two left basal pleural tubes have been
withdrawn approximately 6 cm now projecting over the cardiac
apex and left hemidiaphragm. The other tube is unchanged in
position, tip just to the left of the midline at the level of
the left hemidiaphragm. No appreciable left pneumothorax. Small
left pleural effusion may have increased. Small right pleural
effusion unchanged. Subcutaneous emphysema in the chest wall and
neck is still severe but improving. Heart size remains top
normal. Heterogeneous opacification in the lungs is probably a
combination of pulmonary edema, multifocal pneumonia and
emphysema. Tracheostomy tube in standard placement.
GRAM STAIN (Final [**2176-2-18**]):
[**10-23**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2176-2-20**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH.
ENTEROBACTER CLOACAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
203-0763R
[**2176-2-11**].
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 203-1121R
[**2176-2-12**].
Brief Hospital Course:
Assessment: 85yo woman with chronic obstructive pulmonary
disease, admitted with respiratory failure, intubated in the ED,
likely secondary to multilobar pneumonia, chronic obstructive
pulmonary disease, and congestive heart failure, complicated by
a pneumothorax.
Hospital course is discussed below by problem:
1. Respiratory failure - Her initial respiratory failure was
thought to be multifactorial, secondary to multilobar pneumonia,
chronic obstructive pulmonary disease with very poor baseline
function, and congestive heart failure. She was treated with
vancomycin, zosyn, and azithromycin for 14 days for broad
coverage given that she had recently been living in health care
facilities. DFA for influenza and urinary legionella antigen
were both negative. Sputum cultures only grew yeast, which was
thought to be contamination. Most recent sputum cultures grew E
coli, thought to be a contaminant as well, as the patient has
been afebrile, with resolving leukocytosis, unremarkable chest
x-ray, and no other symptoms of a pneumonia. She then developed
a low grade temperature and with 2/16 sputum culutres with 2+
GNR and with a history of enterobacter, she was restarted on a
10 day course of meropenem to be finished at rehabilitation. Her
sputum culture grew gram positive cocci and she was started on a
course vancomycin, to complete a 10 day course of vancomycin and
10 day course of meropenem. Her vancomycin had been
supratherapeutic and was being monitored daily for dosing
purposes. She was day [**7-8**] fo vancomycin on [**2176-2-23**], she still
remained supratherapeutic on day of discharge at 31 (on day
[**8-8**]). Her chronic obstructive pulmonary disease was treated
with albuterol and atrovent, though she was not very responsive
to these medications. She was also given a dose of solumedrol
125mg IV, with a subsequent prednisone taper that was ongoing at
the time of discharge. She was diuresed intermittently
throughout the hospitalization (see below) She was intubated in
the emergency room and had a tracheostomy on [**1-18**]. Her
ventilator weaning was complicated by a cuff leak, requiring
30mmHg pressure to seal. This improved, and she has done well on
pressure control. She has also had several trach collar trials,
during which she tires within 10-15 minutes.
2. Pneumothorax - On the morning of [**2176-1-5**], the patient's chest
x-ray showed a vertical linear opacity consistent with
pneumothorax. A chest CT at the time confirmed a large
pneumothorax involving most of her left lung. This was thought
to occur secondary to positive pressure with preexisting severe
bullous disease, and likely occurred the night prior to the
chest x-ray, as she began to have low blood pressure responding
to IV fluids that night. Thoracic surgery was called, and in
concert with interventional pulmonology, they placed a chest
tube in the apex of the left lung. She was determined to still
have an element of pneumothorax at her left lung base, so a
second chest tube was placed. The apical chest tube was
displaced slightly and caused subcutaneous emphysema, but it was
effective and was able to be clamped and removed on [**1-10**] without
complications. The basilar chest tube manifested an inspiratory
leak which resolved until the patient's tracheostomy, at which
time the leak recurred. As such, the thoracic team performed
pleurodesis x 3 ([**Date range (1) 40042**]) with doxycycline. The chest tube was
set to suction and the inspiratory leak resolved. The chest tube
was clamped and removed [**1-24**] without complications. A chest
x-ray after chest tube removal showed no pneumothorax. However,
that night she became increasingly tachypneic, and a CXR in the
morning showed recurrence of the pneumothorax. Another chest
tube was placed, with a significant amount of resulting
subcutaneous emphysema (head to toe) and no significant change
in the pneumothorax. A second chest tube was thus placed, which
resulted in some improvement in the pneumothorax. Her course was
also complicated by a bronchopleural fistula, requiring pressure
control ventilation. Her fistula gradually resolved, and she has
been able to be adequately supported on pressure control
ventilation. Since that time, her subcutaneous emphysema has
gradually improved. Her chest tubes were put to water-seal on
[**2176-1-31**], then were clamped on [**2-9**], and daily CXRs have
revealed no evidence of recurrent PTX. The chest tubes were
sequentially clamped and then removed with serial chest xrays
revealing no pneumothorax. The pt is to follow up with
thoracics surgeon Dr. [**Last Name (STitle) **] after discharge.
3. Hypotension - She had an episode of hypotension in the
setting of her pneumothorax. Initially, it responded to fluid
boluses and, given that the patient had been aggressively
diuresed previously, was thought to be secondary to hypovolemia.
This was likely just a contributing factor to hypotension caused
by pneumothorax. It resolved after chest tube placement. Once
she was normotensive, her metoprolol was restarted.
4. Fluid status - On admission, the patient was volume
overloaded. She responded well to lasix 40mg IV. This was held
in the setting of hypotension (with her pneumothorax), and was
thought to be hypovolemic at that time. She has been
intermittently volume overloaded, with good response to lasix.
Over the past 4 days prior to discharge the pt was euvolemic,
not requiring any lasix.
5. Mental status - Early in the hospitalization, the patient was
noted to have decreasing responsiveness. This was likely related
to her sedation, as once the sedation was lessened, she became
very appropriate and responsive. She also has had difficulty in
regulating sleep/wake cycles. Primary team has been moderately
succesful in improving this with pm ambien, gabapentin,
nortriptyline, and haldol.
6. Yeast infection - She had urine cultures sent that showed
only yeast, and vaginal discharge consistent with yeast. She was
treated with one dose of fluconazole with resolution of her
symptoms.
7. Atrial tachycardia - She had a rhythm consistent with
multifocal atrial tachycardia, most likely secondary to her
underlying pulmonary issues. Her metoprolol was restarted and
the tachycardia resolved.
8. Atrial fibrillation with rapid ventricular response - Ms.
[**Known lastname 7474**] has known PAF, but she had increasingly frequent episodes
of RVR to the 150s, with stable blood pressures. Her metoprolol
and diltiazem dosages were increased, with some effect, but she
continued to have these episodes with maximal doses. She was
placed on an esmolol drip, which helped Ms. [**Known lastname 7474**] to revert to
NSR at a dose of 100mcg/min, but experienced recurrent episodes
on the drip. The electrophysiology service was consulted, who
recommended started amiodarone. She was PO loaded, and placed on
200mg PO bid, in addition to her previous dose of diltiazem. Her
comorbid lung and thyroid conditions were noted in terms of
managing with amiodarone, but this was thought to be the most
appropriate treatment option. Daily EKGs were obtained to assess
for prolonged QT. The pt was switched from diltiazem to
metoprolol as the pt has been noted to have better rate control
with BB than CCB. The pts amiodarone was weaned down to 200 mg
po qd prior to discharge. She developed episodes of atrial
fibrillation while on amiodarone and cardiology was consulted
and she was started on a low dose heparin drip for possible DCCV
if she became hypotensive. Long term anticoagulation is to be
determined as an outpatient The pt will need EKG's to assess for
QT prolongation. Her outpt PCP will also need to assess
reinitiation of coumadin; pt seems to be a likely fall risk per
nursing. Her heparin gtt was discontinued on day of discharge.
9. Diabetes - She was monitored with fingersticks. Initially,
she was treated with an insulin drip, but she was later switched
to a sliding scale. Her BS were generally well controlled.
10. Urinary tract infection - Urine culture grew E. coli and
Enterobacter clocae on [**1-24**]. She was treated with a 7 day
course of meropenem.
9. Hypertension - Other than during her brief episode of
hypotension, she was treated with her outpatient metoprolol and
diltiazem. The pts medications wer changed to metoprolol and
amiodarone.
10. Peripheral vascular disease - Plavix and aspirin was
continued. Vascular surgery was consulted to assess her
gangrenous toe, but the decision was made to defer any
interventions until such time as her respiratory status had
significantly improved. The pt is to follow up with vascular
surgery 1 month after discharge to f/u her dry gangrene. She had
no post-operative complications stemming from her recent left
BKA.
11. Hyperthyroidism - She was continued on methimazole. Her TSH
was high and free T4 low. This needs to be readdressed as an
outpatient, as her current status was likely complicated by her
stay in the ICU, and should be assessed once in an outpatient
setting.
Nutrition - She was treated with tube feeds, initially by
orogastric tube, then by PEG once she had the tracheostomy.
Communication - her son, [**Name (NI) **] [**Name (NI) 7474**], lives in [**State **], and can usually be reached at [**Telephone/Fax (1) 56720**].
Code status - full
Medications on Admission:
Atrovent neb
Flagyl 500mg IV q8
Ceftriaxone 1gm IV daily
Monistat derm [**Hospital1 **]
Lasix 40mg po q8
Vancomycin 1gm IV daily
Fosomax 70mg q Sat
ASA 325mg daily
Tapazole 5mg po daily
Lopressor 75mg q8
Plavix 75mg daily
Cardizem 30mg po q8
Colase 100mg [**Hospital1 **]
[**Doctor First Name **] 60mg daily
Nuerontin 100mg [**Hospital1 **]
Robitussin 200mg [**Hospital1 **]
Heparin SC
RISS
MVI
Prednisone 2.5mg daily
Nortrptyline 25mg qhs
Zantac 150mg
Serevent 50 [**Hospital1 **]
Probenecid 500mg [**Hospital1 **]
Accolate 10mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Zafirlukast 20 mg Tablet Sig: 0.5 Tablet PO daily ().
6. Docusate Sodium 150 mg/15 mL Liquid Sig: Thirty (30) ml PO
BID (2 times a day) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
12. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale units based on FS see attached sheet for details.
Injection four times a day.
13. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
once weekly on Sat.
15. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
16. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Lorazepam 0.5-1 mg IV Q6H:PRN
Use before haldol for agitation
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
20. Morphine Sulfate 1-4 mg IV Q2H:PRN
21. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO DAILY
(Daily).
22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
23. Gabapentin 250 mg/5 mL Solution Sig: One Hundred (100) mg PO
BID (2 times a day).
24. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
25. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
26. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q1HR () as needed.
27. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
28. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
29. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for toe pain.
30. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day.
31. Meropenem 1 g Recon Soln Sig: One (1) Intravenous twice a
day for 2 days.
Disp:*4 grams* Refills:*0*
32. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Pneumonia
2. COPD with bullous disease on home oxygen
3. Pneumothorax
4. Atrial tachycardia
5. Atrial fibrillation
Secondary:
1. DM II
2. Peripheral vascular disease with necrotic toes
3. Hyperthyroidism
4. Anemia
5. Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
Please follow up with all of your doctors, including your PCP as
well as your vascular surgeon regarding your necrotic toes.
Please weight yourself daily, if you notice a significant
increase in your weight more than 3lb daily, please call your
PCP for possible change in medications.
Please note several changes have been made in your medication
regimen. For details, see the following changes:
1. You should continue your antibiotics for the prescribed
length of time.
2. Please continue to take your aspirin, plavix, and lopressor
as you have been doing. You are on a new medication called
amiodarone.
3. Your serevent has been discontinued as it would be difficult
to take with the tracheostomy tube. Instead place take
albuterol IH 6 puffs Q4 hours in addition to the atrovent IH 6
puffs Q4 hours.
4. Please continue your other medications as you have been
doing as well.
If you develop any chest pain, palpitations. shortness of
breath, fevers, chills, nauseas, vomiting, diarrhea or other
concerning health problems, please call your PCP or come
directly to the ED.
Followup Instructions:
1). Please follow up with your PCP within two weeks of
discharge.
2). Please follow up with thoracics Dr. [**Telephone/Fax (1) 56721**]
3). Please follow up with Dr. [**Last Name (STitle) 1391**] (vascular surgeon) on
[**3-27**] at 9:45 AM, [**Last Name (NamePattern1) **] Suite 5c, [**Telephone/Fax (1) 1393**]
|
24290,2639,42731,3572,39891,3970,496,70715,44024,25060,3941,V5867,4019,53081,2859,73300,V441,V440 | 286 | 135,917 | Admission Date: [**2176-4-10**] Discharge Date: [**2176-4-12**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
right foot gangrene
Major Surgical or Invasive Procedure:
amputation of right first toe amputation
History of Present Illness:
transfreered [**Location 56722**] rehabfor suspicion of gangrenous ulcer
on right foot. HAd recent complicated admission toBIDMC for
PNA,CHF,respiratory failure,PTX,hypoand hypertension and A fib
with PVP. Before transfer, she did not have any reported
infectious prodrome,fever,chills,or erythema. NO reported
respiratory status and pt cannot report difficulaty breathing.
Past Medical History:
type 2 diabetes
hypertension
gout
osteoporosis
chronic obstructive pulmonary disease, steroid dependent,
oxygen-dependent, (FVC 1.89,FEV1 0.83, FEV1/FVC 44, DLCO:
Severely reduced)
paroxysmal atrial fibrillation
anemia
peripheral neuropathy secondary to diabetes
gastroesophageal reflux disease
history of MRSA
hyperthyroidism
PAST SURGICAL HISTORY:
right below knee popliteal bypass graft with nonreversed
saphenous vein and a left popliteal bypass graft with saphenous
vein angiogram on [**2175-9-30**].
mastectomy in [**2150**].
PICC line placement [**2175-9-30**].
left BKA
Social History:
The patient is a resident at [**Hospital **] rehabilitation. There is
no smoking or alcohol history.
Family History:
Noncontributory
Physical Exam:
nad
NCAT/ MMM/OP clear, carotid pulse +2
irregular . No murumurs
soft/NT/ND
radila pusle 2+ b/l. DP 2+ b/l, PT 1+ b/l, popliteal 2+R
right foot bandaged . GAngrene of 1st digit
sacral ucler
Pertinent Results:
FOOT AP,LAT & OBL RIGHT [**2176-4-10**] 10:35 PM
FOOT AP,LAT & OBL RIGHT
Reason: assess for osteomyelitis
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with R toe 1 gangrene
REASON FOR THIS EXAMINATION:
assess for osteomyelitis
STUDY: Right foot three views performed on [**2176-4-10**].
HISTORY: This is an 85-year-old woman with right first toe
gangrene. Evaluate for osteomyelitis.
FINDINGS: No prior studies available for comparison. There are
extensive vascular calcifications identified. There is a soft
tissue defect seen over the distal aspect of the right first
toe. However, no definite cortical destruction is seen to
indicate radiographic signs of osteomyelitis. Lateral radiograph
is suboptimal as a portion of the first digit has been excluded
from the image.
IMPRESSION:
Soft tissue defect overlying the distal aspect of the first
digit without definite radiographic evidence for acute
osteomyelitis.
CHEST (PORTABLE AP)
Reason: Question CHF
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman s/p PTX, s/p removal of CTs, now with
increasing dyspnea and increased secretions
REASON FOR THIS EXAMINATION:
Question CHF
HISTORY: 85-year-old female with dyspnea.
COMPARISON: CT chest [**2176-2-9**], and multiple chest
radiographs in [**2176-1-31**].
AP PORTABLE CHEST: Endotracheal tube is in appropriate position
approximately 7 cm above the carina. A left-sided PICC line
terminates in the proximal SVC. Compared to most recent prior
chest radiograph, [**2176-2-22**], there has been interval
improvement in small bilateral pleural effusions. Chronic
bilateral increased interstitial markings persist consistent
with chronic interstitial lung disease. There is improvement in
vascular congestion, and there is no evidence of CHF currently.
The heart size and cardiomediastinal contours are unchanged
given differences in position.
IMPRESSION: Improvement in small bilateral pleural effusions.
Chronic interstitial lung disease. No CHF.
[**2176-4-10**] 09:21PM BLOOD WBC-14.2* RBC-3.14* Hgb-10.1*# Hct-30.5*
MCV-97 MCH-32.0 MCHC-33.0 RDW-16.9* Plt Ct-518*
[**2176-4-11**] 03:28AM BLOOD WBC-14.1* RBC-3.04* Hgb-9.6* Hct-29.7*
MCV-98 MCH-31.5 MCHC-32.3 RDW-17.0* Plt Ct-535*
[**2176-4-11**] 03:57PM BLOOD WBC-12.1* RBC-2.90* Hgb-9.2* Hct-28.2*
MCV-97 MCH-31.9 MCHC-32.8 RDW-16.6* Plt Ct-504*
[**2176-4-12**] 03:45AM BLOOD WBC-17.4* RBC-2.94* Hgb-9.3* Hct-29.2*
MCV-99* MCH-31.7 MCHC-31.9 RDW-16.7* Plt Ct-505*
[**2176-4-10**] 09:21PM BLOOD PT-11.7 PTT-23.8 INR(PT)-1.0
[**2176-4-10**] 09:21PM BLOOD Plt Ct-518*
[**2176-4-11**] 03:28AM BLOOD PT-12.0 PTT-24.3 INR(PT)-1.0
[**2176-4-11**] 03:28AM BLOOD Plt Ct-535*
[**2176-4-11**] 03:57PM BLOOD Plt Ct-504*
[**2176-4-12**] 03:45AM BLOOD PT-12.4 PTT-23.4 INR(PT)-1.1
[**2176-4-12**] 03:45AM BLOOD Plt Ct-505*
[**2176-4-10**] 09:21PM BLOOD Glucose-130* UreaN-47* Creat-0.8 Na-138
K-5.3* Cl-97 HCO3-35* AnGap-11
[**2176-4-11**] 03:28AM BLOOD Glucose-89 UreaN-44* Creat-0.8 Na-140
K-5.0 Cl-99 HCO3-37* AnGap-9
[**2176-4-11**] 03:57PM BLOOD Glucose-134* UreaN-35* Creat-0.8 Na-140
K-5.2* Cl-100 HCO3-35* AnGap-10
[**2176-4-12**] 03:45AM BLOOD Glucose-125* UreaN-31* Creat-0.8 Na-137
K-5.3* Cl-98 HCO3-36* AnGap-8
[**2176-4-10**] 09:21PM BLOOD Calcium-9.8 Phos-4.1
[**2176-4-11**] 03:28AM BLOOD Albumin-2.8* Calcium-9.4 Phos-4.4 Mg-2.0
[**2176-4-11**] 03:57PM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8
[**2176-4-12**] 03:45AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8
[**2176-4-10**] 09:40PM BLOOD Type-[**Last Name (un) **] pH-7.32*
[**2176-4-12**] 08:40AM BLOOD Type-ART pO2-195* pCO2-90* pH-7.25*
calHCO3-41* Base XS-8
[**2176-4-12**] 10:50AM BLOOD Type-ART pO2-78* pCO2-64* pH-7.37
calHCO3-38* Base XS-8
[**2176-4-10**] 09:40PM BLOOD Glucose-136*
[**2176-4-12**] 08:40AM BLOOD Glucose-177*
[**2176-4-12**] 10:50AM BLOOD Glucose-191* K-5.5*
Brief Hospital Course:
Pt directly admitted to SICU due to all her comorbid
conditions.Pt placed on trach mask. Pt palced on VAncomycin as
precautioanry measure for underlying osteomyelitis. A FXR was
ordered and showed soft tissue destruction but no osteomyelitis.
Labs were sent. Pt palced on G-tube to gravity and left NPO. On
HD 2, pt pre-oped for OR. Pt underwent a right hallux
amputation. Offical operative report can be read in the chart.
Pt tolerated the procedure well and was transfered back to the
SICU in stable condition. Infectious disease was consulted to
assess if there were any other underlying infectious causes of
elevated white count. They felt that the increase could be
attributed to the long term steroid use. A UA and sputum culture
were obtained as precautionary measure. Pt d/c back to [**Hospital1 15554**] on HD 3. VAnco was d/c. Instructions sent to have pt
seen by PCP for decreasing steroid dose. pt is to follow up with
Dr [**Last Name (STitle) 1391**] in 2 weeks.
Medications on Admission:
lasix
lopressor
aldectone
neurontin
amio
tramadol
fluconasol
prednision
lisinopril
prevacid
RISS
cardizam
atroven
albuterol
tobramax
nortiptyline
[**Doctor First Name 130**]
lantus
zfilikast
methemazole
plavix
asa
colase
senna
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
2. Furosemide 40 mg IV BID
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methimazole 5 mg Tablet Sig: One (1) Tablet PO QD ().
7. Zafirlukast 20 mg Tablet Sig: 0.5 Tablet PO qd ().
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO QD ().
9. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: [**1-1**]
Inhalation [**Hospital1 **] (2 times a day).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
15. Fluconazole 50 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
19. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
gangrene of right hallux
Discharge Condition:
stable
Discharge Instructions:
Please continue medicatiosn as directed.
You will not be on any antibiotics.
Please monitor patients white count. She is chronically
elevated. THis may be due to her steriods. Please check with her
priamry care doctor to see if the steriod level can be decreased
Followup Instructions:
please monitor pateint in rehab. She can follow up with Dr
[**Last Name (STitle) 1391**] in 2 weeks.
Completed by:[**2176-4-12**] |
7140,1984,1985,1973,1603 | 287 | 174,293 | Admission Date: [**2167-5-22**] Discharge Date: [**2167-5-27**]
Date of Birth: [**2096-12-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old male
with recurrent nasal-ethmoid adenocarcinoma, who underwent a
craniofacial resection for ethmoid cancer with lateral
rhinotomy. Past medical history of this cancer also had
surgery x2 for this problem twice in the past.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: On physical exam, blood pressure was
147/66, pulse 110. In general, elderly man in no acute
distress, walks with a cane. HEENT: Positive clear
rhinorrhea bilateral nares. Pupils are equal, round, and
reactive to light. EOMs full. No lymphadenopathy, no
thyromegaly. Chest was clear to auscultation. Cardiac:
Regular, rate, and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended, negative masses,
negative hepatosplenomegaly. Extremities: No clubbing,
cyanosis, or edema. His strength is [**4-27**] in all muscle
groups.
MEDICATIONS PREOPERATIVE:
1. Ranitidine.
2. Vioxx.
3. Folic acid.
He was admitted status post a subfrontal craniotomy with
resection of the nasal-ethmoid carcinoma. Surgeons were
[**Doctor Last Name 1906**], Caradonnar, and [**Doctor Last Name **]. He had no complications from
the surgery. He was monitored in the Intensive Care Unit
overnight. His vital signs remained stable. He was
afebrile. He remained intubated and sedated. He awoken to
painful stimuli. His pupils were pin point and brisk. He
had cough and gag intact, withdraw extremities to nailbed
pressure. His vital signs were stable. His lungs were
clear.
On postoperative day #1, he still continued to be intubated.
Was awake, following commands bilaterally. His IP strength
was [**4-27**]. He had antigravity strength in both his upper and
lower extremities. His dressing was clean, dry, and intact.
He had no evidence of CSF leak and his vital signs were
stable.
Patient was extubated on [**2167-5-24**]. His vital signs were
stable. He was afebrile. He opened his eyes spontaneously.
He is moving all extremities with good strength. His
dressing was clean, dry, and intact. EOMs were full. He was
transferred to the floor on postoperative day #2. His vital
signs were stable. He is afebrile. Pupils are 2.5 down to 2
and brisk. His grasp was strong, he was following commands.
He had no evidence of CSF leak. His dressing was clean, dry,
and intact. He did have some periods of agitation, and was
receiving Haldol for that and he had a sitter while he was in
the Intensive Care Unit.
His sitter was discontinued before he went to the floor. He
had a swallow evaluation which showed that he was
............. and had aspirating on thin liquids. He was
made NPO.
On [**2167-5-26**], he was awake, alert, and oriented times three
with bilateral drift. Grasps were 4+/5. IPs are [**4-27**]. His
eyes were swollen shut. His smile was symmetric. He was
seen by Physical Therapy and Occupational Therapy and found
to require rehab.
On [**2167-5-27**], he had a repeat swallow evaluation which he
passed. He was started on a soft solid diet with some nectar
thick liquids, and was ready for discharge to rehab. His
vital signs remained stable. His incision was clean, dry,
and intact.
DISCHARGE MEDICATIONS:
1. Heparin 5,000 units subQ q12h.
2. Famotidine 20 mg po bid.
3. Metoprolol 25 po bid, hold for systolic blood pressure
less than 110, heart rate less than 55.
4. Folic acid 1 mg po q day.
5. Acetaminophen 650 po q4h prn.
6. Hydromorphone 1-2 mg po q4h prn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: He should have his staples removed
on postoperative day #10, and follow up with Dr. [**Last Name (STitle) 1906**] at
[**Hospital 4415**] in six weeks.
[**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2167-5-27**] 11:40
T: [**2167-5-27**] 12:20
JOB#: [**Job Number 45953**]
|
99859,3240,496,99669,7907,7140,1700,2536 | 287 | 175,954 | Admission Date: [**2167-5-31**] Discharge Date: [**2167-6-6**]
_----------------------_
Date of Birth: [**2096-12-21**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
gentleman with a past medical history of ethmoid cancer
resected at [**Hospital6 1129**] in [**2162**].
He had a repeat resection here on [**2167-5-22**] by
Ear/Nose/Throat and Neurosurgery. Postoperative course was
uneventful. The patient had no cerebrospinal fluid leak.
He passed a swallow evaluation and was discharged to
rehabilitation on [**2167-5-28**].
He began having mental status changes and seizure activity on
the day of admission. He became unresponsive. He had a
fever to 102 and was transferred here for further management.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Rheumatoid arthritis.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination his temperature was 97.9, blood pressure was
124/55, heart rate was 72, respiratory rate was 20, and
oxygen saturation was 97%. Head, eyes, ears, nose, and
throat examination revealed pupils were equal, round, and
reactive to light. Extraocular movements were full. He had
bilateral orbital edema. His cardiovascular status revealed
a regular rate and rhythm. Normal first heart sounds and
second heart sounds. No murmurs, rubs, or gallops.
Pulmonary examination was clear to auscultation bilaterally.
The abdomen was soft, nontender, and nondistended. No
masses. Extremity examination revealed no clubbing,
cyanosis, or edema. On neurologic examination, he did not
open his eyes. He did grasp hand bilaterally.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some mild
fluid overload; slightly improved. No infiltrates.
HOSPITAL COURSE: He was seen by the Ophthalmology Service
and ruled out for orbital cellulitis. He had a lumbar
puncture and a magnetic resonance imaging with evidence of an
epidural versus subdural frontal collection.
On [**2167-5-31**] the patient was taken to the operating room
for exploration and drainage of a frontal collection. A
drain was in place, and the patient was monitored in the
Intensive Care Unit postoperatively where he had severe
facial swelling, and his eyes were swollen shut.
Postoperatively, he was awake and following commands. He was
moving all extremities to commands. The fluid collection was
sent for a culture.
He was seen by Infectious Disease Service. He was placed on
vancomycin 1 g q.12h. and ceftazidime 2 g q.8h. for initial
antibiotic coverage. The Gram stain showed gram-positive
cocci and gram-negative rods from the abscess.
The patient had a bone flap removed. Therefore, there was a
skull defect. The patient will require six weeks of
intravenous antibiotic coverage. His drain was removed on
postoperative day four (on [**2167-6-3**]), and he was
transferred to the regular floor after being seen by Physical
Therapy and Occupational Therapy.
He was also re-evaluated by the Swallow Service. He passed
the swallow with some modifications. He needs to be on a
nectar-thick ground solid diet. Pills need to be crushed and
pureed. He needs to maintain aspiration precautions. He
should be full upright for all meals, alternating between
bites and sips, and two to three swallows for each bite and
sip.
His dressing was removed, and his incision was clean, dry,
and intact. He had a peripherally inserted central catheter
line placed on [**2167-6-5**]. He currently continues on
gentamicin 100 mg intravenously q.12h. and ceftazidime 2 g
intravenously q.8h. He was growing Proteus from the culture
from his surgery.
The patient was to be discharged on ceftazidime 2 g
intravenously q.8h. and ciprofloxacin 500 mg p.o. q.12h.;
together for a total of six weeks.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 1906**] at [**Hospital 14852**] in four to six weeks.
2. The patient should also have his staples removed at
rehabilitation in 14 days postoperatively.
3. The patient should also be fitted for a helmet due to the
bone defect once at rehabilitation.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Pantoprazole 40 mg p.o. q.24h.
2. Metoprolol 25 mg p.o. twice per day.
3. Sodium chloride nasal spray four times per day as needed.
4. Ceftazidime 2 g intravenously q.8h.
5. Folic acid 1 mg p.o. once per day
6. Gentamicin 100 mg intravenously q.12h. (peak and trough
levels are pending).
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: To rehabilitation.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2167-6-5**] 12:00
T: [**2167-6-5**] 12:19
JOB#: [**Job Number 45954**]
|
76518,7473,76528,77089,V290,V053 | 288 | 110,921 | Admission Date: [**2191-5-19**] Discharge Date: [**2191-5-26**]
Date of Birth: [**2191-5-19**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 71802**] is the 2.2-kilogram product of a
35-4/7-weeks gestation born to a 29-year-old G1, P0 mother.
Prenatal screens: O-positive, antibody negative, hepatitis
surface antigen negative, rubella immune, RPR nonreactive,
GBS unknown. This pregnancy was complicated by
oligohydramnios and suspected intrauterine growth
restriction. Mother was beta complete at time of delivery.
Infant was delivery by C-section secondary to infant breech
position. Infant had Apgars of 8 and 8. Required brief blow-
by O2 and bulb suctioning. Infant was admitted to the newborn
intensive care unit for management of prematurity.
PHYSICAL EXAM ON ADMISSION: Weight was 2.2 kilograms (25-
50th percentile), head circumference 32 cm (25th-50th
percentile), length 45 cm (25th-50th percentile).
PHYSICAL EXAM TODAY AT TIME OF DISCHARGE: Small infant,
swaddled in open crib. She was pink, mildly jaundiced, well
perfused in room air. Chest: Clear with equal breath sounds.
Cardiovascular: Regular rate and rhythm, soft systolic murmur
heard best in axilla. Abdomen is soft with active bowel
sounds. GU: Immature female genitalia. Extremities: Legs
flexed at birth. Infant moving all extremities appropriately.
Neuro: Active with good tone.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] was
admitted to the newborn intensive care unit with mild
respiratory distress requiring nasal cannula O2 400 cc flow
up to 50%. She required nasal cannula for a total of
approximately 72 hours at which time she transitioned to room
air. Has been stable on room air since that time.
Cardiovascular: She has been cardiovascularly stable with a
new onset murmur consistent with PPS in quality. She was assessed
by the Cardiology consult service who agreed murmur was most
likely benign. Blood pressure was normal, 61/30 with a mean of
40 and heart rate ranges have been 130s-180s.
Fluid and electrolyte: Birth weight was 2.21 kilograms.
Discharge weight is 2005gm. She was initially started on
60 cc per kilogram per day of D10W. Enteral feedings were
initiated on day of life #2. She is currently ad-lib feeding
taking in adequate amounts of breast milk or Similac 24
calorie. She is voiding and stooling.
GI: Her peak bilirubin was on [**5-24**], of 9.9/0.2. She has
not required any phototherapy at this time.
Hematology: Hematocrit on admission was 44.1. She has not
required any blood transfusions.
Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours at which time antibiotics were discontinued.
Neuro: Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated auditory
brainstem responses, and the infant passed in both ears on
[**2191-5-26**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34570**],
telephone number is ([**Telephone/Fax (1) 67099**].
CARE AND RECOMMENDATIONS: Continue ad-lib feeding breast
milk 20 calorie or supplementation with Similac 24 calorie.
Follow up appointment with Dr. [**Last Name (STitle) **] of Cardiology at CH has been
scheduled for [**2196-6-10**]:30PM.
MEDICATIONS: Ferrous sulfate supplementation 0.2 mL p.o.
daily (25 mg per mL), Tri-Vi-[**Male First Name (un) **] 1 mL p.o. daily.
IRON AND VITAMIN SUPPLEMENTS: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months of corrected age.
All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units (maybe
provided as multivitamin preparation) daily until 12 months
corrected age.
CAR SEAT POSITION SCREENING: Was performed and the infant
passed.
STATE NEWBORN SCREEN: Was sent most recently on [**5-21**] and
results have been within normal limits.
IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine
on [**5-25**].
DISCHARGE DIAGNOSES: Premature infant born at 35-4/7-weeks
gestation, transient respiratory distress, rule out sepsis
with antibiotics, cardiac murmur - possible peripheral pulmonic
stenosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-5-25**] 21:26:38
T: [**2191-5-26**] 06:56:25
Job#: [**Job Number 71803**]
|
42731,7509,486,5990,99881,9982,311,4019,E8786 | 290 | 138,303 | Unit No: [**Numeric Identifier 60026**]
Admission Date: [**2179-1-26**]
Discharge Date: [**2179-2-8**]
Date of Birth: [**2104-9-8**]
Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Esophageal dysplasia, high grade.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
white male with a history of significant for high-grade
esophageal dysplasia who presented to [**Hospital6 649**] on [**2179-1-26**], for elective
thoracoscopic and laparoscopic esophagogastrectomy.
PAST MEDICAL HISTORY: Hypertension. Depression.
MEDICATIONS ON ADMISSION: Hydrochlorothiazide 50 mg daily,
Atenolol 25 mg daily, Lipitor 10 mg daily, Fluoxetine 20 mg,
Prilosec, Multivitamin, Aspirin 81 mg once daily.
ALLERGIES: None.
SOCIAL HISTORY: The patient has a remote smoking history.
He quit in [**2138**]. He denied alcohol and recreational drug
use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYMPTOMS: He reports feeling well on the day of
surgery. He denied recent fever, chills, nausea, vomiting,
shortness of breath, chest pain, or light-headedness.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.9, heart
rate 80, blood pressure 168/89, respirations 12, oxygen
saturation 96 percent on room air. General: The patient was
alert and oriented. He was comfortable. HEENT: Pupils
equal, round and reactive to light. No scleral icterus. No
jugular venous distension. No lymphadenopathy. No
thyromegaly. Chest: Clear to auscultation bilaterally.
Heart: Regular, rate, and rhythm without murmur. Abdomen:
Nondistended, soft, nontender to palpation. Extremities:
Distal neurovascular intact.
HOSPITAL COURSE: The patient presented to [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2179-1-26**], for elective
laparoscopic and thoracoscopic esophagogastrectomy and
placement of a feeding jejunostomy tube for high-grade
esophageal dysplasia. The patient underwent the procedure on
[**2179-1-26**]. The patient tolerated the procedure well.
After recovery in the Postanesthesia Care Unit, he was
transferred in stable condition to the Surgical Intensive
Care Unit intubated.
On postoperative day 1, he remained intubated and was in
stable condition. He did require two fluid boluses for low
urine output. On postoperative day 2, the patient continued
to remain clinically stable but intubated. He continued to
be weaned from his vent, and on postoperative day 3, he
presented with a temperature spike for which blood cultures,
urine culture, and sputum culture were obtained. He also
went into rapid atrial fibrillation and was promptly
converted to sinus rhythm with intravenous Lopressor, which
he would remain on.
He continued to be weaned from his vent and was extubated on
postoperative day 3, which he tolerated well. He continued
on tube feeds, which were advanced to goal.
On postoperative day 4, he began to get out of bed with
Physical Therapy. On postoperative day 5, he was transferred
to the floor in stable condition. He underwent a swallow
study which was negative for leak. His chest tube remained
draining serosanguineous fluid.
He was started on sips, which he tolerated well. On
postoperative day 7, he was advanced to a clear-liquid diet,
which he tolerated well. He continued to ambulate easily and
often.
On postoperative day 8, he was advanced to a regular diet,
which he tolerated well. His chest tube was discontinued;
however, he did have a fever spike to 102 degrees. Blood
cultures, urine culture, and chest x-ray were obtained.
Chest x-ray was suggestive for right middle lobe/right lower
lobe. He was started on Zosyn.
On postoperative day 9, he was noted to have increased
erythema with exudate from around his [**Location (un) 1661**]-[**Location (un) 1662**] drain
site. Vancomycin was started. His neck incision was
partially opened but revealed no signs of infection at the
incision site.
He continued to remain stable and afebrile, tolerating a
regular diet, and ambulating often. His Vancomycin and Zosyn
were discontinued on postoperative day 12. On postoperative
day 12, his [**Location (un) 1661**]-[**Location (un) 1662**] drain from his neck was removed,
which he tolerated well.
On postoperative day 13, he was discharged to home in good
condition afebrile and vital signs within normal limits. He
was ambulating easily. He was given a seven-day supply of
Levaquin.
FOLLOW UP: The patient is to follow-up with Dr. [**Last Name (STitle) **]
within the next few days after discharge. He is to call Dr.[**Name (NI) 45689**] office at [**Telephone/Fax (1) 2981**] for a follow-up
appointment.
DISCHARGE MEDICATIONS: Protonix 40 mg once daily, Percocet 1-
2 tab p.o. q.4-6 hours as needed, Ambien 5 mg p.o. q.h.s.,
Levaquin 500 mg p.o. daily x 7 days, Metoprolol 50 mg p.o.
t.i.d., Hydrochlorothiazide 25 mg p.o. once daily, Lipitor 10
mg p.o. once daily, Aspirin 81 mg p.o. once daily, Fluoxetine
20 mg p.o. once day, Multivitamin, Albuterol Ipratropium
inhaler as needed.
MAJOR SURGICAL/INVASIVE PROCEDURES: Laparoscopic
thoracoscopic esophagogastrectomy with placement of a feeding
jejunostomy tube.
CONDITION ON DISCHARGE: Good.
DISCHARGE INSTRUCTIONS: The patient is to keep the wound
area clean and dry. He is to take his medications as
prescribed. He is to seek medical attention if he
experiences fevers, chills, nausea, vomiting, or increased
neck, chest, or abdominal pain.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern1) 16264**]
MEDQUIST36
D: [**2179-2-8**] 11:25:32
T: [**2179-2-8**] 15:56:37
Job#: [**Job Number **]
|
99812,41031,E8790,41401,4280 | 291 | 113,649 | Admission Date: [**2102-4-8**] Discharge Date: [**2102-4-12**]
Date of Birth: [**2034-2-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins / Shellfish
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Pt is a 68 yo woman with PMH of tobacco use, RA presents to ED
today with chest pain, found to have inferior/posterior STEMI
with RV involvement. Patient was in her USOH until 2 week PTA
when developed sub-sternal chest pressure w/ radiation down both
arms while raking leaves. She rested after onset of pain, and
pain resolved after 5 minutes. 1 week prior to presentation,
patient again experienced these sxs after having "an emotional
phone call". Again, pt rested and pain resolved after [**10-29**]
minutes, but she was nervous about pain, so presented to [**Hospital 2538**] on [**2102-4-3**]. At that time she was r/o for MI with
negative cardiac enzymes and underwent stress ECHO that was
negative after going 7 minutes on [**Doctor First Name **] protocol, achieving 91%
of maximum HR. Therefore patient was discharged. She then
again had a similar episode of this pain last night, associated
w/ N/V x 1, but then was able to fall asleep without sxs.
Pt then reports this evening, developed same type of substernal
chest pressure, but more severe. Patient states she was baking
pies when had onset of [**9-24**] sub-sternal chest pressure, +
radiation down arms b/l, associated with N/V x 1 and
diaphoresis. Onset of sxs was 7:30pm. Therefore pt called
ambulanace and presented to [**Hospital1 18**].
On presentation to [**Hospital1 18**], pt was initially given NTG gtt and
morphine. Found to have EKG with ST elevations in inferior
leads with reciprical ST depressions in aVL, V1-V2. R sided EKG
demonstrated ST elevations in V4, indicating RV involvment.
Therefore nitro gtt d/ced, started on IVF - received a total of
1 L fluid bolus in ED. Also started on heparin gtt, integrilin
gtt, and given plavix load 300mg x 1 in ED. Also received
benadryl, solumedrol, pepcid prior to cardiac cath given hx of
dye allergy.
Patient presented to cath lab at 10:06 PM (therefore time of
onset of pain to cath lab was approximately 2.5 hours). In cath
lab, patient found to have lesion in RCA extending into PDA and
PL - patient had 1 x stent placed in RCA-to-PDA, jailing the PL,
which was then rescued with balloon angioplasty (TIMI 3 flow
demonstrated). Also noted to have 50% LAD lesion after D1, 70%
L Cx lesion, 40% proximal RCA lesion. Hemodynamics were noted
to be CO 3.48, CI 2.02, PCWP 20, RA mean 15, PAP 46/22, RV 46/8.
Cath course c/b some bradycardia, thought [**2-16**] vagal response,
responded to atropine. Also had hypotension with SBP = 90's
intra-cath, given fluid boluses for total of 1.8L in cath (2.8L
total with 1L fluid bolus in ED). Post cath pt noted to have
small groin hematoma. Post cath EKG notable for resolution of
ST elevations, q waves in leads III and aVF. Patient had
resolution of pain in cath lab.
Currently patient feels well. Denies any chest pain/pressure,
SOB, diaphoresis, nausea, any other complaints.
ROS also negative for orthopnea, PND, LE edema.
Past Medical History:
Rheumatoid arthritis
Social History:
smokes 1-1.5 ppd x 55 years (quit on thursday - got nicotine
patch), rare EtOH, no drug use. Lives alone, 2 daughters live
nearby, also has 2 sons.
Family History:
Mother alive and well, father died in his 60's in a car
accident, has 6 brothers, no FH of CAD or DM
Physical Exam:
Vitals - Afebrile, HR 89, BP 101/85, RR 12, O2 90-92% on RA (not
SOB) -> 96% 2L NC
General - lying supine, awake, alert, pleasant, NAD
HEENT - PERRL, EOMI, dry MM
Neck - could not assess JVP as pt lying flat, no carotid bruit
b/l
CVS - RRR, nl S1, S2, no M/R/G
Lungs - CTA anteriorly and laterally - could not assess
posterior lung fields as pt lying supine
Abd - soft, NT/ND, + BS
Groin - R sided groin w/ some eccymoses, mildy tender to
palpation, ?small hematoma although difficult to assess, no
bruit ascultated
Ext - no LE edema b/l, 2+ DP pulses b/l
Neuro - A+O x 3, FROM x 4 ext
.
EKG on presentation: ST elevations in leads II, III, aVF with
reciprical ST depressions in aVL, V1-V2. R sided EKG with ST
elevation in V4.
.
Post cath EKG: Resolution of ST elevation, q waves noted in
III, aVF
Pertinent Results:
[**2102-4-8**] 09:20PM WBC-12.4* RBC-4.75 HGB-14.7 HCT-42.6 MCV-90
MCH-31.0 MCHC-34.5 RDW-15.1
[**2102-4-8**] 09:20PM NEUTS-50.9 LYMPHS-41.1 MONOS-5.5 EOS-2.2
BASOS-0.4
[**2102-4-8**] 09:20PM PLT COUNT-279
[**2102-4-8**] 09:20PM PT-11.6 PTT-19.2* INR(PT)-1.0
[**2102-4-8**] 09:20PM GLUCOSE-156* UREA N-24* CREAT-1.0 SODIUM-135
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-25 ANION GAP-18
[**2102-4-8**] 09:20PM LD(LDH)-224 CK(CPK)-87
[**2102-4-8**] 09:20PM cTropnT-0.01
[**2102-4-8**] 09:20PM CK-MB-NotDone
.
CXR ([**4-8**]): Prominence of bilateral vasculature, which may
represent
early volume overload versus mild CHF.
.
C.cath ([**4-8**]):
1. Selective coronary angiography of this right dominant system
revealed
two vessel coronary artery disease. The LMCA was patent. The LAD
had
50% stenosis after D1. The LCX had 70% OM2 stenosis. The RCA had
proximal 40% and 100% stenoses distally at the crux.
2. Resting hemodynamics demonstrated elevated right and left
sided
pressures (mean RA pressure was 15mmHg, mean PCWP 20mmHg). There
was
evidence of moderate pulmonary hypertension. The cardiac index
was
normal at 2.02 L/min/m2.
3. Successful PTCA/stenting of the distal RCA with a 3.0x18mm
Cypher DES
posted to 3.5mm in the proximal portion with excellent results
(see PTCA
comments).
.
TTE ([**4-10**]):
1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
Assessment/Plan: Patient is a 68 yo woman with PMH tobacco use,
presents with inferior/posterior STEMI with RV involvement.
.
# Cardiac:
A. Ischemia: Patient presents with inferior/posterior STEMI
with RV involvement. Course complicated by some hypotension
noted in cath lab, responsive to IVF boluses. PCWP noted to be
20 intra-cath. Initially monitored with Swan-Ganz catheter.
Received integrilin gtt x 18 hours. Cardiac enzymes trended
down.
Continued on ASA 325mg QD, Plavix 75mg QD, Lipitor 80mg QD.
Started on a beta blocker and discharged on Toprol XL. Started
on ACE-i and discharged on lisinopril. Further lipid management
deferred to outpatient setting. Discharged to follow up with
Cardiology, may need ETT-MIBI in the future. Encouraged smoking
cessation.
.
B. Pump: Patient with EF=65%, no wall motion abnormalities
noted on stress ECHO done at [**Hospital3 **] on [**2102-4-4**]. Intra
cath hemodynamics consistent with mild fluid overload, with
PCWP=20, RA=15, PAP=46/22. TTE on [**4-10**] with EF 70-75%, no wall
montion abnormality, 1+ MR, and borderline PA systolic
hypertension. Euvolemic on exam upon discharge. Discharged on
beta blocker and ACE-inhibitor as above.
.
C. Rhythm: Patient was in NSR. Given RV involvement, was felt
to be high risk for arrythmia. No signs of nodal block on EKG.
Had asymptomatic run of NSVT with stable vital signs.
Maintained and discharged on beta blocker.
.
# Hematoma: Small hematoma noted in groin site post-cath.
Remained hemodynamically stable, improved to just ecchymosis by
discharge. Hct stable.
.
# Rheumatoid Arthritis: Patient on prednisone as outpatient.
Continued on prednisone with prn Tylenol for pain.
.
# Code status: Full
.
Medications on Admission:
Prednisone 5mg [**Hospital1 **]
HCTZ 50mg QD
Advil
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferoposterior ST elevation MI
Right groin hematoma
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as prescribed.
If you experience chest pain, shortness of breath, or other
concerning symptoms, please call your doctor or go to the ER.
Followup Instructions:
1) PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**], [**2102-4-17**] at 2:30pm, ([**Telephone/Fax (1) 35385**].
2) Cardiology: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], [**2102-5-4**] at 10:00am,
([**Telephone/Fax (1) 11814**].
Completed by:[**2102-9-13**] |
41041,78551,99672,E8798,7140,41401,V5865,3051,72400,53190 | 291 | 125,726 | Admission Date: [**2106-4-17**] Discharge Date: [**2106-4-19**]
Date of Birth: [**2034-2-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins / Shellfish
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization with Bare metal stent to mid and distal
right coronary artery.
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: 72 yo woman with h/o CAD s/p IMI
[**2102**](LAD had 50% stenosis after D1, LCX had 70% OM2 stenosis,
RCA with proximal DES) presents with chest pain 2 hours. Per the
patient, she was taking a shower when she noticed some chest
tightness at 8:30am. She took some nitroglycerin and her chest
pain seemed to resolve. 15 minutes later the pain returned and
continued to progress. She described it as a severe pressure,
substernal that radiated to both arms (L>R). She denied any SOB,
nausea, vomitting, diarrhea, fevers, chills, cough, diaphoresis.
She decided to come to the ED for further evaluation.
In the ED, she had the following vital signs: 98.2 80 85/62 12
98%NRB. Her EKG revealed ST elevations in the inferior leads and
reciprocal depressions in the lateral leads. She was sent to the
cath lab for revascularization.
In the cath lab, she underwent angiography which showed no
obstructive disease in the LMCA, LAD, LCX. It did show 99%
stenosis of the distal RCA secondary to a clot. They also
noticed a mid RCA lesion of approximately 90%. They aspirated
the clot in the distal RCA placed 2 bare metal stents in the
distal and the mid-RCA. Her pain, ST elevations, and hypotension
all resolved promptly after this intervention. She was sent to
the CCU for further management.
In the CCU, the patient remained chest pain free. She denies any
symptoms and claimed she felt much better.
.
On review of systems, she denies any prior history of joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Tobacco abuse (60 pack year)
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
COMMENTS:
CATH REPORT [**3-20**]:
1. Selective coronary angiography of this right dominant system
revealed two vessel coronary artery disease. The LMCA was
patent. The LAD had 50% stenosis after D1. The LCX had 70% OM2
stenosis. The RCA had proximal 40% and 100% stenoses distally at
the crux.
2. Resting hemodynamics demonstrated elevated right and left
sided
pressures (mean RA pressure was 15mmHg, mean PCWP 20mmHg). There
was
evidence of moderate pulmonary hypertension. The cardiac index
was
normal at 2.02 L/min/m2.
3. Successful PTCA/stenting of the distal RCA with a 3.0x18mm
Cypher DES posted to 3.5mm in the proximal portion with
excellent results (see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated filling pressures.
3. Successful stenting of the RCA.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Rheumatoid arthritis with moderate joint deformity requiring
chronic prednisone and methotrexate therapy.
Spinal stenosis with radiculopathy.
Chronic back pain
Social History:
-Tobacco history: 1 PPD for 60 years
-ETOH: None
-Illicit drugs: None
-Used to work as a farmer, grew up in Novascotia
Family History:
No family history of early MI.
Mom - deceased, Alzheimer's. Father - deceased at 54 y.o. in a
car accident, has 6 brothers and 1 sister, no FH of CAD or DM. 1
Brother died of gastric cancer. One brother has [**Name (NI) 2481**].
Physical Exam:
VS: T=98.2 BP=144/88 HR=94 RR=20 O2 sat=100% NRB
GENERAL: Overweight elderly woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP wnl.
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.
EXTREMITIES: No c/c/e. Groin without hematoma, TTP, or bruit.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses 2+ bl,
Pertinent Results:
ADMISSION:
[**2106-4-17**] 10:55AM BLOOD WBC-13.7* RBC-4.24 Hgb-13.2 Hct-40.0
MCV-94 MCH-31.0 MCHC-32.8 RDW-17.2* Plt Ct-355
[**2106-4-17**] 10:55AM BLOOD PT-12.2 PTT-22.5 INR(PT)-1.0
[**2106-4-17**] 10:55AM BLOOD Neuts-58.8 Lymphs-31.4 Monos-6.0 Eos-2.9
Baso-0.9
[**2106-4-17**] 10:55AM BLOOD Glucose-124* UreaN-18 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-26 AnGap-13
[**2106-4-17**] 10:55AM BLOOD CK(CPK)-44
[**2106-4-17**] 08:19PM BLOOD CK(CPK)-278*
[**2106-4-18**] 05:27AM BLOOD CK(CPK)-250*
[**2106-4-19**] 07:00AM BLOOD CK(CPK)-119
[**2106-4-17**] 10:55AM BLOOD cTropnT-<0.01
[**2106-4-17**] 08:19PM BLOOD CK-MB-35* MB Indx-12.6* cTropnT-0.38*
[**2106-4-18**] 05:27AM BLOOD CK-MB-31* MB Indx-12.4* cTropnT-0.36*
[**2106-4-19**] 07:00AM BLOOD CK-MB-7 cTropnT-0.26*
[**2106-4-19**] 07:00AM BLOOD Calcium-8.7 Phos-3.3# Mg-2.0
[**2106-4-17**] 11:02AM BLOOD K-3.5
DISCHARGE:
[**2106-4-19**] 07:00AM BLOOD WBC-12.2* RBC-3.60* Hgb-11.4* Hct-33.9*
MCV-94 MCH-31.8 MCHC-33.7 RDW-17.1* Plt Ct-252
[**2106-4-19**] 07:00AM BLOOD Plt Ct-252
[**2106-4-19**] 07:00AM BLOOD Glucose-74 UreaN-18 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-30 AnGap-10
EKG [**2106-4-17**]:
Sinus rhythm with two to three millimeter ST segment elevation
in the inferior leads and one millimeter ST segment elevation in
leads V4-V6. ST segment depression of one to two millimeters in
leads V1-V2 and ST segment depression of two millimeters in lead
aVL. This is consistent with a large area of nterolateral,
inferior and posterior myocardial infarction. Compared to the
previous tracing of [**2104-7-2**] acute injury pattern in the
inferior-posterior region is new.
ECHO [**2106-4-19**]:
The left atrium and right atrium are normal in cavity size.
There is mild regional left ventricular systolic dysfunction
with mild hypokinesis of the basal inferior and inferolateral
segements. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a promient fat pad.
IMPRESSION: Mild focal LV systolic dysfunction consistent with
inferior ischemia/infarction. No pathologic valvular abnormality
seen. Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2102-4-10**],
mild inferior and inferolateral hypokinesis is seen on the
current study.
CARDIAC CATHETERIZATION [**2106-4-17**]:
1. Cardiac catheterization in this right dominant system
revealed single
vessel coronary artery disease. The LMCA, LCX, and LAD were
without
significant obstructive coronary artery disease. The RCA had a
90%
stenosis in the mid-portion, and a 99% stenosis with thrombus in
the
distal portion.
2. Resting hemodynamics revealed normal blood pressure of 121/72
mmHg.
3. Successful PTCA, manual aspiration thrombectomy, and
placement of a
4.0x12mm Vision bare-metal stent in the mid RCA and a 3.5x12mm
Vision
bare metal stent in the distal RCA were performed. Final
angiography
showed normal flow, no apparent dissection, and a 5% residual
stenosis
in the mid RCA. (See PTCA comments.)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Placement of bare metal stents in the mid and distal RCA.
Brief Hospital Course:
72 yo woman with h/o CAD (LAD had 50% stenosis after D1, LCX had
70% OM2 stenosis, RCA with proximal DES) presents with inferior
STEMI due to late stent thrombosis (4 years later), now s/p BMS
x 2 in mid and distal RCA.
.
# STEMI: Patient with inferior STEMI that was successfully
treated with thrombectomy and PCI with 2 BMS placed one in the
99% occluded distal RCA and another in the 90% occluded mid RCA
lesion. Pt also with hypotension on presentation suggestive of
cardiogenic shock, which has since resolved after PCI in mid and
distal RCA. This may also have been secondary to nitroglycerin.
Pt was treated with integrillin for a total of 18 hours, started
and continued on aspirin 325mg PO Daily, supplemental O2, Plavix
loaded and then 75mg PO Daily, and simvastatin increased from
20mg PO daily to 80mg PO daily. Heart rate was kept near 60 and
BP<140/90, by adding metoprolol 12.5mg PO TID as pressures allow
and uptitrated to 25mg PO TID. The CCU team strongly encouraged
smoking cessation (spent 15 minutes with pt who has been
precontemplative, but now will consider quitting). TTE showed
normal systolic global function (EF 55%) but with inferior
hypokinesis c/w IMI. Pt was continued on a low sodium diet and
physical therapy was consulted. The pt had some episodes of mild
ectopy with a few runs of NSVT. The patient remained CP free
since the catheterization for the remainder of the admission.
The patient was scheduled to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in cardiology on
[**2106-5-21**].
.
# Rheumatoid arthritis: No active issuses. Continued Prednisone
5mg PO daily. Pt to continue weekly MTX tx at home. Continued
gabapentin for chronic pain.
Medications on Admission:
Gabapentin 100 mg PO TID
Prednisone 5 mg PO DAILY
Metoprolol Tartrate 25mg PO BID
Folic Acid 1 mg PO DAILY
Simvastatin 20 mg PO DAILY
Aspirin EC 81 mg PO DAILY
Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain
HCTZ 25mg PO Daily
Calcium/Vitamin D
Vitamin B12
Discharge Medications:
1. Tylenol Ex Str Arthritis Pain 500 mg Tablet Sig: 1-2 Tablets
PO three times a day as needed for pain: no substitutions.
Disp:*270 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 6 weeks.
Disp:*30 patches* Refills:*1*
5. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks.
Disp:*14 patches* Refills:*0*
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain:
take up to 3 tablets 5 minutes apart, call 911 if you still have
chest pain after 3 tablets. .
Disp:*25 Tablet, Sublingual(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Cyanocobalamin 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Calcium Oral
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check CBC on Wednesday [**4-21**] and call results to Dr.
[**Last Name (STitle) 3142**] at [**Telephone/Fax (1) 19980**].
Diag 280.0
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Coronary Artery Disease
.
Secondary:
Rheumatoid Arthritis
Gastric Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack because the stent in your right coronary
artery was partially clotted and because of a new blockage in
the same artery. The artery was fixed and 2 new bare metal
stents have been placed. You will need to take aspirin and
Plavix every day for at least one month and probably longer to
keep the stents open. Do not stop taking aspirin and Plavix
unless Dr. [**Last Name (STitle) **] tells you not to. You will see your new
cardilogist and should go to cardiac rehab when Dr. [**Last Name (STitle) **]
tells you it is OK. Please stop smoking to prevent another heart
attack and to make your new medicines more effective. This is
the single most important thing you can do for your health.
Medication changes:
1. Start taking Aspirin (increase to 325 mg) and Plavix every
day to keep the stent from clotting off
2. Increase the Simvastatin to 80 mg daily
3. Change the short acting Metoprolol to long acting (Succinate)
and take 1.5 tables daily
4. Stop taking Hydrochlorothiazide
5. Do not take Motrin or Aleve for your arthritis pain, take the
high dose Tylenol instead.
6. Start using a nicotine patch to help you quit smoking. You
will take 14mg every day for 6 weeks, then the dose is decreased
to 7mg for an additional 2 weeks.
7. Take nitroglycerin for chest pain as described in the
handout. If you take this medicine, make sure to call Dr.
[**Last Name (STitle) **].
8. Stop taking Prilosec (the purple pill) as this can interfere
with the Plavix. You can take Ranitidine instead twice daily.
Please talk to Dr. [**Last Name (STitle) **] about this.
.
Your blood count went down after the procedure. We would like
you to check the blood count again on Wednesday [**4-21**]. You
can go to the hospital at [**Location (un) 620**].
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 198**] P. Phone: [**Telephone/Fax (1) 19980**] Date/time: Office will
call you with an appt.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 4105**] Date/time: Wednesday [**5-21**] at 11:30am.
.
Gastroenterology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: Phone: ([**Telephone/Fax (1) 41626**] Date/time: please keep any
scheduled appts.
.
Rheumatology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2106-4-27**] 10:30
Completed by:[**2106-4-20**] |
1983,3485,1629,2536,78701,4019,V4986,41401,V4582,7140,2724 | 291 | 126,219 | Admission Date: [**2107-9-13**] Discharge Date: [**2107-9-16**]
Date of Birth: [**2034-2-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Penicillins / Shellfish / Latex / Bee
Pollen
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
nausea and vomitting and altered mental status.
Major Surgical or Invasive Procedure:
Whole brain radiation.
History of Present Illness:
73F w/ metastatic lung cancer to brain, on radiation therapy,
here with severe nausea and vomiting since this morning; sent
from Rad [**Hospital **] clinic with severe hypertension and nausea/vomiting
concerning for increased intracranial pressure. She was recently
admitted to [**Hospital1 18**] from [**Date range (3) 48728**] with hypoxia and back
pain; nausea and vomiting. Patient's symptoms completely
resolved with dexamethasone, complicated by steroid-induced
psychosis. Also initiated whole-brain radiation while in-house
and continued to see rad onc following discharge. She had been
on a dexamethasone taper following discharge. Currently on 2g
[**Hospital1 **].
.
Pt somnolent but arousable. States that she has not had any
other symptoms, including headaches, changes in vision,
dizziness, weakness, or numbness. Reports exhaustion from not
being able to sleep for 1.5d due to vomiting and nausea. States
that she was vomiting "all day yesterday" and "every half hour"
this morning. Pt reports fatigue and sleepiness. Pt A&O to
"hospital, somewhere near [**Location (un) 620**], year [**14**]--, 20-- don't know".
.
In the ED, triggered for hypertension.
Initial vitals were: 16:30 0 98.9 65 170/111 16 97% 2L Nasal
Cannula.
BP --> 16:45 225/119 --> 17:00 179/100
Patient was somnolent but arousable. Neuro exam somewhat limited
by Pt's lack of participation, pupils pinpoint CN 2-12 intact.
Lungs: bibasilar crackles.
EKG: normal sinus rhythm, HR 70, left shifted axis, normal
intervals. 1mm PR depression in V2, V2. Peaked T waves V2, V3. T
wave inversion V1. Consistent with prior.
Labs: show elevated K to 5.6, hemolyzed. Repeat lab -> K 4.0.
CT head w/out contrast: vasogenic edema unchanged, but right
parietal hyperdense lesion is more conspicuously hyperdense and
slightly increased in size than on the prior. This degree of
increased hyperdensity would not be expected in the interval and
raises concern for intralesional hemorrhage.
.
Neurosurgery consulted: feel that Pt's N/V related to WBXRT and
decadron taper. Recommended no acute neuro intervention.
Increase dexa to at least 6mgQ6h standing.
She was started on dexamethasone 6mg IV q6hrs.
On re-exam, Pt's BP improved to 140s/80s w/ only dexamethasone.
Pt is sleeping peacefully.
Past Medical History:
1. Coronary artery disease -S/p inferior/posterior STEMI with
RV involvement [**3-20**] with BMS to distal RCA. Repeat BMS x 2 to
same RCA lesion in [**4-/2106**]
2. Stage IV lung cancer metastatic to brain
3. Hyperlipidemia
4. Rheumatoid arthritis
5. Hypertension
6. Lumbar DJD
7. Basal cell carcinoma of the nose
Social History:
She is widowed and lives alone in senior housing.
She has four children, two daughters and two sons. One son lives
out of state but the others are local. Originally from [**Location (un) 48726**]. She smoked one pack a day of cigarettes for the past 60
years and continues to smoke. Alcohol rare.
Her daughter, [**Name (NI) 1439**] may be reached at [**Telephone/Fax (1) 48724**]. Her
daughter
[**Name (NI) **] may be reached at [**Telephone/Fax (1) 48727**].
Family History:
Mother died of [**Name (NI) 2481**] disease. Father died
at age 54 from an MVA. She has six brothers, one deceased from
cancer ?prostate, another had Alzheimer's disease. One sister
alive and well.
Physical Exam:
Admission Physical Exam:
Vitals: afebrile 149/84 92 14 95% RA
General: Alert, orientedx1-2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRLA
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally. Mild bibasal crackles.
CV: Regular rate and rhythm, normal S1 + S2, SEM II/VI
nonradiating
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing. 1+ pitting
edema on lower extremity to shins bilateral.
.
Discharge Physical Exam:
Vitals: 95.4, 142/84, 53, 20, 96%RA
I/O: 780/470 + large BM this AM
Physical Exam:
General: A&O X 2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRL.
Neck: supple, no JVD, no LAD
Lungs: Clear to auscultation bilaterally.
CV: RRR, normal S1 + S2, SEM II/VI nonradiating
Abdomen: soft, NT/ND, bowel sounds (+), no rebound/guarding, no
HSM
Ext: warm, well perfused, 2+ pulses, no clubbing. no edema.
Pertinent Results:
Labs at Discharge:
[**2107-9-15**] 06:20AM BLOOD WBC-13.6* RBC-4.13* Hgb-12.4 Hct-37.1
MCV-90 MCH-30.0 MCHC-33.4 RDW-16.6* Plt Ct-316
[**2107-9-15**] 06:20AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0
[**2107-9-15**] 06:20AM BLOOD Glucose-117* UreaN-32* Creat-0.7 Na-135
K-4.9 Cl-99 HCO3-25 AnGap-16
[**2107-9-15**] 06:20AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.3
.
Studies & Imaging:
[**2107-9-13**] ECG: Baseline artifact. Sinus rhythm with atrial
premature beats. Left axis deviation. Left anterior fascicular
block. Inferior myocardial infarction, age indeterminate.
Compared to the previous tracing of [**2107-9-4**] the atrial premature
beats are new.
Rate PR QRS QT/QTc P QRS T
70 154 76 388/405 66 -55 46
.
[**2107-9-13**] CT HEAD W/O CON: Increased size of the hyperattenuated
focus with a more amorphous appearance raises suspicion for a
possible intralesional hemorrhage of the right parietal
metastasis. Otherwise, unchanged degree of vasogenic edema in
the right parietal lobe. The other masses demonstrated on the
previous MR are not well identified on this nonenhanced CT
study.
.
[**2107-9-15**] ECG: Sinus rhythm with premature atrial and ventricular
complexes. Marked left axis deviation. Inferior myocardial
infarction of indeterminate age. Delayed R wave progression.
Compared to the previous tracing of [**2107-9-13**] the findings are
similar.
Rate PR QRS QT/QTc P QRS T
72 150 76 376/397 62 -53 29
Brief Hospital Course:
This is the brief hospital course for a 73 year-old female with
non-small cell lung carcinoma metastatic to the brain who
presented here for evaluation of nausea, vomitting, and altered
mental status. The following medical issues were addressed
during this admission:
.
# BRAIN METASTASES: She presented with nausea, vomitting, and
hypertension. CT scan was suspicious for intralesional brain
hemorrhage in the right parietal metastasis and notable for an
unchanged degree of vasogenic edema in that same parietal lobe.
Her nausea and vomitting were thought to be due to her
intracranial processes and changes caused by weaning from
decadron and the most recent episode of whole brain radiation
which the patient underwent. She was started on 6 mg
Dexamethasone every 6 hours per neurosurgery recommendations,
and after discussion with the cardiology service primary
medicine team, and her family, her Plavix was discontinued as
the risks of intracranial bleeding was thought to outweigh the
benefits of blood thinning to prevent myocardial ischemia and
stent re-stenosis.
.
# HYPERTENSION: She presented with systolic blood pressures in
the 220s. This was thought to be due to her intracranial process
following weaning from decadron and also cerebral changes
post-whole brain radiation. She was started on 6 mg
Dexamethasone every 6 hours per neurosurgery recommendations,
and her systolic blood pressures normalized to 110s to 140s.
.
# ALTERED MENTAL STATUS: Psychiatry was consulted given the
patient's history of steroid induced psychosis, and they
recommended starting Seroquel nightly at 12.5mg and once the
patient's QTC was checked for prolongation, she was increased to
a dose of 25mg nightly prior to bedtime.
.
# RHEUMATOID ARTHRITIS: This issue was stable and the patient
remains on her Methotrexate and steroids for disease control.
.
# CORONARY ARTERY DISEASE: This issue was stable and the patient
continues on ASA 81 mg daily, but has been discontinued from her
clopidogrel dose for reasons listed above.
.
# HYPERLIPIDEMIA: This issue was stable and the patient
continues on simvastatin 40 mg daily.
.
The patient was discharged home to the facility in [**Location (un) 745**] where
she was prior to admission. She was upset that she was not going
home, but cooperated. She will have 2 more radiation treatments
for her brain disease, and remains DNR/DNI.
Medications on Admission:
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. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
q5min as needed for chest pain.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
12. haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for agitation.
13. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours): initiating taper on [**9-7**] of 3mg q12 for 5 more days, 2g
[**Hospital1 **] x7d, 1g [**Hospital1 **] x7d, 1g qd x7d and then stop
.
Disp:*90 Tablet(s)* Refills:*0*
14. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
15. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Six (6) Tablets, Dose Pack PO once a week: Take weekly on
Sunday.
16. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
17. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
spoonful PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
12. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
13. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Six (6) Tablets PO Q sundays.
14. haloperidol 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for acute agitation: Please only use if acute
agitated.
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever or pain.
16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual every 5-10 minutes as needed for chest pain for 3
doses.
17. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
18. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Expired
Facility:
[**Hospital 745**] health care center
Discharge Diagnosis:
Non-small cell lung carcinoma
Metastases to brain
Coronary Artery Disease
Hypertension
Steroid Psychosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory- requires assistance or aid
(walker/cane).
Discharge Instructions:
Dear [**Known firstname **],
It was a pleasure to take care of you during your hospital stay.
You were admitted to the hospital because your family and
neighbors noticed a change in your mental status. Tests were run
to look inside your brain at the sites where the cancer is. The
tests did NOT show any current areas of bleeding, but this will
be a constant concern for you from here on out. For this reason,
your doctors have decided, along with your children, that it is
in your best interest to no longer take the medication called
Plavix. This medicine is a blood thinner and can predispose you
to brain bleeding. You were originally on the medication because
of your heart disease. Stopping the medication will place you at
a high risk of getting a blockage in one of your heart's
artery's again. We discussed this with your children and your
other doctors here at the hospital, and everyone agreed that the
risks of taking this medication heavily outweighed the benefit.
Please STOP the following medications:
-Plavix (Clopidegrel)
Please INCREASE the dose of the following medications:
-Quetiapine (Seroquel) now 25mg every night at bedtime
Followup Instructions:
You are already scheduled for the remaining two radiation
treatments. Please have the staff at [**Location (un) 745**] arrange
transportation for you to these appointments and back. The
appointments are:
.
Tuesday, [**2107-9-21**] @ 2:45PM
Wednesday, [**2107-9-22**] @ 2:45PM
.
Both of the appointments are at [**Hospital1 1170**] in [**Location (un) 86**] on the [**Hospital Ward Name **] in the department of
radiation oncology.
.
You may be contact[**Name (NI) **] by your oncologist for additional
follow-up. Meanwhile, the physicians at the [**Location (un) 745**] facility will
be caring for your immediate, acute medical needs.
Completed by:[**2107-10-21**] |
2765,0389,78559,5761,45620,78039,2762,7895,5723 | 292 | 179,726 | Admission Date: [**2103-9-27**] Discharge Date: [**2103-9-28**]
Date of Birth: [**2046-9-17**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 57-year-old female
with history of primary sclerosing cholangitis, inferior
myocardial infarction, and sepsis who fell eight feet onto a
concrete floor on [**2103-9-18**] and broke her right sacrum, right
proximal femur, inferior superior rami, left humeral neck and
nondisplaced right orbital fracture. She presented to the
[**Hospital6 16029**] where CT Scan of the C spine was
negative and where patient received open reduction internal
fixation of the right femur.
On [**2103-9-18**], CT Scan of the head revealed right
intraparenchymal frontal bleeding subarachnoid bleed. The
patient was transfused with two packed red blood cells, eight
units of platelets while in the ICU there. On [**2103-9-21**], the
patient was transferred to the floor at [**Hospital1 11485**]. On
[**2103-9-25**], the patient had an episode of hematemesis and was
transferred to the [**Hospital1 11485**] ICU where she received two units
of platelets.
On [**2103-9-26**], the patient had another episode of hematemesis
and was then brought for EGD where they sclerosed a 3.5 rent
in the lower esophagus. The patient also received one unit
FFP and Octreotide. On [**2103-9-27**], the patient was then
transferred to [**Hospital1 69**] with the
following medications.
ADMISSION MEDICATIONS:
1. Oxycodone.
2. Propanolol.
3. Percocet.
4. Colace.
5. Spironolactone.
6. Actigall.
7. Lactulose.
8. Octreotide.
9. Levophed.
On the air transfer to the [**Hospital1 188**], patient's Levophed had to be increased from 14 to 20
mcg per hour. She also received 750 cc of IV fluids, 2 mg
Ativan and 2 units of packed red blood cells during the air
transfer.
ALLERGIES: None.
MEDICATIONS AT HOME:
1. Actigall 300 mg p.o. q.i.d.
2. Zestoretic 10/12.5 one tablet p.o. q.d.
3. Aldactone 50 mg p.o. b.i.d.
4. Levoxyl 100 mcg p.o. q.d.
5. Propanolol 20 mg p.o. b.i.d.
6. Prilosec 20 mg p.o. q.d.
PAST MEDICAL HISTORY:
1. Two cesarean sections.
2. [**2098**] inferior myocardial infarction with arrest and
cardioversion.
3. Hypothyroidism.
4. Hernia.
5. Cholecystectomy.
6. Pneumonia with sepsis in [**2099**].
7. In [**2097**] primary sclerosing cholangitis by ERCP biopsy.
8. In [**2102**], ascites with Klebsiella bacteremia treated with
Gentamycin and Ciprofloxacin.
9. [**2103-7-12**], ascites with liver transplant work up by
[**Hospital1 69**].
PHYSICAL EXAMINATION: On admission with a temperature of
97.2 F, pulse 88, blood pressure 104/63 on a ventilator SIMV
700 times 15 with a PEEP of 5 and FIO2 of 100%. Generally
this patient is intubated and not arousable to painful
stimuli. Head, eyes, ears, nose and throat: She had right
orbital ecchymosis. Pupils are 8 mm, fixed and dilated
bilaterally with sluggish reaction to light. Tympanic
membranes are normal. Icteric eyes and bloody oropharynx.
Neck is supple. Cardiovascular: Regular rate and rhythm.
Normal S1, S2. No murmurs or thrills noted. Chest: Coarse
rhonchi heard bilaterally. Abdomen is distended with
positive fluid wave. Extremity: +3 pedal edema bilaterally
in the upper and lower extremities. Lower extremities are
cool to touch. Skin: Jaundice noted, but no spider angiomas
noted. There is no caput medusas seen.
LABORATORY: Upon admission labs were a white count of 38.1
with the following differential of 54% neutrophils, 34%
bands, 5% lymphocytes and 4% monocytes. Hematocrit was 22.4,
platelets 198,000. Sodium 135, potassium 5.5, chloride 104,
bicarbonate 13, BUN 40, creatinine 1.0, anion gap 18, glucose
84, calcium 8.1, phosphorus 4.4, magnesium 1.6. PT 20.5, PTT
35.1, INR 2.9. Total bilirubin is 11, ALT 75, AST 163,
amylase 385. Albumin 2.0, LDH 651, alkaline phosphatase 164,
lipase 56, fibrinogen 145, Fibrogen degradation products is
80 to 160. D-dimer is greater than 2,000.
ABG is 7.42 with pCO2 of 21 and pO2 of 250 on tidal volume is
700 with respiratory rate of 15, PEEP of 5 and FIO2 of 100.
Urinalysis is hazy with large blood and positive nitrates, 30
protein and 100 glucose is noted. Urine micro shows six to
10 red blood cells with greater than 50 white blood cells and
many bacteria. Urine blood and acidic cultures are pending.
Serum osmolality pending. Ascites chemistry with a protein
of 1.5, glucose 108, creatinine 0.8, LDH 100, amylase 12,
total bilirubin 2, albumin 0.6, lactate 13.8.
HOSPITAL COURSE:
1. GI: Hepatology Team was consulted and they decided not
to perform an EGD at this time due to the patient being
hemodynamically unstable. Instead, an oral gastric tube was
placed and we lavaged 1.6 liters of dark blood. A
paracentesis was performed and 3.5 liters of acidic fluid was
removed. The patient was continued on Octreotide and given
Protonix 40 mg IV b.i.d. for prophylaxis. The patient was
typed and crossed, but we were unable to get any blood for
transfusion due to difficult type and cross.
2. CARDIOVASCULAR: Hypotension, the Levophed was increased
to 30 mcg per kilogram per minute, however patient remained
hypotensive so Vasopressin 0.04 units per minute was added.
The patient was also bolused with one liter of normal saline
every hour. Since no packed red blood cells were available,
the patient was infused with 25 grams of Albumin. Finally,
Dopamine was added at 10 mcg per kilogram per minute to
control the low blood pressure. The patient's blood pressure
on these triple pressures and fluid boluses was still
settling around a systolic blood pressure of 80.
3. RESPIRATORY: The patient was initially put on SIMV at
700 cc times a respiratory rate of 15 with PEEP of 5 and FIO2
of 100%. Since the ABG shows quite a low CO2 and high PO2,
the patient was switched over to assist-control at 550 cc
times 15 with a PEEP of 5 and FIO2 of 60%. Her ABG at this
time showed a pH of 7.34, CO2 21 and pO2 of 144. However,
patient was overbreathing the respiratory with additional
respiratory rate of 30 rather than the set 15. So she was
switched over to assist-control 550 cc with a respiratory
rate of 30, PEEP of 5 and FIO2 of 60%. It is believed that
the patient is overbreathing to compensate for her metabolic
acidosis.
4. RENAL: The patient did have a high BUN and a normal
creatinine. These values reflect that the patient was having
an upper GI bleed. She also had a metabolic acidosis with
anion gap. It is believed that this is due to the lactate
production due to the ischemia both to her organs. We
attempted to maintain a blood pressure above systolics of 80s
to profuse her organs, however her metabolic acidosis
continued to worsen with a anion gap of 20 and bicarbonate of
11. She was also overbreathing with less CO2 compensation.
Her gasses were showing a pH of 7.18 with a pCO2 of only 27.
5. INFECTIOUS DISEASE: Patient was initially given
Levofloxacin 500 mg times one for prophylaxis for possible
EGD. Since her white count was shown to be 38 with a large
bandemia, we started Ceftazidine 2 grams IV t.i.d. for
treatment of primary spontaneous bacterial peritonitis. We
also attempted to pan culture her which showed no results at
this time.
6. NEUROLOGICALLY: At 2 AM, the patient began to have
seizures. She was given 200 mg of Fosphenytoin, 40 mg of
Ativan and 20 mg of Valium. From 2 AM to 10 AM, the patient
was only able to stop seizing for a couple of minutes for
about three to four times throughout the whole period. We
were finally able to obtain a CT Scan of the head which
revealed diffuse cerebral edema and effacement of the sulci.
No extraocular hemorrhage was found. There were punctate
areas of high attenuation in the right frontal cortex that
likely represented a contusion.
Also, it seems that her cerebral tapholes were heading toward
herniation. Neurosurgery was consulted, but no treatment
could be given at this time. Neurology was consulted and en
EGD was obtained showing electrical activity representing
myoclonic actions. This myoclonic activity is likely due to
hypoxic injury to brain.
Neurology informed the Team who then informed the family of
the poor neurologic prognostic factors. Patient continued to
receive Phenobarbitol and then was put on a Propofol drip for
her presumed seizure activity at the time. She was also
given 25 gram of Mannitol to lessen the cerebral edema.
DISPOSITION: Around 12:45 PM on [**2103-9-28**], the patient's
family did visit her. After the visit, the family decided
that the patient should be comfort measures only. Her
pressor medications were stopped. Then the patient was
extubated. At 1:08 PM on [**2103-9-28**], Mrs. [**Known firstname 501**] [**Known lastname 42396**]
passed away due to hypovolemic and septic shock.
DISCHARGE DIAGNOSES:
1. Hypovolemic and septic shock.
2. Upper GI bleed secondary to esophageal tear.
3. Ascites secondary to portal hypotension which is
secondary to the primary sclerosing cholangitis.
4. Cerebral edema secondary to hepatic failure.
5. Ischemic hepatitis.
6. Sepsis.
7. Lactic metabolic acidosis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2103-9-30**] 13:26
T: [**2103-10-3**] 11:13
JOB#: [**Job Number **]
|
7455,3963,20190,41401,V1259 | 293 | 125,963 | Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-13**]
Date of Birth: [**2078-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Iodine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Migraines/Stroke
Major Surgical or Invasive Procedure:
[**2125-2-9**] - Right Main coronary artery stent placement (Dr.
[**Last Name (STitle) **]
[**2125-2-9**] - ASD closure via mini right thoractomy with Perclose
device (Dr. [**Last Name (STitle) 1290**]
History of Present Illness:
This is a 46 year old female who had suffered a CVA back in
[**2114**]. Work up revealed an atrioseptal defect which was not
amenable to the standard device closure. She also had right
coronary ostium stenoses. The echocardiogram
showed that she had a small atrioseptal defect with
bidirectional flow. It was, therefore, recommended that she
have closure of this ASD. The plan was also to schedule her to
have a stent of her right main coronary ostium at the same time.
Past Medical History:
Migraines
Anemia
Hodgkins lymphoma s/p chemo and XRT
Stroke [**2114**]
ASD
Pneumonia
Sternotomy with mediastinal mass
partial left lung resection via left thoracomtomy
Social History:
Geneticist. lives with husband and 4 children.
Family History:
Noncontributory.
Physical Exam:
Vitals: BP 120/66, HR 93, RR 16
General: well developed female in no acute distress
HEENT: oropharynx benign, poor dental health
Neck: supple, no JVD
Heart: regular rate, normal s1s2, soft systolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, trace edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2125-2-13**] 07:55AM BLOOD Hct-28.0*
[**2125-2-11**] 04:35AM BLOOD Plt Ct-207
[**2125-2-13**] 07:55AM BLOOD UreaN-7 Creat-0.6 Na-141 K-4.1
[**2125-2-12**] CXR
Small bilateral pleural effusions, left greater than right,
which developed between [**1-29**] and [**2-11**], is slightly
smaller today. Aside from severe scarring and radiation-induced
bronchiectasis in the left upper lung, lungs are clear. Heart is
normal size. Preoperative leftward tracheal deviation due to
this scarring is partially obviated by the left pleural
effusion.
[**2125-2-9**] ECHO
Pre device closure of the ASD using a Perclose device. The left
atrium is normal in size. A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present.
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets(3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. TEE guidance was used to help
with placement of the wire and catheter across the interatrial
septum. Dr [**First Name (STitle) 6507**] also present during the procedure to help
with the TEE and concur with the findings.
Post device closure of the ASD
There is no flow demonstrable across the interatrial septum with
color flow doppler. LV and RV systolic function appear to be
normal.
[**2125-2-9**] Cardiac Catheterization
1. Single vessel coronary artery disease.
2. Normal central blood pressures.
3. Successful placement of bare metal stent in ostial RCA.
4. Successful placement of Perclose Proglide in left femoral
arteriotomy.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname 64720**] was admitted to the [**Hospital1 18**] on [**2125-2-9**] for
surgical management of her atrial septal defect and her coronary
artery disease. She was taken to the operating room where she
underwent successful stenting of her right coronary artery and
an atrial septal defect closure. Please see operative note for
details of surgical intervention. Postoperatively she was taken
to the cardiac surgical intensive care unit for monitoring.
Plavix was started for her stent. On postoperative day one, Mrs.
[**Known lastname 64720**] awoke neurologically intact and was extubated. On
postoperative day two, she was transferred to the cardiac
surgical step down unit for further recovery. She was gently
diuresed towards her preoperative weight. Beta blockade was
initiated and titrated for optimal heart rate and blood pressure
control. She remained in normal sinus rhythm with stable
hemodynamics. Mrs. [**Known lastname 64720**] continued to make steady
progress and was discharged home on postoperative day three. She
will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her
primary care physician as an outpatient.
Medications on Admission:
Fosamax
Excedrin
Imitrex
Multivitamin
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
ASD
Migraines
Coma/Seizure
Hodgkin's Lymphoma s/p Chemo/XRT
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 1290**] in four weeks [**Telephone/Fax (1) 170**]
follow up with Dr. [**Last Name (STitle) 5448**] in [**11-27**] weeks [**Telephone/Fax (1) 64721**]
follow up with Dr. [**Last Name (STitle) 20222**] in [**12-29**] weeks [**Telephone/Fax (1) 20223**]
Completed by:[**2125-2-13**] |
41071,99674,5845,44024,2760,29281,E9379,25000,725,V5865,9999,99812 | 294 | 152,578 | Admission Date: [**2118-1-17**] Discharge Date: [**2118-2-2**]
Date of Birth: [**2039-5-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer from outside hospital for PVD/left foot ischemia
and NSTEMI
Major Surgical or Invasive Procedure:
-cardiac catheterization, stenting of LAD
-left common femoral artery - DP bypass
History of Present Illness:
78yo man with 30year history of HTN, 15 year history of DM, PMR
on steroids, and inferior wall MI in [**2108**] who was admitted to
[**Hospital3 **] on [**1-14**] with an ischemic left foot.
Angiography showed SFA occluded and occluded popliteal above the
knee. PTA was done of the mid popliteal with dissection of the
politeal below the knee, which was stented. Post procedure, he
ruled in for NSTEMI and suffered cardiogenic shock. He was on
pressors, natrecor, and intubated. Subsequently, the leg
worsened, becoming cool and cyanotic. He was then referred to
[**Hospital1 18**] for further management.
At [**Hospital1 18**], he underwent cardiac catheterization with stenting of
the LAD. He also had angio/thrombectomy/tpa infusion of left
SFA on [**1-17**]. He then underwent left CFA to DP bypass on [**1-20**].
Of note, creatinine was 1.7 on admission, which trended upward
to 5.7 on [**1-22**].
Past Medical History:
Hypertension
DM II
CAD with inferior wall MI in [**2108**] (no catheterization)
PMR on steroids
peripheral [**Year (4 digits) 1106**] disease
h/o duodenal ulcer
CRI
CHF
BPH
dementia
Social History:
lives with wife
no etoh or drug use
previous history of tobacco use
Family History:
No family history of CAD
Physical Exam:
Physical exam on admission:
P 75, BP 160/76, R 24, 100% sat
exam significant for
- resp: occasional scattered rhonchi
- cv: RRR, S1 and S2
- extr: left extremity cool to the touch, motteld and necrotic
digit
Pertinent Results:
[**2118-1-17**] 11:25PM GLUCOSE-552* UREA N-44* CREAT-2.0* SODIUM-137
POTASSIUM-3.0* CHLORIDE-89* TOTAL CO2-40* ANION GAP-11
[**2118-1-17**] 11:25PM CK(CPK)-297*
[**2118-1-17**] 11:25PM CK-MB-4
[**2118-1-17**] 11:25PM CALCIUM-7.2* PHOSPHATE-3.4 MAGNESIUM-1.6
[**2118-1-17**] 11:25PM WBC-7.5 RBC-2.83* HGB-9.1* HCT-27.1* MCV-96
MCH-32.4* MCHC-33.8 RDW-13.7
[**2118-1-17**] 11:25PM PLT COUNT-156
[**2118-1-17**] 11:25PM PT-13.7* PTT-100.2* INR(PT)-1.2
[**2118-1-17**] 05:25PM INR(PT)-1.6
Brief Hospital Course:
1) CAD:
Suffered NSTEMI at outside hospital, c/b cardiogenic shock.
He underwent cardiac catheterization with placement of stent of
LAD here.
Cardiac catheterization revealed the following:
-left dominant coronary anatomy
-LMCA: distal taper of 40%
-LAD: origin 80% lesion with serial 80% lesion in proximal LAD
with moderate diffuse disease in the LAD
-LCX: dominant vesel with moderate diffuse disease
-RCA: non-dominant vessel with moderate diffuse disease
-LSFA: diffuse disease from the FA to the stent; stents are
occluded without reconstitution distally; there are mild
geniculated collaterals to the infrapopliteal arteries without
named vessels below.
He was medically managed with ASA, plavix, beta blocker, and
statin, ace inhibitor.
He remained stable. Please continue medications on discharge.
2) Pump:
He was felt to be euvolemic. There were no signs/symptoms
of CHF despite receiving free water to correct his hyponatremia.
He had an echo performed on [**1-18**], which demonstrated the
following:
-mild dilation of the left atrium
-mild symmetric left ventricular hypertrophy with normal LV
cavity size
-overall LVEF preserved = 55%
-noted basal inferior hypokinesis
-Mitral valve leaflets mildly thickened
-trivial mitral regurgitation
3) Acute/chronic renal insufficiency:
Acute exacerbation of chronic renal insufficiency; felt to be
secondary to
contrast nephropathy following multiple procedures. Creatinine
peaked at 5.7,
and trended down to 1.5, which may be his new baseline level.
4)Hypernatremia:
Resolved with Free water deficit replaced. Encouraging PO free
h2o.
4) DM2:
He was monitored with finger sticks glucose checks and covered
with sliding scale insulin. BG levels not well controlled and
remained b/w 250-300. He was not on outpt oral medications but
started on glipizide 2.5mg [**Hospital1 **] on [**2118-2-1**] which improved BG
control.
5) [**Date Range **]:
He has a significant history of peripheral [**Date Range 1106**] disease, and
is
now s/p intervention followed by left CFA-DP bypass for this.
As [**Date Range 1106**] surgery was concerned for infection of hematoma on
his
left calf,he was started on antibiotic coverage including
vanc/levo/flagyl. Culture sent and revealed no growth. No
microorganisms seen. His antibiotics were changed to keflex and
levofloxacin on [**2118-2-2**] for empiric coverage. These should be
continued for 1 week (last dose on [**2118-2-9**]). ACE on calf at all
times. He will need toe amputation as an outpatient. He is to
follow up with Dr. [**Last Name (STitle) **] from podiatry on [**2-9**] regarding 4th toe
amputation and Dr. [**Last Name (STitle) 57956**] on [**2-9**] for r/u after surgery.
At that time, he will have staples removed and discuss whether
or not to continue antibiotics.
[**1-18**]: concern for RUE edema and infiltration of IV site.
Plastic surgery was consulted. No compartment syndrome. He has
been keeping R arm elevated, as per recs. Also continue [**Hospital1 **]
dressing changes with xeroform over blisters until resolve. Much
improvement. Swelling/ecchymosis cont to decrease.
6) Mental Status:
Baseline level of dementia/cognitive impairment, complicated by
acute
delirium. Neurology was involved; head CT was negative for
bleed. Attempts
at lumbar puncture failed. Altered mental status was felt to be
secondary to
sedative medications. As these meds were held, his mental status
progressively
improved back toward baseline. Still has some short-term memory
deficits which will likely improve with time, but if they don't
will require further neurologic evaluation.
Medications on Admission:
prednisone 5mg qD
lisinopril 20mg qD
plavix 75mg qD
lipitor 80mg qD
MVI
lopressor 50mg [**Hospital1 **]
protonix 40mg qD
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Insulin Regular Human 100 unit/mL Solution Sig: please see
sliding scale Injection ASDIR (AS DIRECTED).
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
14. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 weeks.
21. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary diagnosis:
NSTEMI - s/p cardiac catheterization
Secondary diagnosis:
Peripheral [**Location (un) 1106**] disease with popliteal artery thrombosis s/p
fem-DP bypass
Diabetes mellitus, type 2
Medication induced delerium
Acute on chronic renal failure secondary to contrast
nephropathy.
Hypertension
Discharge Condition:
stable
Discharge Instructions:
Patient is to be discharged to [**Hospital3 **] Center.
Please return to ED if you develop chest pain, shortness of
breath, opening of left leg incision, or other worrisome
symptom.
Please follow up with podiatry and [**Hospital3 1106**] surgery as
scheduled.
Followup Instructions:
You should call Dr [**First Name (STitle) **] to schedule a follow-up appointment
for 1 week from your discharge for evaluation.
Also, please follow up with Dr [**Last Name (STitle) **] from podiatry to evaluate
your left toes on [**2118-2-9**] at 11:20am. LOCATION: [**Street Address(2) 59787**]. Far building. [**Location (un) 470**].
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2118-2-9**] 9:45
|
4019,4373 | 295 | 192,988 | Admission Date: [**2176-3-6**] Discharge Date: [**2176-3-8**]
Date of Birth: [**2115-2-7**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
female with loss of consciousness on [**2176-2-11**] at
home. She fell in the kitchen sustaining left rib bruising.
Magnetic resonance imaging showed a cerebral aneurysm.
PAST MEDICAL HISTORY:
1. The patient reports having had palpitations in the past.
2. Hypertension.
3. Chronic urinary tract infection.
5. Deep venous thrombosis.
MEDICATIONS ON ADMISSION: Medications at home included
Rhinocort, Tylenol, hydrochlorothiazide, Lipitor, and
aspirin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed blood pressure was 148/89. In general, the patient
was pleasant and in no acute distress. Head, eyes, ears,
nose, and throat examination revealed facial structure was
symmetric at rest and with smile. Pupils were equal, round,
and reactive to light. Extraocular movements were intact.
No nystagmus. Mucous membranes were moist and pink. No
ulcerations. She has a mass on her hard palate which she
said has always been there. Soft palate and uvula rose with
voice. No ulcerations or nodes that were palpable. The
trachea was midline. Carotids were palpable. Regular
pulsations. No bruits were detected. The chest was clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs. The abdomen
was obese with multiple striae. Bowel sounds were present in
all four quadrants. Soft and nontender to palpation.
Extremity examination revealed palpable pulses in the upper
and lower extremities. Normal muscle strength. Gait was
smooth. Increased instability with heel-to-toe ambulation,
toe walk, and heel walk. Swaying with Romberg.
HOSPITAL COURSE: The patient was admitted on [**2176-3-6**]
and was taken directly to the angiogram suite where an
angiogram was performed with coiling of a right internal
carotid artery cavernous aneurysm.
The patient tolerated the procedure quite well and was sent
to the Intensive Care Unit postoperatively where she received
a heparin drip. Her Angiocath was left in during that time.
She also received Ancef for antibiotic prophylaxis both
postoperatively and after the Angiocath was removed.
The following day, the heparin was stopped, and four hours
later the Angiocath was removed without complications. The
patient was discharged to the regular floor and advanced on a
regular diet. The patient ambulated, and in general did
quite well.
On post angiogram two, the patient developed a rash which was
believed to have been caused by the Kefzol. The Kefzol was
immediately stopped, and the patient was given Benadryl, and
it was expected that the rash would resolve on its own with
time after the Kefzol had cleared her system.
CONDITION AT DISCHARGE: On [**2176-3-8**], and the patient
was discharged in good condition.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE: She was to take aspirin 325 mg
p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 1332**]
MEDQUIST36
D: [**2176-3-7**] 09:39
T: [**2176-3-8**] 23:19
JOB#: [**Job Number 31354**]
|
41401,4271,2939 | 296 | 159,503 | Admission Date: [**2191-3-1**] Discharge Date: [**2191-3-9**]
Date of Birth: [**2117-5-15**] Sex: M
Service:
ADDENDUM: The patient was initialy supposed to be discharge
on [**2191-3-5**], however, he continued to have confusion. A
psychiatric consult was obtained and Haldol was recommended.
It was felt that he had postoperative agitation, confusion
and delirium. It is not felt that this is secondary to an
infection or metabolic causes. Over the course of the
weekend on the 14th and 15th he became more agitated and
confused. He does not remember that he is in the hospital or
that he has had surgery. He had electrocardiograms while
getting Haldol 5 mg po q 4 hours, which have not so far shown
a prolongation of his QTC interval. His QTC on the 16th was
.4 of 4. Additionally, the patient's sugars have been
elevated since his surgery and he has required insulin for
management. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained and he is to be
started on Glyburide 5 mg po q.a.m. He will need follow up
for his newly diagnosed type 2 diabetes mellitus.
MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg po b.i.d. 2.
Lasix 20 mg po b.i.d. to be continued for one week after
discharge and then to be reevaluated by the patient's primary
care physician. 3. K-Ciel 20 milliequivalents po q.d. also
to be discontinued in one week. 4. Colace 100 mg po b.i.d.
5. ECASA 325 mg po q.d. 6. Niferex 150 mg po q.d. 7.
Haldol 5 mg po q 4 hours hold for sedation. The patient will
need daily electrocardiograms while taking the Haldol. 8.
Tylenol 650 mg po q 4 hours prn for pain. 9. Regular
insulin sliding scale blood sugars 150 to 200 3 units, 201 to
250 6 units, 251 to 300 9 units, greater then 300 12 units
plus [**Name8 (MD) 138**] MD. 10. Glyburide 5 mg po q.a.m.
The patient is being discharged to [**Hospital3 672**] Medical
Psychiatric Unit. He has had a CT of his head that his
negative for infarct.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 25727**]
MEDQUIST36
D: [**2191-3-9**] 08:53
T: [**2191-3-9**] 09:11
JOB#: [**Job Number 40685**]
|
41401,4271,2939 | 296 | 159,503 | Admission Date: [**2191-3-1**] Discharge Date: [**2191-3-5**]
Date of Birth: [**2117-5-15**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT:
Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
previously healthy male who, on the day of admission,
presented to an outside hospital complaining of substernal
chest pain with radiation to the left arm.
The patient says that in the weeks prior to admission, he had
symptoms consistent with indigestion, which was not being
resolved with Tums. On the day of admission, he was working
on his boat and developed the chest pain. After 20 minutes,
during which the pain did not resolve, he called 911.
On the scene, there were ST elevations noted on the
electrocardiogram. The patient was treated with aspirin and
nitroglycerin and the nitroglycerin relieved the pain. He
continued to have left arm discomfort. He denied any
shortness of breath, nausea, vomiting or diaphoresis. He
also denied any fevers, chills or sweats.
The patient was taken to the outside hospital and underwent a
workup for a myocardial infarction. He remained
hemodynamically stable. His hematocrit was 40. There, he
underwent cardiac catheterization which was significant for a
left anterior descending artery with an ostial 60% stenosis
followed by serial 90% stenosis. It also showed the left
circumflex with 80% stenosis, an obtuse marginal two which
was totally occluded, and an obtuse marginal three which was
90% stenotic. The right coronary artery was totally
occluded.
The patient tolerated the procedure well and was transferred
to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] to Dr.[**Name (NI) 27686**]
service for emergent coronary artery bypass grafting. The
patient arrived at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] in
stable condition.
PAST MEDICAL HISTORY: Negative; the patient denies diabetes
mellitus, hypertension or hypercholesterolemia.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS ON ADMISSION: Tums p.r.n. indigestion; the
patient arrived from the outside hospital on aspirin, Plavix,
heparin drip and nitroglycerin.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient denies any alcohol or tobacco
use.
PHYSICAL EXAMINATION: On physical examination, the patient
was an elderly gentleman in no acute distress, currently
without angina. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, no murmur, rub or
gallop. Abdomen: Soft, nontender, no masses. Extremities:
Warm, no edema. Neurologic: Intact.
LABORATORY DATA: Admission white blood cell count was 7.5,
hematocrit 40.1, platelet count 334,000, sodium 139,
potassium 3.9, chloride 98, bicarbonate 32, BUN 16,
creatinine 0.7, glucose 149, and calcium 9.9.
Electrocardiogram show normal sinus rhythm at a rate of 69
beats per minute, borderline first degree A-V block, and
diffuse ST elevations.
HOSPITAL COURSE: The patient was transferred from an outside
hospital in stable condition. He arrived at [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] and, after evaluation by
cardiothoracic surgery, the patient was taken to the
Operating Room, where he underwent coronary artery bypass
grafting times three. The grafts were left internal mammary
artery to left anterior descending artery, saphenous vein
graft to obtuse marginal one and saphenous vein graft to
obtuse marginal two, performed by the team under Dr.
[**Last Name (STitle) 70**]. The patient tolerated the procedure well. An EVH
was performed on the right side with hypertechnique of the
right graft.
Postoperatively, the patient was transferred to the
Cardiothoracic Intensive Care Unit in stable condition. The
patient was extubated without any incident. He was slowly
weaned off of oxygen. The patient's cardiovascular status
remained stable. Initially, cardiac output was 1.9. The
patient received one unit of packed red blood cells and a
bolus of lactated Ringer's. Output slowly improved to 2.39.
He continued to remain hemodynamically stable. The patient
remained alert and oriented times three.
On postoperative day number one, the patient was transferred
to the floor in stable condition. On postoperative day
number one at 11:00 p.m., the patient's monitor recorded wide
complex ventricular tachycardia. The patient's blood
pressure remained in the 110s. The patient was asymptomatic.
The longest continuous run included a 12 beat run.
Otherwise, the patient's rhythm remained alternating between
sinus rhythm intermixed with wide QRS complexes, often two to
three beats at a time. The patient's blood pressure
continued to remain stable. The patient's electrolytes were
repleted and the patient spontaneously converted to a normal
sinus rhythm.
The patient was evaluated by the electrophysiology service
and it was determined that the patient likely had reperfusion
ventricular tachycardia. The patient has since remained in
sinus rhythm and hemodynamically stable. The patient
otherwise has remained afebrile. His chest tubes were
discontinued on postoperative day number two without
incident. Pacing wires were discontinued on postoperative
day number three without incident. The patient is ambulating
at a level 5.
Early in postoperative day number two, there was a question
of patient's mental status. Though the patient remained
alert and oriented times three, the patient continually
requested to be driving home. He was placed on close
observation. The patient's mental status has improved and he
is at baseline.
On postoperative day number three, the patient's hematocrit
had moved from 24 to 20.8. The patient was transfused two
units of packed red blood cells and his hematocrit remained
stable. The patient is now stable and ready for discharge to
home.
DISCHARGE DIAGNOSIS:
Coronary artery disease, status post coronary artery bypass
grafting times three.
DISCHARGE MEDICATIONS:
Lasix 20 mg p.o.b.i.d. times seven days.
Potassium chloride 20 mEq p.o.b.i.d. times seven days.
Colace 100 mg p.o.b.i.d.
Enteric coated aspirin 325 mg p.o.q.d.
Lopressor 50 mg p.o.b.i.d.
Niferex 150 mg p.o.q.d.
Tylenol 650 mg p.o.q.4h.p.r.n.
Advil 400 mg p.o.q.6h.p.r.n.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 70**] in six weeks. The patient is to follow up with Dr.
[**Last Name (STitle) **], his primary care physician, [**Name10 (NameIs) **] two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2191-3-4**] 10:22
T: [**2191-3-5**] 11:04
JOB#: [**Job Number 26048**]
|
5789,20000,2851,7907,1120,2113,V103,42789,0413 | 298 | 119,446 | Admission Date: [**2140-8-7**] Discharge Date: [**2140-8-19**]
Date of Birth: [**2067-9-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
IVC filter placement on [**2140-8-12**]
History of Present Illness:
72 yo F with DLBCL s/p small bowel performation [**6-30**] with
duodenal-jejunal and jejuenal-jejuenal anastomosis, s/p RCHOP on
[**7-19**]. Her prior hospital course had complications including
post-operative pulmonary embolus and GIB in the setting of
heparin drip/coumadin that stabilized after transfusion of 2U
pRBC. Her course was also complicated by multifocal atrial
tachycardia. She was discharged home with lovenox, diltiazem and
metoprolol.
.
She then represented with 1 day melena and shortness of breath
with right lower quadrant pain, no nausea or vomiting. She
refused NG lavage in emergency department and was found to have
a hematocrit of 27.9 (stable from discharge) that fell to 24.4
on repeat. She was transfused 3U pRBCs and her hematocrit
stabilized. She was then admitted to the ICU for observation and
colonoscopy.
Past Medical History:
1. Rt breast cancer s/p lumpectomy in [**2135**]; no XRT or
chemotherapy. Was on tamoxifen prior to DLBCL dx.
2. DLBCL diagnosed [**6-/2140**] when presented with intestinal
perforation and repair
3. duodenal-jejunal and jejunal-jejunal anastamosis [**6-/2140**]
4. post-operative PE; treated with heparin and then lovenox
5. GI bleed on heparin
6. Multifocal atrial tachycardia vs sinus tach with atrial
ectopy diagnosed [**7-/2140**]
Social History:
Russian immigrant who lives near to [**Hospital1 18**] in [**Location (un) **]. Her
daugter lives in [**Location 4288**] and is involved but unable to take
care of Ms. [**Known lastname 67573**] daily needs.
No tobacco
No ETOH
Family History:
Father died of stomach cancer
Physical Exam:
T 98.7, 118/60, HR 73, 96% RA.
Gen: Well appearing russian female, NAD. skin pink
CV: RRR no m/r/g. good peripheral pulses
Pulm: CTA B
Abd: soft, non-distended. mild abd pain RUQ and epigastrium
Ext: + pedal edema
Pertinent Results:
[**8-6**] CXR:
IMPRESSION:
1. Right PICC likely within the right brachiocephalic vein.
2. No evidence of acute cardiopulmonary process or free
intraperitoneal air.
.
[**8-6**] CT abdomen/pelvis:
Normal appendix. No evidence of obstruction. Significant
improvement in paraaortic retroperitoneal lymphadenopathy.
Decrease in size of rim-enhancing fluid collection within the
cul-de-sac. No change in hepatic cysts. Fibroid uterus.
.
[**8-8**] colonoscopy: small polyp. area of thickened bowl that may
be c/w lymphoma. No bleeding seen
.
[**8-9**]: SBFT: normal
.
[**8-10**]: Pill endoscopy with active bleeding and clot distal to
anastomosis site. No AVMs or diverticuli seen.
.
[**8-19**]:
There is interval decrease in size in the previously
demonstrated rim enhancing fluid collection, now measuring 33 x
9 mm, previously 34.7 mm on [**2140-8-6**], and measuring 56 x 33 mm on
[**2140-7-19**]. There is a calcified fibroid uterus. Bone windows
reveal degenerative changes. Grade II anterolisthesis of L4 and
L5 is again demonstrated.
Brief Hospital Course:
Ms [**Known lastname **] is a 72 yo F with diffuse large B cell lymphoma
originally presenting in [**Month (only) 205**] with small bowel perforation, s/p
D-J and J-J anastamosis and post-op pulmonary embolus. With
history of GI bleed on heparin who represented with GI bleed on
lovenox.
.
GIB: Ms. [**Known lastname **] was admitted to the medical ICU for
observation/stabilization and treatment. She received 3 U pRBCs
in the ED and then 2U pRBCs on [**8-8**] with stabilization of ther
hematocrit. Her heparin was intermittently held until
hematocrit stabilization. She had a colonoscopy in the MICU
which did not reveal any cause of her bleeding but did reveal a
polyp which was not biopsied. The patient was hemodynamically
stable with adequate blood pressure, although she did have
tachycardia to the 150's. Ms. [**Known lastname **] had had an upper
endoscopy in the setting of GIB on her last admission which
showed normal post-operative changes without bleeding.
Therefore the patient had a pill endoscopy on [**8-10**] wich revealed
active bleeding in the area of the distal jejunum, but did not
find a specific source. Then on [**8-12**] Ms. [**Known lastname **] had another
GIB in the setting of a supratherapeutic PTT (approx 100) with 7
point hematocrit drop and 2 episodes of melena. At that point
her heparin was discontinued, a large bore IV was placed, and
she was transfused 2 U pRBCs. Q 6hr hematocrits were followed.
Dr. [**Last Name (STitle) 519**], Ms. [**Known lastname 67573**] GI surgeon, was consulted who felt that
surgery was not the best option. She did have a J-J anastamosis
but it was difficult to assess if the surgical site was the
source of bleeding versus her abdominal lymphoma.
Interventional radiology was called and an IVC filter was placed
on [**8-12**] without complications and anticoagulation was not
resumed. She has had some episodes of melena, however her
hematocrit has now been stable for 4 days.
.
Lymphoma: Ms. [**Known lastname **] was s/p cycle 1 RCHOP on admission. CT
abdomen on [**8-6**] showed decrease in retroperitoneal LAD implying
response to the chemotherapy. She received cycle 2 of
Rituxan-CHOP as scheduled on [**8-10**] with a dose-reduction in
cyclophosphamide and daunorubicin. She was treated with
allopurinol the day prior to and during her chemotherapy
(200mg/day) and will be sent home with this. She has had no
signs of tumor lysis syndrome. She tolerated the chemotherapy
will with some mild nausea and anorexia as side-effects. Daily
CBC with diff was followed. She was treated with GCSF
injections daily due to her rapid nadir on last admission. She
will be due for cycle 3 on [**8-31**].
.
Colon polyp: This was seen on colonoscopy: see OMR for full
report. Biopsy was not taken in the setting of GIB and
heparinization. This should be followed as an outpatient with
repeat colonoscopy and polypectomy.
.
Tachycardia: Ms [**Known lastname **] was diagnosed on her last admission
with multifocal atrial tachycardia vs sinus tachycardia w/
atrial ectopy on her last admission and was started on
metoprolol and diltiazem as per the recommendations of
cardiology consult service. This admission Ms. [**Known lastname **] has had
sinus tachycardia with questionable atrial ectopy up to 150's.
It was difficult to decide how to treat her tachycardia becuase
of the undesirability of suppressing a reactive sinus
tachycardia. After stabilizationin the MICU, it was decided
eventually to keep her on her diltiazem 30 qid and metoprolol 25
po bid because she maintained adequate BP. She was kept on
telemetry. She was tachycardic for a few days in the 100-140
range and then abruptly had a decrease in her HR to 70-100. She
remained in sinus rhythm at this rate for 2 days before
telemetry was discontinued. Her blood pressure has been
tolerating metoprolol 25 [**Hospital1 **] and diltiazem 30 qid, therefore
this regimen will be continued as an outpatient.
.
Kliebsiella bacteremia: Ms [**Known lastname **] was finishing a course of
levofloxacin for klebsiella bacteremia from her last admission.
She finished and was afebrile until [**8-17**] when she had a
temperature of 100.6. Her midline catheter was removed and
blood, catheter tip, and urine cultures were obtained that have
been no growth to date. CXR showed only some minor atelectasis.
Abdominal CT only showed decreased size of lymphoma and no
abcess. Ms. [**Known lastname **] developed oral thrush prior to dispo and
is recieving a 1-week course of nystatin + fluconazole. She is
feeling well.
.
PE: Ms [**Known lastname **] had a small pulmonary embolus on her last
hospitalization in the post operative setting. She clearly
demonstrated that she is not an anticoagulation candidate.
Therefore; and IVC filter was placed without complication on
[**8-12**]. She has never had an oxygen requirement.
.
FEN: Ms. [**Known lastname **] was given IVF with electrolyte replacement as
needed. She was NPO for much of her hospital course for GI
procedures and bleeding. She was advanced to a regular diet
prior to discharge which she has tolerated with some mild
nausea, but mainly with poor appetite in the post-chemotherapy
setting.
.
PPX: Ms. [**Known lastname **] received IV protonix in the setting of GI
bleed.
.
Discharge Medications:
1. scalp prosthesis
scalp prosthesis for alopecia secondary to chemotherapy
ICD-9 704.0
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: [**12-28**] Capsules PO BID (2
times a day) as needed.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for anxiety.
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
12. Outpatient Lab Work
CBC with absolute neutrophil count
q Tuesday and Thursday
fax to Dr. [**Last Name (STitle) **] office
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
14. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Diffuse large B cell lymphoma
2. Jejunal bleed
3. Pulmonary embolus
4. Multifocal atrial tachycardia
5. Colon polyp
6. Thrush
Discharge Condition:
Afebrile, HR 73, BP 118/60, 95% on RA, afebrile, hematocrit
stable.
Discharge Instructions:
Please continue taking all medications as prescribed. Please
have ANC and CBC drawn on Tuesday and Thursday and fax them to
Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 34802**]. Please notify Dr. [**Last Name (STitle) **]
or Dr. [**Last Name (STitle) **] if you continue to have fever over 100.4, if you
notice black or tarry stools, if you have severe abdominal pain,
or if you become light headed or dizzy.
.
Please schedule an appointment for a colonoscopy for polyp
removal. Please discuss the timing of this with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **].
Followup Instructions:
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] will contact you with a follow up
appointment for cycle 3 RCHOP on [**8-31**] at 10:15 am.
|
E9331,28803,V103,45182,9982,20000,5528 | 298 | 119,686 | Admission Date: [**2140-9-29**] Discharge Date: [**2140-10-7**]
Date of Birth: [**2067-9-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, SBO, Repair of enterotomy
History of Present Illness:
This is a 73 year old female with a history of having a B-cell
lymphoma, comes into the hospital on chemotherapy with a 2-day
history of severe abdominal pain and nausea and vomiting. She
describes the pain as crampy and colicky. She reports + flatus
and + BM today. Resuscitated in the ED she was brought to
surgery after CAT scan revealed an internal hernia with swirling
mesenteric suggestive of an ischemic area.
Past Medical History:
1. Rt breast cancer s/p lumpectomy in [**2135**]; no XRT or
chemotherapy. Was on tamoxifen prior to DLBCL dx.
2. DLBCL diagnosed [**6-/2140**] when presented with intestinal
perforation and repair
3. duodenal-jejunal and jejunal-jejunal anastamosis [**6-/2140**]
4. post-operative PE; treated with heparin and then lovenox
5. GI bleed on heparin
6. Multifocal atrial tachycardia vs sinus tach with atrial
ectopy diagnosed [**7-/2140**]
Social History:
Russian immigrant who lives near to [**Hospital1 18**] in [**Location (un) **]. Her
daugter lives in [**Location 4288**] and is involved but unable to take
care of Ms. [**Known lastname 67573**] daily needs.
No tobacco
No ETOH
Family History:
Father died of stomach cancer
Physical Exam:
VS: 97.3, 88, 165/87, 24, 100%
Gen: Elderly, NAD
HEENT: no icterus
Neck: no increased JVD
Chest: CTA bilat.
CV: RRR, no murmur/R/G
GI: soft, + distended, + BS, diffuse mild tenderness. Guaiac
negative.
Neuro: grossly intact
Pertinent Results:
CT ABDOMEN W/CONTRAST [**2140-9-29**] 8:07 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Eval obstruction, diverticulitis, volvulus, other
intraabdom
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with h/o lymphoma, small bowel perf w/p
resection w/ abdominal pain, N/V, ? sentinel loop on KUB
REASON FOR THIS EXAMINATION:
Eval obstruction, diverticulitis, volvulus, other intraabdominal
pathology
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 72-year-old woman with history of lymphoma, small
bowel perforation with resection. Now with abdominal pain,
nausea, vomiting, question sentinel loop on KUB. Evaluate for
obstruction, diverticulitis, other intra-abdominal pathology.
COMPARISON: CT of the abdomen [**2140-8-18**], abdominal x-ray
[**2140-9-29**].
TECHNIQUE: Contrast-enhanced axial CT images of the abdomen and
pelvis were obtained with coronally and sagittally reformatted
images. 130 cc of IV Optiray contrast was used.
CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases reveal a
moderate amount of infiltrate at the lung bases bilaterally. The
visualized portions of the heart and pericardium are
unremarkable. The liver again demonstrates multiple low
attenuation lesions, which are unchanged in size or appearance
compared to the previous study. The spleen, pancreas, and
adrenal glands are unremarkable. The left kidney again
demonstrates a caliceal diverticulum which is unchanged in
appearance compared to the previous study. Also seen is the
previously identified low attenuation lesion at the upper pole
of the left kidney which appears unchanged. The right kidney is
unremarkable. The infrarenal IVC filter is again visualized. The
gallbladder is unremarkable. Retroperitoneal lymphadenopathy is
again visualized with a conglomerate of lymph nodes in series 2,
image 41 measuring 24 x 9 mm. In the previous study in [**Month (only) 216**],
this conglomerate measured 34 x 15 mm.
Contrast is seen passing through the first site of small bowel
anastomosis, however, the small bowel at this level appears
dilated, with a transition point seen distal to the first
anastamosis in series 2, image 57. The small bowel distal to
this transition point is markedly dilated and fluid filled
without contrast seen within the lumen. The small bowel measures
up to 3.8 cm in diameter. Another transition point is seen
distal to this dilated loop of bowel in series 2, images 60 and
the small bowel distal to this transition point is fully
collapsed. This is very characteristic of a closed loop small-
bowel obstruction. The second site of small bowel anastomosis is
distal to the second transition point and is collapsed.
Significant free fluid is seen within the abdomen. The small
bowel wall does not appear to be thickened. No free air is
identified.
CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid appear
collapsed but otherwise unremarkable. Fibroids are again seen
within the uterus and one of the fibroids appears calcified.
Free fluid is identified within the pelvis although the rim
enhancing fluid collection may appear smaller. No pathologically
enlarged lymph nodes are seen within the pelvis. Post-surgical
changes of the ventral abdominal wall are again identified.
Osseous structures again reveal degenerative changes and a Grade
II anterolisthesis of L4 onto L5.
Coronal and sagittal reformations support the above findings.
IMPRESSION:
1. Closed loop small-bowel obstruction as described above.
Contrast is seen going through the first small bowel
anastomosis. The second small bowel anastomosis is distal to the
obstruction. No bowel wall thickening or pneumatosis of the
small bowel is seen. Significant free fluid is seen within the
abdomen.
2. Bilateral lower [**Last Name (un) 8490**] lobe infiltrate suggestive of
infectious process.
ABDOMEN (SUPINE & ERECT) [**2140-9-29**] 4:42 AM
ABDOMEN (SUPINE & ERECT)
Reason: r/o SBO
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with abd pain, Hx operation
REASON FOR THIS EXAMINATION:
r/o SBO
INDICATION: 72-year-old with history of prior operations with
severe abdominal pain, rule out small bowel obstruction.
COMPARISONS: KUB of [**2140-8-10**].
AP AND SUPINE ABDOMEN: Diaphragms are not well shown to fully
evaluate for free intraperitoneal air. There are multiple
dilated loops of small bowel with air-fluid levels. Small amount
of distal air within the ascending colon but a paucity more
distal to this. IVC filter noted.
IMPRESSION: Multiple dilated loops of small bowel with air-fluid
levels, suspicious for small bowel obstruction. No definite free
intraperitoneal air, however, the regions under the diaphragms
are suboptimally evaluated. If there is high suspicion for small
bowel obstruction, CT may provide a more accurate assessment.
Cardiology Report ECG Study Date of [**2140-9-29**] 8:56:58 PM
Sinus tachycardia. Normal ECG. Compared to the previous tracing
the prior
abnormalities have resolved.
TRACING #2
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
119 142 78 316/[**Telephone/Fax (2) 67574**]
Brief Hospital Course:
She was admitted to [**Hospital1 18**] on [**2140-9-29**] due to a closed loop
obstruction. She had a WBC of 1.1 on admission. She received
Neulasta on [**2140-9-23**]. Pre-operatively she received Kefzol and
Flagyl.
Oncology: Oncology was consulted as she was s/p 4 cycles of
chemotherapy and had a low WBC. She was started on Cefepime and
Flagyl post-operatively. If she continues to have fevers, blood
cultures should be checked. She will continue to follow-up with
her Oncologist as an outpatient.
POD 1, she was NPO, with IV fluids, and a NGT. Her pain was well
controlled and her urine output was adequate. She was confused
at times, but able to be redirected. On POD 3, her NGT was
D/C'd. She was started on sips and we awaited return of bowel
function. Urine and wound cultures were negative for growth and
she remained afebrile. She reported + BM on POD #5.
She continued to do well and her diet was slowly advanced. She
complained of decreased appetite. She was tolerating fluids and
small amounts of food. We encouraged PO intake. Her antibiotics
were D/C'd. She was switched to PO pain meds. Her incisions were
clean, dry, and intact without drainage or redness. The staples
will be removed at her follow-up appointment.
Phlebitis: She was noted to have a phlebitic left forearm that
responded to ABX and hot packs.
Medications on Admission:
dilt 30q6, lopressor 25", ativan prn, ambien, ?tamoxifen,
oxycodone prn
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to walk several times per day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2140-10-17**] 8:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-10-13**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-10-13**] 9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2140-10-7**] |
7731 | 299 | 195,143 | Admission Date: [**2176-7-1**] Discharge Date: [**2176-7-3**]
Date of Birth: [**2176-6-26**] Sex: M
Service: NBB
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 61741**] is the 3.380 kg
product of a term gestation. He was born to a 26 year old
gravida 1 para 0, now 1 mother readmitted for
hyperbilirubinemia on day of life #5. The pregnancy was
benign with an EDC of [**2176-6-27**]. Prenatal screens were O+,
antibody negative, hepatitis surface antigen negative, rapid
plasma reagent nonreactive, Rubella immune, Group B strep
negative. The infant delivered vaginally with Apgar scores of
9 at 1 minute and 9 at 5 minutes. [**Known firstname 45501**] blood type is B+,
Coombs negative. He required phototherapy for an elevated
bilirubin of 15.4 at 12 hours of age. He continued
phototherapy until day of life #3 when the bilirubin was 14.4
and he was discharged to home. On day of life #4, his
bilirubin was 15.7 and on day of life #5, in the primary
pediatrician's office, it was 18.8 and he was readmitted for
further phototherapy.
PHYSICAL EXAM ON ADMISSION: On admission, [**Known firstname **] was well-
appearing, though slightly sleepy with jaundice again. He had
bilateral breath sounds that were clear and equal. The heart
rate was regular without murmur and pulses were 2+ and
symmetrical. The abdomen was soft and nontender with no
hepatosplenomegaly. His weight was 3.420 kg (greater than
birth weight). He had normal male genitalia with bilaterally
descended testes. His hips were stable. His tone was normal
with normal neonatal reflexes. He as tolerating his feedings
fine.
SUMMARY OF HOSPITAL COURSE:
1. Respiratory: Without issues on this admission. Breath
sounds are clear and equal.
2. Cardiovascular: Without issues on this admission. He had
regular heart rate and rhythm, no murmur and pulses were
2+ and symmetric.
3. Fluids, Electrolytes and Nutrition: [**Known firstname 45501**] birth weight
was 3.380 kg (7 lb. 7 oz.). His weight on this admission
was 3.420 kg (7 lb. 8 oz.). [**Known firstname **] is currently ad lib
breastfeeding and supplementing with expressed breast
milk. He is feeding well. His discharge weight is
7 lb. 10 oz.
4. Gastrointestinal: [**Known firstname 45501**] bilirubin on [**6-28**] was 15.4 at
which time double phototherapy was started. His
phototherapy was stopped on [**6-29**] for a bilirubin of 13.5
with a rebound of 14.4. His bilirubin on [**6-30**] was 15.7
and then 18.8 at the primary pediatrician's office on [**7-1**] at which time he was readmitted and phototherapy was
started. His bilirubin on [**7-2**] was 16.9 and on [**7-3**],
it was 12.1. Phototherapy was discontinued and the rebound
bilirubin 8 hours later was 10.7/0.3.
5. Hematology: The hematocrit on [**7-1**] was 32.8. On [**7-3**],
his hematocrit was 40.2 with a retic. of 0.5. His blood
type is B+, Coombs negative.
6. Infectious Disease: No issues on this admission.
7. Neurological: The infant has been appropriate for
gestational age.
8. Sensory: Auditory hearing screening was performed with
automated auditory brainstem responses and the infant
passed both ears on his previous admission. Hearing
screens were repeated on [**2176-7-3**] and he passed both
ears.
9. Psychosocial: Family is invested and involved.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY CARE PEDIATRICIAN: SCCHC, [**State 61742**], [**Location (un) 86**], [**Numeric Identifier 53855**], telephone number [**Telephone/Fax (1) 8236**].
CARE RECOMMENDATIONS:
1. Continue ad lib feeding.
2. Follow up with pediatrician at SCCHC on [**2176-7-4**].
3. Medications - not applicable.
4. Car seat position screen - not applicable.
5. State newborn screens were sent on [**2176-6-28**] and have
not been reported as abnormal. On his previous admission,
[**Known firstname **] received hepatitis B vaccine on [**2176-6-28**].
6. Immunizations recommended: 1) Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 3 criteria - i) born
at less than 32 weeks; ii) born between 32 and 35 weeks
with 2 of the following - day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings; or iii) with chronic
lung disease. 2) 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.
7. Follow-up appointments recommended for [**2176-7-4**].
DISCHARGE DIAGNOSES:
1. Term average for gestational age male.
2. Hyperbilirubinemia likely due to mild ABO incompatibility -
resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Doctor Last Name 55781**]
MEDQUIST36
D: [**2176-7-3**] 12:07:35
T: [**2176-7-3**] 12:36:13
Job#: [**Job Number 61743**]
|
19889,5780,27651,5849,2800,2762,2639,2760,5762,4019,2720,33829,7245,4414,V1009,V4501,V667 | 301 | 160,332 | Admission Date: [**2189-11-10**] Discharge Date: [**2189-11-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
transfusion 3Units PRBCs
History of Present Illness:
Pt is a 85 yo man with metastatic gall bladder cancer presents
w/ weakness, disorientation and dehydration. Pt was diagnosed
with cancer 1 year ago and underwent surgery 5 months ago
secondary to increasing RUQ abdominal pain. He remained stable
until about 1 month ago when he began to feel progressively
weaker and have less of an appetite. Pt usually slept 18-20
hours per day and when awake would like in a chair in front of
the television and only sip broth when forced. For the past 3
days pt has had almost no intake po. This morning grandson
describes pt as somnolent and not arousable to voice. He states
that pt would stare at him but not respond and was unable to
answer his name or where he was. he called pts pcp who advised
him to come to the ED.
.
Per pts grandson, during the past month patient has complained
of increasing abdominal pain, mid to low back pain, weakness,
fatigue and decreased appetite. Pt would only take in sips on
broth when forced. Pts grandson estimates that he has lost about
40lbs in the last month. Per Pts grandson, he has not complained
of nausea, vomiting, fever or chills. He has had minimal urine
output. ON ROS, pt is moderately responsive and denies any pain.
Past Medical History:
-gallbladder carcinoma, small cell type. dx [**2188-12-14**],
surgical resection [**2189-5-14**] with positive margins. Pt was not a
candidate for systemic chemotherapy.
-hypertension
-hypercholesterolemia
-sick sinus syndrome s/p pacemaker placement [**2180**]
-PUD
-Abdominal Aortic Aneurysm
-BPH
-chronic back pain, bone scan 3wks ago show no evidence of
metastatic disease.
Social History:
cimetidine 400mg [**Hospital1 **]
metoprolol 25mg daily
percocet 5-325mg TID prn for pain
Family History:
NC
Physical Exam:
VS: Tc: 95.6 P: 72 BP: 108/62 RR: 16 O2 sat: 98% weight: 50.4k
Gen- appears fatigued, responds to commands
HEENT-anicteric, no injections, OP clear, MM dry
Cor- RRR, S1, S2, 2/6 SEM LUSB
Lungs- CTA b/l
Abd-palpable epigastric mass, NT, ND, positive bs
Extrem- no CCE
Pertinent Results:
CBC:
[**2189-11-10**] 12:13PM BLOOD WBC-13.6* RBC-2.34* Hgb-7.6* Hct-23.1*
MCV-99* MCH-32.7* MCHC-33.1 RDW-21.1* Plt Ct-353
[**2189-11-11**] 09:00AM BLOOD WBC-12.4* RBC-2.85* Hgb-9.1* Hct-26.7*
MCV-94 MCH-31.7 MCHC-33.9 RDW-21.8* Plt Ct-245
[**2189-11-12**] 03:23AM BLOOD WBC-14.7* RBC-3.15* Hgb-10.3* Hct-29.4*
MCV-93 MCH-32.5* MCHC-34.8 RDW-20.7* Plt Ct-222
[**2189-11-13**] 05:58AM BLOOD WBC-16.5* RBC-2.99* Hgb-9.8* Hct-27.8*
MCV-93 MCH-32.8* MCHC-35.3* RDW-21.2* Plt Ct-241
[**2189-11-14**] 10:36AM BLOOD WBC-17.4* RBC-3.03* Hgb-9.7* Hct-28.9*
MCV-96 MCH-32.1* MCHC-33.6 RDW-21.4* Plt Ct-223
[**2189-11-15**] 06:15AM BLOOD WBC-16.0* RBC-3.04* Hgb-9.9* Hct-29.2*
MCV-96 MCH-32.5* MCHC-33.9 RDW-21.6* Plt Ct-228
[**2189-11-16**] 06:50AM BLOOD WBC-12.1* RBC-2.87* Hgb-9.4* Hct-27.3*
MCV-95 MCH-32.7* MCHC-34.4 RDW-22.1* Plt Ct-172
.
COAGS:
[**2189-11-10**] 12:13PM BLOOD PT-15.2* PTT-25.2 INR(PT)-1.4*
[**2189-11-11**] 09:00AM BLOOD PT-15.6* PTT-25.9 INR(PT)-1.4*
[**2189-11-12**] 03:23AM BLOOD PT-16.5* PTT-27.1 INR(PT)-1.5*
[**2189-11-13**] 05:58AM BLOOD PT-16.6* PTT-27.2 INR(PT)-1.5*
[**2189-11-14**] 10:36AM BLOOD PT-17.1* PTT-30.2 INR(PT)-1.6*
.
LYTES:
[**2189-11-10**] 12:13PM BLOOD Glucose-122* UreaN-69* Creat-1.8* Na-143
K-4.6 Cl-109* HCO3-19* AnGap-20
[**2189-11-11**] 09:00AM BLOOD Glucose-106* UreaN-55* Creat-1.4* Na-144
K-3.9 Cl-114* HCO3-16* AnGap-18
[**2189-11-12**] 03:23AM BLOOD Glucose-78 UreaN-48* Creat-1.4* Na-145
K-4.0 Cl-119* HCO3-14* AnGap-16
[**2189-11-13**] 05:58AM BLOOD Glucose-103 UreaN-46* Creat-1.3* Na-147*
K-3.8 Cl-122* HCO3-14* AnGap-15
[**2189-11-14**] 10:36AM BLOOD Glucose-97 UreaN-40* Creat-1.4* Na-145
K-3.6 Cl-117* HCO3-15* AnGap-17
[**2189-11-15**] 06:15AM BLOOD Glucose-92 UreaN-38* Creat-1.3* Na-142
K-3.7 Cl-116* HCO3-15* AnGap-15
[**2189-11-16**] 06:50AM BLOOD Glucose-103 UreaN-41* Creat-1.0 Na-141
K-3.3 Cl-113* HCO3-16* AnGap-15
.
LFTs:
[**2189-11-10**] 12:13PM BLOOD ALT-81* AST-171* AlkPhos-3306* Amylase-82
TotBili-4.1*
[**2189-11-11**] 09:00AM BLOOD ALT-74* AST-170* LD(LDH)-898*
AlkPhos-2799* Amylase-57 TotBili-5.7*
[**2189-11-12**] 03:23AM BLOOD ALT-79* AST-169* LD(LDH)-789*
AlkPhos-2798* TotBili-7.4* DirBili-6.0* IndBili-1.4
[**2189-11-13**] 05:58AM BLOOD ALT-74* AST-146* AlkPhos-2740*
TotBili-8.2*
[**2189-11-15**] 06:15AM BLOOD ALT-65* AST-129* TotBili-13.7*
[**2189-11-16**] 06:50AM BLOOD ALT-57* AST-110* AlkPhos-2444*
TotBili-14.5*
Brief Hospital Course:
#) metastatic gall bladder cancer: Pt presented with common bile
duct obstruction [**1-15**] tumor effect from gallbladder mass. There
was a palpable abdominal mass on PE and progressively increasing
transaminases, bilirubin, alk phos. Pt also developed an upper
GI bleed with hematemesis at presentation. GI, GI [**Doctor First Name **], ERCP and
IR were consulted re: possible interventions. Stenting was not
an option given pts anatomy/obstruction during past surgery and
pt was not thought to be stable enough for IR intervention for
the bleeding. Pt was transfused and stabilized in the MICU. He
has been hemodynamically stable with no continued hematemesis.
Hct has been stable between 27-29.
After discussion with patients family the decision was made for
care measure only.
Pt has been pain controlled with morphine IV and SL. He is very
stoic and often denies pain to the medical team but has
complained to his family.
He has been tolerating clear fluids w/o problem.
His family visits him every day.
Medications on Admission:
percocet 5-325mg TID prn for pain
patient has not been taking: cimetidine 400mg [**Hospital1 **] and metoprolol
25mg daily
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: [**12-15**] PO Q1-2H ()
as needed for pain.
2. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea, emesis.
Suppository(s)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Upper GI Bleed, Common Bile Duct obstruction secondary to tumor
from metastatic gallbladder cancer.
Discharge Condition:
stable, poor
Discharge Instructions:
You were evaluated for bleeding in your gastrointestinal tract.
Gastroenterology and Interventional Radiology were consulted and
there was no intervention that would stop the bleeding. You
were transfused with blood and have been stable.
.
It is important that you are comfortable and not in pain.
Please continue to take all medications for pain as prescribed.
Please tell your family or other caretakers if you are in pain,
uncomfortable, or there is anything else you need.
Followup Instructions:
na
|
41011,42821,41401,4280,4240,4019,2720,V1582 | 302 | 191,028 | Admission Date: [**2133-3-29**] Discharge Date: [**2133-4-1**]
Date of Birth: [**2074-3-11**] Sex: M
Service: CARDIAC CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
male with a past medical history of coronary artery disease
status post myocardial infarction, hypercholesterolemia,
hypertension who presents with 10 out of 10 substernal chest
pain occurring at rest to outside hospital. The chest pain
began while lying in bed at around 10:15 p.m. associated with
nausea, diaphoresis and radiation to arm and jaw. He went to
[**Hospital3 1280**] Hospital at 10:30 p.m. At [**Hospital3 1280**] he had an
electrocardiogram with ST elevations in V2 and V4 of 3 mm and
[**Street Address(2) 4793**] elevations in V4 through V6 with reciprocal ST
depressions in 2, 3, and AVF. It was normal sinus rhythm at
62 beats per minute. The PR prolongation at 155. Vital
signs were stable at outside hospital. Pulse 54, blood
pressure 109/80, sating 99% on 4 liters of nasal cannula
oxygen. At outside hospital he received a heparin drip,
nitro drip, aspirin, beta blocker, Integrilin drip and
Retaplase half dose times two, morphine sulfate times three
and Ativan. He became chest pain free after the second dose
of Retaplase and his symptoms and electrocardiogram changes
had also been resolved on arrival at [**Hospital1 190**] Emergency Room. Electrocardiogram in the
Emergency Department showed normal sinus rhythm at 82 beats
per minute, PR 106, left axis deviation of .5 to [**Street Address(2) 4793**]
elevations in V2 through V3 with .5 mm elevations in V1, V4
through V5 and resolution of T wave changes in the inferior
leads. The patient denies any paroxysmal nocturnal dyspnea,
orthopnea or exertional angina at workout, but does report
increased fatigue. Over the last week the patient has
stopped using his statin due to myositis with workouts and
stopped his beta blocker on his own over the past few months.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction with lysis with tissue plasminogen
activator in [**2124**], hypercholesterolemia, hypertension.
MEDICATIONS AT HOME:
1. Aspirin.
2. Folic acid.
3. Niacin.
ALLERGIES: Sulfas.
SOCIAL HISTORY: He quit tobacco 30 years ago.
REVIEW OF SYSTEMS: He reports increased fatigue after
workouts last month. He works out at the gym four to five
times a week with no angina.
PHYSICAL EXAMINATION: He was afebrile. Blood pressure
95/51. Heart rate 62. Sating 97% on 2 liters of nasal
cannula. He was in no acute distress lying in bed.
Extraocular movements intact. Pupils are equal, round and
reactive to light. Mucous membranes are moist. Neck was
supple. No jugulovenous distention. Heart was regular rate
and rhythm. S1 and S2. 1 to 2 out of 6 systolic ejection
murmur at the apex. Lungs were clear to auscultation
bilaterally. Abdomen was nontender, soft, nondistended with
normoactive bowel sounds. No clubbing, cyanosis or edema of
his extremities with 2+ dorsalis pedis pulses. Cranial
nerves II through XII were intact. He was alert and oriented
times three. There were no bruits in his groin.
LABORATORY DATA ON ADMISSION: White blood cell count 9.2,
hematocrit 47.7, platelets 194, INR 1.1, PTT 25. Chemistries
139, 3.9, 101, 32, 12, and 1.2. His CK was 26, 19, ALT and
AST 64 and 334. Total cholesterol 126, triglycerides 37, HDL
45, LDL 74, TSH 2.1. Chest x-ray was negative.
The patient was kept on Integrilin and heparin drip. His
chest pain recurred. He was taken to cardiac
catheterization, which showed normal cardiac index, mitral
regurgitation, severely abnormal left ventricular ejection
fraction, inferobasal akinesis consistent with remote
inferior myocardial infarction, anteroapical severe
hypokinesis, left ventricular global function depressed, 1+
mitral regurgitation, right dominant coronary angiography.
It also showed a large ectatic proximal left anterior
descending coronary artery with 85% focal severe hazy
stenosis with TIMI three flow. A stent was placed showing 0%
residual post stent. There was diffuse ectasia with mild
serial narrowing of the left circumflex on the right coronary
artery.
In summary, the patient was status post anterior myocardial
infarction managed with thrombolysis and then taken to
cardiac catheterization for recurrent chest pain during which
he had a left anterior descending proximal stent placed. He
was continued on Integrilin for 18 hours and recommended to
continue with Plavix for nine months as well as aspirin
therapy. The patient remained asymptomatic post
catheterization without any arrhythmias. A repeat
echocardiogram was done showing ejection fraction of 25% with
apical anterior and septal mid septal and basal inferior,
inferolateral and apical inferior akinesis. The patient was
also evaluated by physical therapy and did well and was
deemed safe to go home. He was discharged home to follow up
with his cardiologist Dr. [**Last Name (STitle) 1295**] on a low sodium diet. He
was given teaching about a 2 gram sodium diet as well as
cardiac rehabilitation. He was discharged with instructions
to ambulate 10 to 15 minutes every day, avoid strenuous
activity until seen by his cardiologist.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Systolic heart failure.
PROCEDURES: Cardiac catheterization with stent placement.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Plavix 75 mg po q.d.
3. Lisinopril 2.5 mg po q.h.s.
4. Lipitor 10 mg po q.h.s.
5. Metoprolol XL 25 mg po q.d.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Doctor Last Name 229**]
MEDQUIST36
D: [**2133-4-2**] 01:31
T: [**2133-4-8**] 07:07
JOB#: [**Job Number 49459**]
|
9654,V652,79092,4019,31401,29680,E8499,E9500,570,486,78039,30590,96509 | 303 | 103,013 | Admission Date: [**2163-3-29**] Discharge Date: [**2163-4-4**]
Date of Birth: [**2142-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
20 year old male s/p unintentional APAP overdose.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 year old male transferred from [**Hospital1 112**] for liver transplant
evaluation after percocet overdose. On Sunday [**3-27**] had a
stressful day and pt took approximately 20 percocet (5/325)
throughout the day after a series of family arguments. Denies
trying to hurt himself. Parents confirm to suicidal attempts in
the past. Pt felt that he had a hangover on Monday secondary to
"percocet withdrawal" and took an additional 5 percocet. Pt was
admitted to the SICU and followed by Liver, Transplant,
Toxicology, and [**Month/Year (2) **]. He was started on NAC q4hr with gradual
decline in LFT's and INR. His recovery was c/b hypertension,
for which he was started on clonidine. Pt was transferred to
the floor on [**4-1**].
Past Medical History:
Bipolar D/o (s/p suicide attempts in the past)
ADHD
S/p head injury [**2160**]: s/p MVA with large L3 transverse process
fx, small right frontal epidural hemorrhage-- with
post-traumatic seizures (was previously on dilantin, now dc'd)
Social History:
Father is HCP, student in [**Name (NI) 108**], Biology major, parents and
brother live in [**Name (NI) 86**], single without children, lived in a
group home for 3 years as a teenager, drinks alcohol 1 night a
week, denies illict drug use, pt in [**Location (un) 86**] for neuro eval
Family History:
no liver disease
Physical Exam:
VS. 96, 154/90, 67, 20, 97%RA
Gen. comfortable, appears combative at times, using swears
words, then appreciative at other times
Heent. MMM
Chest. CTA ant
Cor. RR, nl s1 s2
Abd. +BS, soft, slight tenderness to palpation, improved
overall, no rebound or guarding.
Ext. no edema
Pertinent Results:
[**2163-3-29**] 11:53PM BLOOD WBC-6.4 RBC-4.71 Hgb-14.0 Hct-41.6 MCV-88
MCH-29.8 MCHC-33.7 RDW-14.2 Plt Ct-50*#
[**2163-3-29**] 11:53PM BLOOD Plt Smr-VERY LOW Plt Ct-50*#
[**2163-3-29**] 11:53PM BLOOD PT-23.7* PTT-28.9 INR(PT)-3.6
[**2163-3-29**] 11:53PM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137
K-4.7 Cl-98 HCO3-30* AnGap-14
[**2163-3-30**] 03:36AM BLOOD ALT-[**Numeric Identifier 37727**]* AST-9060* LD(LDH)-5544*
AlkPhos-75 Amylase-49 TotBili-5.0*
[**2163-3-29**] 11:53PM BLOOD Lipase-32
[**2163-3-29**] 11:53PM BLOOD Albumin-3.4 Calcium-8.0* Phos-1.0*#
Mg-1.5*
[**2163-3-30**] 03:36AM BLOOD Hapto-275*
[**2163-3-30**] 04:49PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2163-3-30**] 12:11PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2163-3-30**] 04:49PM BLOOD HIV Ab-NEGATIVE
[**2163-3-30**] 03:36AM BLOOD Phenyto-<0.6* Valproa-<3.0*
[**2163-3-29**] 11:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-3-29**] 11:53PM BLOOD HCV Ab-NEGATIVE
[**2163-3-30**] 10:53AM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-44 pH-7.44
calHCO3-31* Base XS-4
CT Abd:
LLL PNA
There is a confluent air space opacity within the left lower
lobe consistent with pneumonia. The right lung is grossly clear.
There are no pleural effusions. The liver, gallbladder, spleen,
pancreas, adrenal glands, and right kidney appear grossly
normal. There are at least two (2) tiny low attenuation foci
arising from the left kidney which are too small to characterize
further. Stomach and visualized loops of small and large bowel
are unremarkable. No pathologically enlarged retroperitoneal or
mesenteric lymph nodes are present. There is no free fluid.
Head CT: There is no intracranial hemorrhage.
C-spine CT: There is no evidence of fracture or dislocation.
There are numerous cervical lymh nodes seen and thickening of
the adenoidal/nasopharyngeal soft tissues. Clinical correlation
recommended.
Brief Hospital Course:
[**Known firstname 20069**] [**Known lastname 37728**] ia a 20 yo male with h/o bipolar disease,
ADHD, h/o seizures p/w acute hepatitis due to unintentional
percocet overdose.
Acute Hepatitis due to APAP overdose: He was initially admitted
to the SICU where he was evaluated by the liver transplant team.
Luckily, his ALT/AST trended down with 17 doses of
N-Acetylcysteine from a peak of 22,000/14,00 respectively, and
an INR peak of 6.6. With his improvement, he was transferred to
the floor on [**4-1**], with continued improvement of his LFT's. An
abd CT was not surprising, showing expected signs of
inflammation around the liver. Pt's abdominal pain was
improving on discharge.
Hypertension: in setting of acute hepatitis. Pt was treated
with clonidine in house with. Anticipate resolution with
resolution of acute process.
?Bipolar Disease/ADHD: Followed by psychiatry in house. They
recommend not medically treating his reported diagnoses given pt
could not provide names of any psychiatrists, and the psychiatry
team questioned the pt's diagnoses. Pt will follow up with
outpatient psychiatry, and was given the number of a psychiatry
practice near his home.
LLL PNA: Likely due to aspiration while pt was acutely sick. Pt
spiked to 101.9, with evidence of LLL PNA on abd CT. He was
started on Levo/Flagyl [**4-2**] for 1 week. He remained comfortable
on room air and afebrile.
? H/O Seizures d/t subdural hemorrhage in setting of CVA in
[**2160**]: Pt reported being on dilantin and depakote for
seizures/mood stabalization. However, I spoke with both his PCP
and primary neurologist who have no record of him being on
either medication, and no record of him ever having a seizure.
Further, he had an EEG for headaches on [**2163-4-22**] that was normal.
Pt's dilantin and depakote levels on admission were below
assay. Pt was not place on either dilantin or depakote. He
remained seizure free in house and head CT showed no evidence of
subdural hematoma as present three years ago after his car
accident. He will follow up with outpatient neurology.
Drug seeking behavior: Pt was clearly pain med seeking, being
verbally abusive to staff. His episode of falling off the
toilet [**4-2**] was likely due to opioid overuse, with no subsequent
evidence of trauma on exam or CT. With some struggle, we have
negotiated switching him from IV to PO dilaudid. He will be
d/c'd off dilaudid, with a few oxycodones for breaktrough pain.
Comm: PCP [**Name9 (PRE) **] [**Name (NI) **] [**Telephone/Fax (1) 8539**], Neuro [**Doctor Last Name 10653**]
[**Telephone/Fax (1) 37729**] in [**Location (un) **].
Dispo: Pt was discharge home with PCP, [**Name10 (NameIs) **], GI, and neuro
followup plans.
Medications on Admission:
Per patient:
Dilantin (for seizure prophylaxis)
Depakote
Dexedrine
Percocet prn
Wellbutrin
Xanax
Neurontin
--doses unknown
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
3. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [**5-4**]
hours for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute Hepatitis d/t Tylenol Overdose
2. Hypertension
3. Drug seeking behavior
4. ?Bipolar Disease
5. LLL Pneumonia
Discharge Condition:
Pt was in good condition, afebrile, on room air, with stable
vital signs.
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) **] on Friday. Please call your other
doctors at the [**Name5 (PTitle) 37730**] provided so that you may follow up with
them.
Do not take any medications with Tylenol, including Percocet,
until directed otherwise by your doctor.
Followup Instructions:
See you primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 8539**]
(phone), on Friday at 1pm (appointment made).
Call Dr.[**Name (NI) 37731**] office at [**Telephone/Fax (1) 37732**] for a follow up GI
visit in 2 weeks.
Call your neurologist, Dr. [**Last Name (STitle) 10653**] [**Telephone/Fax (1) 37729**], for an
appointment next week.
Call [**Hospital 86**] Health Care at [**Telephone/Fax (1) 37733**] for a follow up
psychiatric appointment in 2 weeks.
|
85246,8054,E8150 | 303 | 175,574 | Admission Date: [**2160-3-17**] Discharge Date: [**2160-3-20**]
Date of Birth: [**2142-4-11**] Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: This 17-year-old male was an
unrestrained driver in a motor vehicle accident with loss of
consciousness in a spider windshield. He was found to be
ambulating at the scene. He was unable to recall events but
was hemodynamically stable, complaining of back pain. He was
brought into the Emergency Room for evaluation.
PAST MEDICAL HISTORY: Past medical history was negative.
PAST SURGICAL HISTORY: He has had no surgery.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: He has no medications.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a well-developed, well-nourished gentleman in a
cervical collar in no distress. Temperature was 99.3, blood
pressure of 146/78, pulse of 80, and respiratory rate of 20.
The neck was in a cervical collar without tenderness. Heart
sounds were regular. No murmurs or gallops. The abdomen was
soft. No tenderness, masses, or organomegaly. The pelvis
was stable. The back contained no stepoff, but there was
some tenderness in the lumbar region. He was neurologically
intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories showed a hematocrit of 44.5, white blood cell
count of 9400, blood urea nitrogen of 21, creatinine of 1.
RADIOLOGY/IMAGING: A CT scan of the head showed a very small
right frontal epidural hemorrhage.
A CT of the abdomen showed a L3 transverse process fracture.
HOSPITAL COURSE: The patient was admitted to the Trauma
Service for observation. He was admitted for neurologic
checks. He initially was stating his first name only but
could not state his last name or details of the accident.
However, he was speaking in full sentences.
The patient was admitted to the Intensive Care Unit and did
not have any progression of symptoms. He had improvement in
his mental status. He was somewhat hypertensive in the
Intensive Care Unit, and therefore he was given nitroprusside
for a brief period of time. He was noted to have some pain
with movement of the left hip, and hip films were performed
which were negative. He remained stable neurologically.
A repeat head CT showed no progression. Pelvic and hip
x-rays were negative.
He was then transferred to the floor. He was cleared by
Orthopaedics with respect to his hip. The patient was fitted
for a brace which he tolerated well. He was again evaluated
by Orthopaedic because of some hip and leg discomfort, but
with negative films, and he was cleared. He was then
progressed on diet and then sent home after receiving
education with respect to seatbelt use.
FINAL DIAGNOSES:
1. Head injury with loss of consciousness and small epidural
hematoma.
2. L3 transverse process fracture.
SURGICAL PROCEDURES: None.
MEDICATIONS ON DISCHARGE: Percocet.
DISCHARGE DISPOSITION: The patient was discharged to home.
DISCHARGE FOLLOWUP: To be followed by the Orthopaedic
surgeons for his lumbar fracture as well as having
neurosurgical followup.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern4) 9706**]
MEDQUIST36
D: [**2160-7-7**] 11:37
T: [**2160-7-9**] 10:46
JOB#: [**Job Number **]
|
2720,V5861,4019,42731,431 | 304 | 177,469 | Admission Date: [**2141-5-18**] Discharge Date: [**2141-5-19**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Massive intracranial hemmorhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o female admitted to the MICU throught the ED with a severe
intracranial hemorrhage. Pt was found unresponsive at home by
her family midmorning. She had been in her normal state of
health at 6:30 AM. When EMS arrived, her respiratory rate was 4.
Per their notes, she did hava a pulse. She was diaphoretic and
having agonal respirations. Per notes, her color was greyish.
Finger stick was 194. The pt was intubated in the field and
brought to [**Hospital6 10353**] for further care.
At the OSH, the pt's VS were 97.9 135 126/68 10 100% on a FiO2
of .100. She was noted to be in atrial fib. CT of the head was
significant for a very large right frontal-temporal lobar
hemorrhage with extensive subarachnoid and ventricular extension
and mass effect. Pt was given 2 units of FFP for an elevated INR
of 3.7. She also received potassium and dilantin. Per notes, her
pupils were 2 mm and equal. Pt was then transferred to [**Hospital1 18**] for
further care.
In the ED, the pt's VS were 104 191/126 16 100% on FiO2 of .100.
She was initially started on a nipride drip with a goal SBP of
130-160 but was later discontinued. The pt also received minitol
50 gm IV x1, FFP, and vitamin K. A neurosurgery consult was
obtained to review the CT from the OSH and speak with the
family. They discussed the pt's very poor prognosis with the
family and the decision was made to gather the rest of the
family and then most probably discontinue ventilation. The pt
will be admitted to the MICU until the family can gather at
[**Hospital1 18**].
Past Medical History:
1. S/P CVA
2. Past LE cellulitis
3. Hypertension
4. Hypercholesterolemia
5. Left shoulder pain
6. Atrial fib
Social History:
Pt lives at home with her daughter. [**Name (NI) **] ETOH, tobacco, or drugs.
Family History:
Noncontributory.
Physical Exam:
PE:
96.4 105 130/88 18 100% on FiO2 of .100
Gen- Unresponsive, intubated lady. Does not respond to verbal or
physical stimuli.
HEENT- NC AT. Intubated. Pupils fixed. Right 3-4 mm. Left [**2-9**]
mm.
Cardiac- Irregularly irregular. No m,r,g.
Pulm- CTA anteriorly and laterally.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- Does not respond to voice or touch. Appears to withdraw
her legs to pain. Pupils fixed. Right pupil appears blown.
Negative gag reflex. Negative pupilary reflex. Upgoing toes
bilaterally.
Pertinent Results:
[**2141-5-18**] 02:50PM BLOOD WBC-13.5*# RBC-4.70 Hgb-13.3 Hct-39.1
MCV-83 MCH-28.2 MCHC-33.9 RDW-13.2 Plt Ct-248
[**2141-5-18**] 02:50PM BLOOD Neuts-80.9* Lymphs-15.6* Monos-2.9
Eos-0.4 Baso-0.2
[**2141-5-18**] 02:50PM BLOOD Plt Ct-248
[**2141-5-18**] 02:50PM BLOOD PT-21.6* PTT-26.4 INR(PT)-3.1
[**2141-5-18**] 02:50PM BLOOD Glucose-269* UreaN-15 Creat-1.0 Na-139
K-5.0 Cl-102 HCO3-22 AnGap-20
[**2141-5-18**] 02:50PM BLOOD CK(CPK)-126
[**2141-5-18**] 02:50PM BLOOD CK-MB-8 cTropnT-0.34*
[**2141-5-18**] 02:50PM BLOOD Calcium-9.0 Phos-3.2 Mg-1.5*
[**2141-5-18**] 03:03PM BLOOD pO2-459* pCO2-30* pH-7.42 calHCO3-20*
Base XS--3
Brief Hospital Course:
1. Intracranial hemorrhage- Pt with a devestating intracranial
hemorrhage as described above. Seen by neurosurgery in the ED. I
spoke to them and per the team she is not a surgical candidate.
At this time, she has evidence of brain death. This was
discussed with the pt's family and they gathered in the MICU for
a family meeting. After a long discussion, the family decided
that she would not wish to be maintaned on the ventilator with
no meaniful hope of any recovery. The pt was extubated and died
approximatley 2 hours later.
[**Name (NI) 1094**] son is [**Name (NI) 25965**] [**Name (NI) 25966**]. His home phone number is [**Telephone/Fax (1) 25967**]
and his cell phone number is [**Telephone/Fax (1) 25968**].
Spoke to pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] so he was aware of the situation
throughout the admission. I also called him once the pt died.
Medications on Admission:
1. Coumadin
2. Atenolol
3. Lipitor
4. Maxzide 25 mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
|
41071,4240,9971,42731,4280,41401,4019,2720,25000 | 305 | 108,015 | Admission Date: [**2125-12-31**] Discharge Date: [**2126-1-10**]
Date of Birth: [**2052-10-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Recurrent chest pain
Major Surgical or Invasive Procedure:
[**2126-1-2**] Single Vessel Coronary Artery Bypass Grafting utilizing
vein graft to right coronary artery, Mitral Valve Repair with 26
millimeter CE ring, and Aortotomy with partial RCA stent
removal.
[**2125-12-31**] Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 19688**] is a 73 year old female who has undergone multiple
percutaneous interventions and stent placement to her right
coronary artery. Her most recent was [**2125-2-22**] at the [**Hospital1 18**]. She
has been relatively chest pain free since that time. She
presented to [**Hospital 1474**] Hospital with recurrent substernal chest
pressure and heaviness with left arm/shoulder discomfort. She
ruled in for a NSTEMI. She was stablized on medical therapy and
transferred back to the [**Hospital1 18**] for further medical management.
Past Medical History:
Congestive Heart Failure, NSTEMI, Coronary Artery Disease - s/p
multiple RCA stents, Mitral Regurgitation, Diabetes Mellitus -
on Insulin Therapy, Hypercholesterolemia, Cerebrovascular
Disease - s/p CVA, Known Carotid Disease, Right Subclavian
Stenosis, Peripheral Vascular Disease, History of Humeral
Fracture, GERD, Depression, Prior Bladder Surgery
Social History:
Lives with her daughter. Denies tobacco, ETOH and recreational
drugs. Ambulates with a walker.
Family History:
Denies premature coronary disease.
Physical Exam:
Vitals: T 97.5, BP 165/40, HR 53, RR 18, SAT 98% on 2L
General: elderly female in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD, soft right carotid bruit noted
Heart: regular rate, normal s1s2, soft systolic ejection murmur
at LLSB
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, trace edema, no varicosities
Pulses: decreased distally
Neuro: alert and oriented, slight left facial droop, mild left
sided weakness otherwise nonofocal
Pertinent Results:
[**2126-1-8**] 05:30AM BLOOD WBC-10.2 RBC-3.80* Hgb-11.5* Hct-32.7*
MCV-86 MCH-30.3 MCHC-35.2* RDW-14.7 Plt Ct-228
[**2126-1-6**] 01:58AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.2*
[**2126-1-8**] 05:30AM BLOOD Glucose-81 UreaN-27* Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-32 AnGap-8
RADIOLOGY Final Report
CHEST (PA & LAT) [**2126-1-8**] 9:49 AM
CHEST (PA & LAT)
Reason: r/o inf., eff
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with CAD for CABG
REASON FOR THIS EXAMINATION:
r/o inf., eff
HISTORY: Status post CABG, evaluate for infiltrate or effusion.
FINDINGS: AP chest radiograph compared to [**2126-1-3**].
There has been interval extubation and removal of the
[**Last Name (un) **]-gastric tube. There has been interval removal of the
Swan-Ganz catheter (via the right IJ) as well.
The previously seen retrocardiac density has improved. The
pulmonary edema has resolved. The enlarged postoperative
mediastinum is unchanged.
IMPRESSION: Resolution of pulmonary edema and decreased left
basilar atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**First Name8 (NamePattern2) **] [**2126-1-8**] 2:21 PM
Brief Hospital Course:
Mrs. [**Known lastname 19688**] was admitted and underwent cardiac catheterization.
During the procedure, the right coronary artery could not be
engaged as there was a significant amount (approximately 7mm) of
previously placed stent jutting out into the lumen of the aorta.
The right coronary artery appeared to have a severe ostial
stenosis despite the presence of the previously placed multiple
stents. The LMCA, LAD and LCx had no angiographic evidence of
coronary artery disease. Distal aortography was also performed.
This demonstrated a large plaque in the aorta just distal to the
renal arteries. There was mild-moderate arterial disease in the
right and left iliac arteries and mild arterial disease in the
right common femoral artery. Based on the above results, cardiac
surgery was consulted and further evaluation was performed. An
echocardiogram on [**1-1**] was notable for 2+ mitral
regurgitation and depressed left ventricular function with an
ejection fraction of 30%. Preoperative evaluation was otherwise
unremarkable and she was cleared for surgery.
On [**1-2**], Dr. [**Last Name (STitle) **] performed single vessel coronary
artery bypass grafting along with a mitral valve repair. He also
removed the stent from the right coronary ostium via aortotomy.
The operation was otherwise uneventful and she transferred to
the CSRU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated. She maintained stable
hemodynamics as she weaned from inotropic support. She
intermittently required intravenous Nitroglycerin for
hypertension. Given her cerebrovascular and peripheral vascular
disease, her SBP was maintained between 120-140 mmHg. She
remained mostly in a normal sinus rhythm. Very briefs episodes
of paroxysmal atrial fibrillation were noted on telemetry, most
likely in the setting of hypokalemia. K and Mg levles were
monitored closely and repleted per protocol. Most of her
preoperative medications were resumed. She made steady progress
and transferred to the SDU on postoperative five. Her blood
sugars remained well controlled. Beta blockade was slowly
advanced as tolerated. She remained in a normal sinus rhythm
without further episodes of atrial fibrillation. Over several
days, she continued to make clinical improvements with diuresis
and made steady progress with physical therapy. She was cleared
for discharge to rehab on postoperative day seven. At discharge,
her chest x-ray showed resolution of pulmonary edema with
decreased left basilar atelectasis. Her BP ranged from the
104-114/50-60's with a heart rate in the 70-80's. Her room air
saturations were 95%. All surgical wounds were clean, dry and
intact without evidence of infection. She had adequate pain
control with Tramadol and Motrin. She was discharged to rehab in
stable condition on POD#8.
Medications on Admission:
Aspirin 325 qd, Plavix 75 qd, Lasix 40 qd, Protonix 40 qd,
Atenolol 25 qd, Lipitor 40 qd, Lisinopril 5 qd, Imdur 60 qd,
Humulin Insulin 70/30 - 35 units qam and 20 units qpm, Advair
MDI, Atrovent MDI, Eye gtts
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks: please decrease to 20 meq QD when Lasix drops to Qd -
titrate accordingly.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks: then decrease to 40 mg QD - titrate accordingly.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig:
15 units units Subcutaneous twice a day: increase to home dose
of 35 units qam and 20 units qpm as tollerated.
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
attached sliding scale Subcutaneous four times a day.
14. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care of [**Location (un) 1475**]
Discharge Diagnosis:
Congestive Heart Failure, NSTEMI, Coronary Artery Disease - s/p
multiple RCA stents, Mitral Regurgitation, Diabetes Mellitus,
Hypercholesterolemia, Cerebrovascular Disease - s/p CVA, Known
Carotid Disease, Right Subclavian Stenosis, Peripheral Vascular
Disease, Brief Postoperative Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-13**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] in [**1-11**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-11**] weeks.
Completed by:[**2126-1-10**] |
4280,4271,2639,5070,99859,42820,2859,4148,25060,3572,4019,53081,41400,V4581 | 305 | 122,211 | Admission Date: [**2127-6-19**] Discharge Date: [**2127-7-16**]
Date of Birth: [**2052-10-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Shortness of breath, increasing lower extremity edema, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 74 yo F w/ CHF EF 20-25%, DM, PVD s/p recent R fem-[**Doctor Last Name **]
[**4-/2127**] c/b groin wound infection s/p debridement and vancomycin
and Aztreonam course, and recent onset c/o SOB, increasing pedal
edema, nonproductive cough X 1 week.
She noted persistent chest pain/pressure triggered by coughing
and heavy breathing. At the time, she was experiencing
subjective chills. No sick contacts, URI sx, fevers, chronic
foley, no back tenderness. The patient also c/o
nausea/nonbloody, nonbilious emesis, abdominal pain X 4 days. No
hematemesis, hematochezia, melena.
.
In ED, the patient presented with rales and BNP >[**Numeric Identifier 4731**]. She was
diuresed 1L with 40 mg IV lasix, with SBP dropping to 50s-60s
transiently and recovering to 100s spontaneously. A central line
was placed during the hypotensive episode with CVP measured at
15. She was started on Ciprofloxacin for UA. Abdominal CT showed
no inflammation or abscess as source of infection, improved
ascites and bilateral pleural effusions. She was admitted for
further management.
.
Past Medical History:
.Congestive Heart Failure
.NSTEMI
.Coronary Artery Disease - s/p multiple RCA stents
.Mitral Regurgitation
.IDDM
.Hypercholesterolemia
.Cerebrovascular Disease - s/p CVA
.Known Carotid Disease
.Right Subclavian Stenosis, Peripheral Vascular Disease
.History of Humeral Fracture
.GERD
.Depression
.Prior Bladder Surgery
.Fem-[**Doctor Last Name **] bypass complicated by infection
Social History:
Lives with her daughter. Denies tobacco, ETOH and recreational
drugs. Ambulates with a walker.
Family History:
Denies premature coronary disease.
Physical Exam:
EXAM on discharge:
Vitals:
Tm: 99.6, Tc: 98.2, 150/70 (SBP range 120 to 150), HR 65 (HR
range 65-76), O2 sat 100%/2L (baseline)
.
Gen: obese elderly talking without difficulty on NC
Neck: Difficult to assess JVP
CV: distant HS, RRR, no MRGs noted
Chest: + increased E/I ration, poor airmovement, + rales,
crackles at bases bilaterally, dull to percussion at bases
Abd: obese, +BS, Tenderness in RLQ above area of groin
debridement/repair, wound vac in place
Ext: 2+ pitting edema in LE (much improved from admission), vac
in place
Pulses: non palpable DP, PT b/l.
Neuro: CN III-XII grossly intact. able to move all 4 ext, nl
sensation to LT
Pertinent Results:
CBC
[**2127-7-16**] 6.9 / HCT-26.3* MCV-94 / 351
[**2127-6-19**] 5.4 / Hct-31.8* MCV-101 / 320
Neuts-75.6* Lymphs-17.3* Monos-3.2 Eos-3.3 Baso-0.6
[**2127-6-20**] folate 773 B12 18.2
[**2127-6-20**] 4.4 / 25.9* MCV-101* / 259
Retic: 4.2*
DIff: N64.1 L25.0 M3.6 E6.6* A0.7
Guiac negative
rbc morphology
Hypochr Anisocy Poiklo Macrocy Microcy Polychr
.
COags
[**2127-6-19**] PT-13.9* PTT-31.3 INR(PT)-1.2*
.
Chem7
[**2127-7-16**] 140/4.3/105/32/15/0.6/103
[**2127-6-24**] 138/ 4.1/ 102/ 33 / 20/ 0.8 /72
.
[**2127-6-23**] Ca 8.0* phos 3.4 Mg 1.7
.
[**2127-6-19**] UA 02:00PM URINE Color-Yellow Appear-Clear Sp
[**Last Name (un) **]-1.021
[**2127-6-19**] 02:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
URINE RBC-0-2 WBC-[**10-28**]* Bacteri-FEW Yeast-FEW Epi-0-2
.
LFTs
[**2127-6-23**] ALT 13 AST 17 LDH 181 Alkphos55 Tbili0.2
.
Cardiac enzymes
[**2127-6-20**] CK(CPK)-24* / BLOOD CK(CPK)-18* /CK(CPK)-22*
cTropnT-0.03* /cTropnT-0.03*/ cTropnT-0.01
[**2127-6-19**] ALT-15 AST-20 AlkPhos-69 Amylase-29 TotBili-0.3
Lipase-9
proBNP-[**Numeric Identifier 42495**]*
.
[**2127-6-20**] 05:10AM BLOOD Cortsol-28.9*
[**2127-6-20**] 04:43AM BLOOD Cortsol-23.7*
.
Reports
CXR [**2127-6-20**]:
Mild pulmonary edema and small-to-moderate right pleural
effusion have worsened. Mild-to-moderate enlargement of the
cardiac silhouette is stable. Left subclavian and right jugular
lines end in the SVC. No pneumothorax.
.
ECG [**2127-6-19**]
Sinus rhythm and occasional atrial ectopy. Left atrial
abnormality. Left
bundle-branch block. Compared to the previous tracing of [**2127-5-7**]
the rate has increased
ECG [**Numeric Identifier 42496**]: HR 85, NSR, LBBB, LVH, TWI in I, avL; Q in III,
AVF, V1; no acute ST changes
.
[**2127-6-19**] CT Abd/Pelvis: no inflammatory process, anasarca
unchanged, pevic ascites and B pleural effusions improved.
atelectasis and bil patchy ground glass opacities, likely
pneumonitis.
.
[**2127-6-20**]
ECHO: LAd, left ventricular hypertrophy. New inferior akinesis,
global hypokinesis of the remaining segments (LVEF = 25 %). No
masses or thrombi in the LV. RV dilated with moderate global
free wall hypokinesis. Mild to moderate ([**12-10**]+) Ar. mitral valve
annuloplasty ring in place. Eccentric Moderate (2+) MR. mild
pulmonary artery systolic Increased interval mild pulmonary
artery systolic/diastolic hypertension.
.
Prior ECHO [**2126-1-2**]: LAD, Dilated LV, LV hypokinesis w/
focalities to the mid and apical infroseptal walls. LVEF`35% -->
25% post bypass. nl RV function. Echodense mass protruding from
R coronary sinus of Valsalva c/w consistent with a coronary
stent --> absent after bypass. ([**12-10**]+) AR. (3+) MR --> not
visualized post bypass.
[**2127-6-27**]
CXR Right internal jugular catheter has been removed and left
PICC line remains in standard position. Congestive heart failure
shows improvement with decreasing pulmonary edema and improving
right pleural effusion. Left effusion and retrocardiac
atelectasis are not substantially changed.
.
Stool Analysis [**2127-7-12**]: Guaiac negative
Urine cx [**2127-7-11**]: yeast, repeat urine cx [**2127-7-13**]: no growth
Isolated blood cx on [**2127-7-11**]: coag negative staph ([**Last Name (un) 36**] pending),
likely contamination
Blood cx on [**2127-7-13**]: NGTD
.
Chest XRAY [**2127-7-11**]
Interval worsening of interstitial edema with left basilar
opacity representative of collapse/consolidation with probable
effusion
Brief Hospital Course:
74 yo with CHF, PVD, CAD, hx of MRSA indwelling foley, s/p
recent aorto-fem [**Doctor Last Name **] bypass c/b wound infection admitted with
SOB likely [**1-10**] to CHF exacerbation with course c/b
self-resolving hypotension following diuresis continued on
diuresis on admission. SOB [**1-10**] decompensated CHF given CXR
showing worsening effusion and edema. Unclear trigger for this
event. A new ECHO performed as an inpatient revealed inferior
hypokinesis suggestive of a recent MI of unknown date (EF of
20-25%) but negative troponins and negative ECG on admission.
Infection was a less likely trigger given the absence of
leukocytosis and hx of aztreonam and vancomycin prior to
admission. UCx and wound cultures were negative, though the
patient presented with thick secretions. PNA was an unlikely
trigger given a stable CXR with improving pleural effusions,
absence of fever/leukocytosis on aztreonam/vancomycin. PE less
likely given anticoagulation with lovenox at rehab and absence
of supportive hx. No hx of dietary indiscretion or medical
noncompliance.
.
On [**2126-7-3**], while actively being diuresed (on a lasix drip with
metolazone), the patient had episode of hypotension and
unresponsiveness (a code was called). The patient was
subsequently transferred to the MICU. This was thought likely to
be cause by a combination of hypotension, slight bradycardia and
medications administered prior to the code (zofran and
morphine). Also of note, the systolic blood pressures in her
right arm are 30-40 mmHg lower than her left arm (likely [**1-10**]
subclavian artery stenosis on right). Patient had an episode of
vomiting and likely aspirated based on the chest x-ray finding
of likley aspiration PNA. Patient had persistent hypotension
after the code and the patient was started on dopamine. Patient
was slowly weaned off, but cause of hypotension is not
completely clear though it was thought likely secondary to both
hypovolemia and possible measurement of blood pressure from
right arm. The patient briefly had an elevated oxygen
requirement in the MICU, but was kept on aztreonam and
vancomycin (as previously started by vascular team with
indefinite time course). However, the patient had subsequent
fevers and metronidazole was started for concern for aspiration.
Of note, an ART line was placed while in the MICU for accurate
measurement of BP and ABG. Subsequently, her lisinopril and
carvedilol were resumed. The patient was also noted to have
episodes of NSVT, for which an ICD may be indicated in the
future. The EP team did not recommend amiodarone at the present.
Will follow up with EP Dr. [**Last Name (STitle) 42497**] as outpatient.
.
Infectious Disease: The patient was treated for >8 weeks on
aztreonam and vanc for double coverage given e/o from OSH
([**Hospital1 1474**]) with wound cultures on [**2127-5-8**] positive for E. coli R
to TMX-SMX, gentamicin, amp, cipro; Proteus R to tmx-smx, cipro,
levo, cirpo, nitro; and MRSA R to cefazolin, oxacillin, clina,
pen, erythro, confirmed with wound cultures from [**Hospital1 18**]. Blood
cultures continued to be negative. Urine culture positive for
yeast only. The patient was therapeutic on vancomycin as an
inpatient, with troughs within range. The goal is to continue
with the IV Aztreonam and Vancomycin for indefinite duration.
She has follow up appointments with Infectious Disease
Specialists at [**Hospital1 18**].
.
Fevers: cultures were drawn for occasional spikes in
temperature, with no significant growth from blood. Initially it
was thought to be due to aspiration PNA--she was on Falgyl and
completed 7 day course. Also her PICC line was taken out on
[**2127-7-8**]. A new PICC was placed on [**2127-7-11**]. Blood cultures grew
coag neg staph from [**7-11**] from 1/2 bottles - likely contaminant
given that she was already on Vanc which was therapeutic. Urine
cultures grew out yeast initially, with resolution after removal
of the Foley catheter. Her fever curve started trending down and
was afebrile for more than 3 days prior to discharge.
.
Abdominal pain: had this during admission though LFTs wnl,
abdominal CT negative and abdominal exam unimpressive. The
patient had a known SMA and celiac artery stenosis, though
ischemic changes were not evident.
.
Pain control: She continued to have lower extremity pain from
her neuropathy and groin wound. Gabapentin and tylenol were
adequate for pain, with only low doses of morphine as needed, as
narcotic effect was causing her somnolence.
.
Anemia: the patient was noted to have a newly macrocytic anemia
despite folate and B12 supplementation, most likely anemia of
chronic disease. TSH wnl, and LFTs wnl. This may also reflect a
drug suppressive effect on bone marrow, but the rest of the CBC
has been wnl. Stool has been guaiac negative, RBC morphology
with macrocytosis but no polychromia. The patient was transfused
pRBC on two occasions in the for Hct<24 during this
hospitalization.
.
Diabetes: insulin regimen was titrated and upon discharge, it
was NPH 22U in am, 12U in pm; insulin SS beginning at 4U for FS
151-200mg, with increment of 2U for every +50mg.
.
Pulmonary: She had aspiration PNA as mentioned above and
completed Flagyl course.
Incentive spirometry as well as chest PT and continued
treatement with nebs were encouraged, and the patient's
respiratory status improved to an oxygen requirement of 1-2L NC,
with CPAP as needed at night.
.
Code status: discussed with patient (confirmed by Dr. [**First Name (STitle) **] on
[**2127-7-8**], patient's status is DNR/DNI as of [**2127-7-16**].
Medications on Admission:
Latanoprost 1 gtt OU qhs
tylenol PRN
Metoprolol (12.5 mg or 25 [**Hospital1 **], unclear from records
Aspirin 81 mg PO DAILY
Miconazole Powder 2% 1 Appl TP TID:PRN
Modafinil *NF* 200 mg Oral qAM
Simvastatin 10 mg PO DAILY
lasix 20mg qdaily
.
Multivitamins 1 CAP PO DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN
Ca/VitD
Percocets PRN
omeprazole qdaily
Cyanocobalamin 1000 mcg PO DAILY
Sertraline 75 mg PO DAILY
Thiamine HCl 100 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Zinc Sulfate 220 mg PO DAILY
senna, colace, dulcolax
.
Aztreonam 1000 mg IV Q8H
Vancomycin 1000 mg IV Q 12H
lovenox 40SC daily
.
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Tiotropium Bromide 1 CAP IH DAILY
insulin 18 NPH qAM, 10qPM
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
15. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
16. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
20. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q8H (every 8 hours) as needed.
21. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
22. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed.
23. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
24. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
25. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
26. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
27. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
28. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours).
29. Vancomycin 1000 mg IV Q 24H
30. Insulin NPH, Humalog Sliding Scale
Please see the attached sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: decompensated systolic congestive heart failure
Secondary:
- CAD s/p SVG-RCA CABG and RCA stent
- CHF EF 20-25%
- DM
- HTN
- Hyperlipidemia
- MV repair with annuloplasty.
- CVA with residual right sided weakness
- bilateral Carotid Stenosis
- Right Subclavian Stenosis
- Peripheral Vascular Disease s/p s/p aortic and right external
iliac
stent; s/p Rt fem-[**Doctor Last Name **] bypass w/ goretex c/b groin wound
infection and exposed graft s/p 2X Debridement and sartorius
muscle flap
- GERD
- Depression
- Prior Bladder Surgery
Discharge Condition:
fair
Discharge Instructions:
You were admitted with shortness of breath, dry cough, and low
blood pressure. Your symptoms were most likely caused by heart
failure, which caused fluid to accumulate around your lungs and
led to difficulty breathing and leg swelling. An ultrasound of
your heart compared to an ultrasound done last year demonstrated
that your heart was pumping at less than 25% of its expected
level and that a new area at the bottom of your heart was not
pumping and injured.
.
We adjusted the following medications: we increased your insulin
NPH does to 22U in the morning and 12U at night. You are also on
a sliding scale of insulin with meals, starting at 4U at a
glucose>151, and increasing by increments of 2U for every 50mg
glucose. Please see the attached sliding scale.
.
We added the following new medications: Lisinopril, for
protection against heart failure, and carvedilol and
spironolactone to protect your heart.
.
We gave you gabapentin and morphine on an as needed basis for
your pain. Morphine must be used in very low doses as it may
make you confused or drowsy.
.
The wound in your right groin is covered with a VAC dressing.
This will be changed every three days.
.
Watch for the following signs and symptoms and notify your
doctor if these occur: Foul-smelling drainage or fluid from the
wound; Increased redness or swelling of the wound or skin
around it; Increasing tenderness or pain in or around the wound
.
If you experience shortness of breath, chest pain, fevers
>100.4, copious diarrhea, light headedness/feeling as if you are
going to faint, inability to perform your normal activities, or
a productive cough, please come to the nearest emergency room or
talk to your doctors.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] Tuesday [**7-22**] at 10:30am. Please call Phone [**Telephone/Fax (1) 3183**] to reschedule.
.
You have an appointment for lung function tests [**8-7**], at
1:30pm, [**Location (un) 436**] [**Hospital Ward Name 23**]. You will go first to do lung function
tests at 1:30pm, and then meet with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the
pulmonologist to discuss these tests. Phone:[**Telephone/Fax (1) 612**]
.
You should follow up with your vascular surgeon Dr. [**Last Name (STitle) **]
on [**2127-7-28**] at 1pm. Please call to reschedule if this is
inconvenient to the number [**Telephone/Fax (1) 3121**] or [**Telephone/Fax (1) 1237**].
.
You have an appointment with the infectious disease doctor Dr.
[**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] on [**2127-7-29**] at 10:30am, on [**Last Name (NamePattern1) 439**] in
the [**Hospital **] medical building. You need to please call [**Telephone/Fax (1) 3395**]
to confirm your appointment prior to the appointment.
.
You have an outpatient appointment with a cardiologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on Tuesday [**8-5**] at 3:20pm, where you will
discuss options for medication called amiodarone, and use of a
implanatable cardiac defibrillator vs. biventricular pacemaker
to control your heart rhythm.
.
An interpreter will be present at all these visits.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2127-7-16**] |
42820,4471,V5867,25000,4389,43330,41401,4240,4280,99672,41071 | 305 | 133,059 | Admission Date: [**2125-4-26**] Discharge Date: [**2125-5-3**]
Date of Birth: [**2052-10-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
acute coronary syndrome
Major Surgical or Invasive Procedure:
1. cardiac catheterization with RCA stenting
History of Present Illness:
72 y/o W with h/o CVA, carotid stenosis, MR, CAD s/p MI s/p
instent thrombosis x 2 transferred from OSH w/ ACS s/p cath
[**2125-4-26**] w/out intervention, who was planned for CABG. She was
admitted to the CCU for intensive BP and symptom monitoring and
is transferred back to the [**Hospital Unit Name 196**] service after RCA stenting which
obviated a need for CABG.
.
Pt has a hx of CAD s/p stent to RCA [**10-12**], returned w/ in-stent
thrombosis in [**11-11**] w/ RCA stent and restenosis in [**2-10**] s/p
baloon angioplasty. Pt presented to OSH w/ intermittent
left-sided chest pain over the last several days PTA which was
relieved with SL nitro. The night PTA pt had an episode of CP
that was unrelieved by SL nitro x 3 and was associated w/
diaphoresis/SOB and radiation to the LUE. She presented to
[**Hospital 1474**] Hospital where she ruled in by enzymes and was
transferred to [**Hospital1 18**] for cath. At [**Hospital1 18**] peak CK 550, MB 88, MBI
16, trop 0.60.
.
At cath on admission, she was found to have 90% RCA ostial
stenosis that was originally not amenable to intervention at the
time; the lesion was felt to be calcified instent thrombosis.
Single-vessel CABG & MVR was planned for [**2125-4-30**].
.
Post cath, the pt had persistent CP which was relieved w/ low
dose nitro gtt w/ goal BP 100-160. She was transferred to the
CCU for monitoring and optimizaiton of BP to ensure adequate
cerebral perfusion in the context of known intracranial
stenosis.
.
She had reported no CP or SOB except for progressive exertional
dyspnea over the past year intermittently associated w/ CP. She
has had no dysuria, cough, or abd pain. She has had occasional
constipation relieved with bowel movement.
Past Medical History:
PMHx:
1. DM
2. HTN
3. Hyperlipidemia
4. CAD s/p MI stents. Presented [**10-12**] with 90% ostial lesion of
RCA c/b in-stent trhombosisx2 ([**10-12**] and [**2-10**]) s/p repeat stent
and PTCA.
5. humeral fx
6. CVA with right sided weakness
7. Carotid Stenosis
Social History:
no tobacco, ETOH, drugs; ambulates with a walker, lives at home
alone but her 2 sons and dtr rotate [**Name2 (NI) 20515**] to sleep in her house
so she is never alone overnight. She wants to continue in her
current living situation.
Family History:
Mother w/ [**Name2 (NI) 2320**], CVA; father w/ ? ca; no FHx of SCD
Physical Exam:
On admission to [**Hospital1 18**]
VS: T AF, 97% RA, L 105/43, R = 121/45, RR = 19.
Gen: Pleasant elderly female laying in bed NAD
HEENT: MMM, JVP 5 cm above sternal notch
CV: nml S1, S2, soft 2/6 SEM @ LUSB
Lungs: CTAB
Abd: Soft, obese, nt.
Extremties: Faint pulses apprciable with dopplers.
No groin bruits or hematomas bilaterally.
.
On transfer to CCU:
AF 100.1 BP 92/29 92-122/24-43 80 20 2L NC FS 163
Gen: cauc W lying in bed in NAD
HEENT: EOMI, OP clear, L nasolabial fold flattened at baseline
Neck: jvp @ 16cm H20
Heart: SEM at apex III/VI, no radiation; L subclavian sustolic
bruit; no R subclavian or carotid bruits;
Lungs: CTBLA, no rales, no wheezing or rhonchi
Abd: obese, S/NT/ND/no masses
Ext: trace pitting edema b/l
Pertinent Results:
[**2125-4-26**] 09:35AM GLUCOSE-211* UREA N-33* CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
[**2125-4-26**] 09:35AM ALT(SGPT)-21 AST(SGOT)-61* ALK PHOS-61
AMYLASE-55 DIR BILI-0.1
[**2125-4-26**] 09:35AM ALBUMIN-3.1*
[**2125-4-26**] 09:35AM WBC-7.7 RBC-3.40* HGB-10.8* HCT-31.7* MCV-93
MCH-31.6 MCHC-33.9 RDW-13.5
[**2125-4-26**] 09:35AM PT-14.2* PTT-123.2* INR(PT)-1.3
[**2125-4-26**] 08:00AM GLUCOSE-207* UREA N-29* CREAT-1.0 SODIUM-146*
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-27 ANION GAP-16
[**2125-4-26**] 08:00AM CK(CPK)-520*
[**2125-4-26**] 08:00AM CK-MB-88* MB INDX-16.9* cTropnT-0.23*
[**2125-4-26**] 08:00AM WBC-8.6 RBC-4.18*# HGB-13.2 HCT-39.0# MCV-93
MCH-31.6 MCHC-33.8 RDW-13.5
[**2125-4-26**] 08:00AM NEUTS-60.9 LYMPHS-34.1 MONOS-3.9 EOS-0.6
BASOS-0.5
[**2125-4-26**] 08:00AM PLT COUNT-253hct 33 stable creat 1.0
.
# 1 CK 520 MB 88 MBI 16.9 trop 0.23
# 2 CK 550 MB 86 MBI 15.6 trop 0.60
# 3 CK 260 MB 30 MBI 11.5 trop 0.62
.
U/A lg bld, 74 RBCs
.
@ [**Hospital1 1474**]
CK 114 MB 11 trop I 0.10
BNP 121
.
Studies:
Cath [**2125-4-26**]:
LMCA/LAD non-obstructed.
LCx diffusely diseased
large, dominant RCA w/ 90% ostial stenosis, couldn't be engaged
[**1-10**] aorto-ostial nature of the plaque and the prior crushed
stent extruding into the aorta; nl flow.
.
80% eccentric stenosis of R subclavian involving origin of R
vertebral artery w/ gradient
40% eccentric stenosis of L subclavian artery
.
Carotid US ([**2125-4-26**]):
<70% stenosis BL
.
EKG:
[**2125-4-27**]: HR 100bpm, LBBB c/w baseline [**2-10**] no significant
changes.
[**2125-5-1**]: HR 72bpm, LBBB c/w baseline [**2-10**] no significant changes
except mild J-point elevation.
.
MRA [**2125-4-29**]:
Demonstrates several areas of focal narrowing/stenosis in the
middle cerebral arteries bilaterally, right greater than the
left and also in the A1 segment of the right anterior cerebral
artery. Irregular areas of narrowing is also noted in the
posterior cerebral arteries bilaterally, left greater than the
right. The study is minimally limited by motion. If clinically
warranted, a MRA may be performed when the patient is more
stable and cooperative.
.
TTE [**2125-4-27**]: 3+ MR, EF 40% (down from 56% in [**2-10**]), nl RV size
and wall motion.
TTE ([**2-10**]): EF 56%, 3+ MR; basal portion of inferolat wall HK
.
Cath [**2-10**]: RCA 90% stenosis, s/p baloon;
Cath [**11-11**]: s/p stent to RCA [**1-10**] instent restenosis
Cath [**10-12**]: s/p RCA stent [**1-10**] 80-90% lesion
Cath [**2125-4-26**]: unsuccessful RCA stenting.
Cath [**2125-5-1**]: successful RCA stenting with Cypher DES.
1. RCA angiography demonstrated a 99% ostial RCA in-stent
restenosis.
2. Successful stenting of the ostial RCA was performed with two
3.5 x
23 mm Cypher DES.
Brief Hospital Course:
A/P: 72 yo woman with progressive mitral regurgitation and
severe right coronary artery disease s/p multiple interventions
including successful stenting [**5-1**] now in need of optimization
of her medical program.
.
1. Coronary Artery Disease: Ostial RCA lesion was successfully
intervened upon [**5-1**]. The patient had an episode of exertional
dyspnea on ambulating to the bathroom earlier today but is
currently free of CP and dyspnea and doing well. Troponin bump
[**5-2**] likely due to intervention [**5-1**].
- Continue ASA, metoprolol, atorvastatin
- Clopidogrel 75 mg daily x9 months
- Added ACE-inhibitor after stenting and renal function
stable. Titrated up to 10 mg po daily and tolerated by BP.
- Troponin and CK peaked at 1.04 and 109, have since trended
downwards.
.
2. Stroke: The patient has a known old right-sided stroke and
carotid and intracranial stenoses. At baseline, she has
bilateral upgoing toes, left facial droop, and general
left-sided sensory loss. There are no new neurologic deficits.
Followed by neurology consultation service as inpatient.
Continue ASA, clopidogrel.
.
3. Mitral Regurgitation: Although coronary ischemia was likely
playing a role in her dyspnea, her MR is likely contributing as
well. MR has been thought to be due to papillary muscle
stunning in the setting of myocardial ischemia as opposed to
intrinsic valvular defect.
- Afterload reduced with lisinopril as noted above
- No current plans for MVR
- Goal fluid balance roughly even
.
4. DM-II: Continue RISS, insulini 70/30 [**Hospital1 **].
.
5. HTN: Control with meds as above.
.
6. NSVT: No further events on telemetry.
.
7. Asthma: Continue fluticasone/salmeterol, ipratropium.
.
8. Depression: Continue sertraline.
.
9. Neuropathic Pain: Continue gabapentin.
.
10. F/E/N: Cardiac diet/[**Doctor First Name **], check lytes daily.
.
11. Proph: heparin sq, bowel regimen, PPI.
.
12. Code: Full code, but patient has stated, "I don't want to be
on machines for a long time." HCP are pt's children.
.
13. Disposition: Pt stable and improved. PT recommending
rehabilitation, from which patient will benefit.
Medications on Admission:
ALLERGIES: PCN, sulfa
.
MEDICATIONS AT HOME:
atenolol
asprin
lipitor
plavix
colace
lisinopril
isosorbide mononitrate
fluticasone-salmeterol
.
MEDICATIONS ON TRANSFER TO CCU:
Acetaminophen
Aspirin EC 325 mg po q24h
Atenolol 25mg po q24h
Atorvastatin 80mg po q24h
Clopidogrel Bisulfate 75mg po q24h
Docusate Sodium
Fluticasone-Salmeterol (100/50)
Furosemide 40mg po q24h
Heparin gtt
Insulin SS
Ipratropium Bromide Neb
Isosorbide Mononitrate (Extended Release) 60mg po q24h
Lisinopril 5mg po q24h
Magnesium Sulfate
Morphine Sulfate
Nitroglycerin SL
Nitroglycerin gtt now d/c'ed
Pantoprazole
Sertraline HCl
Senna
Travatan OU
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic at
bedtime.
5. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation every six (6) hours.
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 10 months.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Insulin 70/30 70-30 unit/mL Suspension Sig: Thirty Five (35)
units Subcutaneous qAM.
13. Insulin 70/30 70-30 unit/mL Suspension Sig: Twenty (20)
units Subcutaneous qPM.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
1. coronary artery disease
2. systolic heart failure
3. mitral regurgitation
4. bilateral carotid artery stenosis
Discharge Condition:
Chest pain free with mild exertional dyspnea likely due to
deconditioning. Stable for discharge to [**Hospital 3058**] rehab.
Discharge Instructions:
Take all medications as prescribed.
Followup Instructions:
Call Dr. [**Last Name (STitle) 6700**] ([**Telephone/Fax (1) 3183**]) when you get home to arrange
for a follow-up appointment at his discretion.
|
0389,42823,V4582,41401,2724,25000,78551,78552,5849,34831,6826,2869,43820,99592,4280,5859,44020 | 305 | 194,340 | Admission Date: [**2129-8-20**] Discharge Date: [**2129-9-7**]
Date of Birth: [**2052-10-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
foot pain, fevers, sepsis, cardiogenic shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Chief complaint: Transferred from [**Hospital3 417**] for management
of acute on chronic congestive heart failure.
.
History of present illness: Mrs. [**Known lastname 19688**] is a 76 year-old
Portuguese-speaking woman with insulin dependent diabetes,
hyperlipidemia, cerebrovascular disease (with stroke), COPD,
depression, GERD, heart failure (LVEF 20%) and chronic renal
failure presenting to [**Hospital3 417**] Hospital with generalized
weakness, possible abdominal pain, and leg and right foot pain.
Today she is transferred to [**Hospital1 18**] for management of fluid
overload.
.
The discharge summary from [**Hospital3 417**] mentions that she was
suffering from gout with treatment begun in the nursing home,
abdominal CT to assess ?abdominal pain, and generalized
weakness. She had also presented with a creatinine of 2.2 and it
appears that fluid resuscitation was commenced that has now
reduced her creatinine but worsened her heart failure. In her
summary, lower extremity pain was attributed to vascular disease
and possibly in need of vascular studies and intervention. She
is also to be worked-up for acute causes of heart failure. CT
scan of the right kidney is suggestive of pyelonephritis that
has so far been treated with Levaquin (renal dosing). While
in-house at [**Hospital3 **]. one blood culture bottle was positive for
staphlococcus but this was atributed to contamination. Another
set from [**2129-8-17**] was negative at the time of transfer. CXR was
suspicious for infiltration of the lower lobes.
.
Per the patient: There was no joint tap to diagnose gout. OSH
records state that she was given allopurinol two weeks ago in
the nursing home for suspected gout along with colchicine
(unclear if renally dosed). She is mostly concerned for the pain
in her right foot which is the reason she gave for her admission
to [**Hospital3 417**]. She says that it had become painful in the
nursing home and that she could no longer stand on it. She has
trouble walking due to her left hemiparesis, and now with foot
and bilateral leg pain.
Past Medical History:
.Chronic Congestive Heart Failure (LVEF ~ 20%)
.NSTEMI
.Coronary Artery Disease - s/p multiple RCA stents
.Mitral Regurgitation
.IDDM
.Hypercholesterolemia
.Cerebrovascular Disease - s/p CVA (left hemiparesis)
.Known Carotid Disease
.Right Subclavian Stenosis, Peripheral Vascular Disease
.History of Humeral Fracture
.GERD
.Depression
.Prior Bladder Surgery
.Fem-[**Doctor Last Name **] bypass complicated by infection
.Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Lives in [**Hospital 1475**] Nursing Home and is retired. Denies
tobacco, ETOH and recreational drugs. Ambulates with a walker at
baseline. Lives with her daughter. Denies tobacco, ETOH and
recreational drugs.
Family History:
Denies premature coronary disease.
Physical Exam:
VS - T 99.2 BP 117/54 HR 91 RR 22 SatO2 100% 2L glucose 310 pain
0/10
Gen: Resting awake and comfortably. Very pleasant and grateful.
Some poverty of spontaneous speech and movement.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP to the angle of the mandible at 60
degrees.
CV: RRR with occasional ectopy, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Crackles worse on the right base. No
wheezes or rhonchi. Patient could not sit so listened to
posterolateral lung. Patient had some difficulty following
instructions for breathing during examination.
Abd: Soft, NTND. No HSM or tenderness.
Ext: [**1-11**]+ edema of the extremities. No clubbing.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: Edema was severe limiting examination.
Neurological: Left hemiparesis of leg, arm, face, with an upper
motor neuron pattern of weakness. Speech was not dysarthric,
slightly slowed, little spontaneous expression or speech.
Possibly some limitation of comprehension but English is second
to Portuguese. Sensation intact at extremities, forearm and
lower legs. Some degree of pain asymbolia possible - said
touching feet very painful but seemed blase. Reflexes not
tested. Unable to walk.
Pertinent Results:
IMAGING:
.
[**2129-9-7**] CXR: IMPRESSION: Minimal pulmonary edema in the presence
of mild cardiomegaly. No new consolidation.
.
[**2129-9-5**] Echo: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = 15-20 %).
The right ventricular cavity is dilated with depressed free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Moderate (2+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: No evidence of vegetation or abscess. Severe global
LV hypokinesis. The lateral wall has relatively better function.
The ventricle appears dyssynchronous. Moderate mitral, aortic
and tricuspid regurgitation (all may be UNDERestimated due to
acoustic shadowing from widespread calcification). Moderate
pulmonary artery systolic hypertension.
.
Compared with the prior study (images reviewed) of [**2129-8-22**],
overall ejection fraction is probably slightly less. Degree of
aortic regurgitation has increased, degrees of mitral and
tricuspid regurgitation probably similar. Estimated pulmonary
artery systolic pressures are higher.
.
[**2129-9-3**] CT chest/abdomen/pelvis:
CHEST:
Trace pleural fluid is present bilaterally with minimal
dependent bibasilar atelectasis. Images are somewhat degraded
due to respiratory motion artifact; however, there is no
consolidation. Small amount of fluid is present in the dependent
portion of the central trachea. Cardiomegaly and heavy coronary
arterial calcifications and atherosclerotic calcification of the
thoracic aorta is unchanged. There is no mediastinal or axillary
lymphadenopathy. Median sternotomy wires
are in place.
.
ABDOMEN:
The liver, spleen, adrenals, and kidneys are within normal
limits. Numerous surgical clips in the gallbladder fossa and at
the posterior aspect of the right hepatic lobe from previous
cholecystectomy are again seen. There is no biliary ductal
dilatation. The pancreas is within normal limits. There is
diffuse atherosclerotic calcification of the abdominal aorta,
aortic branches, and intrarenal vascular calcifications are
noted. Right femoropopliteal arterial graft is again noted.
There are no peritoneal fluid collections. There is a large
amount of stool in the rectum, descending colon, and distal
transverse colon. There is no small- bowel obstruction. A normal
appendix is noted. There is no bowel wall thickening or
pneumatosis.
.
PELVIS:
The urinary bladder is collapsed about a Foley catheter balloon.
Focus of air in the nondependent portion of the bladder is
likely related to Foley catheter placement. Again seen is a
calcified uterine fibroid. There are no adnexal masses. There
are no pelvic fluid collections.
.
ABDOMINAL WALL:
Numerous areas of infiltration of the subcutaneous fat in the
anterior
abdominal wall, few foci of subcutaneous air are likely related
to injection sites.
.
BONES:
Multilevel degenerative changes of the thoracic and lumbar spine
are
unchanged. Compression deformity of the superior endplate of L1
is unchanged. Right glenohumeral joint degenerative change and
mild bilateral hip osteoarthritis is noted.
.
IMPRESSION:
1. No pneumonia, as questioned.
2. No abdominal or pelvic collections. No findings suggestive of
ischemic
colitis.
.
[**2129-9-3**] CT head:
FINDINGS: There is no intracranial hemorrhage, mass effect,
shift of normally midline structures, or edema. The ventricles
and cerebral sulci remain prominent, compatible with age-related
involutional change. Periventricular regions of hypodensity are
unchanged, consistent with small vessel ischemic change.
Bilateral basal ganglia calcifications are again noted. The
[**Doctor Last Name 352**]-white matter differentiation remains normal. Chronic left
basal ganglia, thalamic and left frontal infarcts are unchanged.
Mastoid air cells are hypoplastic. The paranasal sinuses are
otherwise well aerated.
.
IMPRESSION: No intracranial hemorrhage.
.
[**2129-8-26**] CTA lower extremities
IMPRESSION:
1. Occluded left superficial femoral artery with reconstitution
at the
popliteal. Complete occlusion of the left posterior tibial
artery with
severely diseased, but patent anterior tibial and peroneal
arteries.
2. Patent fem-[**Doctor Last Name **] bypass graft on the right with stable severe
narrowing at the insertion of the bypass graft into the
popliteal artery. Occluded native superficial femoral artery on
the right. Evaluation for the runoff to the lower right leg is
limited as the entire lower leg is not visualized on this study.
However, it does appear that the posterior tibial artery is
occluded on this side.
.
MICRO:
.
[**9-6**], [**9-3**] C. diff: neg
Blood cx: [**9-6**], [**9-3**], [**9-2**] x2: NGTD
Blood cx: [**8-26**], [**8-23**], [**8-20**] x2: NEGATIVE
Urine cx: [**9-2**]: yeast, [**8-23**]: NEGATIVE
.
LABS ON ADMISSION:
[**2129-8-20**] 08:10PM BLOOD WBC-14.9*# RBC-4.01*# Hgb-12.7# Hct-40.0#
MCV-100* MCH-31.7 MCHC-31.7 RDW-15.7* Plt Ct-146*#
[**2129-8-20**] 08:10PM BLOOD Neuts-89* Bands-0 Lymphs-10* Monos-0
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2129-8-20**] 08:10PM BLOOD PT-19.3* PTT-29.2 INR(PT)-1.8*
[**2129-8-20**] 08:10PM BLOOD Glucose-303* UreaN-63* Creat-1.6* Na-131*
K-4.6 Cl-96 HCO3-26 AnGap-14
[**2129-8-20**] 08:10PM BLOOD ALT-378* AST-177* CK(CPK)-41 AlkPhos-76
TotBili-0.6
[**2129-8-20**] 08:10PM BLOOD CK-MB-NotDone cTropnT-1.67*
[**2129-8-20**] 08:10PM BLOOD Albumin-2.9* Calcium-8.4 Phos-2.3*
Mg-2.8*
[**2129-8-29**] 05:28PM BLOOD Lactate-1.4
.
LABS ON DISCHARGE:
[**2129-9-7**] 05:50AM BLOOD WBC-23.4*# RBC-3.96* Hgb-12.6 Hct-40.9
MCV-103* MCH-31.8 MCHC-30.9* RDW-17.5* Plt Ct-232
[**2129-9-7**] 05:50AM BLOOD Neuts-90.9* Lymphs-6.8* Monos-1.9*
Eos-0.2 Baso-0.2
[**2129-9-7**] 10:00AM BLOOD PT-23.8* PTT-34.5 INR(PT)-2.3*
[**2129-9-7**] 10:00AM BLOOD Glucose-307* UreaN-129* Creat-2.3* Na-143
K-5.7* Cl-108 HCO3-17* AnGap-24*
[**2129-9-4**] 04:24AM BLOOD ALT-80* AST-96* LD(LDH)-303* AlkPhos-40
TotBili-1.3
[**2129-9-7**] 10:42AM BLOOD Type-[**Last Name (un) **] pO2-63* pCO2-35 pH-7.29*
calTCO2-18* Base XS--8
[**2129-9-7**] 10:42AM BLOOD Lactate-6.3*
Brief Hospital Course:
76 yo F with MMP including CHF and PAD, initially admitted for
foot pain, transferred to [**Hospital1 18**] and felt to be in acute on
chronic CHF (EF 20%), s/p aggressive diuresis, now presenting
with intermittent fevers without source, progressive altered
mental status, noted to be in oliguric acute renal failure, and
in early sepsis.
.
BRIEF HOSPITAL COURSE:
In brief, 76 yo F with MMP, admitted [**2129-8-20**] to [**Hospital3 **]
Hospital for foot pain. She was empirically started on
colchicine and allopurinol, despite lack of gout hx or joint
tap. She was noted to be in ARF (Cr 2.2, baseline 1.2 in [**2127**]).
Some concern for pyelo, despite normal U/A. Transferred to [**Hospital1 18**]
for heart failure. Admitted to [**Hospital1 1516**] service, where she was
aggressively diuresed total of 10L over next several days. Cr
started to rise and 1.6-1.8. Pt spiked on [**2129-8-23**] and WBC 11.
Left leg appeared red. Neg LENI's. Started on vanco and cipro
for cellulitis. Switched to vanc and ceftriaxone given hx of
cipro resistant E.coli at the site of her fem-[**Doctor Last Name **] bypass in the
past. On [**8-26**], underwent CTA with contrast, seen by vascular,
and planned for angio procedure, given concern for ischemia in
leg. On [**9-21**], triggered for ?encephalopathy and AMS. On
[**8-30**], CT head negative for hemorrhage. NGT placed for concern
for inability to take in PO. On [**9-3**], triggered again, this time
unresponsive and tachycardic. Concern for SIRS/sepsis given BP
90/50, HR 130, and transferred to MICU. Given fluid boluses,
started on vanco/cefepime/flagyl. CT chest/abd/pelvis without
consolidation or fluid collections. Echo neg for vegetations.
Pancultured without source. On [**9-4**], given fluid boluses for low
UOP. On [**9-5**], had neg TTE study again, given concern for
intermittent temp spikes. After discussion with ICU team,
patient DNR/DNI. On [**9-7**], spiked again and WBC to 23, with
lactate rising (now 4.5). Discussion with family re: goals of
care, and family wished to pursue comfort measures.
.
DETAILED HOSPITAL COURSE:
.
[**Hospital1 **] COURSE:
# Acute on chronic heart failure/fluid overload: felt to be
significantly fluid overloaded from aggressive hydration in OSH
and perhaps earlier, given her poor systolic heart function.
Physical exam significant for basilar crackles, raised JVP,
significant edema throughout. CXR imaging noting pulmonary
edema, without signs of infection. Other acute causes of pump
dysfunction were considered including myocardial
ischemia/infarction, medication error, colchicine, thyroid
disease, anemia, atrial fibrillation. Patient initially started
on sodium restriction, fluid restriction, lasix drip 15 mg/hr,
metolazone (5 mg PO BID). EKG, cardiac enzymes, and TSH were
non-revealing. Echo was performed showing, "severe global left
ventricular hypokinesis with relative preservation of the basal
anterior septum and inferolateral walls. The remaining segments
are severely hypokinetic (LVEF = 25 %). Mild to moderate ([**12-10**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, anteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. Moderate
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension." Patient diuresed approximately 10L.
.
## Lower and right foot pain: Possible etiologies felt to
include arterial insufficency, DVT, severe edema secondary to
acute on chronic renal and heart failure as well as
hypoalbuminemia, possibly with neuropathic contribution. Gout is
possible, but the appearance of the feet and distribution of
pain are not consistent with monoarticular or oligoarticular
gout, particularly not the great toe. DVT is possible but seen
as less likely given bilateral symmetry and given the the degree
of edema is somewhat in keeping with that of her hand and other
signs such as crackles, raised JVP. Arterial insufficiency is
also possible as is diabetic neuropathy. Initial workup
consisted of LENI's (negative for DVT), and treatment for
cellultis (started on vanco and cipro, switched to vanc and
ceftriaxone given hx of cipro resistant E.coli at the site of
her fem-[**Doctor Last Name **] bypass in the past). CTA lower extremities performed
showing occluded left superficial femoral artery with
reconstitution at the popliteal. Complete occlusion of the left
posterior tibial artery with severely diseased, but patent
anterior tibial and peroneal arteries. Patent fem-[**Doctor Last Name **] bypass
graft on the right with stable severe narrowing at the insertion
of the bypass graft into the popliteal artery. Occluded native
superficial femoral artery on the right. Evaluation for the
runoff to the
lower right leg is limited as the entire lower leg is not
visualized on this
study. However, it does appear that the posterior tibial artery
is occluded
on this side. It was felt that patient's leg pain was largely
from PAD/PVD/lower extremity ischemia, and vascular was
consulted. However, angiogram was not performed, given
co-morbidities and remainder of hospital course.
.
## Renal failure: multifactorial, and likely from medications,
impaired forward flow from heart failure, being physiologically
pre-renal despite fluid overload, contrast nephropathy and
possibly ATN.
.
## Confusion/altered mental status: unclear but felt to be toxic
metabolic in setting of elevated BUN. Head CT negative for
CVA/ICH. Diuresis was held at this point.
.
MICU COURSE:
Ms. [**Known lastname 19688**] is a 76 yo female w/ multiple medical problems,
transferred to MICU for further management of presumed sepsis.
.
# Sepsis: Patient re-developed fevers on [**9-2**] on a regimen of
vancomycin / ceftriaxone. Patient had no previous positive
cultures since [**2129-8-20**]. Initial concern for infectious
etiologies included the following:
*** Intra-abdominal: given pain on palpation, and fevers while
on broad spectrum gram positive coverage with somewhat limited
gram negative/anaerobic coverage. Initial differential included
C. diff colitis, mesenteric ischemia (given multiple
vasculopathies, elevated lactate), abscess. However, CT torso
was negative and pain resolved with disimpaction and bowel
regimen. Patient was intermittently started on flagyl which was
discontinued after the negative imaging.
*** Urine: there was initial concern for renal abscess given
prior history of pyelonephritis; however, CT was negative.
*** Graft site infection of right fem-[**Doctor Last Name **] graft site: given
right foot pain and history of resistant E. coli/ MRSA at the
wound site. In ICU, antibiotics were initially broadened for
gram negative coverage to cefepime to cover pseudomonas.
Infectious disease was consulted who. Drug induced fever was
considered.
.
# Volume status/Chronic systolic HF: as evidenced by her ABGs
and electrolyte profile, she may have been over-diuresed at time
of admission to MICU. Diuresis was held and the patient was
provided fluids. Her ACE was also held given hypotension.
.
# Peripheral arterial disease: will follow up vascular surgery
recs re: need for angio once hemodynamically stable.
.
# Insulin dependent diabetes: continued ISS with fingersticks
# Hypertension: held antihypertensives while managing sepsis
.
# Peripheral arterial disease: s/p recent right fem-[**Doctor Last Name **] bypass
graft c/b wound infections with MRSA/E. coli requiring prolonged
courses of vanc/cefazolin/aztreonam-->linezolid/cephpodoxime
(for cipro resistant E. coli). Then minocycline for MRSA
suppression lifelong.
.
GENERAL WARDS:
# Altered mental status: after discussion with family and
extensive chart review, markedly off baseline. At baseline,
patient alert, oriented, and conversant. Now has had progressive
decline in mental status to the point that she is no longer
verbal. Has had trigger for same event for unresponsiveness. DDX
includes toxic metabolic (uremia) vs. infectious (though culture
negative to date) vs. CVA/ICH (CT negative). Most likely
etiology felt to be toxic metabolic. Nephrology was consulted,
but given other co-morbidities, goals of care were discussed in
parallel with potential dialysis.
.
# Oliguric acute renal failure: likely multifactorial in the
setting of sepsis, cardiorenal syndrome (at baseline with poor
EF), contrast/dye load (given [**2129-8-26**]), overdiuresis
([**Date range (1) 42498**]), and then decreased PO intake ([**Date range (1) 26417**]). Baseline
Cr 1.2, then has been progressively increasing. Now holding
diuresis. Currently BUN 118, Cr 2.1. Renal consulted, and goals
of care discussed.
.
# SIRS/early sepsis: patient with intermittent fevers without
source throughout hospital stay. On morning of [**9-7**], lactate
4.4, patient tachycardic and tachypnic, and low grade fevers.
Repeat lactate > 6. With regard to source, suspect overt
infection as opposed to occult infection, given jump in WBC from
13.5 to 23.4. Suspect Cdiff or bacteremia despite previous
negative blood cultures/negative micro. Started on PO flagyl (in
addition to previous IV vanco and cefepime). Goals of care
discussed with family and HCP. Family and HCP elected to make
patient [**Name (NI) 3225**]. Palliative care and pastoral care services offered.
Family at bedside when patient passed.
Medications on Admission:
Medications on Transfer:
SSI
Phytonadione 2 mg PO DAILY Duration: 3 Days
Acetaminophen 325-650 mg PO Q6H:PRN fever >100
Lactulose 30 mL PO TID
Senna 1 TAB PO BID
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC TID
CefePIME 1 g IV Q24H
Vancomycin 1000 mg IV Q48H DAY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY:
septic shock
cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2129-9-8**] |
3484,4321,5990,0414,37992,41401,412 | 306 | 167,129 | Admission Date: [**2199-9-15**] Discharge Date: [**2199-9-21**]
Date of Birth: [**2138-10-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Headaches.
Major Surgical or Invasive Procedure:
Right craniotomy for evacuation of subdural hematoma.
History of Present Illness:
60yo woman with PMH signficant for CAD s/p MI in [**2182**], San
[**Location 68545**]fever s/p RUL lung resection, presents as an OSH
transfer with two weeks R sided headache. She reports her
symptoms began approximately two weeks ago, when she had
"flu-like symptoms" - body aches, headache. She was concerned
this was the San [**Location 68546**], as the body aches were
similar (but were accompanied by fever and unclear if
accompanied
by headache, this time they were without fever and with
headache). She treated these symptoms with tylenol, alleve, and
other cold medications but the headache did not go away. It
continued to worsen, and was waking her up from sleep. She
describes it as a shooting pain behind her right ear (never on
the left side), constant and gnawing, with occasional "jolts"
that cause her to lose her balance, become nauseous, and once
vomit. It feels "like someone's driving a stake through your
head." She went to the hospital when she could no longer stand
the pain or the lack of sleep. She found no aggravating or
alleviating factors (?if ice may have helped), no change with
position. She had no preceding trauma, loss of consciousness,
numbness, tingling, weakness, change in speech, difficulty
thinking, bowel or bladder dysfunction, hearing problems, or
diplopia. She feels it is more difficult to see becuase her eyes
are "running" more and it hurts to focus, as if she has
sandpaper
over her eyes. She denies fevers or chills.
She presented to an OSH, where she had a HCT and was found to
have a right sided subdural hematoma. She was transferred to the
[**Hospital1 18**] ED, where she had a repeat HCT and received first
morphine,
then dilaudid for her headache.
Further history became somewhat limited as she became more
somnolent immmediately after receiving the dilaudid.
Past Medical History:
-San [**Location **]fever s/p RUL resection [**2187**]
-CAD s/p MI in [**2182**]
Social History:
smokes 1/2ppd x 40yrs, no EtOH or drug use
Family History:
noncontributory
Physical Exam:
afebrile, 113/61,71,17,98% RA
.
Gen: WD/WN, uncomfortable
HEENT: NCAT, neg raccoon's, neg battles,
Neck: Supple.
Lungs: decreased breath sounds to RUL RML regions / otherwise
clear.
Cardiac: RRR. S1/S2. no obvious murmur
Abd: Soft, NT, BS+ no obvious masses
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and year/month - thought
today was the 27th (24th)
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. no diplopia
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-26**] throughout. Left upper
extremity
drifts upward on testing
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Pertinent Results:
[**2199-9-21**] 08:30AM BLOOD WBC-5.7 RBC-3.95* Hgb-11.8* Hct-34.6*
MCV-87 MCH-29.9 MCHC-34.3 RDW-13.2 Plt Ct-371
[**2199-9-19**] 06:40AM BLOOD WBC-9.0 RBC-3.87* Hgb-11.4* Hct-33.7*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.0 Plt Ct-281
[**2199-9-18**] 03:04AM BLOOD WBC-10.5 RBC-3.89* Hgb-11.7* Hct-33.9*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.3 Plt Ct-238
[**2199-9-17**] 01:47PM BLOOD WBC-7.8 RBC-3.81* Hgb-11.6* Hct-33.5*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.3 Plt Ct-290
[**2199-9-15**] 04:50PM BLOOD Neuts-71.0* Lymphs-24.8 Monos-3.1 Eos-0.8
Baso-0.4
[**2199-9-21**] 08:30AM BLOOD Plt Ct-371
[**2199-9-19**] 06:40AM BLOOD Plt Ct-281
[**2199-9-19**] 06:40AM BLOOD PT-13.6* PTT-28.6 INR(PT)-1.2*
[**2199-9-21**] 08:30AM BLOOD Glucose-93 UreaN-10 Creat-0.6 Na-145
K-3.5 Cl-107 HCO3-30 AnGap-12
[**2199-9-19**] 06:40AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-140
K-3.7 Cl-104 HCO3-23 AnGap-17
[**2199-9-18**] 05:05AM BLOOD Glucose-109* UreaN-9 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2199-9-19**] 06:40AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
[**2199-9-18**] 05:05AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8
[**2199-9-18**] 03:04AM BLOOD Phenyto-7.9*
[**2199-9-15**] 07:40PM URINE Blood-LG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
.
.
[**2199-9-15**] 7:40 pm URINE Site: CATHETER
**FINAL REPORT [**2199-9-18**]**
URINE CULTURE (Final [**2199-9-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
[**2199-9-16**] 2:29 pm MRSA SCREEN Site: RECTAL
Source: Rectal swab.
**FINAL REPORT [**2199-9-18**]**
MRSA SCREEN (Final [**2199-9-18**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
.
.
[**2199-9-16**] 2:29 pm MRSA SCREEN Site: NARIS (NARE) NASAL
SWAB.
**FINAL REPORT [**2199-9-18**]**
.
.
CT HEAD W/O CONTRAST
IMPRESSION: Acute on chronic right subdural hemorrhage measuring
9 mm with 11 mm of rightward midline shift. No evidence for
acute ischemia, hydrocephalus or herniation. Given the foci of
acute hemorrhage within this chronic subdural collection, close
short-term followup is recommended.
NOTE ADDED AT ATTENDING REVIEW: There is subfalcial and uncal
herniation. This revised interpretation will be conveyed to the
physicians caring for the patient.
.
.
CT HEAD W/O CONTRAST [**2199-9-16**] 11:07 AM
IMPRESSION: Acute on chronic right subdural hemorrhage
accompanied by rightward midline shift, subfalcial and uncal
herniation, unchanged from prior exam.
.
.
CT HEAD W/O CONTRAST [**2199-9-18**] 7:30 AM
IMPRESSION: Status post right frontal craniotomy and evacuation
of extra-axial hematoma, with small residual collection, and
improvement in ventricular effacement, shift of the midline
structures and uncal herniation.
.
.
CT HEAD W/O CONTRAST
IMPRESSION: 1. Essentially unchanged appearance of the right
frontal craniotomy site with small residual collection.
Unchanged degree of midline shift and mass effect on the right
cerebral hemisphere from 9/27/06.2. Hypodensity within the right
temporal lobe probably represents contusion secondary to the
recent craniotomy. This contusion contains a linear hyperdensity
which may represent a thrombosed vessel or hemorrhage.
MRSA SCREEN (Final [**2199-9-18**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
.
.
Brief Hospital Course:
This patient was admitted on [**2199-9-15**]. She had a urinary
tract infection for which she was treated; she was then prepared
and consented for surgery as per standard. Intraoperatively,
there were no major complications which occured. The patient
recovered well and was transfered to the Neuro stepdown unit.
She had some complaints of bilateral eye swelling but no changes
in her vision. She was seen by anesthesia for this. The patient
was then transfered to the floor, where she was able to tolerate
a regular diet, ambulate and was discharged in a good condition.
She is to return to the clinic for staple removal 10 days
post-surgery; she is also to arrange a follow-up appointment in
the [**Hospital 4695**] clinic in [**3-28**] weeks.
Medications on Admission:
ASA
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*1*
3. Outpatient Occupational Therapy
Outpatient OT per reccomendation of [**Hospital1 18**] OT department.
4. FOSAMAX 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Please begin after [**2199-10-6**].
Disp:*30 Capsule(s)* Refills:*2*
6. Soma 350 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for muscle pain.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic right subdural hematoma.
Discharge Condition:
Good.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please arrange a follow-up appointment with
[**Last Name (LF) **],[**First Name3 (LF) 742**] by calling [**Telephone/Fax (1) 58980**]. This
appointment is to be arranged in [**3-28**] weeks time from now.
You must also call the above number for your staples to be
removed on [**2199-9-28**].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2199-9-21**] |
5845,5121,5990,4280,4821,40391,2875,2767,99812,4401,4359,5856,V1052,V1301,3051,2753,6930,E9308 | 307 | 132,807 | Admission Date: [**2162-11-24**] Discharge Date: [**2162-12-13**]
Date of Birth: [**2088-3-6**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
Renal artery stent
Chest tube
History of Present Illness:
The patient is an elderly female who had
undergone a left nephrectomy at an outside institution. She
had diminished urine output over approximately 48 hours and
was diagnosed on MRA with a high-grade right renal artery
stenosis. She was urgently transferred to our institution.
She was received directly in the cardiac catheterization
holding area and brought urgently into the procedure room.
She was prepped with ChloraPrep and draped in the usual
fashion.
Past Medical History:
PMH: HTN, TCC, RAS, L. maxillary sinus tumor, TAH/BSO
Social History:
pos smoker
pos drinker
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2162-12-12**] 04:50AM BLOOD
WBC-12.6* RBC-3.16* Hgb-9.6* Hct-28.4* MCV-90 MCH-30.4 MCHC-33.8
RDW-18.9* Plt Ct-178
[**2162-12-7**] 03:44AM BLOOD
PT-12.7 PTT-26.0 INR(PT)-1.1
[**2162-12-12**] 04:50AM BLOOD
Plt Ct-178
[**2162-12-13**] 10:13AM BLOOD
Glucose-109* UreaN-56* Creat-5.3* Na-137 K-3.7 Cl-101 HCO3-26
AnGap-14
[**2162-12-8**] 03:48AM BLOOD
LD(LDH)-465* TotBili-0.7 DirBili-0.3 IndBili-0.4
[**2162-12-13**] 10:13AM BLOOD
Calcium-8.1* Phos-5.7* Mg-2.0
URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.010
URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-0 RenalEp-<1
[**2162-11-29**] 10:05 pm SPUTUM Site: EXPECTORATED
GRAM STAIN (Final [**2162-11-30**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-12-1**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
[**2162-12-11**] 4:16 PM
CHEST (PA & LAT)
Reason: please reassess pneumonia
Comparison is made with the prior chest x-ray of [**12-8**].
Patchy infiltrates are still present in the right upper lobe,
mildly improved since the prior chest x-ray. Bilateral effusions
are again seen, probably indicating the presence of some
underlying failure as well. The position of the two lines
remains unaltered.
IMPRESSION: Marginal improvement in right upper lobe pneumonia,
some failure persists.
Cardiology Report ECHO Study Date of [**2162-11-30**]
INTERPRETATION:
Findings:
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Dilated IVC (>2.5
cm), with
minimal respiratory variation c/w elevated RA pressure of >20
mmHg.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%).
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of
mitral valve chordae. Calcified tips of papillary muscles. No
MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of
MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Severe PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is dilated. The right atrium is dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF 60-70%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is severe pulmonary artery systolic hypertension. There
is no pericardial effusion.
11:16:48 PM
EKG
Sinus rhythm and occasional ventricular ectopy. Otherwise,
compared to the
previous tracing of [**2162-12-7**] no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 158 96 428/451.85 9 -24 45
[**2162-12-2**] 2:29 PM
CT CHEST W/O CONTRAST
Reason: elevated WBC with persistent right infiltrate, ?
pulmonary a
Diffuse bilateral pulmonary abnormalities are present, including
smoothly thickened septal lines, areas of reticulation, and
multifocal ground-glass opacities. These findings involve
multiple lobes of both lungs but are asymmetrically distributed.
In the left lung, they are most severe in the lingula and in the
right lung, most severe in the right upper lobe. Additionally,
there are multiple areas of patchy consolidation, most
pronounced in the right upper lobe. Within the left lower lobe,
there is a focal area of confluent opacity with associated
volume loss, favoring atelectasis over consolidation. Similarly,
a confluent area of opacity in the right lower lobe, immediately
adjacent to pleural fluid is probably due to focal atelectasis.
Asymmetric soft tissue density in right supraclavicular region
could be due to asymmetrical musculature but is difficult to
distinguish from lymphadenopathy in the absence of intravenous
contrast. Numerous mediastinal lymph nodes are present,
measuring up to 2 cm in diameter in greatest short axis
dimension in the precarinal region. Subcarinal nodes measure up
to 1.3 cm in short axis dimension. Pulmonary hila are difficult
to assess in the setting of enlarged pulmonary arteries and
absence of intravenous contrast, but there is likely at least
mild hilar lymphadenopathy present. The main pulmonary artery is
enlarged at 3.7 cm. The heart is upper limits of normal in size.
Coronary artery calcifications are present.
Small bilateral dependent pleural effusions are present, right
slightly greater than left.
Within the imaged portion of the upper abdomen, there is diffuse
nonspecific soft tissue stranding within the mesentery. Right
renal artery stent is present. No suspicious abnormalities are
identified within the liver on this unenhanced study. There is a
rounded low attenuation lesion within the spleen measuring about
1.8 cm in diameter, and a second smaller central lesion
measuring about 8 mm in diameter. These are also difficult to
assess in the absence of contrast. Superficial surgical clips
are present in the left posterior upper abdominal wall, and
there is nonspecific soft tissue stranding near the clips.
Comparison CT abdomen [**2162-11-30**] demonstrates a similar
appearance in this region.
The pleural effusions have slightly increased in size
bilaterally since the prior abdominal CT, and the left basilar
opacity has worsened. Right lower lobe is slightly better
aerated posteriorly compared to the prior abdominal CT. With
regard to the splenic lesions, the two lesions appear unchanged
from the recent abdominal CT.
IMPRESSION:
1. Multifocal ground glass opacities and septal thickening, most
likely due to hydrostatic pulmonary edema.
2. Asymmetrical consolidation predominantly involving the right
upper lobe is concerning for infectious pneumonia given the
history of elevated white blood cell count. Asymmetrical edema
is within the differential diagnosis.
3. Small bilateral pleural effusions, right greater than left,
slightly increased from recent abdominal CT.
4. Bulky mediastinal lymphadenopathy and questionable right
supraclavicular nodes. If nephrectomy was performed for renal
cell carcinoma, followup CT with intravenous contrast would be
recommended to exclude the possibility of metastatic
lymphadenopathy. Differential diagnosis includes
reactive/hyperplastic lymph nodes.
5. Status post left nephrectomy and right renal artery stenting.
6. Splenic lesions without change from recent abdominal CT
[**2162-12-1**] 3:00 PM
CT HEAD W/O CONTRAST
FINDINGS: There is no intracranial mass effect, hydrocephalus,
shift of normally midline structures, or major vascular
territorial infarction. The [**Doctor Last Name 352**]-white differentiation is
preserved. A small rounded area of low attenuation is seen in
the head of the caudate nucleus on the right side, representing
an old lacunar infarct. A similar area of low attenuation is
visualized in the right medial temporal lobe, also representing
lacunar infarct, chronic in age.
The surrounding soft tissue and osseous structures are
unremarkable. There is evidence of a probable left maxillary
medial wall antrostomy- please confirm and correlate with prior
history.
IMPRESSION: No mass effect or hemorrhage
RADIOLOGY Final Report
[**2162-11-28**] 11:18 AM
MR HEAD W/O CONTRAST
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain
was performed. However, this study could not be completed as the
patient's sats dropped and patient did not want to continue the
study.
FINDINGS: The few sequences (sagittal and axial T1, axial T2,
and axial FLAIR) are limited due to motion artifacts. The
cerebral sulci appear hyperintense on the pre-contrast
T1-weighted images. This appearance could be due to the retained
CT contrast given intravenously, due to the associated renal
failure. The ventricles are unremarkable. No mass effect, shift
of normally midline structures noted. The osseous and the soft
tissues structures are unremarkable, including the paranasal
sinuses and the orbits.
IMPRESSION:
1. Incomplete study as the patient's sats dropped and did not
want to continue the study.
2. Limited images reveal hyperintense cerebral sulci, which
could be due to be retained CT contrast given intravenously,
considering the patient's renal failure
Brief Hospital Course:
The patient is an elderly female who had undergone a left
nephrectomy at an outside institution. She had diminished urine
output over approximately 48 hours and was diagnosed on MRA with
a high-grade right renal artery stenosis. She was urgently
transferred to our institution. She was received directly in the
cardiac catheterization holding area and brought urgently into
the procedure room.
Renal stent placed / plavix started / Sheath removed without
complications.
Nephrology consulted.
K normal, anuric x 24 hours. Swam placed / Pt with PNX / chest
tube placed without incident
[**11-25**]
Pt needs dialysis, persistently anuric evaluated for replacement
of right IJ with HD catheter team to decide currently also with
left swan ganz. No HD needed, not volume overloaded.
TTE w/LVEF, no thrombus
[**11-26**]
Acute R hemiplegia and dysarthria. Suspect d/t HTN, vs ? HIT.
Still oliguric, K 5.8, 7.33/45/97. kayexelate. HD after head CT.
Goal SBP 150-160, UF 1.5 kg, Qb 150-200, x 2 h. Overall volume
up, tachypneic but better with suctioning so a lot is upper
respiratory.
[**11-27**]
BCx x2 neg
SpCx w/4+GNR, heavy pseudomonas, klebsiella pan sensitive
likely TIA, neuro consulted, CT head neg, EEG neg, CVL changed,
moved to SICU
[**11-28**]
UCx w/pseudomonas>100k
[**11-29**]
SpCx w/2+GPC, 2+GPR, Cx w/oropharyngeal flora
Duplex carotids w/bilat<40% stenosis
[**11-30**]
CT abd w/o bleed, has bilat effusions
TTE w/elevated PA pressures
[**12-3**]
Right IJ Perma-Cath placement. No complications.
Pt seen by hematology for decreased plts / DIC vs TTP
[**12-4**]
stable tolerated HD today with 2 U pRBC some problems with
hypotension throughout, chilled dialysate, modeled na seemed to
help blood helped most
[**12-5**]
doing much better evaluate for HD in am if creatinine continues
to increase dialyze but no more than 1kg off, to allow good
pressures not expand ATN if cr stable of decreased would hold
HD.
[**12-6**]
she is fine. the BP running slightly high but no evidence of
uremic S/S and volume overload is noted. will get HD on [**12-7**].
[**12-7**]
got HD. dropped her BP. had SOB. got nebs and 1 unit of PRBC.
[**12-8**]
she is feeling fine. no HD.
she feels fine. U/O is going up. no need for HD today.
LUE PICC placed, CXR w/persistent LLL consolid, bilat
infiltrates
[**12-10**]
she feels fine. U/O OK. will possibly get HD on [**12-11**].
[**12-11**]
she is getting better. no volume overload or uremic symptoms.
the creatinine is going up but slower every day. no HD done over
the weekend. evaluate daily. Nephrology clears for home
[**12-12**]
PT / OOb / pt did well / cleared for home
[**12-13**]
Final recommendations for home with PT, given by nephrology. Pt
to follow-up in [**Location (un) 620**]. Appointments made for one week. Pt to
get lab draws at home.
Medications on Admission:
lisinopril, HCTZ
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for 10 days: prn.
Disp:*2 Ipratropium Bromide (Inhalation) 0.02 % Solution*
Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*2 Albuterol Sulfate (Inhalation) 0.083 % Solution*
Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
7. Labs
Please draw a chem 10 / Fax the results to [**Telephone/Fax (1) 68282**] / This
should be done [**12-16**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ARF s/p left nephrectomy
PTX requiring chest tube
PNA
UTI
CHF
HD M/W/F
Discharge Condition:
Stable
Discharge Instructions:
What Is It?
There are two general categories of kidney failure: acute and
chronic. In acute kidney failure, the kidneys suddenly lose much
of their ability to filter blood, often because of an injury,
serious damage to the kidneys or other organs, or exposure to a
toxin (poison).
Some of the illnesses that can lead to acute kidney failure
include a severe blood loss, severe dehydration, severe drops in
blood pressure, heatstroke, severe muscle damage and heart or
liver failure. In addition, anything that blocks the organs'
blood supply or the outflow of urine -- including tumors or an
enlarged prostate -- can lead to kidney shutdown. The toxins
that can trigger acute kidney failure include such medications
such as antibiotics, nonsteroidal anti-inflammatory drugs
(NSAIDs), and certain anesthetics. Occasionally, procedures done
in a hospital can also lead to acute kidney failure.
Whatever the cause, acute kidney failure can be deadly. Without
the normal waste removal system, the blood often becomes loaded
with potassium -- an imbalance called hyperkalemia, which can
lead to heart rhythm disturbances. The blood also becomes highly
acidic and dangerously low in sodium. If a patient isn't
producing enough urine, fluids build up rapidly and swamp other
tissues.
The death rate from acute renal failure can be high, depending
on the cause of the kidney failure and other complications that
the patient may have.
On the bright side, the kidneys have an amazing capacity to heal
themselves. This means most patients who survive acute kidney
failure can enjoy a complete recovery within one to two months.
Some patients, however, need a year or so before their kidneys
are fully functional again. Others, whose kidneys have been
severely damaged, may go on to chronic kidney failure.
While acute kidney failure can happen in days, chronic kidney
failure is a slow decline that often spans several years and
often leads to irreversible damage. Diabetes and high blood
pressure can slowly damage the kidneys and trigger a long-term
decline in function. Other conditions associated with chronic
kidney failure include polycystic kidney disease and use of the
drug lithium. Kidneys in chronic failure will never recover
their normal function.
When kidneys go into chronic failure, much of the body suffers.
The buildup of fluids and waste products can set off a cascade
of complications, including weakened bones, hypertension,
stomach ulcers, anemia, miscarriages, changes in skin color,
congestive heart failure, and lapses in concentration and
memory. (Not all kidney failure patients -- acute or chronic --
have a decrease in urine. In some patients, the kidneys continue
to excrete urine that's mainly water without removing most of
the body's waste products. While these people don't suffer from
fluid buildup, imbalances from excess waste products remain a
problem.)
When the symptoms of advanced renal failure are present, a
person is said to have end-stage renal disease, often called
ESRD. At this point, the patient will need treatment -- either
dialysis or a kidney transplant -- to stay alive.
Followup Instructions:
Call Dr [**Last Name (STitle) 8888**] office, he can be reched at [**Telephone/Fax (1) 1241**].
Your daughter has scheduled an appoinment with nephrology in
[**Location (un) 620**] for you to continue dialysis. It is very important that
you keep this appointment. The point of contact is [**Name (NI) **]
[**Name (NI) 68283**], phone number [**Telephone/Fax (1) 15173**].
Completed by:[**2162-12-13**] |
4401,55321,V1582,V4573,V1052,4940,V667,V641,5859,40390,4280,1991,2761,5180,4239,56882,5849,1977,42833,1970 | 307 | 161,712 | Admission Date: [**2163-12-27**] Discharge Date: [**2164-1-4**]
Date of Birth: [**2088-3-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
75yoW with pmh sig for RCC s/p L nephrectomy, 50 pack year
smoking history, presented to [**Hospital1 **] [**Location (un) 620**] with sob and right
side flank pain, found to have hilar mass and multi liver
lesions. She was transferred to [**Hospital1 18**] for further evaluation.
On arrival to [**Hospital1 **] [**Name (NI) 86**], pt stated sob improved and r flank
pain [**2166-1-18**] and like "a dull cramp" without radiation.
Past Medical History:
PMH: HTN, TCC, RAS, L. maxillary sinus tumor, TAH/BSO
Social History:
pos smoker - quit 1 yr ago, 50 pack year hx
pos drinker
Daughter is contact- [**Name (NI) 6480**] [**Telephone/Fax (1) 68301**]
Family History:
non contributary
Physical Exam:
T 98 BP 140/80 P 70 RR 14 O2sat 98% 2Lnc
NAD
No JVD
RRR nl s12 no mrg
Lungs with decr bs on right, no rales
Abd soft nt nd nabs
LE wwp min edema
Pertinent Results:
CT torso: 8X6 CM hilar mass, mult liver lesions
========================
[**2164-1-2**] 06:00AM BLOOD WBC-8.5 RBC-4.11* Hgb-12.3 Hct-37.3
MCV-91 MCH-29.8 MCHC-32.9 RDW-13.9 Plt Ct-192
[**2164-1-2**] 06:00AM BLOOD Neuts-66.4 Lymphs-25.2 Monos-5.7 Eos-1.9
Baso-0.8
[**2164-1-2**] 06:00AM BLOOD PT-12.8 PTT-28.2 INR(PT)-1.1
[**2164-1-2**] 06:00AM BLOOD Glucose-90 UreaN-19 Creat-1.3* Na-131*
K-4.1 Cl-93* HCO3-28 AnGap-14
[**2164-1-2**] 06:00AM BLOOD ALT-36 AST-64* LD(LDH)-1230* AlkPhos-230*
TotBili-0.3
[**2163-12-29**] 06:45AM BLOOD GGT-70*
[**2164-1-2**] 06:00AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.4
=========================
ECHO: There is mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function (LVEF>55%). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a moderate sized pericardial effusion. No right
ventricular diastolic collapse is seen. There is brief right
atrial diastolic collapse. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
=========================
CT ABDOMEN WITHOUT IV CONTRAST: Large pericardial effusion
similar to last examination. There is a right small-to-moderate
loculated pleural effusion and tiny left pleural effusion.
Additionally, bronchiectasis and
consolidation is present in the anterior portion of the right
lower lobe.
Coronary vascular calcifications are present.
The multiple liver lesions, spleen, adrenals, right kidney,
pancreas, stomach and small bowel loops are unchanged. The left
kidney is surgically absent, and there is a wide-mouthed (5cm)
incisional hernia over the left posterior flank. The right
renal artery stent is again noted. Small nonpathologically
enlarged lymph nodes are unchanged.
CT PELVIS WITH IV CONTRAST: Bladder, distal ureters, small
bowel loops are normal. The sigmoid colon has scattered
diverticula. Cecum and right colon are airfilled but normal.
There is no free fluid, lymphadenopathy, or free air. In the
right lateral vastus muscle, there is an intramuscular lipoma
that is incompletely imaged, measuring 20 x 44 mm.
BONE WINDOWS: A bone island is present in the right iliac bone.
There are degenerative changes in the pubic symphysis, and
spine.
==========================
CXR: Again seen is prominence of the right mediastinal and hilar
region
with increased interstitial markings in the right upper lobe.
There are right greater than left pleural effusions with volume
loss at both bases.
Brief Hospital Course:
75y/o WF w/ TCC s/p L nephrectomy is being called out from the
CCU after an admission for SOB. She was originally admitted to
BIDN on [**12-27**] with flank pain and SOB and was found to have
hilar masses and liver lesions. At [**Hospital1 18**], she was initially
managed on the floor where ECHO showed no tamponade but CT chest
showed partial collapse of the L bronchus by her hilar mass as
well as a pericardial effusion. She was prepped for
bronchoscopy with probable stent placement but desaturated
during preparation for the bronch and was transfered to the MICU
for further management on [**1-2**].
.
In the ICU, she was treated symptomatically with morphine for
her SOB with improvement and possible pericardiocentesis and
tissue biopsy were discussed with the family. However, in light
of her over all poor prognosis, discussion was initiated with
palliative care at the request of both the daughter and the
patient. Plans now exist for the patient to be transfered home
with hospice services on [**1-4**]. She denies any complaints
currently outside of some lower back pain and mild dyspnea which
is much improved since admission. She is comfortable with
avoiding vital signs and blood draws for the remainder of her
admission but elected to continue taking her home medications.
Home hospice companies were contracted and supplies delivered to
the home. Standard home hospice prescriptions (pain meds, bowel
regimen, anxiolytics, and antisecretory agents) were filled out
and faxed to the hospice per their protocol. She was d/c home
on the day after call-out to the floor with home hospice
services.
Medications on Admission:
norvasc
metoprolol
plavix
lasix
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Hospice medications
per facility protocol
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
Disp:*60 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
8. Oxygen per nasal canula
prn patient comfort
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please
remove for 12hrs in any 24hr period.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**] & Hospice
Discharge Diagnosis:
Primary: Metastatic cancer of unknown primary
Pleural effusion
Pericardial effusion
.
Secondary:
HTN
Renal artery stenosis
Discharge Condition:
Stable: tolerating PO intake and stable SpO2 on supplemental O2
Discharge Instructions:
Please call your PCP or return to the ER with shortness of
breath, chest pain, yellowing of skin, or other concerning
symptoms.
.
Followup Instructions:
Please call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**]
appointment as needed ([**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 19980**])
Completed by:[**2164-1-4**] |
75889,2762,78039,51881,9661,E8550,486,43491,5601 | 308 | 166,606 | Admission Date: [**2135-9-2**] Discharge Date:
Date of Birth: [**2106-3-1**] Sex: F
Service: CURLIN
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 20741**] is a 29 year-old
woman with MELAS (mitochondrial encephalo-myopathy with
lactic acidosis and stroke like symptoms) who was brought into
the Emergency Room by her mother for a gradual decline in
mental status over the past week that led to a fall the
had been increasingly agitated and emotional for the past few
days. Family members report that she took her anti-seizure
medication of the next 3-4 days all at once and became
"confused". The patient remembers falling, but cannot relay the
immediate events prior to and after the fall.
Until recently [**Known firstname **] was driving, working as a greeter at an
mother reports that she has been less able to care for
herself and has had to move back into her mother's house in
the past few weeks.
[**Known firstname **] states that she feels like she is "going to die" and
that her "mother is going to leave," but expresses no
intention to harm herself.
PAST MEDICAL HISTORY: MELAS diagnosed at age 18 after
presenting with poor weight gain, headaches, repeated
seizures. Prior to these events [**Known firstname **] was enrolled in
college. [**Known firstname 20742**] mother reports three strokes at age 20, 24
and 29 namely one month ago. Her mother reports no residual
effects of any of the strokes.
MEDICATIONS ON ADMISSION: 1. Dilantin 100 t.i.d. 2.
Verapamil 240 q.d. 3. Vitamin C 500 b.i.d. 4. Vitamin E
400 IU q.d. 5. Co-enzyme q 150 q.d. 6. Riboflavin/calcium
100/40 q.d. 7. Mebaral 50 q.d. 8. Klonopin 0.5 t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No alcohol, drugs or tobacco use. Her
parents are divorced. She is currently cared for by her
mother and a [**Name (NI) 269**].
PHYSICAL EXAMINATION: She was afebrile. She had a blood
pressure of 127/73. Heart rate of 70 and was sating 100% on
room air. She was lying in the stretcher and was easily
distracted. She had an ecchymosis over her left eye and some
perioral dermatitis. Her abdomen was soft, nontender and
nondistended. Her fundi were clear. She was alert and did
not follow commands well. She knew her name, date and place.
She was able to spell her name forward and backward. Her
immediate recall was 4 out of 4 with her memory being 0 out
of 4 after 30 seconds. She was able to repeat sentences,
read name tags and follow two step commands. She was able to
clap her hands. She had normal facial sensation. Her face
was symmetric. Her hearing was intact and her tongue was
midline. Her muscle bulk was decreased without hypotonia.
She is moving her extremities spontaneously and on command
and lifted her legs well. She had no tremor. Her sensation
was intact to light touch throughout her upper and lower
extremities. Her toes were down going. Her lungs were clear
and her heart rate was regular in rhythm and rate with no
murmurs.
LABORATORY: Her HCG was negative. Her electrolytes were
normal. Her Dilantin level was 35.
Head CT showed no acute process.
HOSPITAL COURSE: Ms. [**Known lastname 20741**] was admitted for observation
given her high Dilantin levels and her mental status changes.
Over the next few days, Ms. [**Known lastname 20741**] developed severe metabolic
acidosis with high lactate levels and an aspiration pneumonia
that required intubation and ICU admission. She was given
Levaquin with clearing of her pneumonia. Her lactic acidosis was
succesfully corrected with hyperventilation and fluids in the
next day. However, she failed extubation twice and on the [**8-17**] required placement of a tracheostomy tube. She also had a
PEG tube placed at that point. She then developed seizures that
were eventually controlled with Dilantin, Keppra, and Ativan. At
this point she developed a second right lower lobe pneumonia. She
was initially treated with Clindamycin and Cipro. Due to her
decreased responsiveness with quadriplegia, a head MRI was
obtained on the [**8-24**] that showed wide spread bilateral
cortical hyperintensitis on FLAIR, DWI and T2WI consistent with
stroke- like lesions and remarkable subcortical atrophy with a
normal MRA. EMG was also obtained that showed diffused severe
myopathy possibly consistent with critical care myopathy. An
abdominal CT obtained around that time showed a right colon
impaction believed to be secondary to dysmotility from MELAS
syndrome. A general surgical consult believed that she was not a
good surgical candidate and had recommended that she become NPO
with NGD compression and TPN for nutrition. Dr [**Last Name (STitle) **] from the
neuro-muscular service was also consulted who reccomended a 5
day-course of high dose IV Prednisone. At the end of the 5 days
due to her lack of significant improvement, a family consult was
obtained that agreed on making the patient DNR/DNI, comfort
measures only and the antibiotics were stopped on the [**8-29**].
At this point she began to show clinical improvement and so was
reinstated to full code status on the [**8-2**]. TPN was
restarted and aggressive bowel regimen was begun to try to clear
her partial large bowel obstruction. On the [**8-3**] she
became febrile and was found to have coag negative staph
bacteremia. The right subclavian line she had in was stopped at
that point and she was started on Vancomycin and Ceftriaxone.
A chest x-ray on the [**8-8**] showed increasing
infiltrates in the right middle lobe and the left lung, so her
Ceftriaxone was changed to Zosyn. As she was seizure free from
the [**7-31**] she was transferred to the Medicine Service
to manage her pneumonia and her partial large bowel obstruction.
After her transfer she remained afebrile and repeat blood
cultures were negative. An infectious disease consult was
obtained that recommended five days of Vanco for her line sepsis
and fourteen days of Zosyn for her pneumonia. She did well on
both of these treatments. A GI consult was obtained with regard
to her partial large bowel obstruction and an aggressive bowel
regimen including Reglan, suppositories, enemas, Colace and
Golytely was recommended, which helped to clean out most of her
bowel. By the time of this dictation her abdomen is soft and
only a single mass of stool is palpable in the suprapubic region.
She was on TPN for nutrition for most of [**Month (only) **] until the
[**8-17**] when her family decided they wished to
withdraw treatment and at that point her TPN was stopped.
From a neurological standpoint her Dilantin level was 26 on the
[**8-16**] and so it was held and will be restarted after
her level drops to the low 15. She will continue on IV
Ativan for seizure prophylaxis.
On the [**8-18**] her neurological status has progressed
to the point where she is not responsive to voice except for
occasionally. She has been afebrile for over a week and has
improved clinically in terms of her pneumonia with decreased
secretions on the Zosyn. She will have three more days of Zosyn
and then be done with antibiotics. Her NG tube and PEG tube are
clamped and she is receiving no more drugs for her bowel regimen.
She continues to receive trach care and suctioning with stable
amount of secretions. Her antiepileptic drugs include Ativan and
Dilantin. The Dilantin is being held and his being restarted
after the levels are less then 15. She is in the midst of a
Solu-Medrol taper. The only other medications that she is
receiving are heparin and Protonix for prophylactic purposes.
DISCHARGE DIAGNOSES:
1. End-stage MELAS with diffused multiple bilateral cortical
stroke-like lesions, a severe generalized myopathy and GI
dysmotility resulting in a partial large bowel obstruction.
2. Resolving pneumonia.
DISCHARGE MEDICATIONS: 1. Ativan 0.5 mg IV t.i.d. 2.
Dilantin 300 mg IV q.h.s. 3. Zosyn 4.5 mg q 8 hours times
three days. Her Zosyn will end on the [**8-20**].
Solu-Medrol 10 mg IV q 8 hours being tapered. 5. Heparin
5000 units subcutaneously b.i.d. 6. Protonix 40 mg IV q.d.
7. Tylenol prn. 8. Ativan 0.25 to 0.5 mg q 6 hours prn for
facial twitching and arm trembling.
[**Last Name (LF) 726**],[**Name8 (MD) 725**] M.D. [**MD Number(1) 727**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2135-10-19**] 10:17
T: [**2135-10-19**] 10:54
JOB#: [**Job Number 18804**]
|
2761,7248,74101,9181,E8788,3004 | 310 | 142,159 | Admission Date: [**2139-5-6**] Discharge Date: [**2139-5-10**]
Date of Birth: [**2096-7-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Suboccipital decompressive craniotomy, C1 laminectomy,
duraplasty
History of Present Illness:
The patient is a 42-year-old
patient who is well known to the [**Hospital1 **] neurosurgical
service. He has been seen in Dr.[**Name (NI) 9034**] office multiple times
on an
outpatient basis. He has been diagnosed with a Chiari II
malformation in the setting of a previously operated spinal
meningeal viral series. The patient has classic signs of
headaches that are positional and aggravated by coughing. The
patient has been worked up with an MRI scan that shows the
tight posterior fossa with inferior displacement of parts of
the cerebellum to the level of C1. He was counseled. He
wished to proceed with elective decompression today. The
patient was consented in the office. He was taken to the
operating room on the evening of [**2139-5-6**].
Past Medical History:
PAST MEDICAL HISTORY:
1. Anxiety/depression.
2. Chiari II malformation with hydrocephalus.
Family History:
not obtained
Physical Exam:
GENERAL: mildly anxious man but well appearing.
NEUROLOGIC EXAM:
Mental status:
Patient is alert, awake, mildly anxious affect with some
tangential speech. Good attention, tells a coherent story.
Language is fluent with good comprehension, repetition, able to
read. He naming intact. No dysarthria. No neglect or
left/right
mismatch. Cranial Nerves:I-XII-intact.
Sensory: Normal touch, vibration, proprioception, pinprick
sensation.
Motor: Slightly increased tone in the legs. No pronator drift.
Mild postural tremor, fine, low amplitude with arms
outstretched.
Full strength.
Reflexes: brisk throughout 3+ with crossed adductors and
bilaterally upgoing toes. + [**Doctor Last Name **] bilaterally.
Coordination: finger-to-nose slowwer on L, but normal heel to
shin, rapid alternating movements.
Gait:Gait appears normal but unable to tandem.
Brief Hospital Course:
Pt was admitted and brought to the OR electively on [**2139-5-6**] for
decompressive suboccipital craniotomy and C1 laminectomy and
duraplasty under general anesthesia. Post op he was transferred
to SICU for close neurological monitoring. He remained
neurologically intact. He was intermittently bradycardic. Post
op head CT showed good appearance. He was transferred to the
floor. His diet and activity were advanced. His dressing was
clean and dry.
Medications on Admission:
lithium bicarbonate (generic) 300/150/300,
cymbalta 60mg daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari malformation
Discharge Condition:
neurologically stable
Discharge Instructions:
Keep incision dry. Call for fever or any signs of infection
-redness, swelling or drainage from wound.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] for suture removal in 10 days - call
[**Telephone/Fax (1) 2731**]- for appt.
Completed by:[**2141-5-19**] |
7248,74101,3004,2761,9181,E8788 | 310 | 142,159 | Admission Date: [**2139-5-6**] Discharge Date: [**2139-5-10**]
Date of Birth: [**2096-7-16**] Sex: M
Service: NSU
CHIEF COMPLAINT: Chiari type II malformation with
hydrocephalus.
PHYSICAL EXAMINATION: The exam of the patient on admission
is as follows: Vital signs: The blood pressure is 118/70 and
the heart rate is 60. In general, he is a mildly anxious man
but well appearing. He has no visible rashes. He has a large
head with anicteric sclera, moist mucous membranes. His neck
was supple. His chest reveals a normal respiratory pattern
and is clear to auscultation. Cardiovascularly, he has
regular rate and rhythm without murmurs. Abdomen is soft and
nontender. His extremities reveal no edema and are warm and
well perfused. On his back exam, he is noted to have some
scoliosis and an old scar at the L2-L3 level. His neurologic
exam is as follows: He is alert and oriented x3. He is mildly
anxious. His cranial nerves are fully intact without any
visible deficits. His sensory exam is fully intact. His motor
exam is fully intact. His reflexes are quite brisk
throughout, 3+/4, with bilaterally positive Babinskies and
positive [**Doctor Last Name **] sign bilaterally. His coordination exam
reveals mild end target dysmetria bilaterally on finger to
nose but normal heel to shin and rapid alternating movements.
His gait is normal but he is unable to do tandem gait well
and is noted to rotate his feet internally while walking on
his toes.
HOSPITAL COURSE: The patient was admitted on the same day of
his surgery which was [**2139-5-6**], and underwent a bilateral
suboccipital craniotomy, Chiari compression, C1 laminectomy
and duraplasty. Please refer to the operative note of [**5-6**]/[**2139-5-7**], for further details of operative procedure.
He was taken to recovery to the surgical intensive care unit
on postoperative day zero where he made a good recovery. In
the immediate postoperative period, he underwent a CT scan
which revealed postoperative changes but was unconcerning for
any abnormalities or hematomas. He had no neural deficits on
exam. He was noted, however, in the immediate postoperative
period to have some sinus bradycardia which readily resolved
when the patient was awakened. His EKG was checked and was
normal. Cardiac enzymes were checked and were found to be
normal as well. He did have a large volume of urine output
and serum osmolality was checked and found to reveal a mildly
reduced serum sodium which eventually restored itself on
postoperative day #2. Also on postoperative day 1, the
patient was noted to have right eye erythema and was
diagnosed with a right corneal abrasion for which he was
treated with erythromycin. He was kept in the intensive care
unit until postoperative day 3 when he was transferred to the
floor with hemodynamic stability. A physical therapy
consultation was obtained to evaluate the patient for his
back pain. He was started on cyclobenzaprine for back spasms
and he was continued on the erythromycin ophthalmic ointment
for his corneal abrasion. He made a good recovery and,
because physical therapy deemed him as not a candidate for
home physical therapy, he was discharged home without
services on postoperative day 5 in good condition, and he was
to follow-up with Dr. [**Last Name (STitle) **] in clinic in 2 weeks after his
discharge.
DISCHARGE MEDICATIONS:
1. Lithium carbonate 300 mg twice a day.
2. Duloxetine 60 mg daily.
3. Docusate sodium 100 mg twice a day.
4. Percocet 1-2 tablets q.4 hours as needed for pain.
5. Erythromycin ophthalmic ointment to be applied to the
right eye 4 times a day for 5 days.
DISCHARGE DIAGNOSES:
1. Chiari II malformation.
2. Major depression.
3. Generalized anxiety disorder.
4. Corneal abrasion.
5.
Sinus bradycardia.
6. Hyponatremia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 9031**]
Dictated By:[**Doctor Last Name 9032**]
MEDQUIST36
D: [**2139-6-10**] 14:58:42
T: [**2139-6-10**] 16:26:17
Job#: [**Job Number 9033**]
|
E8889,4019,2948,43491,80507,85220,V4365 | 313 | 199,765 | Admission Date: [**2139-7-26**] Discharge Date: [**2139-8-9**]
Date of Birth: [**2060-11-20**] Sex: F
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Subdural hematoma s/p fall
Major Surgical or Invasive Procedure:
four vessel angiography
History of Present Illness:
78 yo F s/p fall found down, pt denies LOC . on XRAY has a C7
cervical fracture, head CT with small L SDH. Neurologically
intact, no focal weakness, numbness, parasthesias
Past Medical History:
glaucoma, hydrocephalus, R total knee replacement
Social History:
unknown
Family History:
unknown
Physical Exam:
99 127/52 91 18 100% on nasal canula
A/O x 3
PERRL
RRR
CTA b/l
ABD soft, nt/nd
ext warm, no edema
neuro intact
Pertinent Results:
four vessel angio
with Right MCA acute occlusion
Brief Hospital Course:
Pt admitted with C7 fracture and L SDH after 4 vessel angio
found to have R MCA occlusion and will need intervention.
Medications on Admission:
toprol
mvi
aricept
Discharge Medications:
protonix
metoprolol
hydralazine
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute Right MCA Occlusion/Stroke
L Sub dural hematoma
C7 fracture
Glaucoma
?Hydrocephalus
R total Knee replacement
hypertension
dementia
Discharge Condition:
critical
Discharge Instructions:
bedrest
venodyes
pul toilet
npo
ivf
C collar on
neuro checks
Followup Instructions:
f/u with interventional neuroradiology
Completed by:[**0-0-0**] |
4019,2948,E8889,43491,80507,85220,V4365 | 313 | 199,765 | Admission Date: [**2139-7-26**] Discharge Date: [**2139-8-9**]
Date of Birth: [**2060-11-20**] Sex: F
Service: TRA
HISTORY OF PRESENT ILLNESS: Acute right middle cerebral
artery occlusion, stroke, following four vessel angiogram,
left subdural hematoma, C7 fracture, glaucoma, question of
hydrocephalus and a right total knee replacement.
HOSPITAL COURSE: The patient was a 78 year old woman with a
history of hypertension, glaucoma and dementia who was found
unconscious by her bed by her brother and wife. She was
taken to an outside hospital and found to have a C6-7
fracture and sent to [**Hospital1 69**].
Hemodynamically stable in the hospital but on route she had
an episode of confusion and in the hospital with garbled
speech. Neurologic examination was intact at the time. She
had no complaints of pain on arrival.
Neurosurgery was consulted for the subdural hematoma and on
[**2139-7-27**], she underwent a four vessel angiogram. After
[**2139-7-27**], four vessel angiogram, the patient was noted to
have signs and symptoms consistent with a right
cerebrovascular accident. The four vessel angiogram was to
rule out vertebral artery dissection. Per Dr. [**First Name (STitle) **],
throughout the procedure, she was conversant, though slightly
agitated, but she was given 0.5 mg of Midazolam times two.
She remained conversant until just after the right carotid
was imaged at which time she manifested garbled speech. On
examination, she had garbled speech and was uncooperative
with motor examination although she was moving all
extremities but decreased on the left. Head CT showed no
focal lesions, however, magnetic resonance imaging showed
silent embolus of middle cerebral artery and accordingly Dr.
[**Last Name (STitle) **] of neurology-stroke was consulted. Trauma surgery
considered transfer of patient to [**Hospital6 **] for
neurosurgery intervention, however, this was not possible due
to procedure space availability. [**Hospital6 15291**] already had another intervention team to complete
another emergent procedure until 10:00 p.m. when the window
for intervention would have been ended. Therefore, the plan
was for supportive care. No Aspirin or Heparin was provided
per neurosurgery because of her left subdural hematoma.
The patient's course in the Intensive Care Unit continued to
improve at which point on [**2139-8-1**], she was transferred to
the floor. The patient then required a percutaneous
endoscopic gastrostomy tube for feeding which was placed on
[**2139-8-4**], without incident. She was started on tube feeds
and tolerated that well. She is currently no full strength
tube feeds at 60 cc/hour. The patient continued to improve
throughout the hospital course.
CONDITION ON DISCHARGE: Fair.
MEDICATIONS ON DISCHARGE:
1. Bisacodyl 10 mg p.o. or PR as needed.
2. Metoprolol 12.5 mg twice a day.
3. Aspirin 81 mg once daily.
4. Colace in liquid form 100 mg twice a day.
5. Lasoprazole 30 mg p.o. once daily.
FOLLOW UP: The patient is to follow-up with [**Hospital6 8866**] Interventional Neuroradiology Department
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 22242**]
MEDQUIST36
D: [**2139-8-9**] 11:57:52
T: [**2139-8-9**] 13:09:44
Job#: [**Job Number 56356**]
cc:[**Hospital6 **] |
4210,042,30591,2920,2762,07054,07032,0785,49390 | 314 | 155,540 | Admission Date: [**2181-9-18**] Discharge Date: [**2181-9-24**]
Date of Birth: [**2141-5-22**] Sex: F
Service: MEDICINE
Very briefly, this is a 40-year-old female with a history of
HIV, CD4 account around 1, and self-reported high viral load
presently with hepatitis B and hepatitis C, asthma, history
of bacterial endocarditis, and active polysubstance abuse
including alcohol, smoking crack, and shooting up with
heroin. She is homeless and lives occasionally at her
sister's place.
According to patient her primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**Name (STitle) 7474**] at the [**Hospital1 756**] Home, whom she last saw on [**5-/2181**], but
Dr. [**Last Name (STitle) 7474**] had left. She was admitted to [**Hospital6 1760**] Intensive Care Unit on
[**2181-9-18**] after she presented to [**Last Name (un) 33912**] Detox Facility and
was found to have a low blood pressure.
In brief, she was found to have endocarditis and CMV viremia.
She was treated appropriately with improvement of her
symptoms. She was transferred out of the ICU onto the floor
on [**2181-9-23**] when the General Medicine team became involved
in her care. We continued her on IV Oxacillin via her
peripherally inserted central catheter line as well as other
medicines. She looked well.
The 24 to 36 hours she spent on 5 South were marked with
complaints about wanting to leave and smoke. Despite the
staff's best attempts at watching her, she was noticed
missing on several occasions. When she returned she was
asked repeatedly to stay on the floor and not to leave
without permission or notification of the nurse. She was
noted missing from her room last seen at approximately 2:40
p.m. on [**2181-9-24**]. The hospital security was notified, and
her family was called, but no one answered. The nurses were
instructed to contact Security if patient should return;
however, patient did not return and, hence, left the hospital
against medical advice.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 105446**]
MEDQUIST36
D: [**2181-11-3**] 17:18
T: [**2181-11-5**] 17:08
JOB#: [**Job Number 105447**]
|
30501,2720,2859,45829,4019,4280,41401,4240,V4581 | 315 | 152,144 | Admission Date: [**2177-4-24**] Discharge Date: [**2177-5-8**]
Date of Birth: [**2104-10-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 72-year-old white male is
status post CABG in [**2164**] and recently presented to his
physician with PND and wheezing. He has had these symptoms
for 2 weeks. This has been associated with increasing fatigue
and dyspnea on exertion. He also has had worsening pedal
edema which he says is chronic. He was seen by his physician
and then evaluated in the emergency room for CHF and treated
with Lasix. He ruled out for a myocardial infarction but had
BNP of 810. He had an echocardiogram which revealed an EF of
35%, moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], and mild AI, with distal septal
dyskinesis, and moderate hypokinesis in the inferior lateral
region. He is transferred for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for a history of
hypertension, coronary artery disease, status post CABG in
[**2164**] (with a saphenous vein graft to the RCA), and a history
of chronic lower extremity edema.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION: Propranolol 20 mg p.o. b.i.d.,
Adalat 30 mg p.o. daily, aspirin 81 mg p.o. daily, and
Combivent inhaler.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
drinks 3 beers a day and quit smoking 20 years ago.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: He is an elderly white
male in no apparent distress. Vital signs were stable,
afebrile. HEENT exam revealed normocephalic and atraumatic.
Extraocular movements were intact. The oropharynx was benign.
Neurologic exam was nonfocal. The neck was supple with full
range of motion. No lymphadenopathy or thyromegaly. The
carotids were 2+ and equal bilaterally without bruits. The
lungs had bibasilar rales. Cardiac exam was regular in rate
and rhythm with a 3/6 systolic murmur and a positive S4. The
pulses were 1+ bilaterally throughout.
HOSPITAL COURSE: He was admitted and underwent cardiac
catheterization which revealed an occluded RCA, 90% stenosis
of saphenous vein graft, a complex LAD lesion at the
bifurcation of 90%, and a 70% left circumflex lesion, with an
EF of 35%.
Dr. [**Last Name (STitle) **] was consulted. He had carotid studies which
revealed a less than 40% bilateral stenosis. He was diuresed.
On [**4-29**] he underwent a redo CABG x 1 with a Mosaic MVR.
He had a LIMA to the diagonal, and he had a 29-mm Mosaic MVR.
His vessels were intramyocardial, and his other vessels were
unable to be bypassed. He was transferred the CSICU on
Levophed, epinephrine, and propofol. On his postoperative
night he had some hypotension but then was more stable by the
morning. He was transfused a unit of blood. He remained
intubated the first day to stabilize his blood pressure. His
epinephrine was discontinued on postoperative day #2. His
Levophed was gradually weaned off. He was extubated on
postoperative day #2. He required aggressive diuresis and
pulmonary therapy. He continued to slowly progress.
DISCHARGE STATUS: He was transferred to the floor on
postoperative day #5. He had his wires discontinued on
postoperative day #6. He continued diuresis and physical
therapy. He was discharged to home in stable condition with
visiting nurse services and home physical therapy on
postoperative day #9.
LABORATORY DATA ON DISCHARGE: His laboratories on discharge
were white count of 10,400, a hematocrit of 27.3, platelets
of 409,000, 138, 5.1, 104, 26, 27, 1.0, and 133.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 80 mg p.o. b.i.d. for 1 week and then 80 mg p.o.
daily for another week.
3. Plavix 75 mg p.o. daily.
4. Multivitamin 1 p.o. daily.
5 Lipitor 10 mg p.o. daily.
1. Percocet 1 to 2 p.o. q.4-6h. as needed (for pain).
2. Aspirin 81 mg p.o. daily.
3. Protonix 40 mg p.o. daily.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Hyperlipidemia.
3. Coronary artery disease.
DISCHARGE FOLLOWUP: He will follow up with Dr. [**Last Name (STitle) **] in 4
weeks and with Dr. [**Last Name (STitle) 24717**] in 1 to 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2177-5-8**] 18:31:34
T: [**2177-5-8**] 19:02:15
Job#: [**Job Number 40178**]
|
V053,V290,7706,V3001 | 316 | 110,748 | Admission Date: [**2134-11-3**] Discharge Date: [**2134-11-5**]
Date of Birth: [**2134-11-3**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former
3.49 kg product of a 38-2/7 weeks gestation pregnancy born to
a 26-year-old G5, P2, now 3 woman. Prenatal screens were
blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown. The pregnancy was uncomplicated. The
mother presented for repeat elective cesarean section.
Previous OB history was notable for 2 cesarean sections. The
infant was born at 1540 hours on [**2134-11-3**]. He was
noted to have retractions after birth and was transferred to
the neonatal intensive care unit for observation and
monitoring. He required blow-by oxygen. Apgars were 8 at 1
minute and 8 at 5 minutes.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit, weight was 3.49 kg, length 51 cm, head
circumference 35 cm, all 75th to 90th percentile for
gestational age. GENERAL: The infant appears consistent with
a gestational age of 38 weeks, pink and nasal cannula O2,
well-perfused, responsive. HEAD, EARS, EYES, NOSE AND THROAT:
Normocephalic, anterior fontanelle soft and flat. Ears are
normal. Palate is intact. NECK: Normal. CHEST: Clavicles
normal, breath sounds equal bilaterally with grunting,
intercostal retractions. CARDIOVASCULAR: Normal heart sounds,
no murmur. Peripheral pulses are normal. ABDOMEN: Soft,
nondistended, nontender, no masses, no hepatosplenomegaly.
GU: Normal male, anus patent. SPINE: Normal. EXTREMITIES:
Normal. SKIN: Normal without lesions. NEURO: Mildly decreased
tone with intact reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: [**Known lastname **] was initially on nasal cannula O2
due to his increased work of breathing. He was changed to
continuous positive airway pressure. He remained on the
continuous positive airway pressure until 8 p.m. on [**2134-11-3**] when he transitioned to room air. He remained stable
in room air with oxygen saturations greater than 95% with
minimal work of breathing. Chest x-ray was consistent with
retained fetal lung fluid on day of life #1. Repeat chest x-
ray on day of life #2 showed improvement. There was no
concern for pneumonia and the antibiotic course was
discontinued at 48 hours.
CARDIOVASCULAR: [**Known lastname **] has maintained normal heart rates and
blood pressures. No murmurs have been noted.
FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was initially NPO
on intravenous fluids. After the discontinuation of the
continuous positive airway pressure, enteral feeds were
started. He has been breastfeeding ad lib and maintaining
normal glucoses. The mother's choice is to exclusively
breastfeed with no formula. Weight on the day of transfer is
3.44 kg. Serum electrolytes at 24 hours of life were within
normal limits.
INFECTIOUS DISEASE: Due to the unknown etiology and severity
of the respiratory distress, [**Known lastname **] was evaluated for sepsis
upon admission to the neonatal intensive care unit. A
complete blood count had a white count of 25,100 with a
differential of 39% neutrophils, 20% band neutrophils and
normal platelets. Intravenous ampicillin and gentamicin were
started. A repeat complete blood count on day of life #2 had
a white blood cell count of 29,400 with a differential of 77%
polymorphic neutrophils and 7% band neutrophils. Blood
culture obtained prior to starting antibiotics was no growth
and the antibiotics were discontinued at 48 hours as the
respiratory symptoms had resolved.
GASTROINTESTINAL: Serum bilirubin on day of life #1 was a
total of 5.7 mg/dL. A recheck bilirubin is to be drawn along
with the state screen on the morning of [**2134-11-6**].
HEMATOLOGICAL: Hematocrit was birth was 47.8%.
NEUROLOGICAL: [**Known lastname 49225**] neurological exam improved with his
improvement in respiratory status. He has maintained a normal
neurological exam and there are no neurological concerns at
the time of discharge.
SENSORY: Audiology hearing screening has not yet been
performed.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to the newborn nursery
under the care of the [**Doctor Last Name 46742**] Newborn Service.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location 48056**] Center, phone number [**Telephone/Fax (1) 6951**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breastfeeding.
2. No medications.
3. Car seat position screening not recommended.
4. State newborn screen to be drawn on [**2134-11-6**].
5. No immunizations administered to date.
DISCHARGE DIAGNOSES:
1. Near term infant.
2. Respiratory distress secondary to retained fetal lung
fluid.
3. Suspicion for sepsis ruled out.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2134-11-5**] 23:03:48
T: [**2134-11-6**] 07:39:05
Job#: [**Job Number 68497**]
|
311,2720,4239,99601,4240,4251 | 317 | 173,307 | Admission Date: [**2113-10-24**] Discharge Date: [**2113-10-27**]
Date of Birth: [**2079-2-20**] Sex: M
Service:
CHIEF COMPLAINT: Status post ethanol ablation for HOCM.
HISTORY OF PRESENT ILLNESS: The patient is a 34 year-old
male with hypertrophic obstructive cardiomyopathy diagnosed
four years ago status post new
ethanol ablation on [**10-24**] this admission. He was active until
about last [**Month (only) **]
experiencing increased dyspnea on exertion even with short
walks and short climbs of stairs. Also often accompanied
by mild chest discomfort, which the patient has described as
aching/burning. Note this patient had a Holter monitoring in
[**Month (only) 216**], which was normal. The patient denies any
claudication, orthopnea, paroxysmal nocturnal dyspnea, but
positive lightheadedness since starting his medications. His
last echocardiogram in [**2113-7-21**] showed a dilated left atria,
also a posteriorly directed narrow jet flow of MR hugging the
wall of the LA with an asymmetric septal hypertrophy with [**Male First Name (un) **]
of the mitral valve and outflow track gradient of 102 mmHg.
Posterior wall thickening was 1.2 with fractional shortening
of at least 54%.
Denies any fevers or chills, nausea or vomiting.
The patient was admitted to Coronary Care Unit post planned
ethanol septal ablation for observation with temporary RV
pacemaker in place per protocol for risk of acute heart block
accompanying the ablation.
PAST MEDICAL HISTORY:
1. Depression.
2. HOCM diagnosed four years ago.
3. Left ankle surgery in [**2097**].
4. Partial parathyroidectomy for hypercalcemia in [**2107**].
5. Tonsillectomy in [**2107**].
ALLERGIES: General anesthesia gives him a violent reaction
when awakening up from it.
HOME MEDICATIONS:
1. Atenolol 50 q day.
2. Verapamil 120 SR q.d.
3. Aspirin 81 mg po q day.
SOCIAL HISTORY: Single, divorced male, has a supportive
girlfriend. Occasional ethanol use. No tobacco. No drugs.
Manages a construction company.
FAMILY HISTORY: Strong family history of HOCM. Mother and
maternal grandmother and aunts all with HOCM. No family
history of sudden death. Mother has had a history of
ventricular tachycardia and has required a defibrillator
placed and duel chamber pacemaker two years ago.
PHYSICAL EXAMINATION ON ADMISSION (from cath lab following
ablation): Temperature 98.3. Blood
pressure 134/69. Pulse 96. Respirations 18. O2 sat 95% on
room air. Examination generally no acute distress, alert and
oriented times three. HEENT pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Mucous membranes are moist. Neck supple. The
patient has a right ventricular temporary pacemaker placed
through a right IJ sheath. Dry and intact and functional.
Cardiovascular
regular rate and rhythm. Trace systolic murmur best heard at
the apex, blowing in nature. No gallops or rales.
Respirations clear to auscultation bilaterally. Abdomen soft,
nontender, nondistended. Bowel sounds present. No rebound or
guarding.
No costovertebral angle tenderness. Extremities no
clubbing, cyanosis or edema. Groin sites were dry and
intact. No hematoma. Bilateral pulses present, 2+. No
bruit appreciated. No hematoma appreciated on both groin
sites, the entry sites for the catheterization.
LABORATORIES ON ADMISSION: White blood cell count 11.7,
hematocrit 39.9, platelets 208, sodium 132, potassium 4.3,
chloride 104, bicarb 23, BUN 17, creatinine 1.5, glucose 155,
magnesium 1.7. His arterial blood gas was 7.36, 41, CO2 150
02 on room air, 24 bicarb, CK 1292, CKMB 174, troponin T was
3.39.
HOSPITAL COURSE: The patient was admitted for his cardiac
procedure. The patient was status post ethanol ablation,
which is a deliberate controlled myocardial infarction
hich was done without complication.
For coronary artery protection he was placed on
aspirin. His home dose of aspirin was increased to 325 mg po
q day. He tolerated well without any complications. He had
no chest pain until the day before discharge at which point
he complained of some chest pressure. No electrocardiogram
changes noted. No radiation and positionally changed more
comfortable in sitting forward position then laying backward,
but resolved with Ibuprofen since. No electrocardiogram
changes. His pre cath echocardiogram showed a HOCM with valve
[**Male First Name (un) **] and severe resting LVOT gradient, moderate eccentric
mitral regurgitation, biatrial enlargement, peak resting, LVOT
gradient of 60, PASP of 25 and his left ventricular EF was
greater then 75% and inducible gradient was 80-160 mmHg. At
conclusion following intervention, peak LVOT gradient in
presence dobutamine reduced to 20 mmHg.
In terms of his rate the patient was placed on a temporary
pacemaker in the cath lab. The temporary pacemaker was
initially set at a
rate of 70 with a threshold, which was about 1.5 to 2, which
upon the [**Hospital 228**] transfer to Coronary Care Unit the lead
had moved up from the right ventricle to the right atrium and
the patient was A pacing. At which point the Cardiology
Service was consulted and he had a bedside fluoroscopy,
readjustment of his pacemaker leads done and was replaced
back into the right ventricle without any difficulty. Follow
up chest x-ray showed patient's lead again correctly placed in
RV.
The patient had two episodes of occasional V pacing two days
prior to discharge when his heart rate dropped into the 50s.
Since then his heart rate parameter was decreased to 35 and
the problem was alleviated since then and the patient since
has not required any V pacing since he was in the Coronary
Care Unit.
In terms of his history of parathyroidectomy, his calcium was
checked on admission and his calcium levels had been within
normal limits and monitored closely without any difficulties.
In terms of his fluids, electrolytes and nutrition he
tolerated his diet well after the first day and no nausea or
vomiting and he was advanced to a regular diet cardiac since.
Prophylactically, he was on Protonix, Pneumoboots and a bowel
regimen and did well while he was here. Because of his age,
strong family history of HOCM, and high physical stress
occupation, the EP service was consulted re consideration of
future placement of AICD to lower risk of sudden death.
After talking to Dr.
[**Last Name (STitle) **] and the other cardiologists on service he is now
thinking about getting an ICD placed in a couple of weeks. He
has Dr.[**Name (NI) 1565**] number and will follow up
with. He is also to follow up with his cardiology
physician who is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1884**] in [**Location (un) 3844**] in the
next week. The patient is being discharged to home in stable
and good condition. The patient is to call or follow up if
any new chest pain or shortness of breath, lightheadedness,
difficulty breathing, palpitations develop, seek medical
attention as soon as possible.
FINAL DIAGNOSIS:
Familial HOCM, NYHA Class III on multidrug therapy. Status
post ethanol septal ablation this admission.
RECOMMENDED FOLLOW UP: The patient is to follow up with Dr.
[**Last Name (STitle) **] on [**2113-11-16**] at 1:00 p.m., [**Telephone/Fax (1) 3512**] at the [**Hospital Ward Name 23**]
Building. He is also to follow up with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 285**] in two weeks, call for an appointment. Also
follow up with his [**Location (un) 3844**] physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1884**]
within one week. Per usual protocol for ablation, repeat echo
should be performed in 3 months (LV will undergo continued
remodeling of outflow track in this interval). If outflow
gradient at rest and with provocation is minimal, tapering of
atenolol and/or verapamil may be considered at that time.
MAJOR SURGICAL AND INVASIVE PROCEDURES DONE WHILE IN SERVICE:
Status post ethanol septal ablation, status post cardiac
catheterization.
DISCHARGE CONDITION: Good, stable.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg po q day.
2. Verapamil 120 mg SR q 24 hours.
3. Aspirin 81 mg po q day.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2113-10-27**] 02:21
T: [**2113-10-30**] 08:03
JOB#: [**Job Number 51755**]
cc:[**Last Name (NamePattern1) 51756**] |
41401,42741,4280,41071 | 318 | 193,264 | Admission Date: [**2129-6-7**] Discharge Date: [**2129-6-15**]
Date of Birth: [**2066-9-1**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This 62-year-old gentleman
presented with two week history of epigastric discomfort
ruled in for myocardial infarction and had an episode of
V-fib that responded to cardioversion. He was transferred
into [**Hospital1 69**] for cardiac
catheterization, which showed 80% left anterior descending
artery lesion, 40% diagonal lesion, 60% circumflex lesion,
OM-2 30% lesion, OM-3 30% lesion, a 50% right coronary artery
lesion with a 30% PDA lesion, and an ejection fraction of
27%.
On Cath Lab an intra-aortic balloon pump was placed for his
ventricular dysfunction and severe three-vessel disease. He
is referred to Cardiothoracic Surgery Service for evaluation
of CABG.
Preoperative laboratory work was white count of 9.3,
hematocrit 42.5. Sodium 137, K 4.4, chloride 102, CO2 27,
BUN 18, creatinine 1.1 with a blood sugar of 219.
Past medical history includes hypertension and
hypercholesterolemia as well as bilateral kidney stone
removal and appendectomy. Patient also reported a two small
purulent nodal areas in his abdomen and his left thigh,
non-insulin dependent-diabetes mellitus.
He had no known allergies.
Medications on admission were Zocor, Cozaar, Glyburide,
Glucophage, and was now on IV Integrilin when seen by Cardiac
Surgery.
On examination, his blood pressure was 107/64 with a heart
rate of 71. He had no carotid bruits. Heart was regular,
rate, and rhythm. His lungs were clear bilaterally. His
abdominal examination was benign. He had no varicose veins
and had distal pulses present in his feet.
His electrocardiogram showed Q waves in V1 through V3 as well
as ST depressions in V4, V5, and 6, and aVL.
He will referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. On [**6-9**], he
underwent coronary artery bypass grafting x4 with a LIMA to
the left anterior descending artery, a vein graft to the PDA,
a vein graft to diagonal-1 and vein graft to OM-2, who was
transferred to Cardiothoracic Intensive Care Unit in stable
condition.
On postoperative day one, he continued on his perioperative
Vancomycin and was on the following drips: Neo-Synephrine at
1 mcg/kg/min, nitroglycerin at 0.25 mcg/kg/min, milrinone at
0.25 mcg/kg/min, and insulin drip for glucose coverage. He
was extubated the night of operation and the following
morning was in sinus rhythm in the 90s with a blood pressure
of 95/43. Cardiac index of 2.6 with an intra-aortic balloon
pump at 1:1. He remained on a face mask with postoperative
laboratories of a hematocrit of 27.5, K of 4.8, and BUN of
18, and creatinine of 0.8. His heart was regular, rate, and
rhythm. His respiratory sounds were slightly coarse. He had
dopplerable pulses in his feet with no signs of ischemia in
his legs.
The plain was to discontinue his milrinone first and try to
wean his balloon later. He remained in the Intensive Care
Unit. Diuresis was not started pending his hemodynamic
status following drips and balloon removal.
On postoperative day two, his balloon was removed. His chest
tubes were removed. He remained only on a Neo-Synephrine
drip at 0.75 mcg/kg/min. He was saturating well on nasal
cannula with a good blood pressure and was slightly
tachycardic at 106, but his Lopressor was held until he was
off his Neo-Synephrine and he started his oral medications.
He was transferred 2 units of blood for his hematocrit of
20.8.
He was seen by physical therapy for evaluation and case
management. On postoperative day three, his hematocrit rose
to 25 after transfusion. He was restarted on his oral sugar
medications. He remained tachycardic in sinus rhythm at 105
with a good blood pressure. He was started on Lopressor 12.5
[**Hospital1 **]. His diet was advanced. His Foley was removed. He
began his Lasix diuresis and was transferred to the floor.
On postoperative day four, he continued with his Lopressor
and diuresis. Remained now in sinus rhythm at 82 with a good
blood pressure. Hematocrit holding at 24.1 with a BUN of 14
and creatinine of 0.6. He was alert and oriented. He was on
po pain medications. He continues diuresis.
On postoperative day five, he continued to do well and to
improve. He was ambulating. His pacing wires were removed.
His incisions were clean, dry, and intact. His lungs were
clear bilaterally. He was sating 92% on room air. He was
receiving Percocet for po pain.
On [**6-15**], postoperative day six, he was discharged to
home in stable condition with instructions to followup with
Dr. [**Last Name (STitle) **], his primary care physician [**Last Name (NamePattern4) **] [**1-24**] weeks, and
follow up with Dr. [**Last Name (STitle) 1537**], his surgeon in four weeks at the
office.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Docusate 100
mg po bid, Glyburide 5 mg po q day, metformin 500 mg po bid,
Lopressor 50 mg po bid, Zocor 40 mg po q day, ibuprofen 600
mg po prn q8h, Percocet 1-2 tablets po prn q4-6h for pain.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times four.
2. Non-insulin dependent-diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
5. Status post bilateral kidney stone removal.
6. Status post appendectomy.
Again, he was transferred home in stable condition on [**2129-6-15**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2129-8-17**] 13:02
T: [**2129-8-23**] 04:15
JOB#: [**Job Number 43557**]
|
2113,2851,56212 | 319 | 124,954 | Admission Date: [**2156-8-12**] Discharge Date: [**2156-8-16**]
Date of Birth: [**2109-5-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Transfused 2 units packed red blood cells.
Colonscopy
EGD
History of Present Illness:
This is a 47to F h/o fibroids with BRSPR and diarhhea of 3 days
duration.
On Thursday afternoon ([**2156-8-12**]), Ms. [**Known lastname **] was at work (employed
as unit coordinator at the [**Hospital1 18**]) when she began to feel dizzy
and short of breath, without any associated chest pain. She went
home, where she had her first episode of bloody diarrhea at 5
pm. The observed blood was described as dark and sufficiently
voluminous to fill the toilet bowel (estimated volume = 1 cup).
She went to bed, and the next morning, she had two more episodes
of bloody diarrhea, with progressively worsening
light-headedness with shortness of breath on walking short
distances (ie., to bathroom). She came to the ED on [**Hospital1 2974**]
because she was concerned by her bloody diarrhea and shortness
of breath.
.
On arrival to the ED vital signs were T 98.6 HR 110, BP 134/59
RR 24 O2 sats 100 on RA. She was found to have a HCT of 17, MCV
of 57, Hgb 4.4 (calc HCT 13). Gross blood was found in the
vault, but NG lavage was negative. She received 2 Units of PRBC
in the ED and remained stable throughout her admission to the
MICU, with slight tachychardia to the 120's.
Past Medical History:
Sx: elbow fx with surgical intervention
fibroids removed 13 years ago
.
OB/GYN:
Regular periods 26x5 days. reported as heavy first two days.
.
Social History:
The patient works as a unit coordinator at [**Hospital1 18**]. She lives by
herself in [**Location (un) 47**]. She occasionally uses alcohol, and smokes
about 10 cigarettes per week. Previous 10 pack-year history.
Family History:
Family History: Father--MI at age 55. Mother--lung cancer.
Sister--uterine fibroids.
.
Physical Exam:
GEN: NAD, supine on bed.
HEENT: NC/AT, PERLA, No LAD
Heart: Distinct S1, S2, Systolic murmer at URSB and ULSB. No T/R
ABD: S/NT. Distended. + Bowel Sounds
EXT: Warm, well-perfused.
Neuro: Aox3, No focal defecits.
Pertinent Results:
[**2156-8-12**] 09:11PM HCT-22.5*
[**2156-8-12**] 04:06PM HCT-19.4*
[**2156-8-12**] 10:53AM HGB-4.4* calcHCT-13
[**2156-8-12**] 09:40AM URINE HOURS-RANDOM
[**2156-8-12**] 09:40AM URINE GR HOLD-HOLD
[**2156-8-12**] 09:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2156-8-12**] 09:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-8-12**] 08:45AM GLUCOSE-130* UREA N-17 CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-20* ANION GAP-13
[**2156-8-12**] 08:45AM LD(LDH)-152
[**2156-8-12**] 08:45AM IRON-7*
[**2156-8-12**] 08:45AM calTIBC-420 HAPTOGLOB-76 FERRITIN-2.2*
TRF-323
[**2156-8-12**] 08:45AM PT-13.2* PTT-22.9 INR(PT)-1.1
[**2156-8-12**] 08:30AM WBC-12.1* RBC-3.09* HGB-4.7* HCT-17.5*
MCV-57* MCH-15.1* MCHC-26.7* RDW-19.4*
[**2156-8-12**] 08:30AM PLT COUNT-405
[**2156-8-12**] 08:30AM RET MAN-3.3*
Brief Hospital Course:
On arrival to the ED ([**2156-8-13**]), vital signs were T 98.6 HR 110,
BP 134/59 RR 24 O2 sats 100 on RA. The patient was found to
have a HCT of 17, MCV of 57, Hgb 4.4 (calc HCT 13). Gross blood
was found in the vault, and NG lavage was negative. The patient
received 2 Units of PRBC in the ED and remained stable
throughout her admission to the MICU, with slight tachychardia
to the 120's.
.
In the MICU, the patient was started on iron and scoped from
above and below. Upper endoscopy was unremarkable except for
grade I esophagitis in the GE junction and lower third of the
esophagus. Colonoscopy showed clotted blood as well as
diverticuli in the distal transverse colon, splenic flexture,
descending colon and sigmoid colon. A single non-bleeding polyp
was located in the mid-sigmoid region. The polyp was not removed
but recommendation was made for removal at a later date.
.
The patient remained hemodynamically stable and was transferred
to the [**Location (un) **] internal medicine service on Saturday night
([**2156-8-14**]). Hematocrit was in the 27's on Saturday night and
Sunday morning. She had one episode of dark bloody stool on
Sunday afternoon, likely residual and not indicative of new
bleeding. Her heamtocrits trended upwards from Sunday to Monday
afternoon (27.3-->29.0-->30.1) with no bloody stool. The patient
was discharged on iron and ascorbic acid with follow-up
[**Month/Day/Year 1988**] with her PCP. [**Name10 (NameIs) **] was made to Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] ([**Telephone/Fax (1) 111401**] for removal of polyp.
.
Medications on Admission:
Advil
Zantac
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
2. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO three
times a day: Please take one tablet each time you take your
ferrous sulfate for better absorbtion.
Disp:*90 Tablet(s)* Refills:*2*
3. 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*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticulitis
2. Acute on chronic anemia
Discharge Condition:
Good.
Discharge Instructions:
1. Please follow-up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below.
2. Please return to the ED for new shortness of breath,
difficulty breathing, bloody diarrhea, or severe abdominal pain.
3. Please take your Iron pills (ferrous sulfate) and Ascorbic
Acid as directed. You will take these pills until your PCP
determines that your hemoglobin level normalizes.
Followup Instructions:
1. Please go to [**Street Address(2) 8667**] ([**Hospital1 18**] [**Hospital Ward Name 517**]) at 9:30 on
this [**Last Name (LF) 2974**], [**8-20**] for repeat colonoscopy with removal of
your polyp. Instructions for your bowel prep. will arrive at
your home in the mail this week.
2. Please follow-up with your PCP (Dr. [**Last Name (STitle) 111402**] [**Name (STitle) 111403**]) on
[**8-25**] at 11:30. Please ask your PCP to evaluate your
systolic murmur best heard at the right upper sternal border, as
well as your history of heavy menses.
Completed by:[**2156-8-16**] |
4271,41021 | 320 | 172,849 | Admission Date: [**2145-10-9**] Discharge Date: [**2145-10-9**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: 65-year-old gentleman with past
medical history significant for neck cancer, admitted to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization
following arrest. The patient originally was admitted to
[**Hospital3 3583**] following an unwitnessed arrest. The
patient's wife reports that patient got up to go to the
bathroom. He did not return and his wife subsequently found
him down unresponsive and approximately five minutes later
EMS found patient to be in asystole. He was resuscitated
following epinephrine, atropine and lidocaine. He also got
an aspirin and heparin. The rhythm strip showed him to be in
the rhythm of atrial fibrillation with a blood pressure
initially of 25/palp and then 60/palp. The patient was then
taken to [**Hospital3 3583**]. Upon arrival at [**Hospital3 3583**] an
EKG showed inferolateral ST depression. He was then
transferred to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for
cardiac catheterization.
PAST MEDICAL HISTORY: Neck cancer, status post dissection in
[**2141**] and status post chemotherapy and radiation.
MEDICATIONS: No home medications.
MEDICATIONS ON TRANSFER: Heparin, lidocaine.
ALLERGIES: Unknown
SOCIAL HISTORY: Married. Tobacco use 1?????? packs per day.
PHYSICAL EXAMINATION: Temperature 92.4??????, heart rate 95,
blood pressure 131/86, respirations - intubated, on
ventilator. GENERAL: Intubated and sedated, on vent.
HEENT: Pupils dilated and non-reactive to light.
CARDIOVASCULAR: Regular rate, no murmurs, rubs or gallops.
LUNGS: Clear to auscultation anteriorly, right breath sounds
slightly decreased as compared to the left. ABDOMEN:
Decreased bowel sounds. EXTREMITIES: Pulses intact in
extremities times four. NEUROLOGICAL: Pupils fixed and
dilated, no corneal reflexes, no gag reflexes. No response
to pain or stimuli. Areflexic. Does not withdraw
extremities to pain.
LABORATORY DATA: On admission, white count 7.8, hematocrit
35.7. Sodium 138, potassium 4.3, chloride 105, bicarbonate
14, BUN 7, creatinine 1.2, glucose 152. Electrocardiogram -
sinus tachycardia with inferior ST depression at
approximately 2 mm. Normal axis. ABG 6.97, 64, 52 on 100%
FIO2.
HOSPITAL COURSE:
1. Cardiovascular. Patient admitted following asystolic
arrest with prolonged down time. There is significant
concern for patient's neurologic status given his neurologic
exam and his pH of 6.97 at admission. Initially cardiac
catheterization was held until a further determination of his
prognosis and likelihood of recovery could be determined.
His arrest was thought to be likely ischemic with his lateral
ST depressions versus primary arrhythmia. The patient was
monitored. He had an echo which showed an ejection fraction
of 50% and significant valvular disease. The patient was
monitored supportively and further cardiac intervention was
not undertaken given his neurologic status.
2. Neurology. Patient admitted unresponsive with no brain
stem functions. However, he did not meet the criteria for
brain death. Patient continued to decline neurologically and
began to develop wide temperature fluctuations and autonomic
dysfunction. Patient was thought to have hypothalamic
dysfunction due to his severe anoxic brain injury. Neurology
was consulted and patient was thought to have a very poor
prognosis, supportively, until he suffered the
cardiorespiratory arrest.
3. Severe acidosis. Patient admitted with an pH of 6.97.
This was thought to represent severe lactic acidosis in the
setting of prolonged hypoxia and asystolic arrest. He was
maintained supportively.
DISPOSITION: Patient transferred to the IDMC following the
asystolic arrest with prolonged down time in the field.
Patient was severely acidotic and had minimal intact
neurologic function. His status rapidly declined following
admission to the CCU and he developed severe autonomic
dysfunction thought to be due to his anoxic brain injury.
Patient then suffered a cardiopulmonary arrest.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**First Name3 (LF) 94400**]
MEDQUIST36
D: [**2145-11-29**] 16:53
T: [**2145-11-30**] 09:33
JOB#: [**Job Number 94401**]
|
73382,42731,29281,2851,25000,V4501,4019,53081 | 321 | 192,097 | Admission Date: [**2190-3-1**] Discharge Date: [**2190-3-5**]
Date of Birth: [**2113-12-13**] Sex: F
Service: MICU
HOSPITAL COURSE: The patient is a 76-year-old woman admitted
to the hospital for elective hip surgery, open reduction and
internal fixation of the left hip, status post hip fracture
in [**2189-5-30**], coming again as an inpatient for elective
surgery for revision due to nonunion of the fracture. The
patient had the surgery on [**3-1**], without any
complications, intraop blood loss of 900.
On postop day #2, the patient was noted to have altered
mental status per nursing and daughter. The patient was not
responding to commands, and was not answering questions
appropriately, and did recognize family members. The patient
also was noted to be in atrial fibrillation with a rapid
ventricular response rate in the 120s. Given these two
conditions, the patient was transferred to the MICU service.
PAST MEDICAL HISTORY: Pertinent for hypertension; obesity;
status post pacemaker for sick sinus syndrome in [**2186**]; CVA x
2, first in [**2182**], a second in [**2183**], affecting the left side
with minimal permanent deficits; osteoarthritis; GERD, status
post intestinal bypass; as well as appendectomy; and
cholecystectomy, as well as a hernia repair; depression;
fibromyalgia; diabetes mellitus, baseline.
ALLERGIES: Sulfa with which she gets a rash.
OUTPATIENT MEDS: Include atenolol 50 mg qd, perphenazine
37.5 mg po bid, and Tagamet, aspirin.
INITIAL EXAM: The patient was not alert and oriented, was
not answering questions, or following commands. Vitals -
97.6, heart rate 92-117, BP 156/70, respiratory rate 16,
satting 96% on room air. In general, she was in no apparent
distress. Oropharynx was clear. Pupils equally round and
reactive to light. Mucous membranes were dry. No bruits on
neck. Chest - anterior chest with coarse breath sounds.
Cardiology - irregularly, irregular, borderline tachycardic.
Abdomen was mildly distended, good bowel sounds, nontender.
Extremities - good distal pulses. Neuro exam - again, not
alert and oriented, 1+ reflexes diffusely, good muscle tone,
unable to answer questions.
LABORATORY DATA: The patient's hematocrit was 28.4, repeat
25.5, white blood cell count not elevated. Chem-7 141,
sodium 4.7, potassium 110, chloride 22, bicarb 26, creatinine
1.4. All three sets of cardiac enzymes were negative. INR
1.3, PT 14, PTT 27.6. ABG 7.34, carbon dioxide 40, and
oxygen 115. UA was noted to have [**3-3**] white blood cells, with
occasional bacteria. Urine culture showed no growth. Hip
culture on [**3-2**] showed no growth to date. Chest x-ray had
ventricular enlargement and possible early CHF. EKG had
atrial fibrillation.
ISSUES - 1) MENTAL STATUS CHANGES: Most likely secondary to
narcotic overuse. The patient was given 3 tabs po percocet,
as well as 2 mg of IV dilaudid. There was a question of
stroke versus subdural versus infection. CT scan of the head
was negative. The patient remained afebrile. Urine culture
was negative. Blood culture pending. Again, the patient
responded very well during the hospital course in terms of
mental status changes resolved. The patient, upon dispo, is
clear mentally, back to baseline.
2) ATRIAL FIBRILLATION: Blood pressure has been stable, but
because of a rapid ventricular response was given Lopressor
pushes, and then finally po atenolol to keep her heart rate
within normal limits. The patient was on telemetry. The
patient was started on anticoagulation of IV heparin, will be
D/C on Lovenox and then coumadin 4 mg until she is
therapeutic.
3) LOW HEMATOCRIT: Likely secondary to blood loss, given the
900 blood loss. Stool guaiac negative. Post-transfusion,
her crit has been stable for 24 hours.
4) HIP FRACTURE: She will continue Lovenox anticoagulation,
as well as continue physical therapy, going to [**Hospital **] Rehab.
She has a right subclavian in terms of access which will be
D/C. She was full code, and we were in communications with
the daughter.
DISCHARGE MEDICATION: Included Lovenox 40 mg subcu qd,
atenolol 50 mg po qd, perphenazine 37.5 mg po bid, Tylenol
650 mg po q 4-6 h.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 49124**]
MEDQUIST36
D: [**2190-3-5**] 11:07
T: [**2190-3-5**] 10:10
JOB#: [**Job Number **]
|
78650,82022,E8889,42731,5845,2765,2760,2662,4019 | 321 | 199,004 | Admission Date: [**2189-6-11**] Discharge Date: [**2189-6-19**]
Date of Birth: [**2113-12-13**] Sex: F
Service:
STAT ADDENDUM:
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg po q hs to be adjusted for an INR of 2 to 3
2. Vitamin B12 1000 mcg intramuscular or subcutaneous q week
x3 weeks and then q month
3. Heparin intravenous until Coumadin is therapeutic
4. Protonix 40 mg po qd
5. Lopressor 100 mg po tid
6. MSIR 15 mg po q6h prn pain. The MSIR should be adjusted
according to her mental status and pain control.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2189-6-19**] 14:08
T: [**2189-6-19**] 14:30
JOB#: [**Job Number 109255**]
cc:[**Hospital 109256**] |
78650,82022,E8889,42731,5845,2765,2760,2662,4019 | 321 | 199,004 | Admission Date: [**2189-6-11**] Discharge Date: [**2189-6-19**]
Date of Birth: [**2113-12-13**] Sex: F
Service: GENERAL MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a history described in the past medical history,
who was admitted to [**Hospital **] Hospital on [**2189-6-8**] with
left-sided chest pain and ruled out for myocardial
infarction. She was found to be in new onset atrial
fibrillation. Persantine Thallium revealed a reversible
defect, prompting transfer to [**Hospital1 188**] for catheterization. However, prior to
catheterization, she had chest pain and fell, a mechanical
fall resulting in a left intertrochanteric fracture. She had
a negative head CT and cervical spine, and then was
transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Hypertension
2. Obesity
3. History of sick sinus syndrome status post pacemaker in
[**2186**]
4. Depression
5. Cerebrovascular accident x 2 in [**2182**] and [**2183**] affecting
the left side
6. Osteoarthritis
7. Gastroesophageal reflux disease
8. Intestinal bypass, cholecystectomy, appendectomy and
hernia repair
9. Fibromyalgia
MEDICATIONS ON TRANSFER: Her medications as an outpatient
are atenolol, Zoloft, aspirin and Tagamet.
ALLERGIES: Sulfa drugs, which cause a rash.
SOCIAL HISTORY: She has no tobacco or alcohol use. She
lives in [**Hospital3 **].
PHYSICAL EXAMINATION: At the time of admission, notable for
a blood pressure of 112/72, pulse 78, respirations 24, 91% on
room air, 97% on 3 liters. In general, she is sleepy,
falling asleep during the examination, complained of pain,
but in no acute distress. Heart was irregularly irregular,
no murmurs, no jugular venous distention, no carotid bruits.
The lungs are clear to auscultation anteriorly and laterally.
The abdomen is soft, obese, with active bowel sounds,
nontender. The extremities showed no edema, cool, 2+ pedal
pulses bilaterally. Neurological examination is alert and
oriented x 3. Cranial nerves intact. Upper extremities 4/4
strength bilaterally.
LABORATORY DATA: On admission, notable for creatinine of
1.3, normal liver function tests. Troponin less than .02 x
3. Urinalysis was negative. All of this was at the outside
hospital. Upon admission to [**Hospital1 188**], her CK was 1058 with an MB of 19, presumed secondary
to the fall, and her BUN and creatinine had increased to 36
and 2.6 respectively. Phos was 7.0. Hip x-ray revealed a
left hip intertrochanteric fracture with varus deformity,
superior displacement of the distal fragment, no evidence of
dislocation. Persantine Thallium revealed an ejection
fraction of 48% with an ischemic inferoapical wall and
anteroapical fixed abnormality, hypokinesis of the apex and
lateral wall and inferoapical wall. Chest x-ray revealed
moderate cardiomegaly, no pneumonia or congestive heart
failure.
HOSPITAL COURSE BY SYSTEM:
1. Neurology: The patient had mental status changes after
extubation, was able to only answer a few questions, however,
this improved as her sodium decreased back down to a normal
range. It may also have been related to benzodiazepines or
medications that she had at the time of intubation, which
were washed out of her system. At the time of discharge, she
is alert and oriented x 3. The patient also had two head CT
studies which did not show any evidence of acute focal
processes.
2. Heart: She was in atrial fibrillation rhythm. It is
unclear when that originally occurred. She remained on
telemetry for her hospital course, and she was not taking
oral medications. She was taking metoprolol intravenously to
keep her pulse and blood pressure stable. She became
hypertensive and tachycardic in the 130s to 140s at times.
Once she was able to pass her swallowing evaluation, she was
restarted on Lopressor and then switched to atenolol at
discharge. Possible cardioversion was discussed, possibly as
an outpatient. The cardiac catheterization was done and
revealed minimal coronary artery disease. Therefore, the
chest pain was believed not to be secondary to cardiac
ischemia.
3. Pulmonary: The patient was intubated at the time of
surgery for the left hip repair, and was weaned in the
Surgical Intensive Care Unit after surgery.
4. Gastrointestinal: The patient was kept nothing by mouth
until her mental status had cleared. She had failed two
swallowing studies because of lack of cooperation, however,
she was finally able to pass a swallowing study on the [**12-18**], and was restarted on oral intake and oral
medications. She received Zantac throughout her hospital
course intravenously.
5. Endocrine: Her sugars were well controlled for the most
part on regular insulin sliding scale.
6. Renal: Creatinine and BUN improved during the hospital
course.
DISCHARGE PLAN: To transfer the patient on the following
medications: Coumadin 5 mg by mouth daily at bedtime to be
adjusted for an INR of 2 to 3, vitamin B12 1000 mcg
intramuscularly or subcutaneously weekly for three weeks then
monthly, heparin intravenously until the Coumadin is
therapeutic, Protonix 40 mg by mouth once daily, atenolol 100
mg by mouth once daily. She will have physical therapy and
be on a cardiac diet.
DISCHARGE DIAGNOSIS:
1. Left hip fracture
2. Hypernatremia
3. Atrial fibrillation
4. Diabetes mellitus
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2189-6-19**] 01:36
T: [**2189-6-19**] 03:28
JOB#: [**Job Number 32608**]
|
4241,4019,V5331,2724,2449,7455 | 322 | 177,634 | Admission Date: [**2135-5-2**] Discharge Date: [**2135-5-10**]
Service: CARDIOTHORACIC
Allergies:
Levaquin / Penicillins / Flagyl
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion/Syncope
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (21mm CE Pericardial Tissue Valve)
[**2135-5-2**]
History of Present Illness:
83 y/o female with dyspnea on exertion and syncope who was found
to have severe Aortic Stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 cm2. Referred
for elective cardiac surgery.
Past Medical History:
Hypertension, Hypercholesterolemia, Asthma, Hypothyroidism,
Gastroesophageal Reflux Disease, Patent Foramen Ovale, h/o C.
Diff colitis, Heart Block s/p Pacemaker insertion [**5-2**], s/p ERCP
w/ Bile Duct Stent, s/p Cholecystectomy, s/p Hernia Repair
Social History:
lives alone, independent in all ADL/IADLs; 8 children involved
in her care
no tob, EtOH
Family History:
Father died of MI in 60's
Physical Exam:
VS: 74 16 136/76 140/82 5'3" 150
General: WD/WN female in NAD
Skin: Erythema inferior to breasts
HEENT: EOMI, PERRL, Edentulous
Neck: Supple, FROM, -JVD, -Carotid Bruits
Chest: CTAB -w/r/r
Heart: RRR +S1S2, [**1-3**] murmur
Abd: Soft, NT/ND +BS,
Ext: Warm, Well-perfused, Trace Edema, few varicosities
Neuro: Grossly intact, A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**5-2**]: Prebypass: There is a bidirectional shunt across the
interatrial septum at rest. A small secundum atrial septal
defect is present. There is mild symmetric left ventricular
hypertrophy. Resting regional wall motion abnormalities include
mild hypokinesia of the mid and apical portions of the inferior
wall. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-29**]+) mitral regurgitation is seen.
Post Bypass: Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. Valve is well
seated and the leaflets move well. No Aortic insufficiency
present. Peak gradient across the aortic valve post replacement
is 17 mm Hg. The mitral regurgitation is more on the mild side
post aortic valve replacement. Small secundum ASD present- not
repaired by surgeons.
[**2135-5-2**] 02:47PM BLOOD WBC-6.9 RBC-3.35* Hgb-9.7* Hct-28.3*
MCV-85 MCH-29.0 MCHC-34.4 RDW-14.0 Plt Ct-107*
[**2135-5-2**] 02:47PM BLOOD PT-15.1* PTT-39.8* INR(PT)-1.4*
[**2135-5-2**] 04:03PM BLOOD UreaN-15 Creat-0.7 Cl-111* HCO3-23
[**2135-5-6**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2135-5-8**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA: Negative.
[**2135-5-9**] 07:50AM BLOOD WBC-10.5 RBC-3.87* Hgb-11.4* Hct-33.3*
MCV-86 MCH-29.5 MCHC-34.3 RDW-14.5 Plt Ct-324#
[**2135-5-4**] 02:00AM BLOOD PT-12.8 PTT-28.3 INR(PT)-1.1
[**2135-5-9**] 07:50AM BLOOD Glucose-95 UreaN-13 Creat-1.0 Na-140
K-4.3 Cl-100 HCO3-31 AnGap-13
[**2135-5-6**] 07:55AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] was electively admitted after pre-operative work-up
was done as an outpatient. She was brought directly to the
operating room where she underwent an Aortic Valve Replacement
(tissue). Please see operative report for surgical details. She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition. She remained intubated
until post-op day one secondary to decline in SpO2. She was
extubated following awaking neurologically intact. Chest tubes
were removed on post-op day two. Beta blockers and diuretics
were started and she was gently diuresed towards her pre-op
weight. EP interrogated pacemaker before and after surgery.
Later on post-op day two she was transferred to the cardiac
surgery step down floor. Epicardial pacing wires were removed on
post-op day three. Physical therapy worked with patient during
entire post-op course for strength and mobility. C. Diff assay
was negative all 3 times. Over the next several days she
continued to make good progress and was discharged to rehab on
post-op day eight with the appropriate follow-up appointments.
Medications on Admission:
Lipitor 20mg qd, Levoxyl 75mcg qd, Omeprazole 20mg qd, Atenolol
25mg qd, Celexa 10mg qd, Aspirin 325mg qd, MVI, Vancomycin 250mg
[**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1474**] TCU
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hypertension, Hypercholesterolemia, Asthma, Hypothyroidism,
Gastroesophageal Reflux Disease, Patent Foramen Ovale, h/o C.
Diff Colitis, s/p Pacemaker insertion [**5-2**], s/p ERCP w/ Bile
Duct Stent, s/p Cholecystectomy, s/p Hernia Repair
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Gently pat incision dry. Do not take bath.
Do not apply lotions, creams, ointment or powders to incision.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 10 weeks.
If you develop a fever or notice redness or drainage from
incision, please contact office immediately.
Please call to make all follow-up appointments.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-31**] weeks
Dr. [**Last Name (STitle) **] in [**11-29**] weeks
Completed by:[**2135-5-10**] |
4582,3694,V4975,41401,V420,4280,99672,99762,25041 | 323 | 106,158 | Admission Date: [**2116-5-3**] Discharge Date: [**2116-5-11**]
Date of Birth: [**2062-12-24**] Sex: M
Service: CCU
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old man
with a history of coronary artery disease, insulin dependent
diabetes mellitus for 40 years and a renal transplant in [**2103**]
who presented who presented with an increased dyspnea on
exertion and shortness of breath at rest, increased over a
chronic baseline level. The patient noted symptoms acutely
worsened one day prior to admission prompting an Emergency
Room visit. In the Emergency Room the patient denied chest
pain, palpitations, nausea, vomiting or diaphoresis as well
as fever and chills. The patient did note that his usual
dose of Lasix was not working. In the Emergency Room he was
found to be sating high 90s on 2 liters after 80 mg of Lasix.
He was admitted to the [**Hospital Unit Name 196**] floor he was found to have a low
saturation. He was put on 100% nonrebreather, sating in the
mid 90s. Respiratory rate was 30s to 40s. The patient was
given 40 plus 40 of intravenous Lasix without any increased
urine output. On the nitroglycerin drip and Morphine the
patient was able to diurese 200 cc. The patient's
respiratory rate decreased to the 20s. The patient's
examination had improved. the patient was taken to the
Catheterization laboratory where he was found to be 80% on
100% nonrebreather. The patient was also found to have
lateral electrocardiogram changes. He was diaphoretic and
not complaining of chest pain but noting paroxysmal nocturnal
dyspnea and orthopnea.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus for 40 years with triopathy; 2. Status post renal
transplant [**2103**]; 3. Status post bilateral below the knee
amputation; 4. Coronary artery disease, with three vessel
disease with poor touchdowns, not a surgical candidate with
recent in-stent stenosis of the left anterior descending
stent treated with brachytherapy; 5. Recent admit for right
knee ulcer to [**Hospital3 **].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Pravachol 20 mg p.o. q.d.; Aspirin
325 mg p.o. q. day; Lasix 60 mg p.o. q. day; Enalapril 20 mg
p.o. b.i.d.; Lasix 75 mg p.o. q. day; Isordil 20 mg p.o.
t.i.d.; Prednisone 10 mg p.o. q.o.d.; Sandimmune 100 mg p.o.
q. AM and 50 mg p.o. q. PM; Imuran 50 mg p.o. q. day; Ativan
2 to 4 mg p.o. q. 4 to 6 hours prn; NPH 20 units
subcutaneously in the morning and 14 units subcutaneously in
the PM; regular insulin sliding scale; Toprol XL 12.5 mg p.o.
q. day.
SOCIAL HISTORY: The patient is full code. He lives alone.
His wife had died recently. The patient quit smoking tobacco
20 years ago. He denied any alcohol use.
FAMILY HISTORY: Significant for gastrointestinal and breast
cancer.
PHYSICAL EXAMINATION: The patient's pulse was 95, blood
pressure was 125/38 with MAP 67, respiratory rate 22 and
oxygen saturation 97% on 100% nonrebreather. On general
examination the patient was a very chronically ill appearing
man in no apparent distress who was bolt upright in bed. On
head, eyes, ears, nose and throat examination the patient had
pupils which were nonreactive. Neck examination revealed no
lymphadenopathy and a central venous pressure of
approximately 10 cm of water. Cardiac examination revealed a
regular rate and rhythm, normal S1 and S2 with no murmurs,
rubs or gallops. There was presence of an S3. Pulmonary
examination revealed rales up to [**1-19**] of the lung fields with
bilateral pleural effusions. On abdominal examination the
patient's belly was soft, nontender, nondistended with normal
bowel sounds. Extremity examination reveals bilateral below
the knee amputations, 2+ edema. There was a left Stage 3
decubitus ulcer of the patella region.
LABORATORY DATA: Pertinent laboratory findings revealed a
white blood cell count of 9.4, hematocrit 40, platelets 291.
The patient had a BUN of 31, creatinine 1.4. The patient's
CK was trending downwards.
Electrocardiogram revealed normal sinus rhythm at 75 with
normal axis, left atrial abnormality, ST elevations V1
through V4, 1 to 3 mm. There were also small Q waves in 3
and F. Chest x-ray showed congestive heart failure with
bilateral pleural effusions. [**2115-11-16**], stress MIBI,
the patient with reversible moderate inferior and anterior
and septal wall defect.
Echocardiogram performed [**2116-5-6**], revealed sinus
tachycardia with no anxiety, abdominal aortic aneurysm, ST
increased V2 to V4, the patient also had biphasic T in V6.
Cardiac catheterization, the patient had ejection fraction of
20 to 30% with 100% proximal right coronary artery lesion,
95% recurrent in-stent mid left anterior descending lesion.
This focal lesion was dilated successfully.
HOSPITAL COURSE: The patient is a 53 year old man with a
history of coronary artery disease, myocardial infarction and
renal transplant as well as insulin dependent diabetes
mellitus and congestive heart failure.
1. Cardiovascular - From the cardiovascular standpoint the
patient presented in acute decompensated heart failure in the
setting of ischemic heart disease.
From a coronary artery disease standpoint the patient has
severe three vessel disease. Multiple interventions
including recent percutaneous transluminal coronary
angioplasty and brachiotherapy to the left anterior
descending now presented with recurrent in-stent left anterior
descending
stenosis, status post percutaneous transluminal coronary
angioplasty. The patient was ruled out for myocardial
infarction. He was evaluated by Cardiac Surgery who felt
that the patient was not a coronary artery
bypass candidate. He was continued on Aspirin, Plavix and
Beta blockers as well as Pravachol.
From a myocardial standpoint the patient had an ejection
fraction of 20% with severe hypokinesis, left ventricular
hypertrophy, and diastolic dysfunction. He presented with
decompensated heart failure. He ruled out for myocardial
infarction, however, his congestive heart failure was felt to
be secondary to ischemic heart disease. The patient was
diuresed with Lasix and eventually a combination of Diuril
and Lasix. The patient was started on Natrecor which
initially caused some hypotension but then the patient
reported improvement in his shortness of breath. He had
augmented diuresis while on the Natrecor. The patient was
considered for Aldactone although with his history of
hyperkalemia this was deferred. Plan was to use BiPAP if the
patient were to have further acute pulmonary edema. Post
cardiac catheterization the patient had an episode of acute
pulmonary edema which was responsive to Morphine and Lasix.
The patient was continued on his outpatient heart failure
regimen which included Enalapril, Isordil, and Toprol.
From a conduction standpoint the patient remained in sinus
rhythm and was continued on his Beta blocker.
From an endocrine standpoint the patient presented with a
history of insulin dependent diabetes mellitus and was
maintained on a regimen of NPH and regular insulin sliding
scale as per his outpatient regimen.
From a renal standpoint the patient is status post renal
transplant on an immunosuppressant regimen. He presented at
his baseline creatinine. However, with fingerstick diuresis
the patient's creatinine climbed from 1.4 to approximately
1.8. His Cyclosporin level of 113 was within normal limits.
The renal transplant team followed the patient. His
creatinine gradually began to trend down at the end of the
[**Hospital 228**] hospital course.
Infectious disease - The patient presented with a left knee
ulcer near the site of the left below the knee amputation.
Vascular surgery was consulted and felt the patient should be
on Levofloxacin and Flagyl. They debrided the ulcer. The
patient was continued on Levofloxacin and Flagyl for
approximately a course of 14 days. The patient had a swab
that grew Enterobacter as well as Stenotrophomonas.
Infectious Disease was contact[**Name (NI) **] regarding the treatment of
his Stenotrophomonas. Given the marked clinical improvement
in the ulcer, the feeling was that the Stenotrophomonas was a
colonizer and that there was no need to add additional
coverage. Vascular Surgery recommended the patient follow up
with his vascular surgeon at [**Hospital3 **].
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged to follow up
with Dr. [**Last Name (STitle) **] in Heart Failure Clinic in approximately one
to two weeks. The patient will also follow up with his
vascular surgeon at [**Hospital3 **] in approximately one week.
Due to high likelihood of repeat LAD in-stent stenosis,
elective relook angiography with standby for PTCA will be
considered in 4 months. DISCHARGE MEDICATIONS:
1. Tylenol 650 mg p.o. q. 4-6 hours prn
2. Pravachol 20 mg p.o. q. day
3. Plavix 75 mg p.o. q. day
4. Cyclosporin 100 mg p.o. q. AM and 50 mg p.o. q. PM
5. Azathioprine 50 mg p.o. q. day
6. Metoprolol XL 2.5 mg p.o. q. day
7. Colace 100 mg p.o. b.i.d.
8. Aspirin, enteric coated 325 mg p.o. q.d.
9. Ativan 0.5 to 1 mg p.o. q. 4-6 hours prn anxiety
10. Flagyl 500 mg p.o. t.i.d. for nine days
11. Levofloxacin 500 mg p.o. q. day for nine days
12. Prednisone 10 mg p.o. q.o.d.
13. Enalapril 20 mg p.o. b.i.d.
14. Lasix 80 mg p.o. q. day
15. Isordil 20 mg p.o. t.i.d. prn
16. Regular insulin sliding scale, NPH 20 units
subcutaneously q. AM and 14 units subcutaneously q. PM
DISCHARGE INSTRUCTIONS: The patient is to have dry sterile
dressings b.i.d. to his left lower extremity ulcer. He will
also need daily weights at home with a sitdown scale. Case
management was contact[**Name (NI) **] to obtain a sitdown scale for the
patient. [**Hospital6 407**] Services will aid the
patient in the dressing changes.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure
2. Coronary artery disease with three vessel disease status
post percutaneous transluminal coronary angioplasty
3. Insulin dependent diabetes mellitus
4. Sepsis, recent
5. Status post bilateral below the knee amputations
6. Left knee ulcer
7. Renal transplant with chronic immunosuppression.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2116-5-10**] 13:33
T: [**2116-5-10**] 15:41
JOB#: [**Job Number 21048**]
cc:[**Last Name (NamePattern1) 21049**] |
4280,4148,5363,4019,3693,5939,4401,V4976,41401,28521,2767,25071,78551,51881,4241,99681,5845 | 323 | 128,132 | Admission Date: [**2119-9-21**] Discharge Date: [**2119-10-6**]
Date of Birth: [**2062-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Intubation
Central line placement
Echocardiography
History of Present Illness:
58 year old with PMH of ischemic CM (EF 20%), CAD, severe 3VD
(not a CABG candidate), type 1 DM presents with nausea and
hypotension. Recently seen in advanced heart failure clinic on
[**9-14**], BP noted to be over 200, and his hyral was increased from
25 qid to 50 tid. Lasix increased from 60 qam to 60 am/40 qpm.
Also got MRI of his kidneys which showed severe renal artery
narrowing. Pt reports that since the next day after the MRI, he
has increasing nasuea; no
f
/
c
/
n
s
/
c
p/sob/pnd/orthopnea/vomiting/diarrhea/hematochezia/melena/recent
NSAID use/decreased UOP.
In ED, initial VS SBP in 60s, AF, pulse in 60s. Given
INsulin/D50, Kayexalate, Ca for K of 6.1. Blood and urine sent.
Started on dopa, central line placed. Given
vanc/levo/flagyl/hydrocort, 1 am Nabicarb.
Past Medical History:
1. Ischemic CM with EF 20%
2. CAD with severe 3VD, not cabg candidate
3. PVD s/p B AKA
4. Type 1 DM
5. Blindness
6. Complete occlusion of R ICA
7. CRI s/p renal xplant [**2103**]; b/l cr 1.2-1.4
Social History:
Lives alone, no smoking or alcohol use
Family History:
Non-contributory
Physical Exam:
PE 97.8 90 94/47 20 91%2L CVP 5
pertinents
mmm
supple, jvp 8 cm
rales [**12-19**] way up
rrr, grade ii/vi SEM, ?diastolic murmur
no tenderness around iliac fossa
Pertinent Results:
DATA CT [**9-22**]
1. No evidence of intraabdominal abscess.
2. Patchy consolidation at the right lung base. Could represent
pneumonia or atelectasis. Clinical correlation is recommended.
Bilateral pleural effusions, right greater than left.
3. Distended stomach likely representing gastroparesis.
4. Extensive vascular calcification.
5. Transplant kidney is seen in the right lower quadrant
Brief Hospital Course:
This is a 56 year old gentleman with DM Type I and a history of
3 vessel coronary disease (seen in [**2114**] cath.), ischemic
cardiomyopathy (EF of 25 % on echo this admission), aortic
stenosis ([**Location (un) 109**] 0.9 cm), PVD s/p b/l AKA, s/p renal transplant
(baseline Cr 1.2 to 1.4) who was admitted for hypotension and
nausea. PTA he had been in heart failure clinic on [**9-14**] where
SBP noted to be in 200's; his hydralazine dose was doubled and
his lasix dose increased. On presentation to ED SBP noted to be
60's pulse in 60s. Also Given INsulin/D50, Kayexalate, Ca for K
of 6.1. Started on dopa, central line placed. Given
vanc/levo/flagyl/hydrocort, 1 am Nabicarb. Pt admitted to MICU,
intubated. Started on 2 pressors for blood pressure support
with gentle IVF. Per cardiology service recommendations, a
Swan-Ganz catheter was placed to help determine etiology of
hypotension. Initial Swan numbers revealed elevated PCWP of 23,
PAP of 63/23, CVP 9, and SVR of 1300 consistent with cardiogenic
shock and L ventricular overload. Echo peformed on [**9-22**]
revealed no significant changes from prior with EF of 25%,
degree of AV stenosis was essentially unchanged. Pt weaned off
pressors and began lasix diuretic therapy for CHF exacerbation.
His estimated PCWP has trended down since then with creatinine
today 1.8 down from 2.2. Serial chest x-rays revealed resolving
pulmonary edema.
Pt also being followed by renal service for elevated creatinine
and for his status post renal transplant in [**2105**]. The patients
creatinine was elevated on admission but slowly trended back to
normal range by discharge. He was maintained on his
immunosuppressive therapy of azathioprine, prednisone, and
cyclosporine. Per his nephrologist Dr. [**First Name (STitle) **], his cyclosporine
levels were adequate. There was some concern for rejection on a
renal ultrasound but the patient's creatinine had returned to
his baseline
Pt was extubated [**9-30**]. Pt is now off pressors with stable
blood pressure, breathing normally on room air. Swan Ganz
catheter d/c'd [**2119-10-2**]. Last readings were PAP of 54/21 CVP
of 7. He was transferred to the floor. His stay was relatively
uneventful. His blood pressure was generally stable (SBPs in
100-110 range). His blood sugars were noted to trend downward
and was found to be 31 in morning of [**10-6**]. This resolved with
[**12-18**] Amp of D50 (to 131); his insulin sliding scale was converted
from regular to humalog; his NPH dosing was adjusted to 10 units
in the morning and 5 units at bedtime. Pt was also noted to
have a hematocrit that had trended down from 28 to 25 over the
prior week. Per renal service, this was felt to be secondary to
his renal disease and his Epogen was therefore doubled in
dosing; in addition, the patient received one unit of blood
before his discharge; blood was given with Lasix.
In summary, this is a 56 year-old type I diabetic male with 3
vessel CAD, ischemic cardiomyopathy with EF 25%, aortic
stenosis, s/p b/l AKA, admitted for hypotension after increases
in blood pressure medication and admitted to MICU for
hypotension, intubated for respiratory distress. Found to be in
cardiogenic shock necessitating pressor support and in CHF. Now
off pressors, blood pressure w.n.l. breathing on room air with
no sign of volume overload on physical exam. Infectious workup
has been unrevealing.
.
Issues and pal
1) Cardiovascular
.
Perfusion: Three vessel disease not amenable to PCI, not
candidate for CABG
-continue aspirin and plavix
-continue lipitor (40)
-started smaller dose of beta blocker (metoprolol 12.5)
.
Pump: EF 25%, aortic stenosis ([**Location (un) 109**] 0.9), CHF seems to be class
II. Status post cardiogenic shock--now resolved, appears
secondary to increase in his blood pressure medications.
-continue lasix at 40 mg PO BID
-continue digoxin at 0.0625 mg every other day, check digoxin
levels regularly
-avoid lisinopril given renal disease
-continue hydralazine at 25 mg PO TID
-please restart isordil and uptitrate as his pressure tolerates.
-will follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital1 **]
Outpatient Heart Failure service.
Rhythm: NSR occasional PVCs
-low EF, pt may benefit from ICD placement; per attending Dr.
[**Last Name (STitle) **], patient has declined this option understanding that he
remains at increased risk of SCD.
.
PVD: s/p b/l amputations
-continue aspirin and plavix
-will need physical therapy from extended hospital stay
.
2) Renal disease, s/p transplant, creatinine now at baseline
-continue azathioprine, cyclosporine, please have nephrologist
follow this patient. Dr.[**Name (NI) 4849**] is his primary nephrologist.
-CSA levels to be checked regularly
-if creatinine levels rise, please check renal ultrasound
-renally dose all medications
.
3) Anemia. Status post 1 pRBC transfusion prior to discharge
-have increased epogen from 4000 to 8000 qMWF
-monitor hct
-if pt needs further transfusion, please give Lasix (40 mg IV)
before and after transfusion to prevent volume overload.
.
4) Diabetes, (type I)
-In setting of renal insufficiency and renal transplant will
need to be on Humalog Sliding Scale. Also should continue NPH
10 units qAM, 5 units qPM.
.
5) FEN: Diabetic/cardiac healthy; please continue sodium and
fluid restriction.
.
6)Prophylaxis should include Hep SC, PPI
.
7) Code: Full
.
8) Disposition: Was seen by physical therapy who recommended
rehabilitation. Patient is being discharged to [**Hospital **]
[**Hospital **] Hospital.
Medications on Admission:
Prednisone 10 qod
Lipitor 40
Hydral 50 TID
Plavix
ASA
Enalapril 10 [**Hospital1 **]
Lasix 60/40
Toprol Xl 50
Imuran 50 qd
Isordil 20 tid
Cyclosporin 100/50
Ativan
Insulin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cyclosporine Modified 100 mg/mL Solution Sig: 0.25 mL PO Q PM
().
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD ().
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
Q AM ().
11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
13. Lorazepam 1 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
16. Insulin NPH Human Recomb Subcutaneous
17. insulin
For insulin, please give 10 units in the morning and 5 units at
bedtime.
Please use humalog sliding scale per attached flow sheet.
18. Digoxin 50 mcg Capsule Sig: 1.5 Capsules PO EVERY OTHER DAY
(Every Other Day).
19. Metoclopramide 5 mg/mL Solution Sig: One (1) mL Injection
Q6H (every 6 hours).
20. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) injection
Intravenous Q8H (every 8 hours) as needed for nausea.
21. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cardiogenic shock.
Congestive heart failure exacerbation/ischemic cardiomyopathy.
Aortic stenosis.
Coronary artery disease (three vessel disease)
Diabetes Type I.
Peripheral
Status post kidney transplant.
Discharge Condition:
Good. Now breathing normally on room air. Blood pressure
stable. No symptoms of dizziness or nausea. No chest pain.
Able to work with physical therapy for rehabilitation exercises.
Discharge Instructions:
Please return to hospital if you experience chest pain,
shortness of breath or palpitations.
Please return to hospital if you start becoming light-headed,
dizzy, and/or you feel like passing out.
Please return to hospital if pt becomes hypotensive.
Followup Instructions:
Patient is going to rehabilitation facility.
Please follow up with the [**Hospital3 **] Nephrology service.
Please coordinate care with his PCP and Nephrologist Dr.[**Doctor Last Name 4849**]
[**Telephone/Fax (1) 12847**].
Pt also to be followed up by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital3 **]
outpatient Heart Failure service.
|
0389,V420,486,4280,5849,25093,4148,41401,28521,4439,36900,99592 | 323 | 143,334 | Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-17**]
Date of Birth: [**2062-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
lethargy and hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
58 year old with history of ischemic cardiomyopathy (EF 20%),
severe 3 vessel coronary artery disease, type 1 diabetes,
chronic renal disease status post renal transplant in [**2103**] who
presents with lethargy and fever to 102.6. He had had decreased
ability to care for himself over the last few days with a
progressive nonproductive cough. He notes a dry nonproductive
cough. He denies chest pain, shortness of breath, nausea,
vomiting, diarrhea, or hematochezia.
Past Medical History:
1. Ischemic cardiomyopathy with EF 20%
2. Coronary artery disease with severe 3 vessel disease and not
a cabg candidate
3. Peripheral vascular disease status post bilateral above knee
amputation
4. Type 1 diabetes
5. Blindness
6. Complete occlusion of right ICA
7. Chronic renal insufficiecy renal xplant [**2103**]; baseline
creatinine 1.2-1.4
Social History:
He lives alone and Independent of ADL's. His sister is
extremely involved in his care and stays with him 4 times a
week. She sets up his medications, checks his glucose
fingersticks and draws up his insulin. He has a VNA nurse [**1-19**]
times per week when his sister is not there.
Family History:
Non-contributory
Physical Exam:
Vitals: Temperature:102.6 Pulse:67 Respiratory rate:25 Blood
pressure:90/50 Oxygen saturation:100% on non-rebreather
Gen: Frail, diaphoretic, chronically ill-appearing male in NAD
HEENT: Right eye enucleated
Neck: supple, JVP at ear, left carotid bruit
Pulm: anteriorly with crackles throughout, no wheezes
Cardiac: RR, nl. S1, S2, II/VI systolic murmur heard best USB
Abd: scaphoid, soft, NT/ND, normoactive bowel sounds
Ext: bilateral above knee amputations
Skin: warm, diaphorectic
Neuro: Sleeping but alert
.
Pertinent Results:
Hematology:
WBC-7.9 Hgb-10.1 Hct-30.8 Plt Ct-346
Neuts-87.8 Lymphs-5.8 Monos-5.5 Eos-0.8 Baso-0.2
.
Chemistries:
Glucose-117* UreaN-69* Creat-1.3* Na-138 K-4.4 Cl-102 HCO3-24
Calcium-8.9 Phos-2.2* Mg-1.9
.
LFTs:
ALT-40 AST-81 LD(LDH)-251 AlkPhos-116 Amylase-22 TotBili-0.7
.
Cardiac:
CK(CPK)-178 CK-MB-5 cTropnT-0.38
proBNP-[**Numeric Identifier 21050**]
IMAGING:
Chest x-ray: New moderate-to-severe pulmonary edema.
Brief Hospital Course:
This is 56 year-old male with severe ischemic cardiomyopathy (EF
20%) and Type 1 diabetes who presented with hypotension,
pulmonary edema, and fever to 102.6.
.
1. Hypotension/Fever: Etiology of his presentation was unclear.
His hypotension responded to fluid ressucitation and pressors.
He was intially treated with stress dose steroids, which were
stopped once he had a normal cortisol stimulation test.
Infectious work-up was negative with the exception of a possible
infiltrate on chest x-ray. Urinary legionella was negative. He
was treated with levofloxacin for presumed community acquired
pneumonia. He was discharged to complete a 14 day course of
levofloxacin.
.
2. Ischemic Cardiomyopathy: He had no evidence of acute
ischemia. He had 3 sets of cardiac enzymes that were negative.
He was maintained on his outpatient aspirin, plavix, statin, and
digoxin. His metoprolol was initially held given hypotension,
but was restarted prior to discahrge. Once he was no longer
hypotensive, he was restarted on his outpatient diuretics to
decrease his pulmonary edema. He diuresed well.
.
3. Chronic kidney disease: He is status post renal transplant.
His creatinine was initially slightly above his baseline and
that improved with fluid ressucitation. he was maintained on
cyclosporin (level therapeutic), azathioprine, and prednisone
for immunosuppression.
.
4. Diabetes: While in the intensive care unit, he required an
insulin drip for good glycemic control. Once on the floor, he
was restarted on his outpatient glargine at 26 units at night.
At the time, he was not eating regularly and he had problems
with hypoglycemia. His glargine was decreased to 6 units with
improvement in hypoglycemia. His glargine will need to be
increased back to 26 once he is eating regularly.
.
5. Anemia: He has anemia secondary to renal disease. He
receives epoeitin as an outpatient and did not received any
while an inpatient. He did receive 1 unit of red cells during
this admission.
.
6. FEN: Cardiac, low salt, diabetic diet. He had speech and
swallow evaluation that recommended a soft diet.
.
7. Code: full code
.
8. Dispo: He was discharged to an acute rehab
Medications on Admission:
MEDICATIONS AT HOME:
- metoprolol 12.5 mg b.i.d.
- hydralazine 25 mg t.i.d.
- digoxin 150 mg every other day (last [**2120-1-10**])
- Lipitor 40 mg once daily,
- azathioprine 50 mg qam
- prednisone 10 mg every other day (last dose [**2120-1-11**])
- cyclosporin 100 qam, 50 qpm
- Lasix 40 mg b.i.d.
- metoclopramide 5 mg q.i.d.
- Ativan 2 mg qam, 4 mg qhs
- Lantus insulin 26 units qhs
- Humalog insulin sliding scale
- Procrit 35,000 units,last given (Monday [**2120-1-7**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pneumonia.
Diabetes.
Renal disease status post-transplant.
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed and keep all follow-up
appointments.
.
Seek medical attention if you have fevers, chills, nausea,
vomiting, shortness of breath, chest pain, or anything else that
you find worrisome.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2120-2-26**]
9:00
Completed by:[**2120-1-17**] |
41071,41401,99762,7854,V420,51881,4280,2639,25051 | 323 | 192,631 | Admission Date: [**2115-5-17**] Discharge Date: [**2115-5-27**]
Date of Birth: [**2062-12-24**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old man
with diabetes type 1, for 40 years, complicated by
retinopathy with blindness, status post living donor kidney
transplant in [**2103**], status post bilateral BKAs with recent
stump revision on [**2115-5-8**], with prior known
.............. from catheterization in [**2108**], who presented
with chest pain on [**2115-5-17**], from [**Hospital6 3953**] admitted for unstable angina, as well as right stump
cellulitis.
The patient was treated with Ancef and Cipro per Infectious
Disease recommendations for the cellulitis. He was kept on
intravenous Heparin, Aspirin, Nitroglycerin drip,
beta-blocker over the weekend for unstable angina without
further chest pain or shortness of breath, awaiting prior
catheterization data which had reportedly shown
unintervenable ........... per the patient. His primary
cardiologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Laboratory showed a troponin on admission of 0.8 which
increased to 16.8 with negative CKs but positive MB fraction.
On the morning of [**2115-5-20**], the patient had sudden
shortness of breath, diaphoresis, nausea and vomiting. He
was found to be hypoxic with an oxygen saturation in the 60s,
on 100% non-rebreather, systolic blood pressure 150-160,
heart rate 80-90s. His electrocardiogram showed hyperacute
T-wave anteriorly, ST depressions in V2-V4, and chest x-ray
was consistent with failure. The patient was given Lasix 40
IV x 1, with 500 cc urine output. He was given 1 amp of
Calcium Gluconate and was started on intravenous
Nitroglycerin with improvement in his electrocardiogram
changes.
ABG was done which showed pH of 7.18, pCO2 73, pO2 46. The
patient was intubated on the floor emergently. The decision
was made to take him to Cardiac Catheterization for acute
coronary event. Bedside echocardiogram revealed an ejection
fraction of less than 20-25%, inferior akinesis, and
anterolateral hypokinesis. In the Catheterization Lab, his
coronaries were diffusely diseased. The patient had been
previously turned down for a coronary artery bypass grafting,
but CT Surgery was reconsulted and again did not feel that he
would be a good operative candidate. ..................
requested a second CT Surgery opinion which was prior to
recathaterization to attempt LAD intervention. This was
obtained, and again several CT surgeons did not feel that he
would be a good operative candidate secondary to high risk,
lack of good touchdown, and lack of vein grafts secondary to
his previous surgeries.
Otherwise in the CCU, the patient was diuresed and extubated
on [**2115-5-21**], without complication. His creatinine was
slightly increased with this event. His Captopril was
temporarily discontinued, and diuresis was continued. He was
on continued antibiotics for stump cellulitis.
LABORATORY DATA: His initial lab data at the time of
transfer back to the [**Hospital Unit Name 196**] Service on [**2115-5-23**], showed a
white count which was 19.1, hematocrit 30.0, platelet count
466,000; INR 1.1, PTT 58.0; sodium 128, potassium 4.3,
chloride 93, bicarb 23, BUN 78, creatinine 1.8, glucose 255,
CK 45, calcium 8.5, magnesium 2.2, phosphorus 4.2;
cyclosporin level was normal at 151.
Cardiac catheterization showed RA pressure of 9, RV was
40/10, RA 40/21, wedge pressure 21, SER 1390, cardiac index
of 3.0. He had 100% proximal RCA lesion, normal PDA, left
main was normal, mid LAD had a tubular 90% lesion, distal LAD
40% lesion, D1 70%, D2 99%, OM1 70%. Echocardiogram showed a
................. ASD with left-to-right shunt seen, left
ventricular size and thickness normal. There were multiple
areas of akinesis and hypokinesis. There was a hypertrophied
right ventricular free wall with normal right ventricular
function. There was a small amount of mitral regurgitation,
small to moderate pericardial effusion, and a right pleural
effusion noted.
MEDICATIONS ON TRANSFER: Cyclosporin 100 mg b.i.d.,
Neurontin 100 mg t.i.d., Lipitor 20 mg q.d., Fentanyl patch
25 q.72, sliding scale Insulin, Cefazolin IV, Cipro 500 q.d.,
Mucomyst 600 b.i.d., Colace 100 b.i.d., Lasix 80 p.o. b.i.d.,
Lopressor 75 mg p.o. b.i.d., Prednisone taper, Zantac,
Enteric Coated Aspirin q.d., NPH 4 U subcue at 6:30 a.m. and
4:30 p.m.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PAST MEDICAL HISTORY: As above. He is also with
hypertension, hyperlipidemia, diabetes, peripheral vascular
disease, status post bilaterally BKAs, chronic angina,
legally blind since [**2090**].
SOCIAL HISTORY: The patient is married. His wife is also
blind. He has two daughters. [**Name (NI) **] was recently in the nursing
home.
HOSPITAL COURSE: 1. Cardiovascular issues: He was turned
down for coronary artery bypass grafting. He was taken for
re-catheterization on [**2115-5-24**], and he had PTCA stent
placement to LAD. In addition to his other cardiac
medications, Heparin was discontinued, and he was started on
Plavix x 1 month. He was continued on Aspirin, beta-blocker,
Lipitor, Lasix, and his ACE inhibitor was restarted prior to
discharge given his normal renal function.
2. Pulmonary: He was able to be weaned off his oxygen with
good room air saturations and was continued on
............... 6 b.i.d. without p.r.n. doses needed.
3. Renal insufficiency: The patient had resolving BUN and
creatinine with a creatinine of 1.1 on discharge. He did
well continuing on his Cyclosporin for status post renal
transplant.
4. From a vascular and infectious disease standpoint
concerning his most pressing issue currently, he is continued
on antibiotics for stump cellulitis. An Infectious Disease
consult was requested, as the area of cellulitis spread with
dry gangrene setting in. They did not feel that he was
septic or toxic and that this most likely represented stump
failure. Vascular was consulted, and they too agreed that
this was most likely not primarily an infectious process but
represented a failure of the stump revision. This was
discussed at length with the patient who wished to pursue
further surgery at [**Hospital6 1597**] where he had been with
the same surgeon for 20 years. We discussed this with the
covering surgeon who agreed to accept him for evaluation.
His need for surgery will have to be balanced against his
recent cardiac catheterization, as he would be at very, very
high risk for reclosure of his LAD stent if his Aspirin or
Plavix were to be discontinued at all, and Cardiology
recommended strongly that the Aspirin nor Plavix should be
held for even a day or two given his high risk and the very
narrow caliber of the LAD stent.
DISCHARGE MEDICATIONS: ................ t.i.d., Captopril
12.5 t.i.d., Hydralazine 10 mg p.o. q.i.d., Tylenol 650 mg
p.o. q.4 hours p.r.n., Aspirin 325 p.o. q.d., Plavix 75 mg
p.o. q.d. x 30 days, Insulin NPH 14 U q.a.m. and 10 U q.p.m.,
Cyclosporin 100 mg p.o. b.i.d., Neurontin 100 mg p.o. t.i.d.,
Lipitor 20 mg p.o. q.d., Fentanyl patch 25 mg q.72 hours,
sliding scale Insulin, Cefazolin 1 g q.12 IV, Lopressor 75 mg
p.o. b.i.d., Lasix 80 mg p.o. q.d., Prednisone taper which is
now down to 10 mg p.o. q.d. which is his baseline dose status
post kidney transplant, Colace 100 mg p.o. b.i.d., Zantac 150
mg p.o. b.i.d., Cipro 500 mg p.o. b.i.d.
FOLLOW-UP: The patient should follow-up with his primary
cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one month. He will be
evaluated at the [**Hospital **] Hospital for possible AKA.
Cardiology recommended that the surgery be done emergently as
our Vascular surgeons feel that it should be postponed for
two weeks to one month until the Plavix can be discontinued,
as it is imperative that the Aspirin and Plavix not be
stopped even for an operation, as he at high risk for stent
reclosure.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 21042**]
MEDQUIST36
D: [**2115-5-27**] 10:44
T: [**2115-5-27**] 11:59
JOB#: [**Job Number **]
|
1520,1977,1962,2851,4240 | 325 | 155,989 | Admission Date: [**2190-1-5**] Discharge Date: [**2190-1-16**]
Date of Birth: [**2132-6-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Metastatic duodenal cancer
Major Surgical or Invasive Procedure:
OPERATIVE PROCEDURE:
1. Pylorus-preserving pancreaticoduodenectomy.
2. Open cholecystectomy.
3. Right hepatic lobectomy
History of Present Illness:
Dr. [**Known lastname 107769**] is a 57-year-old patient with a known adenocarcinoma
in the duodenum causing recurrent gastrointestinal bleeding and
recurrent anemia. She has had exhaustive preoperative evaluation
which has demonstrated also the presence of a single metastasis
in the liver. For palliation, if not curative ntent, I
recommended that she undergo a combined Whipple procedure to try
to get the primary tumor out to eliminate the bleeding and
impending obstruction of the duodenum. I also convened with Dr.
[**Last Name (STitle) **] of our hepatobiliary surgery team to consider resection of
the metastatic disease in the liver, as there is no other
evidence of systemic metastases.
Past Medical History:
PAST MEDICAL HISTORY: Significant only for known cyst in the
breast.
Brief Hospital Course:
Patient went to the operating room on [**2190-1-5**]. Please see the
OMR note for operative details. There were no unanticipated
intra-operative complications, and the patient lost
approximately one liter of blood and received three units PRBCs
during the procedure. 2 19-French [**Doctor Last Name 406**] drains were placed to
liver bed and pancreatic biliary anastomoses locations.
Post-operatively she went to the surgical ICU. Her pain was
controlled with epidural and PCA. On POD1 INR was 2.0 and the
patient received 2 units of FFP. POD1 liver US also demonstrated
normal spectral analysis and color Doppler evaluation of the
vasculature of the residual left hepatic lobe. On POD2 she
received another 2 units FFP for INR 1.9, and since
transaminases remained elevated another liver ultrasound.
Ultrasound was normal-"Again, seen are widely patent main and
left portal veins with appropriate direction of flow. The left
hepatic vein and hepatic artery are also patent and patency
and appropriate direction of flow. Again, the left hepatic
artery demonstrates a resistive index of 0.60. There is no
biliary ductal dilatation. here is no free fluid. The inferior
vena cava is widely patent." POD3 the G-tube was clamped and
half-strength J-tube feedings were begun. Patient was also
transferred out of the unit to the floor on POD3. TF were slowly
advanced and on POD4 she was advanced to sips as well as
transitioned to oral pain medications. Foley catheter was
removed from the bladder on POD5 and tube feeds were cycled at
night. Lasix was given on POD5 and the patient began to mobilize
significant fluid accumulation, especially in the lower
extremities. By POD5 she was also tolerating full liquids and
was doing well ambulating around the floor and working with
physical therapy. Her central line was removed on POD6 and she
was transitioned to all oral medications per the "Whipple
Protocol". Her electrolytes were aggressively repleted and
intermittent doses of lasix were helpful in gaining euvolemia.
She continued to have some trouble with nausea that was
controlled with antiemetics but was troublesome nonetheless. JP
drains were removed before discharge, and the patient was begun
on a 7 day course of cefazolin for a superficial cellulitis. She
was discharged to home with services on POD10. She was afebrile,
tolerating a full diet and ambulating without difficulty. Her
wounds were healing nicely and she was instructed on proper G
and J tube care. She has follow-up as outlined below.
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. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*100 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO once a day.
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic duodenal cancer
Discharge Condition:
Stable
Discharge Instructions:
Please call the office or the emergency room if you develop
fever greater than 101.5, your wounds become red, swollen or
begin draining pus or you develop severe nausea or vomiting.
Please take the full 7 day course of antibiotics, as well as all
other medications prescribed.
Do not drive while taking narcotic pain medications, and use a
stool softener such as colace while you are taking the pain
medication.
You may shower when you get home but avoid tub bathing for 3
weeks.
No heavy lifting or activity for at least 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in the office in [**2-8**] weeks.
Please call ahead of time to make an appointment. ([**Telephone/Fax (1) 27734**].
Completed by:[**2190-3-10**] |
E8500,96501,2920,30471,E8490,9701,E8543 | 326 | 188,926 | Admission Date: [**2118-11-1**] Discharge Date: [**2118-11-5**]
Date of Birth: [**2076-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Altered MEntal Status
Major Surgical or Invasive Procedure:
Lumbar puncture (X 2)
History of Present Illness:
41yo M with history of drug abuse who presents with altered
mental status. History is obtained from mother.
.
According to his mother, patient was arrested last tuesday for
possession of drug. SHe was however not aware of the kind of
drug that he possessed. He was in jail and was released on
probation on Wednesday. He admits to taking 2 tablets of
Saboxone on Saturday prior to seeing his daughter on Saturday as
he does not want to appear sick while seeing his daughter. [**Name (NI) **]
then returned to his mothers home on [**Name (NI) 766**] night feeling unwell
and stayed with his mother overnight. On morning of admission,
he woke up feeling unwell. His mother noticed that he became
more disoriented as the day goes by. His gait became unsteady
and he had slurred speech. There was no alcohol in his breath
and his mother was pretty sure that he has been sober. He was
intermittently agitated but not violent. He took 3 tablets of
Soboxone to "prevent sickness". Of note, he has been having
diarrhea and muscle ache for 1 day. His mother reported that he
was diaphoretic on the way to the addiction clinic. He however
denies
n
a
u
s
e
a
/
v
o
m
i
t
i
n
g
/
l
a
crimation/rhinorrhea/headache/photophobia/halucination/flushing.
His mother brought him to the addiction center and then he was
sent straight to the ED because of altered mental status.
Past Medical History:
Drug dependency
Social History:
Drug abuse
Lives in [**Hospital1 3597**] by himself. He has a 6 year old daughter who is
under the care of her grandparents. He is unemployed most of the
time, did some odd job from time to time and financially
supports himself.
Family History:
NC
Physical Exam:
T 101.2 P122 BP122/87 R18 100% on RA
Gen- intubated, sedated, in C collar
HEENT- pupils 2mm bilaterally, reactive to light, anicteric,
oropharynx moist, neck in C collar
CV- rrr, no r/m/g
resp- CTAB from anterior
abdomen- active BS, obese abdomen
extremities- in 4 point restraint, no edema
Pertinent Results:
[**2118-11-1**] 10:28PM CEREBROSPINAL FLUID (CSF) PROTEIN-98*
GLUCOSE-89
[**2118-11-1**] 10:28PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-[**Numeric Identifier 22397**]*
POLYS-70 LYMPHS-30 MONOS-0
[**2118-11-1**] 10:28PM CEREBROSPINAL FLUID (CSF) WBC-25 RBC-[**Numeric Identifier 62617**]*
POLYS-68 LYMPHS-32 MONOS-0
[**2118-11-1**] 09:14PM PO2-274* PCO2-39 PH-7.43 TOTAL CO2-27 BASE
XS-2
[**2118-11-1**] 08:56PM LACTATE-1.1
[**2118-11-1**] 07:40PM URINE HOURS-RANDOM
[**2118-11-1**] 07:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
Cultures of CSF and Blood w/o growth
[**2118-11-1**] 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEGATIVE barbitrt-NEGATIVE tricyclic-POS
[**2118-11-1**] 07:20PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-3.7
MAGNESIUM-2.1
Brief Hospital Course:
41yo M with drug abuse, history of opioid withdrawal admitted
for altered mental status
.
1) Mental status changes
Pt had LP x2 and was extubated with no resiudual mental status
changes
- LP results were negative including Cx
- Fever, altered mental status, diarrhea, diaphoresis, muscle
aches c/w opiod withdrawal, especially given history of
oxycontin use and urine tox positive for opiates, recent use of
suboxone, and history of prior withdrawal symptoms. Continued
methadone.
- addiction consult ordered, pt was unwilling to start [**Hospital 17073**]
rehab
.
2) Respiratory Distress
- Intubated for airway protection. Pt extubated without
complications. Respirtory status stable on discharge.
Medications on Admission:
None
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for agitation for 3 days: take 1-2 tablets every 4
hours as needed for agitation for the first day. Take 1 tablet
every 4 hours as needed on the second day. Take [**1-30**] tablet every
4 hours as needed on the third day.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
altered mental status with respiratory distress
Secondary:
drug abuse
Discharge Condition:
Stable, alert, oriented, respiratory status stable with no
supplemental O2 requirement.
Discharge Instructions:
Please call your doctor or return to the hospital if you have
any changes in your mental status or feel confused, have any
trouble breathing, chest pain, fever and chills, severe
headache, or any other health concern.
Please taper your ativan as directed.
Please follow up with Dr. [**Last Name (STitle) **] (or another physician) in
clinic at [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 191**] clinic.
Followup Instructions:
Please call [**Hospital 191**] clinic at [**Hospital3 **] Hospital at [**Telephone/Fax (1) 250**]
for an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (or any
available physician) within the next 7-10 days to follow up on
your health and final laboratory results.
|
41041,4260,496,2762,41401,41402,25000,4019,53081 | 328 | 121,438 | Admission Date: [**2149-12-19**] Discharge Date: [**2149-12-22**]
Date of Birth: [**2083-12-2**] Sex: M
Service: Cardiac Intensive Care Unit
HISTORY OF PRESENT ILLNESS: Patient is a 66-year-old Spanish
speaking male with a past medical history significant for
type 2 diabetes mellitus, congestive obstructive pulmonary
disease, and coronary artery disease status post three vessel
coronary artery bypass graft in [**2147**], PTCA and stenting of
the right coronary artery in [**2148-9-21**], PTCA of the
left anterior descending artery in [**2149-7-21**], and inferior
wall myocardial infarction with right ventricular infarction
in [**2149-10-21**] with subsequent PTCA and stenting of the
proximal right coronary artery, who presents with an episode
of acute onset [**10-30**] substernal chest pain.
The patient reports acute onset of substernal chest pain with
radiation down both arms. The pain began approximately one
hour prior to presentation. Pain was associated with nausea,
syncope, diaphoresis, shortness of breath, and chills. The
patient was transported to the Emergency Department by EMS
and on route, was found to have a blood pressure of
60/palpation and complete heart block with a ventricular rate
of 36.
In the Emergency Department, the patient complained of
persistent chest pain and was found to have a blood pressure
of 92/50, heart rate 37, and oxygen saturation of 100% on a
100% nonrebreather. The patient's initial electrocardiogram
demonstrated complete heart block with a sinus rate of 60 and
junctional rate of 38, with ST elevations in the inferior
leads and reciprocal ST depressions laterally. The patient
also demonstrated [**Street Address(2) 2051**] elevation in right sided lead V4
consistent with right ventricular infarct.
The patient was started on Integrilin and Heparin and sent
for emergent cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease with three-vessel disease status
post coronary artery bypass graft surgery in [**2147**] with LIMA
to the left anterior descending artery, saphenous vein graft
to the OM, and saphenous vein graft to the posterior
descending artery. Also status post right coronary artery
stenting x2 in [**2148-9-21**], status post left anterior
descending artery PTCA in [**2149-7-21**] (80% stenosis distal
to the LIMA touchdown), status post inferior wall myocardial
infarction in [**2149-10-21**] with PTCA and stenting of a
proximal right coronary artery total occlusion; the inferior
wall myocardial infarction was just complicated by a right
ventricular infarction with hypotension requiring intraaortic
balloon pump and pressors.
2. Type 2 diabetes.
3. Gastroesophageal reflux disease.
4. Congestive obstructive pulmonary disease.
5. Hypertension.
6. Hypercholesterolemia.
ALLERGIES: ACE inhibitor with a reaction of cough.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po q day.
2. Lipitor 10 mg po q day.
3. Lopressor 50 mg po bid.
4. Insulin 75-25 66 units q am, 30 units q pm.
SOCIAL HISTORY: The patient is married and lives with his
wife. The patient reports prior tobacco use, quit five years
ago.
FAMILY HISTORY: Noncontributory.
EXAM ON ADMISSION: VITAL SIGNS: Temperature 98.8, heart
rate 79, blood pressure 123/80, respiratory rate 16 with an
oxygen saturation of 95% on room air. In general, the
patient is an obese male lying at 30 degrees in no acute
distress. HEENT: Normocephalic, atraumatic. Anicteric
sclerae. Pupils are equal, round, and reactive to light and
accommodation. Clear oropharynx, dry mucous membranes. Neck
examination: Notable for elevated jugular venous distention
with no lymphadenopathy, supple. Pulmonary examination
notable for expiratory wheezes predominantly on the right,
otherwise clear to auscultation. Cardiovascular examination:
Regular, rate, and rhythm with normal S1, S2, S4 with no
murmurs or rubs. Abdominal examination: Obese, soft,
nontender, nondistended.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2149-12-26**] 13:38
T: [**2149-12-30**] 11:00
JOB#: [**Job Number **]
|
41041,99672,78551,4260,486,99812,496,41401,41402 | 328 | 146,586 | Admission Date: [**2149-10-31**] Discharge Date: [**2149-11-6**]
Date of Birth: [**2083-12-2**] Sex: M
Service: CCU
CHIEF COMPLAINT: Cardiogenic shock, status post acute
inferior myocardial infarction.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
a history of diabetes and coronary artery disease (status
post coronary artery bypass graft times three in [**2147-5-22**],
status post right coronary artery stent times two in
[**2148-9-21**], and status post percutaneous transluminal
coronary angioplasty of the left anterior descending artery
in [**2149-7-21**]) who presented with 10/10 chest pain
(persistent pressure similar to his past acute myocardial
infarction) starting around 8 o'clock in the morning on the
day of admission.
He was seen in his primary care physician's office and was
sent to the Emergency Room directly. In the Emergency Room,
his temperature was 98.3, blood pressure was 183/65, pulse
was 94, respiratory rate was 12, and oxygen saturation was
97% on room air. His initial electrocardiogram was
unremarkable. He was given sublingual nitroglycerin for his
chest pain. However, in the Emergency Room, his systolic
blood pressure dropped to the 50s and heart rate went down to
the 40s. His repeat electrocardiogram showed high-grade
atrioventricular block with acute inferior myocardial
infarction. He was given atropine and dopamine for
bradycardia and hypotension in the Emergency Room, and he
went into supraventricular tachycardia.
He was brought to the catheterization laboratory directly for
percutaneous transluminal coronary angioplasty. During the
catheterization, an intra-aortic balloon was placed for blood
pressure support, and he was intubated for airway protection.
He also required pressors including Neo-Synephrine and
dopamine during the catheterization. A transvenous temporary
pacing wire was also placed during the catheterization. His
proximal right coronary artery (which was totally occluded
with thrombus) was successfully stented with normal flow. At
the end of the catheterization, his heart rate remained
stable off pacer, and blood pressure remained stable off
pressors. He was transferred to the Coronary Care Unit for
monitoring.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post 3-vessel coronary
artery bypass graft in [**2147-5-22**]; status post right
coronary artery stent in [**2148-9-21**]; and status post
percutaneous transluminal coronary angioplasty of left
anterior descending artery in [**2149-7-21**].
2. Diabetes.
3. Hypercholesterolemia.
4. Chronic obstructive pulmonary disease.
6. Gastroesophageal reflux disease.
7. Hypertension.
MEDICATIONS ON ADMISSION: Insulin 75/25 50 units q.a.m. and
30 units q.p.m., Imdur 10 mg p.o. t.i.d., Cozaar 25 mg p.o.
q.d., Lopressor 100 mg p.o. b.i.d., Zantac 150 mg p.o.
b.i.d., Lipitor 20 mg p.o. q.d., aspirin.
ALLERGIES: ACE INHIBITOR (cough).
SOCIAL HISTORY: He stopped smoking five years ago.
FAMILY HISTORY: Denies coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to catheterization laboratory revealed
temperature was 96.9, blood pressure was 136/71, heart rate
was 133. In general, intubated and sedated, responsive to
painful stimuli. Cardiovascular examination revealed normal
first heart sound and second heart sound, tachycardic. Lungs
revealed breath sounds were equal bilaterally. The abdomen
was soft, nontender, and nondistended. Extremities revealed
distal pulses bilaterally by Doppler. Left groin arterial
and venous sheaths with intra-aortic balloon pump and
Swan-Ganz catheter.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed white blood cell count was 9.6, hematocrit was 48.4,
platelets were 179. PT was 13.5, PTT was 25.5, INR was 1.3.
Sodium was 136, potassium was 4.5, chloride was 95,
bicarbonate was 31, blood urea nitrogen was 9, creatinine
was 0.7, and blood glucose was 414. Calcium was 8.7,
magnesium was 1.5, phosphate was 4.2. Albumin was 3.9, total
bilirubin was 0.7, ALT was 20, AST was 14, alkaline
phosphatase was 85, lipase was 13, amylase was 24, LD
was 196, creatine kinase was 45 (which later peaked at 1081).
Arterial blood gas revealed 7.31/47/358 on ventilator with
FIO2 of 0.8.
RADIOLOGY/IMAGING: Electrocardiogram revealed ST elevations
in II, III, and aVF; ST elevations in I and aVL; right-sided
electrocardiogram showed ST elevations in leads V2 through
V6.
Catheterization in [**2148-9-21**] revealed 3-vessel
coronary artery disease, patent left internal mammary artery
to left anterior descending artery, and saphenous vein graft
to obtuse marginal. Total occlusion of saphenous vein graft
to right coronary artery. Normal ejection fraction of
about 60%. Successful percutaneous transluminal coronary
angioplasty and stenting of the distal right coronary artery
and direct stenting of the mid right coronary artery.
Catheterization in [**2149-7-21**] revealed 2-vessel coronary
artery disease, patent left internal mammary artery to left
anterior descending artery and saphenous vein graft to obtuse
marginal. Severe diastolic dysfunction. Successful
percutaneous transluminal coronary angioplasty of 80% left
anterior descending artery stenosis just distal to the
anastomosis. Ejection fraction was about 70%.
Catheterization on admission revealed left main coronary
artery was normal, left anterior descending artery with
severe proximal disease, left circumflex was nondominant with
total occlusion of the first obtuse marginal. Right coronary
artery was dominant vessel with proximal total occlusion with
thrombus. The proximal right coronary artery was
successfully stented. Right heart catheterization showed
right atrial mean pressure of 19, pulmonary artery pressure
of 57/40, with a mean pressure of 49, wedge of 28.
HOSPITAL COURSE: He was weaned off pressors and intra-aortic
balloon pump quickly in the Coronary Care Unit. Metoprolol
and Cozaar were added as his blood pressure tolerated. The
18-hour course of post catheterization Integrilin had to be
stopped prematurely due to epistaxis. He also developed
severe laryngeal edema secondary to traumatic intubation on
admission. He was evaluated by Ear/Nose/Throat and treated
with a dose of intravenous Solu-Medrol with significant
improvement. He was extubated on hospital day five without
any difficulty. He was also treated with a 7-day course of
Levaquin for possible aspiration pneumonia given the
prolonged course of intubation and a low-grade temperature.
His cardiac enzymes trended downward throughout the hospital
stay with a peak creatine kinase of 1081 and CK/MB of 125.
Repeat echocardiogram showed inferoseptal hypokinesis with an
ejection fraction of 55%. No evidence of ventricular septal
defect.
On the day of discharge, he was evaluated by Physical Therapy
and deemed stable to go home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Status post acute inferior myocardial infarction with
right ventricular infarct; status post proximal right
coronary artery stent.
2. Diabetes.
3. Chronic obstructive pulmonary disease.
4. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Insulin 70/30 50 units q.a.m. and 30 units q.p.m.
2. Aspirin 325 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. (for 30 days).
4. Lipitor 10 mg p.o. q.d.
5. Metoprolol 50 mg p.o. b.i.d.
6. Levofloxacin 500 mg p.o. q.d. (for three more days).
DISCHARGE FOLLOWUP: Follow-up appointment with primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (telephone number [**Telephone/Fax (1) 1792**]) on
[**2149-11-11**] at 1:20 p.m. Dr. [**First Name (STitle) **] will arrange for
the patient to see his outpatient cardiologist, and
outpatient cardiac rehabilitation will be arranged.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2149-11-8**] 20:27
T: [**2149-11-12**] 08:00
JOB#: [**Job Number 106713**]
|
5718,42789,5762,99591,5715,27651,07032,1970,1550,5761,0389,99682,E8780,E8499,V5869,V1582,V1209,53550,2841 | 329 | 172,132 | Admission Date: [**2154-4-5**] Discharge Date: [**2154-4-9**]
Date of Birth: [**2102-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
RUQ pain and fevers x 1 day
Major Surgical or Invasive Procedure:
ERCP s/p CBD stent
History of Present Illness:
51 yo male with Hep B and C s/p liver trx from [**Country **] 1 year ago
and now new dx of likely HCC now with fevers to 105, right upper
quadrant abdominal pain. Denies nausea, vomiting, or diarrhea.
He had similar presentation in [**3-20**]/0707 and underwent ERCP and
was found to have a stricture in the CBD exchange of stent.
ROS
No night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, rhinorrhea or congestion. Reported cough x 1
day. Denies shortness of breath. Denied chest pain or tightness,
palpitations. Has been having 2 bm/ day no change. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias
Past Medical History:
1. Hepatocellular carcinoma diagnosed in [**12/2152**] with multiple
tumors; patient was not a candidate for transplant in US so had
an orthotopic transplant in [**Country 651**] [**5-/2153**] - f/u by Dr. [**Last Name (STitle) 497**] the
liver center.
2. Hepatitis B, diagnosed in [**2149**] - last viral load:
undetectable [**2154-2-21**]
3. Hepatitis C, diagnosed in [**2149**] - viral load undetectable in
[**12-26**]
His hepatitis B surface antibody was positive in the range of
1:450 on [**2154-3-28**]. His last alpha-fetoprotein level was
53.2 with an L3 fraction of 44.1 on [**2154-2-21**]. His last
HBV viral load was nondetectable in [**2154-2-21**].
4. Subcapsular liver fluid collection status post biopsy on
[**2153-12-27**]
5. Recent CT imaging in [**3-27**] demonstrates multiple lung nodules
in lungs concerning for recurrence with AFP rising to >60 in
[**2-27**].
6. Recurrent c diff [**2154-2-11**] and [**2153-12-31**]
Social History:
He was a bus driver until the diagnosis of his hepatocellular
carcinoma. He has been in the US since [**2145-7-21**] and is
originally from [**Country 3992**]. He smoked half a pack a day for 35
years, but quit about 8 months ago. He denies any alcohol use or
any IV drug abuse. He has 4 children who are all healthy. He
lives at home with his wife and family.
Family History:
No family history of liver disease, diabetes, or cardiovascular
disease.
Physical Exam:
VS T 102 upon arrival to MICU and Tm = 105 in ED P = 117, BP =
146/70 RR O2Sat = 100% 3L
GENERAL: Diaphoretic but not in acute distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, 2/6 SEM at LUSB noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
Pertinent Results:
[**2154-4-5**] 01:30PM BLOOD WBC-5.4# RBC-4.08* Hgb-12.7* Hct-37.0*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.1 Plt Ct-144*
[**2154-4-6**] 05:16AM BLOOD WBC-6.7 RBC-3.81* Hgb-12.1* Hct-33.7*
MCV-89 MCH-31.8 MCHC-35.9* RDW-14.3 Plt Ct-118*
[**2154-4-7**] 01:22AM BLOOD WBC-3.2*# RBC-2.82*# Hgb-9.1* Hct-24.9*#
MCV-89 MCH-32.3* MCHC-36.5* RDW-14.3 Plt Ct-74*
[**2154-4-7**] 09:08AM BLOOD WBC-2.5* RBC-3.27* Hgb-10.4* Hct-30.1*
MCV-92 MCH-31.8 MCHC-34.5 RDW-13.9 Plt Ct-70*
[**2154-4-8**] 04:11AM BLOOD WBC-2.3* RBC-3.15* Hgb-10.0* Hct-28.2*
MCV-90 MCH-31.8 MCHC-35.5* RDW-14.2 Plt Ct-79*
[**2154-4-9**] 05:07AM BLOOD WBC-3.0* RBC-3.41* Hgb-10.7* Hct-30.1*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.3 Plt Ct-105*
[**2154-4-5**] 01:30PM BLOOD Glucose-109* UreaN-11 Creat-1.0 Na-135
K-4.7 Cl-100 HCO3-23 AnGap-17
[**2154-4-5**] 09:30PM BLOOD Glucose-132* Na-135 K-3.7 Cl-103 HCO3-21*
AnGap-15
[**2154-4-6**] 05:16AM BLOOD Glucose-112* UreaN-10 Creat-1.1 Na-136
K-3.6 Cl-105 HCO3-21* AnGap-14
[**2154-4-7**] 01:22AM BLOOD Glucose-121* UreaN-10 Creat-0.9 Na-138
K-3.4 Cl-111* HCO3-18* AnGap-12
[**2154-4-7**] 09:08AM BLOOD Glucose-116* UreaN-9 Creat-0.8 Na-140
K-3.6 Cl-113* HCO3-18* AnGap-13
[**2154-4-8**] 04:11AM BLOOD Glucose-97 UreaN-6 Creat-0.7 Na-139 K-3.7
Cl-111* HCO3-20* AnGap-12
[**2154-4-9**] 05:07AM BLOOD Glucose-119* UreaN-6 Creat-0.8 Na-141
K-3.6 Cl-112* HCO3-22 AnGap-11
[**2154-4-5**] 01:30PM BLOOD ALT-40 AST-73* Amylase-73 TotBili-0.6
[**2154-4-5**] 09:30PM BLOOD ALT-36 AST-53* LD(LDH)-274* AlkPhos-72
TotBili-0.9
[**2154-4-6**] 05:16AM BLOOD ALT-35 AST-48* LD(LDH)-273* AlkPhos-68
TotBili-1.1
[**2154-4-7**] 01:22AM BLOOD ALT-32 AST-44* AlkPhos-56 Amylase-70
TotBili-0.7
[**2154-4-7**] 09:08AM BLOOD ALT-31 AST-42* AlkPhos-54 Amylase-71
TotBili-0.5
[**2154-4-8**] 04:11AM BLOOD ALT-28 AST-35 AlkPhos-55 Amylase-67
TotBili-0.4
[**2154-4-9**] 05:07AM BLOOD ALT-26 AST-35 AlkPhos-65 TotBili-0.4
ERCP:
1.The major papilla was located in the second part of the
duodenum with an existing plastic stent within. 2.This was
removed and the papilla was cannulated to access the CBD.
3.Previous sphincterotomy was noted.
4.There was pus draining from the duct on removal of the stent.
5.The CBD was moderately dilated with an anastomotic stricture
as noted previously in the mid CBD.
5.The intrahepatic /CHD above the stricture were only mildly
dilated as previously.
6.The anastomotic stricture was dilated to 6mm using a hurricane
balloon.
7.Two Cotton [**Doctor Last Name **] biliary stents (10Fr x 10cm and 10 F X 12 cm)
were placed successfully across the stricture in the CBD.
8.There was good drainage of bile into the duodenum.
CT abd/pelvis:
1. No definite cause for abdominal pain or fever identified.
2. Biliary stent spans the length of the common duct. No
biliary ductal
dilatation.
3. Tiny amount of residual subcapsular fluid around the hepatic
dome is
significantly improved.
4. Fatty infiltration of the liver with areas of sparing.
5. No change in 4-mm nodules at the base of the right lower
lobe and lingula.
6. Long appendix with top normal caliber of 6mm appears similar
to [**2153-12-25**].
No periappendiceal inflammation or fluid.
RUQ u/s:
1. No abnormalities identified to explain the patient's
symptoms.
2. Redemonstration of 1.3-cm left hepatic lesion. Followup MRI
in four to six months from the prior MRI is recommended.
CXR: Heart size is normal, and there is no mediastinal or hilar
abnormality. The lungs are clear, and there is no pleural
effusion or pneumothorax.
CXR:
Brief Hospital Course:
51 yo man with Hep B/C cirrhosis and HCC s/p liver tx in [**Country 651**]
presents with ascending cholangitis. Now post-ERCP with changing
of biliary stent.
## Ascending cholangitis: pt s/p ERCP with changing of biliary
stent. Had frank pus draining after stent was pulled. Now on
levo, metronidazole. Changed to PO and discharged on 14-day
course. Pt remained afebrile and clinically stable afterward.
## Cirrhosis s/p liver tx: Has multiple pulmonary nodules
concerning for recurrent HCC. His MMF was held out of concern
for malignancy. His sirolimus was decreased to 2 qd, and his
prednisone was continued. He was scheduled for a PET-CT and f/u
with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 497**].
## Hep B: Continued entecavir
## Pulmonary nodules: ? HCC mets. Scheduled for outpt PET-CT and
f/u appointments with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 497**]. His MMF was
discontinued.
## Panctyopenia: ? immunosuppressives, Bactrim was discontinued
Medications on Admission:
Entecavir 0.5 mg qam
- rapamycin 3 mg qd
- CellCept [**Pager number **] mg b.i.d. d/c'ed yesterday to minimized the
amount of immunusuppression given recurrence of his cancer
- Bactrim single strength 1 tablet 3 times per week, M/W/F
- hepatitis B immunoglobulin with last shot on [**2154-3-6**], and s/p hep B IgG on [**2154-4-3**]
- Prilosec
- oxycodone 5 prn
Discharge Medications:
1. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ascending cholangitis
Secondary:
Cirrhosis s/p orthotopic liver transplant in [**Country 651**]
Chronic Hepatitis C
Chronic Hepatitis B
Hepatocellular carcinoma
Discharge Condition:
Afebrile, ambulatory, stable
Discharge Instructions:
You were admitted with fevers and abdominal pain. This was
likely from an infection in your transplant kidney that has been
treated with antibiotics.
Please take all of your medications as prescribed. We have
stopped your Bactrim and your Cellcept. You should not take
these medications unless told to do so specifically by Dr.
[**Last Name (STitle) 497**].
Please keep all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, abdominal pain, bleeding, chest pain,
shortness of breath or anything else concerning.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2154-4-18**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-4-18**] 9:30
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-4-19**]
12:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEPATOLOGY Date/Time:[**2154-5-1**] 8:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
4414,9971,4280,496,9973,5180,4019,2720,2749 | 330 | 184,134 | Admission Date: [**2132-1-15**] Discharge Date: [**2132-1-17**]
Date of Birth: [**2065-6-10**] Sex: M
Service:
HISTORY: Patient is a 66-year-old gentleman and has a
history of coronary artery disease and CHF, and he had an
abdominal aortic aneurysm, which was found on CT scan. The
aneurysm is approximately 5.6 cm infrarenal in diameter,
infrarenal aortic aneurysm.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Gout.
4. COPD.
5. Smoking history.
MEDICATIONS AT HOME:
1. Digoxin.
2. Coumadin.
3. Toprol.
4. Colchicine.
5. Lipitor.
6. Moexipril.
PAST SURGICAL HISTORY: No past prior surgical history.
HOSPITAL COURSE: Patient was admitted on [**1-15**], and
underwent an endovascular abdominal aortic aneurysm repair.
Postoperatively, patient had some respiratory distress, and
remained intubated in the PACU on postoperative day #1, and
patient appeared to go into CHF intraoperatively, and Lasix
was given. The patient's pulmonary status improved after the
diuresis, and patient subsequently underwent a bronch, which
showed no plugging, no secretions, and no signs of CHF, and
patient was subsequently extubated in the recovery room.
Post extubation, the patient did well, and patient was
transferred to the floor. On chest x-ray, the patient
appeared to have a left lower lobe consolidation, question
pneumonia. Patient was started on Levaquin, and patient was
deemed ready for discharge on postoperative day #2. Prior to
discharge, patient was afebrile and vital signs are stable.
Patient was tolerating p.o. and was voiding without a Foley
catheter. Patient's pulse exam: He has bilateral palpable
DPs and good palpable femoral pulses. Patient's incision was
clean, dry, and intact.
FOLLOW-UP INSTRUCTIONS: Patient will be discharged to home
with instructions to followup with Dr. [**Last Name (STitle) **] in [**12-18**]
weeks, and he will have a follow-up CT angiogram here in
about one month.
The patient is to be discharged on all his preoperative home
medications. Also including Levaquin for 10 days.
DISCHARGE MEDICATIONS:
1. Atorvastatin 20 mg p.o. q.d.
2. Colchicine 0.6 mg p.o. q.d.
3. Digoxin 0.25 mg p.o. q.d.
4. Lasix 120 mg p.o. q.d.
5. Lopressor XL 150 mg p.o. q.d.
6. Moexipril 7.5 mg p.o. q.d.
7. Percocet 1-2 tablets p.o. q.4-6h. prn.
8. Coumadin 5 mg p.o. q.h.s.
9. Levaquin 500 mg p.o. q.d. for 10 days.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Congestive heart failure.
3. Atrial fibrillation.
4. Gout.
5. Status post endovascular abdominal aortic aneurysm repair.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**First Name (STitle) 53438**]
MEDQUIST36
D: [**2132-1-17**] 08:52
T: [**2132-1-17**] 09:02
JOB#: [**Job Number 54149**]
(cclist)
|
5185,43330,9971,4275,99702,43411,9973,5070,5119,486,2851,99889,5180,496,7806,2749,4439,41401,4019,2720,42789,4148,E9421,79092,3051 | 330 | 197,569 | Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-16**]
Date of Birth: [**2065-6-10**] Sex: M
Service: VSU
CHIEF COMPLAINT: Carotid stenosis.
HISTORY OF PRESENT ILLNESS: This patient is well known to
Dr. [**Last Name (STitle) **]. He underwent abdominal aortic aneurysm repair
[**2132-1-15**] endovascular repair for a 5.7-cm abdominal
aortic aneurysm. His postoperative course was complicated by
congestive heart failure and a right groin infection. He
denies any claudication since his repair. He is seen in
followup because of his carotid disease. He has known
asymptomatic carotid disease, 60-69% on the left and 40-59%
on the right. Patient now is admitted for elective carotid
endarterectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Included Coumadin 7.5 alternating
with 5 mg; last dose was [**2-23**], Lasix 80 mg q.a.m. and 40
q.p.m., Toprol 200 mg daily, digoxin 0.5 daily, moexipril 7.5
mg daily, colchicine 0.6 mg daily.
SOCIAL HISTORY: Is significant for smoking. He denies
alcohol use.
ILLNESSES: Include congestive heart failure with ejection
fraction of 55%, chronic atrial fibrillation, history of
hypertension, history of COPD, history of
hypercholesterolemia, history of gout.
PAST SURGICAL HISTORY: Endovascular AAA repair and a type-II
endovascular leak repair.
HOSPITAL COURSE: Patient was admitted to the preoperative
holding area. He underwent a left carotid endarterectomy on
[**2133-2-27**]. He tolerated the procedure well. He was
transferred to the PACU in stable condition. Extubated and
neurologically intact. The patient developed at 4:15 p.m.
respiratory distress. Attempted intubation was unsuccessful.
Patient went into PEA arrest. ACLS protocol was followed.
Patient was successfully intubated and transferred to the
SICU for continued monitoring and care.
It was noted on transfer to the SICU, the patient had unequal
pupils, and a neurology consult was placed. A MRI was
obtained along with a carotid ultrasound. CT of the head was
obtained with contrast. The preliminary report was no acute
hemorrhage. Neurology felt the patient would require a MRI of
the head with multiple areas of restricted diffusion in the
anterior cerebral artery and middle cerebral artery on study.
That was most consistent with embolic phenomena. Source for
embolization needed to be followed up. IV Heparinization
could not be given because of patient's history of GI
bleeding.
Patient continued to be followed by the stroke service.
Recommendations were that we should obtain a MRA of the neck
to assess for evidence of reocclusion. Patient remained in
the SICU intubated. Pulmonary consult was placed. Patient
failed to wean, and they felt this was first of all COPD with
acute respiratory failure, questionable left lower lobe
aspiration pneumonia and a new CVA. Recommended to continue
pressure support. Hold off on aggressive weaning until
patient has improved clinically both from sputum and chest x-
ray and physical exam. Continued on levofloxacin and Flagyl
for presumed aspiration pneumonia. Start bronchodilators,
Atrovent and albuterol nebulizers q.4-6h., Solu-Medrol 40 mg
IV q.12h. for a few days, then can be converted to inhaling
Flovent. Continue diuresis and continue to monitor.
Patient was placed on triple antibiotics of vancomycin and
levofloxacin. He developed a T-max of 103 on postoperative
day 3. They felt this was related to his pneumonia. On
postoperative day 4, a post-pyloric tube was placed for
enteral feeding. He has been on a regular insulin-sliding
scale. Ultrasound of the chest was obtained for a left
pleural effusion. This was not loculated. Vancomycin and
levofloxacin were continued. The patient had significant
amount of secretions, which inhibited extubation and weaning.
Patient underwent bronchoscopy on [**2133-3-4**] secondary to
failure to wean from ventilator. Airways were without lesions
or bleeding. There were copious thick, mucoid secretions
right bronchotracheal tree greater than left. Patient
remained intubated.
By postoperative day 4, the patient continued still to have a
temperature of 101.9 to 101.3. His tube feeds were at goal,
and he remained on the vent. By postoperative day 6, the
patient's temperature curve had improved to 99.8. His
clinical exam was improved. His white count was improved.
On postoperative day 7, the patient's levofloxacin was
discontinued and was begun on Zosyn. His vancomycin was
continued. Still remained intubated with a T-max of 101.2.
Patient was successfully weaned and extubated on
postoperative day 9, that was [**2133-3-7**]. Mental status
was much improved. Tube feeds were continued. POs were held.
Ambulation to chair was begun.
Postoperative day 10, it was noted the patient had some
inflammatory response of the left 5th finger, which was
consistent with gout. Colchicine was reinstituted along with
Indocin with improvement in his inflammatory response.
Initial evaluation by physical therapy was on postoperative
day 10, [**2133-3-9**]. Patient would require rehab prior to
discharge to home. Antibiotics were discontinued. Tube feeds
were continued and gentle diuresis was continued for a 0.5
liter to a liter of fluid. White count was 18.3, hematocrit
27.7.
Fluconazole was added to the patient's antibiotic regimen of
vancomycin and Zosyn on [**2133-3-10**] for persistent sputums
with yeast. Patient was seen by speech and swallow. The
initial evaluation could not be done because the patient was
not awake enough to follow commands. They did feel the
patient might be aspirating and aspiration precautions were
required.
Patient continued to be seen by physical therapy, and they
continued with aggressive pulmonary therapy. The patient was
re-evaluated on [**2133-3-12**] by speech and swallow, who
felt that the patient had questionable signs and symptoms of
aspiration. Was list at the bedside. A video swallow was
recommended. The patient should remain NPO with his tube
feeds, to continue until the swallow was completed.
Infectious disease was requested to see the patient, and
again the recommendations regarding current antibiotic
treatment and length of therapy.
Recommendations were that the right basilar effusions should
be evaluated by CT with drainage if indicated and fluid sent
for culture. Continue meropenem until chest CT is obtained.
Patient also recommended stop vancomycin and fluconazole.
Recommendations of a right thoracentesis and culture of the
fluid was discussed with Dr.[**Name (NI) 5695**] service, that they
did not want to do any further invasive procedure on the
patient and will diurese the patient and follow the pleural
effusion. Patient's temperature curve continued to show
improvement with improvement in his white count. Blood
cultures, which were obtained showed no growth.
Patient was begun on meropenum on [**2133-3-12**]. The Zosyn
was discontinued. The fluconazole was continued. This was
added to his antibiotic regimen secondary to a new right
lower lobe opacity on chest x-ray. Patient underwent an
oropharyngeal video fluoroscopic swallowing evaluation on
[**2133-3-13**]. There was no aspiration or component of
aspiration noted. Recommendations to advance the diet to thin
liquids, and purees, and medicines in thin liquids. As the
patient's mental status improves and overall strength
increases, the team may wish to advance his diet further.
Patient required transfusion on [**2133-3-13**] for hematocrit
of 26. Patient was transferred to the VICU on [**2133-3-13**].
His white count continued to show improvement, and he
continued to be diuresed. At this point, recommendations were
to continue the meropenum for a total of 7 more days, that
was on [**2133-3-14**].
PICC line was requested on [**2133-3-16**] for continued
antibiotics. Patient continued to show improvement in his
respiratory status. Patient was discharged to rehab in stable
condition.
DISCHARGE MEDICATIONS: Acetaminophen liquid 325-650 mg q.4-
6h. p.r.n., moexipril 7.5 mg daily, fluticasone propionate
110 mcg puffs 2 b.i.d., insulin-sliding scale, albuterol
0.083% nebulizers q.6h., ipratropium bromide nebulizers q.6h.
p.r.n., colchicine 0.6 mg daily, Protonix 40 mg q.12h.,
Plavix 75 mg daily, aspirin 325 mg daily, warfarin 5 mg
daily, digoxin 0.5 mg daily, metoprolol 50 mg q.a.m.,
metoprolol 25 mg q.p.m., meropenum 1 gram q.8h. for total of
7 days from [**2133-3-16**].
DISCHARGE DIAGNOSES:
1. Carotid stenoses bilaterally status post left carotid
endarterectomy on [**2133-3-29**].
2. Respiratory failure.
3. Pulseless electrical activity arrest secondary to failed
intubated.
4. Left anterior cerebral and middle cerebral artery infarct
by MRI.
5. Postoperative fever with left lower lobe collapse and
pleural effusion, pneumonia treated.
6. Aspiration pneumonia treated.
7. Gout exacerbation treated.
8. Status post bronchoscopy on [**2133-3-4**].
SECONDARY DIAGNOSES:
1. Chronic atrial fibrillation.
2. Coronary artery disease.
3. History of congestive failure, compensated.
4. History of hypertension controlled.
5. Chronic obstructive pulmonary disease.
6. Blood loss anemia corrected.
Patient should follow up with Dr. [**Last Name (STitle) **] as directed. He
should follow up with neurological service as directed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2133-3-16**] 11:56:11
T: [**2133-3-16**] 12:40:30
Job#: [**Job Number 54150**]
|
41041,4271,41401,45829,E8790,E8498,42789 | 333 | 160,548 | Admission Date: [**2137-9-29**] Discharge Date: [**2137-10-2**]
Date of Birth: [**2072-4-8**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p bare metal stent in RCA
History of Present Illness:
65 yo F with tobacco history presented to OSH with sudden onset
chest pain. The patient reports that the pain began at 11:30PM
while at home. The pain was described as sudden, [**10-15**]
constant, substernal, unrelieved by rest or position. She also
reports radiation of the pain to the left arm, jaw, and neck.
She also experienced nausea and vomitting x 1, diaphoresis, mild
LH. She denied any SOB, syncope, palpitations.
.
In the ED at the OSH, the patient had an EKG which showed ST
elevations in II, III, aVF, as well as in V3-V6, with
depressions in V1-V2, I, aVL. CPK 54, MB 4.2, Trop I 0.16. She
was given nitro and morphine with mild relief of her chest pain.
She also received ASA, lopressor, integrillin bolus, and was
transferred to [**Hospital1 18**] for urgent cath.
.
On cath lab noted to have totally occluded RCA, otherwise
normal. Bare metal stent was placed. After reprofusion she had
bradycardia and required atropine. On right heart cath went
into Vfib and was shocked once returning to sinus rhythm.
Currently chest pain free.
.
ROS: Prior to event she was feeling well except for recent back
injury. However this had improved by yesterday. Denied any
recent fevers, chills, nausea, vomting. No SOB, orthopnea, PND,
LE edema. No diarrhea, constipation, melena, abd pain.
Past Medical History:
Uterine ca s/p XRT
Rt Fem- Lt [**Doctor Last Name **] bypass
Social History:
tobacco use 1ppd for 40 yrs. Occasional ETOH use. No illicit
drug use. Lives with mother, brother. Widowed, 2 children.
Family History:
Mother alive at 93, questionable history of CAD in 40-50's.
Father died at age 83 from complications of hip surgery.
Physical Exam:
Vital signs: T 97.1 BP 118/67 HR 87 RR 16 O2sats 100% 3LNC
General: Comfortable, lying flat in bed, NAD
HEENT: PERRL, EOMI, dry mm, anicteric
Neck: No JVD
Lung: CTAB anteriorly
Heart: Distant HS, RRR, no m/r/g
Abdomen: Soft, NT, ND, + BS
Ext: Right groin with sheath in place. 1+ DP bilaterally
Neuro: A&O times 3
Pertinent Results:
Cardiac Cath: FINAL DIAGNOSIS:
1. Inferior ST elevation MI due to mid RCA occlusion.
2. Cardiac arrest during right heart catheterization.
3. Successful PCI of a totally occluded RCA with a bare metal
stent.
.
EKG: NSR, STE in II,III,aVF,V3-V6, STD in V1-V2,I,aVL
.
Echo [**2137-9-30**]
LA is normal in size. IVC is dilated (>2.0 cm). LV wall
thicknesses and cavity size are normal. EF 35-40%, Moderate
regional LVsystolic dysfunction with focal severe hypokinesis of
the inferior septum, inferior, and inferolateral walls. The
remaining segments contract well. RV chamber size is normal. AV
leaflets (3) are mildly thickened but aortic stenosis is not
present. MV leaflets are structurally normal. There is no mitral
valve prolapse. Mild (1+) MR, mild 1+ TR. Mild PA systolic
hypertension. There is an anterior space which most
likely represents a fat pad.
.
[**2137-9-29**] 06:57PM TYPE-ART PO2-87 PCO2-31* PH-7.42 TOTAL CO2-21
BASE XS--2 INTUBATED-NOT INTUBA
[**2137-9-29**] 06:57PM GLUCOSE-106* LACTATE-1.4 NA+-133* K+-3.9
CL--105
[**2137-9-29**] 06:57PM HGB-10.2* calcHCT-31
[**2137-9-29**] 06:57PM freeCa-1.16
[**2137-9-29**] 04:12PM GLUCOSE-92 UREA N-10 CREAT-0.6 SODIUM-132*
POTASSIUM-8.1* CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2137-9-29**] 04:12PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.2
[**2137-9-29**] 04:12PM PT-15.8* PTT-25.5 INR(PT)-1.4*
[**2137-9-29**] 02:31PM POTASSIUM-4.6
[**2137-9-29**] 02:31PM CK(CPK)-4297*
[**2137-9-29**] 02:31PM CK-MB->500
[**2137-9-29**] 02:31PM MAGNESIUM-2.0
[**2137-9-29**] 12:32PM POTASSIUM-6.4*
[**2137-9-29**] 12:32PM CK(CPK)-5090*
Brief Hospital Course:
Mrs.[**Doctor Last Name 14539**] is a 65 year old female presenting with acute
substernal chest pain, nausea, vomiting, and EKG with STE in II,
III, aVF admitted for STEMI, now s/p RCA bare metal stent.
.
Cardiac:
Ischemia: Ms. [**Name13 (STitle) **] presented with sudden onset chest pain
found to have inferior STEMI. Unfortunately the patient waited
several hours and developed Q-waves inferiorly. On admission to
[**Hospital1 18**] the patient underwent cardiac catheterization which showed
a total occluded RCA otherwise patent vessels. A bare metal
stent was placed in the RCA. After reperfusion she had
bradycardia and required atropine. On right heart
catheterization the patient went into VF and was shocked once
returning to sinus rhythm. A bare metal stent was used
secondary to the patient's need for chronic coumadin therapy, in
an attempt to avoid long term use of aspirin, plavix and
coumadin. The patient was started on plavix 600mg load,
followed by 75mg qday which she will continue for 1 month, ASA
325mg qday. She was originally started on a beta blocker and an
ACE inhibitor however as her blood pressure could not tolerate
both (SBPs in the 80s), metoprolol was d/c'd based on her heart
rate in the 60s. A trial of captopril 6.25mg tid alone was
attempted the evening prior to her discharge, however, again her
blood pressure remained in the 80s (low of SBP of 69) despite
fluids. Based on this inability to tolerate both the ACE
inhibitor and metoprolol, both medications were d/c'd. She was
also placed on lipitor 80mg qday for an elevated LDL and low
HDL. Her HgA1c was checked and was 5.4%. She was monitored on
telemetry. An Echo showed LVEF 35-40% with moderate regional
left ventricular systolic dysfunction with focal severe
hypokinesis of the inferior septum, inferior, and inferolateral
walls. In addition, smoking cessation was discussed with the
patient and she expressed understanding of the importance of
this. By report the patient had a questionable reaction to
heparin at the outside hospital.
.
Pump: The patient had no signs of failure on exam. Echo results
are as above.
.
Rhythm: The patient maintained sinus rhythm with PVC's after MI.
She was briefly put on metoprolol but this was d/c'd due to low
SBPs. She remained in sinus rhythm.
.
Valve: No known valve disease.
.
PVD: Ms. [**Name13 (STitle) **] is s/p bilateral fem-[**Doctor Last Name **] bypass which she
required as a result of raditation. After catheterization she
was restarted on coumadin. Her INR was followed and she will
continue to follow up with this as an outpatient.
.
Back pain: The patient reported lower back pain after an injury
sustained a week prior to admission. She says the pain had been
improving prior to admission, however she continued to report
LBP and paraspinal tenderness. She was given valium and heat
packs which reportedly relieved her pain.
FEN: She was maintained on a cardiac diet
.
Code: Full
Medications on Admission:
Warfarin 2/3mg qhs(alternate)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
pci.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for pci.
Disp:*30 Tablet(s)* Refills:*0*
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: STEMI s/p stent of RCA
VF
Secondary: fem-[**Doctor Last Name **] bypass bilaterally
Discharge Condition:
Stable. The patient is ambulating around the unit.
Discharge Instructions:
You were admitted for a heart attack. You are now on
medications which help patients after a heart attack including
Plavix and aspirin. Please take all medications as prescribed.
If you begin to experience chest pain, shortness of breath,
lightheadedness, or any other concerning symptoms please call
Followup Instructions:
CARDIOLOGY
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2137-10-18**] 9:00
INTERNAL MEDICINE PCP
[**Name Initial (PRE) 2169**]: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-10-10**] 1:30
|
V3401,76518,769,7793,76527,V290,V053,V721,75251 | 334 | 104,852 | Admission Date: [**2136-1-16**] Discharge Date: [**2136-1-30**]
Date of Birth: [**2136-1-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 42484**] is the number one
first born triplet of a 34 and [**1-11**] week gestation pregnancy
born to a 36 year-old G4 P2 woman. Estimated date of
confinement was [**2136-2-26**]. Prenatal screens blood type B
negative, antibody positive, anti-D treated with RhoGAM,
hepatitis C surface antigen negative, RPR nonreactive,
Rubella immune, group beta strep status unknown. Pregnancy
was complicated by pregnancy induced hypertension. This was
a spontaneous triplet conception. This infant was born by
cesarean section. Apgars were 9 at one minute and 9 at five
minutes. He was admitted to the Neonatal Intensive Care Unit
for treatment of prematurity and respiratory distress.
PHYSICAL EXAMINATION: Weight 2.090 kilograms, length 43.5
cm, head circumference 32 cm. General, age appropriate with
obvious respiratory distress. Head, eyes, ears, nose and
throat normocephalic, atraumatic. Scalp palate intact. Red
reflex present bilaterally. Neck supple with no masses.
Chest lungs with poor air entry, active grunting, intercostal
retractions and nasal flaring. Cardiovascular regular rate
and rhythm. No murmur. Abdomen soft with active bowel
sounds. Femoral pulses 2+. Hips stable by midline. Anus
patent. Genitourinary male with testes present bilaterally
in canal. Neurological tone and reflexes consistent with
gestational age.
HOSPITAL COURSE/PERTINENT LABORATORY DATA: 1. Respiratory:
[**Known lastname **] required intubation and received one dose of
surfactant. He was extubated on room air on day of life
number one and remained in room air through the rest of his
Neonatal Intensive Care Unit admission. He has had no
episodes of spontaneous apnea or bradycardia.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rates
and blood pressures, a soft murmur was heard on day of life
12. Has been intermittent since then. It is felt to be
benign in nature.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
NPO and maintained on intravenous fluids. Enteral feeds were
started on day of life number one and gradually advanced to
full volume. He has been all po since day of life number 10
[**2136-1-26**]. At the time of discharge he is taking Enfamil 24
calories per ounce minimum of 130 cc per kilogram per day.
Discharge weight is 2.37 kilograms with a length of 47 cm and
a head circumference of 33 cm.
4. Infectious disease: Due to the unknown etiology of his
respiratory distress [**Known lastname **] was evaluated for sepsis and
treated presumptively. A white blood cell count was 14,300
with a differential of 30% polys, 0% bands. The blood
culture was obtained prior to starting antibiotics. The
blood culture was no growth at 48 hours and the antibiotics
were discontinued.
5. Gastrointestinal: Peak serum bilirubin occurred on day
of life number three a total of 5.6/0.3 mg per deciliter
direct. He did not require treatment.
6. Neurological: [**Known lastname **] has maintained a normal
neurological examination during admission and there are no
neurological concerns at the time of discharge.
7. Sensory: Audiology, hearing screen was performed with
automated auditory brain stem responses. [**Known lastname **] passed in
both ears.
8. Hematological: [**Known lastname **] is blood type A positive, Coombs
negative. Birth hematocrit was 43.5%.
CONDITION ON DISCHARGE: Good.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1894**] [**Last Name (NamePattern1) 53133**] General Medical
associates [**Apartment Address(1) 53134**], [**Location (un) 86**],
[**Numeric Identifier 53135**]. Phone number [**Telephone/Fax (1) 53136**]. Fax number
is [**Telephone/Fax (1) 53137**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Enfamil 24 calories per ounce ad lib.
2. No medications.
3. Car seat position screening was performed. [**Known lastname **] was
observed in his car seat for 90 minutes without any episodes
of desaturation or bradycardia.
4. State new born screen: Initial was sent on [**2136-1-19**]
with a repeat on the day of discharge [**2136-1-30**]. No
notification of abnormal results to date.
5. Immunizations received: Hepatitis B vaccine was
administered on [**2136-1-25**].
6. 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 criterias, first born at
less then 32 weeks; second born between 32 and 35 weeks with
two of three of the following; day care during RSV season,
smoker on the household, neuromuscular disease, airway
abnormalities, or school age siblings; or thirdly 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 age. Before this age the family and other
care givers should be considered for immunization against
influenza to protect the infant.
7. Follow up appointments: Recommended with Dr. [**Last Name (STitle) 53133**]
within three days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and [**1-11**] week gestation.
2. Triplet number one of triplet gestation.
3. Respiratory distress syndrome.
4. Suspicion for sepsis ruled out.
5. Intermittent heart murmur likely benign
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 50655**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2136-1-30**] 06:37
T: [**2136-1-30**] 06:27
JOB#: [**Job Number 53138**]
|
5990,0414,4019,4373,2762 | 335 | 110,777 | Admission Date: [**2195-3-18**] Discharge Date: [**2195-3-31**]
Date of Birth: [**2118-3-16**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
woman with a history of right upper extremity tremor. She
had an MRI scan which showed a 7 mm right posterior
communicating artery fetal PCA aneurysm. She was seen by Dr.
[**Last Name (STitle) 1132**] and admitted for angio and possible coil embolization
of this aneurysm. She was admitted status post arteriogram
which showed evidence of this right PCA aneurysm which was
not amenable to coiling; therefore, the patient was scheduled
for clipping of this aneurysm. She remained in the hospital,
was seen by cardiology and cleared for surgery.
PAST MEDICAL HISTORY: 1) Migraines, 2) Palpitations, 3)
Hepatitis A.
ALLERGIES: 1) codeine, 2) sulfa, 3) penicillin.
PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy as a
child.
HOSPITAL COURSE: She was taken to the OR on [**2195-3-24**] for
clipping of this right fetal PCA aneurysm without intraop
complication. Postop, the patient was in the Intensive Care
Unit. She was extubated on postop day #1. She was awake,
alert, oriented, following commands, moving all extremities
with no drift. She was weaned to 2 liters nasal cannula.
She was ruled out for an MI per protocol per cardiology,
which she did rule out for. Her vital signs remained stable.
She was afebrile, and she was transferred to the floor on
postop day #2. She remained neurologically awake, alert,
oriented x 3 with a slight left drift on postop day #3.
Repeat head CT showed no new evidence of hemorrhaging or
stroke. She had an upper extremity Doppler due to some left
upper extremity weakness and swelling which was also
negative. She was seen by physical therapy and occupational
therapy and found to require rehab. Her left upper extremity
weakness did improve greatly before discharge. Her vital
signs remained stable. Her incision was clean, dry and
intact.
DISCHARGE MEDICATIONS: 1) hydrocodone 1-2 tabs po q 4 h prn,
2) aspirin 81 mg po qd, 3) famotidine 20 mg po bid, 4)
albuterol inhaler 1 puff q 6 h prn, 5) Dilantin 100 mg po
tid, 6) heparin 5,000 units subcu q 12 h, 7) fexofenadine 60
mg po bid, 8) metoprolol 100 mg po bid, 9) alprazolam 0.25 mg
po bid prn, 10) albuterol 1-2 puffs q 6 h prn.
DISCHARGE CONDITION: Stable at the time of discharge.
FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in one month.
Staples should be removed on postop day #10.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2195-3-30**] 14:19
T: [**2195-3-30**] 13:28
JOB#: [**Job Number 49053**]/[**Numeric Identifier 49054**]
|
5920,4019,5997,42731,59381,V4582,2720,49390,V5861,7245,60000 | 338 | 194,592 | Admission Date: [**2135-10-26**] Discharge Date: [**2135-11-3**]
Date of Birth: [**2059-10-6**] Sex: M
Service: MEDICINE
Allergies:
Opioid Analgesics
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
s/p catheterization and tpa thrombolysis
History of Present Illness:
76 yo man with PMH significant for afib and recent
subtherapuetic INR, who presented to PCP's office on [**2135-10-26**]
with left flank pain. The pain started suddenly on [**2135-10-25**],
was described as sharp "like a knife", and was located in left
flank region without radiation. Mr. [**Known lastname 62631**] also had significant
nausea, concommitant with the flank pain, which he attempted and
failed to relieve through self-induced vomiting. He had no
hematuria, fever, or diarrhea. No recent trauma.
The pain persisted, constant in intensity at 10/10, and he saw
his PCP [**Last Name (NamePattern4) **] [**10-26**] where he was found to have microscopic
hematuria by UA and was referred to the [**Hospital 1474**] Hospital ED. CT
there showed a left renal artery obstruction c/w thrombosis vs.
thromboembolism. He was transferred to [**Hospital1 18**].
Past Medical History:
Coronary artery disease status post angioplasty ~ 15 yrs ago
Atrial fibrillation
Prostate condition - unspecified
Hypertension
Hypercholesterolemia
Asthma - pt unaware of PFTs in past
Social History:
60 pack yr smoking hx, quit 30 yrs ago
Alcohol occasionally
No drug use
Lives with wife
retired, former [**Name (NI) 62632**] worker
Family History:
Father with unknown type cancer
Mother with MI
Physical Exam:
VS: T 98.6 HR 99 BP 161/94 RR 15 O2sat 96%RA
Genl: NAD
HEENT: PERRLA, EOMI
Neck: no carotid bruits, no LAD, no JVD
CV: Irregularly irregular, nl s1s2, no mrg
Pulm: Lungs clear
Abdomen: soft, tender at left flank, nondistended, normoactive
bowel sounds, no abdominal bruit, no pulsating mass to suggest
AAA
Back: left CVa tenderness, no ecchymosis
Ext: LE without edema, 1+DP pulses/ 1+[**Doctor Last Name **] pulses, no cyanosis
Pertinent Results:
Admission labs:
CBC: WBC-9.4 RBC-5.07 Hgb-12.5* Hct-37.8* Plt Ct-164
Diff: Neuts-85.0* Bands-0 Lymphs-10.8* Monos-3.8 Eos-0.1
Baso-0.3
Coags: PT-14.0* INR(PT)-1.3
Chem10: Glucose-118* UreaN-20 Creat-1.5* Na-137 K-4.8 Cl-96
HCO3-28
Calcium-8.7 Phos-2.8 Mg-1.8
Fe studies: Iron-21* calTIBC-365 Ferritn-54 TRF-281
Anemia studies: VitB12-496 Folate-15.8 Ret Aut-1.3 Fibrino-667*
Discharge labs:
Chem10: Glucose-157* UreaN-13 Creat-1.3* Na-140 K-4.6 Cl-106
HCO3-23
Calcium-8.8 Phos-3.3 Mg-2.2
CBC: WBC-4.8 RBC-4.03* Hgb-10.2* Hct-30.7* Plt Ct-232
Coags: PT-18.8* PTT-115.7* INR(PT)-2.5
Micro:
Blood cx x 2 - negative
Urine cx - negative
Studies:
.
UA at OSH with 0-2 rbc, 0-2 wbc, creat 1.3
Stool guaiac negative
.
CT abd/pelvis at OSH with essentially complete absence of flow
to the left kidney other than min flow to some portions of ant
mid pole and lower pole, contrast in prox left renal aa with
lack beyong that point suggests in situ thrombus or embolism;
cysts in both kidneys, aorta diffusely calcified but nl in
caliber, no aortic dissection, prostate enlarged, no LAD,
diverticuli, enlarged heart; otherwise nl
.
EKG at [**Hospital1 18**] with afib, normal axis, no LVH, q in III, no ST/T
wave abnormalities.
ECHO ([**10-27**]):
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.1 cm (nl <= 3.4 cm)
Aorta - Arch: *3.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 181 msec
TR Gradient (+ RA = PASP): *22 to 30 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. RV function
depressed.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+]TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Inferior hypokinesis is
present.
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Cath [**10-27**]: Selective renal angiography demonstrated a large
blood clot present within the left main renal artery extending
into the peripheral branches. Perfusion of the left renal
parenchyma was significantly reduced. Catheter-directed
intrathrombus pulse spray infusion of 10 mg of TPA was performed
via a multisidehole infusion catheter. The multisidehole
infusion catheter positioned within the thrombosed was connected
to a continuous drip of TPA at 1 mg per hour during the first
hours of the infusion and 0.5 mg per hour continuous infusion of
TPA thereafter. Followup angiogram was planned to be performed
in approximately 15 hours.
Cath [**10-28**]: Followup left renal angiography demonstrated
significantly reduced amount of thrombus within the left renal
artery. Perfusion to the left renal parenchyma has significantly
improved. Areas of the left renal parenchyma in its lower
lateral pole demonstrated persistent hypoperfusion. Pulse spray
catheter-directed infusion of 6 mg of TPA into the left renal
artery was performed. The catheter was connected to the
continuous infusion of TPA at 1 mg per hour for 4 hours. A
followup left renal angiography will be then performed.
Follow-up 10/28: Marked improvement of the left renal artery
thrombus with only small residual filling defects, predominantly
in the lower renal artery branch. Overall, improved parenchymal
perfusion compared with the prior study with still some areas of
hypoperfusion in the interpolar region and lower pole.
Arterial duplex, right lower extremity, [**11-3**]: No evidence of
right inguinal pseudoaneurysm or AV fistula.
Brief Hospital Course:
76yo man with afib, CAD, HTN, BPH, w/ left renal artery
occlusion, renal failure, s/p catheter guided TPA lysis to
restore flow.
.
History is detailed below by problem:
.
1) Left renal artery occlusion: The patient was found to have a
left renal artery thrombus [**1-2**] cms distal to origin of aorta
with occlusion of the tributaries extending into renal pelvis.
Renal arteriography was performed with injection of TPA x 3.
Adequate flow was restored and patient received heparin bridging
to coumadin over 5 days. On the night following his TPA therapy,
He had bleeding from a hematoma at the right groin catheter
site. Bleeding was stopped with pressure and the hematoma was
monitored closely; it resolved throughout his hospital course.
2) Renal insufficiency: Mr. [**Known lastname 62633**] creatinine was 1.5 on
admission, up from baseline of 1.0, believed secondary to renal
artery occlusion. With restoration of arterial perfusion, his
creatinine trended down to 1.3 at discharge. Per the
interventional radiology service, this would be analagous to
slow recovery from ATN and would expect for it to continue to
fall.
3) Anemia: Pt has Fe deficiency anemia. His hematocrit dropped
from 37 on admission to 29 to a low of 27.1 on [**10-28**]. Guaiac
exams were negative, and no active sources of bleeding were
idenitified. His hematocrit stabilized in the low 30s prior to
discharge.
4) Hypertension: he was normotensive throughout his course,
received lasix home med dose of 40 mg po qd and continued on
verapamil SR 240 mg PO Q24H. [**Last Name (un) **] was held given the ACE
inhibitor component.
Medications on Admission:
[**Last Name (un) **] 180 mg po qd
Furosemide 40 mg po qd
Zocor 40 mg po qd
Coumadin 5 mg po qd
Discharge Medications:
1. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
7. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) INH Inhalation
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Renal artery embolus and renal infarct s/p thrombolysis
Discharge Condition:
good
Discharge Instructions:
Please call your primary care doctor if you have fevers > 101.5,
severe chest pain, shortness of breath, worsening back pain,
blood in your urine or if your symptoms worsen.
Take your coumadin as prescribed and have your INR checked by
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] at clinic.
Followup Instructions:
Follow up appointment w/ PCP on [**Name9 (PRE) 766**], [**11-7**], at 215pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2135-11-29**] 10:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2135-11-17**] 2:00
|