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5789,2851,2761,1809,193,4589,5296,7919,2822,2768,V8741,E9331 | 99,712 | 159,835 | Admission Date: [**2161-10-5**] Discharge Date: [**2161-10-8**]
Date of Birth: [**2106-11-20**] Sex: F
Service: MEDICINE
Allergies:
Levetiracetam / Latex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Lower GI bleed, pelvic pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 54-year-old woman with a pmhx. significant for stage
IIIA (T3, N0 Mx)
high-grade cervical cancer, papillary thyroid cancer, seizure
disorder, and atypical meningioma who is admitted from the ED
with fever, lower GI bleed, and UTI. Patient has been
undergoing active treatment for cervical cancer with
Taxol/carboplatin with C4 on [**10-1**]. Ms. [**Known lastname **] has been having
trouble with GI bleeding (in the setting of constipation and
straining as per outpatient notes), and has been supported
conservatively with blood transfusions. No history of EGD or
colonsocopy in our system.
Ms. [**Known lastname **] states the for the last weekshe has noticed increased
blood in her stool. Also endorses fevers, chills, and abdominal
pain.
In the ED, initial vitals were: 102.0 109 105/65 16 100% ra.
Hgb was 9.4 and u/a was consistent with UTI. Patient received
3L of NS and 1 gram of ceftriaxone. CT abdomen/pelvis showed:
"thickening of the rectum and sigmoid colon with extension to
possibly the mid-descending colon raise suspicion for a
proctocolitis due to an infectious or inflammatory process.
Heterogenous irregular cervical mass appears stable in size but
there is more hypodense material endometrial canal suggesting
either outlet obstruction by the mass or possibly involvement of
the region by the mass. Left upper lobe nodule has decreased in
size." Vitals on admission were: 98.3, 67, 92/55, 15, 100% ra.
Past Medical History:
1. Atypical meningioma, s/p resection [**2159-3-30**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD)
2. Brief seizure disorder, given Keppra, developed rash. Not
taking AED at this time. Purportedly to undergo radiation
therapy, but did not undergo therapy.
3. Chronic eczematous process involving thighs, chronic
hyperpigmented shins bilaterally, seen by dermatology in past.
4. G6P4 - 2 Ab
5. Cervical Cancer - Stage IIIa; dx [**2160-6-21**]-lung mets and
progression in [**6-25**]-
-cycle #1 [**Doctor Last Name **]-taxol [**2161-7-17**].
6. Thyroid Cancer-no treatment
Social History:
She lives in the [**Location (un) 4398**] with her husband and works as a
tailor. No tobacco or ETOh use. She is originially from [**Country 651**]
and speaks Cantonese only.
Family History:
Father: lung cancer, smoker.
Mother: no known medical issues.
She has 5 sisters, 1 brother. She has 4 children.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3, 67, 92/55, 15, 100% RA
GENERAL: Alert, oriented, pleasant no acute distress
HEENT: Mucous membranes moist
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, slightly tender, non-distended
EXTREMITIES: Dry skin, no edema bilaterally
DISCHARGE EXAM:
Tmax: 37.2 ??????C (99 ??????F), Tcurrent: 36.6 ??????C (97.9 ??????F), HR: 61 (60 -
93) bpm
BP: 102/69(77) {93/53(65) - 126/93(98)} mmHg
RR: 13 (11 - 22) insp/min
SpO2: 99%
GENERAL: Alert, oriented, NAD
HEENT: MMM
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, S1 S2, no MRG
ABDOMEN: +BS, soft, suprapubic mass is mildly tender,
non-distended, hepatic edge palpable, no cvat
EXTREMITIES: Dry skin, no edema bilaterally
Pertinent Results:
ADMISSION LABS:
[**2161-10-5**] 12:20PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2161-10-5**] 12:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
[**2161-10-5**] 12:20PM URINE RBC-36* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
[**2161-10-5**] 12:20PM URINE MUCOUS-MOD
[**2161-10-5**] 11:26AM TYPE-[**Last Name (un) **] COMMENTS-ADDED TO G
[**2161-10-5**] 11:26AM LACTATE-1.7
[**2161-10-5**] 10:45AM GLUCOSE-183* UREA N-14 CREAT-0.5 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-14
[**2161-10-5**] 10:45AM estGFR-Using this
[**2161-10-5**] 10:45AM ALT(SGPT)-21 AST(SGOT)-19 LD(LDH)-170 ALK
PHOS-113* TOT BILI-0.7
[**2161-10-5**] 10:45AM ALBUMIN-3.0*
[**2161-10-5**] 10:45AM WBC-6.3 RBC-3.09* HGB-9.4* HCT-29.0* MCV-94
MCH-30.3 MCHC-32.3 RDW-16.1*
[**2161-10-5**] 10:45AM NEUTS-92.7* LYMPHS-5.7* MONOS-1.4* EOS-0.1
BASOS-0.2
[**2161-10-5**] 10:45AM PLT COUNT-298
[**2161-10-5**] 10:45AM PT-10.5 PTT-30.7 INR(PT)-1.0
STUDIES:
[**2161-10-5**] CT Chest Abd Pelvis
IMPRESSION:
1. Proctocolitis, which may be due to an infectious or
inflammatory process.
2. Heterogenous irregular cervical mass appears relatively
similar, compatible with known carcinoma. Increased hypodense
material in the endometrial canal with peripheral irregular
enhancement is suggestive of increased endometrial fluid due to
cervical obstruction by the mass with endometritis, but
neoplastic involvement of the endometrium may also be present.
Air within the cervix and vagina is unchanged from the prior
studies; while no communication is seen between the vagina and
rectum, if there is concern for a rectovaginal
fistula, this can better be assessed with rectal contrast.
3. Interval decrease in size of the left upper lobe nodule.
4. Heterogeneous hypodense area within the right lobe of the
thyroid gland, consistent with the patient's known thyroid
carcinoma.
5. Mild dilatation of the ureters without frank hydronephrosis,
likely due to mass effect upon the distal ureters by the
cervical tumor.
[**2161-10-6**] KUB
FINDINGS: There is retained contrast within the large bowel.
There is no
dilated bowel. There is no free air or pneumatosis. IMPRESSION:
No gas abnormality.
MICROBIOLOGY
[**2161-10-6**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2161-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2161-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2161-10-5**] URINE CULTURE-FINAL INPATIENT
[**2161-10-5**] BLOOD CULTURE -PENDING
[**2161-10-5**] BLOOD CULTURE- PENDING
DISCHARGE LABS
[**2161-10-8**] 03:59AM BLOOD WBC-2.4* RBC-3.43* Hgb-10.5* Hct-30.2*
MCV-88 MCH-30.7 MCHC-34.9 RDW-16.9* Plt Ct-200
[**2161-10-8**] 03:59AM BLOOD Glucose-111* UreaN-10 Creat-0.5 Na-136
K-3.7 Cl-104 HCO3-23 AnGap-13
[**2161-10-8**] 03:59AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.3*
[**2161-10-7**] 04:51AM BLOOD Lactate-1.3
Brief Hospital Course:
This is a 54-year-old woman with a history of cervical cancer
stage IIIA (T3, N0 Mx), papillary thyroid cancer, atypical
meningioma, and anemia who is admitted with fever, lower GI
bleed, and likely UTI.
ACTIVE ISSUES:
1. LOWER GI BLEED: Patient received IVF and an active type,
screen and crossmatch was maintained. She had a CT scan
demonstrating colitis. Given recent chemotherapy,
chemotherapy-induced colitis was high in our differential. We
also considered infectious colitis and patient was started on
antibiotics. She was afebrile in the ICU and not passing stool,
so an infectious etiology was felt to be less likely and Zosyn
was discontinued on [**10-7**]. Ischemic bowel was unlikely given
lactate is within normal limits and patient does not appear
systemically ill. On [**10-6**], patient received 2 units pRBC for a
HCT of 21, with HCT increasing appropriately to 29 on the
morning of [**10-7**]. While in the [**Hospital Unit Name 153**], patient passed small blood
clots through her rectum but did not have frank hematochezia or
melena. Patient was called out of the [**Hospital Unit Name 153**] on [**10-7**] but a floor
bed was not available. On [**10-8**] she was stable for discharge
home.
2. UTI: Patient with evidence of UTI on u/a on admission.
Asymptomatic. She was initially treated with antibiotics.
However, urine studies were felt to represent fecal
contamination and her imaging was concerning for possible
fistula. Antibiotics were discontinued on [**10-7**] and patient
remained afebrile.
3. CERVICAL CANCER: Patient currently undergoing chemotherapy
with taxol and carboplatin. Her outpatient oncologist was
contact[**Name (NI) **] who felt colitis could be secondary to chemotherapy
and chemotherapy was not given in house. Patient will follow up
with oncology as outpatient.
4. HYPOTENSION: Patient was initially transferred to the [**Hospital Unit Name 153**]
with an SBP in the 80's in spite of aggressive fluid
resuscitation and concern for sepsis. Upon further
investigation, patient's baseline outpatient SBP is 80's-100.
She denied symptoms of orthostatic hypotension.
CHRONIC ISSUES:
1. THYROID CANCER: No treatment at this time.
2. PAIN: Patient was continued on oxycodone and oxycontin.
Ibuprofen was held in the setting of GI bleed.
TRANSITIONAL ISSUES
- Avoid NSAIDS
- Determine future chemo regimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 2 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia
Please hold for oversedation or RR <10.
3. Ondansetron 8 mg PO Q8H:PRN Nausea
4. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN Pain
Please hold for oversedation or RR <10.
5. Oxycodone SR (OxyconTIN) 30 mg PO QAM
Please hold for oversedation or RR <10.
6. Oxycodone SR (OxyconTIN) 20 mg PO QPM
Please hold for oversedation or RR <10.
7. Prochlorperazine 10 mg PO Q8H:PRN Nausea
8. Docusate Sodium 100 mg PO BID
9. Senna 1 TAB PO BID:PRN Constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
11. Ibuprofen 400 mg PO Q8H:PRN Pain
Discharge Medications:
1. Dexamethasone 2 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia
Please hold for oversedation or RR <10.
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN Pain
Please hold for oversedation or RR <10.
6. Oxycodone SR (OxyconTIN) 30 mg PO QAM
Please hold for oversedation or RR <10.
7. Oxycodone SR (OxyconTIN) 20 mg PO QPM
Please hold for oversedation or RR <10.
8. Prochlorperazine 10 mg PO Q8H:PRN Nausea
9. Senna 1 TAB PO BID:PRN Constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Hypotension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted for
low blood pressure and blood in your stool. You had a blood
transfusion which improved your blood pressure and your anemia.
A CT scan showed inflammation of your colon which is most likely
due to your chemotherapy. You also complained of tongue pain,
which is also likely due to your chemotherapy. We have
prescribed a lidocaine mouth rinse to help with the pain.
In the future, please avoid over the counter non-steroidal
anti-inflammatory medications (NSAIDs), as they may cause worse
bleeding in your GI tract. This means you should NOT take
ibuprofen (advil, motrin), aspirin, or naproxen. It is OK to
take Tylenol.
Please continue to follow up with your Oncologist for care of
your cervical cancer.
Followup Instructions:
Dr. [**First Name (STitle) **]
[**Hospital3 **]
Thursday, [**2161-10-15**] 3pm
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2161-10-23**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19895**], MD [**Telephone/Fax (1) 4152**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MRI
When: FRIDAY [**2161-10-16**] at 8:20 AM
With: MRI [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: FRIDAY [**2161-10-9**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
2252,6929,73819,45829 | 99,712 | 194,361 | Admission Date: [**2159-3-30**] Discharge Date: [**2159-4-4**]
Date of Birth: [**2106-11-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2159-3-30**]: Left craniotomy/cranioplasty for excision of
skull-based mass
History of Present Illness:
The patient was electively admitted for resection of a skull
lesion.
Past Medical History:
unknown
Social History:
lives with husband; from [**Country 651**] and speaks Cantonese; works in a
factory
Family History:
non-contributory
Physical Exam:
Exam upon discharge:
Chinese speaking only, but able to follow commands with prompts.
Pupils 4 to 3 mm bilaterally
EOMI
Face symetric
No drift or droop
Full strength with motor exam.
Left sided cranial wound: C/D/I, closed with sutures.
Pertinent Results:
Head CT [**2159-3-30**]:
Expected post-surgical changes after craniectomy and
cranioplasty for a
left frontoparietal calvarial lesion.
MRI Head [**2159-3-31**]:
Since the previous study, the patient has undergone resection of
left parietal skull mass. There is no residual nodular
enhancement seen.
There remains a small left-sided subdural collection and
meningeal
enhancement. There is no midline shift or hydrocephalus. No
acute infarct
seen.
IMPRESSION: Status post resection of left parietal skull mass.
No residual
nodular enhancement is seen. No acute infarct.
Brief Hospital Course:
The patient was electively admitted for resection of a
skull-based lesion. She had a craniectomy and cranioplasty with
mesh . The procedure went well and the patient was transferred
to the ICU for monitoring overnight. The patient's
post-operative MRI revealed complete resection of the lesion.
She was neurologically stable and post-op imaging was consistent
with total resection of the mass. The patient was transferred to
the floor on [**2159-3-31**]. She worked with PT and OT but was slow to
mobilize. She continued to work with PT and OT on [**4-1**] and [**4-2**].
She was re-evaluated on [**4-3**] and was deemed safe for discharge
home on [**4-4**] with home services.
The patient had lesions on her legs when she came into the OR.
Dermatology was consulted and felt that she had chronic eczema
for which she was discharged home with creams. She will
follow-up with them in clinic.
Medications on Admission:
none
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 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: No driving while on this medication.
Disp:*50 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 9 days: Continue for two weeks from the date of
your surgery.
Disp:*10 Tablet(s)* Refills:*0*
6. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day) for 10 days.
Disp:*1 tube* Refills:*0*
7. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) for 10 days.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Carecentrix
Discharge Diagnosis:
Left skull-based mass - preliminary diagnosis is Meningioma
Discharge Condition:
Neurologically stable
Mental Status: Clear and coherent (with interpreter)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
- Have a friend/family member check your incision daily for
signs of infection.
- Take your pain medicine as prescribed.
- Exercise should be limited to walking; no lifting, straining,
or excessive bending.
- Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
-You may shower before this time using a shower cap to cover
your head.
-Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
-Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
-If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
-Clearance to drive and return to work will be addressed at your
post-operative office visit.
-Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
-New onset of tremors or seizures.
-Any confusion or change in mental status.
-Any numbness, tingling, weakness in your extremities.
-Pain or headache that is continually increasing, or not
relieved by pain medication.
-Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
-Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-up in the Brain [**Hospital 341**] Clinic. It is located on the [**Hospital Ward Name 5074**] on [**Hospital Ward Name 23**] 8. Call [**Telephone/Fax (1) 1844**]. Your appointment is [**4-16**] at 4 pm.
Follow-up with dermatology in the clinic. Call [**Telephone/Fax (1) 1971**] to
schedule an appointment within 2 weeks.
Completed by:[**2159-4-4**] |
42781,99601,42610,4580,4019,2724,25000,V5867,59970,32723,27800,7948,7904,42731,V5861,7823,41401,2449,3331,3659,V1582,V140 | 99,714 | 176,601 | Admission Date: [**2125-6-9**] Discharge Date: [**2125-6-13**]
Date of Birth: [**2043-12-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Attending Info 11308**]
Chief Complaint:
Transfer for pacemaker
Major Surgical or Invasive Procedure:
pacemaker placement
History of Present Illness:
Patient is an 81 yo M with history of HTN, HLD, IDDM, CAD s/p
cardiac catherization in [**2118**], atrial fibrillation on Coumadin
who was transferred to [**Hospital1 18**] from [**Hospital1 **] for
pacemaker.
Per medical history and patient account, he was in his USOH
until he Friday [**2125-6-8**] morning when he felt lightheaded and
dizzy while completing a crossword puzzle. Initially though it
was hypoglycemia but his FS was 150. Patient then took his BP
and found it to be 50/30 and his pulse was 28. He experienced
orthostatic symptoms and felt dizzy while walking to bathroom
and then fainted. At [**Hospital1 **] ED he was found to be
hypotensive and with HRs in 20s, he was given Atropine in the ED
which raised his BP to 30s. Patient was started on Dopamine and
given another amp of Atropine and admitted to CCU. He was
scheduled for a pacemaker but emergent interventions pushed his
interventino back. Patient was transfered to [**Hospital1 18**] for planned
pacemaker.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, [**Known lastname **]
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations.
In terms of his functional status, he used to be able to walk 3
miles without becoming SOB though in recent years he has been
more limited. He is able to walk about a mile slowly without
becoming short of breath and he denies CP with exertion though
does report some calf pain occasionally. He also has chronic [**Location (un) **]
for which he takes Lasix though the patient denies it is related
to CHF and TTE/C.Cath with preseved LVEFs in the past.
Past Medical History:
- CAD
- HTN
- A.Fib: Rate controlled and anti-coagulated
- Insulin Dependent Diabetes Mellitus: A1c 5.8%
- OSA: uses CPAP
- Hypothyroidism
- Glaucoma
PAST SURGICAL HISTORY:
- Laparoscopic cholecystectomy [**2122-6-30**]
- C.Cath [**2118**]
- Laminectomy [**2124-7-5**]
Social History:
- Tobacco history: + smoking history though quit in [**2093**] <5
pack-yr
- ETOH: Glass wine per month
- Illicit drugs: Nont
- Lives with wife in [**Name (NI) **], MA. Daughter lives in [**Name (NI) **], [**First Name3 (LF) **]
has MR and lives in group housing in [**State 760**]
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- MI in Uncle in his 70s
Physical Exam:
VS: Afebrile, HR 40s, BPs 134/60, RR 12, 98%RA
GENERAL: Pleasant, friendly, comfortable seated in bedside chair
and in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm.
CARDIAC: Bradycardic, S1S2 clear and of good quality,
physiologic splite S2, no murmurs, rubs or gallops appreciated.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Obese, distended abdomen but Soft and non-tender. No
HSM, normoactive bowel sounds
EXTREMITIES: Cold LE bilaterally, faintly palpable pulses, 1+
pitting [**Location (un) **] bilaterally to mid shin, chronic hyperpigmentation
of LE bilaterally. Bilateral radial pulses 2+ and symmetric
.
Pertinent Results:
Labs on Admission:
[**2125-6-9**] 07:39PM BLOOD WBC-7.7 RBC-3.81* Hgb-12.5* Hct-37.6*
MCV-99* MCH-32.9* MCHC-33.4# RDW-15.5 Plt Ct-112*
[**2125-6-9**] 07:39PM BLOOD PT-22.0* PTT-43.5* INR(PT)-2.1*
[**2125-6-9**] 07:39PM BLOOD Glucose-204* UreaN-41* Creat-1.5* Na-127*
K-4.5 Cl-93* HCO3-21* AnGap-18
[**2125-6-9**] 07:39PM BLOOD ALT-33 AST-41* AlkPhos-231* TotBili-2.1*
[**2125-6-9**] 07:39PM BLOOD CK-MB-3 cTropnT-0.01
[**2125-6-9**] 07:39PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
[**2125-6-10**] 09:42AM BLOOD calTIBC-363 Ferritn-183 TRF-279
[**2125-6-9**] 07:39PM BLOOD TSH-0.52
Imaging:
RUQ US
1. Suboptimal exam due to portable technique. The liver
echotexture may be
coarse. Hyperechoic lesions in the liver, may represent
hemangiomas; however, HCC cannot be excluded in the setting of
underlying liver disease. Further assessment with dedicated
cross-sectional imaging is recommended.
2. Splenomegaly and ascites raising possibility of portal
hypertension.
3. Right renal cyst.
Chest X-ray:
Left chest wall pacemaker is seen with leads in the right atrium
and apex of the right ventricle. There is no pneumothorax. There
is no focal consolidation or pleural effusion. Linear opacities
at the bases are likely atelectasis. Cardiomediastinal
silhouette is stable.
IMPRESSION: Pacemaker leads in right atrium and apex of the
right ventricle. No pneumothorax.
Labs on Discharge:
[**2125-6-13**] 06:08AM BLOOD WBC-4.6 RBC-3.20* Hgb-10.5* Hct-31.6*
MCV-99* MCH-32.8* MCHC-33.1 RDW-15.5 Plt Ct-112*
[**2125-6-13**] 06:08AM BLOOD PT-23.8* PTT-50.3* INR(PT)-2.3*
[**2125-6-13**] 06:08AM BLOOD Glucose-134* UreaN-29* Creat-1.2 Na-138
K-4.5 Cl-104 HCO3-27 AnGap-12
[**2125-6-13**] 06:08AM BLOOD ALT-28 AST-36 LD(LDH)-173 AlkPhos-179*
TotBili-1.6*
[**2125-6-13**] 06:08AM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.6* Mg-2.0
[**2125-6-10**] 09:42AM BLOOD calTIBC-363 Ferritn-183 TRF-279
Brief Hospital Course:
Mr. [**Known lastname 4887**] is an 81y/o gentleman with HTN, CAD, DM2 who presented
initially to OSH with syncope and bradycardia, and was found to
have sick sinus syndrome with junctional escape rhythm,
transferred to [**Hospital1 18**] CCU for pacemaker implantation.
# Bradycardia/tachycardia: Sick sinus syndrome, also with some
His-Purkinje disease.
His disease is likely due to age-related fibrotic replacement of
his conduction system, though other etiologies were considered.
Lyme negative DDI pacemaker (range 50-110). Per pacemaker
interrogation [**6-12**], the RA lead seemed to not be capturing
correctly and on CXR, was dislodged. Had revision of that lead
[**6-12**]. Repeat chest x-ray confirmed lead was in place.
Initially, all nodal agents were held. After pacemaker
implantation, patient was stable on metoprolol. Discharged on
metoprolol XL 25mg qd. Also, d/c on Keflex 500mg qid x7 days
for prophylaxis (7 days because patient is at increased risk for
ICD pocket infection as he had the pocket re-opened) Noted that
patient had history of penicillin allergy (rash), so instructed
patient to stop the Keflex and call his pcp if he develops a
rash.
.
# CAD: stable.No recent episodes of chest pain, SOB or DOE
though the patient reports his exercise capacity has been more
limited in recent years though mainly due to hip pain. C.Cath in
[**2118**] showing diffuse vessel disease though no intervenable
lesions. D/c on metoprolol as above and home dose lisinopril.
Not on aspirin because he is on coumadin. Continued pravastatin.
.
# LE edema : Stable. NO TTE in OMR but [**2118**] cath showed EF>55%.
Continued home Lasix.
.
# Atrial Fibrillation: stable. Chronic, rate controlled with
Labetalol at home, and on Coumadin. INR 1.9. Stopped labetalol
while in house. Started metoprolol low dose as above.
Continued coumadin. Will have INR checked as outpatient.
.
# HTN: Chronic, well controlled on Lisinopril and new metoprolol
as above
.
# LFT abnormality: AST 34, ALT 34, AP 225, TBili 2.1 on [**6-10**].
Unclear etiology. He says he thinks this is baseline but he is
not sure. No known h/o cirrhosis. RUQ U/S demonstrated ?
coarse echotexture, but no clearly defined biliary abnl. Will
likely need repeat exam s/p pacer placement. Albumin 4.3. Iron,
ferritin and transferring nl. Informed PCP about this and [**Month/Day (4) **]
report.
.
# Hematuria: patient with small amount of hematuria. UA
negative for infection. Urine culture ngtd.
.
# Diabetes Mellitus: stable. Chronic, Insulin Dependent, Well
controlled with recent A1c of 5.8% per patient report. Was on
ISS.
.
# OSA: Chronic, on CPAP, continued in house.
.
# Hypothyroidism: Chronic, stable. TSH normal this admission.
Continued Synthroid per home regimen.
.
# Glaucoma: chronic, stable. Continued home eye drop meds
(except Timolol)
.
# Essential Tremor: stable
.
TRANSITIONAL ISSUES:
- repeat UA; hematuria workup if still positive for RBCs
- liver nodules on US and splenomegaly, small amount of ascites;
will need f/u by PCP, [**Name10 (NameIs) **] report
- will have INR checked as outpatient and results [**Name10 (NameIs) **] to PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] complete 7 day course of keflex 500mg PO qid for
prophylaxis for ICD infection
Medications on Admission:
HOME MEDICATIONS:
- Pravastatin 40mg Daily
- Lisinopril 40mg PO Daily
- Labetalol 200mg PO BID
- Furosemide 60mg Daily
- Primidone 50mg DAily
- Warfarin 2.5mg x2days/week 5mg x5days/week
- Insulin
- Levothyroxine 137mcg Daily (except Sat and Wed (274mcg))
- Allopurinol 300mg daily
- Brimonidine Both eyes [**Hospital1 **]
- Pilocarpine eye drops 2 drops both eyes
- Timolol one drop both eyes
- Bimatoprost 0.03% 1 drop right eye
- Finasteride 5mg Daily
.
TRANSFER MEDICATIONS:
- Dopamine 10mcg/kg/min IV drip
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 4887**],
You were transferred to [**Hospital1 69**]
from [**Hospital6 4620**] for pacemaker placement because
you were having episodes of very low heart rates. One of the
wires of the device became dislodged so you had to go back for a
second procedure to have it fixed. You tolerated the procedures
well. We are discharging you on a 1 week course of antibiotic
called Keflex to prevent infection around the pacemaker device.
We know you have had a rash from penicillin in the past. There
is an approximately 8% chance that you may develop a rash from
this antibiotic, Keflex. We are prescribing this one because it
is the best choice for preventing infection without causing
adverse effects. If you do develop a rash or any swelling in
the mouth or trouble breathing, please stop taking it and let
your primary care doctor know so that you can be started on a
different antibiotic instead. Again, the chance of you having an
allergy to this medicine is small.
We have made the following changes to your medications:
-STOP taking Labetalol
-START Metoprolol 25mg daily
-START Keflex 500mg 4 times per day for 7 days (antibiotic to
prevent infection)
Please have your INR checked on Friday [**6-15**] and the results
[**Month/Year (2) **] to Dr. [**Last Name (STitle) **] (prescription included below)
On discharge, please follow up with your primary care doctor
(please call to make an appointment) and in cardiology device
clinic as scheduled below.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **], your primary care doctor, to schedule an
appointment in the next week
Phone: [**Telephone/Fax (1) 64601**]
Department: CARDIAC SERVICES
When: MONDAY [**2125-6-25**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**]
Completed by:[**2125-6-14**] |
1510,5185,5533,53081,71690,53085,V1582 | 99,721 | 166,309 | Admission Date: [**2124-6-21**] Discharge Date: [**2124-6-29**]
Date of Birth: [**2060-4-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal Adenocarcinoma
Major Surgical or Invasive Procedure:
[**2124-6-21**]
1. [**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy.
2. Buttressing of intrathoracic anastomosis with
pericardial fat.
3. Laparoscopic jejunostomy.
4. Esophagogastroduodenoscopy.
History of Present Illness:
Mr. [**Known lastname **] [**Known lastname **] is a 54-year-old male with an intramucosal
adenocarcinoma of the esophagus seen while undergoing his
routine 1 year endoscopy for surveillance of his gastric mucosa
APC gene mutation. He was admitted for esophagectomy.
Past Medical History:
GERD
Hiatal hernia
Barretts
APC gene mutation
Colonic adenoma [**2122**]
Social History:
former smoker 40-50 ppy
Family History:
NC
Physical Exam:
VS: T: 98.9 HR: 72 SR BP: 128/80 Sats: 98% RA
General: 64 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp; decreased breath sounds otherwise clear
GI: bowel sounds positive abdomen soft non-tender/non-distended
Extre: warm no edema
Incision: Right VATs site clean, dry intact, well approximated.
J--tube site clean dry intact
Neuro: non-focal
Pertinent Results:
[**2124-6-21**] WBC-11.3* RBC-5.18 Hgb-16.1 Hct-45.4 MCV-88 MCH-31.1
MCHC-35.6* RDW-13.2 Plt Ct-201
[**2124-6-22**] 02:13AM BLOOD WBC-9.2 RBC-5.23 Hgb-15.5 Hct-46.4 MCV-89
MCH-29.6 MCHC-33.4 RDW-13.5 Plt Ct-206
[**2124-6-22**] 02:13AM BLOOD WBC-9.9 RBC-4.88 Hgb-15.2 Hct-44.0 MCV-90
MCH-31.2 MCHC-34.5 RDW-13.7 Plt Ct-221
[**2124-6-23**] 02:27AM BLOOD WBC-11.6* RBC-4.64 Hgb-14.2 Hct-41.3
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.4 Plt Ct-205
[**2124-6-24**] 07:45AM BLOOD WBC-8.5 RBC-4.18* Hgb-12.9* Hct-38.1*
MCV-91 MCH-30.9 MCHC-34.0 RDW-13.5 Plt Ct-159
[**2124-6-25**] 07:05AM BLOOD WBC-8.0 RBC-4.36* Hgb-13.5* Hct-39.9*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.6 Plt Ct-190
[**2124-6-26**] 07:15AM BLOOD WBC-7.5 RBC-4.54* Hgb-14.5 Hct-41.0
MCV-90 MCH-31.9 MCHC-35.3* RDW-13.9 Plt Ct-216
[**2124-6-21**] 06:22PM BLOOD Glucose-174* UreaN-18 Creat-0.8 Na-138
K-3.9 Cl-103 HCO3-26 AnGap-13
[**2124-6-22**] 02:13AM BLOOD Glucose-160* UreaN-16 Creat-1.0 Na-133
K-8.0* Cl-103 HCO3-25 AnGap-13
[**2124-6-23**] 02:27AM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
[**2124-6-24**] 07:45AM BLOOD Glucose-119* UreaN-15 Creat-0.6 Na-139
K-3.5 Cl-100 HCO3-33* AnGap-10
[**2124-6-25**] 07:05AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-141
K-3.5 Cl-100 HCO3-33* AnGap-12
[**2124-6-26**] 07:15AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-139
K-3.9 Cl-100 HCO3-30 AnGap-13
[**2124-6-21**] 06:22PM BLOOD Calcium-8.0* Phos-4.0 Mg-1.7
[**2124-6-22**] 02:13AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.3
[**2124-6-22**] 02:13AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.2
[**2124-6-23**] 02:27AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.1
[**2124-6-24**] 07:45AM BLOOD Calcium-7.7* Phos-1.8* Mg-1.9
[**2124-6-25**] 07:05AM BLOOD Calcium-8.3* Phos-3.4#
[**2124-6-26**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
imaging:
[**2124-6-21**] CXR
Endotracheal tube, the tip projects roughly 7 cm above the
carina.
Normal course and position of the right-sided chest tube. No
safe evidence of pneumothorax. No evidence of mediastinal
widening. Moderate perihilar haze on the right, likely due to
the post-operative situation. Mediastinal drains are in expected
position. The lung bases show bilateral areas of atelectasis.
Post-operative subcutaneous gas inclusions. Normal size of the
cardiac silhouette.
[**2124-6-22**] CXR
Right apical chest tube remains in place. Nasogastric tube is in
unchanged
position with tip at the level of the hemidiaphragms. Enlarged
cardiomediastinal silhouette is stable. There is no evident
pneumothorax.
Left lower lobe retrocardiac opacities have minimally increased,
consistent with increasing atelectasis. Drain projects midline.
[**2124-6-23**] CXR
1. Probably increased bilateral atelectasis or could be early
pulmonary
edema.
2. Stable mild cardiomegaly with likely new small bilateral
pleural effusion.
[**2124-6-25**] CXR
Very small right apical pneumothorax with chest tube in place.
Improving bibasilar atelectasis and persistent small pleural
effusions
[**2124-6-26**] CXR
Small bilateral pleural effusions, including a right fissural
component, have increased. Tiny right apical pneumothorax is
stable. Moderate atelectasis at the lung base has worsened.
Upper lungs clear. Heart size increased though normal.
[**2124-6-27**] CXR Barium Swallow
microbiology: none
Brief Hospital Course:
The patient was admitted to the Thoracic Surgical Service for
elective esophagectomy for intramucosal adenocarcinoma of the
esophagus. Patient tolerated the operation well. He arrived in
the ICU NPO, on IV fluids and antibiotics (3 doses total), with
a Foley catheter, JP drain, chest tube, epidural and PCA
Dilaudid for pain control. Patient was extubated and re
intubated shortly after secondary to the respiratory distress in
the ICU. He was extubated once again shortly after, which he
tolerated well. The patient was hemodynamically stable.
Neuro: The patient received epidural and PCA Dilaudid with good
effect and adequate pain control. On POD 6, after patient passed
the barium swallow study, the epidural was removed and PCA was
discontinued. When tolerating oral intake, the patient was
transition ed to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: After the initial reintubation and successful
re-extubation on POD 0 in the ICU, the patient remained stable
from a pulmonary standpoint. The chest tube was placed in the
operating room. It was initially placed to suction and on POD 1
to water seal. It remained to water seal, with no air leak,
until POD 6, when it was taken out. The chest x-rays were
obtained daily. Following the removal of the chest tube, there
was tiny right apical pneumothorax seen on chest x-ray. Patient
was stable and his oxygen saturation was > 92% on room air. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Tube feeds were started at 20 cc/hr on POD 1 as per
pathway, and advanced by 20 cc/hr daily, up to a goal of 125
cc/hr. Patient tolerated the tube feeds well. The barium swallow
study was obtained on POD 6. It demonstrated no leak.
Subsequently, the diet was slowly advanced to full liquid.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and replete when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient remained
afebrile throughout the hospital stay. He received 3 doses total
of intra and perioperative antibiotics.
Endocrine: No issues.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled on oral pain medications. Patient was
discharged with tube feeds at goal rate of 100 cc/hrs 12 hrs.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
OMEPRAZOLE 20 MG DAILY
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*6*
2. Roxicet 5-325 mg/5 mL Solution Sig: [**5-15**] ml PO every six (6)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation: while on narcotics.
4. Tube feedings
Replete full strength at 125 ml/hr via j-tube cycled over 18
hours each day for nutritional support, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12351**] [**Doctor Last Name **]
esophagectomy. Flush feeding tube with 50 ml q 8 hr, and before
and after use. Do not put any crushed meds down j-tube, only
liquids. Pt will need feeding pump and tube feeding supplies.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever 101 or greater
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficult or painful swallowing.
-Nausea, vomiting, diarrhea or abdominal pain
-Chest tube site cover with a bandaid until healed
-You may shower. No tub bathing or swimming
-Call immediately [**Telephone/Fax (1) 2348**] if Feeding tube falls out.
Please bring the feeding with you so it can be replaced
promptly.
-No driving while taking narcotics. Take stool softners with
narcotics
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2124-7-11**] 10:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Chest X-Ray [**Location (un) **] radiology 30 minutes before your
appointment.
Completed by:[**2124-6-29**] |
0389,78552,51881,5849,1977,1978,72973,9982,99592,4019,27541,V1046,E8700 | 99,726 | 186,684 | Admission Date: [**2200-11-24**] Discharge Date: [**2200-11-26**]
Date of Birth: [**2139-11-15**] Sex: M
Service: SURGERY
Allergies:
Quinine
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Septic shock and pneumatosis coli.
Major Surgical or Invasive Procedure:
Exploratory laparotomy.
History of Present Illness:
The patient is a 61-year-old man with a
personal history of prostate cancer and a diagnosis of
pancreatic cancer with multifocal liver metastases on
chemotherapy. He had an acute event and was transferred to
our emergency room septic in shock. Resuscitation and
intubation failed to improve his status and he was noted to
have pneumatosis coli on a CT scan. Despite his poor
prognosis from stage IV pancreatic cancer, his wife wished
for all measures to be taken and he was taken to the
operating room emergently for exploratory surgery with the
presumptive diagnosis of ischemic bowel.
Past Medical History:
HTN
PSH: LIHR, radical prostatectomy, L fibula steel plate
insertion.
Social History:
Lives with his wife.
Family History:
NC
Pertinent Results:
Small bowel:
Focal recent hemorrhage. No evidence of malignancy.
Brief Hospital Course:
[**11-24**] PT transferred to emergency room septic in shock.
Resuscitation and
intubation failed to improve his status and he was noted to
have pneumatosis coli on a CT scan. Emergent exploratory
surgery performed without evident cause of decompensation other
than abdominal compartment syndrome without obvious causative
factor. PT transferred to the ICU on mechanical intubation,
pressors. BCx with GNR, started Cipro. DNR code statue per
family meeting. Insulin GTT.
[**11-25**] Episode relative hypotension with increased pressor
requirements - SVV 14-17, gave fluid bolus. Continued
intubation, full ICU support.
[**11-26**] patient made CMO after family meeting with Dr [**Last Name (STitle) 35981**]. Pt
expired 3:22 p.m. was pronounced dead roughly 45 minutes after
made CMO. Family notified and offered autopsy. Family declined
autopsy.
Medications on Admission:
Diltiazem, Tylenol, Milk of Magnesium.
Discharge Medications:
Does not apply
Discharge Disposition:
Expired
Discharge Diagnosis:
Death secondary to metastatic pancreatic cancer, sepsis,
respritory failure.
Discharge Condition:
Death
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
SUMMARY NEITHER DICTATED NOR READ BY ME
Completed by:[**2200-11-26**] |
07030,570,5184,0389,99592,51881,78552,4846,5722,5849,1173,2869,07032,V641,2875,2512,4019 | 99,740 | 161,687 | Admission Date: [**2135-5-1**] Discharge Date: [**2135-5-17**]
Date of Birth: [**2084-1-15**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Liver failure
Major Surgical or Invasive Procedure:
[**2135-5-9**]: Cardiac catheterization
History of Present Illness:
52 M cambodian native w/ h/o hep B treated w/ IFn-a and adefovir
followed by entecovir. THe patient had been taking no
medications for approximately 2 years. He was transferred from
[**Hospital 794**] Hospital, RI, with N/V, weakness and abdominal pain with
associated jaundice for ~2weeks. At the time of transfer, the
patient had worsening LFTs to ALT 928, AST 624, Bili of 26.8
(direct 16.3), INR of 4.9 and Cr of 1.7. On arrival at [**Hospital1 18**] he
had a MELD of 41
Past Medical History:
PMH: Hep B, Tuberculosis, HTN, HL.
PSH: Left lower lobectomy for TB, inner ear implant.
Social History:
No tob, rare etoh, no illicits. Lives at home w/ family
Family History:
Unknown
Pertinent Results:
Admission labs:
[**Age over 90 **]|101|19
----------<53
5.2|23|1.8
7.2>37.9<136
ALT 425 AST 321 AP 87 TBili 22.0
INR 4.6 PT 46.4 PTT54.2
Brief Hospital Course:
Pt was admitted to [**Hospital1 18**] where he underwent a transplant workup
by the hepatology and transplant surgery services. On [**5-5**] he
was listed as a transplant candidate with a MELD of 41. On [**5-6**]
he was transferred to the SICU in preparation for a possible
iver transplant. Unfortunately the procedure was unable to
proceed due to poor donor graft. He remained in the SICU under
the managment of the transplant surgery service and the SICU
team.
On [**5-8**] he was once again prepared for a possible liver
transplant but on the following morning he developed tachycardia
with ST depressions on EKG. The transplant was cancelled and an
urgent cardiology consult obtained. They recommended urgent
heart catheterization, however his elevated INR required
correction w/ 9U FFP prior to procedure. Cath identified 80%
circumflex lesions that were deemed unstentable and cardiology
recommended rate control. After receiving blood products the
patient developed pulmonary edema requiring treatment with lasix
and noninvasive ventilation (BiPAP). The following morning his
respiratory status had improved and BiPAP d/c'd. He also
received 2U PRBCs for Hcts 24 to maximize oxygen carrying
capacity.
On the afternoon of [**5-11**] he developed a rapid drop in blood
pressure requiring urgent IV fluids, placement of a central
line, intubation, and initiation of pressors. An echo obtained
at this time demonstrated hyperdynamic left ventricle and he was
presumed to be septic and antibiotics were started. His urine
output on this day was minimal and his creatinine had risen to
3.3. Bladder pressure was 19 and the patient was not felt to
have compartment syndrome.
By [**5-12**] his blood pressure had improved sufficiently to
discontinue pressors but he remained intubated due to his mental
status. His INR remained elevated (7.3) and he received FFP for
correction. He underwent bronchoscopy and one of the BAL samples
grew mold which was eventually speciated to Aspergillis for
which he was started on Voriconazole.
His multisystem organ failure worsened over the next several
days ([**2133-5-12**]): Despite several days without sedation his
neurologic status worsened until he was no longer withdrawing to
painful stimuli and his pupillary reflexes became nonexistent.
His hemodynamic status worsened as evidenced by the progression
from intermittent pressors to requiring increasing doses of
levophed. His course was further complicated by oliguric renal
failure with rising creatinine, which peaked at 8.4. His liver
failure likewise worsened with Tbili's climing to 32 and
coagulopathy marked by INRs > 7.
In the setting of pulmonary aspergillosis, the patient was not a
transplant candidate until he could receive at least two weeks
of treatment and demonstrate clearing of the fungal infection.
After consultation among the teams involved in the patient's
care (transplant surgery, hepatology, SICU, infectious disease)
consensus was reached that supporting the patient through
multisystem organ failure for that amount of time was extremely
unlikely. Several conversations were had with the family
explaining that the patient's accumulated physiologic insults
had made further treatment futile. The family agreed to
withdrawal of care and within half an hour of extubation the
patient died on [**5-17**].
Medications on Admission:
Cipro 500 mg daily
Losartan 50 mg daily
Zofran 4 mg PRN
Pravastatin 40 mg daily
Vit D3 2000u daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Multisystem organ failure (liver failure, renal failure),
pulmonary aspergillosis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2135-5-18**] |
42833,51881,5849,40390,1749,28521,49121,4280,4139,41400,5853,2720,28529,4240,28860,V4581,V4986,V5865,V462 | 99,747 | 136,052 | Admission Date: [**2103-11-23**] Discharge Date: [**2103-11-30**]
Date of Birth: [**2023-9-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
dyspnea at rest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 year old female with COPD on home 2L, HTN, recurrent anemia,
diastolic CHF who presents with progressive dyspnea. She was
discharged from [**Hospital1 112**] 7 days PTA for COPD and CHF, where she was
treated with blood transfusions, steroids and diuresis. Since
discharge her dyspnea has progressively worsened. She states
that it is exacerbated by activity and laying flat. Symptoms
accompanied by cough with clear sputum for 1 day, palpitations,
and chest pressure associated with some gas. No radiation to
extremities or jaw, diaphoresis. Patient states that chest
pressure was present for many hours on admission, consistent
with her baseline chest discomfort she has experienced for
years. Of note, the patient is on 2L home O2 at baseline, with
home O2 sat ranging from 92-95%.
.
In the ED, initial VS were: 98.1, Pulse: 73, RR: 30, BP: 137/46.
CXR revealed pulmonary edema. Foley was placed and the patient
was given 40mg IV lasix, IV solumedrol, and levofloxacin. She
was placed on a BIPAP. On arrival to the MICU, patient was
satting 96% 40% BIPAP.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Diastolic CHF
COPD, severe
COLONIC ADENOMA
CANCER - BREAST, INTRADUCTAL
Anemia
CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min
Tobacco dependence
INTESTINAL VASC INSUFFIC
HISTORY CAROTID ENDARTERECTOMY
DIVERTICULOSIS
HYPERCHOLESTEROLEMIA
CORONARY ARTERY DISEASE S/P CORONARY ARTERY BYPASS [**Doctor First Name 147**]
HYPERTENSION - ESSENTIAL
Social History:
- Tobacco: 1 pack/day for 50 years, currently does not smoke
- Alcohol: denies
- Illicits: denies
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals:afebrile, 115/80, P-77, 95% face mask 40%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, poor air movement, no
wheezes, bibasilar insp. rales, ronchi.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: brown, Guiac neg stool
GU:foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge Physical Exam:
VS: 98.0 143-166/70-84 79-92 20 98%3L
General: Pleasant woman; Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 8 mm H2O, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement bilaterally, scattered expiratory
wheezing.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU:foley in place draining light colored urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2103-11-23**] 04:00PM BLOOD WBC-16.6* RBC-2.54* Hgb-7.3* Hct-21.7*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.0 Plt Ct-240
[**2103-11-23**] 04:00PM BLOOD PT-13.3* PTT-25.4 INR(PT)-1.2*
[**2103-11-23**] 04:00PM BLOOD Glucose-163* UreaN-47* Creat-2.2* Na-137
K-3.4 Cl-99 HCO3-25 AnGap-16
[**2103-11-23**] 11:38PM BLOOD Mg-2.1 Iron-75
[**2103-11-24**] 03:28PM BLOOD Type-[**Last Name (un) **] pO2-83* pCO2-72* pH-6.96*
calTCO2-18* Base XS--17
.
Discharge Labs:
[**2103-11-30**] 06:30AM BLOOD WBC-13.0* RBC-3.30* Hgb-9.8* Hct-28.0*
MCV-85 MCH-29.9 MCHC-35.2* RDW-15.0 Plt Ct-212
[**2103-11-30**] 06:30AM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1
[**2103-11-30**] 06:30AM BLOOD Glucose-112* UreaN-121* Creat-2.6* Na-139
K-4.0 Cl-90* HCO3-36* AnGap-17
[**2103-11-30**] 06:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9
.
CXR [**2103-11-23**]:
FINDINGS: Single AP upright portable view of the chest was
obtained. Diffuse alveolar opacities throughout the lungs,
right greater than left, which could represent asymmetric edema
and/or infection. Slight blunting of the left costophrenic angle
may be due to trace pleural effusion. The patient is status post
median sternotomy. The cardiac silhouette is top normal. The
aorta is calcified.
.
IMPRESSION: Diffuse bilateral, right much greater than left
alveolar opacities could relate to asymmetric edema and/or
infection. Correlate clinically and consider repeat after
diuresis. Comparison with prior radiographs would be helpful.
.
ECHO [**2103-11-26**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
normal free wall contractility. The diameters of aorta at the
sinus, ascending and arch levels are normal. 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. Moderate to severe ([**12-21**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
80 year old female with COPD, HTN, recurrent anemia, diastolic
CHF who was admitted for dyspnea and anemia.
.
#Dyspnea- The patient was admitted to the MICU with hypoxia to
the 70%s on room air. She briefly required non-invasive
ventilation. She was covered for a possible COPD exacerbation
with nebs, prednisone and azithromycin (antibiotic course
completed). She also was started on a lasix and nitro drip for
acute on chronic diastolic CHF (EF 60%). Chest X-ray revealed
bilateral pulmonary opacities with pulmonary edema. The patient
diuresed well and dyspnea improved, making acute on chronic
diastolic CHF the chief diagnosis. The patient underwent a
transthoracic echo that showed moderate to severe MR worsened
since [**9-/2103**], which may be contributing to CHF exacerbation.
Cardiac enzymes were negative X3 for ischemic cause of heart
failure exacerbation. Prior to transfer to the floor, lasix and
nitro drips were discontinued. The patient was started on
torsemide (in place of home lasix) and imdur. She continued to
diurese well. Her oxygenation improved. At time of discharge,
the patient was saturating well on 3L O2. She was discharged on
torsemide for diuresis and a prednisone taper.
.
#Anemia- Patient has a history of significant anemia, with acute
decrease in HCT on admission from 30 to 21. Stools guaiac
negative. Patient was transfused 1 unit PRBCs. Hematocrit
stabilized at 25 for the remainder of admission. Etiology of
anemia likely multifactorial, secondary to CKD, repeated
phlebotomy. Stools remained guaiac negative throughout
admission.
.
#Acute on chronic kidney injury - Baseline creatinine is 1.5-2.0
over the past few months. With diuresis, creatinine increased
to 2.4-2.6 daily. The patient should follow up regarding her
creatinine within a week of discharge.
.
#Chronic Angina/CAD- Chronic angina has been controlled on
ranolazine and isosorbide mononitrate. Stress test in [**10/2103**]
revealed reversible inferior defect on nuclear imaging. Patient
remained chest pain free throughout admission. The patient was
continued on atorvastatin, ASA, hydralazine and imdur. Ranexa
was discontinued due to acute kidney injury. The patient should
follow up with her cardiologist about reinitiation of ranexa
with improvement in renal function to baseline.
.
# Code:DNR/DNI
====================================================
TRANSITIONAL ISSUES:
#The patient should follow up regarding her BUN/creatinine [**12-4**].
Results to be reported to Dr. [**Last Name (STitle) **].
#The patient should follow up with her cardiologist about
reinitiation of ranexa with improvement in renal function to
baseline.
Medications on Admission:
Prednisone 10 mg Oral Tablet Take 1 tablet in morning or as
directed
Atorvastatin 80 mg Oral Tablet Take one-half tablet (40mg) daily
Folic Acid 1 mg Oral Tablet Take 1 tablet daily
Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1
capsule 30 minutes before first meal of day
Ranolazine 500 mg Oral Tablet Extended Release 12 hr one [**Hospital1 **]
Ferrous Sulfate 325 mg (65 mg iron) Oral Tablet one qd
Docusate Sodium (STOOL SOFTENER) 100 mg Oral Capsule one [**Hospital1 **]
Furosemide 40 mg Oral Tablet Take 1 tablet daily
Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg Inhalation
Capsule, w/Inhalation Device One capsule (2 puffs) inhaled daily
Prednisone 20 mg Oral Tablet 2 tablets daily for 3 days, then 1
tablet daily for 3 days, then [**11-19**] tab daily for 3 days.
Isosorbide Mononitrate (IMDUR) 60 mg Oral Tablet Extended
Release 24 hr 3 tablets = 180 mg once daily
Metoprolol Tartrate 100 mg Oral Tablet Take 1 tablet twice daily
Hydralazine 25 mg Oral Tablet one pill 3 x per day
Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation HFA
Aerosol Inhaler INHALE 2 PUFFS EVERY FOUR TO SIX HOURS AS NEEDED
Fluticasone-Salmeterol (ADVAIR DISKUS) 500-50 mcg/dose
Inhalation Disk with Device use 1 inhalation TWICE DAILY and
rinse thoroughly afterward
Amlodipine 10 mg Oral Tablet Take 1 tablet daily
Montelukast (SINGULAIR) 10 mg Oral Tablet take one tablet once
daily
Aspirin 325 mg Oral Tablet, Delayed Release (E.C.) 1 tablet
daily
Alendronate 70 mg Oral Tablet TAKE 1 TABLET one day a week in
the morning 30 minutes before food. do not lie down for at least
30 minutes
Discharge Medications:
1. prednisone 10 mg Tablet Sig: as directed Tablet PO daily ():
take 4 tablets x 1 day, then take 3 tablets x 2 days, then take
2 tablets x 2 days, then take 1 tablet daily (ongoing).
Tablet(s)
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): take 30 min
prior to first meal.
5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
Two (2) puffs Inhalation once a day.
9. Imdur 60 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
inh Inhalation twice a day: rinse thoroughly afterward.
13. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
take in AM 30 min prior to eating. Do not lie down for at least
30 min .
16. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
Please check BUN/creatinine [**12-4**]. Report results to:
[**Last Name (LF) **],[**First Name3 (LF) 488**] M.
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 80426**]
Fax: [**Telephone/Fax (1) 6808**]
18. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary diagnosis: Acute on chronic systolic CHF
Secondary diagnosis: COPD exacerbation, acute on chronic kidney
disease, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the intensive care unit with shortness of
breath and found to have an acute worsening of your heart
failure and a possible exacerbation of your COPD. In the ICU,
you received medications IV to help remove the excess fluid from
your body. You were also treated for worsening COPD with
antibiotics and steroids. You will complete a steroid taper as
an outpatient. You will also be discharged on torsemide to
continue to remove the excess fluid form your body.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
MEDICATIONS CHANGED THIS ADMISSION:
STOP lasix
STOP ranexa. Please discuss reinitiation of this medication
with your cardiologist
START torsemide 80 mg by mouth daily
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital1 641**]/CARDIOLOGY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
When: [**Last Name (LF) 2974**], [**12-7**], 9:10 AM
.
DEPARTMENT: INTERNAL MEDICINE
WITH: [**Last Name (LF) **],[**First Name3 (LF) 488**] M.
When: [**2103-12-25**] 1:00PM
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 80426**]
.
Department: VASCULAR SURGERY
When: TUESDAY [**2104-1-15**] at 10:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: VASCULAR SURGERY
When: TUESDAY [**2104-1-15**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]/ CARDIOLOGY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
*Dr. [**Last Name (STitle) 80427**] office staff will contact you to schedule a
follow up appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
5789,2851,7840,53081,4019,2809,2724,32723,311,79029,V1204,V1582,V4586,V1082,V1272 | 99,752 | 187,858 | Admission Date: [**2138-7-15**] Discharge Date: [**2138-7-18**]
Date of Birth: [**2074-8-23**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine / aspirin / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Dizziness, lightheadedness
Major Surgical or Invasive Procedure:
EGD [**2138-7-16**]
History of Present Illness:
63 year old female with a past medical history of Roux en Y in
[**2134**] who presented to the ED today with dizziness,
lightheadedness, and black stools. She states that the black
stools began about a week ago, initially resembling coffee
grounds. She has had dark diarrhea since, and then had dark
black stool today. For the past 2 days, she has also become
increasingly lightheaded, dizzy, and short of breath, worse with
standing. This morning, she had a syncopal episode during which
she stood up, felt dizzy, fell to the floor, no head strike.
Her husband also states that she looks pale. No chest pain,
abdominal pain, nausea, or vomiting. Of note, she had a
colonoscopy in [**2137-1-29**] which noted a sigmoid and ascending
polyps, both found to be adenomas on pathology. There were no
diverticuli noted.
She took a two week course of [**Hospital1 **] ibuprofen in [**Month (only) **] when she had
her upper teeth extracted. She also tapered off of her
omeprazole and has not been currently taking this. She denies
any recent symptoms of early satiety (more than normal), pain
with eating, or pain after eating. She takes a baby aspirin
daily.
In the ED, initial HR in the 70s and SBPs in 110s-120s. Stools
were guiac + black, Hct was 18.2 from baseline 37. She was type
and crossed 2 units, however did not get the blood. She was also
started on a protonix gtt. GI was notified.
On arrival to the MICU, patient is comfortable, alert, in NAD.
She notes a throbbing frontal headache, similar to prior but
lasting longer. She denies any visual changes or neck pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Laparoscopic Roux-en-Y gastric bypass with cholecystectomy on
[**2135-4-6**]
- GERD
- Hypertension
- Hyperlipidemia
- Cholelithiasis
- OSA on CPAP
- Depression
- Breast atypia s/p excisional breast biopsy via wire
localization on [**2136-9-17**]
- Melanoma s/p excision c/b MRSA infection in [**2123**]
- Hysterectomy in [**2115**]
Social History:
She has been married for 14 years. She has one
son. She is a former tobacco user and drinks approximately a
cocktail with dinner. Activities remain the same. She
participates in water aerobics and swimming and always wears a
seatbelt.
Family History:
Mother died at 88. Father died at 62. She has no siblings.
Physical Exam:
On Admission:
Vitals: 99.3 85 117/52 16 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
GU: no foley
Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
Pertinent Results:
Labs on Admission:
======================
[**2138-7-15**] 12:48PM BLOOD WBC-8.6# RBC-2.11*# Hgb-5.9*# Hct-18.2*#
MCV-86 MCH-27.7 MCHC-32.2 RDW-16.3* Plt Ct-298
[**2138-7-15**] 12:48PM BLOOD PT-11.4 PTT-26.3 INR(PT)-1.1
[**2138-7-15**] 12:48PM BLOOD Glucose-178* UreaN-31* Creat-0.7 Na-139
K-3.9 Cl-107 HCO3-23 AnGap-13
[**2138-7-16**] 05:38AM BLOOD ALT-13 AST-23 AlkPhos-31* TotBili-0.5
[**2138-7-16**] 05:38AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1
[**2138-7-15**] 12:48PM BLOOD %HbA1c-5.0 eAG-97
Labs Prior to Discharge:
==========================
Brief Hospital Course:
Assessment and Plan
63 year old female with a history of Roux en Y in [**2134**]
presenting with melena and acute blood loss anemia.
# Acute blood loss anemia: Initially an UGIB was suspected given
melena and elevated BUN. However EGD this morning showed no
source of bleeding. Bleeding may have stopped prior to endoscopy
or it may be a small bowel or lower GI source. There was concern
for anastomotic ulcers since patient has a gastric bypass and
she is off omeprazole but nothing was seen at the GJ anastomotic
site. The J-J anastomosis was not reached. Patient was using
ibuprofen but no gastric ulcers seen. Metastatic melanoma is
always a rare possibility in a patient with prior melanoma.
Colonoscopy was negative. CTA abdomen pelvis showed no active
bleeding. On discharge, she was HD stable with no sign of
acutely active bleeding. Her aspirin was held and she was
discharged on pantoprazole and misoprostol per GI and Bariatric
surgery recs. She received a total of 4 units PRBCs. She will
follow up with GI in two weeks.
# Hypertension: Metoprolol initially held, then restarted on
discharge.
# HL: Continued simvastatin.
# Depression: Continued sertraline.
# OSA: continued CPAP
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Sertraline 100 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. traZODONE 50 mg PO HS:PRN insomnia
6. Aspirin 81 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
9. cod liver oil *NF* 1,250-135 unit Oral daily
10. Cyanocobalamin 1000 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Sertraline 100 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. traZODONE 50 mg PO HS:PRN insomnia
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin E 400 UNIT PO DAILY
11. Misoprostol 100 mcg PO QID
Give with meals, final dose at bedtime.
RX *misoprostol 100 mcg 1 tablet(s) by mouth four times a day
Disp #*20 Capsule Refills:*0
12. Calcium Carbonate 500 mg PO QD
13. cod liver oil *NF* 1,250-135 unit Oral daily
14. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- GI bleed
- Acute Blood Loss Anemia
- Iron deficiency
Secondary:
- Gastric Bypass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 12330**], it was a pleasure taking care of you here at
[**Hospital1 18**]. You were admitted to the hospital because were dizzy and
had dark stools. This was because you were anemic from bleeding
in your digestive track. You had an upper endoscopy and a lower
endoscopy (colonoscopy) which did not see any source of
bleeding. However these studies are not able to visualize the
areas in between. Your blood counts stabilized and there were no
signs that you were still bleeding.
It is VERY important that you avoid all NSAIDs, including
aspirin, ibuprofen, aleve, and advil.
Because your blood tests reveal an iron deficiency anemia, we
gave you a dose of IV iron. You will continue to receive
infusions of IV iron at the hematology clinic at the appointment
listed below.
Followup Instructions:
IV Iron Transfusion, [**Hospital **] Clinic: Please call [**Telephone/Fax (1) 12331**]
to schedule an appointment for IV iron next Thursday [**7-24**]. The
infusion clinic is aware and should be contacting you as well.
You will need to see Dr. [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) 12332**] in the gastroenterology
clinic in 2 weeks. You should receive a call from his office by
Monday to schedule an appointment, but just in case, the clinic
number is [**Telephone/Fax (1) 9891**].
Department: BIDHC [**Location (un) **]
When: WEDNESDAY [**2138-7-23**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2138-8-1**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 12333**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BARIATRIC SURGERY
When: THURSDAY [**2138-8-14**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
5722,4589,7824,5712,2875,2767,30393,5723,27503,3004,7242,78650,2819 | 99,756 | 145,054 | Admission Date: [**2191-8-3**] Discharge Date: [**2191-8-7**]
Date of Birth: [**2140-1-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine / Hydrocodone / Oxycodone / Ativan
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 51 year old man w/ hx of cirrhosis, reportedly
secondary to alcohol and hemochromatosis, recently hospitalized
[**Date range (1) 83051**] for hepatic encephalopathy, now re-presenting
with altered mental status progressive over the last week.
[**Name (NI) **] sister states that he has been at [**Location (un) 169**]
nursing home since discharge from [**Location (un) **] facility, where
she believes he is getting a decreased dose of lactulose from
hospitalization and has not been having regular bowel movements.
She reports that his mental status has been progressively
worsening over the course of the last week, such that he was
less and less interactive. He was only alert and oriented x1
today and was scheduled for an endocrinology appointment, so
family brought him into the hospital. En route to hospital via
EMS, patient admitted to chest pain.
.
.
In the ED, initial vs were afebrile 93 135/95 18 100%RA. On
arrival to ED, patient was unable to express any pain. He was
reported to have scleral icterus and asterixis. He was able to
open eyes to name but did not otherwise follow commands. ECG
showed NSR rate 70, LAD, flattened T-waves throughout
precordium, low voltages, similar to prior. CXR does not show
clear infiltrate, though left hemidiaphragm border is obscured.
A RUQ US was performed showing a patent portal vein, gallstone,
and no ascites. He received 1 L of fluids. Transferred to the
MICU for further management.
.
On arrival in the MICU the patient has VS 96.9 85/62 74 17 and
100%RA. He was responding able to state his name and sometimes
respond yes to questions, though not clear to be appropriately
responding.
.
Sister did state, over the phone, that patient has been in
nursing home since last fall. She states that he was told he is
not likely a candidate for liver transplant because he has not
kept multiple appointments and because he is not independently
functional at baseline, though she feels that all of the
appointments missed were during hospitalizations here at [**Hospital1 18**].
She states that patient was much more independent with ADLs and
IADLs, though living with her, prior to [**9-/2190**] at which time he
was hospitalized for hepatic encephalopathy. In [**12/2190**], he had
fallen in the shower at the nursing home. He fell twice since
then in [**5-/2191**] when family took him out and 6/[**2191**]. Sister
feels that his mental status has been worse since the initial
fall. Sister feels that patient may have some depression with
not likely qualifying for transplant, feeling like he may die
soon. Per OMR notes, prior Head CT shows global cerebral
atrophy, and there is some question from the transplant team of
raising potential underlying dementia, which may be why he never
seems to recover completely from his episodes of encephalopathy.
Past Medical History:
1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given
elevated iron levels (ferritin ~1500, TIBC ~200). Saw
cardiology here in [**2191-4-15**], who performed an MRI and saw iron
deposits in liver concerning for hemochromatosis. Mild CHF on
last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis.
2. Recurrent cellulitis of left leg
3. DVT following trauma to left leg (MVA) Was on warfarin for 1
year.
4. Chronic low back pain
5. Depression
6. Anxiety
Social History:
No current tobacco use, former tobacco ~ 10 pack years (quit 3
years ago). Former alcohol and Klonopin abuse. Patient lives
in [**Hospital 169**] Center, he does not work. He is separated from
his wife. The patient's weekly exercise regimen consists of
walking daily around the building. Patient usually tries to
adhere to a sensible diet and manages ADLs well with assistance.
He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31,
27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago.
Family History:
His father died of lung cancer and his mother has diabetes. He
has 3 sisters and 1 brother who are healthy. His 3 children who
are healthy.
Physical Exam:
Physcial Exam on Admission:
Vitals: T: 96.9 BP: 85/62 P: 74 R: 17 O2: 100% RA
General: Alert, oriented to self (stuttering when he says his
name) but not able to answer any other questions, answers "yes"
to some questions but not clearly appropriately, no acute
distress
HEENT: Scleral icterus, mildly dry mucous membranes, some
asterixis of the tongue
Neck: supple, difficult to assess JVP
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal rhythm, soft heart sounds
Abdomen: soft, obese, non-tender, non-distended, no rebound
tenderness or guarding
Ext: warm, well perfused, 2+ pulses
Physical Exam on Discharge:
Vitals: T: 97.7 BP:109/65 P: 71 R:18 O2sat:100%RA
General: alert, oriented to person, to some degree place, and
on/off to time
Neuro:CN II-XII intact, sitting up in bed and feeding himself
Psych: able to answer questions appropriately and follow
commands, alert
Neuro: no asterixis
Lungs: CTAB
Ext: warm, well perfused, 2+ pitting edema
Otherwise unchanged from admission
Pertinent Results:
Labs on Admission:
[**2191-8-3**] 04:15PM BLOOD WBC-4.4 RBC-3.42* Hgb-12.8* Hct-37.1*
MCV-109* MCH-37.3* MCHC-34.4 RDW-17.6* Plt Ct-55*
[**2191-8-3**] 04:15PM BLOOD Neuts-62.8 Lymphs-23.5 Monos-10.4 Eos-2.7
Baso-0.6
[**2191-8-3**] 04:15PM BLOOD Plt Ct-55*
[**2191-8-4**] 02:09AM BLOOD PT-18.6* PTT-41.7* INR(PT)-1.7*
[**2191-8-3**] 04:15PM BLOOD Glucose-316* UreaN-10 Creat-0.9 Na-131*
K-4.9 Cl-101 HCO3-21* AnGap-14
[**2191-8-3**] 04:15PM BLOOD ALT-27 AST-46* AlkPhos-139* TotBili-5.0*
[**2191-8-3**] 04:15PM BLOOD Lipase-22
[**2191-8-3**] 04:15PM BLOOD cTropnT-<0.01
[**2191-8-3**] 08:36PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
[**2191-8-4**] 02:09AM BLOOD Hapto-<5*
[**2191-8-3**] 04:15PM BLOOD Ammonia-102*
[**2191-8-4**] 02:09AM BLOOD TSH-1.7
[**2191-8-4**] 02:09AM BLOOD AFP-2.7
[**2191-8-3**] 08:42PM BLOOD pH-7.44
[**2191-8-3**] 08:42PM BLOOD freeCa-1.19
[**2191-8-4**] 02:09AM BLOOD T4, FREE, DIRECT DIALYSIS-PND
Labs on Discharge:
[**2191-8-7**] 06:21AM BLOOD WBC-4.6 RBC-3.09* Hgb-11.4* Hct-32.5*
MCV-105* MCH-37.0* MCHC-35.1* RDW-17.0* Plt Ct-43*
[**2191-8-7**] 06:21AM BLOOD PT-19.0* PTT-47.1* INR(PT)-1.7*
[**2191-8-7**] 06:21AM BLOOD Glucose-158* UreaN-11 Creat-0.7 Na-138
K-4.4 Cl-110* HCO3-23 AnGap-9
[**2191-8-7**] 06:21AM BLOOD ALT-33 AST-60* TotBili-4.8*
[**2191-8-7**] 06:21AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.4*
Microbiology:
[**2191-8-4**] 8:11 am URINE Source: Catheter.
**FINAL REPORT [**2191-8-5**]**
URINE CULTURE (Final [**2191-8-5**]): NO GROWTH.
[**2191-8-4**] 8:44 am BLOOD CULTURE Source: Venipuncture #2.
Blood Culture, Routine (Pending):
Imaging:
[**8-3**] RUQ U/S
IMPRESSION: Extremely limited ultrasound demonstrating a patent
periumbilical
vein and splenomegaly. Cholelithiasis without cholecystitis.
[**8-3**] CXR
IMPRESSION: Limited exam. No gross consolidation or edema
evident.
[**8-3**] CT-PA
IMPRESSION:
There is no CT evidence of pulmonary embolism within the main,
lobar and
segmental pulmonary arteries. Due to suboptimal opacification of
the
subsegmental pulmonary arteries evaluation of subsegmental
pulmonary embolism
was limited.
Cirrhotic liver with splenomegaly suggestive of portal
hypertension
Cholelithiasis and choledocholithiasis without bile duct
dilatation, unchanged
since [**2191-6-17**].
Brief Hospital Course:
Primary Reason for Hospitalization:
Mr. [**Known lastname **] is a 51 y/o male with alcoholic cirrhosis and possibly
hemochromatosis who presented with one week of altered mental
status from hepatic encephalopathy.
.
Acute Care:
1. Hepatic Encephalopathy: Patient presented with no response to
sternal rub and was admitted to the MICU overnight. There was no
evidence of bleed and patient's Hct was stable. Ultrasound
showed patent portal veins and no ascites. It also showed
cholelithiasis without cholecystitis. He was afebrile and had a
normal WBC count, clean UA, and blood and urine cultures with no
growth to date on discharge. In the MICU he receved lactulose
enemas and laculose PO when he was able to take PO medication
and his mental status improved. He was also continued on
rifaximin. Given no history of recent falls and evident
improvement with lactulose hepatic encephalopathy was diagnosed
and head CT was deferred. He was transferred to the floor still
only oriented to person but easily arousable and able to answer
questions and call the nurse if needed. With continued standing
lactulose administration on the floor patient became more alert
and was able to speak more to staff. He was still only oriented
to person on discharge, but knew that he had stayed in the
hospital and could express complaints. He was discharged with
instructions to titrate bowel movements to 3-5 per day with
lactulose PO and to continue home rifaximin.
.
2. Hyperbilirubinemia
Patient noted to have TBili of 5.0 on presentation with mildly
elevated alk phos. RUQ US had mention of gallstones, but no
signs of ductal dilation. Patient was monitored with serial
abdominal exams and had no RUQ pain and no changed on abdominal
exam. He was discharged with his Tbili having decreased to 4.8.
.
3. Chest Pain: Patient complained of chest pain en route to ED.
ECG was unchanged from prior, NSR rate 70, LAD, flattened
T-waves throughout precordium, low voltages. Troponins were
negative x2 and patient ruled out for MI.
.
Chronic Care:
1. Chronic Hypotension- During his prior admission, the patient
had significant hypotension with BPs in the ~90s systolic. This
admission SBPs were 110-130s systolic and patient's midodrine
was [**Known lastname **] but restarted once SBP dropped to 90's. With re-start,
patient's BP again improved to 110's-130's systolic. During
episode of hypotension/tachycardia patient received CT-PA for
concern of PE which was negative for PE.
.
2 Diabetes Mellitus: On presentation, patient had a glucose of
316. Patient was monitored with FSGS and treated with Insulin
sliding scale with good glucose control.
.
3. Cirrhosis/Transplant-The patient was worked up for potential
transplant at [**Hospital1 18**]. Per last transplant note dated [**2191-7-29**]
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) the patient is a poor transplant candidate
for a number of medical and psychosocial reasons. Has been
instructed to follow with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**] for continued mgmt of
end-stage liver disease. Patient was continued on lactulose and
rifampin for hepatic encephalopathy and on midodrine for
hypotension.
.
Transitional Care:
Patient should follow-up with his primary care physician within
one week of discharge.
The final results of patient's blood and urine cultures were
pending on discharge and should be followed-up by his primary
care physician.
[**Name10 (NameIs) **] should receive only lactulose to produce bowel movements
and should be titrated to [**3-19**] bowel movements per day as
prescribed.
Medications on Admission:
- rifaximin 550 mg Tablet PO BID
- lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical
to back and hip
- tramadol 50 mg Tablet PO Q6H prn pain
- testosterone 5 mg/24 hr Patch 24 hr Q24H
- Calcium Citrate + D 315-200 mg-unit [**Hospital1 **]
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- multivitamin daily
- pyridoxine 25 mg Tablet daily
- heparin (porcine) 5,000 unit/mL Solution TID
- omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
- ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE) for 3 weeks: to be completed [**2191-7-20**].
- nystatin 100,000 unit/g Powder Sig: powder to skin folds
Topical twice a day as needed for rash.
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: limit to 2g/24hrs.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for <3 BM's day prior.
17. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): see humalog sliding scale.
18. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Medications:
1. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week for 12 weeks: Please continue this
medicine until 12 weeks from your original dose, then re-check
vitamin D levels.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: hold
for SBP<100.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
5. Novolog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
6. Levemir 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
7. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H
(every 4 hours): titrate to [**3-19**] bowel movements per day.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: 12 hours on 12 hours off to
affected area.
9. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
10. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day as needed for rash.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
14. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**4-20**]
hours as needed for pain: do not exceed 2gm/day.
16. Atrac-Tain [**4-24**] % Cream Sig: One (1) application Topical
once a day: apply to lower extremities once daily.
17. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
18. Ensure Plus 0.05-1.5 gram-kcal/mL Liquid Sig: Two Hundred
Forty (240) mL PO twice a day: mix with 60mL Propass.
19. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO three
times a day.
20. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
twice a day as needed for if less than 3 bowel movements per
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 5344**]
Discharge Diagnosis:
1)Hepatic Encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname **],
You were admitted to our facility with altered mental status.
You spent a day in the ICU where we were looking for causes of
your altered mental status. We felt that your confusion was
caused by your liver disease and we gave you medication for this
condition. Your mental status improved.
Please make the following changes to your medications:
1)START Lactulose 60ml by mouth every four hours and titrate to
[**3-19**] bowel movements per day
2)STOP milk of magnesia and miralax for constipation treatment.
If you are constipated take more laculose.
Followup Instructions:
Please make an appointment to see your primary care physician
[**Name Initial (PRE) 176**] 1 week of discharge to arrange re-starting your full
Lasix dosing.
Department: LIVER CENTER
When: WEDNESDAY [**2191-9-28**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2191-8-31**] at 4:30 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
5722,2869,5849,2763,2761,4589,2875,7892,5990,2841,5712,30393,7823,V1251,V5413,3004,7242,33829,2572,28850,0414,27503,2819,V1582,79029,2767 | 99,756 | 154,665 | Admission Date: [**2191-6-15**] Discharge Date: [**2191-7-6**]
Date of Birth: [**2140-1-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine / Hydrocodone / Oxycodone / Ativan
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 51 year old male with a history of cirrhosis secondary
to alcohol use and possibly hemochromatosis who was admitted for
unresponsiveness. Per his family, he was found by the nursing
staff to be unresponsive on the morning of [**6-15**], they were unable
to arouse him. Per his sister, the day prior they had seen him
at the hospital after his elective EGD, and he was doing well,
talking, at his baseline. She came to visit him today with the
rest of the family and states that he was able to recognize
them, but definitely far from his baseline. She states that this
seems like prior episodes when "his ammonia is high." He has had
prior episodes of encephalopathy, last at [**Hospital6 33**]
from [**Date range (1) 83045**] because he "couldn't speak" per the family. After
receiving lactulose, he returned back to his baseline. He has
since had 2 falls in [**Month (only) 116**] - once on Mother's day where he tripped
and broke his right hip. No intervention was done. He then fell
again, which per the family he doesn't remember. He had head
strikes during both falls (one requiring stitches to the
forward), but per the family, he was no different mentally after
those falls.
.
On [**6-14**], he underwent an EGD at [**Hospital 83046**] hospital for a hct
that was trending down of unclear etiology. He has been getting
blood transfusions for this downtrending Hct. Over this time his
edema has been getting worse and a foley catheter was placed [**2-17**]
days prior to admit as his scotal swelling prevented him from
voiding effectively. Per his family he has been taking all of
his medications as prescribed.
.
On admission yesterday, he was noted to be in the 90s systolic,
afebrile. A RUQ US could not get great views of vasculature, but
no ascites. A CXR was difficult to interpret but showed no
obvious consolidation. He is guaiac negative and given a
lactulose enema in the ED. In the MICU, he received 3 doses of
30ml lactulose, and 1 dose of PR enema with ~ 3 BM's. He was
placed on Lasix 20mg IV bid and Spironolactone 100mg po daily.
He is net negative 2L during his MICU stay. He seemed improved
after lactulose enemas per the MICU team.
.
On the floor, he is arousable to voice, able to answer a few
questions, states his name. Very poor attention.
.
ROS: Denies pain. Otherwise unable to obtain given pt's mental
status. But, per the family, he was not having any pain, fever,
or other complaints the day prior.
Past Medical History:
1. Cirrhosis [**2-16**] alcohol and hemochromatosis complicated by
encephalopathy
2. Recurrent cellulitis of left leg
3. DVT following trauma to left leg (MVA) Was on warfarin for 1
year.
4. Chronic low back pain
5. Depression
6. Anxiety
Social History:
No current tobacco use, former tobacco ~ 10 pack years (quit 3
years ago). Former alcohol and Klonopin abuse. Patient lives
in [**Hospital 169**] Center, he does not work. He is separated from
his wife. The patient's weekly exercise regimen consists of
walking daily around the building. Patient usually tries to
adhere to a sensible diet and manages ADLs well with assistance.
He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31,
27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago.
Family History:
His father died of lung cancer and his mother has diabetes. He
has 3 sisters and 1 brother who are healthy. His 3 children who
are healthy.
Physical Exam:
ADMISSION:
ON THE MEDICINE FLOORS, HOD#2
Vitals: T: 96.5 BP: 105/60 P: 79 R: 12 O2: 97%RA
General: sleeping, arouses to voice, poor attention, appears
very somnolent, able to only answer few questions with one word
answers including stating his name and "no" to pain
HEENT: NCAT, PERRL, ecchymoses over left eyelid, dry MM, unable
to fully visualize oropharynx, no apparent tongue fasiculations
Neck: supple, obese, JVP not elevated
Lungs: no use of access mm, poor effort, no crackles or wheezes
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: +NABS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly, no fluid wave, no flank
dullness
GU: foley in place, dark yellow urine, diffusely edematous/tense
scrotum
Ext: warm, diffuse anasarca up to his abdomen
Neuro: somnolent, poor attention, oriented only to self, able to
follow limited commands, raise hands, unable to wiggle toes, 2+
DTR's in biceps & brachioradialis, downgoing toes, + asterixis
DISCHARGE:
Vitals: 98.4 98.2 92-115/46-66 70-101 18 100%RA BG 133-228
24H 1750/inc, BMx4
8H 540/inc, large BM
General: awake, lying in bed, able to follow commands,
tremulous, NAD, appears confused
HEENT: NCAT, mildly icteric sclera, Dobhoff in place
Neck: supple, obese, JVP not elevated
Lungs: clear anteriorly without wheezes or crackles, no use of
access mm
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: +NABS, soft, non-distended, non-tender, no rebound
tenderness or guarding, no fluid wave, no flank dullness
GU: in adult diaper, no foley
Ext: pitting edema to hip, left leg with 3+ edema in shin,
stasis dermatitis, tender to palpation of shins bilaterally
Neuro: oriented to person, states he does not know, says "[**2181**]"
for the date, says "I'm confused," +asterixis
**PT'S MENTAL STATUS FLUCTUATES THROUGHOUT THE DAY. Pt is always
oriented to person, but occasionally not oriented to place or
date. He seems to be better in the afternoon, frequently
oriented to place and year but not exact date.
Pertinent Results:
ADMISSION LABS:
[**2191-6-15**] 02:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2191-6-15**] 12:50PM GLUCOSE-123* UREA N-21* CREAT-0.8 SODIUM-138
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-9
[**2191-6-15**] 12:50PM ALT(SGPT)-43* AST(SGOT)-88* ALK PHOS-143* TOT
BILI-4.2* DIR BILI-0.9* INDIR BIL-3.3
[**2191-6-15**] 12:50PM LIPASE-26
[**2191-6-15**] 12:50PM cTropnT-<0.01
[**2191-6-15**] 12:50PM ALBUMIN-2.2* CALCIUM-8.4 PHOSPHATE-3.3
MAGNESIUM-1.7 IRON-187*
[**2191-6-15**] 12:50PM calTIBC-213* FERRITIN-1494* TRF-164*
[**2191-6-15**] 12:50PM AMMONIA-173*
[**2191-6-15**] 12:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2191-6-15**] 12:50PM WBC-4.5 RBC-3.35* HGB-11.8* HCT-34.2*
MCV-102* MCH-35.2* MCHC-34.4 RDW-19.9*
[**2191-6-15**] 12:50PM NEUTS-78.4* LYMPHS-13.3* MONOS-5.8 EOS-2.1
BASOS-0.5
[**2191-6-15**] 12:50PM PLT COUNT-50*
[**2191-6-15**] 12:50PM PT-16.9* PTT-32.7 INR(PT)-1.5*
[**2191-6-15**] 12:48PM GLUCOSE-116* LACTATE-1.9 NA+-136 K+-4.4
CL--101 TCO2-29
[**2191-6-15**] 12:48PM HGB-12.0* calcHCT-36
[**2191-6-15**] 12:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2191-6-15**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-TR
[**2191-6-15**] 12:40PM URINE RBC->182* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
[**2191-6-15**] 12:40PM URINE MUCOUS-RARE
DISCHARGE LABS:
Na 136 K 5.4 Cl 99 HCO3 36 BUN 34 Cr 1.3 BG 182
WBC 3.2 Hgb 9.2 Hct 27.3 Plt 58
INR 1.5
ALT 14 AST 29 AP 90 Tbili 2.8
PERTINENT STUDIES:
Urine hemosiderin: negative
Ammonia: 35
IgG: 1323
QG6PD: 11.8 (normal)
UPEP: no abnormalities
SPEP: no abnormalities
TSH: 2.4 FreeT4 1.2
Ret-Aut: 3.6
HFE gene: RESULT: NEGATIVE
A1AT: 122 (range 83-199 mg/dL)
Ceruloplasmin: 13 L (range 18-36 mg/dL)
Copper: 34 (low)
[**Doctor First Name **]: negative
FSH: <1.0
LH: <1.0
Testost: 19
SHBG: 41
calcFT: 3.6
TSH:4.3 Free-T4:1.1
ACTH, PLASMA 12 ([**7-/2130**] pg/mL)
cortisol, free Results Pending
cortisol binding globulin (Transcortin) Results Pending
STUDIES:
CXR [**2191-6-15**]:
FINDINGS: In comparison with the study of [**3-31**], there are lower
lung volumes. Increased opacification in the retrocardiac region
most likely represents pleural fluid and atelectasis. In the
appropriate clinical setting, the possibility of supervening
pneumonia would have to be considered.
CT HEAD W/O [**2191-6-15**]:
IMPRESSION:
1. No acute intracranial abnormality.
2. Global cerebral atrophy, disproportionate to the patient's
age.
3. Diffuse sinus inflammatory disease.
4. Incidental note made of an arachnoid cyst in the left middle
cranial fossa.
LIVER U/S [**2191-6-15**]:
FINDINGS:
Evaluation is limited due to patient's body habitus and
overlying bowel gas. Within the limitations the extremely
limited portion of the liver that was imaged is unremarkable.
The portal vein, common hepatic duct, spleen or pancreas could
not be seen. A stone is noted in the gallbladder. The partially
imaged gallbladder appears unremarkable. No ascitic fluid is
noted.
IMPRESSION:
Gallstone noted. Severely limited study
CXR [**2191-6-16**]:
FINDINGS: As compared to the previous radiograph, the
pre-existing left basal opacity has decreased in extent and
severity. Otherwise, the radiograph is unchanged. No newly
appeared focal parenchymal changes.
CT ABD [**2191-6-17**]: could not fully visualize hepatic vv due to
contrast timing
IMPRESSION:
1. Patent portal vein, although direction of flow cannot be
evaluated with this study.
2. Cirrhosis with evidence of portal hypertension, recanalized
umbilical vein and splenorenal shunt.
3. Cholelithiasis and choledocholithiasis without evidence for
inflammation.
TTE [**2191-6-27**]:
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic arch is mildly dilated. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2191-4-5**], no change.
RUQ U/S [**2191-6-28**]:
FINDINGS: Note is made that this is a very limited ultrasound
technically due to the patient's body habitus and his inability
to hold his breath. No gross hepatic lesion is identified and no
gross biliary dilatation is seen, although Visualization of the
liver is very limited. Gallstones are again seen within the
gallbladder. The spleen is enlarged measuring about 14.5 cm. No
ascites is seen in the abdomen.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. Within the right portal vein, flow is noted to be
reversed. Flow in the left portal vein is presumed to be patent
and forward as there is a large patent umbilical vein. The main
portal vein could not be identified.
IMPRESSION: Extremely limited visualization of the anatomy due
to the
patient's body habitus. A large patent umbilical vein is
identified.
Shadowing gallstones are again seen within the gallbladder.
Splenomegaly is also identified and there is no ascites seen.
Visualization of the remainder of the structures is extremely
poor.
LENI left leg [**2191-7-3**]: No DVT in the left lower extremity.
MICRO:
URINE CX [**2191-6-15**]: NO GROWTH.
BLOOD CX [**2191-6-15**]: NO GROWTH.
STOOL CX, C DIFF [**2191-6-15**]: c. diff negative
[**2191-6-16**] 7:39 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2191-6-19**]**
FECAL CULTURE (Final [**2191-6-19**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2191-6-18**]): NO CAMPYLOBACTER
FOUND.
UA [**2191-6-23**]: RBC 17 WBC 146 Nitrite pos Leuks few
Urine Cx [**2191-6-23**]: URINE CULTURE (Final [**2191-6-29**]):
YEAST. 10,000-100,000 ORGANISMS/ML.
Blood culture [**2191-6-23**], [**6-25**], [**6-26**], [**6-28**]: NO GROWTH.
Brief Hospital Course:
Pt is a 51 year old male with EtOH cirrhosis and possible
hemochromatosis (still undergoing evaluation) who presented with
increased confusion at home. He was initially taken to the ICU
for close monitoring. He had no active s/s infection. He was
treated with lactulose for hepatic encephalopathy and mildly
improved. He was transferred to the medicine service where he
continued to improve with lactulose. However, several days into
his stay he appeared more confused. Infectious workup was
resent, and pt was found to have a UTI, and was treated for 14
day course. Pt continued to be encephalopathic and was treated
with Vancomycin for cellulitis of his left leg. Hospital course
was complicated by hypotension, most likely due to diuresis and
poor intravascular volume. He had mild renal insufficiency
secondary to overiduresis. Tube feeds were started for
nutrition. Eventually, pt was no longer able to be diuresed, and
family meeting was [**Known lastname **], with the decision to be discharged to
LTAC for further care and PT.
He will follow-up with Hepatology on discharge.
# Hepatic encephalopathy: On admission to the ICU, patient was
arousable to pain and had asterixis, concerning for HE. There
was no evidence of infection. Most likely precipitating factor
was a medication effect from pain medicine and sedating medicine
from the EGD (at OSH) or possibly medication noncompliance. RUQ
U/S was performed to look for thrombus but inconclusive for PVT.
CT scan showed patent portal vein but unable to fully visualize
hepatic vein given contrast timing. Pt was transferred to the
medicine liver service, where he continued to improve after
increasing bowel movements with lactulose. However, as discussed
below, course was complicated by complicated UTI, cellulitis,
and hypotension, all likely contributing to continued
encephalopathy. On discharge, he was more alert than on
admission, but his mental status continued to fluctuate
throughout the day. He was always oriented to person, able to
state facts (such as President, current events), but
occasionally not oriented to place or date and had poor
attention. He had no other sources of infection and no further
etiologies to treat to improve encephalopathy.
# Cirrhosis: Alcoholic (last drink 4 years prior) and possible
hemochromatosis suspected initially (based on elevated Ferritin
and iron deposition on previous imaging). Multiple
decompensations in the past with hepatic encephalopathy. On
rifaximin (only once daily) and lactulose (only 60ml daily), and
had been taking these as directed per the family and [**Hospital 4382**] facility. Prior to admission, had started evaluation for
transplant, but had not yet completed it. His continued
decompensation was concerning for secondary process in addition
to alcoholic cirrhosis. Ferritin levels were elevated and
previous imaging suggested possible hemochromatosis. Pt had no
family history but has received blood transfusions in the past.
HFE gene mutation analysis was negative. Additional studies for
other etiologies for Cirrhosis were sent, including IGG, [**Doctor First Name **],
A1AT, copper, ceruloplasmin. IGG was normal, [**Doctor First Name **] negative, A1AT
negative, ceruloplasmin mildly low at 13, Copper was low at 34,
24hour urine copper showed normal levels. He was continued on
spironolactone 100mg daily, and his lasix was uptitrated given
anasarca (see below). However, given hypotension, further
diuresis was limited and [**Known lastname **] for last several days prior to
discharge. He was continued on Rifaxamin, increased to twice
daily as it was recorded only as once daily at [**Hospital3 **]
facility. Lactulose dose was uptitrated as well, and should
maintain at least [**3-18**] bowel movements per day.
**At [**Month/Day (3) **], he will need to have diuretics restarted
and titrated as able.
**Need to ensure [**3-18**] bowel movements per day.
# Macrocytic anemia: DDx included hemolysis vs. hypersplenism
vs. bleeding vs. ACD. Hct had been reportedly been drifting down
at OSH, requiring blood transfusions, with EGD [**6-14**] without any
bleeding and no varices seen, guaiac negative here on admission.
Hapto <5 and elevated LDH concerning for hemolysis. However,
given that he has cirrhosis, not unexpected that haptoglobin
would be low, and LDH to be mildly elevated. SPEP and UPEP were
negative. Hematolgoy was consulted, and reported that there were
spherocytes in the peripheral smear, but no schistocytes. The
DAT was negative, making differential for Coombs negative
hemolysis hereditary spherocytosis (HS)/erythrocyte membrane
defect (can also cause splenomegaly), G6PD, and paroxysmal
nocturnal hemoglobinuria all possible. G6PD was normal. Urine
hemosiderin showed was negative. He was transfused one unit
PRBC's on [**2191-6-29**] with Hct at 25.7, mostly for improvement in
intravascular volume (no active bleeding), with appropriate
increase in Hct. He was found to have brown, guaiac positive
stools the week prior to discharge, thought to be possibly due
to gastritis seen on EGD at OSH. He had no melena or frank
blood. His Hct remained stable at 27-28 for one week prior to
discharge.
On discharge he will follow-up with hematology.
# Anasarca: Most likely [**2-16**] low albumin and cirrhosis with poor
synthetic function. No protein seen in the urine. Pt was
diuresed with IV lasix 40mg [**Hospital1 **], increased titration limited by
SBP in 90s. He was continued on Spironolactone 100mg daily.
However, pt became hypotensive, requiring decreased diuresis.
Diuresis was attempted with albumin given back. However, pt had
some mild ARF as well, and further diuresis was [**Known lastname **]. Nutrition
was consulted and while he was eating well, he was started on
TF's to try to improve nutrition.
**On discharge, the physicians at rehab will restart and titrate
diuresis as able (limitations will be renal insufficiency and
hypotension).
# Hypotension: DDx includes overdiuresis & dry intravascular
volume, vs. SIRS physiology vs. adrenal inusfficiency. Diuretics
stopped [**6-28**]. Midodrine uptitrated and given albumin. Consulted
endocrine given low cortisol on testing, though confusing
picture given Albumin only 2.1, therefore assay difficult to
interpret. Pt was treated with appropriate antibiotics for UTI
and cellulitis, and did not appear to be septic. Diuresis was
[**Known lastname **] as above. He was started on Midodrine. Repeat RUQ u/s and
CXR were unremarkable. Repeat Urine cultures showed yeast, and
the foley was discontinued. Blood cultures on repeat showed no
growth. Endocrine followed and did not think the picture was
consistent with adrenal insufficiency. LH, FSH were low, in
addition to low testosterone. He was restarted on testosterone
patch.
His BP remained stable in the systolic 90s-100s for 48hrs prior
to discharge.
He was discharged to continue Midodrine 10mg tid.
# Acute renal failure: [**2-16**] pre-renal etiology given attempted
diuresis, with Cr bump to 1.4. Diuresis was discontinued. His
Creatinine was stable at 1.3 for 2 days prior to discharge.
# Complicated UTI: Discovered on [**2191-6-23**] after pt appeared more
confused, and infectious workup resent. He was treated with
Ceftriaxone for 14 day course. Repeat urine culture showed
yeast, but no bacterial growth.
# Left leg erythema: Started on Vancomycin to cover for possible
cellutlitis. Pt had already been on CTX for UTI, and therefore
was getting adequate coveraged accept for MRSA. Completed a 7
day course with improvement. LENI was checked to ensure no DVT,
which was negative.
He had some mild erythema of bilateral legs on discharge,
attributed to stasis dermatitis.
# Depression: [**Known lastname **] home Abilify given concern for causing
somnolence in addition to side effects of leukopenia in this
patient who is already at risk. Recommend follow-up with PCP
after discharge for further management.
# Leukopenia: Most likely [**2-16**] hypersplenism, cirrhosis. No s/s
infection. WBC remained stable. His WBC ranged from high 2s-3s
consistently for the last 2 weeks prior to discharge.
# Back pain: Chronic in nature. Continued lidocaine patch and
tramadol for pain.
# Recent avulsion fracture: Conservative management. PT was
consulted and recommended acute rehab. Given tramadol for pain
control.
TRANSITIONAL CARE:
1. CODE: FULL
2. CONTACT: sister [**Name (NI) 83047**] (HCP) [**Telephone/Fax (1) 83048**] (c), [**Telephone/Fax (1) 83049**]
(w);
Brother [**Name (NI) **] [**Telephone/Fax (1) 83050**]
3. [**Name2 (NI) **]OW-UP:
- Liver transplant
- PCP after discharge
- Hematology
- Endocrinology
4. MEDICAL MANAGEMENT:
- Stopped lasix, Abilify
- Increased Lactulose, increased Rifaximin, start Miralax prn
- Start Humalog sliding scale
- Nutrition with tube feeds
5. OUTSTANDING TASKS:
- tests: cortisol, free Results Pending , cortisol binding
globulin (Transcortin) Results Pending. Pt will be seen by
Endocrinology on follow-up.
Medications on Admission:
-atrac-tain 10% cream apply to both lower extremities daily
-nystatin 100000units/gm apply to skin folds [**Hospital1 **]
-abilify 10mg daily
-lidoderm 5% patch 12 hours on lower back
-tramadol 50mg q6hrs prn pain
-lasix 20mg 2 tabs daily
-androderm 5mg/24hr patch for 24hr
-benadryl 25mg q6hrs prn agitation
-calcium+d 600-400 twice daily
-ergocalciferol 50,000 units cap weekly for 12 weeks (end date
[**2191-7-1**])
-folic acid 1mg daily
-lactulose 60ml daily
-magnesium oxide 400mg po bid
-MVI daily
-omeprazole 20mg po bid
-thiamine 100mg daily
-vitamin b6 100mg daily
-xifaxan 550mg daily
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
lower back and hip.
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
Disp:*2 Patch 24 hr(s)* Refills:*0*
5. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE) for 3 weeks: to be completed [**2191-7-20**].
13. nystatin 100,000 unit/g Powder Sig: powder to skin folds
Topical twice a day as needed for rash.
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: limit to 2g/24hrs.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for <3 BM's day prior.
17. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): see humalog sliding scale.
18. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnoses:
1. Hepatic encephalopathy
2. Anasarca
3. Hypotension
4. Macrocytic anemia
5. Complicated urinary tract infection
6. Cellulitis
Secondary Diagnoses:
1. Depression
2. Chronic low back pain
4. Avulsion hip fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during this admission. You
were admitted with unresponsiveness. You were initially cared
for in the ICU. You were given lactulose, and you began to feel
better.
We sent off several tests to assess for your liver disease.
However, we think the cirrhosis is mostly due to your previous
alcohol use.
You had a lot of swelling, and we had to increase the amount of
diuretics you were getting. However, your blood pressure was a
bit low, and we had to stop the diuretics.
We had the endocrinologists see you to make sure there was [**Last Name **]
problem with your adrenal glands. We restarted you on
testosterone. Your blood sugars were high, and we had to start
you on insulin.
We found two infections during this admission, a urinary tract
infection and cellulitis. We treated both of these with
antibiotics.
We had the nutritionists see you because your albumin was low.
They recommended tube feeds, which we started you on to improve
your nutrition.
You continued to be confused. We discussed with you and your
family that perhaps more intensive [**Last Name **] would be the
best for you.
The following medications were changed during this admission:
- STOP Abilify
**This medication can cause sleepiness and also lower your blood
counts. Please discuss with your doctors whether there is a
better medication for you.
- STOP Benadryl, as this can cause confusion
- STOP Magnesium oxide
- STOP Lasix 20mg 2 tablets daily
**The doctors [**First Name (Titles) **] [**Last Name (Titles) **] [**Name5 (PTitle) **] need to restart diuretics
when you are there.
- INCREASE the amount of lactulose you were taking from 60ml
daily to 30ml four times daily to at least [**3-18**] bowel movements
per day.
- INCREASE the dose of Rixafamin from 550mg daily to twice daily
- CHANGE the Pyridoxine dose from 100mg daily to 25mg daily
- START Insulin per the sliding scale provided
- START Midodrine 10mg by mouth three times daily
- START Acetaminophen 325mg by mouth every 6 hours as needed for
pain (do NOT exceed 2grams/day)
- START Miralax 17g by mouth daily as needed for constipation
Please continue the other medications you were taking prior to
this admission.
Followup Instructions:
Please follow-up with the following appointments:
Department: CARDIAC SERVICES
When: TUESDAY [**2191-7-19**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2191-7-27**] at 4:30 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: FRIDAY [**2191-7-29**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV OF GI AND ENDOCRINE
When: WEDNESDAY [**2191-8-3**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
**Your primary care doctor, Dr. [**Last Name (STitle) 5861**], [**First Name3 (LF) **] need to get prior
authorization so that you can see the Endocrinologists before
your appointment.
Completed by:[**2191-7-6**] |
0389,56723,51881,78552,5722,5724,28419,78959,5849,2869,99592,5712,30390,27503,311,30000,V1582,25000,V5867,V1251 | 99,756 | 172,485 | Admission Date: [**2191-12-23**] Discharge Date: [**2191-12-23**]
Date of Birth: [**2140-1-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine / Hydrocodone / Oxycodone / Ativan
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
generalized weakness, diffuse abdominal pain, abnormal labs
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is a 51 year old male with cirrhosis reportedly
secondary to alcohol and hemochromatosis complicated by
encephalopathy who presents to ED with concern for hyperkalemia
noted on labs with outside provider.
.
In the ED, his potassium was noted to be normal though he
appeared altered and reported generalized weakness and new
diffuse abdominal pain without fever, chills, dysuria and
headache. His physical exam was notable for SIRS criteria with
heart rate of 110 and MAP of 50.
Bedside TTE showed normal ejection fraction though showed
collapsed IVC whose diameter improved with 2 liters of NS
resuscitation and 150 g of albumin resuscitation though no
response to his MAP with CVP 8 - 12 and SvCO2 of 97%. RIJ line
was placed and levophed was started with concern for septic
shock. He was given Vancomycin 1 gm IV x 1, ceftazidime 2 gm IV
x 1 and flagyl 500 mg IV x 1 as empiric coverage and admitted to
MICU for management of septic shock with likely nidus of
infection being SBP.
.
Of note, FAST in the ED showed trace free fluid without any
ascites though abomdinal ultrasound later confirmed moderate
ascites. Labs notable for elevated creatinine to 3.9, lactate
of 4.4, WBC of 3.8, elevated liver enzymes, INR of 2.09 and
T.bili of 4.7.
.
CXR showed no acute cardiopulmonary process with satisfactory
positioning of RIJ line. UA was WNL except for high specific
gravity. EKG showed diffusely low voltage. He also has
cellulitis.
.
Vitals prior to tranfer were 133/92 on levo gtt.
.
On arrival to the MICU, he was encephalopathic with somnolence
but did arouse to voice and sternal rub. He answered questions
with simple yes and no. He denied bloody bowel movements and
vomiting blood although he had copious amounts of dried blood in
his mouth. He was not making urine in the foley.
Past Medical History:
1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given
elevated iron levels (ferritin ~1500, TIBC ~200). Saw
cardiology here in [**2191-4-15**], who performed an MRI and saw iron
deposits in liver concerning for hemochromatosis. Mild CHF on
last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis.
2. Recurrent cellulitis of left leg
3. DVT following trauma to left leg (MVA) Was on warfarin for 1
year.
4. Chronic low back pain
5. Depression
6. Anxiety
Social History:
No current tobacco use, former tobacco ~ 10 pack years (quit 3
years ago). Former alcohol and Klonopin abuse. Patient lives
in [**Hospital 169**] Center, he does not work. He is separated from
his wife. The patient's weekly exercise regimen consists of
walking daily around the building. Patient usually tries to
adhere to a sensible diet and manages ADLs well with assistance.
He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31,
27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago.
Family History:
His father died of lung cancer and his mother has diabetes. He
has 3 sisters and 1 brother who are healthy. His 3 children who
are healthy.
Physical Exam:
Vitals: temperature 91.1, BP 80s/40s, HR 130s, RR 8-10, O2 sats
100% 5LNC
General: somnolent, arouses to voice and sternal rub, answers
"yes" to some questions but not clearly appropriately
HEENT: Very mild scleral icterus, dried blood in the mouth
Neck: supple, difficult to assess JVP
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal rhythm, soft heart sounds
Abdomen: firm, obese, diffusely tender with guarding, worse in
the RUQ
Ext: cold, left radial pulse 2+, right trace pulse, b/l DP trace
Pertinent Results:
[**2191-12-23**] 09:59AM BLOOD WBC-4.2 RBC-1.71* Hgb-6.4* Hct-21.0*
MCV-123*# MCH-37.5* MCHC-30.5* RDW-16.9* Plt Ct-28*
[**2191-12-23**] 09:29AM BLOOD WBC-4.4 RBC-1.95* Hgb-7.2* Hct-22.5*
MCV-116* MCH-36.8* MCHC-31.8 RDW-17.1* Plt Ct-46*
[**2191-12-23**] 05:01AM BLOOD WBC-4.2 RBC-2.26* Hgb-8.4* Hct-25.5*
MCV-113* MCH-37.3* MCHC-33.1 RDW-17.0* Plt Ct-33*
[**2191-12-22**] 09:40PM BLOOD WBC-3.8* RBC-2.52* Hgb-9.5* Hct-28.6*
MCV-114*# MCH-37.7* MCHC-33.2 RDW-17.0* Plt Ct-24*
[**2191-12-23**] 09:59AM BLOOD Plt Smr-VERY LOW Plt Ct-28*
[**2191-12-23**] 09:59AM BLOOD PT-24.1* PTT-88.5* INR(PT)-2.3*
[**2191-12-23**] 09:29AM BLOOD Plt Ct-46*
[**2191-12-23**] 09:29AM BLOOD PT-21.9* PTT-53.7* INR(PT)-2.1*
[**2191-12-23**] 05:01AM BLOOD Plt Ct-33*
[**2191-12-23**] 05:01AM BLOOD PT-22.0* PTT-65.2* INR(PT)-2.1*
[**2191-12-22**] 11:05PM BLOOD PT-22.0* PTT-150* INR(PT)-2.09*
[**2191-12-23**] 09:59AM BLOOD Glucose-513* UreaN-48* Creat-3.3* Na-135
K-4.1 Cl-101 HCO3-17* AnGap-21*
[**2191-12-23**] 09:29AM BLOOD Glucose-336* UreaN-48* Creat-3.3* Na-136
K-4.4 Cl-100 HCO3-17* AnGap-23*
[**2191-12-23**] 05:01AM BLOOD Glucose-304* UreaN-54* Creat-3.5* Na-134
K-4.3 Cl-97 HCO3-23 AnGap-18
[**2191-12-22**] 09:40PM BLOOD Glucose-340* UreaN-57* Creat-3.9*# Na-134
K-5.0 Cl-98 HCO3-22 AnGap-19
[**2191-12-23**] 09:59AM BLOOD CK(CPK)-76
[**2191-12-23**] 05:01AM BLOOD ALT-73* AST-112* LD(LDH)-277* CK(CPK)-65
AlkPhos-241* TotBili-5.3*
[**2191-12-22**] 09:40PM BLOOD ALT-83* AST-138* AlkPhos-282*
TotBili-4.7*
[**2191-12-23**] 09:59AM BLOOD Calcium-9.6 Phos-7.0* Mg-3.5*
[**2191-12-23**] 09:29AM BLOOD Calcium-8.3* Phos-6.9* Mg-2.4
[**2191-12-23**] 05:01AM BLOOD Calcium-9.0 Phos-7.0*# Mg-2.7*
[**2191-12-23**] 10:43AM BLOOD Lactate-8.1*
[**2191-12-23**] 10:17AM BLOOD Lactate-7.9*
[**2191-12-23**] 09:43AM BLOOD Lactate-5.4*
[**2191-12-23**] 07:27AM BLOOD Lactate-4.1*
[**2191-12-23**] 03:17AM BLOOD Lactate-3.5*
[**2191-12-23**] 01:08AM BLOOD Lactate-3.7*
[**2191-12-22**] 11:07PM BLOOD Lactate-4.4*
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year old male with a history of alcoholic
cirrhosis and hepatic encephalopathy presented with new
abdominal pain, altered mental status, and hypotension.
.
# Septic shock: Admitted to MICU with MAP 58 after 2L IVF.
Etiology seemed to be SBP vs pneumonia, CXR was not c/w
pneumonia. Cardiac causes less likely given normal bedside echo
in ED w/ FAST negative for pericardial effusion. RUQ showed some
ascites but did not characertize hepatic vasculature well. He
was continued on pressors to maintain his MAP >65, and treated
per standard MUST protocol. He was also started on vancomycin
and zosyn in the ED. Despite aggressive goal-directed
resuscitation and prompt antibiotic treatment, his septic
physiology rapidly worsened and his lactate continued to rise
and his blood pressure progressively fell. He subsequently went
into PEA arrest as described below.
.
# Altered mental status: Most likely a combination of his
baseline hepatic encephalopathy with infection and superimposed
delirium. There is also concern that his MAP is not high enough
to maintain cerebral perfusion pressure at this point since he
has had low MAP for >3 hours and is also not making urine. We
continued aggressive fluid resucication and pressors to maintain
MAP. He was also continued on lactulose and rifaximin, but
ultimately had to be intubated for declining mental status.
.
# Acute kidney injury: His creatinine is acutely elevated from
baseline < 1. The possible etiologies include HRS versus ATN.
We had planned to obtain renal consult in the morning. Patient
had little to no urine output overnight, renal ultrasound in ED
negative for obstruction or hydronephrosis.
.
# Coagulopathy: Patient with baseline coagulopathy and
thrombocytopenia and presented with dried blood in his mouth.
Anesthesia also found blood in the oropharynx. He was not known
to have varicies. Given septic shock there was a concern for DIC
as his condition worsened.
.
# Cirrhosis: Known to be alcoholic and suspected also
hemochromatosis. His synthetic function is poor now with
increasing INR and decreasing albumin. His known
decompensations include hepatic encephalopathy and SBP.
.
# Cardiac arrest: Despite continued aggressive intervention with
pressors, antibiotics, and fluid resuscitation, the patient's
condition continued to decline with decreasing blood pressure,
increasing lactate, and no clinical improvement. Bedside echo
showed poor cardiac systolic function. He subsequently went into
PEA cardiac arrest for which standard ACLS protocol was
initiated. He briefly return of spontaneous circulation, and
showed mildly improved systolic cardiac function on repeat
bedside echo. Within one hour of ROSC his blood pressure started
to trend downward, and family meeting was initiated at the
bedside. During this meeting the family decided not to continue
resuscitation of the patient given poor prognosis on maximal
support (he was on four pressors at that time). His family and
the medical team were all in agreement with this decision.
Chaplain was called to the bedside, and supportive care was
withdrawn. Patient subsequently expired.
Medications on Admission:
- rifaximin 550 mg Tablet PO BID
- lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical
to back and hip
- tramadol 50 mg Tablet PO Q6H prn pain
- testosterone 5 mg/24 hr Patch 24 hr Q24H
- Calcium Citrate + D 315-200 mg-unit [**Hospital1 **]
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- multivitamin daily
- pyridoxine 25 mg Tablet daily
- heparin (porcine) 5,000 unit/mL Solution TID
- omeprazole 20 mg [**Hospital1 **]
- nystatin 100,000 unit/g twice a day as needed for rash
-lactulose 10 gram/15 mL 30 ML PO QID
-acetaminophen 325 mg Q6H prn pain: limit to 2g/24hrs
-polyethylene glycol 17 gram/dose PO DAILY
-insulin lispro 100 unit/mL sliding scale.
-midodrine 10 mg PO tid
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2191-12-24**] |
3962,42731,4168,5859,40390,2875,2724,29420,71590,V1051,V5861 | 99,759 | 157,932 | Admission Date: [**2161-3-9**] Discharge Date: [**2161-3-14**]
Date of Birth: [**2079-8-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
New chest discomfort
Major Surgical or Invasive Procedure:
Aortic valve replacement #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve
History of Present Illness:
81 year old male with known aortic stenosis who is followed
closely by Dr. [**Last Name (STitle) 11250**]. Recent cardiac catheterization
confirmed severe aortic stenosis
and showed only mild coronary artery disease. He has been
referred to Dr. [**Last Name (STitle) **] for consideration of aortic valve
replacement. His symptoms included chest discomfort on exertion
and occasionally at rest. He also admited to exertional
shortness of breath. He denied syncope, orthopnea, PND, and
pedal
edema. Also admitted to intermittent palpitations from his
chronic atrial fibrillation, and described occasional
lightheadedness. Despite above symptoms, he remains extremely
active and performs routine ADL without difficulty. He denies
unsteady gait and recent falls. He recently recovered from a
pneumonia in [**Month (only) 956**]
Past Medical History:
Aortic Stenosis
Mild to [**Month (only) 1192**] MR [**First Name (Titles) 151**] [**Last Name (Titles) **] TR
Pulmonary Hypertension
Chronic AF on Warfarin
Renal Insufficiency
Chronic Thrombocytopenia
Dyslipidemia
Hypertension
History of Bladder Cancer s/p tumor removal(no chemo or rad)
Recent Pneumonia
Varicose Veins
Arthritis, prior cortisone injections to left hip
History of ETOH abuse, sober for over 3 years
PSH: Bilateral Hernia Repairs, Hemorrhoidectomy, Bilateral
Cataracts, Bladder tumor removal, Tonsillectomy
Social History:
Lives with:care giver
Contact:[**Name (NI) **] [**Known lastname **](son)
Occupation:retired saleman
Cigarettes: Smoked no [] yes [x] last cigarette 15yr__ Hx:
Other Tobacco use:n
ETOH: < 1 drink/week [] [**1-20**] drinks/week [] >8 drinks/week
[x]stopped 3 yrs
Illicit drug use: None
Family History:
Family History:Premature coronary artery disease
Physical Exam:
Physical Exam
Pulse: Resp:16 O2 sat:
B/P Right:126/77 Left:110/70
Height:71" Weight:103kg
General:WDWN, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade [**2-17**] ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
Extremities: Warm [x], well-perfused [x] Edema [n] _____
Varicosities: None [n]bilat LE varicosities
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:1 Left:1
Carotid Bruit Right:n Left:n
Discharge Exam:
VS: T: 97.4 HR: 70-80's afib BP: 153/81 Sats: 94% RA Wt:101
kg (preop 103 kg)
General: 81 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: irrgular.
Resp: decreased breath sounds otherwise clear throughout
GI: obese, benign
Extr: warm with 1+ bilateral edema
Wound: sternal incision clean, dry intact no erythema or
discharge
Neuro: awake, alert, oriented
Pertinent Results:
TEE [**3-10**]: Conclusions
PRE-BYPASS:
The left atrium is markedly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. [**Month/Year (2) **] to
severe spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. The right atrium is markedly dilated.
There is mild symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). [Intrinsic right
ventricular systolic function may be depressed given the
[**Month/Year (2) 1192**] tricuspid regurgitation.]
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The three
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). No
ascending aortic aneurysm is seen.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. [**Month/Year (2) **] (2+) mitral regurgitation is
seen.
[**Month/Year (2) **] [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
POST-BYPASS:
The aortic bioprosthesis is well seated and functioning well
with a residual mean gradient of 10 mm of Hg across the valve.
No peri valvular leaks seen. LVEF 50%.
Mild to [**Month/Year (2) **] MR. Mild to [**Month/Year (2) **] TR. Dilated IVC like
prebypass.
RV function appears normal. Intact thoracic aorta.
CXR: [**2161-3-11**]: All the lines with the exception of the right
internal jugular sheath have been removed. There is no
pneumothorax. Volume loss at the left lung base may be slightly
worse.
[**2161-3-14**] WBC-7.8 RBC-2.70* Hgb-8.9* Hct-26.8* MCV-99* MCH-32.9*
MCHC-33.1 RDW-15.7* Plt Ct-92*
[**2161-3-9**] WBC-8.9 RBC-3.59* Hgb-11.5* Hct-35.8* MCV-100* MCH-32.0
MCHC-32.1 RDW-15.0 Plt Ct-113*
[**2161-3-14**] PT-13.5* PTT-28.1 INR(PT)-1.3*
[**2161-3-13**] PT-13.3* INR(PT)-1.2*
[**2161-3-12**] PT-12.1 INR(PT)-1.1
[**2161-3-14**] Glucose-82 UreaN-27* Creat-1.0 Na-138 K-4.1 Cl-103
HCO3-26
[**2161-3-9**] Glucose-178* UreaN-29* Creat-1.4* Na-140 K-3.8 Cl-105
HCO3-21
[**2161-3-9**] ALT-23 AST-24 LD(LDH)-182 AlkPhos-48 TotBili-0.5
[**2161-3-13**] Mg-2.3
[**2161-3-10**] MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2161-3-12**]): No MRSA isolated.
Brief Hospital Course:
Patient was admitted to the hospital on [**3-9**] from OSH long
standing history of AS. On [**3-10**] he was brought to the operating
room where the patient underwent aortic valve replacement.
Please see intraoperative note for further details.` Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He initially required vasopressor and
phenylephrine for blood pressure support. Slow to wean from
ventilator but eventually weaned and extubated without
difficulty. On POD#1 he was extubated and off pressors. He has
long history of rate control atrial fibrillation. Low dose
Lopressor, diuretics and ACE were initiated. His pre-operative
dose of prednisone for thrombocytopenia was restarted. He was
mildly confused post-operative and given his history of mild
dementia his Aricept was started and his mental status improved.
He transferred to the floor in POD#2. Pacing Wires and chest
tube were removed per protocol. Anticoagulation therapy was
started. He was evaluated by the physical therapy service for
assistance with strength and mobility. He continued to make
steady progress and was discharged to [**Location (un) 15739**] Manor in NH
[**Telephone/Fax (1) 92122**] on [**2161-3-14**]. He will follow-up as an outpatient.
Medications on Admission:
Prednisone 10mg daily,Lisinopril 2.5mg daily,Donepezil 5mg
daily,Folate 1mg daily,Coumadin 2.5mg daily(LD 5d),Metoprolol
Succ 50mg daily,EcASA 81mg daily
Discharge Medications:
1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 4 days: last dose [**2161-3-15**].
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
13. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
INR Goal 2.0-3.0.
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days: while take
lasix.
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 15739**] Manor
Discharge Diagnosis:
Aortic Stenosis
Mild to [**Location (un) 1192**] MR [**First Name (Titles) 151**] [**Last Name (Titles) **] TR
Pulmonary Hypertension
Chronic AF on Warfarin
Renal Insufficiency
Chronic Thrombocytopenia
Dyslipidemia
Hypertension
History of Bladder Cancer s/p tumor removal(no chemo or rad)
Recent Pneumonia
Varicose Veins
Arthritis, prior cortisone injections to left hip
History of ETOH abuse, sober for over 3 years
PSH: Bilateral Hernia Repairs, Hemorrhoidectomy, Bilateral
Cataracts, Bladder tumor removal, Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Edema: 1+ edeam
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2161-4-22**] 1:15 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
[**Hospital Unit Name **]
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 92123**] in [**12-15**] weeks for a
follow-up appointment.
Cardiologist Dr.[**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] in [**12-15**] weeks for a
follow-up appointment.
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Coumadin for Atrial Fibrillation: INR Goal 2.0-3.0
Coumadin follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24524**] as previous [**Telephone/Fax (1) 92123**]
Completed by:[**2161-3-14**] |
80111,3485,80121,319,3439,34590,81000,E8809 | 99,762 | 182,472 | Admission Date: [**2157-10-30**] Discharge Date: [**2157-11-5**]
Date of Birth: [**2119-1-21**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
status post fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 38 year old female with history of [**First Name3 (LF) 91272**] palsy and
mental retardation who is non verbal at baseline who was at her
group home when she fell down some stairs striking the back of
her head. The patient was brought to an outside hospital and
received Zofran, 1 gram fosphenytoin, and Reglan. A Head CT was
performed which was consistent with skull fracture and temporal
contusions and the patient was transferred to this hospital for
further treatment and evaluation.
The patient presents to the ED alone. There is no one to relay
the events of the fall. Information was taken from the chart to
complete the history. The brother was called at home and he was
able to describe the patient's baseline mental status as non
verbal with minimal eye contact and minimal interaction with
strangers. The patient uses gestures at times to communicate.
She lives in a town house with three other residents with 24
hour supervision and attends a day school. Normally the patient
ambulates around her home independently.
Past Medical History:
[**First Name3 (LF) 91272**] palsy, mental retardation.
Social History:
lives in a group home, she is able to do activities of normal
living, she in nonverbal at baseline
Family History:
NC
Physical Exam:
On Admission:
O: T:98.7 BP: 144/82 HR:84 R:16 O2Sats: 100%
Gen: flicker eye opening to noxious, GCS 8
HEENT:Laceration occiput. No raccoon sign, No Battle Sign, No
otorrhea, NO tympanum Pupils: 4.5-3 EOMs:pt unable to
perform
Neck: hard cervical collar
Extrema: Warm and well-perfused.
Neuro:
Mental status: no commands, non verbal, no eye opening-(baseline
MR [**First Name (Titles) **] [**Last Name (Titles) 91272**] palsy with inability to communicate)
Orientation/Recall/Language: patient is non verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4.5 to 3
mm bilaterally. Visual fields: patient is unable to cooperate
with exam
III, IV, VI,V, VII,VIII, IX, X,[**Doctor First Name 81**],XII: patient does not
cooperate
with exam
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Bilateral upper extremities spontaneous movement,
bilateral lower extremities bends knees spontaneously. NO
Commands. Pronator drift- pt does not cooperate with exam
Sensation: pt does not cooperate with exam
Toes downgoing bilaterally
Coordination:pt does not cooperate
Discharge exam:
Eyes open to voice. Will follow commands intermittently. Moves
all ext with good strength.
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of [**2157-10-30**] 7:44 PM Left frontal
and right parietal subarachnoid hemorrhage - small and stable.
small left subdural hematoma as well. Contusions left frontal
lobe/left temporal lobe with surrounding edema. Midline shift 3
mm to the right - unchanged.Non-displaced fracture involving the
greater [**Doctor First Name 362**] of the sphenoid on the right extending posteriorly
into the right parietal bone.
Labs: WBC RBC Hgb Hct Plt Ct
[**2157-10-30**] 19:15 12.5* 4.25 12.3 36.8 231
BASIC COAGULATION (PT, PTT,INR)
[**2157-10-30**] 19:15 12.1 20.7* 1.0
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2157-10-30**] 19:15 160*1 12 0.7 137 3.8 102 20* 19
[**2157-10-30**] Pelvis AP
Single AP view of the pelvis was obtained. No acute fracture or
dislocation is seen. The pubic symphysis and sacroiliac joints
are not
widened. There is a linear radiopaque structure measuring
approximately 6 mm projecting over the soft tissue superior to
the right greater trochanter. Recommend clinical correlation
for whether this is external to the patient, artifact, versus
embedded foreign body.
CT head [**2157-10-31**]:
No significant interval change in multicompartmental hemorrhage
since [**2157-10-30**], including subarachnoid, subdural and
parenchymal hemorrhage, with no evidence of expansion of the
small right frontoparietal epidural hematoma.
[**2157-10-31**] CT head
In comparison with the study of [**10-30**], single view does not show
the linear opacification suggested on the previous study. The
prior finding presumably represented an artifact.
[**2157-11-1**] MRI c-spine
1. No evidence of ligamentous injury. Normal alignment. Please
note that a
CT scan would be more sensitive for a subtle fracture,
particularly in the
posterior elements.
2. Global spinal canal narrowing from C3 through C6 due to
congenitally short pedicles. This is exacerbated by degenerative
disease, most notable at C3-C4 and C4-C5, where a moderate
spinal canal narrowing with spinal cord deformity is present.
However, spinal cord signal remains normal.
3. Moderate neural foraminal narrowing at several levels, as
detailed above.
[**2157-11-2**] R Clavicle X ray
Non displaced R clavicular fracture
Brief Hospital Course:
Ms. [**Name13 (STitle) 91273**] was admitted to neurosurgery into the ICU for further
management. She had a repeat CT head on [**10-30**] which
demonstrated evolution of SDH with slight increase in edema. A
repeat was performed on [**10-31**], which showed stable evolution of
left frontal and temporal contusions. During the day, she had
developed episodes of questionalble simple partial seizures of
her right face. She had a therapeutic dilantin level, keppra
was initiated. Neuromed was consulted and they recommended a 24
hour EEG and to hold keppra. Additionally, pt require a
cervical hard collar during her admission and a cervical MRI was
ordered but was cancelled due to foreign body in the right hip.
A repeat pelvis xray demonstrated no harware, only artifact.
She was cleared for MRI imaging of the cervical spine which did
not demonstrate ligamentous injury. It did demonstrate some
congenital anitomical varients which were insignificant. Her
collar was removed in the afternoon of [**11-1**]. She was tolerating
a soft/ground diet. She was more alert inthe afternoon.
She was transfered to the floor. She had one epsidoe of
self-limiting epistaxis. She was doing well with her altered
diet. She had clavicle imaging with no further displacement.
Orthopedics was called and they recommended a sling as needed
for comfort and follow up with orthopedics in one week. She was
seen by PT and required rehab. Dilantin was discontinued. The
EEG showed showed no active seizure activity but she will remain
on Keppra 1000mg [**Hospital1 **] for treatment of her seizures while in the
hospital.
Medications on Admission:
Desogen 1 tab po qd, Levoxyl 50 mcg 1 tab po qd, lexapro 10 mg 1
tab po qd, multivitamin, MiraLax.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain headache.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for headace/pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 3894**] Nursing & Rehabilitation Center - [**Location (un) 5503**]
Discharge Diagnosis:
Seizure
[**Location (un) **] Palsy
Mental Retardation
Aphasia
Skull Fracture / non dispalced
Subdural hemaotoma
Intraerenchymal hemorrhage
Subarachnoid hemorrhage
subgaleal hematoma
tahcycardia
hypertension
Right clavicel fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. This is to prevent seizures.
You must take it for 3 months.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain with contrast.
You need to see the orthopedics department for follow up on your
right clavicle fracture. You have an appointment on Thursday
[**11-10**] at 9:20 in the [**Hospital Ward Name 23**] Bld, [**Location (un) **], [**Hospital Ward Name **].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2157-11-4**] |
07044,452,51881,34839,1550,4254,5789,5849,2760,2851,5712,5728,4019,V4986,28860,30503 | 99,768 | 140,641 | Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-23**]
Date of Birth: [**2061-7-9**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
persistent encephalopathy
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Endoscopy (OSH)
History of Present Illness:
Mr. [**Known lastname 1349**] is a 60y/o gentleman with EtOH and HCV cirrhosis
complicated by ascites, varices with bleeding in the past, HCC
s/p TACE [**12/2121**] who presented to [**Hospital3 **] Hospital on [**2-18**] after
being found unresponsive requring intubation and is transferred
to the [**Hospital1 18**] MICU due to continued encephalopathy.
.
His wife reports that on the evening of [**2-17**] he was doing fine
(oriented x3). Early on [**2-18**] at 2AM he felt nauseated and had
dry heaves. Passed foul-smelling loose stools. Was lethargic
and confused, not answering questions appropriately so his wife
gave him an extra dose of Lactulose. Later that morning at 10AM
she found him unresponsive with slow breathing. She called 911
and he was taken to [**Hospital3 **] Hospital.
.
There, he was hemodynamically stable, was intubated for airway
protection. Head CT and CT abdomen/pelvis were unrevealing. He
was noted to have maroon stools. His hospital course has been
significant for GI bleed (Hct 32 but was noted to pass some
blood clots per rectum so received a total of 3u pRBC, 2u FFP,
vitamin K, and is on an IV PPI and Octreotide gtt), fever to 102
of unclear source being covered empirically with CTX/Flagyl then
switched to Zosyn/Flagyl on [**2-19**] when he developed a
leukocytosis, and shaking episodes yesterday and today (head
tilting to right with head jerking movements - received Ativan
yesterday). He was being sedated with a Versed drip @8/hr for
~36hrs, but then he was switched to Propofol. Despite QID
Lactulose, his mental status is no more clear so he is
transferred here for further workup/management.
.
On arrival to the MICU, he is intubated and sedated. Not
responding to voice but withdrawing from pain.
Past Medical History:
Past Medical History:
- EtOH and Hep C Cirrhosis, Hepatocellular CA, Ascites, ESLD
- s/p [**2122-1-1**] TACE transarterial chemoembolization of HCC
- 3 bands of grade 1 varices, last bleed [**2119**] ([**State 108**])
- failed treatment for HCV (IFN, IFN/Ribavirin 10 yesrs ago)
- GI bleed from duodenal ulcer
- Dilated cardiomyopathy with an ejection fraction of 55%
- Hypertension
- Hypogonadism
- IBS
.
Past Surgical history:
- Herniorrhaphy x 3
- Right wrist fracture s/p fixation
- Left toe surgery
- Knee arthroscopy x 4
Social History:
-Home: Lives with wife [**Name (NI) **]. They have an adopted daughter. [**Name (NI) **]
4 children from a prior marriage.
-Tobacco: None
-EtOH: prior history of heavy use, quit 6 yrs ago but relapsed
and now has been sober again for 6 months
-Illicits: None
Family History:
No history of cancer or hepatitis.
Physical Exam:
Admission
Vitals: T: 100.1 BP: 125/62 P: 117 O2sat 100% on PS 10/5, rate
20, FiO2 60%
Gen: well-nourished gentleman appearing his stated age,
intubated, sedated
HEENT: Anicteric sclerae, MMM, normal oropharynx
CVS: RRR, no MRG.
Resp: CTAB, no rhonchi or crackles
Abd: Obese but nondistended, no rebound or guarding
Ext: Warm, 2+ DP and PT pulses bilaterally; no edema or
cyanosis; right femoral CVL site with no erythema or hematoma
Neuro: withdraws to pain, VOR intact, bracioradialis 2+
bilaterally, patellar reflexes 1+ bilaterally
Discharge:
Expired
Pertinent Results:
[**2122-2-18**] EGD (OSH)
small esophageal varices without bleeding, no blood in the
stomach, nodules in the gastric body, few gastric antral
erosions
.
[**2122-2-18**] CT ABDOMEN/PELVIS W/O CONTRAST (OSH)
1. Abnormality of the right hemicolon with mural thickening may
be secondary to portal hypertension although the possibility of
colitis is difficult to exclude
2. Hepatic cirrhosis and new extensive abnormality in the right
lobe of the liver suspicious for HCC
3. Abdominal ascites
4. Periportal lymphadenopathy
5. Gallstones
6. Right renal cyst unchanged and isodense nodule of right
kidney also unchanged
7. Colonic diverticulosis without acute diverticulitis
8. Small right inguinal hernia containing fat
9. Bibasilar atelectasis and/or infiltrates
.
[**2122-2-18**] CT HEAD W/O CONTRAST (OSH)
No evidence of acute intracranial abnormality. Mucous retention
cysts in maxillary sinuses.
.
[**2122-2-21**] Liver U/S Limited examination showing unchanged
thrombosis of the anterior right portal vein. Minimal/slow flow
in the main portal vein noted, although this could be related to
the limited examination. Patent hepatic artery. No significant
ascitic fluid noted.
.
[**2122-2-21**] CTA Abd/Pelvis
1. Hyperdense material within the cecum and small bowel
resection
anastomosis. These regions are potential candidates for a bleed
source. No
active extravasation is seen.
2. New, likely bland thrombus within the main portal (nearly
occlusive) and right portal veins (occlusive)and origin of left
portla vein (nearly
occlusive) since the [**2122-1-29**] MR examination.
3. Post-TACE changes and small hypodense nodules, representing
tumor thrombi, in segment 5. No definite arterially enhancing
hepatic lesions identified.
4. Varicose veins at the anterior abdominal hernia repair site
and small
bowel anastomosis.
5. Cholelithiasis.
6. Small amount of abdominal and pelvic ascites.
Brief Hospital Course:
Mr. [**Known lastname 1349**] is a 60y/o gentleman with EtOH and HCV cirrhosis
complicated by ascites, varices, HCC s/p TACE [**12/2121**] who is
transferred from an OSH with continued encephalopathy, GI bleed,
and fevers.
.
#. Encephalopathy: likely multifactorial.
Acute onset of depressed level of consciousness at home could
represent hepatic encophalopathy. Has been taking Lactulose QID
but no report of if he has been stooling. Precipitants could
include upper GI bleed, medication effect (was on a Versed drip
at OSH for ~36h), or infection (see "fevers" below). Doppler and
CT Abdomen visualized portal vein thrombus which likely is
contributing to current presentation of encephalopathy. Switched
to bolus sedation and continued lactulose and rifaximin without
improvement of mental status. Given his poor prognosis and
absence of mental status, patient was terminally extubated on
[**2-21**] and transitioned to CMO.
.
#. Bloody loose stools: lower GI bleed vs brisk upper GI bleed.
Has history of bleeding ulcers as well as esophageal varices.
At the OSH, he underwent EGD showing portal gastropathy and
small gastric nodules which were not bleeding; had "diminutive
varices." Patient had persistent Hct drops during this
hospitalization along with persistently bloody bowel movements.
Patient was transfused a total of 5units and CTA was obtained
showing sources of bleeding in the cecum and at a prior small
bowel anastomosis, likely ectopic varices. Initial plan was for
colonoscopy but goals of care were discussed with family and as
it was felt that this was a nonintervenable source of bleeding,
supportive transfusions were discontinued and no further
interventions were undertaken. PPI and octreotide drips were
continued and patient was transitioned to CMO.
.
#. Fevers: Initially concerning for infection.
Had leukocytosis and had bandemia at OSH. Sources could include
PNA (especially concerning while intubated), UTI, SBP. Tap here
was not suggestive of infection and CXR and urine were
unremarkable. He was covered with Zosyn and Flagyl which were
discontinued on HD #2 as there was no clear source of infection.
.
#. [**Last Name (un) **]: Prerenal with low urine Na and FeNa. Creatinine improved
somewhat with fluids.
.
#. HCV and EtOH cirrhosis: No response to lactulose and
rifaximin so these were discontinued. His lasix and
spironolactone were held.
.
# Code Status: Given patient's persistent absence of mental
status improvement, his poor prognosis given his underlying HCC
and ongoing GI bleed, patient was made CMO on HD #2.
Medications on Admission:
- Spironolactone 200 mg daily
- Furosemide 80 mg Tablet daily
- Ursodiol 500 mg [**Hospital1 **]
- Lactulose 10 gram/15 mL 15-30 MLs PO QID
- Rifaximin 550 mg [**Hospital1 **]
- Gabapentin 300 mg TID
- Temazepam 30 mg QHS
- Citalopram 10 mg daily
- Sodium fluoride 1.1 % Gel [**Hospital1 **]
- Pantoprazole 40 mg [**Hospital1 **]
- B complex vitamins daily
- Magnesium oxide 400 mg daily
- Calcium 600 + D(3) 600 mg(1,500mg) -400 unit [**Hospital1 **]
- Testosterone 1 %(50 mg/5 gram) Gel daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2122-2-23**] |
3241,34830,51881,3229,5119,42832,4280,73027,2851,70715,42731,30500,79902,25000,79092,41400,2449,311,V5861,0414,04102,V4581,V454,3051,7821,32723 | 99,776 | 136,231 | Admission Date: [**2171-7-8**] Discharge Date: [**2171-7-23**]
Date of Birth: [**2115-2-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / morphine / IV Dye, Iodine Containing Contrast
Media / Zestril / Glucocorticoids (Corticosteroids) / Lipitor /
ceftazidime
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Back pain
Respiratory distress
Major Surgical or Invasive Procedure:
- Endotracheal intubation
- T6 & T7 laminectomy for evacuation of epidural hematoma.
- L hallux amputation
History of Present Illness:
Mr. [**Known lastname 89225**] is a 56-year-old gentleman with a history of atrial
fibrillation on coumadin, DM, CAD s/p 3-vessel CABG & chronic
back pain s/p spinal surgery in [**2166**] who complained of worsening
"flank pain" after having a root canal on [**2171-7-3**]. The next day
he was unable to stand & the pain was described as being much
worse than his chronic back pain.
He initially presented to [**Hospital **] [**Hospital 1459**] Hospital on [**2171-7-7**]
with back pain that was radiating to the top of his thights. He
was discharged but returned later that day. On his second
presentation, labs were drawn which revealed an INR 17 (the
patient had been taken antibiotics in association with his root
canal). The patient was started on ceftriaxone for a possible
toe infections that was noted on exam.
The patient was transferred to [**Hospital1 18**] for MRI (he has an allergy
to contrast). A repeat INR was 4.5 s/p Vit K administration. In
the ED, the patient was noted to be tachypneic & in respiratory
distress s/p IV dilaudid & valium (for concern about possible
EtOH withdrawal) administration; he was subsequently intubated.
He was started on broad-spectrum antibiotics (cefepime & vanco),
and was admitted to the MICU.
In the ED, he was writhing in pain and was given Dilaudid. He
drinks 3-4 drinks per day, but had not in the last 3 days. Given
the posibility of withdrawal, he was given valium. He became
hypoxic to the low 80s, tachypneic, and was intubated. A CT head
was negative for an acute process. His INR here was 4.5. He was
started on cefepime for a presumed L toe infection. He remained
persistently tachycardic to high 120s/low 130s, even after
intubation and sedation for which he was admitted to the ICU.
Past Medical History:
- CAD s/p CABG x3 in [**2163**], s/p stents
- [**8-/2166**] bone graft
- diabetes
- carotid stenosis
- anemia
- atrial fibrillation
- chronic back pain
Social History:
- Currently on disability from a job as a dispatcher
- Previously worked as an critical care nurse
- Denies tobacco use
- Drinks approximately [**3-15**] drinks per day. He wife believes
that he has had withdrawal symptoms in the past during previous
hospital admissions, although he has never had seizures, nor has
been been admitted for detoxication.
- Lives with his wife.
Family History:
- Not-contributory
Physical Exam:
ADMISSION EXAM:
Tmax: 37.2 ??????C HR: 130 BP: 115/86 RR: 22 SpO2: 96%
GENERAL: Intubated, sedated
HEENT: Sclera anicteric, PERRL, MMM
COR: Tachycardic, regular. Normal S1S2, no m/g/r.
PULM: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
ABDOMEN: Obese, + NABS. Soft, non-tender, non-distended. No
rebound or guarding, no organomegaly.
GU: Foley in place
EXT: Warm, well-perfused. 2+ pulses. Large ulcers in bilateral
great toes. The left leg has a necrotic center with pus
draining.
DISCHARGE EXAM:
T 98.3 HR 54 BP 126/76 RR 18 SP02 97%
Gen: well-appearing, NAD
HEENT: no lymphadenopathy, MMM, PERRL
CV: Irregularly irregular, no murmurs
Lungs: CTA b/l
Abd: obese, +BS, soft, NT ND, no organomegaly
Ext: WWP, no CCE, Left hallux amputed with clean dry dressing
Back: well-healed midline scar over thoracic spine
Pertinent Results:
ON ADMISSION:
[**2171-7-8**] WBC-15.0* RBC-4.63 Hgb-13.2* Hct-39.9* Plt Ct-168
Neuts-78* Bands-1 Lymphs-14* Monos-5 Eos-0 Baso-0 Atyps-2*
PT-43.3* PTT-41.9* INR(PT)-4.5*
Glucose-126* UreaN-33* Creat-0.9 Na-139 K-4.4 Cl-104 HCO3-22
AnGap-17
ALT-21 AST-27 AlkPhos-124 TotBili-0.8
cTropnT-<0.01
Art. Blood gas Rates-22/ Tidal V-550 PEEP-5 FiO2-100 pO2-386*
pCO2-46* pH-7.34* calTCO2-26
CT Head IMPRESSION: No acute intracranial process. Specifically,
there is no evidence of an acute hemorrhage
CXR IMPRESSION: ET tube terminating 5.7 cm above the carina.
Vascular crowding is seen in the setting of low lung volumes,
however, no acute intrathoracic process is detected. Please note
that the right costophrenic angle is completely excluded from
the study.
MR [**Name13 (STitle) **] IMPRESSION:
1. 5 cm x 13 mm x 9 mm left posterior epidural collection
posterior to the
T12 and L1 vertebral bodies is consistent with an epidural
abscess with mild involvement of the left posterior paraspinal
muscles.
2. Anterior displacement of the nerve roots of the cauda equina
with mild
thickening and clumping is most consistent with arachnoiditis.
MR L spine [**2171-7-12**] IMPRESSION:
Status post evacuation of epidural abscess. Except for tiny
residual areas of fluid slightly above the level of the
laminectomy site and also at T11-12 level majority of fluid seen
within the epidural space is no longer visible. Some residual
enhancement of the epidural soft tissues is noted with
considerable decrease in mass effect on the thecal sac. No
abnormal signal seen within the spinal cord.
MR [**Name13 (STitle) 430**] [**2171-7-11**] FINDINGS: There is an area of slow diffusion in
both occipital horns of the lateral ventricles. No corresponding
abnormality is noted on the susceptibility T2 or T1-weighted
images. No infarct, mass or mass effect is noted in the brain.
There is no significant FLAIR hyperintensity within the brain
parenchyma. The paranasal sinuses and mastoid air cells show
mild fluid in the right maxillary and sphenoidal sinuses.
IMPRESSION: Small areas of slow diffusion in both occipital
horns concerning for pus within the ventricles. A small amount
of blood is a less likely possibility.
ECHO IMPRESSION: Very suboptimal image quality due to body
habitus. Left ventricular systolic function is difficult to
assess, ejection fraction is probably at least 45%. The right
ventricle is not well seen. No significant valvular abnormality
seen.
ON DISCHARGE:
[**2171-7-22**] 05:45AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.2* Hct-30.9*
MCV-86 MCH-28.3 MCHC-33.0 RDW-17.1* Plt Ct-496*
[**2171-7-23**] 05:48AM BLOOD PT-28.5* INR(PT)-2.8*
[**2171-7-22**] 05:45AM BLOOD Glucose-107* UreaN-11 Creat-1.2 Na-136
K-3.6 Cl-100 HCO3-28 AnGap-12
Coags:
[**7-20**] - INR 1.9 (warfarin 3.5mg)
[**7-21**] - INR 2.9 (warfarin held)
[**7-22**] - INR 3.2 (warfarin held)
[**7-23**] - INR 2.8 (warfarin 3mg)
Brief Hospital Course:
56 yo male w/ CAD s/p CABG & stents, Afib on coumadin and EtOH
abuse here w/ acute on chronic back pain. Pt was admitted to the
MICU after intubation in the ED for hypoxia.
ACUTE DIAGNOSES:
# Epidural Abscess & Hematoma: The patient was intubated on
admission to the MICU. An MRI was obtained which showed an
epidural fluid collection concerning for infection or hematoma.
He was started on vancomycin and piperacillin-tazobactam.
Neurosurgery was consulted and considered that the fluid was a
hematoma consistent with his INR of 17 at presentation. His INR
was partially corrected after FFP and Vit K to an INR of 4.5. On
hospital day 2, a repeat MRI was ordered to help further
identify the fluid collection. On hospital day 4, the patient
had a brain MRI due to a concern for his mental status (given
that he was not responding off of sedation). After his INR was
corrected to 1.4 in preparation for surgery, he underwent a
T5-T8 laminectomy and hematoma evacuation, during which purulent
material was also found in the space. The culture from the
epidural mass showed pan-sensitive E-coli as well as Group B
strep. As per ID recs, the Pip-Tazo was changed to Ceftazadime,
which was then changed to ciprofloxacin because of a drug rash
presumed to be secondary to the ceftazidime. ID recommends
continuance of the Vancomycin and Ciprofloxacin for a duration
of 6 weeks (Vanc started on [**2171-7-8**], Cipro started on [**7-16**]).
# Supratherapeutic INR: The patient presented to OSH with an INR
of 17. His INR decreased to 4.5 after treatment with fresh
frozen plasma & vitamin K. The patient states that he had
recently been on a cephalosporin in preparation for his root
canal procedure. His coumadin was resumed on [**2171-7-18**] after his
podiatric surgery. Due to the ciprofloxacin, his coumadin was
held for a few days with a slightly high INR. He was restarted
at a lower dose of 3mg daily, but will need consistent
monitoring while being treated with cipro.
# ? Ventriculitis: The patient's MRI brain revealed "small areas
of slow diffusion in both occipital horns concerning for pus
within the ventricles. A small amount of blood is a less likely
possibility." The patient will be on antibiotics for 6-8 weeks
and neurosurgery did not feel that this finding required
intervention. However, this radiographic finding will be
followed up with a repeat head CT without contrast in [**6-19**] weeks.
# Atrial fibrillation & Tachycardia: The patient had occasional
tachycardia of unclear etiology. Possibilities included
hypovolemia, atrial flutter, discomfort, or infection. After the
MRI, the pt became agitated and developed Afib with RVR with a
heart rate in 110's. Rate control was achieved with diltiazem 10
and 10 of metoprolol; the pt remained normotensive throughout.
He had one further episode of rapid atrial fibrillation on the
floor, which ultimately responded to 15 mg IV diltiazem.
# Encephalopathy: Following his laminectomy, extubation, and
weaning off sedation, the patient had episodes of aggression,
cursing, and agitation. He appeared to be talking to people who
were not present in the room. Psych was consulted, and it was
felt that it was likely due to delirium. He was treated with
seroquel and haldol, and his mental status steadily improved.
While alcohol withdrawal remained a possibility, his lengthy
hospitalization made the timeline for withdrawal unlikely. Upon
transfer to the floor, the patient was alert & oriented to
person, place, & time with a clear mental status. He had no
further bouts of aggression or confusion
# Congestive Heart Failure: The patient's volume status & I/O's
were monitored throughout hospitalization. He occasionally
required some diuresis with lasix while he was on the floor. His
home spironolactone & metoprolol were held until the patient was
able to take medications by mouth.
#Foot ulcers: The patient was noted to have bilateral toe ulcers
on admission; he had necrotization with purulent discharge of
the left hallux. Podiatry was consulted and the patient
underwent a left hallux amputation on [**2171-7-18**]. He will f/u with
podiatry as an outpatient.
CHRONIC DIAGNOSES:
# Depression & Hypothyroidism: The patient was continued on his
home levothyroxine & citalopram.
# Diabetes: The patient's metformin was held during
hospitalization and an insulin sliding scale was instituted.
TRANSITIONAL ISSUES:
# Follow-up: The patient has several follow-up appointments with
neurosurgery, infectious disease, & podiatry. He will need a
head CT without contrast in [**6-19**] weeks (prior to his outpatient
neurosurgery appointment).
# Lab Work: The patient will need weekly lab draws while he is
on IV vancomycin. He will have services established upon
discharge to arrange his weekly CBC, BUN/CR & vanco level
checks. He will also need consistent INR monitoring while on
cipro.
Medications on Admission:
- celexa 10mg daily
- vitamin E 400 units daily
- colace 100mg [**Hospital1 **]
- levoxyl 250mcg daily
- omeprazole 20mg daily
- spironolactone 25mg daily
- naprosyn 500mg daily PRN
- metoprolol 100mg [**Hospital1 **]
- coumadin
- ASA 81mg
- crestor 10mg daily
- proair 90mcg 2 puffs Q6hrs
- metformin 500mg [**Hospital1 **]
- potassirum ER 20 mEq
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 6 weeks.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day.
11. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
13. naproxen 500 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
14. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
15. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
16. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 weeks.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Spinal abscess
- Left hallux infection
- Atrial fibrillation
SECONDARY DIAGNOSES:
- CAD s/p CABG x3 in [**2163**], s/p stents
- [**8-/2166**] bone graft
- diabetes
- carotid stenosis
- anemia
- atrial fibrillation
- chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 89225**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital because of back
pain that worsened after some dental treatment. While you were
here, you were admitted to the ICU. An MRI of your back showed
that you had an area of infection with bleeding resting on your
spine. You were taken to the operating room on [**2171-7-11**] to have
this area of infection removed. You also had your left big toe
amputated due to infection.
The neurosurgeons & infectious disease doctors followed [**Name5 (PTitle) **]
throughout your hospitalization. The infectious disease
specialists recommended that you have 6-8 weeks of IV
antibiotics to fight your infection.
Medication Changes:
- Medications ADDED: IV vancomycin 1250 mg twice a day for at
least 6 weeks, oral ciprofloxacin 750 mg every 12 hours for at
least 6 weeks
- Medications CHANGED: Warfarin dose was lowered to 3mg daily,
but will fluctuate with your INR
- Medications STOPPED: None.
Followup Instructions:
Department: PODIATRY
When: FRIDAY [**2171-8-2**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: MIDHA,SALIL [**Doctor Last Name 162**]
Address: [**Last Name (un) **] [**Apartment Address(1) 82921**], [**Location (un) **],[**Numeric Identifier 28669**]
Phone: [**Telephone/Fax (1) 40969**]
When: Friday, [**8-9**], 2:30PM
Department: INFECTIOUS DISEASE
When: TUESDAY [**2171-8-6**] at 9:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2171-9-17**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2171-9-25**] at 8:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2171-9-25**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
41401,2762,4139,49120,27800,4019,V4582,V173,32723,29680,2724 | 99,777 | 197,851 | Admission Date: [**2167-9-15**] Discharge Date: [**2167-9-22**]
Date of Birth: [**2111-3-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
fatigue, weakness, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2167-9-15**] Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein grafts to the posterior left ventricular branch
artery and the obtuse marginal artery
History of Present Illness:
56 year old male with known coronary artery disease status post
stents to right coronary artery and left anteriopr descending
artery who now has complaints of fatigue and weakness. Several
weeks ago he presented to [**Hospital **] Hospital with complaints of
chest pain, ruled out for myocardial infarction, and was sent
home for outpatient stress test which was abnormal. He presented
on [**9-7**] for cardiac catheterization which revealed three vessel
coronary artery disease. Now presents for surgical
revascularization.
Past Medical History:
Coronary Artery Disease s/p Cypher stents to RCA and LAD [**2164-5-31**],
s/p LAD stent in [**2165**]
Hypertension
Hyperlipidemia
COPD
Chronic cough/bronchitis
Bipolar disease
Diverticulitis
Recent "spot on liver"-found on imaging study for abdominal pain
***Episodes of epistaxis. Stopped ASA but continued plavix and
epistaxis stopped.
[**2137**] left ankle bullet wound injury, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
s/p tonsillectomy
ear surgery as child
Social History:
Race: Caucasian
Last Dental Exam: many years
Lives with: wife
Occupation: On disability
Tobacco: 1ppd x45 years
ETOH: Rare
Recreational drugs: Marijuana daily
Family History:
Father died of MI age 59
Physical Exam:
Pulse:83 Resp:16 O2 sat: 100%RA
B/P Right:130/83 Left: 151/94
Height: 5'7" Weight:260 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema +2 Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left:0
Pertinent Results:
[**9-15**] Echo: PRE BYPASS The left atrium is moderately dilated. The
left atrium is elongated. Mild spontaneous echo contrast is seen
in the body of the left atrium.. No thrombus is seen in the body
of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate global left ventricular hypokinesis.
In addition, the distal lateral, anterolateral, and anterior
walls seem more hypokinetic than the other segments. The overall
ejection fraction is about 35%. The right ventricle displays
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POSTBYPASS The patient is atrially paced on a phenylephrine
infusion. Global left ventricular function is now slightly
improved (overall ejection fracture about 40-45%) although
global left ventricular hypokinesis persists. The distal
lateral, anterolateral, and anterior walls continue to be more
hypokinetic than the other segments. Valvular function is
essentially unchanged. Thoracic aorta is unchanged after
decannulation.
Brief Hospital Course:
Mr. [**Known lastname 73256**] was a same day admit after undergoing his cardiac
cath and pre-admission testing during previous hospital visit.
On [**9-15**] he was brought directly to the operating room where he
underwent a coronary artery bypass graft x 3. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one his chest tubes were removed
and he was transferred to the telemetry floor for further care.
Beta blockers and diuretics were started and he was diuresed
towards his pre-op weight. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 7 the patient was
ambulating freely, the wound was healing well and his pain was
controlled with oral analgesics. The patient was discharged to
home in good condition with appropriate follow up instructions.
Medications on Admission:
Albuterol 90mcg inhaler-2 puffs PRN
Plavix 75mg po daily
Diltiazem 120mg po q12 hrs
Advair Diskus 1 puff IH [**Hospital1 **]
Furosemide 20mg po daily
Atrovent 2 puffs IH four times a day
Risperidone 2mg po qHS
Sertraline 200mg po qHS
Simvastatin 80mg po daily
MVI
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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Zocor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
6. Zoloft 100 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
1 puff Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
9. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Puffs Inhalation four times a day.
Disp:*1 MDI* Refills:*2*
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
Disp:*1 MDI* Refills:*2*
11. Lasix 20 mg Tablet Sig: Take 2 tabs daily for 7 days, then
decrease dose to 20mg daily. Tablet PO QAM: Take 2 tablets
(40mg) daily with 20mEq potassium for 7 days, then decrease dose
to 20mg daily without potassium supplement.
Disp:*30 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO QAM for 7 days:
Take for 7 days with lasix and then stop.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 3
Past medical history:
Hypertension
Hyperlipidemia
s/p Cypher stents to RCA and LAD [**2164-5-31**], s/p LAD stent in [**2165**]
COPD
Chronic cough/bronchitis
Bipolar disease
Diverticulitis
Recent "spot on liver"-found on imaging study for abdominal pain
***Episodes of epistaxis. Stopped ASA but continued plavix and
epistaxis stopped.
[**2137**] left ankle bullet wound injury, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
s/p tonsillectomy
ear surgery as child
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet prn
Incisions:
Sternal - healing well, no erythema or drainage. No instability.
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+ bilaterally
Discharge Instructions:
1. Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2. Please NO lotions, cream, powder, or ointments to incisions
3. Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4. No driving for approximately one month until follow up with
surgeon
5. No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
6. Take lasix 40mg (2 - 20mg tablets) once daily in the morning
for 1 week, then decrease dose to 1 tablet (20mg) daily
thereafter as per prior to surgery. You will take a potassium
supplement 20mEq daily with your lasix dose of 40mg for for 1
week and then stop.
7. Please call with any questions or concerns.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on Wednesday [**2167-10-14**] at 1:00PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 73257**] [**Name (STitle) 19772**] in [**1-31**] weeks [**Telephone/Fax (1) 8506**]
Cardiologist Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] in [**1-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2167-9-22**] |
486,34400,5119,2761,V6284,2930,80705,E8147,45829,27669,56400,2859,3090,V454,2724,3051,4019,V4986 | 99,781 | 147,562 | Admission Date: [**2133-8-1**] Discharge Date: [**2133-8-6**]
Date of Birth: [**2061-6-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 88733**] is a 72 year old gentleman who was discharged to
[**Hospital 38**] rehab yesterday after admission for c3-t1 fusion
following peds vs. MVA 1 wk ago leading to parapelgia, now
presenting with confusion and respiratory distress. This morning
at rehab he was noted to be in resp distress, with tachypnea and
sats in low 90s, not aaox3. He was given O2 at the rehab and
tachypnea resolved and sats improved to the high 90s.
.
In the [**Name (NI) **], pt was reportedly comfortable. Vitals on arrival were
97.8 (100.4 rectal) 72 145/77 16 97% 2L NC. CXR showed
increasing bilateral pleural effusions with bibasilar
consolidation ? atelectasis vs pneumonia. He was given vanc,
cefepime and levofloxacin for treatment of HCAP. Blood and urine
cultures were sent. He was admitted to the ICU because of
concern for partial diaphramatic paralysis from his recent
accident which could lead to respiratory distress. Vital signs
on transfer were stable.
.
On the floor, pt is aaox0. Unable to answer any medical hx
questions. Denies pain. States his breathing is a little
difficult. Otherwise answers "no" to most questions.
Past Medical History:
-hyperlipidemia
-tonsillectomy
-maxillary surgery with likely screw placed for intractable nose
bleed
-MVA vs peds accident 1 wk PTA requiring multiple orthopedic
procedures
Social History:
Prior to his accident, Mr [**Known lastname 88733**] was retired and lived in his
home alone. Smokes 1 ppd, occ EtOH, no drug use.
Family History:
unknown
Physical Exam:
Admission:
VS: Temp: BP: 164/95 HR:84 RR:21 O2sat 95% 2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, [**Location (un) 2848**] J-collar in
place
CV: RR, S1 and S2 wnl, no m/r/g
RESP: rhonchorous BS in L base, otherwise CTA b/l. Poor air
movement, belly breathing, poor cough, minimal acccessory muscle
use.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: boots in place. R arm wrapped in gauze. 1+ edema in upper
extremities, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], no CCE
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx0. Cn II-XII intact. unable to follow commands.
Moves arms and legs spontaneously but does not follow commands.
Discharge:
VS: Temp: 97.9 BP: 144/72 HR:56 RR:24 O2sat 97% 2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, [**Location (un) 2848**] J-collar in
place
CV: RR, S1 and S2 wnl, no m/r/g
RESP: mildly decreased breath sounds @ left lower lung base,
otherwise CTA b/l. Moderate air movement, belly breathing,
occasional difficulty with cough.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: boots in place. R arm wrapped in gauze. 1+ edema in upper
extremities, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], no CCE
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. Conversant. Total paralysis of
the lower extremity bilaterally. Limited ability to raise UE b/l
to face, strength 3/5 in biceps, adduction 3-4/5.
Pertinent Results:
[**2133-7-31**] 06:19AM BLOOD WBC-8.3 RBC-2.74* Hgb-9.2* Hct-26.1*
MCV-95 MCH-33.6* MCHC-35.4* RDW-13.1 Plt Ct-246
[**2133-8-1**] 02:12PM BLOOD Neuts-89.0* Lymphs-6.8* Monos-3.6 Eos-0.4
Baso-0.1
[**2133-8-1**] 02:12PM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.2*
[**2133-8-1**] 02:12PM BLOOD Ret Aut-3.9*
[**2133-7-31**] 06:19AM BLOOD Glucose-94 UreaN-14 Creat-0.4* Na-135
K-4.3 Cl-102 HCO3-28 AnGap-9
[**2133-8-1**] 02:12PM BLOOD ALT-25 AST-36 AlkPhos-101 TotBili-0.5
[**2133-8-1**] 02:12PM BLOOD Lipase-31
[**2133-8-1**] 02:12PM BLOOD proBNP-2173*
[**2133-7-31**] 06:19AM BLOOD Calcium-7.4* Phos-2.6* Mg-2.0
[**2133-8-1**] 02:12PM BLOOD Albumin-2.6* Iron-35*
[**2133-8-1**] 02:12PM BLOOD calTIBC-215* Ferritn-146 TRF-165*
[**2133-8-2**] 11:09AM BLOOD Type-ART Temp-37.1 FiO2-40 pO2-94 pCO2-35
pH-7.46* calTCO2-26 Base XS-1 Intubat-NOT INTUBA
[**2133-8-1**] 04:23PM BLOOD Lactate-0.9
[**2133-8-2**] 11:09AM BLOOD Lactate-0.8
REPORTS:
CXR [**2133-8-1**]
IMPRESSION: Increasing bilateral pleural effusions with
bibasilar
consolidation which may represent atelectasis and/or pneumonia.
No
pneumothorax. Left-sided rib fractures are again noted.
LUE U/S [**2133-8-2**]
INDICATION: Upper extremity swelling.
COMPARISON: No relevant comparisons available.
FINDINGS: Doppler and grayscale son[**Name (NI) 1417**] of the bilateral
subclavian veins
and the left internal jugular, axillary, basilic, brachial, and
cephalic veins
was performed. There is normal compressibility, flow and
augmentation.
IMPRESSION: No left upper extremity DVT.
CLINICAL INFORMATION: A 72-year-old male status post motor
vehicle collision,
now paraplegic, question need for G-tube.
VIDEO OROPHARYNGEAL SWALLOW [**2133-8-5**]
COMPARISON: [**2133-7-30**].
TECHNIQUE: Barium containing foods of various consistencies were
administered
by the speech pathologist.
FINDINGS: There is normal swallowing function. Mild-to-moderate
vallecular
pooling is noted, which is cleared with swallows of thin
liquids. There is no
laryngeal penetration or aspiration.
IMPRESSION: No laryngeal penetration or aspiration. Please see
the speech
pathologists note for further details.
The study and the report were reviewed by the staff radiologist.
MICRO:
[**2133-8-2**] URINE Legionella Urinary Antigen -PENDING
INPATIENT
[**2133-8-1**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2133-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2133-8-1**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2133-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
72 yo gentleman with recent hemiplegia s/p peds vs MVA, s/p
c3-t1 fusion, now presenting from rehab with AMS and respiratory
distress.
Active Issues:
#. Respiratory distress/Pneumonia:
At rehab patient noted to be dyspneic. On presentation to the
ED, the patient was reportedly comfortable with minimal O2
supplementation (2-3L NC) Admission CXR demonstrated bilateral
increasing pleural effusions with bibasilar consolidations.
Bibasilar considations thought secondary to aspiration vs
hospital acquired pneumonia. Patient started on
vanc/levoquin/cefepime which was eventually tailored to
vanc/cefepime. Urine legionella negative. Patient respiratory
status improved while on treatment. In regard to his aspiration
risk, a swallow study was performed and advanced to a video
swallow study, which demonstrated normal swallowing function
without laryngeal penetration or aspiration.
Pleural effusions were thought secondary to volume overload
(patient was 14L up last admission) with possible parapneumonic
contribtion. PNA was treated. In addition patient was actively
diuresised with 5mg -10mg of IV lasix daily.
Throughout his time on the medicine floor, the patient also
received an evaluation and extensive chest PT.
At time of discharge patient was saturating >92% on RA with
improved aeration on exam.
#. AMS:
On admission, the patient was delerious, likely due to PNA,
hypoxia. Although metabolic/electrolyte abnormalities were
considered as a source of AMS, the minimal degree of the
patient's hyponatremia (130) was deemed unlikely to cause AMS.
While in the MICU, his mental status cleared upon abx, diuresis,
and chest physical therapy, and his sensorium remained clear
from his transfer to the medicine floor and onward.
#. Hypotension:
After the patient's initial diuresis in the MICU (20mg IV
lasix), his SBP decreased to the to the 80s, which however was
asymptomatic without change in MS, urine output, heart rate. BPs
stabilized overtime on their own. Hypotension was thought to be
secondary to intravascular volume depletion in setting of low
albumin state vs autonomic dysreflexia. Blood pressures improved
with stimulation and 25gm of albumin in 500cc. There were no
sign of sepsis. On the medicine floor, his pressures remained
stable, and he was diuresed on multiple occasions without his
systolic blood pressure decreasing below the 100s.
#. Hyponatremia:
Thought to be [**3-4**] a combination of hypervolemia and diuresis
with free H2O intake. Improved with fluid restriction and
further diuresis with IV lasix. Also helpful was switching abx
fluid from D5 to NS. At the time of discharge, the patient's
serum sodium level had increased from 130 to 135.
# Depression
Shortly after the [**Hospital 228**] transfer to the floor, he became
withdrawn and dysphoric, stating that he no longer wished to
have any treatment. His wishes were respected, and antibiotics
were briefly held, although he stated that he wished to continue
receiving IV fluids. At this time, he also endorsed suicidal
ideations and mentioned that he had made a suicide attempt
approximately 30 years prior. He was subsequently placed on 1:1
precautions. A psychiatric evaluation was requested for a
capacity evaluation. The psychiatry team felt that although
dysphoric, he did not seem to be suffering from major
depression, and was coherent and logical in his thought process.
He was able to clearly articulate the risks associated with not
treating his pneumonia, including that he might die. His desire
to be left to die stemmed from the decline in the quality of his
life since the accident, and not from depression, per se. The
best course of action was being contemplated by all physicians,
however the next morning, he stated that he had changed his
mind. This change in sentiment resulted from several
conversations with friends which had helped him decide that he
would like to give life a shot. He had also been visited by PT,
who helped him understand that there is a chance he will regain
some function of his hands, and was given information regarding
the psychiatric prognosis related to spinal cord injury - namely
that most people are much more satisfied with their situation 6
months to a year after the accident. He accepted antibiotics
after this point and was cooperative with further evaluations.
He was not felt to be a suicide risk at present, per psychiatric
evaluation, and he was also provided counseling by a social
worker. The patient expressed a desire to speak with the
psychiatrist again, and was amenable to doing so in the future.
At the time of discharge, the patient stated that he was hopeful
that he could recover a degree of independence, and his mood was
considerably improved compared to his initial presentation on
the medicine floor. He was also told that he may schedule a
psychiatry outpatient appointment via his PCP. [**Name10 (NameIs) 2772**], [**Name Initial (NameIs) **]
remaining issue is that he mentioned that he does possess a
firearm in his home, and given his recent depression it is
necessary to make sure that this issue is addressed as soon as
is feasible.
Patient should be re-evaluated by psychiatry or psychology at
rehab to assess mood, social supports with plans to arrange
family meetings, as well as ongoing discussion of end of life
care.
Of note patient does have loaded firearm at home and has
expressed suidical ideation in the past but not at time of
discharge from [**Hospital1 18**] .
Chronic Issues:
#. Anemia:
Pt's H/H remained near his recent baseline throughout his
hospitalization, with no clear source of bleed. This is
consistent with losses from recent procedures and prior trauma.
This issue remained remained stable throughout the period of
hospitalization.
# Hypertension:
Initially, midodrine was held given his hypertension shortly
after presentation. Thereafter, his BPs stabilized and this was
restarted shortly after his admission to the floor.
# Hyperlipidemia:
Continued atorvastatin; this issue remained unchanged throughout
the hospital course.
# Tobacco use:
Continued nicotine patch; this issue remained unchanged
throughout the hospital course.
Transitional issues
# Med rec:
Famotidine discontinued, no clear indication at this time.
# s/p peds vs MVA
Given the patient's multiple orthopedic injuries and paraplegic
status, he continues to have little movement in UEs. He is to
continue wearing his C-collar when out of bed. As mentioned
above, the patient's disability remains a cause of deep
distress, and much of his psychological improvement may be
contingent on his continued involvement with social supports and
measures designed improve his mobility and independence.
# CODE: DNI/DNR at time of discharge; plan to continue having
ongoing discussions regarding end of life care
Medications on Admission:
Meds on transfer (per dc summary [**2133-7-31**]):
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q 3 hrs as needed
for pain.
11. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
14. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 5 days. DC [**2133-8-4**]
Discharge Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 6 days: start date [**8-3**]; end date [**8-11**].
Disp:*11 soln* Refills:*0*
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
15. Zosyn 4.5 gram Recon Soln Sig: 4.5 gram Intravenous every
six (6) hours for 6 days: end date [**8-11**].
Disp:*23 soln* Refills:*0*
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO TID (3 times
a day) as needed for constipation.
19. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO ONCE (Once) as needed for bloating.
20. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**2-1**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Altered Mental Status secondary to Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 88733**],
You were admitted to the hospital from your rehabilitation
facility because you had become confused and were having
difficulty breathing. You were admitted to the medical intensive
care unit where you were monitored overnight, and a chest x-ray
showed that you had a pneumonia which may have caused fluid to
build up in your lungs which was making it difficult for you to
breathe. You were treated with IV antibiotics, and you became
more responsive.
You were later transfered to the general medicine floor, where
you were given medication to help you to get rid of some of the
extra fluid you had. You responded well to the medication and
the fluid cleared from your lungs.
You were also given an evaluation of your ability to swallow to
ensure that you will be able to take in adequate nutrition when
you are at rehab. The test demonstrated that your ability to
swallow is generally intact, and you should be able to handle
progressively more difficult foods while you are in rehab.
You were also seen by a psychiatrist during your time on the
medicine floor because it was felt that you could use additional
support to discuss how you were reacting to the accident.
Toward the end of your hospital stay, you received a special
type of IV line called a PICC line. This IV line will stay with
you when you leave the hospital so that you can continue to
receive your complete course of antibiotics while in
rehabilitation.
During your hospital stay, the following changes were made to
your medications:
To treat infection: start taking Abx with scheduled end date
[**8-11**]
** Start Zosyn 4.5g IV every 6 hours (administered via your
PICC)
** Start Vancomycin 1000 mg IV every 12 hours (via your PICC)
These medications will be administered to you at your rehab
facility.
** Stop famotidine 20mg one tablet twice a day.
.
To treat constipation and gas we added an aggressive bowel
regimen as well as anti-emetics
You will have a follow-up appointment with the orthopedic
surgeons in a few weeks to evaluate your recovery and to talk
about your long-term prognosis.
You should contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 51794**] a
meeting with a psychiatrist for 1-2 weeks from now.
If you begin to feel faint, nauseated, or disoriented, please
call your doctor or go to the nearest emergency room.
It was a pleasure taking care of you.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] G
Location: [**Hospital **] MEDICAL GROUP
Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 34362**]
Phone: [**Telephone/Fax (1) 35269**]
**Please discuss with the staff at the facility a need for a
follow up appointment with your PCP when you are ready for
discharge. Also, please speak with your PCP about the need to be
referred to Psychiatry within 1-2 weeks of your discharge from
the hospital**
Department: ORTHOPEDICS
When: WEDNESDAY [**2133-8-19**] at 12:10 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: WEDNESDAY [**2133-8-19**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2133-8-11**] |
80608,80705,86122,2761,78550,8600,E8147,3051,88101,2724,7224,45829 | 99,781 | 167,791 | Admission Date: [**2133-7-23**] Discharge Date: [**2133-7-31**]
Date of Birth: [**2061-6-30**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
pedestrian struck by MVC while crossing street
Major Surgical or Invasive Procedure:
[**2133-7-24**]
1. C3 bilateral hemilaminotomy.
2. Laminectomy, C4-C7.
3. Bilateral hemilaminotomy, T1.
4. Posterior spinal instrumentation, C3-T1.
5. Open treatment, cervical fracture/dislocation posterior.
6. Posterolateral fusion, C3-T1.
7. Application of local autograft for fusion.
8. Allograft for fusion.
[**2133-7-27**]
Right AC PICC
History of Present Illness:
72M pedestrian struck by car on right side while crossing the
street (?25mph). Denies LOC. Notes inability to move his legs
after accident. Brought in by [**Location (un) **] to [**Hospital1 18**]. On imaging,
patient has L sided [**9-11**] posterior rib fractures, small L
pulmonary laceration and small pneumothorax, C5-C6
retrolisthesis and question of cord injury.
Past Medical History:
PMH: HLD
PSH: tonsillectomy; maxillary surgery with likely screw placed
for intractable nose bleed.
Social History:
Patient now retired, lives alone at home. Smokes 1ppd.
Occasional EToH use.
Family History:
Non-contributory
Physical Exam:
Temp: 97.1 HR: 63 BP: 106/56 Resp: 23 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: decreased BS at bases
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema, + pulses
Skin: No rash, Warm and dry
Pertinent Results:
[**2133-7-23**] 01:35PM BLOOD WBC-14.9* RBC-4.00* Hgb-13.4* Hct-38.0*
MCV-95 MCH-33.5* MCHC-35.2* RDW-13.0 Plt Ct-217
[**2133-7-30**] 04:38AM BLOOD WBC-8.6 RBC-2.86* Hgb-9.4* Hct-26.6*
MCV-93 MCH-32.9* MCHC-35.4* RDW-13.1 Plt Ct-194
[**2133-7-30**] 04:38AM BLOOD Glucose-96 UreaN-13 Creat-0.5 Na-137
K-4.1 Cl-104 HCO3-25 AnGap-12
CT c-spine [**7-23**]
1. No fracture.
2. Grade 1 retrolishesis of C5 on C6 with widening of the C5/6
interspace
anteriorly and a small amount of prevertebral fluid concerning
for anterior ligament injury/disruption.
3. Posterior disc osteophyte complexes at C5-6 and C6-7 causing
severe and
moderate canal narrowing, respectively.
4. Calcified left thyroid nodule. Please correlate with exam
findings.
Thyroid ultrasound may be obtained nonemergently if indicated.
CT Head [**7-23**] - no acute intra-cranial process
CT Chest [**7-23**] -
1. Left posterior eighth through twelfth rib fractures,
segmental from ninth through eleventh ribs, with small left
pulmonary laceration and pneumothorax.
2. Left-sided calcified thyroid nodule.
3. No aortic dissection, vertebral fractures, or free pelvic
fluid. No
evidence of traumatic injuries to the abdomen or pelvis.
Brief Hospital Course:
The patient was admitted to the ICU upon admission.
On [**7-24**], the patient went to the OR spine for decompression with
C3-C7 laminectomy, C3-T1 fusion. Postoperatively the patient
was hypotensive likely from cord injury, otherwise he was
hemodynamically stable. He required intermittent pressor with
neo gtt, and this was unable to be weaned until [**2133-7-27**]. On
[**2133-7-25**], the patient was started on full liquid diet and
transitioned to po pain medications. However, on [**2133-7-27**] patient
was noted to have difficulty with swallowing and failed a speech
and swallow study. He was kept on regular pureed solid diet. The
patient's had a drain in place after his procedure, which was
removed on [**7-26**]. His R arm laceration was closed with a penrorse
drain on [**2133-7-26**]. He was started on ancef when the penrose
drain was placed. On [**2133-7-28**], the patient was hemodynamically
stable off pressors, his pain was well controlled, and he was
afebrile with stable vital signs. He was transferred to the
floor.
Following transfer to the Surgical floor he was evaluated by the
Physical Therapy and Occupational Therapy service for full
evaluations. [**Hospital **] rehab was recommended to help in
learning compensation techniques. He was also evaluated again
by the Speech and swallow therapist and a video swallow was done
which showed some aspiration of thin liquids and his diet
currently remains pureed with nectar thick liquids.
He underwent vigorous pulmonary toilet and has remained free on
any pulmonary complications. His right elbow laceration is
draining serous fluid but there is surrounding erythema and
needs to be watched. The Penrose is out and Keflex will remain
until [**2133-8-4**].
After an unfortunate accident he was transferred to rehab on
[**2133-7-31**] with the hopes of returning home soon, able to compensate
for his deficits. His upper extremities are improving daily but
his lower extremities are without movement.
Medications on Admission:
atorvastatin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q 3 hrs as needed
for pain.
11. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
14. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 5 days. DC [**2133-8-4**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
S/P MVC
1. Left posterior [**9-11**] rib fractures
2. Cervical spinal cord injury.
3. C5-C6 fracture-dislocation.
4. Cervical spinal stenosis.
5. Small left pulmonary laceration and pneumothorax
6. Large laceration ?avulsion R elbow (no obvious joint
involvement)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital with multiple injuries after
your motor vehicle accident including fractured ribs, a spinal
cord injury and an elbow laceration. You have improved daily
but need acute rehab to try to increase your mobility.
* Wear your cervical collar when out of bed.
* Continue to use your incentive spirometer, cough and deep
breath to improve your lungs and prevent pneumonia.
* Work hard with Physical and Occupational Therapy to get your
muscles conditioned.
* Continue to eat pureed foods and the Speech and Swallow
therapist at rehab will re evaluate you to hopefully increase
your diet.
* Please call your doctor or return to the ED if you develop
fever > 101.5, chills, nausea, vomiting, worsening pain not
controlled by pain medications, decreased sensation/movement in
any or extremities, chest pain, or SOB.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**4-3**] weeks.
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 4 weeks.
Completed by:[**2133-7-31**] |
99661,51881,0388,2866,430,43411,570,99592,78552,5849,99811,1173,00845,449,44422,4260,45385,9971,78959,2851,7464,4200,6826,72972,E8788,42731,V1365,E8782,99662,37741,04104,V0980,72210 | 99,783 | 126,090 | Admission Date: [**2125-11-1**] Discharge Date: [**2125-12-5**]
Date of Birth: [**2083-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
endocarditis/ perivalvular abscess
Major Surgical or Invasive Procedure:
[**2125-11-9**]:Mediastinal exploration and chest closure/ CorMatrix
patching of the pericardium.
[**2125-11-5**]:Redo sternotomy and redo Bentall
procedure and ascending aortic and hemi-arch replacement
under deep hypothermic arrest with a 25 mm homograft and a 28
mm Gelweave tube graft.
[**2125-11-6**]: L femoral thrombectomy/LLE fasciotomy
[**2125-11-6**]: RLE fasciotomies
[**2125-11-18**]: L leg debridement and VAC placement
[**2125-11-25**]: L leg debridement
[**2125-12-3**]: Exploratory lap
History of Present Illness:
42 year old gentleman well known to the cardiac surgery service
as he is s/p Bentall(29 StJude mech Ao valved graft) on [**2125-9-13**]
with Dr.[**Last Name (STitle) **]. He was evaluated at [**Hospital6 17390**]
on [**10-19**] for right facial numbness and concern for posiible
TIA-however his symptoms resolved and he was not admitted at
that
time. He presented to [**Hospital6 2910**] on [**2125-10-30**]
complaining of lower back pain, left hip pain and a low grade
temp for which he was admitted for presumed endocarditis. At OSH
a CT of abdomen and pelvis were done, as well as MRI which were
unremarkable. His INR>6 and he was given 5mg Vitamin K. He
spiked
a temp to 103 and was cultured. He was empirically placed on
Vancomycin and Rocephin. Cardiology was consulted and there was
a
question of perivalvular abscess.He was admitted for suspected
endocarditis with perivalvular abscess and peripheral
stigmata/recent suspected TIA on [**10-19**]/and supratherapeutic INR.
[**Hospital1 18**] was contact[**Name (NI) **] and the pt was transferred for further
workup
and TEE.
Past Medical History:
Past Medical History:
Bicuspid aortic valve
Aortic insufficiency
Dilated ascending aorta
Hyperlipidemia
Hypertension
Past Surgical History:
[**Last Name (un) 8509**] eye surgery [**2117**]
Social History:
Lives with: Wife
Contact: Wife Phone #
Occupation: HVAC
Cigarettes: Smoked no [X] yes [] last cigarette Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [] [**2-27**] drinks/week [] >8 drinks/week [X] -
2
drinks/day
Illicit drug use: Denies
Family History:
Family History: Father with CAD and stent at age 60. GF
underwent
CABG. Mother and brother without issues.
Physical Exam:
Pulse:94 Resp:18 O2 sat: 97% R/A
B/P 109/68
Height: 70" Weight:
General: A&Ox3, appears uncomfortable lying flat 2' back pain
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: (R)basilar crackles [X]
Heart: RRR [] Irregular [x] Murmur [] (+)Valvular click
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [X] U/LE splinter
hemorrhages/osler nodes
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 3688**] [**Hospital1 18**] [**Numeric Identifier 112444**]Portable TEE
(Complete) Done [**2125-11-2**] at 1:51:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 31496**]
[**Last Name (LF) **], [**First Name3 (LF) **] C.
[**Apartment Address(1) 112445**]
[**Location (un) 86**], [**Numeric Identifier 8542**] Status: Inpatient DOB: [**2083-7-22**]
Age (years): 42 M Hgt (in): 70
BP (mm Hg): 94/74 Wgt (lb): 175
HR (bpm): 101 BSA (m2): 1.97 m2
Indication: Endocarditis.
ICD-9 Codes: 424.90
Test Information
Date/Time: [**2125-11-2**] at 13:51 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TEE (Complete)
3D imaging. Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West
Cath/EP Lab
Contrast: None Tech Quality: Adequate
Tape #: 2012W000-0:00 Machine: E9-1
Sedation: Versed: 4 mg
Fentanyl: 50 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Abnormal ascending aorta tube graft. Normal descending
aorta diameter. Normal abdominal aorta diameter. No thoracic
aortic dissection.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR).
MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate
([**1-22**]+) MR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. Informed consent was obtained. A TEE was performed in
the location listed above. I certify I was present in compliance
with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 69920**]e throughout the procedure. The patient was sedated for
the TEE. Medications and dosages are listed above (see Test
Information section). Local anesthesia was provided by
benzocaine topical spray. The posterior pharynx was anesthetized
with 2% viscous lidocaine. No glycopyrrolate was administered.
No TEE related complications. Resting tachycardia (HR>100bpm).
patient.
Conclusions
The ascending aorta tube graft appears abnormal. There is
dehiscence of the proximal aortic graft/valve apparatus with the
intervalvular fibrosa, with a false lumen in communication with
the left ventricular outflow tract. Color doppler confirms flow
in systole and diastole through the communication. The maximal
diameter of the false lumen measures 1.6cm. The false lumen is
bordered by the adjacent pulmonary artery and pericardium. No
pericardial effusions seen elsewhere. The distal end of the
false lumen could not be visualized. There are multiple
lobulated structures at the proximal end of the false lumen,
which may represent vegetations or thrombi. The distal
anastomosis of the aortic graft appears normal. Mechanical valve
appears well seated within the graft with no paravalvular leak
within the graft. No evidence of masses/vegetations on aortic
valve.
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. No
thoracic aortic dissection is seen. A mechanical aortic valve
prosthesis is present. The mitral valve leaflets are
structurally normal. Mild to moderate ([**1-22**]+) mitral
regurgitation is seen. There is no pericardial effusion. There
is no evidence of thoracic or descending aortic dissection.
IMPRESSION: Dehiscence of the composite aortic root valved
conduit with an extensive aortic root abscess, as described
above.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2125-11-2**] at
1:40pm.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2125-11-2**] 17:22
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 3688**] [**Hospital1 18**] [**Numeric Identifier 112446**] (Complete) Done
[**2125-11-9**] at 9:20:48 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 31496**] Status: Inpatient DOB: [**2083-7-22**]
Age (years): 42 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. H/O cardiac surgery.
ICD-9 Codes: 424.90
Test Information
Date/Time: [**2125-11-9**] at 09:20 Interpret MD: [**Name6 (MD) 95342**] [**Name8 (MD) 95343**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 95343**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2012AW-3: Machine: IE33
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Stroke Volume: 60 ml/beat
Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm
Hg
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 14 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 2.0 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV. Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Normal regional LV systolic function. No LV
mass/thrombus. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. Borderline normal RV systolic function. Mild
global RV free wall hypokinesis.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3).
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Patient was brought to OR for chest closure. Repeat TEE was
performed. The right atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. No masses or thrombi are seen in the left ventricle. The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with borderline normal free
wall function. There is invaginateion of the IAS into LA with a
CVP of 24mmHg. 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. There is a small probably vegetation on
the anterior leaflet of the mitral valve. Not pedunculated,
affecting the MV apparatus functionally. Surgeons aware. There
is no pericardial effusion. Probe was placed and removed
uneventfully and atraumatically
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 95342**] [**Name8 (MD) 95343**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-11-9**] 09:37
.
[**2125-12-4**]
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular systolic function is hyperdynamic (EF>75%). The
aortic valve appears to be a homograft. The aortic valve
prosthesis appears well seated, with normal leaflet motion. No
masses or vegetations are seen on the aortic valve. A large,
extensive aortic annular abscess is seen, involving the entire
extent of the anterior mitral continuity and full extention into
the anterior fibrous skeleton. No aortic regurgitation is seen.
There is a large vegetation involving the anterior mitral
leaflet with leaflet abscess and mutliple areas of perforation
(including one large perforation and partial flail). Severe (4+)
mitral regurgitation is seen, with reversal of flow in the right
superior pulmonary vein. The regurgitant jet is principally
posteriorally directed through a large perforation of the
anterior mitral valve leaflet, but additional regurgitation is
seen through poor leaflet coaptation. The tricuspid valve
leaflets are normal, with no masses or vegiations seen. There is
mild to moderate ([**1-22**]+) tricuspid regugitation.
IMPRESSION: Large vegetation/abscess involving the anterior
mitral valve leaflet and extending throughout the anterior
fibrous skeleton and aortic root. Extensive destruction of the
anterior mitral valve leaflet with multiple sites of perforation
and secondary severe, eccentric mitral regurgitation.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
was notified in person of the results on[**2125-12-4**] at 1615.
.
[**2125-12-4**]
CONCLUSION:
1. Normal-appearing liver without focal abnormalities.
2. Patent portal and hepatic venous system with pulsatile flow
suggesting
right heart failure or tricuspid insufficiency.
3. Bilateral pleural effusions, left greater than right.
4. Gallbladder sludge without evidence of cholecystitis.
Brief Hospital Course:
42 year old male s/p Bentall(29 StJude mechanical Aortic valve
graft) on [**2125-9-13**] with Dr.[**Last Name (STitle) **]. He presented to [**Hospital1 16549**] on [**2125-10-30**] complaining of lower back pain, left
hip pain and a low grade temp. He was admitted for presumed
endocarditis and transferred to the [**Hospital1 18**] for further workup. On
his admission on [**11-1**], he was admitted to [**Hospital Ward Name 121**] 6,ID
consulted,Empiric Vancomycin/Ceftriaxone were started,Blood CXs
obtained, reversal of INR for TEE to evaluate paravalvular
abscess/endocarditis with Cardiology and a CT torso was done.
Pain service was consulted for his chronic lower back pain
likely of multifactorial etiology:
myofascial vs neuropathic vs infectious, however his chronic
back pain is complicated by infectious processes on his aortic
valve, high grade fevers, cerebral emboli hemorraghic and
possibly septic. As such there was concern that his severe
lower back pain could be a result of a disseminated infection to
vertebral body or epidural space. MRI of the spine was done on
[**11-3**], per Radiology showed: No evidence of spinal infection.
Small midline L5-S1 disc protrusion. Neurosurgery and neurology
was consulted and MRI/MRA of the brain performed. Per Radiology
it showed: Multiple bilateral punctate infarctions,
acute-to-subacute in chronicity,most compatible with embolic
infarcts.Some of these infarcts are noted with small
intraparenchymal hemorrhage,Small amount of subarachnoid
hemorrhage in
the adjacent sulci and No evidence of developing hydrocephalus
or significant
edema. MRA brain shows no vascular occlusion. During Mr.[**Known lastname 67977**]
testing in the CT scanner his left antecubital fossa was
infiltrated with 75cc of CT contrast. Hand surgery was consulted
and found his arm had soft compartments without threatened
overlying skin. Recommendations were appreciated. [**11-4**]
Opthamology was consulted due to new blurry vision. His visual
acuity and anterior exam were found to be normal. During
intermittent episodes of extreme back pain, the pt was
incontinent. Neurology was contact[**Name (NI) **] for evaluation of caudus
equinus. Neuro felt it was narcotic induced. Due to Mr.[**Known lastname 67977**]
worsening pain and mental status waxing and [**Doctor Last Name 688**], he was
transferred to the CVICU to undergo a controlled intubation and
intensive monitoring prior to surgery.
[**Hospital1 18**] was informed on [**11-4**] by the OSH, the blood CXs from the
outside institution grew Aspergillus. As previously stated,
repeat imaging at the [**Hospital1 18**] was done on admission. It showed a
dehiscence of the proximal suture line of the valve to the
anulus with a contained pseudoaneurysm or abscess. He also
suffered from multiple embolization. Dr.[**Last Name (STitle) **] discussed,
numerous times, with Mr.[**Known lastname 30380**] and his family, that he is
presenting for a very high risk undertaking of reoperative root
most likely with the homograft in the setting of fresh embolic
strokes seen on CT scan and an inadequately treated fungal
infection.
On [**2125-11-5**] Mr.[**Known lastname 30380**] was taken to the operating room and
underwent Redo sternotomy and redo Bentall procedure and
ascending aortic and hemi-arch replacement
under deep hypothermic arrest with a 25 mm homograft and a 28 mm
Gelweave tube graft. Please see operative report for further
surgical details. He was transferred to the CVICU intubated,
sedated, requiring multiple pressors and inotropic support to
augment his cardiac function. He was received in the CVICU in
very critical condition. Postoperative bleeding occurred and
aggressive resuscitation with multiple blood products ensued. He
was taken back to the operating room for exploration.
Hemodynamic stability was obtained. At the completion of the
rexploration, it was noted that Mr.[**Known lastname 67977**] left leg appeared
mottled. He returned to the CVICU paralyzed with an open chest.
Due to the extensive surgery, CRRT was initiated for [**Last Name (un) **] and
volume removal. Renal was consulted. Postop night the left lower
extremity became cool with no pulses distal to femoral artery.
Vascular surgery reevaluated. On [**11-6**] he was taken to the
angiosuite with vascular and underwent a left femoral common
artery thrombectomy and lateral and medial left lower leg
fasciotomies. Later that day it was noted that his right lower
extremity was now cool and larger in appearance with associated
elevated pressures. Vascular performed a fasciotomy on the right
lower extremity, with wound vac placed. The following day his
hemodynamics allowed for weaning off of inotropic support.
Pressors were decreased as tolerated. On [**11-9**] Mr.[**Known lastname 30380**] returned
to the operating room and Exploration of the mediastinum showed
no active bleeding. There was no collection of fluid anywhere.
All the surgical sites were free of any active bleeding. The
heart size was small enough for chest closure to be
accomplished. His fasciotomies were debrided. Postoperatively he
developed persistent heart block with nonfunctional epicardial
pacing wires after his redo Bentall/aortic homograft procedure.
Despite his weaning off pressors with a stable heart rate in the
50s, his EKGs suggest an escape focus with alternating
conduction down the anterior and
posterior fascicles. EP was consulted and it was felt that he
will eventually require a permanent pacemaker, but still being
critically ill and actively being treated for fungemia, a
pacemaker implantation would be premature at this time. EP
therefore placed a temporary pacemaker with the use of a
temporary screw-in lead. Due to the patients prolonged postop
course, Physical Therapy was consulted while he was in the CVICU
to evaluate his strength and mobility. It was noted that he
moved all extremities to verbal commands except for his left
lower extremity. Neurology reassesed.A repeat head Ct scan on
[**11-13**] showed:Resolving right frontal subarachnoid hemorrhage/ No
new hemorrhage/ Stable appearance of right frontal embolic
infarct. Apparent new right cerebellar hemisphere infarct,
likely also embolic. His Cultures returned positive for
C-Difficile. Flagyl was added to his antibiotic regimen, ID
continued to follow. Mr.[**Known lastname 67977**] left upper extremity was noted
to be larger than his right. A LUE U/S was done: Acute deep vein
thrombosis seen in the left subclavian vein with non-occlusive
thrombus seen surrounding the vascular line in the left internal
jugular vein. Hematology was consulted for recommendations. IV
Heparin continued and his result was HIT negative. On [**2125-11-16**]
Vascular intervened for Compartment syndrome of the right lower
extremity. A Three-compartment fasciotomy of the right lower
extremity was performed. Please see operative report for further
surgical details. The following day he was taken to the
operating room by Vascular surgery for Acute left lower
extremity ischemia.He underwent Left lower extremity angiogram/
Femoral embolectomy/ Four-compartment fasciotomy of the lower
leg. Please see operative report for further surgical details.
He continued to have leukocytosis and he was cultured regularly.
All lines were changed and he was given a line 'holiday'. On
[**2125-11-19**] he was panscanned and found no obvious source of
leukocytosis. A repeat bronch was performed and a BAL sent for
culture. All lines were changed in IR. A repeat TEE was done
which revealed:
Interval development of cavitary space surrounding the
bioprosthetic aortic root and aortic graft compared with post
bypass images obtained intraoperatively. Severe thickening of
the aortic root was noted. The following day he was taken back
to the OR by vascular for a bilateral lower extremity
debridement. On [**2125-11-21**] EP reevaluation felt that Mr.[**Known lastname 67977**]
rhythm would recover. The temporary RV pacing lead was
discontinued. He weaned to extubate. He remains anuric and CVVH
continues.
Her continued to improved and was advanced to a soft solid diet.
He was found to have VRE in his leg and was started on
Linezolid. He also complained of some vision loss in his R eye
and was evaluated by opthamology and neurology. They was a
dulling of the optic nerve on the R and could have been from his
embolic issues.
He had another leg debridement on [**11-27**] and had a tunnelled HD
line and PICC placed on [**11-29**].
On [**12-2**] he became acutely short of breath and was reintubated.
He became hypotensive and acidotic and was restarted on CVVH.
He had a rising lactate and WBC up to 40,000. He had an
abdominal and pelvic CT which was unremarkable. General surgery
was consulted and he had a negative exploratory lap on [**2125-12-3**].
He continued to have an increased pressor requirement and
remained acidotic. He also received large amounts of bicarb and
volume. There was a family meeting on [**12-4**] to communicate the
gravity of the situation to them.
Echo on [**2125-12-4**] revealed 4+MR. After extensive thought,
discussion and family meetings, it was decided that Mr. [**Known lastname 67977**]
condition was not survivable. This was explained to the family
in detail and they understand. The patient was made DNR, then
CMO. Pressors were discontinued and ventillatory settings
minimized. The patient died with his family at the bedside at
12:06pm.
Medications on Admission:
Ambien 5 (1)/HS prn, ASA 81(1), Diltiazem CD
120 (1),Chlorzoxazone 500 (3) prn, Warfarin daily, Deltasone 5
(1), Dilauded 2-4 mg q4h prn,
Meds on TX from OSH: Ambien 5(1)HS prn, Ditiazem CD 120(1),
Colchicine 0.6 mg qHS (pericarditis), Amiodarone 200 mg daily,
Tylenol prn, Vanco 1250 q 12h, Ceftriaxone 2g q 24h, Prednisone
5
mg daily,Diazepam 10q6h prn, Protonix 40(1),Warfarin-4mg-held
due
to supratherapeutic INR
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Procedure:[**2125-9-13**]: Bentall(29 StJude mech Ao valved
graft)[**9-13**]-on Coumadin
-postop AFib (on Coumadin)
-postop pericarditis
-Bicuspid aortic valve
-recently seen at OSH for right facial numbness/ likely TIA on
[**10-19**]
-Aortic insufficiency
-Dilated ascending aorta
-Hyperlipidemia
-Hypertension
-Fungal endocarditis
-bilat lower extremity compartment syndrome with VRE infection
-respiratory failure with prolonged intubation
-renal failure
-hepatic failure
-sepsis
Discharge Condition:
Expired
Discharge Instructions:
.
Followup Instructions:
.
Completed by:[**2125-12-5**] |
7464,4412,2859,4263,4019,2724 | 99,783 | 174,582 | Admission Date: [**2125-9-13**] Discharge Date: [**2125-9-18**]
Date of Birth: [**2083-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2125-9-13**]: Bental(29 StJude mech Ao valved graft)[**9-13**]
History of Present Illness:
42 year old gentleman with a known bicuspid aortic valve and a
dilated ascending aorta which has been followed by serial
echocardiograms. His most recent echocardiogram showed mild to
moderate aortic insufficiency however his CT scan showed his
aortic root to measure 6.0cm. Given the size of his aorta, he
has
been referred for surgical evaluation. He denies any chest pain,
dyspnea, palpitations, edema or syncope but does admit to mild
fatigue.
Past Medical History:
Past Medical History:
Bicuspid aortic valve
Aortic insufficiency
Dilated ascending aorta
Hyperlipidemia
Hypertension
Past Surgical History:
[**Last Name (un) 8509**] eye surgery [**2117**]
Social History:
Race: Caucasian
Last Dental Exam: [**1-22**] yrs ago
Lives with: Wife
Contact: Wife Phone #
Occupation: HVAC
Cigarettes: Smoked no [X] yes [] last cigarette Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [] [**2-27**] drinks/week [] >8 drinks/week [X] -
2
drinks/day
Illicit drug use: Denies
Family History:
Family History: Father with CAD and stent at age 60. GF
underwent
CABG. Mother and brother without issues.
Physical Exam:
Physical Exam
Pulse: 69 Resp: 16 O2 sat: 100%
B/P Right: 116/69 Left: 136/70
Height: 70" Weight: 196
General: Well-developed male in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**2-26**] sys/diastolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [X]
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
[**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5*
MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191
[**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5*
[**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138
K-5.1 Cl-102 HCO3-28 AnGap-13
[**2125-9-17**] 03:46AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.3* Hct-29.4*
MCV-87 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-148*#
[**2125-9-17**] 03:46AM BLOOD Plt Ct-148*#
[**2125-9-17**] 03:46AM BLOOD PT-18.2* PTT-34.3 INR(PT)-1.7*
[**2125-9-17**] 03:46AM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-138
K-4.8 Cl-102 HCO3-29 AnGap-12
[**2125-9-17**] 03:46AM BLOOD Mg-2.0
[**2125-9-14**] 05:31AM BLOOD Glucose-108* K-4.4
TEE [**2125-9-13**]
Conclusions
Pre-Bypass:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta and arch are moderately dilated. The aortic
valve is bicuspid. Moderate (2+) aortic regurgitation is seen.
There is no aortic stenosis.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
Post-Bypass:
The patient is in sinus ryhthm on a phenylephrine infusion.
#29 St. [**Male First Name (un) 923**] Mechanical Aortic Valve graft appears well seated.
There are no apparent peri-valvular leaks. Washing jets are
present.
Normal left ventricular function - EF50-55%
Trace MR remains.
Remainder of exam is unchanged.
[**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5*
MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191
[**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5*
[**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138
K-5.1 Cl-102 HCO3-28 AnGap-13
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2125-9-13**] where the patient underwent Bental
with #29 mechanical aortic valve. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
He was initially hypertensive and required a nicardipine gtt. He
was started on lopressor and lasix. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable. On
POD#1 he transferred to the floor. Chest tubes and pacing wires
were discontinued without complication. Post opertatively he was
noted to have a new LBBB which has since resolved. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. He was started on anticoagulation
therapy his goal INR 2.5-3.5. He was given the following
Coumadin doses -5mg/7.5mg/7.5mg/7.5mg/5 mg with INR 2.5 at the
time of discharge. By the time of discharge on POD# 5, the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home with visiting nurse services in good condition with
appropriate follow up instructions. His first VNA INR draw is to
be done [**2125-9-19**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 5 mg PO DAILY
2. LeVITRA *NF* (vardenafil) unknown Oral unknown
3. Clindamycin 150 mg PO Frequency is Unknown
prn dental
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
2. Furosemide 20 mg PO Q12H
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
3. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**1-22**] tablet(s) by mouth Q 4 hrs Disp #*30
Tablet Refills:*0
4. Metoprolol Tartrate 50 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
5. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Warfarin MD to order daily dose PO DAILY mechanical AVR
Take as directed for INR goal 2.5-3.5 for mechanical valve
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Milk of Magnesia 30 ml PO HS:PRN constipation
Discharge Disposition:
Home With Service
Facility:
amedisys
Discharge Diagnosis:
Bicuspid aortic valve
Aortic insufficiency
Dilated ascending aorta
Hyperlipidemia
Hypertension
[**Last Name (un) 8509**] eye surgery [**2117**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema minimal
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
No driving for approximately one month and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2125-9-27**]
at 10:30a
Surgeon Dr. [**Last Name (STitle) **] on [**2125-10-17**] at 1:00p
Cardiologist: Dr. [**Last Name (STitle) 2912**] on [**2125-10-8**] at 1:45pm
Please call to schedule the following:
Primary Care Dr [**First Name (STitle) **] in [**4-26**] weeks
Coumadin for Prosthetic Aortic Valve
INR Goal: 2.5-3.5
Coumadin follow-up with Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 63696**]
Confirmed fax [**Telephone/Fax (1) 112397**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Next INR Draw: [**2125-9-19**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2125-9-18**] |
80126,82021,2639,82123,8052,99731,340,2875,70703,2763,8020,20410,04112,2449,2724,4019,70721,E8849,2859,E8798,E8497 | 99,785 | 120,655 | Admission Date: [**2122-10-7**] Discharge Date: [**2122-10-23**]
Date of Birth: [**2050-5-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
polytrauma status post fall
Major Surgical or Invasive Procedure:
[**2122-10-8**]:
1. Open reduction internal fixation left distal femur fracture
with [**Last Name (un) **] plate. 2. Open reduction internal fixation right
distal femur with [**Last Name (un) **] plate. 3. Open reduction internal
fixation right hip fracture with TFN devices, 11 x 170 x 130.
4. Hemiarthroplasty left hip with cemented [**Doctor Last Name 3389**] unipolar
stem, 44 mm head, 0 mm neck, #8 cemented. 5. Closed treatment
right proximal humerus fracture.
[**2122-10-14**]:
Insertion of inferior vena cava filter
[**2122-10-14**]:
Percutaneous tracheostomy; Percutaneous endoscopic gastrostomy
tube.
History of Present Illness:
72F with a history of MS [**First Name (Titles) **] [**Last Name (Titles) **] transferred from OSH after fall
from wheelchair sustaining bilateral femoral head/neck fx as
well as SAH/SDH. Reported mechanical fall, in wheelchair d/t MS.
+ headstrike and LOC. BPs dropped to 80s systolic, intubated
electively w/etomidate and succinylcholine. Transfer via
[**Location (un) **], recv'd fentanyl during xport. Rec'vd 1700cc and 4U
PRBCs for hypotension w/BP in 120s on arrival to ED.
Past Medical History:
PMH: hypothyroid, hyperlipidemia, htn, MS, [**Location (un) **]
PSH: unknown
MEDS: tylenol, baclofen, amantadine, lasix, provigil, Copaxone,
Lasix, Lexapro 40', ASA 81', Simvastatin
Social History:
Wheelchair bound pre-admission. Patient w no living relatives.
Attorney as executor of estate. Taken care of by care giver,
[**Doctor First Name **]. Tobacco/EtOH/Recreational drugs: denies
Family History:
Non-contributory
Physical Exam:
P/E on D/C:
VS: 101.0 98 123/57 29 100% 0.5FM
GEN: WD bedbound F in NAD
HEENT: +large R frontal subgaleal hematoma; EOMI; PERRLA;
+tracheostomy w no erythema/drainage
CV: RRR
PULM: coarse breath sounds b/l
ABD: S/NT/ND; +PEG tube in LUQ w no erythema/drainage;
+suprapubic catheter in place
EXT: 2+ b/l lower extremity edema; b/l multipodus boots; L knee
w staples at anterior incision; B/L lateral thigh incisions w
staples in place; all incisions c/d/i w no erythema or drainage
NEURO: A&Ox0; opens eyes spontaneously; does not track; does not
follow commands; does not vocalize; B/L LE 0/5 strength; UE 1+/5
B/L
Pertinent Results:
LABORATORIES:
Admit:
[**2122-10-7**] 04:40PM BLOOD WBC-40.9* RBC-4.06* Hgb-12.8 Hct-36.2
MCV-89 MCH-31.5 MCHC-35.3* RDW-16.2* Plt Ct-105*
[**2122-10-7**] 04:40PM BLOOD PT-13.7* PTT-22.0 INR(PT)-1.2*
[**2122-10-7**] 04:40PM BLOOD Glucose-151* UreaN-21* Creat-0.6 Na-143
K-4.0 Cl-111* HCO3-20* AnGap-16
[**2122-10-7**] 04:40PM BLOOD ALT-36 AST-54* AlkPhos-85 TotBili-0.7
[**2122-10-7**] 08:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2122-10-7**] 04:40PM BLOOD Albumin-3.4* Calcium-7.4* Mg-1.8
Discharge:
[**2122-10-20**] 01:42AM BLOOD WBC-17.4* RBC-2.26* Hgb-7.0* Hct-20.7*
MCV-92 MCH-31.0 MCHC-33.8 RDW-16.1* Plt Ct-413
[**2122-10-20**] 01:42AM BLOOD Glucose-115* UreaN-53* Creat-1.0 Na-141
K-4.4 Cl-111* HCO3-23 AnGap-11
[**2122-10-20**] 01:42AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.3
[**2122-10-10**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE
MICROBIOLOGY:
[**2122-10-11**]: Mini-BAL: STAPH AUREUS COAG +. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
[**2122-10-11**]: UCx: YEAST. >100,000 ORGANISMS/ML..
IMAGING:
CT Pelvis [**10-7**]: 1. Complex fracture of the right femoral neck
and intertrochanteric region. 2. Complex fracture of the left
femoral neck.
3. Bilateral complex supracondylar fractures. 4. Bilateral
hemarthrosis of the knees. 5. Subcutaneous soft tissue hematoma
tracking along bilateral thigh. 6. Severe osteopenia. 7.
Degenerative changes in the lower lumbar spine, SI and hip
joints. 8. Suprapubic Foley catheter in the urinary bladder and
air in the urinary bladder, presumably from catheter placement;
correlate clinically. 9. Nonspecific fat stranding about the
rectum; correlate clinically.
CT Max/Sinus [**10-8**]: 1. Multiple maxillofacial fractures including
the posterior sphenoid sinus, anterior and posterior frontal
sinus, ethmoidal air cells, nasal bone, medial wall of the right
maxillary sinus and anterior wall of the left maxillary sinus
and nasal bones . The bones are diffusely demineralized which
makes identification of any additional fractures difficult to
exclude. 2. Paranasal sinuses are filled with hyperdense
material, likely blood. 3. Small foci of pneumocephalus
posterior to the right frontal sinus. An underlying dural tear
and CSF leak cannot be excluded. 4. Diffuse intracranial
hemorrhage better characterized on concurrent head CT.
CT Head [**10-8**]: 1. Slightly increased small extra-axial hematoma
overlying the left frontal lobe convexity and possible small
secondary frontal hematoma noted on the right. 2. Stable
bilateral subarachnoid hemorrhage layering around the bifrontal
and temporal lobes and extending into the suprasellar,
prepontine and interpeduncular cisterns with indentation on the
pons. 3. Likely anterior maxillary and nasal bone fractures
better evaluated on subsequent maxillofacial CT. Opacification
of the paranasal sinuses likely related to blood. 4. Subgaleal
hematoma overlying the right frontal bone.
CT Head [**10-8**]: No significant change compared to study performed
approximately 12 hours prior. Multifocal subarachnoid, subdural,
or intraventricular hemorrhage is redemonstrated, as is a
contusion involving the left inferior frontal lobe. Extensive
facial fractures with blood in the paranasal sinuses was better
characterized on prior dedicated facial bones CT. There is again
no midline shift or evidence of central brain herniation.
MRI C-spine [**10-9**]: 1. No obvious focus of marrow edema in the
cervical vertebrae. Multilevel, multifactorial degenerative
changes, with adequate assessment is significantly limited on
the axial images, due to motion-related artifacts. Vague areas
of cord signal intensity are noted, inadequately assessed on the
present study. Areas of altered signal intensity in the thecal
sac may relate to blood products/pulsation artifacts or a
combination of both given the presence of subarachnoid and
intraventricular hemorrhage on prior CT head study.
CT T/L Spine [**10-9**]: 1. Acute compression fracture of the T3
vertebral body, with buckling of the posterior cortex, the
inferior aspect of which is displaced posteriorly by
approximately 3 mm. Suspected T2 vertebral body fracture (seen
on concurrent cervical spine MRI) is not apparent by CT.
2. Compression deformities involving the T11, T12, and L1
vertebral bodies. While as detailed above these may be chronic,
given the concurrent acute injury in the upper thoracic spine,
it is difficult to exclude an acute component.
MR T/L Spine [**10-10**]: 1. Areas of marrow edema in the T2 and T3
vertebral bodies, with mild contour irregularity of the
posterior cortex of T3 which is seen to indent the ventral
thecal sac and the ventral surface of the cord. Osseous details
are better assessed on the prior CT. Mild diffuse disc bulge,
with small-to-moderate sized disc extrusion, on the right side
deforming the right side of the cord at T7/8. Small central
protrusion at T6-T7 level indenting the ventral thecal sac and
ventral cord.
Moderate loss of height T12 vertebral body with Schmorl's nodes,
likely
chronic. Mild-to-moderate loss of height of the L1 vertebral
body, with a Schmorl's node with an acute component of marrow
edema in the L1 vertebral body. Multilevel disc and facet
degenerative changes in the lumbar spine with mild foraminal
narrowing at L4 and L5 levels. 2. Diffusely altered signal
intensity in the thecal sac, may relate to pulsation artifacts;
however, blood products cannot be completely excluded given the
presence of subarachnoid and intraventricular hemorrhage on the
prior CT head study. 3. Vague areas of increased signal
intensity in the thoracic cord, nature of which is uncertain.
Assessment of cord lesions is limited due to artifacts.
Attention on followup can be considered. 4. Diffuse hypointense
signal of the marrow- correlate with hematology labs. 5.
Bilateral pleural effusions and distended gall bladder
-correlate with
dedicated imaging.
CT Head [**10-10**]: 1. Minimal increase of the intraventricular
hemorrhage layering in the occipital horns. Otherwise, no change
of the intraparenchymal, subarachnoid and subdural hemorrhage.
2. No shift of midline structures and no intracranial
herniation. 3. Stable minimal dilatation of the ventricles.
PATHOLOGY:
[**2122-10-8**]: Bone, left femoral head, hemiarthroplasty:
- Bone and cartilage with changes consistent with fracture site.
- Bone marrow with an atypical lymphoid infiltrate, consistent
with known history of chronic lymphocytic leukemia.
Current labs:
[**2122-10-23**] 04:27AM BLOOD WBC-21.4* RBC-2.94* Hgb-8.8* Hct-27.6*
MCV-94 MCH-29.7 MCHC-31.7 RDW-16.1* Plt Ct-546*
[**2122-10-22**] 04:45AM BLOOD WBC-20.1* RBC-2.89* Hgb-8.6* Hct-26.6*
MCV-92 MCH-29.9 MCHC-32.5 RDW-16.6* Plt Ct-473*
[**2122-10-23**] 04:27AM BLOOD Plt Ct-546*
[**2122-10-22**] 04:45AM BLOOD Plt Ct-473*
[**2122-10-23**] 04:27AM BLOOD Gran Ct-2573
[**2122-10-22**] 04:45AM BLOOD Gran Ct-3618
[**2122-10-23**] 04:27AM BLOOD Glucose-116* UreaN-46* Creat-0.9 Na-142
K-5.6* Cl-110* HCO3-23 AnGap-15
[**2122-10-22**] 01:38PM BLOOD Na-144 K-5.6* Cl-112*
[**2122-10-22**] 04:45AM BLOOD Glucose-119* UreaN-47* Creat-0.9 Na-144
K-5.4* Cl-112* HCO3-21* AnGap-16
[**2122-10-21**] 12:51AM BLOOD Glucose-133* UreaN-51* Creat-1.0 Na-143
K-4.7 Cl-112* HCO3-20* AnGap-16
[**2122-10-23**] 04:27AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.5
[**2122-10-22**] 04:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.5
Brief Hospital Course:
Patient was transferred from OSH via [**Location (un) **] intubated and
sedated. STAT trauma protocol was initiated on arrival to [**Hospital1 18**]
ED. Evaluation was carried out by ACS trauma team and ED
trauma. Imaging was obtained as per above. Patient was
tachycardic/hypotensive despite crystalloid fluid resuscitation.
4 units pRBC were given in trauma bay. Patient was then
stabilized and admitted to the TSICU for further management.
Neuro: At baseline patient is wheelchair bound secondary to MS.
Cognitive baseline is described as mentally sharp with ability
to do crossword puzzles. On arrival to [**Hospital1 18**] ED patient was not
seen to be spontaneously moving extremities and not following
commands. This mental status persisted throughout admission.
CT head obtained on admission demonstrated traumatic brain
injury (left frontal subdural hematoma and scattered
frontotemporal subarachnoid hemorrhage). This was found to be
grossly stable on interval imaging during admission. Seizure
prophylaxis was administered per neurosurgical recommendation.
Patient will follow up with neurosurgery with interval imaging
per instructions.
Throughout hospital course patient was given pain medication
with good effect and adequate relief. Tylenol and narcotics
initially administered via IV and then transition to enteral
with good effect.
CV: Patient demonstrated sinus tachycardia on admission to
TSICU. This was minimally responsive to fluid resuscitation.
Beta blockade was initiated following confirmation of adequate
pain control and stable hematocrit. This was titrated up with
good effect.
At time of discharge patient is on stable dose of metoprolol
with no cardiac issues. Vital signs were routinely monitored.
Pulmonary: Patient was admitted intubated. Respiratory support
was continued. [**10-11**] patient was febrile with desaturations.
Bronchoscopy was performed that demonstrated thick secretions
and treatment was initiated for VAP.
Given inability to wean from ventilatory support a tracheostomy
was placed [**10-14**]. Procedure was tolerated well and remains in
good position at time of discharge. At time of discharge
patient tolerating T-piece supplemental oxygen with persistent
requirement for Q2-3 hour suctioning/pulmonary toilet.
GI/GU: Patient was NPO with IVF at time of admission. Enteral
feeding was initiated [**10-9**] with appropriate recommendations made
by nutrition service. These were well tolerated and bowel
regimen was given with good effect. Enteral access via PEG tube
was obtained [**10-14**] given expectation for long term inability to
tolerate po intake. This was noted to be in good position and
functioning well. At time of discharge patient on stable
enteral feeding regimen and passing flatus/BMs appropriately.
Patient was admitted with suprapubic catheter in place related
to MS. This was continued throughout admission. Following
initial resuscitation lasix was utilized to assist in diuresis
of massive volume previously required for cardiovascular
support. At time of discharge patient with adequate urine
output via pre-existing suprapubic catheter. Intake and output
were closely monitored.
MSK: Patient sustained bilateral proximal and distal fractures
of the femur that were repaired by orthopedics as per above
[**10-8**]. Patient is discharge with recommendation to be non-weight
bearing at bilateral hips but may have full range of
active/passive motion at knees. Multipodus boots used
throughout admission per PT recommendations. Patient was seen
early by physical therapy who continued to work with patient
throughout admission.
Patient was noted to have thoracic spine fractures as above. A
[**Location (un) **] brace was recommended by ortho spine. This was obtained
during admission. She should wear this at all times when not in
bed. In bed patient may be without brace on logroll
precautions.
Facial fractures were evaluated by plastic surgery. Nasal bone
fracture was reduced at the bedside [**10-8**]. Other fractures
non-operative per plastic surgery with no need for plastics
follow up.
HEME: Patient has a history of [**Month/Year (2) **] which was demonstrated via
WBC in 40s on admission. Patient was transfused 4 pRBC prior to
arrival in TSICU related to refractory hypotension at OSH. [**10-8**]
patient was further transfused 3 pRBC, 1 FFP and 1 platelets
while in operating room with orthopedics. [**10-9**] hematocrit was
persistently low without appropriate increases seen on prior
day's transfusions. Three additional units of pRBC were
transfused and patient's hematocrit remained stable in the low
to mid 20s for remainder of admission. Hematology/oncology were
consulted during this admission for considerations of [**Month/Year (2) **] in
trauma patient. They recommended further workup of hematologic
malignancy if patient manifested symptoms of hematologic
dysfunction which she did not.
An IVC filter was placed [**10-14**] given likelihood of protracted
immobility and multiple orthopedic injuries. LENIs had been
obtained prior to this ([**10-13**]) and these were negative.
A HIT panel was sent for concern of low platelets during this
admission and this was found to be negative. Heparin products
were briefly held related to this but resumed when negative test
was found.
ID: Patient had recently completed a course of antibiotics for
UTI at time of admission.
Patient was febrile on [**10-11**] and pan cultures were obtained.
Given desaturations and CXR findings at this time VAP protocol
was initiated with triple antibiotic therapy (vancomycin,
cefepime and cipro). BAL specimens demonstrated MRSA on [**10-11**]
and [**10-16**]. Antibiotics were tailored appropriately. Cipro was
discontinued [**10-14**] and fluconazole started for finding of yeast
in BAL and UCx. Cefepime was discontinued [**10-15**]. At time of
discharge patient is completing 14 day course of vancomycin and
fluconazole and had been afebrile for over 72 hours. Vancomycin
and fluconazole have been discontinued.
Prophylaxis: See heme.
Disposition: Patient was actively screened for appropriate
post-hospital care and was accepted to facility. Regarding code
status health care proxy has stated that patient is full code.
Discussions prior to injury HCP states that patient never wanted
to discuss things of this nature.
At the time of discharge on [**2122-10-23**], the patient was doing
well, afebrile with stable vital signs, tolerating enteral
feeding, bedbound, voiding via suprapubic catheter, and pain was
well controlled.
Of note: borderline potassium of 5.6 reported on [**10-23**]. 15 gm
Kayexalate given. Please repeat potassium [**10-23**] and [**10-24**]
Patient was not started on home lasix dose while hospitalized
because of borderline creatinine. Please resume 40 mg lasix
daily ( records unclear as to home dose....40 mg daily or 40 mg
[**Hospital1 **]) Continue to monitor lytes/creat.)
Medications on Admission:
[**Last Name (un) 1724**]: Copaxone, Lasix, Lexapro 40', ASA 81', Simvastatin
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
2. amantadine 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous daily ().
6. baclofen 10 mg Tablet Sig: One (1) Tablet PO Q AM ().
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. insulin regular human 100 unit/mL Solution Sig: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
9. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) mg
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
10. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): hold for systolic bp <110, hr <60.
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
16. dextrose 50% in water (D50W) Syringe Sig: 12.5 g
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
17. neutra-phos Sig: One (1) packet once a day: please
continue to monitor phos.
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
1. Traumatic brain injury (Left frontal subdural hematoma,
scattered frontotemporal subarrachnoid hemorrhage)
2. Bilateral intertrochanteric fractures
3. Bilateral distal femur fractures
4. Multiple maxillofacial fractures including the posterior
sphenoid sinus, anterior and posterior frontal sinus, ethmoidal
air cells, nasal bone, medial wall of the right maxillary sinus
and anterior wall of the left maxillary sinus and nasal bones
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the acute care surgery service for
management of polytrauma secondary to fall.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may also take acetaminophen (Tylenol) as directed, but do not
exceed 4000 mg in one day.
Please also follow-up with your primary care physician within
three weeks of discharge.
Continue nursing care, enteral feeding, physical therapy per
attached.
Followup Instructions:
Please follow up in [**Hospital 2536**] clinic in approximately two weeks. Call
([**Telephone/Fax (1) 2537**] at time of discharge to arrange appointment.
Clinic located at [**Hospital1 18**] [**Hospital Ward Name 517**], [**Hospital 2577**] Medical Office
Building, [**Location (un) 470**].
Please follow up with Dr. [**Last Name (STitle) 739**], neurosurgeon, in
approximately one month. Call ([**Telephone/Fax (1) 88**] at the time of
discharge to arrange an appointment to be seen and to have a
non-contrast CT scan of the head on the day of your appointment.
Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1005**], orthopedic
surgeon, in two to four weeks. Call ([**Telephone/Fax (1) 2007**] at the time
of discharge to arrange an appointment.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], orthopedic spine surgeon,
in four weeks. Call ([**Telephone/Fax (1) 11061**] at time of discharge to
arrange an appointment.
Completed by:[**2122-10-23**] |
42732,29181,496,5225,4254,V1254,4019,53081,32723,30391,3051 | 99,790 | 183,369 | Admission Date: [**2190-11-11**] Discharge Date: [**2190-11-18**]
Date of Birth: [**2125-8-17**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Atrial flutter, ETOH withdrawl
Major Surgical or Invasive Procedure:
Ablation of Atrial Flutter
drainage of molar abscess
History of Present Illness:
Mr. [**Known lastname 11270**] is a 65M with a PMH s/f ETOH abuse and a
tachyarrhythmia in the past that the patient cannot identify who
is presenting with atrial flutter and ETOH withdrawl. The
patient has been an alcoholic for 40 years off and on, where he
intermittently consumes ~1 quart of vodka daily, of note he
denies any prior history of withdrawl seizures. His last drink
was on Monday at 8PM. On Tuesday he was at a dental appointment
for a tooth extraction, where he was noted to be tremulous. The
dentist took his pulse and noted him to be tachycardic. He was
sent to [**Hospital1 **] ED. From there he was medically cleared to be
transferred to [**Hospital1 **] for ETOH detox. At [**Hospital1 **] the
patient was placed on an ativan sliding scale. At 8PM on [**11-11**],
the on-call physician was called for a rapid HR to 144 despite
three doses of ativan. He was otherwise hemodynamically stable.
He was transferred to [**Hospital1 18**] for further evaluation.
.
In the emergency department initial vitals were 96.8, 142/107,
146, 18, 100% on 2L. CIWA score on arrival to the ED was 21 He
recieved a total of 30mg IV diazepam. Vagal maneuvers were
unsuccessful. After 18mg of IV adenosine (6mg followed by 12mg),
his rate slowed down to 110s and revealed 3:1 atrial flutter. At
that time he recieved a total of 3L of NS, and 3 10mg IV
diltiazem doses. A diltiazem drip was started at 10mg/hr with
minimal effect. He was transferred to the ICU for further
monitoring.
.
ROS is negative for any changes in vision, headache, chest pain,
palpitations, dyspnea, light-headedness, abdominal pain, or
weakness. ROS is notable only for tremor and nausea
Past Medical History:
HTN
GERD
S/p multiple CVA's: last one seven months ago, where the patient
presented with dysarthria
Obstructive sleep apnea
ETOH abuse: no history of withdrawl seizures
Social History:
40 year history of ETOH abuse, off an on since his 20s. During
active periods, he consumes ~8 drinks/day. He has been smoking 2
packs per day over the past 30 years. He denies any other
substance abuse.
Family History:
Non contributory
Physical Exam:
T=98.6... BP=140s systolic... HR=140s... RR=13... O2=97% RA
.
.
PHYSICAL EXAM
GENERAL: Alert and oriented x3, tremulous, able to answer
questions appropriately. NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Dry mucous membranes. OP clear.
Neck Supple, No LAD, No thyromegaly.
NECK: No carotid bruits
CARDIAC: Regular rhythm, tachycardic, unable to auscultate any
murmurs secondary to rapid rate
LUNGS: Inspiratory and expiratory wheezes diffusely.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
==================
ADMISSION LABS
==================
WBC-7.6 RBC-3.98* Hgb-13.2* Hct-37.2* MCV-93 MCH-33.0*
MCHC-35.4* RDW-13.8 Plt Ct-170
PT-13.1 PTT-26.3 INR(PT)-1.1
Glucose-114* UreaN-15 Creat-1.0 Na-140 K-4.1 Cl-107 HCO3-24
AnGap-13
CK(CPK)-72, cTropnT-<0.01,
Calcium-8.3* Phos-3.4 Mg-1.3*
=====================
TRANSTHORACIC ECHO ([**2190-11-12**])
=====================
The left atrium is mildly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Impression: Mild spontaneous echo contrast in the left atrial
appendage. No thrombus in the left atrial appendage. Normal left
ventricular function. Mild mitral regurgitation.
=============
CHEST X-RAY
=============
The cardiomediastinal silhouette is within normal limits. There
is
no pneumothorax, consolidation, or pleural effusion. The
pulmonary
vasculature is normal. The osseous structures appear within
normal limits.
IMPRESSION: No acute cardiopulmonary process.
==================
DISCHARGE LABS
==================
WBC-6.7 RBC-3.82* Hgb-12.5* Hct-36.0* MCV-94 MCH-32.8* MCHC-34.8
RDW-14.1 Plt Ct-188
PT-13.9* INR(PT)-1.2*
Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.6 Cl-107 HCO3-26
AnGap-11
Calcium-9.3 Phos-3.9 Mg-1.6
BLOOD TSH-1.4
Brief Hospital Course:
Mr. [**Known lastname 11270**] is a 65M with a PMH s/f ETOH abuse and atrial flutter
in the setting of alcohol withdrawal, status post ablation.
Below is a problem based summary of this hospitalization:
.
#. Atrial flutter: Likely related to underlying un-diagnosed
COPD given smoking history. Patient was placed on heparin drip
and electrophysiology consultation was obtained. Patient was
taken to radiofrequency ablation of atrial flutter which was
found to be typical counter-clockwise at rate of 220 msecs. HV
intervals and SA nodes were normal, and no atrial flutter was
inducible after ablation. Patient will be anticoagulated for 4
weeks, with coumadin (INR goal [**3-7**]) with Lovenox bridge. On
discharge, INR was 1.8 and he had been on 3 days of coumadin 5
mg daily. Patient will also be maintained on atenolol per
pre-admission medications. This information was relayed to his
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8049**] who will follow his INR. [**Hospital 197**] clinic
appointment was also arranged for the patient.
.
#. ETOH withdrawal: Patient was closely monitored and maintained
on Diazepam per CIWA scale > 10. Patient was also maintained on
MVI, thiamine, folate.
.
# Dental abscess: Pt had abscess involving molar #19. He was
seen by OMFS and underwent drainage of abscess. He was
discharged on 7 days PO clindamycin and can follow-up with his
outpatient dentist PRN.
.
#. History of CVA: We continued home ASA but discontinued his
plavix as it was deemed no longer necessary.
.
#. HTN: Patient had good BP control on atenolol.
.
#. GERD: We continued home regimen of omeprazole
.
FEN: Patient tolerated a cardiac healthy diet
PPX:
-DVT ppx: On systemic anticoagulation
-Bowel regimen: colace
-Pain management: tylenol as needed.
ACCESS: PIV's
CODE STATUS: Patient remained FULL CODE during this admission.
Medications on Admission:
Plavix 75mg daily
Atenolol 50mg daily
Omeprazole 20mg daily
ASA 325mg daily
Lipitor 40mg daily
MVI daily
Thiamine 100mg daily
Folic acid 1mg daily
Ativan taper
-Lorazepam 1mg [**Hospital1 **] on [**11-12**]
-Lorazepam 1mg x1 on AM of [**11-13**]
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) for 1 weeks.
Disp:*120 Tablet(s)* Refills:*0*
8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day) for 4 days.
Disp:*8 syringe* Refills:*1*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
11. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four
times a day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
ATRIAL FIBRILLATION
ALCOHOL WITHDRAWAL
dental abscess
Discharge Condition:
Hemodynamically stable, with sinus rhythm and with ongoing
alcohol withdrawal symptoms.
Discharge Instructions:
You were admitted to the hospital with a rapid heart rate after
you stopped alcohol intake. We helped to control your withdrawal
and were able to perform a procedure to keep this type of fast
heart rate from happening. You will need to continue
anticoagulation for 4 weeks, with a medication called Coumadin.
Dr. [**Last Name (STitle) 8049**] will check your coumadin level on Monday.
You also had an abscess in your tooth which was removed by the
oral surgeon. Please follow up with your dentist after this
procedure. You should take an antibiotic called clindamycin for
7 days to prevent infection after your operation.
Please keep all doctors [**Name5 (PTitle) 4314**] and take [**Name5 (PTitle) **] medications as
prescribed. If you experience any nausea, vomiting, fevers,
chest pain, palpitations, or any other symptoms that concern
you, please seek medical attention immediately.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Primary care:
Please attend the appointment at Dr. [**Last Name (STitle) 79813**] office with Nurse,
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79814**] on Monday [**11-22**] at 1:40PM for your
coumadin level checked and coumadin teaching.
.
You also have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**] Phone: ([**Telephone/Fax (1) 79815**] Date/Time: Monday [**11-22**] at 2:45pm.
.
Please call to make an appointment with your regular dentists
for follow-up.
.
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**]
[**Last Name (NamePattern1) 51148**], [**Location (un) 551**]
[**Location (un) 47**], [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 20259**]
Date/time: Office will call you with an appt
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
99659,5754,5762,5856,99749,57441,40391,5849,99669,04104,E8798,V4511,496,V462,57490,32723,2720,V1254,71690,25000,V5867,3051,30503,28521,45829,E9413,E9429,E9379,5728,V1581 | 99,791 | 175,690 | Admission Date: [**2170-4-9**] Discharge Date: [**2170-4-15**]
Date of Birth: [**2109-1-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Arterial Line in RIGHT RADIAL
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
s/p failed gallstones removal c/b gallbladder perforation
Major Surgical or Invasive Procedure:
IR guided attempted removal of gallstones and fragmented
cholecystostomy tube (failed attempt), complicated by
perforation of the gallbladder.
History of Present Illness:
Mr. [**Known lastname 92497**] is a 61 y/o male with h/o HTN, COPD, chronic renal
disease on HD, s/p AAA repair and cholecystitis who was admitted
to the MICU after a failed attempt to remove stones/biliary
dilation and removal of previous catheter fragment that was
complicated by gallbladder/cystic duct perforation. The patient
presented with acute cholecystitis on [**2169-10-17**] and
underwent percutaneous cholecystostomy; at that time as based on
his comorbidities he was not felt to be a good surgical
candidate. Since then he has undergone ERCP x 2 with
sphincterotomy as well as failed laparoscopic cholecystectomy
because of adhesions on [**2170-2-8**]. His cholecystostomy
tube came out accidentally and a new percutaneous tube was
replaced on [**2170-3-9**]. Unfortunately this
cholecystostomy tube was severed by VNA, leaving him with a
cathetar fragment at his ostomy site.
.
Of note, all of his prior care has been at [**Hospital1 498**]. He was
referred to IR (Dr. [**Last Name (STitle) 4686**] for a cholangiogram via his
existing cholecystostomy tube +/- stone extraction, catheter
fragment removal and sphincteroplasty. The procedure performed
yesterday was unsuccessful in removing the gallbladder stones or
the catheter fragment, and was also complicated by
gallbaldder/cystic duct perforation. Pt was hemodynamically
stable, complaining only of RUQ pain ([**5-8**]).
.
This morning pt had episodes of hypotension with SBP's to the
70's prior to dialysis. Pt was mentating well, Tmax of 100.1.
Pt not currently complaining of abdominal pain. Pt was
transferred to the MICU because of concern for sepsis following
perforation.
Past Medical History:
-Hypertension
-COPD on home oxygen (2L)
-Chronic renal disease on HD (T,Th,Sat schedule. Last HD on
Saturday [**2170-4-7**])
-Open AAA repair in [**2164**] c/b abdominal wall hernia repaired with
mesh.
-Thoracic aortic aneurysm, s/p endograft repair
-S/p LUE AVF
-Cholelithiasis
-Sleep apnea
-Hypercholesterolemia
-CVA -recent (diagnosed via MRI)
-Arthritis
Social History:
- Tobacco: 2-3packs/day x 40 years
- Alcohol: very heavy drinker x 15 years
- Illicits: none
Family History:
- No family history of gallstones
- Kidney stones: brothers
Physical Exam:
Vitals: T:97.5 BP:90/50 P:79 R:12 O2:99% 2L
General: Alert, interactive, oriented, no acute distress
HEENT: Sclera anicteric, mucus membranes [**Doctor Last Name **], oropharynx
clear, EOMI
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, GII systolic and
diastolic murmer at RUSB, GII holosystolic and diastolic murmer
at LSB, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, mild distension, ostomy site clean
with bandage in place and cholecystostomy drain with
serosanguinous drainage in bag, +BS
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
MICU Admission Exam:
Vitals: T: 99.5 BP: 83/48 P: 85 R:9 18 O2: 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness to palpation in the RUQ,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
[**2170-4-9**] 09:40PM BLOOD WBC-11.1* RBC-3.57* Hgb-9.7* Hct-29.4*
MCV-82 MCH-27.1 MCHC-32.9 RDW-16.0* Plt Ct-309
[**2170-4-10**] 10:40AM BLOOD Neuts-79* Bands-0 Lymphs-9* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2170-4-10**] 10:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-4-9**] 09:40PM BLOOD Glucose-102* UreaN-29* Creat-4.6* Na-138
K-4.0 Cl-102 HCO3-23 AnGap-17
[**2170-4-10**] 05:35AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.1
[**2170-4-10**] 05:35AM BLOOD ALT-5 AST-10 LD(LDH)-158 AlkPhos-65
TotBili-0.2
[**2170-4-9**] 09:40PM BLOOD PT-12.5 PTT-34.0 INR(PT)-1.2*
[**2170-4-11**] 03:24AM BLOOD Cortsol-8.7
[**2170-4-11**] 03:24AM BLOOD Vanco-18.6
Micro:
[**4-11**] BCx pending
[**4-10**] BCx negative
[**4-10**] UCx negative
[**2170-4-11**] 9:58 am BILE BILE.
**FINAL REPORT [**2170-4-15**]**
GRAM STAIN (Final [**2170-4-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2170-4-15**]):
ENTEROCOCCUS SP.. RARE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH. SECOND MORPHOLOGY.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S 0.5 S
PENICILLIN G---------- 4 S 2 S
VANCOMYCIN------------ 1 S <=1 S
ANAEROBIC CULTURE (Final [**2170-4-15**]): NO ANAEROBES ISOLATED.
Imaging:
CT Abd/Pelvis ([**2170-4-10**]):
1. Phlegmonous change within the gallbladder fossa with one
intact pigtail
catheter in place. There is also a fragment present laterally
within No
drainable collection identified. Adjacent inflammatory fat
stranding and
pericholecystic fluid.
2. Moderate duodenal diverticulum.
3. Simple cysts within both kidneys.
4. Multiple stable subcentimeter hepatic hypodensities which are
too small to characterize.
4. Intrahepatic ductal dilation with enhancement of the
intrahepatic duct
suggestive of cholangitis.
5. Stable aneurysmal aorta and right common iliac artery.
6. Sigmoid and ascending colon diverticulosis, without evidence
of acute
diverticulitis.
.
TTE ([**2170-4-11**]):
The left atrium is mildly dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
RUE Ultrasound ([**2170-4-12**]): No evidence of deep venous thrombosis
in the right upper extremity.
.
CXR ([**2170-4-15**]):
Normal size of the cardiac silhouette. No lung parenchymal
disease.
Brief Hospital Course:
61yoM with h/o HTN, COPD, chronic renal disease on HD, s/p AAA
repair and cholecystitis who was admitted after failed attempts
by IR to remove stones and previous catheter fragment,
complicated by gallbladder/cystic duct perforation and sepsis.
.
# Hypotension/Perforated Gallbladder/Common Bile Duct: The
patient was admitted on [**4-9**] following a failed IR attempt to
remove gallstones and a cholecystostomy catheter fragment, which
was complicated by gallbladder/cystic duct perforation with
contrast seen extravasating from the gallbladder. Post
procedure BPs were in the 90s from a baseline of 120-140
systolic, attributed to sedation with slow clearance in the
setting of liver failure. He was covered with Ceftriaxone and
Flagyl. However, he then became hypotensive with SBP 70's-80's
the following morning on [**4-10**] with low grade fever and
increasing white count, and he was broadened to Vanc/[**Last Name (un) **] for
concern for early peritonitis and sepsis. Blood pressures did
not respond to several boluses of IVF and he was transferred to
the MICU, where he received 8L NS. His blood pressures
stablilized and white count down-trended, fever resolved on
Vanc/[**Last Name (un) **]. CT was concerning for cholangitis, but LFTs did not
show a cholestatic picture. ERCP was consulted and did not have
plans to intervene unless the patient developed a cholestatic
hepatitis. Surgery was consulted and is planning to perform an
open cholecystectomy when he becomes medically stable. GB was
determined to be adequately decompressed with his
cholecystostomy tube at this time, and LFTs were WNL. He was
discharged with a plan to continue Vancomycin/Meropenem for a 2
week course. Bile culture grew enterococcus sensitive to
Vancomycin. The patient was given Acetaminophen and Oxycodone
was increased for pain control. Gemfibrozil was discontinued,
as this can precipitate gallstone formation. The day of
discharge, there was question of whether the patient's insurance
would cover his Vancomycin and Meropenem as an outpatient, but
the patient refused to remain in-house to wait for confirmation
of insurance approval. He will follow-up with his PCP as an
outpatient regarding this, as he was refusing to remain in-house
for this issue, despite knowing the risks of leaving. The day
after discharge, on [**4-16**], the patient was called and he
confirmed that the VNA just finished giving him the IV
antibiotics and confirmed that his insurance would cover enough
antibiotics for 10 days, for a full course.
.
# Anemia: The patient had hct 29 on initial presentation that
slowly down-trended to 24 post-op. Likely dilutional in the
setting of missing HD due to hypotension vs slow blood loss from
ostomy vs anemia of ESRD without EPO repletion given recent
initiation of HD. He was transfused 2 units PRBC in the MICU
with subsequent increased and stable HCTs. He will receive EPO
with HD per renal.
.
# R Hand Ischemia: While in the MICU, the patient developed
cyanosis of the right hand, which was attributed to A-line
insertion in the setting of visualized small caliber vessel.
Perfusion returned s/p removal of the line. Surgery/Hand
consulted, felt there were no concerning findings. [**Doctor Last Name **]??????s test
normal.
.
# HD dependent ESRD: The patient was initially on a T/Th/Sat
hemodialysis schedule but while in the MICU, his schedule was
switched to M/W/F. He received an extra dose of HD in-house
after being called out to the floor, as he initially missed HD
while in the MICU for sepsis. Continued sodium bicarb 650 mg
tid, sevelamer 1600 mg tid with meals. Renal was following
in-house.
.
# Hypertension: Patient was recently hypotensive in the setting
of sepsis, and his home lisinopril and metoprolol were held
until follow-up with his PCP.
.
# COPD on home oxygen (2L): Patient is currently asymptomatic,
with no shortness of breath or wheezing. The patient is on 2L
at home chronically but has been non-compliant with his oxygen
use at home. He was intermittently on 2L NC in-house. His home
regimen of tiotropium and albuterol were continued in-house.
.
#Hypercholesterolemia: Pt currently on Simvastatin 40mg daily,
continued in-house.
.
#CVA: Recent (diagnosed via MRI). Continued home aspirin 81mg
daily.
.
.
# Code: Full code
Transitions of Care:
- Vancomycin, to be continued until [**2170-4-23**] - needs confirmation
that insurance will cover outpatient medication
- Meropenem to be continued until [**2170-4-23**] - needs confirmation
that insurance will cover outpatient medication
- f/u BP; re-start Lisinopril and Metoprolol as BP tolerated
- Tamsulosin was STOPPED for hypotension; follow up PCP or
nephrologist prior to re-starting this medication
- Furosemide was STOPPED for hypotension; follow up with
nephrologist prior to re-initiation
- Percocet was INCREASED in frequency temporarily for pain
control post-procedure
- Gemfibrozil was STOPPED, as this can cause gallstones
- Genasyme was HELD; follow up with nephrologist or PCP before
[**Name9 (PRE) 18290**]
Medications on Admission:
-Aspirin 81mg daily
-Flovent (1puff twice daily)
-Furosemide 40mg [**Hospital1 **]
-Genasyme
-Lisinopril 20mg QD
-Metoprolol 100mg [**Hospital1 **]
-Gabapentin 100mg tab x 2 tabs TID
-Ursodiol 300mg [**Hospital1 **]
-Sevelemer 800mg TID
-Meclizine 12.5mg [**Hospital1 **]
-Darbepoetin injections on Thursday
-Oxycodone/Acetaminophen PRN
-Simvastatin 40mg dialy
-Spiriva daily
-Budesonide 2 puffs twice daily
-Gemfibrizol 600mg [**Hospital1 **]
-Tamsulosin
-Sodium bicarbonate 325mg x 2 tabs three times daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO three times
a day.
4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. darbepoetin alfa in polysorbat Injection
8. oxycodone-acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain for 7 days: You should
not drive or do anything that requires alertness while taking
this medication. You should AVOID drinking alcohol while taking
this medication. .
Disp:*20 Tablet(s)* Refills:*0*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. budesonide 90 mcg/actuation Aerosol Powdr Breath Activated
Sig: Two (2) puffs Inhalation twice a day.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. sodium bicarbonate 325 mg Tablet Sig: Two (2) Tablet PO
three times a day.
14. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon
Soln Intravenous Q24H (every 24 hours) for 10 days: Last dose on
[**2170-4-24**].
Disp:*5000 mg Recon Soln(s)* Refills:*0*
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous HD PROTOCOL (HD Protochol) for 10 days: Last dose
on [**2170-4-24**].
Disp:*5000 mg* Refills:*0*
16. Normal Saline Flush 0.9 % Syringe Sig: One (1) injection
Injection twice a day: 10 cc of normal saline flush- before and
after MEROPENEM INFUSION.
Disp:*20 INJECTIONS* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Acclaim
Discharge Diagnosis:
Perforated gallbladder/common bile duct
Sepsis
Acute on chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were at [**Hospital1 18**].
You came to the hospital to have Interventional Radiology remove
stones and a catheter fragment from your gallbladder.
Unfortunately the procedure was very difficult and it was not
possible to remove the stones nor the catheter fragment. During
the procedure your gallbladder was perforated and you had to be
admitted to the hospital for observation. While you were in the
hospital, your blood pressure dropped most likely due to your
body reacting to a bacteria in the blood. Your antibiotics were
switched and you were in the intensive care unit until your
blood pressure stabilized. You will be discharged on a course
of antibiotics to be taken at home.
You will have the VNA who will be doing the antibiotic infusion
daily. The infusion company called [**Location (un) 511**] Home therapy will
be calling you tomorrow in the morning to set up the delivery
time of your antibiotic. However, we were not able to get it
approved by your insurance today given it is [**Last Name (LF) 1017**], [**First Name3 (LF) **] we do
not know the cost of your copay. We have recommended that you
stay inpatient until this is cleared tomorrow morning, but you
have refused. IT IS EXTREMELY IMPORTANT THAT YOU GET THE
ANTIBIOTIC- MEROPENEM TOMORROW IN THE AFTERNOON. IF YOU HAVE ANY
PROBLEMS PLEASE CALL OUR FLOOR AT [**Telephone/Fax (1) 3633**].
While in the hospital, your kidney function was found to be
abnormal, likely due to ****dehydration**** and your kidney
function improved after receiving intravenous fluids. Please
call your dialysis unit on Monday morning at 06:00 AM to make
sure if you will need to go on Monday or back to your regular
schedule Tues/Thurs/Sat schedule.
The following changes were made to your home medications:
- Vancomycin was STARTED, to be continued until [**2170-4-23**]
- Meropenem was STARTED, to be continued until [**2170-4-23**]
- Nephrocaps was STARTED
- Sevelamer was INCREASED
- Percocet was INCREASED in frequency temporarily
- Gemfibrozil was STOPPED, as this can cause gallstones
- Tamsulosin was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
- Furosemide was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
- Genasyme was HELD; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
-Lisinopril was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
-Metoprolol was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
Followup Instructions:
Department: HEMODIALYSIS
Please call your dialysis unit on Monday morning at 06:00 AM to
make sure if you will need to go on Monday or back to your
regular schedule.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 92498**], and arrange to follow up with him within 5 days of
discharge from the hospital.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the surgery department at [**Hospital1 18**]
at ([**Telephone/Fax (1) 16915**] and arrange to follow up with him within [**3-2**]
weeks after discharge to discuss removing your gallbladder.
|
41401,51852,4111,99859,5119,9975,7885,42731,4589,4240,7962,2859,79029,2724,30000,71690,32723,72400,3051,V173,E8782 | 99,796 | 144,804 | Admission Date: [**2115-2-11**] Discharge Date: [**2115-2-19**]
Date of Birth: [**2052-3-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2115-2-11**] Cardiac Cath
[**2115-2-12**] Coronary bypass grafting x3 with left internal mammary
artery to left anterior descending artery and reverse saphenous
vein graft to posterior descending artery and distal circumflex
artery.
History of Present Illness:
62 year old male reports about a two year history of
intermittent chest pressure that has no exertional component. He
describes his discomfort as a very mild mid sternal pressure
that occurs randomly and at rest several times a week, lasting
about five to ten minutes before resolving spontaneously. About
three to four weeks ago he went for an appointment with his new
PCP. [**Name10 (NameIs) **] did an EKG and compared it to one from a few years ago
and told him that there were significant changes and evidence of
a possible MI. He was then referred to Dr. [**Last Name (STitle) 7047**] for stress
testing. Imaging revealed a large fixed inferior defect with
mild to moderate peri-infarction ischemia and an LVEF of 31%. He
was started on Aspirin, Lipitor and Coreg and is was referred
for cardiac catheterization. He was found to have coronary
artery disease and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Borderline hypertension
Dyslipidemia
Mild glucose intolerance
Arthritis/ Spinal stenosis
Chronic back pain/leg numbness
Possible sleep apnea (wife has witnessed periods of apnea)
Anxiety
s/p Hemorrhoid surgery
Hx of remote back surgery
Social History:
Race:Caucasian
Last Dental Exam:edentulous
Lives with:wife
Contact:[**Name (NI) **] [**Name (NI) 46298**] (wife) [**Telephone/Fax (1) 92407**]
Occupation:disabled from work
Cigarettes: Smoked no [] yes [x]last cigarette [**2115-2-9**], quit 2
years ago and started smoking again 3 months ago, 1ppd x 20
years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-26**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Brother died in his late 50's
from complications of heart disease and diabetes
Physical Exam:
Pulse:86 Resp:18 O2 sat:98/RA
B/P Right:179/88 Left:172/91
Height:5'7" Weight:234 lbs
Temp: 99.9
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: (s/p cardiac cath, no bleed/hematoma) Left:
palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2115-2-11**] Cath: 1. Selective coronary angiography of this right
dominant system demonstrated severe three vessel coronary artery
disease. The LMCA had no significant stenoses. The LAD had an
80% proximal lesion. The LCx was occluded proximally. The RCA
was occluded at mid-vessel with heavy calcification. 2. Limited
resting hemodynamics revealed severe systemic systolic arterial
hypertension with an SBP of 176mmHg.
.
Carotid U/S [**2115-2-11**]: 1. Less than 40% stenosis of the right
internal carotid artery. 2. 50-69% stenosis of the left internal
carotid artery.
.
Echo [**2115-2-12**]:
PRE-CPB: 1. The left atrium is moderately dilated. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
thrombus is seen in the left atrial appendage. 2. No atrial
septal defect is seen by 2D or color Doppler. 3. Left
ventricular wall thicknesses are normal. 4. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 30 %). The inferior wall
is severely hypokinetic. 5. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. 6. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. 7. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. 8. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. 9. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results. POST-CPB: On infusion of epi, phenylephrine briefly. A
paced. Improved biventricular systolic function on inotropic
support. LVEF = 45%. Inferior hypokinesis remains. MR remains
1+. The aortic contour is normal post decannulation.
[**2115-2-18**] 04:45AM BLOOD WBC-11.3* RBC-4.00* Hgb-11.5* Hct-34.3*
MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 Plt Ct-311
[**2115-2-11**] 02:44PM BLOOD WBC-8.9 RBC-4.83 Hgb-14.0 Hct-41.7 MCV-86
MCH-29.0 MCHC-33.6 RDW-13.3 Plt Ct-183
[**2115-2-15**] 06:00AM BLOOD PT-13.0* PTT-30.9 INR(PT)-1.2*
[**2115-2-11**] 07:25PM BLOOD PT-12.4 PTT-33.6 INR(PT)-1.1
[**2115-2-18**] 04:45AM BLOOD Glucose-124* UreaN-22* Creat-1.2 Na-135
K-4.3 Cl-96 HCO3-31 AnGap-12
[**2115-2-11**] 02:44PM BLOOD Glucose-105* UreaN-12 Creat-1.0 Na-135
K-4.0 Cl-100 HCO3-25 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 46298**] was admitted following his cardiac cath which
revealed severe three vessel coronary artery disease. He
underwent surgical work-up and on [**2-12**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 3 (left internal mammary artery to left anterior descending
artery and reverse
saphenous vein graft to posterior descending artery and distal
circumflex artery).
CROSS-CLAMP TIME:61 minutes.PUMP TIME:74 minutes.Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. He weaned off pressor
support. Beta-blocker/Statin/Aspirin and diuresis was initiated.
All lines and drains were discontinued per protocol. POD#1 he
transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. The following day he went into rapid atrial
fibrillation which was treated with Amiodarone. He converted
into normal sinus rhythm. Postoperatively serosanguinous
drainage was evident from his sternal incision and IV ABX was
started. Aggressive diuresis was continued. The remainder of his
hospital course was essentially uneventful. His sternal drainage
and edema improved and by POD# 7 only a scant amoune of sternal
drainage was able to be expressed. His sternum remains stable
with no [**Doctor Last Name **] or click. He was placed on oral ABX for a 10 day
course upon discharge. He was cleared for discharge to home with
VNA. Wound check will be done in 1 week following discharge.
Mr.[**Known lastname 46298**] was advised of signs and symptoms of concern and
advised to contact the cardiac surgery department if any of
these changes occur. All follow up appointments were advised.
Medications on Admission:
ALPRAZOLAM 0.25 mg, 1-2 times a day as needed
ATORVASTATIN 40 mg Daily
CARVEDILOL 6.25 mg [**Hospital1 **]
PERCOCET 1 Tablet every six hours as needed for back pain
ASPIRIN 325 mg Daily
ALEVE 220 mg Capsule - 2 Capsules a day as needed for pain
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day for
10 days: then decrease to 1 tab twice daily until reevaluated by
MD.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO twice a day.
[**Last Name (Titles) **]:*120 Tablet Extended Release(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 7 days then decrease to 2 tabs (400 mg)once daily x 7
days, then decrease to 1 tab (200 mg) daily until MD advises
differently.
[**Last Name (Titles) **]:*120 Tablet(s)* Refills:*2*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
[**Last Name (Titles) **]:*40 Capsule(s)* Refills:*0*
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
[**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Borderline hypertension
Dyslipidemia
Mild glucose intolerance
Arthritis/ Spinal stenosis
Chronic back pain/leg numbness
Possible sleep apnea (wife has witnessed periods of apnea)
Anxiety
s/p Hemorrhoid surgery
Hx of remote back surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema [**2-22**]+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2115-3-21**] at 1PM in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] Please call for a follow-up
appointment in [**2-22**] weeks
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] in [**4-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2115-2-19**] |
1911,3485,34839,99702,431,78093,E8788,37941,37854,4019,49390 | 99,797 | 135,425 | Admission Date: [**2152-6-23**] Discharge Date: [**2152-7-7**]
Date of Birth: [**2094-9-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
Stereotactic brain biopsy on [**2152-6-26**].
History of Present Illness:
Per Mr. [**Known lastname 97022**] wife, Mr. [**Name13 (STitle) 97023**] has been acting "strangly" for
the last month. He was staying at work all night or going into
work early. He was unable to hold conversations or talking
about things that did not make sense. Prior to that his wife
denies any changes in his mental status. He has been seeing his
primary physcian who sent him for a neurology consult at the [**Hospital1 **]. He was found to be hypotensive by the
neurologist and told to stop his blood pressure meds. He
continued to have low blood pressure and mental status changes,
and his PCP recommended coming to the emergency room at [**Hospital1 1535**].
Past Medical History:
Hypertension
Asthma
Incisional Hernia
Social History:
The patient drinks 3 to 5 beers weekly. He does not smoke
cigarettes. He works at the [**Doctor Last Name 97024**].
Family History:
He denies any family history of heart disease or cancer.
Physical Exam:
VITAL SIGNS: Temperature 98.3 F, blood pressure 82/58, pulse
80, respiration 20, and oxygen saturation 94% in room air.
GENERAL: WD/WN, comfortable, NAD.
HEENT: Pupils: [**1-24**] bilaterally EOMs full
NECK: Supple.
LUNGS: CTA bilaterally.
CARDIOVASCULAR: RRR, S1/S2.
ABDOMEN: Soft, NT, BS+
EXTREMITIES: Warm and well-perfused.
NEUROLOGICAL EXAMINATION:
Mental status: Awake and alert, cooperative with exam, flat
affect.
Orientation: Oriented to person, place, and had difficulty with
date with time he was able to state [**2152-9-23**] than said [**6-23**].
Recall: [**12-28**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements
or
tremors. Strength full power [**3-28**] throughout. No pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+ 2+
Left 2+ 2+
Toes downgoing bilaterally
Coordination: Normal on finger-nose-finger
Pertinent Results:
MR HEAD W & W/O CONTRAST [**2152-6-23**]:
FINDINGS: There is a large frontal lobe mass identified
extending from corpus callosum to both frontal lobes with
central area of low T1 and high T2 signal with areas of low
signal on susceptibility images indicating small areas of
chronic blood products. There is an extensive enhancement
identified in the mass. The location and the appearance of the
mass are suggestive of a glioma or less likely a lymphoma.
Additionally, there is enhancement seen in the left frontal
sulci as well as in the basal cisterns and internal auditory
canals indicative of leptomeningeal spread of the neoplasm.
There is mass effect on the anterior horns of both lateral
ventricles. A prominent flow voids are identified adjacent to
the inferior aspect of the neoplasm indicative of hypertrophic
blood vessels or draining veins.
IMPRESSION: Large bifrontal neoplasm extending through the
corpus callosum
likely a primary neoplasm such as glioma or lymphoma.
Hypertrophic vessels
are visualized in the inferior aspect of the tumor, indicating
vascular supply and whatever the diagnosis of glioma.
Leptomeningeal extension of the neoplasm is identified through
the basal ganglia and internal auditory canal.
CT Torso [**2152-6-24**]:
FINDINGS:
CHEST: There are no pathologically enlarged thoracic lymph
nodes. There is
no pericardial or pleural effusion. There is mild dilatation of
the
esophagus. Lung windows demonstrate no nodules or masses. The
central
airways are patent, without endobronchial lesions. There are no
suspicious
osseous lesions.
ABDOMEN: The liver, spleen, kidneys, adrenal glands, pancreas,
and
gallbladder are normal. There are no pathologically enlarged
lymph nodes.
There is an umbilical hernia containing fat and small bowel,
without evidence of obstruction. There is no free fluid in the
abdomen. Delayed images demonstrate normal contrast excretion of
the kidneys bilaterally.
PELVIS: The bladder is decompressed with a Foley catheter. The
pelvic bowel loops are unremarkable. There is no free fluid.
There are no pathologically enlarged lymph nodes.
Bone windows demonstrate a lytic lesion in the posterior left
iliac bone with a thick sclerotic border. No other focal lesions
are identified. There are minimal degenerative changes of the
spine.
IMPRESSION:
1. No evidence of mass in the chest, abdomen or pelvis.
2. Umbilical hernia containing fat and small bowel.
3. Nonaggressive-appearing lesion within the posterior left
iliac bone,
unlikely to represent a metastatic lesion.
4. Mild esophageal dilatation.
CT HEAD W/O CONTRAST [**2152-6-25**]:
FINDINGS: Again noted is extensive hypodensity involving both
frontal lobes and the genu of the corpus callosum. There is
persistent mass effect on the bilateral frontal horns. Allowing
for differences in slice selection, there may be slight interval
increase in the diameter of the lateral ventricles. The left
lateral ventricle measures 14 mm compared to 10 mm previously
and the right lateral ventricle measures 14 mm compared to 12 mm
previously. There is no shift of normally midline structures or
evidence of uncal or transtentorial herniation. The 3rd and 4th
ventricles are preserved. There is no evidence of hemorrhagic
conversion. The [**Doctor Last Name 352**]-white matter differentiation is otherwise
preserved without evidence of infarction. The visualized portion
of the paranasal sinuses and mastoid air cells are well aerated.
No osseous abnormality is identified.
IMPRESSION: Extensive hypodense lesion in the bilateral frontal
lobes with
slight interval increase in the diameter of the lateral
ventricles. Third and fourth ventricles remain patent and
basilar cisterns preserved.
Pathology Examination from steriotactic biopsy [**2152-6-26**]:
DIAGNOSIS:
1. Brain, target point, stereotactic biopsy (A):
Glioblastoma multiforme, (WHO Grade IV); See note.
2. Brain, -4, stereotactic biopsy (B):
Glioblastoma multiforme, (WHO Grade IV); See note.
3. Brain -8, stereotactic biopsy (C):
Glioblastoma multiforme, (WHO Grade IV); See note.
4. Brain, -12, stereotactic biopsy (D):
White matter infiltrated by glioma.
5. Brain, -16, stereotactic biopsy (E):
White matter with reactive gliosis and rare atypical cells.
6. Brain, -20, stereotactic biopsy (F):
White matter with reactive gliosis and rare atypical cells.
Note: The tumor displays hypercellularity, vascular
proliferation, necrosis, and mitotic figures.
Gross:
The specimen is received in the O.R. in 11 parts, all labeled
with the patient's name, "[**Known firstname 449**] [**Known lastname **]" and the medical record
number. Each part consists of a 0.1 x 0.1 x 0.1 cm fragment of
white soft tissue, except for the target point.
Part 1 is additionally labeled "target point" and measures 0.6
cm x 0.1 cm and is red in color. It is entirely submitted in
cassette A.
Part 2 is additionally labeled "-2" and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "Malignant glioma".
Part 3 additionally labeled "-4", and is entirely submitted in
cassette B.
Part 4 is additionally labeled "-6", and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "Malignant glioma".
Part 5 additionally labeled "-8", and is entirely submitted in
cassette C.
Part 6 is additionally labeled "-10", and is consumed entirely
by intraoperative smear diagnosis. Smear diagnosis by Dr.
[**First Name (STitle) 4223**] is: "Malignant glioma".
Part 7 is additionally labeled "-12", and is entirely submitted
in cassette D.
Part 8 is additionally labeled "-14" and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "White matter with reactive gliosis and rare atypical
cells".
Part 9 is additionally labeled "-16", and is entirely submitted
in cassette E.
Part 10 is additionally labeled "-18", and is consumed entirely
by intraoperative smear diagnosis. Smear diagnosis by Dr.
[**First Name (STitle) 4223**] is: "Reactive gliosis with scattered atypical cells".
Part 11 is additionally labeled "-20", and is entirely submitted
in cassette F.
CT Head without contrast post-op [**2152-6-26**]:
FINDINGS: There is a new left frontal burr hole for stereotactic
biopsy.
There is a small focus of new hemorrhage along the biopsy path
in the left
frontal lobe (2:18). Extensive vasogenic edema is again seen in
association with the known mass involving both frontal lobes and
the genu of corpus callosum, with unchanged mass effect on the
frontal horns of the
lateral ventricles. Overall, the ventricles are stable in size.
Mild
rightward shift of the anterior falx is stable.
There is a large mucus retention cyst in the right maxillary
sinus and a
possible polyp in the left nasal cavity, as before.
IMPRESSION:
Small amount of blood along the left frontal biopsy path. No
change in mass effect from the bifrontal mass.
MRI Head ([**2152-6-29**])
FINDINGS: Study is slightly limited due to patient motion during
examination.
Again demonstrated is a heterogeneous mass located within
bilateral frontal lobes, and crossing the corpus callosum,
compatible with biopsy proven glioblastoma multiforme. This mass
measures grossly 6.5 cm x 4.6 cm, with central areas of
susceptibility, particularly within the left frontal region,
likely reflecting intratumoral hemorrhagic products from recent
biopsy. The mass is situated in the expected location of the A2
segments of the anterior cerebral arteries, which are not
clearly visualized.
There is associated significant vasogenic edema of bilateral
frontal lobes. Significant mass effect on the adjacent frontal
horns of the lateral ventricles and a rightward shift of
normally midline structures by
approximately 7 mm are not significantly changed.
Increased FLAIR signal and enhancement surrounding the left
lateral ventricular ependymal surface is noted. Abnormal
enhancement is also evident within the basal cisterns and in the
region of the thalamus/tectal junction. These findings suggest
subarachnoid spread of tumor with a
differential diagnosis of infection, if clinically appropriate.
No other foci of hemorrhage are identified. There is no infarct,
without
evidence of diffusion-weighted abnormality. Mucus-retention cyst
in the right maxillary sinus with mucosal thickening of the
ethmoid sinuses is noted.
IMPRESSION:
1. Large butterfly glioma in the frontal lobes, compatible with
known
glioblastoma multiforme, with associated significant mass effect
and vasogenic edema, unchanged.
2. Post-biopsy changes, including a small amount of intratumoral
hemorrhage.
3. Abnormal enhancement of the left lateral ventricular
ependymal surface, in the basal cisterns, and in the
thalamo-tectal junction. These findings could indicate
subarachnoid spread of tumor. However, a concomitant infection
could have a similar appearance and needs clinical correlation .
An MRI of the spine is recommended to assess for leptomeningeal
involvement of the spinal axis.
4. Incomplete visualization of the A2 segments of the anterior
cerebral arteries. A dedicated MRA or CTA is recommended to
assess for vascular patency.
CT head ([**2152-6-30**])
FINDINGS: Again demonstrated is a large bifrontal mass,
compatible with
biopsy-proven GBM, with significant mass effect on the adjacent
frontal horns of the lateral ventricles and rightward shift of
midline by approximately 7 mm. Surrounding low attenuation in
bilateral frontal lobes is compatible with vasogenic edema, with
a track of high density in the left frontal lobe compatible with
post-biopsy hemorrhagic tract. These findings are not
significantly changed from the prior study. The size of the
ventricular system is stable, without evidence of new
hydrocephalus. There are no other foci of intracranial
hemorrhage. No major vascular territorial infarction is
identified. Visualized paranasal sinuses and mastoid air cells
are normally aerated. Osseous structures reveal biopsy burr hole
in the left frontal bone.
IMPRESSION: No significant change in large bifrontal mass,
compatible with
biopsy-proven GBM, and associated significant mass effect on the
adjacent lateral ventricles and rightward shift of midline.
Brief Hospital Course:
The patient was admitted to the ICU for Q1 hour neuro checks
after he was found to have a very large bifrontal brain mass.
He had been given 1 dose of steroids at the outside hospital but
they were not continued here in anticipation of a steriotactic
brain biopsy. The patient had a CT torso that did not show
evidence of metastatic disease. On [**2152-6-25**] his neurological
examination changed and he was unable to speak. A stat head CT
showed increased edema in the frontal region. At that time he
was started on steroids due to his worsening examination and
increased edema. Afterwards, he improved significantly and was
oriented x 3 and following commands.
On [**2152-6-26**], the patient had a steriotactic brain biopsy. The
pathology revealed that the mass was a glioblastoma WHO Grade
IV. Post-operatively the CT scan showed a new small hemorrhage
at the surgical bed. He was transferred back to the ICU still
intubated. The patient was started on mannitol.
On [**2152-6-27**], the patient was extubated and his neurological
examination was improved. His mannitol and steroids were weaned
and he was transferred to the neuro step-down unit. He
continued to be stable as the weaning of both mannitol and
steroids continued and was transferred out of step-down to the
floor on [**2152-6-28**]. In the afternoon of [**2152-6-29**] (after
radiation planning appointment), he was found to have
significant aniscoria (right greater than left) and sixth
cranial nerve palsy. Head CT was repeated; and found to have
significantly worsened edema. He was given a one time dose of
mannitol 50 gm, re-loaded with Decadron 10 mg, and continued on
Decadron 4 mg every 6 hours. Given his marked neurological
decline, palliative care was again urgently consulted to assist
with appropriate planning. At this time, the family changed his
code status to include no cardiac compressions, defibrillation,
or CPR; they agree to chemical code only. In subsequent hours,
his neurological examination significantly improved to the point
that he could possibly be discharged. In the setting of his
progressive decline, and sensitivity to increasd steroids,
emergent whole brain radiation was sought. Pursuant to this
plan, he was transferred to the [**Hospital Ward Name 516**] 7 [**Hospital Ward Name 1950**] [**Hospital1 **]
under the Neuro-Oncology Service on [**2152-7-2**] to make
arrangements for this to occur.
From [**2152-7-3**] to [**2152-7-7**], he received 5 of 22 total treatments
of whole brain radiation. He also began temozolomide while
in-house. He was started on Bactrim prophylaxis since he was on
both radiation and temozolomide. His neurological examination
remained stable during this time with mild right greater than
left anisicoria (1 mm difference), with brisk pupillary
reflexes. He remained oriented x 2 (difficulty with date) and
with 1/3 recall after 5 minutes. He had poor attention and poor
comprehension of his disease.
He was discharged on Decadron 4 mg every 6 hours, with proton
pump inhibitor, bowel regimen, and instructions to ambulate
frequently in an attempt to prevent DVT. He was also discharged
on [**Month/Day/Year 13401**]. He is scheduled for follow-up on [**2152-7-10**].
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 puffs Q4 prn
FLUTICASONE 50 mcg Spray 2 sprays each nostril QD
Flovent 110 mcg 2 puffs [**Hospital1 **]; HCTZ
Lisinopril 1 QD; Simivastatin; ASPIRIN - 81 mg QD
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0*
4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours). Disp:*100 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)*
Refills:*0*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation. Disp:*30 Tablet(s)* Refills:*0*
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO
DAILY (Daily) as needed for constipation. Disp:*1 month supply*
Refills:*0*
11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
14. [**Hospital1 13401**] 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Visiting Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Glioblastoma multiforme
Discharge Condition:
Neurologically stable; R sided anisicoria, oriented x 2.
Discharge Instructions:
You were admitted to the hospital on [**2152-6-23**] with confusion.
You were found to have a brain tumor. You had a brain biopsy on
[**2152-6-26**]. The sutures have already been removed. You had 5
treatments of radiation so far and you have gotten 3 days of
temozolomide chemotherapy. You can take zofran ODT as needed
for nausea.
You are being discharged on steroids because of the swelling in
your brain. You must take omeprazole to avoid stomach
irritation with steroids. You must take a bowel regimen to make
sure you have a bowel movement everyday while you are on
steroids. If you do not have a bowel movement in two days call
your doctor. You must also be sure to walk around at least 5
times per day to avoid clots in your legs.
You are also being discharged on [**Last Name (LF) 13401**], [**First Name3 (LF) **] anti-seizure
medication, as you may be more prone to seizures now that you
have a brain tumor.
You are being discharged on Bactrim to prevent infection now
that you are getting radiation and chemotherapy.
DO NOT DRIVE. DO NOT DO ANY HEAVY LIFTING. YOU ARE AT AN
INCREASED RISK FOR FALLING WITH YOUR BRAIN TUMOR AND CONFUSION.
You are being sent home with a VNA for help with your
medications and for a home safety evaluation.
You will be contining your radiation and chemotherapy as an
outpatient.
General Instructions and Information:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on [**First Name3 (LF) 13401**] (Levetiracetam) as
anti-seizure medication.
?????? You are being sent home on steroid medications, so make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? DO NOT DRIVE
?????? Make sure to continue to use your incentive spirometer while
at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF
THE FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
You have an appointment in the Brain [**Hospital 341**] Clinic on [**2152-7-10**] at
9:30 a.m. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building on the [**Location (un) 858**]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
When you go to radiation treatment on Monday, please talk to
the nurses about seeing a social worker so [**Name2 (NI) **] can be set up.
|
2752,29181,2651,78039,25000,496,2724,30391,3051,27541,2768,5589,53081,4019,29420,2875,2819,4439 | 99,802 | 108,099 | Admission Date: [**2109-1-17**] Discharge Date: [**2109-1-23**]
Date of Birth: [**2039-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV contrast dye
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this is a 69 yo F with a recent PMH significant for
weight loss, anorexia, electrolyte abnormalities, who was sent
in to the ED by her PCP for [**Name9 (PRE) 108827**] and tremor and had a
tonic-clonic seizure in the ED likely related to alcohol
withdrawal +/- electrolyte abnormalities. The patient had a head
CT that was negative for acute intracranial process. The patient
was seen by neurology who recommend continuing CIWA scale and
attributed much of her confusion, confabulation, and ataxia to
Wernickes Disease. The patient recieved IV folate, thiamine, as
well as electrolyte repletion.
.
Prior to transfer, VS 98.7, 74, 141/86, 10, 95% RA. The patient
was alert and oriented x [**12-28**], although she was extremely
tangential with her thought process. She had poor attention and
was easily distractable. She had no acute complaints, otherwise.
.
Review of systems:
(+) Per HPI, complains of chronic diarrhea, some mild abdominal
pain
Past Medical History:
Diabetes mellitus type 2, controlled
Hypomagnesemia
Collagenous colitis
Diverticulitis
Reflux
Peripheral vascular disease
COPD (chronic obstructive pulmonary disease)
Tobacco abuse
Thyroid nodule
Hyperlipidemia LDL goal < 130
Lower extremity edema
Fibrocystic disease of breast
Obese
Skin cancer
Hypertension goal BP (blood pressure) < 130/80
Proteinuria
Colon polyp
Chest pain
Transaminitis
Chronic left shoulder pain
Osteoporosis screening
Vitamin D deficiency
Sciatica
Heart murmur
Social History:
- Tobacco: 1ppdX45 yrs
- Alcohol: 2 drinks per day/unknown last drink. Likely
underestimating the amount that she drinks
- Illicits: denies
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.7 BP: 141/82 P: 74 R: 10 O2: 95% RA
General: AOx2-3, tangential, distractable
HEENT: dry skin, conjunctival pallor, coarse hair, tongue with
some cuts on sides
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, bronchial breath
sounds, prolonged expiratory phase
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no dullness
to percussion, no shifting dullness
Ext: dry, coarse skin, poor nail care
Skin: palmar erythema, spider angiomas, no caput, coarse, dry
skin
Neuro: Poor at following commands, decreased sensation stocking
and glove pattern, slowed rapid alternating movements, able to
do months of the year backwards, 0/3 recall at 5minutes.
Pertinent Results:
ADMISSION LABS
[**2109-1-17**] 02:10PM BLOOD WBC-6.8 RBC-3.52* Hgb-12.6 Hct-35.8*
MCV-102* MCH-35.7* MCHC-35.1* RDW-12.8 Plt Ct-161
[**2109-1-17**] 02:10PM BLOOD Neuts-75.4* Lymphs-17.6* Monos-5.2
Eos-0.9 Baso-1.0
[**2109-1-17**] 05:34PM BLOOD PT-10.3 PTT-31.6 INR(PT)-0.9
[**2109-1-17**] 02:10PM BLOOD Glucose-103* UreaN-14 Creat-1.0 Na-143
K-3.6 Cl-106 HCO3-22.3 AnGap-18
[**2109-1-17**] 02:10PM BLOOD ALT-34 AST-43* AlkPhos-52 TotBili-0.6
[**2109-1-17**] 02:10PM BLOOD Albumin-3.9 Calcium-6.9* Phos-4.1 Mg-0.6*
[**2109-1-17**] 10:12PM BLOOD 25VitD-6*
[**2109-1-17**] 02:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2109-1-17**] 06:02PM BLOOD Ethanol-NEG
CT head:
NONCONTRAST HEAD CT: There is no evidence of hemorrhage, mass,
mass effect, or infarction. There is no shift of the usually
midline structures. Suprasellar and basilar cisterns are widely
patent. Mild periventricular and deep white matter
hypoattenuation is suggestive of chronic small vessel ischemic
changes. Proportional enlargement of the ventricles and sulci is
suggestive of age-related cortical atrophy. There is no scalp
hematoma or acute skull fracture. The visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: No acute intracranial process
Liver US:Small simple hepatic cyst. Otherwise, normal-appearing
liver. No ascites. Aneurysmal abdominal aorta, measuring up to
3.2 cm. Absent left kidney, possibly congenital versus
post-surgical. Clinical correlation recommended. Tiny
gallbladder polyps or adherent stones.
[**2109-1-18**] 04:03AM BLOOD WBC-5.7 RBC-3.24* Hgb-11.7* Hct-32.9*
MCV-102* MCH-36.2* MCHC-35.6* RDW-12.8 Plt Ct-150
[**2109-1-19**] 07:23AM BLOOD WBC-7.1 RBC-3.09* Hgb-11.5* Hct-31.3*
MCV-101* MCH-37.3* MCHC-36.8* RDW-13.1 Plt Ct-153
[**2109-1-20**] 07:30AM BLOOD WBC-4.0 RBC-3.06* Hgb-11.1* Hct-31.3*
MCV-102* MCH-36.4* MCHC-35.6* RDW-12.6 Plt Ct-123*
[**2109-1-21**] 06:10AM BLOOD WBC-5.4 RBC-3.25* Hgb-11.7* Hct-32.6*
MCV-100* MCH-35.8* MCHC-35.7* RDW-12.8 Plt Ct-153
[**2109-1-22**] 06:05AM BLOOD WBC-5.0 RBC-3.08* Hgb-11.1* Hct-31.0*
MCV-101* MCH-36.2* MCHC-35.9* RDW-12.8 Plt Ct-149*
[**2109-1-23**] 06:10AM BLOOD WBC-4.5 RBC-3.02* Hgb-10.7* Hct-31.0*
MCV-103* MCH-35.6* MCHC-34.7 RDW-12.3 Plt Ct-175
[**2109-1-18**] 04:03AM BLOOD Glucose-313* UreaN-10 Creat-0.7 Na-133
K-7.1* Cl-103 HCO3-21* AnGap-16
[**2109-1-18**] 05:08AM BLOOD Glucose-148* UreaN-9 Creat-0.6 Na-137
K-4.2 Cl-105 HCO3-21* AnGap-15
[**2109-1-18**] 10:33AM BLOOD UreaN-9 Creat-0.7 Na-140 K-4.1 Cl-107
HCO3-20* AnGap-17
[**2109-1-18**] 06:50PM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-140
K-4.8 Cl-107 HCO3-23 AnGap-15
[**2109-1-19**] 07:23AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-138
K-5.0 Cl-108 HCO3-20* AnGap-15
[**2109-1-19**] 04:00PM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-137
K-4.7 Cl-103 HCO3-22 AnGap-17
[**2109-1-20**] 07:30AM BLOOD Glucose-123* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-106 HCO3-22 AnGap-15
[**2109-1-21**] 06:10AM BLOOD Glucose-127* UreaN-7 Creat-0.8 Na-138
K-3.7 Cl-104 HCO3-24 AnGap-14
[**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8
Cl-109* HCO3-25 AnGap-12
[**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8
Cl-109* HCO3-25 AnGap-12
[**2109-1-23**] 06:10AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-142
K-4.0 Cl-109* HCO3-24 AnGap-13
[**2109-1-18**] 04:03AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1
[**2109-1-18**] 05:08AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
[**2109-1-18**] 10:33AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
[**2109-1-18**] 06:50PM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
[**2109-1-19**] 07:23AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
[**2109-1-19**] 04:00PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
[**2109-1-20**] 07:30AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.6
[**2109-1-21**] 06:10AM BLOOD Calcium-9.2 Phos-4.9* Mg-1.3*
[**2109-1-22**] 06:05AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.4*
[**2109-1-23**] 06:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.5*
[**2109-1-19**] 07:23AM BLOOD VitB12-268
[**2109-1-21**] 06:10AM BLOOD TSH-3.2
Brief Hospital Course:
Ms. [**Known lastname **] is a 69F with PMH hypomagnesemia, collagenous
colitis, T2DM, COPD, who presents with seizure, electrolyte
abnormalities, and confusion.
#Altered Mental Status--Per PCP, [**Name10 (NameIs) **] has had a slow decline
over the past couple of months but previously very redirectable
and making her outpatient appointments. Per friend [**Name (NI) **], patient
has sensical conversations and is able to take care of herself.
During admission, patient was intermittently nonsensical. CT
head showed chronic small vessel ischemic changes and age
related cortical atrophy. Patient has reportedly abused ETOH in
the past and is currently confabulating, however history, exam,
and labs are not convincing for withdrawal, wernicke's or
korsikoffs dementia. Patient has not scored on CIWA and does not
have evidence of cirrhosis on abd US. B12 was low-nml, on folate
and thiamine supplementation. Electrolyte disturbances could be
causing AMS (esp hypomagnesemia). Patient additionally was found
on the ground on [**1-19**], without complaints, no focal signs of
head trauma. Concern low for stroke (strong family history per
patient), but no focal neuro abnormalities. Currently patient is
refusing HIV test and MRI brain. TSH 3.2. RPR negative. Mental
status continued to improve throughout admission and with
additional input from her long-time partner that her mental
status continued to improve. Based on this collateral
information and [**Hospital 228**] medical stability, plan for discharge
to rehab for further therapy.
#Electrolyte abnormalities--Pt presents with hypomagnesemia 0.6
mg/dl on presentation, hypocalcemia (6.9), and hypokalemia
(3.6-->3.2). Hypomagnesemia is ongoing, pt was prescribed PO
magnesium supplementation 2 months ago, as Mg was 1.0 on
[**2108-11-6**]. The patient was non-compliant with this therapy.
Hypomagnesemia is likely due to chronic diarrhea from
collagenous colitis, PPI use, EtOH, as well as poor nutrition.
It does not seem as though she is having renal wasting of her
electrolytes, given her FE of magnesium. After repletion with IV
magnesium, she was transitioned to PO magnesim oxide. She
initially got diarrhea as a result of the magnesium oxide which
resolved with concurrent administration of immodium. Immodium
should be minimized to avoid constipation and obstruction.
# EtOH Abuse -- Pt states she usually has 1-2 drinks/night of
vodka. Unclear about last drink. Pt has s/s of alcohol abuse and
her seizure in the ED was likely due to withdrawal. Neurology
agress with this assessement. The patient has skin
manifestations of alcohol abuse including palmar erythema and
telangectasias although palmar erythema may be dishydrotic
eczema. However she had an Abd US that showed no evidence of
chirrosis. She will continue supplementation with Thiamine and
Folate. SW saw patient but evaluation was limited by patients
confusion
# Seizure -- Pt had a shaking episode in the ED that was thought
to be a seizure, for which she received ativan. This was likely
due to EtOH withdrawal and electrolyte abnormalities. The
patient was monitored on CIWA but did not score making
withdrawal unlikely. She did not require anti-epileptics and she
had no further seizures during her stay.
#Collagenous colitis--Diagnosed by colonic biopsy in 10/[**2108**]. Pt
has ongoing diarrhea, improved from previously, only once per
week according to PCP. [**Name10 (NameIs) **] is unable to provide detailed history.
Home budesonide dose was continued.
#GERD--PPI was d/c'd on [**1-16**] due to hypomagnesemia. No current
complaints. If pt has symptoms, you should use H2 blocker.
#HTN-- Her home HTN medications were continued (losartan 100mg
daily and atenolol 50mg daily), However she continuned to have
elevated BPs to 200s and had to be covered with Iv hydralazine
and Labetolol. Amlodipine 5mg was added to her regimen and this
improved her BPs.
#COPD--~40 pack year smoking history. No O2 requirement or SOB
at present. Ipratropium inhaler at home.
#DM2--Diet controlled, HbA1c 5.3 in 1/[**2108**]. Diabetic diet
TRANSITION OF CARE ISSUES
-Added Amlodipine 5mg daily
-Added Magnesium Oxide 400mg [**Hospital1 **] to be taken with immodium and
meals
-Methylmalonic acid level Pending
-Added 50000U Vitamin D per week which she will need to continue
for 7 weeks
-She may need an MRI brain to asess for infarcts or other
possible etiologies of her confusion, however, patient declined
at this [**Doctor First Name **]
-Health Care Proxy form signed after consistent statements that
her long-time partner of 30 years be her HCP. She will need
further home evaluation
-Hypomagnesemia and electrolyte management should be closely
monitored.
Medications on Admission:
-Budesonide (ENTOCORT EC) 3 mg Oral Capsule, Delayed &
Ext.Release 2 tablets daily
-Losartan 100 mg Oral Tablet Take 1 tablet daily
-magnesium chloride (SLOW-MAG) 71.5 mg Oral Tablet, Delayed
Release (E.C.) take 1 tablet 4 times per day
-Potassium Chloride 20 mEq Oral Tablet, ER Particles/Crystals
Take 1 tablet daily
-Atenolol 50 mg Oral Tablet Take One Tablet Daily
-Aspirin 81 mg Oral Tablet Take 1 tablet daily.
-Ipratropium Bromide (ATROVENT HFA) 17 mcg/Actuation Inhalation
HFA Aerosol Inhaler
Discharge Medications:
1. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Two (2)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation once a day.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA) for 7 weeks.
Disp:*7 Capsule(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day:
with morning magnesium oxide.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Dementia
Alcohol Withdrawal Seizures
Hypomagnesemia
Chronic Alcohol Abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with confusion, low magnesium,
potassium, and calcium. In the ED, you had a seizure that was
most likely due to your low electrolytes and also alcohol
withdrawal. Your low electrolytes were attributed to your
chronic diarrhea, alcohol use, and poor nutrition. A CT scan of
your head did not show any acute problems. Our neurology
colleagues saw you and recommended correction of your
electrolytes and abstinence from alcohol. You were seen by PT,
OT and social work who are concerned about your ability to care
for yourself at home. You are being discharged to a rehab
facility to help you regain your strength and ensure a safe
return home.
The following changes were made in your medications:
START Magnesium Oxide 400 mg twice daily with breakfast and
dinner
START Amlodipine 5 mg by mouth daily
START Folic Acid 1 mg daily
START Thiamine 100 mg daily
START Vitamin D 50,000 units weekly (on Saturdays) for 6 weeks
DISCONTINUE
Magnesium Chloride
You may changed the Magnesium Oxide to Magnesium Chloride if you
continue to have difficulties tolerating the medication.
Followup Instructions:
Please call to arrange an appointment with your primary care
provider and gastroenterologist after discharge.
|
2767,99859,6826,25080,7823,04112,44023,70715,40390,5859,V4586,V1047 | 99,806 | 133,851 | Admission Date: [**2107-9-24**] Discharge Date: [**2107-9-29**]
Date of Birth: [**2041-4-11**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 665**] is a 66 yo M with DM2, PVD, s/p surgical debridement
of right thigh MRSA abscess sent to ED for evaluation when he
was found to have elevated potassium at his PCP's office. He
reports that he presented to his PCP's for a scheduled follow up
visit but otherwise was without specific complaints. He does
endorse weight gain of 21 pounds since his hospital discharge on
[**9-11**]. Due to this he took some of his wifes water pills, the
name he cant remember for three doses total. Otherwise he
reports recent decrease in his total daily naproxen dose and
slight increase in his tramadol dose. He has recently been
taking Bactrim and Augmentin following surgical debridement
Recent admission [**Date range (1) 27372**] to vascular surgery service for right
groin mass c/w abscess on CTA without any evidence of
communication with prior right CIA to SFA graft. He had
ultrasound guided drainage which showed purulent material so he
was taken to the OR for surgical debridement. He was discharged
on bactrim and augmentin with a wound vac in place.
In the ED, initial vs were: T 98 P 58 BP 118/46 R 18 O2 sat 100%
RA. Potassium was checked in the ED and was noted to be 7.8.
Patient was given calcium gluconate 1g IV x1, insulin 10 units
x1, D50 x 1 amp, bicarb x1amp and kayexalate 30g po. He had an
EKG which showed PR prolongation compared with baseline but no
other changes. Following this therapy he became
asymptomatically hypoglycemic with decrease in blood sugar to 56
from 114 on arrival and he was given a second amp of D50.
Repeat glucose three hours later was persistently low at 40 and
he was given a third amp of d50. He reports being asymptomatic
with all of these levels.
On the floor, he reports feeling at his baseline. His FSBG was
100 on arrival.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denied cough, he does
endorse occasional dyspnea on exertion. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Past Medical History:
DM2 - last A1C 5.9 [**1-/2106**]
HTN
severe DJD
hyperlipidemia
PVD
testicular CA
Anemia - unknown cause (bl HCT ~30)
chronic renal insufficiency (bl creatinine ~1.5)
.
Surgical History:
s/p right common iliac artery to SFA bypass
s/p gastric bypass [**2101**]
right groin dissection and XRT
right cataract surgery
appendectomy tonsillectomy
multiple foot surgeries
Social History:
lives with wife, works as CEO of company and does a lot of
travelling for work, remote smoking history of 1 PPD x12 years
quit in [**2071**], denies ETOH or drug use.
Family History:
both parents died from aplastic anemia
Physical Exam:
Vitals: T: 98.1 BP: 177/48 P:76 R:19 O2: 100% RA
General: Alert, oriented, no acute distress
Skin: warm, scattered bruises over extremities
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, well healed surgical
scars, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
Ext: 2+ pitting edema of LE's bilaterally, atrophy of right
lower leg muscles, clean bandage in placeover toes of letf foot.
Pertinent Results:
[**2107-9-23**] 02:45PM BLOOD WBC-6.1 RBC-3.07* Hgb-9.3* Hct-30.1*
MCV-98 MCH-30.2 MCHC-30.8* RDW-14.8 Plt Ct-404#
[**2107-9-23**] 02:45PM BLOOD Neuts-45.0* Lymphs-40.5 Monos-8.4
Eos-5.4* Baso-0.7
[**2107-9-23**] 11:00PM BLOOD PT-12.8 PTT-30.1 INR(PT)-1.1
[**2107-9-23**] 02:45PM BLOOD UreaN-14 Creat-1.6* Na-132* K-7.8* Cl-107
HCO3-21* AnGap-12
[**2107-9-23**] 11:00PM BLOOD ALT-18 AST-28 LD(LDH)-157 CK(CPK)-27*
AlkPhos-136* TotBili-0.2
[**2107-9-23**] 11:00PM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.8 Mg-1.9
[**2107-9-23**] 02:45PM BLOOD VitB12-1824*
[**2107-9-23**] 02:45PM BLOOD Triglyc-76 HDL-51 CHOL/HD-2.9 LDLcalc-80
[**2107-9-24**] 07:43AM BLOOD TSH-9.0*
[**2107-9-24**] 07:43AM BLOOD Free T4-1.0
[**2107-9-24**] 02:09AM BLOOD Cortsol-6.5
[**2107-9-24**] 07:43AM BLOOD Cortsol-15.5
[**2107-9-29**] 06:55AM BLOOD WBC-5.9 RBC-3.06* Hgb-9.4* Hct-29.5*
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.0 Plt Ct-281
[**2107-9-29**] 01:10PM BLOOD UreaN-17 Creat-1.6* Na-134 K-4.8 Cl-97
HCO3-32 AnGap-10
[**2107-9-29**] 06:55AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.6
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
#Hyperkalemia - Patient presented with severe hyperkalemia K of
7.8 with EKG changes of prolonged PR interval, it was 3.8 less
than a month ago. Unclear etiology, but differential diagnoses
include adrenal insufficiency given hyponatremia, hyperkalemia,
and peripheral eosinophilia. However, he does not have
hypotension. Morning cortisol was within normal limits. Other
consideration would be hyperkalemia associated with metabolic
acidosis, although ph normal on ABG. Another consideration was
renal tubular acidosis given elevated potassium and low serum
bicarbonate on admission. No evidence of tissue breakdown or
hemolysis with normal CK. Hypoaldosteronism was also a possible
cause, however he was not volume depleted on examination.
Transtubular potassium gradient was 2.5, suggesting that
patient's hyperkalemia was likely secondary to
hypoaldosteronism. Renal was consulted who suggested that
hyperkalemia was likely due to renal K secretion inhibition by
multiple medications (benzapril, [**Last Name (un) **], triamtereme, nsaids,
bactrim). All were discontinued. IV lasix was started to enhance
K secretion and remove volume. On discussion with ID, patient's
bactrim was replaced with linezolid. Pt's K currently corrected
to 4.8, and he is being discharged on Lasix 10mg PO Daily.
#MRSA abscess s/p surgical debridement with wound vac in place -
Patient was evaluated by vascular surgery team in the ED, no
acute issues. As bactrim may have played a role in patient's
hyperkalemia, it was replaced with linezolid after discussing
with ID. given the risk for serotonin syndrome, his Tramadol was
discontinued.
#DM2 - Diabetes was very well controlled per history with last
A1c in our system of 5.9. Humalog sliding scale was continued,
and NPH [**Hospital1 **] was held per patient's request.
#Hypertension - Clonidine 0.3mg qam and 0.2mg qpm was continued
while metoprolol and benicar were held in the setting of
hyperkalemia. His blood pressures remained well-controlled.
#PVD - Arterial insufficiency ulcers were seen on lower
extremities bilaterally. Aspirin was continue during his stay in
the hospital.
Medications on Admission:
Reconciled on [**2107-9-26**] [**Doctor Last Name **]
Lotrel (Amlodipine/benazepril) 5/20 QD
Benicar (olmesartan/hctz) 40/25 one tab [**Hospital1 **]
Bactrim DS 160-800 mg One (1) Tablet PO BID x 4 weeks.
Augmentin 875-125 mg one po tid (stopped [**9-22**])
Metoprolol Tartrate 50 [**Hospital1 **]
Clonidine 0.3mg AM and 0.2mg PM
Pantoprazole 40 mg [**Hospital1 **]
Januvia (Sitagliptin) 100mg QD
Aspirin-Coated 325 mg PO QD
NPH 2 units [**Hospital1 **]
Humulin R 10 units AM, 8 NOON, 9 PM
Zetia 10mg [**Hospital1 **]
Naproxen 220mg [**Hospital1 **]
Tramadol 50mg qam and 100mg qpm
Aspirin 325 mg PO DAILY
Protonix Pantoprazole Sodium 40mg in the morning
Ferrous Sulfate Ferrous Sulfate 325(65)mg 1 time per day
Multivitamin Multivitamins 1 per day
Vitamin C Ascorbic Acid 1000mg 1 per day
Vitamin B-6 Pyridoxine Hcl 100mg twice a day
Viactiv Ca Carbonate/vitamin D3/vit K 500-500-40 twice a day
Vitamin B12 Cyanocobalamin 100mcg 1 time per day
Vitamin E Vitamin E Acetate
Super B Complex Vitamin B Complex 1 per day
Glucagon Emergency Kit Glucagon 1mg as directed
Folic Acid Folic Acid 0.4mg take 1 tablet (0.4MG) by ORAL route
every day
Chromium Picolinate Calcium Phosphate/[**First Name9 (NamePattern2) 27373**] [**Last Name (un) 27374**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
4. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: As directed
Injection ASDIR (AS DIRECTED).
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia
Discharge Condition:
Improved
Discharge Instructions:
Please return to the hospital if you develop fevers, chills,
nausea, vomiting, chest pain or shortness of breath. It is very
important that you have your blood drawn tomorrow to make sure
your potassium and creatinine are stable. Dr.[**Last Name (STitle) 5263**] will
follow-up those results and help adjust your medications. You
also need to follow-up in the [**Hospital 1944**] clinic to have your
blood pressure checked since two of your blood pressure
medicines have been stopped.
Followup Instructions:
Dr. [**Last Name (STitle) **], [**Location (un) **], Central Suite, [**Hospital **] Clinic:
Monday [**10-3**] 8:30 [**Telephone/Fax (1) 250**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-10-19**]
11:00
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-10-27**]
12:40
[**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **],MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 721**] Date/Time:[**2107-10-28**]
9:00
|
41401,4111,42731,4019,25000,2720,41072 | 99,809 | 154,672 | Admission Date: [**2166-2-4**] Discharge Date: [**2166-2-8**]
Date of Birth: [**2096-3-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CABG X4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) [**2166-2-4**]
History of Present Illness:
69 year old male with a history of coronary artery disease s/p
remote MI, stent placement in the late [**2144**]'s and a positive
stress test around 6 months ago. In [**2165-12-7**], he presented
to the Emergency Room with crushing substernal chest pain at
rest with associated nausea and diaphoresis. He ruled in for MI
and underwent cardiac catheterization which revealed 3 vessel
coronary artery disease. Cardiac surgery was consulted and
preoperative evaluation was performed. The patient was
discharged home to recover from his MI prior to surgical
revascularization. He presents [**2-4**] for elective CABG.
Past Medical History:
Hypertension
Dyslipidemia
Coronary Artery Disease -- s/p multiple PCI
-- ([**2143**]) s/p inferior MI no intervention
-- ([**2151**]) mid and distal RCA stenting with three PS1530
-- ([**2152**]) Diag and multiple OM branch disease on cath
-- ([**2152**]) rotational atherectomy of RCA after exertional angina
Diabetes Mellitus
Glaucoma
Social History:
Race:Caucasian
Last Dental Exam:edentulous
Lives with: sister
Occupation:retired
Tobacco:quit Friday [**2165-12-27**], smoked 1 pack per week for 50years
ETOH:denies
Family History:
Brother with MI in his 50s, Mother had MI
Physical Exam:
Admission Physical Exam
Pulse:56 Resp:16 O2 sat:98% RA
B/P Right:140/62 Left: 160/67
Height:5'5" Weight:180 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] no Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], obese
Extremities: Warm [x], well-perfused [x] [**1-9**]+ (B)LE edema; no
Varicosities;
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit none
Pertinent Results:
[**2166-2-4**] 03:00PM BLOOD WBC-6.9 RBC-1.85*# Hgb-5.9*# Hct-17.4*#
MCV-94 MCH-32.2* MCHC-34.1 RDW-13.6 Plt Ct-48*#
[**2166-2-4**] 04:50PM BLOOD WBC-8.9 RBC-2.43*# Hgb-7.9*# Hct-22.9*#
MCV-94 MCH-32.7* MCHC-34.7 RDW-13.8 Plt Ct-74*#
[**2166-2-4**] 08:59PM BLOOD WBC-10.6 RBC-3.05*# Hgb-9.8* Hct-27.9*#
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.9 Plt Ct-78*
[**2166-2-5**] 12:58AM BLOOD WBC-8.5 RBC-3.04* Hgb-9.4* Hct-27.1*
MCV-89 MCH-31.1 MCHC-34.8 RDW-14.0 Plt Ct-84*
[**2166-2-6**] 04:40AM BLOOD WBC-6.0 RBC-3.02* Hgb-9.8* Hct-27.7*
MCV-92 MCH-32.4* MCHC-35.2* RDW-14.1 Plt Ct-109*
[**2166-2-7**] 04:30AM BLOOD WBC-6.1 RBC-3.01* Hgb-9.6* Hct-27.8*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.8 Plt Ct-138*
[**2166-2-4**] 03:00PM BLOOD PT-16.9* PTT-33.1 INR(PT)-1.5*
[**2166-2-4**] 03:00PM BLOOD Plt Ct-48*#
[**2166-2-4**] 04:50PM BLOOD Plt Ct-74*#
[**2166-2-4**] 08:59PM BLOOD Plt Ct-78*
[**2166-2-5**] 12:58AM BLOOD Plt Ct-84*
[**2166-2-6**] 04:40AM BLOOD Plt Ct-109*
[**2166-2-7**] 04:30AM BLOOD Plt Ct-138*
[**2166-2-4**] 03:00PM BLOOD Fibrino-127*
[**2166-2-4**] 04:50PM BLOOD UreaN-23* Creat-1.0 Na-141 K-5.4* Cl-116*
HCO3-22 AnGap-8
[**2166-2-5**] 12:58AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-139
K-4.5 Cl-110* HCO3-23 AnGap-11
[**2166-2-6**] 04:40AM BLOOD Glucose-162* UreaN-23* Creat-1.3* Na-141
K-5.2* Cl-107 HCO3-27 AnGap-12
[**2166-2-7**] 04:30AM BLOOD Glucose-72 UreaN-29* Creat-1.1 Na-141
K-4.7 Cl-106 HCO3-28 AnGap-12
[**2166-2-8**] 04:35AM BLOOD UreaN-25* Creat-1.0 Na-137 K-4.2 Cl-100
Introp TEE [**2166-2-4**]:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 35 cm from the incisors.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Post Bypass
The patient is now s/p 4 vessel CABG,on an Neosynephrine drip at
0.3mcg/kg/min and AV sequentially paced
LV function and Ejection fraction are preserved with no new
regional wall motion abnormalities
There are no dissection flaps visible in the proximal ascending
aorta
There is persistent mild Mitral regurgitation.
CXR [**2166-2-7**]
FINDINGS: There is residual small right apical pneumothorax
which is
similar-appearing compared to most recent prior. Mild
cardiomegaly is
unchanged. There is minimal stable pulmonary vascular
congestion. Small
bilateral pleural effusions are seen.
IMPRESSION: Unchanged small right apical pneumothorax.
Brief Hospital Course:
The patient was electively brought to the operating room on
[**2166-2-4**] where the patient underwent CABG x4 LIMA>LAD, SVG>Diag,
SVG>OM, SVG>PDA). Please see operative report for full details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Postoperatively,
he received a total of 3 units of PRBCs for postoperative blood
loss with a hct of 17. His hematocrit bumped appropriately to
27. POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. On POD 3,
the patient had a brief burst of rapid atrial fibrillation and
beta blockade was increased. By the time of discharge on POD 4,
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged on [**2166-2-8**] in good condition with appropriate follow
up instructions.
Medications on Admission:
crestor 20mg daily
metoprolol xl 50mg daily
glyburide/metformin 5/500 2 tab [**Hospital1 **]
actos 30mg daily
doxyzosin 2mg daily
lisinopril 40mg daily
fenofibrate 160mg daily
aspirin
travatan z 0.004% 1 drop QHS
NTG sl (but does not use)
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take stool softeners while taking narcotic
pain medication. .
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Please do
not drive or operate machinery while taking this medication.
Take stool softeners to prevent constipation. Wean yourself off
as tolerated.
Disp:*40 Tablet(s)* Refills:*0*
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): Per home regimen.
9. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
once a day.
10. doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Per
home regimen.
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
13. glyburide-metformin 5-500 mg Tablet Sig: Two (2) Tablet PO
twice a day: Per home regimen. Do not restart Actos. Please log
your blood sugars and f/u with PCP. .
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
LE Edema: trace-1+
Discharge Instructions:
DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
You are scheduled for a wound check on [**Hospital Ward Name 121**] 6 with a midlevel
provider on [**Name9 (PRE) 5929**] [**2166-2-13**] at 10am.
Surgeon Dr.[**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2166-3-6**] 1:15 [**Telephone/Fax (1) 170**]
PCP/Cardiologist Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2-20**] at 3:00pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2166-2-8**] |
185,5185,2851,5849,9975,7885,25000,4019,2449,32723 | 99,810 | 196,261 | Admission Date: [**2109-2-1**] Discharge Date: [**2109-2-6**]
Date of Birth: [**2051-5-25**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
prostate cancer
Major Surgical or Invasive Procedure:
radical prostatectomy
History of Present Illness:
57 y/o male with T2DM, HTN, OSA, and prostate cancer (recent PSA
4.2, Gl 6+7 disease comprising up to 90% of the cores on the
right, [**4-29**]; h/o colovesical fistula/repair. Got 10.0L EBL:
1.5L. Difficult intubation requiring fiber optic scope - took
15 minutes. Per anesthesia, would like monitoring overnight in
unit before attempting extubation.
ROS: Unable to obtain as patient is intubated and sedated
Past Medical History:
Diverticulitis s/p exploratory laparotomy, sigmoid and left
colectomy with mobilization of the splenic flexure, repair of
bladder, and
primary anastomosis
s/p repair of his bladder from a fistula [**2099**]
Anti-platelet antibodies with chronic thrombocytopenia
OSA s/p palatal surgery
T2DM
HTN
Hypothyroidism
Physical Exam:
Vitals: T 101 BP: 100/65 HR: 107
GEN: No acute distress, intubated
HEENT: Intubated, pupils small but reactive
NECK: No JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: rhonchorous throughout
ABD: Soft, NT, JP drain in place draiing serosanguinous fluid
EXT: no [**Location (un) **], 2+ DP pulses bilaterally
NEURO: sedated
SKIN: no rashes
Pertinent Results:
[**2109-2-1**] 07:06PM GLUCOSE-143* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13
[**2109-2-1**] 07:06PM CALCIUM-7.9* MAGNESIUM-1.5*
[**2109-2-1**] 07:06PM WBC-13.7* RBC-3.67* HGB-11.4* HCT-32.5*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.4
[**2109-2-1**] 10:57PM LACTATE-3.7*
[**2109-2-1**] 02:34PM TYPE-ART TIDAL VOL-800 O2-100 PO2-227*
PCO2-46* PH-7.30* TOTAL CO2-24 BASE XS--3 AADO2-440 REQ O2-76
INTUBATED-INTUBATED VENT-CONTROLLED
[**2109-2-1**] 05:10PM TYPE-ART TEMP-35.3 RATES-10/ TIDAL VOL-1100
PEEP-5 O2-60 PO2-95 PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2
INTUBATED-INTUBATED VENT-CONTROLLED
[**2109-2-1**] 10:57PM TYPE-ART TEMP-37.6 RATES-/18 TIDAL VOL-865
PEEP-5 O2-100 PO2-153* PCO2-44 PH-7.32* TOTAL CO2-24 BASE XS--3
AADO2-516 REQ O2-86 INTUBATED-INTUBATED VENT-SPONTANEOU
Imaging:
CXR: No evidence of consolidation, ? blunting on CP angles
bilaterally
Brief Hospital Course:
57 yo M with prostate CA 2/p radical prostatectomy with
difficult intubation requiring fiber optic scope. Admitted to
ICU for monitoring now s/p extubation.
# Difficult Intubation: Patient with fiber optic intubation, per
anesthesia, needed monitoring overnight. Required increased
fentanyl for sedation. Was sucessfully extubated [**11-1**] and was
on CPAP overnight for OSA. This morning was satting well on RA.
# Oliguria: The patient postoperatively had oliguria and was
given LR boluses. This resolved with IVF.
# Anemia: Hct decreased from 29.9 to 26.6 this am, on recheck
was 26.3, likely secondary to dilution from IVF and
intraoperative blood loss, EBL 1.5L. Recheck pm Hct, if
continues to decrease would have a low threshold to scan his
abdomen/pelvis with a CT to rule out RP bleed.
# Lower extremity numbness: Patient had new onset numbness in
her lower extremities b/l overnight which was improving this am.
No motor deficits. Unclear cause, possible related to how he
was laying for the operation (possible nerve compression?).
# Positive UA: Patient had trace LE, pos nit, but >1000 RBC's.
Has colovesicular fistula in past. Difficult to interpret UA in
this setting. Was on cefazolin post surgically, wihch has some
urine pathogen coverage. Per urology, expected to have dirty UA,
no tx indicated at this time.
# Fever: The patient spiked a fever to 101 on [**2-1**] and was
cultured. Unclear source, could be post-op vs infectious,
slighly tachy to 100's with the fever. WBC elevated at 14.9,
but decreased to 11.9 today. Cx have been NGTD except for the
dirty UA as above. No fever for the last day.
# Tachycardia: Patient has been in the 90??????s to 100??????s; was on
verapamil as an outpatient and this was held, so may be reflex
tachycardia from this. Received IVF yesterday without much
response. His home verapamil was added back and ****.
# Prostate CA: T3N0M0, s/p radical prostatecomy. His JP tube
continued to put out a large amount of serosanguinous fluid.
# HTN: Patient is on verapamil and diovan as an outpatient. His
pressures have been well-controlled, but he??????s been tachycardic.
These medications were initally held perioperatively, however
verapamil was restarted the day he left the MICU.
#Hypothyroidism: The patient was continued on his home
levthyroxine.
He was admitted to Urology after undergoing radical
prostatectomy. No concerning intraoperative events occurred;
please see dictated operative note for details. He received
ancef for perioperative prophylaxis. He was transferred to the
ICU from the PACU in stable condition. On POD0 he remained
intubated with large urine output from his JP. He was extubated
on POD 1 and transferred to the floor on POD 2. His pain was
well controlled on PCA , hydrated for urine output >30cc/hour,
provided with pneumoboots and incentive spirometry for
prophylaxis. A physical therapy consult was obtained who
recommended home with VNA. On POD3, he was restarted on his home
medications, basic metabolic panel and complete blood count were
checked, pain control was transitioned from PCA to oral
analgesics, diet was advanced to a regular diet with start of
colace. JP removed POD5 without difficulty after drainage was
<10 for the past 2 days. The remainder of the hospital course
was relatively unremarkable. He was discharged in stable
condition on POD1, ambulating independently, eating well, and
with pain control on oral analgesics. On exam, his incision was
clean, dry, and intact, with no evidence of hematoma collection
or infection. He was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 9125**] in 1 week, and that the urethral catheter
(foley) would be removed during the follow-up appointment. He
was instructed to start 3 day course of Ciprofloxacin on day
prior to Foley removal.
Medications on Admission:
Diovan
Verapamil SR 240 mg PO daily
Metformin 500 mg PO BID
Levothyroxine 0.225mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while taking narcotics.
Disp:*60 Capsule(s)* Refills:*0*
4. Levothyroxine 200 mcg Tablet Oral
5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days: Start day before appointment.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
prostate cancer
Discharge Condition:
stable
Discharge Instructions:
-You may take motrin and narcotic together for pain control
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks.
-Allow bandage strips to fall off over time, remove all
remaining dressings in 2 days
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
-Follow up in 1 week for wound check/foley removal
-Please do not drive or consume alcohol while taking pain
medications.
-Take first dose of Ciprofloxacin 1 day prior to foley catheter
removal and for subsequent 2 days.
- Wear Large foley bag for majority of time, leg bag is only for
short-term when leaving house.
Followup Instructions:
1-2 weeks
Completed by:[**2109-2-6**] |
43310,5990,43330,25000,4439,4280,42731,496,V4972,2859,78009 | 99,814 | 186,518 | Admission Date: [**2142-2-16**] Discharge Date: [**2142-2-21**]
Service: SURGERY
Allergies:
Morphine / Ativan
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Menatl status changes
Major Surgical or Invasive Procedure:
Left carotid endarterectmoy
History of Present Illness:
86 F transfered from [**Location (un) **] ED s/p R toe amputation and Fem [**Doctor Last Name **]
bypass in mid [**Month (only) **] who presents now with MS changes
concerning for TIA. Pt has been recooperating in nursing home
being treated for chronic infection. Today she developed acute
episode of altered mental status- She was reported to be sitting
in a chair and subsequently felt lightheaded. Pt was noted to
have mom[**Name (NI) 12823**] garbled speech. Thought to be either delirium s/p
infection vs mutiple TIAs. She was brought to the ED where she
was noted to have elevated WBV, UTI. INR was subtherapeutic 1.6.
Creatinin at 1.2 baseline <1. Pt was transfered to [**Hospital1 18**] for
further evaluation.
Past Medical History:
-PVD s/p FEM [**Doctor Last Name **] bypass and toe amputation
-DM2
-CHF
-A-Fib
-COPD
-Bilateral carotid stenosis
Social History:
former tobacco use, no ETOH use, no drugs, lives with son and
daughter in law. Recently d/c;d from rehab after fall with no
major injuries
Family History:
N/C
Physical Exam:
VS: 98.4 79 121/52 20 96% RA
Neck, left with incision intact, steri stripped
RRR
CTAB
soft NT/ND, no pulsitile masses
no LE edema, B/L feet warm
RLE - 2+ Fem, MP PT, DP
[**Name (NI) **] - 2+ Fem, MP PT, DP
RLE: toes necrotic changes
RLE wound on shin
[**Name (NI) **]: blister like lesion on shin
Pertinent Results:
[**2142-2-21**] 06:30AM BLOOD WBC-9.4 RBC-3.08* Hgb-9.4* Hct-27.8*
MCV-90 MCH-30.7 MCHC-33.9 RDW-16.0* Plt Ct-214
[**2142-2-21**] 06:30AM BLOOD Plt Ct-214
[**2142-2-21**] 06:30AM BLOOD Glucose-79 UreaN-15 Creat-1.1 Na-140
K-4.4 Cl-100 HCO3-33* AnGap-11
[**2142-2-20**] 02:46AM BLOOD Glucose-79 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-29 AnGap-10
Brief Hospital Course:
[**2141-2-16**] Patient was transferred from OSH for mental status
changes, admitted to vascular surgery/Dr. [**Last Name (STitle) 1391**] service.
Concerning for TIAs in the setting of bilateral carotis
stenosis. Head/brain CT was done-negative for ICH w/ severe
narrowing of the common carotid artery bifurcation and proximal
cervical internal carotid arteries, right more than left,
started heparin drip. She was scheduled for L CEA on [**2142-2-19**],
remained on Heparin drip over the weekend. She was pre-oped and
consented for L CEA.
[**2142-2-19**] Patient was taken to the OR and underwent L CEA,
patient tolerated procedure well, transferred to PACU for
recovery. In the PACU, patient became unresponsive, needing to
be intubated and transferred to the ICU where she stayed
intubated oevrnight. She was also placed on Neo drip to keep her
SBP above 150 mmHg. Neurology consulted, Head CT repeated-no
stroke.
[**2142-2-20**] Patient was weaned and extubated, weaned off pressors,
alert and oriented and neurologically intact. By the end of the
day patient was transferred to floor. Patient recieved blood
transfusion for HCT 21.4 <- from 27, also given Lasix. Physical
therapy evaluated [**Hospital 84041**] rehab (which is patient's
baseline).
[**2-21**]/Overnight patient had episodes of wheezing, started
Albuterol nebs prn. Resolved by morning. Patient is now stable,
ambulating w/ assistance, eating and voiding. Discharged back to
her rehab (LifeCare Center in [**Location (un) **]) in good condition. Will
FU w/ Dr. [**Last Name (STitle) 1391**] in [**4-12**] weeks.
Medications on Admission:
Coumadin 2 mg po qd
Celexa 10 mg po qd
Lisinopril 2.5 mg po qd
Verapamil 120 mg po qd
Neurontin 100 mg po qd
Metformin 500 mg po qd
Lasix 40 mg po qd
Amiodarone 200 mg po qd
Lantus 100 unit/mL 16 units injection once daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Bilateral carotid stenosis with TIA's now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 84042**], [**First Name3 (LF) **] need
RXEA in the near future
Anemia-acute on chronic, Hct drop from 27->21+, transfused w/ 1
u PC
History of:
-PVD s/p FEM [**Doctor Last Name **] bypass and toe amputation
-DM2
-CHF
-A-Fib
-COPD
Past Surgical History:
[**2142-1-9**] Right lower extremity diagnostic angiogram
[**2142-1-11**] Right femoral-Below Knee popliteal bypass w/NRSVG
[**2142-1-15**] Right 2nd toe amputation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - needs assistance
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
ACTIVITIES:
- [**Month (only) 116**] shower, pat dry your incision, no tub baths
- No driving till seen in FU by Dr. [**Last Name (STitle) 1391**]
- No lifting heavy objects, suddent neck turns or excessive neck
bending and rotating
- Resume activities as tolerated, slowly incraese activiy as
tolerated
- Expect your activity level to return to normal slowly
DIET:
- Diet as tolerated, eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
WOUND:
- You may have some swelling and feel a firm ridge along the
incision, slightly red and raised
- Keep your incision open to air
- Keep wound dry and clean, call if noted to have redness,
draining, or swelling, or if temp is greater than 101.5
WHEN TO CALL:
- Call the office or go to ED if you experience severe headache
that is not relieved by Tylenol, signs of TIA or stroke
(weakness/paralysis of any or all extremities, difficulty of
speech, facial drooping), difficulty of speaking, or swallowing.
OTHERS:
- You may have a sore throat and/or mild hoarseness
- Try warm tea, throat lozenges or cool/cold beverages
MEDICATIONS:
- Continue all medications as instructed
Followup Instructions:
Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone:
[**Telephone/Fax (1) 1393**]
Completed by:[**2142-2-21**] |
4413,41071,5609,5762,9974,5601,51881,56881,41402,486,5990,5849,5854,2761,496,E8782,2355,40390,412,41401,55321,78551,04104,2767,V4975,V1052,53081,2724 | 99,817 | 195,557 | Admission Date: [**2166-10-14**] Discharge Date: [**2166-11-20**]
Date of Birth: [**2096-2-28**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Endovascular aneurysm repair with bilateral groin cutdowns
[**2166-10-14**]
History of Present Illness:
70 year old male presented with abdominal pain. The pain started
the afternoon of [**10-14**] afternoon he laid down. Pt reported
dizziness when he stood up. He had similar abdominal pain
approximately 4 days prior, and at that time, he had a CT scan
without IV contrast that demonstrated a non-leaking 4 cm
abdominal aortic aneurysm. The patient was then sent to the
[**Location 1268**] VA for admission and further evaluation. He
reports he was discharged 2 days ago from the VA with a negative
work-up for his abdominal pain. He had been pain free the day
prior to admission but he also had nothing to eat until this
afternoon. He denied fever, chills. No nausea or vomiting. No
diarrhea.
Blacked out at home and went to Caritas HC where a CT without
contrast showed leaking aneurysm and creatinine up to 5.8 from
baseline 1.8. He was hydrated and [**Last Name (un) **] Flighted to [**Hospital1 18**] to have
emergent EVAR of AAA by Dr. [**Last Name (STitle) **].
Past Medical History:
Past Medical History: Coronary artery disease s/p myocardial
infarction, hypertension, hyperlipidemia, GERD, reflux
esophagitis, constipation, cataract, blepharitis, cri, COPD,
ventral
hernia, renal cancer, low back pain, renal cell ca, pvd,
elevated psa,
.
Past Surgical History: status post nephrectomy for renal cancer,
Right femoral [**Doctor Last Name **] bypass in [**2161**] and s/p thrombolysis of his
graft, Right below the knee amputation, CABG x 4 in 93,
appendectomy, exploratory laparotomy with lysis of adhesions
-internal hernia, biliary stenting
[**2166-10-15**] EVAR for ruptured AAA
Social History:
Lives by himself. Ex-smoker and quit 8 years ago. He drinks
about 3 alcoholic drinks per week.
Family History:
Non-contributory
Physical Exam:
VS: 98.3, 97.7, 91/47, 105, 20, 94%2L
GEN: NAD, A&Ox3, NGT in place
HEENT: anicteric sclera, neck supple, no LAD
CV: RRR, nl S1 and S2
Lungs: Decreased BS B/L
Abd: soft, distended, reducible large ventral hernia, diffusely
tender to palpation, +tympany
EXT: R BKA site well healed, L DP is 2+ palp
B/L groin sites with slight erythema but no active drainage
Pertinent Results:
Please see OMR
Brief Hospital Course:
Pt was admitted on [**2166-10-14**] transferred from an OSH for ruptured
abdominal aortic aneurysm. An urgent CAT scan with IV contrast
performed at [**Hospital1 18**] demonstrated a contained, leaking abdominal
aortic aneurysm. Due to prohibitive surgical risk, the pt
underwent an endovascular aneurysm repair with bilateral groin
cutdowns on emergent basis on [**2166-10-14**]. BP during the procedure
was initially 90-100s over 40-50s (one value to 80/40) then
110/80s. Postoperatively, the pt was transferred to the CVICU
intubated on pressors. He required fluid boluses and prbc as
well as albumin. BP stabilized. He was extubated.
Due to increase in creatinine from baseline of 1.8 to 5.0,
nephrology was consulted on [**2166-10-15**]. ARF on CRF felt [**2-8**] to
hypotension and poor perfusion. HD was not indicated. Avoidance
of all nephrotoxins was advised as well as keeping MAP >65.
On [**2166-10-16**], surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was consulted for concern for
ischemic bowel as the patient had an episode of watery diarrhea.
A flex sig was performed at the
bedside which revealed no evidence of either mucosal slough or
transmural ischemia. The colon was entirely normal up to 45 cm.
No further episodes of diarrhea occured following the
sigmoidoscopy. On [**10-19**],he was kept NPO, an NGT was placed for
vomiting and a KUB was done to eval for free air.
Urine was positive for pan sensitive enterobacter cloacae. Cipro
was started.
CT abdomen on [**10-21**] demonstrated findings consistent with ileus.
Status post aortobifemoral graft with no interval change in the
size of extensive right retroperitoneal hematoma.
Cholelithiasis was noted. Of note, there were gas locules noted
in the aneurysmal sac and in the retroperitoneal region likely
post-surgical in nature. Although, there was concern for
possible fistula. Hepatobiliary was reconsulted on [**10-22**].
On [**10-22**], hepatobiliary surgery was reconsulted for concerns for
obstruction as he had abdominal pain and distention since
[**2166-10-16**] without BM. The NGT output was 1L to 1.5L of gastric
contents on a daily basis for the past 72 hours. After review of
the MRI and CT scans from the VA, the pancreatic mass was felt
to likely be either a primary pancreatic adenocarcinoma or
potential renal cell carcinoma metastasis. Because the mass was
obstructing the distal common bile duct, the patient underwent
ERCP and stent placement. Brushings obtained during the ERCP
were negative for malignancy, and biopsy obtained during a
subsequent EUS of the mass was an insufficient sample and thus a
proper diagnosis could not be made.
GI was consulted on [**10-22**] for possible EGD. This was not felt to
be indicated and recommendations to assess the pancreatic stent
were recommended given elevated t.bili and alk phos (6.5 and
272). On [**10-23**],
He was started on vanco, zosyn and flagyl for possible small
perforation.
Of note, patient's other current major issue is progressive
renal
dysfunction.
***NO SUMMARY FROM [**10-22**] - [**11-18**].
On [**11-18**], the patient was noted by nephrology to have altered
mental status concerning for uremia, and so he received a
tunnelled hemodialysis cathether.
On [**11-19**] he was started on hemodialysis but became hypotensive
to 40s and so dialysis was stopped early.
On [**11-20**] AMS, hypoxic, transferred to SICU, intubated, became
tachy/brady then asystolic, pulse returned w/ CPR found to have
massive MI by echo put on pressors and taken to cath lab. Pt had
stent placed in left main coronary and required IABP support,
which was problem[**Name (NI) 115**] given recent AAA repair. Pt required 4
pressors and transient CPR. IABP was removed shortly due to
distal skin mottling thought to be due to emboli from his aorta.
He continued to deteriorate with pH on ABG of <7, and Potassium
at 6.7. Pt's family was contact[**Name (NI) **] and decision was made to be
DNR/DNR, and soon after CMO. Pt's medications were all stopped,
including pressors and morphine drip started for comfort. Pt
passed away within 30 minutes from cardiopulmonary arrest. Pt
was warm, with no heart sounds or breath sounds. Negative gag
reflex, neg corneal reflex and neg oculocephalic reflex. Pt's
family was notified and appropriate death certificate and
autopsy paperwork was filed.
Primary cause of death: Cardiopulmonary arrest
Secondary cause of death: NSTEMI
Medications on Admission:
Tylenol prn, Lisinopril 5', Senna 8.6", Omeprazole 20',
Lubricating OPH ointment QHS, Carboxymethylcellulose 1% 0.4mL
gtts"', Colace 100", Flunisolide 0.025%", Loratiadine 10',
Lopressor 25", Simvastatin 80', Tamsulosin 0.4', Ketotifen 0.025
gtts ou prn: qd, Doxepin 50'
Discharge Disposition:
Expired
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cardiopulmonary Arrest
NSTEMI
partial small bowel obstruction
pancreatic mass
Right lobe pneumonia
Urinary tract infection.
Acute on chronic renal failure.
Abdominal aortic aneurysm
ileus
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2166-11-21**] |
4241,5849,9971,5990,27652,2724,42731,E8782,4019,25000,2749,2859,27800 | 99,819 | 126,883 | Admission Date: [**2136-3-27**] Discharge Date: [**2136-4-3**]
Date of Birth: [**2066-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2136-3-27**] cardiac cath
[**2136-3-28**] aortic valve replacement (21mm St. [**Male First Name (un) 923**] Porcine)
aortic root enlargement (pericardial patch)
History of Present Illness:
69 yo male with hx of aortic stenosis followed by serial echos.
Recent echo shows severe AS with [**Location (un) 109**] 0.54 cm2 and mild LVH.
Known heart murmur for 10 years. Referred for pre-op cath and
surgery.
Past Medical History:
gout
obesity
aortic stenosis
non-insulin depenedent diabetes mellitus
hypertension
hypercholesterolemia
benign left parotid mass
nephrolithiasis
Social History:
works an an engineer
never used tobacco
occasional ETOH drink
lives alone
Family History:
non-contrib.
Physical Exam:
HR 71 RR 12 145/60
5'3 [**12-9**]" 168#
NAD, obese
skin unremarkable
large firm left parotid mass
neck supple, full ROM
CTAB
RRR 4/6 SEM with radiation throughout precordium to carotids
abd + BS
warm,well-perfused, no peripheral edema or varicosities noted
MAE [**4-10**] strengths, grossly intact
1+ bil. femorals
2+ bil. DP/PT/radials
Pertinent Results:
Cardiac Catheterization
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
The
LMCA was a short vessel. The LAD had mild diffuse plaquing to
25% in
the mid-vessel. The distal LAD wrapped around the apex. There
was
slight pulsatile flow. The high Diagonal-1 and the Diagonal-2
branches
had mild plaquing. The LCX was patent and supplied small OM1
and OM2
branches and a major, slightly tortuous LPL and distal AV groove
LCX.
The RCA had minimal diffuse plaquing and bifurcated into large
RPDA
and RPL systems.
2. Resting hemodynamics revealed severe elevations in right and
left
sided filling pressures with a RVEDP of 24 mmHg and a LVEDP of
29 mmHg.
There was mild pulmonary arterial hypertension with a PA
pressure of
42/23 mmHg. There was mild systemic arterial systolic
hypertension with
a central aortic pressure of 158/76 mmHg. The mean gradient
across the
aortic valve was 50 mmHg. The calculated aortic valve area was
0.5 cm2.
The cardiac index was 1.8 L/min/m2.
FINAL DIAGNOSIS:
1. No angiographically apparent flow-limiting coronary artery
disease.
2. Severe aortic stenosis.
3. Severe biventricular diastolic dysfunction.
4. Mild pulmonary arterial hypertension.
5. Mild systemic arterial systolic hypertension.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
ECHO
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen.
6. Trivial mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 16-22 mmHg). No aortic regurgitation is seen.
2. Aorta appears intact post decannulation
3. Biventricular function is normal.
4. MR appears slightly worse, No [**Male First Name (un) **] is seen. It is mild to
moderate in severity
Dr. [**First Name (STitle) **] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD,
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81291**]Portable TTE
(Complete) Done [**2136-4-3**] at 2:00:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-11-28**]
Age (years): 69 M Hgt (in): 63
BP (mm Hg): 159/70 Wgt (lb): 191
HR (bpm): 84 BSA (m2): 1.90 m2
Indication: Evaluate for pericardial effusion. Recent aortic
valve prosthesis.
ICD-9 Codes: 423.9, 424.1
Test Information
Date/Time: [**2136-4-3**] at 14:00 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:0 Machine: Vivid [**6-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 13 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 0.78
Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms
TR Gradient (+ RA = PASP): 21 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 1.3 cm
Findings
This study was compared to the prior study of [**2136-2-27**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR.
PERICARDIUM: Small to moderate pericardial effusion. Effusion
circumferential. No RA or RV diastolic collapse. Sgnificant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, c/w impaired ventricular filling.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a small to moderate (1.3 cm) sized pericardial
effusion. The effusion appears circumferential. No right atrial
or right ventricular diastolic collapse is seen. There is
accentuated respiratory variation in mitral valve inflows,
consistent with impaired ventricular filling. This may be
secondary to etiologies other than pericardial tamponade (lung
disease, etc..).
Compared with the prior study (images reviewed) of [**2136-2-27**], an
aortic valve bioprosthesis is now present. The aortic root
appears thickened, consistent with aortic root enlargment. The
pericardial effusion is new. The estimated pulmonary artery
pressure is lower.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2136-4-3**] 17:10
Radiology Report CHEST (PA & LAT) Study Date of [**2136-4-3**] 1:34
PM
Reason: assess for effusions
Preliminary Report !! PFI !!
1. Enlargement of the cardiac silhouette relative to both the
most recent
prior and the pre-operative chest x-ray without evidence of CHF.
These
findings could represent interval development of a pericardial
effusion and a cardiac echo may be obtained for further
characterization.
2. Small bilateral pleural effusions and improved aeration of
the left lung base.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**]
[**2136-3-27**] 04:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2136-3-27**] 04:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-3-27**] 04:55PM URINE RBC-[**5-16**]* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2136-3-27**] 03:32PM GLUCOSE-132* UREA N-23* CREAT-0.9 SODIUM-139
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2136-3-27**] 03:32PM ALT(SGPT)-30 AST(SGOT)-26 LD(LDH)-188 ALK
PHOS-64 AMYLASE-57 TOT BILI-0.5
[**2136-3-27**] 03:32PM LIPASE-61*
[**2136-3-27**] 03:32PM ALBUMIN-4.3 CALCIUM-9.4 MAGNESIUM-1.8
[**2136-3-27**] 03:32PM %HbA1c-6.6*
[**2136-3-27**] 03:32PM WBC-15.6* RBC-4.65 HGB-13.6* HCT-38.8* MCV-83
MCH-29.2 MCHC-35.0 RDW-13. [**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3947**] [**Medical Record Number 81292**] M 69
[**2066-11-28**]
[**2136-3-27**] 03:32PM PLT COUNT-452*
[**2136-3-27**] 03:32PM PT-12.6 PTT-21.4* INR(PT)-1.1
[**2136-4-2**] 05:35AM BLOOD WBC-23.6* RBC-3.46* Hgb-10.1* Hct-29.2*
MCV-84 MCH-29.3 MCHC-34.7 RDW-15.2 Plt Ct-446*#
[**2136-4-2**] 05:35AM BLOOD Plt Ct-446*#
[**2136-4-2**] 05:35AM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2*
[**2136-4-2**] 05:35AM BLOOD Glucose-86 UreaN-24* Creat-1.2 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
Brief Hospital Course:
Admitted [**3-27**] and underwent cardiac cath. This did not reveal
any significant coronary disease. Underwent surgery with Dr.
[**First Name (STitle) **] on [**3-28**]. Transferred to the CVICU in stable condition on
titrated insulin, phenylephrine, and propofol drips. Extubated
later that day. Transferred to the floor on POD #2 to begin
increasing his activity level. Rapid A Fib treated with
amiodarone and metoprolol, converted to sinus rhythm. Low grade
fever prompted UA which showed a UTI, Started on Cipro for a
three day course. Chest tubes and pacing wires removed per
protocol.
Remainder of hospital stay uneventful. Cleared for discharge to
home with VNA on POD 6.
Medications on Admission:
colchicine 0.6 mg [**Hospital1 **]
colace 100 mg [**Hospital1 **]
tenormin 50 mg daily
glucophage XR 1000 mg [**Hospital1 **]
diovan 320 mg daily
HCTZ 25 mg daily
zocor 20 mg daily
glipizide 2.5 mg [**Hospital1 **]
ASA 81 mg daily
amlodipine 5 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x7 days then 200mg QD.
Disp:*35 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO twice a day: 20meq [**Hospital1 **] x 1 week
then 20meq QD x 2 weeks.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 20mg [**Hospital1 **] x 1 week then 20mg QD x 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO twice a day: resume preop
schedule. Tablet Sustained Release 24 hr(s)
Discharge Disposition:
Home With Service
Facility:
Home health and Hospice
Discharge Diagnosis:
aortic stenosis
postop atrial fibrillation
PMH:
hypercholesterolemia
hypertension
non-insulin dependent diabetes mellitus
h/o nephrolithiasis
left parotid mass (benign)
gout
obesity
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **],SUDARSHAN [**Telephone/Fax (1) 7660**] in 1 week
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2136-4-3**] |
V5811,1960,2536,1481,V1582,4019,V1046,53081 | 99,822 | 146,997 | Admission Date: [**2197-5-30**] Discharge Date: [**2197-5-31**]
Date of Birth: [**2136-3-17**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
chemotherapy with hypertomic saline administration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 y/o with Stage [**Doctor First Name 690**] Squamous cell carcinoma of the right
piriform sinus presenting for C2D1 of TPF (Taxotere, cisplantin,
5-fluorouriacil). He originally presented with neck pain and in
[**4-12**] underwent direct laryngoscopy with a biopsy of a pyriform
sinus mass diagnostic of SSC.
.
Mr [**Known lastname 35716**] started Cycle 1 of TPF on [**2197-5-5**] on C1D13 he
presented with NA of 120 and was hospitalized from [**5-17**] to [**5-19**].
He Na nadir was 118 and patient experienced decreased
concentration at that time. He has a h/o chronic hyponatremia
with Na 126 dating back to [**2188**]. Labs were consistent with
SIADH, with the acute exacerbation thought to be a consequence
of his platinum based chemotherapy. His sodium improved with 1L
fluid restriction and NaCL tablets to 126 on discharge. He is
followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], nephrology.
.
Given Mr [**Known lastname 35717**] hyponatremia with the last cycle
chemotherapy admission for close Na monitoring and ppx
hypertonic saline is planned.
Past Medical History:
Past Oncologic History:
Mr. [**Known lastname 35716**] presented with a pain in his right neck after
holding in a sneeze. A lump developed in the area and he was
referred to Dr. [**Last Name (STitle) 1837**] and laryngoscopy demonstrated a
post-cricoid hypopharyngeal lesion and was referred to have a CT
scan of the neck. The CT scan of the neck revealed an enhancing
mass in the right pyriform sinus with extensive conglomerate
adenopathy in the right level 2 and level 3 nodes. Biopsy of the
mass was positive for squamous cell carcinoma. On [**2197-4-13**]
he underwent direct laryngoscopy and biopsy of right pyriform
sinus lesion and rigid esophagoscopy. Pathology from this
procedure revealed squamous cell carcinoma, moderately
differentiated. He was HPV negative. Port was placed [**2197-5-5**]. He
started C1D1 TPF on [**2197-5-5**].
.
Other Past Medical History:
- History of prostate cancer status post radical prostatectomy
with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**],
status post salvage radiation therapy and has since followed
with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**].
- hypertension
- acid reflux disease with hiatal hernia
- hernia repair in [**2177**]
- appendectomy in [**2149**]
Social History:
Social History: Lives in [**Location **]. The patient is married with
five children, all local. He smoked half a pack per day for 10
years but quit smoking 30 years ago. He drank alcohol heavily in
the past mostly associated with his job as a bar tender but has
been sober for the last two and half years. He is retired navy
and currently works as a doorman/security, which he enjoys.
Family History:
FAMILY HISTORY: His mother died of CHF. Father died of a heart
attack. He has four siblings. His children are healthy.
Physical Exam:
Tmax=97.5=Tcurrent, HR=50s-60s, BP=100s-150s/60s-80s, RR=13-22,
POx=93%
General: Alert, NAD
HEENT: NC/AT
CV: RRR, No m/r/g appreciated
Resp: CTA bilaterally
Abd: S/NT/ND; BS present
Ext: trace pitting edema in the LE??????s bilaterally
Pertinent Results:
[**2197-5-30**] 01:05PM GLUCOSE-86 UREA N-22* CREAT-0.7 SODIUM-123*
POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-23 ANION GAP-16
[**2197-5-30**] 01:05PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.7
[**2197-5-30**] 01:05PM WBC-14.4*# RBC-3.52* HGB-11.0* HCT-31.6*
MCV-90 MCH-31.2 MCHC-34.8 RDW-13.6
[**2197-5-30**] 01:05PM NEUTS-85.7* LYMPHS-7.1* MONOS-6.8 EOS-0.2
BASOS-0.2
[**2197-5-30**] 01:05PM PLT COUNT-480*#
[**2197-5-30**] 01:05PM PT-12.3 PTT-21.7* INR(PT)-1.0
Brief Hospital Course:
This is a 61 year old male with Stage IV squamous cell carcimona
of the right pyriform sinus presenting for his second cycle of
TPF requiring an elective ICU admission for hypertonic saline
because his previous cycle was complicated by acute on chronic
hyponatremia.
.
# Squamous cell carcinoma of right pyriform sinus: Pt was
discharged on C2D2 of TPF (taxotere, cisplatin, 5-FU). He
received Taxotere 75 mg/m2 and cisplatin 100 mg/m2 on admission.
He was also set up with a 5-fluorouracil pump at 1000 mg/m2/24
hours X 96 hours via continuous infusion on the day of
discharge. The patient says that he feels well after the chemo
which he attributes to the cisplatin being infused over 8 hours
instead of 5 hours like his previous treatment. He received
hypertonic saline while the chemo was administered and his
sodium remained above 123. He received the following
antiemetics per oncology recommendations: Emend 125mg PO and
zofran 8mg IV 1 hr prior to chemo on [**5-30**]. He also received
Emend 80mg PO on [**5-31**] and was continued on zofran 8mg PO q8h
standing. He also took dexamethasone 8mg prior to arrival and
was continued on 8mg [**Hospital1 **] with a plan to take 4mg daily while
getting the 5-FU infusion. Ativan and compazine were continued
for breakthrough nausea. He will start cipro prophylaxis when
his 5-FU infusion is complete. He will also use clotrimazole
troches QID PRN mouth pain.
.
# Hyponatremia: He completed a regimen of normal saline and
hypertonic saline per renal recs. Sodium was 127 on discharge
and was never below 123. He will continue a 1 liter fluid
restriction and start Lasix 20mg PO to keep his sodium up at
home.
.
# Leukocytosis: Likely related to patient??????s recent steroid
administration and improved on discharge. He did not spike a
fever.
.
# HTN: His home atenolol was continued and his home enalapril
was decreased to 5mg [**Hospital1 **] from 10mg.
.
# GERD: His home omeprazole was continued.
Medications on Admission:
Emend Dose pack (on hold)
Atenolol 50mg daily
dexamethasone 4-8mg as directed (has taken 8mg last two days)
enalapril 10mg [**Hospital1 **]
Hydrocodone- Acetaminophen 5/500mg [**2-4**] tab q6h prn (on hold)
lidocaine - diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] mouthwash TID (on hold)
lorazepam 0.5mg PO q6h prn (on hold)
omeprazole 40mg PO daily
Ondansetron 8mg q8h prn (on hold)
Prochlorperazine 10mg q6h ( on hold)
viagra 100mg PO prn
tolvaptan 15mg PO dailyl (currently on hold, never started)
multivitamin daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Dexamethasone 4 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12
hours): take two tablets twice daily on [**5-31**] then reduce to one
tablet once daily on [**5-31**] and [**6-3**] then stop.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
take in the morning.
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Clotrimazole 10 mg Troche Sig: One (1) troche Mucous membrane
four times a day as needed for mouth pain.
Disp:*100 troches* Refills:*0*
6. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours: on [**5-31**] and [**6-1**], take every 8 hours. Then, can take
every 8 hours as needed for nausea.
7. Emend 80 mg Capsule Sig: One (1) Capsule PO once a day: take
on [**2197-6-1**].
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fluorouracil 500 mg/10 mL Solution Sig: 1800 (1800) mg
Intravenous continuous infusion: until [**2197-6-3**].
13. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Ten (10) ml Mucous membrane three times a day: as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Stage IV sqaumous cell carcinoma of the pyriform sinus
Hyponatremia from SIADH
.
Secondary diagnoses:
-Hypertension
-GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for chemotherapy and concentrated
saline administration. You tolerated the chemotherapy well and
your sodium levels remained at your baseline. You are being
discharged on a 5-FU chemotherapy pump.
Be sure to continue to restrict your fluid intake to 1 liter a
day. In addition try to eat salty foods.
The following changes were made to your medication regimen:
- Lasix was started to help keep your sodium level normal
- Enalapril was decreased to 5mg twice a day.
- Clotrimazole as needed for mouth pain
- You should start cipro as directed on Saturday [**6-3**] when your
5-FU chemo pump is stopped
Be sure to follow up with your doctors as listed below.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
Heme/onc: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-6-2**] 9:30
.
Renal: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2197-6-20**] 4:30
|
5789,486,2536,79001,1960,4589,1481,V1046,4019,2800,53081,27652,V153,52801,E9331,2929,E9320 | 99,822 | 163,117 | Admission Date: [**2197-6-16**] Discharge Date: [**2197-6-25**]
Date of Birth: [**2136-3-17**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Cough, confusion, hyponatremia --> Cycle 3 TPF
Major Surgical or Invasive Procedure:
Cycle 3 TPF (Taxotere, cisplantin, 5-fluorouriacil) chemotherapy
History of Present Illness:
The patient is a 61 yo M with h/o prostate cancer and currently
undergoing treatment for piriform SCC who presents from home
with non-productive cough and mental slowing. Pt reports a
repeated sensation of abd cramping followed by coughing, only
when supine. The cough is nonproductive and does not reaccure
when sitting upright. Per the wife over the last few days Mr
[**Name (NI) 35716**] has seemed slow with his thinking. He was not
disoriented. No fevers, however 2 days ago he had rigors. No NS.
No CP. + loose BM, no abd pain. NO dysuria.
.
In the ED, initial vs were: T 97 P72 BP 108/72 R16 O2 sat 100.
BP droped to 89/64 but improved to 101/69 following resusitation
with 3.5L NS. A chest xray showed a possible RLL PNA and
crackles were heard in that area. Patient was given ceftriaxone,
azithro and flagyl. His was admitted to the ICU given his
transient hypotension.
.
On the floor, he is without complains other than pain at the
finger tips from his chemo.
Past Medical History:
Oncologic history:
# Head and neck cancer:
- Mr. [**Known lastname 35716**] presented with a pain in his right neck. A lump
developed in the area and he was referred to Dr. [**Last Name (STitle) 1837**]
and laryngoscopy demonstrated a post-cricoid hypopharyngeal
lesion and was referred to have a CT scan of the neck. The CT
scan of the neck revealed an enhancing mass in the right
pyriform sinus with extensive conglomerate adenopathy in the
right level 2 and level 3 nodes. Biopsy of the mass was positive
for squamous cell carcinoma. On [**2197-4-13**] he underwent
direct laryngoscopy and biopsy of right pyriform sinus lesion
and rigid esophagoscopy. Pathology from this procedure revealed
squamous cell carcinoma, moderately differentiated. He was HPV
negative. Port was placed [**2197-5-5**]. He started C1D1 of cisplatin,
docetaxel, 5-FU on [**2197-5-5**].
# prostate cancer: status post radical prostatectomy
with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**],
status post salvage radiation therapy and has since followed
with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**].
Non-oncologic history:
- hypertension
- acid reflux disease with hiatal hernia
- hernia repair in [**2177**]
- appendectomy in [**2149**]
Social History:
Lives in [**Location **]. The patient is married with five children,
all local. He smoked half a pack per day for 10 years but quit
smoking 30 years ago. He had extensive second hand smoke
exposure working in a tavern. No alcohol use for the last 2
years. Previous drinking history. He is retired Navy and
currently works as a doorman/security.
.
Family History:
His mother died of CHF. Father died of a heart
attack. He has four siblings. His children are healthy.
.
Physical Exam:
General: Alert, orientedx 3, no acute distress. Slightly
tangential and perseverating speech.
HEENT: Sclera anicteric, pale conjuctiva, MMM, oropharynx clear
(no visible mouth lesions)
Neck: supple, JVP not elevated, no LAD
Lungs: crackles RLL. No rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2197-6-16**] 05:46PM GLUCOSE-110* UREA N-16 CREAT-0.8 SODIUM-125*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-26 ANION GAP-12
[**2197-6-16**] 05:46PM CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.9
[**2197-6-16**] 11:00AM URINE HOURS-RANDOM UREA N-454 CREAT-38
SODIUM-63 POTASSIUM-31 CHLORIDE-80
[**2197-6-16**] 11:00AM URINE OSMOLAL-386
[**2197-6-16**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2197-6-16**] 10:14AM HCT-22.2*
[**2197-6-16**] 10:14AM FIBRINOGE-501*
[**2197-6-16**] 10:14AM RET AUT-4.3*
[**2197-6-16**] 08:05AM GLUCOSE-91 UREA N-24* CREAT-0.7 SODIUM-120*
POTASSIUM-3.5 CHLORIDE-90* TOTAL CO2-26 ANION GAP-8
[**2197-6-16**] 08:05AM LD(LDH)-185
[**2197-6-16**] 08:05AM CALCIUM-7.1* PHOSPHATE-1.7* MAGNESIUM-1.5*
URIC ACID-4.9
[**2197-6-16**] 08:05AM HAPTOGLOB-220*
[**2197-6-16**] 08:05AM WBC-6.2 RBC-2.22*# HGB-7.2* HCT-19.8* MCV-89
MCH-32.5* MCHC-36.4* RDW-14.9
[**2197-6-16**] 08:05AM NEUTS-66 BANDS-2 LYMPHS-17* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-3*
[**2197-6-16**] 08:05AM PLT SMR-NORMAL PLT COUNT-221
[**2197-6-16**] 03:53AM LACTATE-2.9*
[**2197-6-16**] 03:40AM GLUCOSE-109* UREA N-28* CREAT-0.9 SODIUM-122*
POTASSIUM-3.0* CHLORIDE-89* TOTAL CO2-26 ANION GAP-10
[**2197-6-16**] 02:16AM LACTATE-2.2*
[**2197-6-15**] 11:45PM GLUCOSE-102* UREA N-33* CREAT-1.1 SODIUM-119*
POTASSIUM-3.6 CHLORIDE-82* TOTAL CO2-31 ANION GAP-10
[**2197-6-15**] 11:45PM ALT(SGPT)-43* AST(SGOT)-30 CK(CPK)-117 ALK
PHOS-112 TOT BILI-0.3
[**2197-6-15**] 11:45PM cTropnT-<0.01
[**2197-6-15**] 11:45PM WBC-7.4 RBC-2.98* HGB-9.6* HCT-26.4* MCV-89
MCH-32.3* MCHC-36.4* RDW-16.8*
[**2197-6-15**] 11:45PM PLT COUNT-242
.
CXR [**6-16**]: FINDINGS: In comparison with study of [**5-17**], there is
little change in the appearance of the heart and lungs. There
are some bilateral areas of opacification most likely
representing atelectasis. In the appropriate clinical setting,
the possibility of pneumonia would have to be considered.
Continued mild cardiomegaly. The port-A-Cath remains in place.
Definite
vascular congestion. Central catheter.
.
EKG [**6-25**]: Sinus tachycardia. Non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2197-6-2**] heart
rate has increased and Q-T interval prolongation is no longer
seen.
Brief Hospital Course:
This is a 61 year old male with PMH of SCC of the pryiform sinus
s/p C2 of TPF (taxotere, cisplatin, 5-FU) on [**5-30**] presenting
with cough and confusion and found to have a possible RLL PNA on
imaging, worsening of his known chronic SIADH hyponatremia, and
anemia with a Hct=19.8.
.
# Pyriform sinus squamous cell carcinoma: # Stage [**Doctor First Name 690**] squamous
cell carcinoma of the right piriform sinus: S/p Cycle 2 of TPF
(taxotere, cisplatin, 5-FU) on [**5-30**]. Due to patient's
hyponatremia, confusion and generally complex medical condition,
he stayed in-house for his third cycle of TPF once his cough,
confusion and anemia had improved. He required special
preparations of his 5-FU with normal saline, not D5W given his
hyponatremia. Discontinued dexamethasone 2 days early given
steroid psychosis. He completed the cycle with no significant
complications, although he did have some emotional lability with
the steroids. The patient was discharged with antibiotic
prophylaxis (Cipro) as well as Emend.
.
# Anemia: His hematocrit was down to 19.8 on [**6-16**] from 31.9 on
[**6-13**]. He reports 2 days of BRBPR. He may have GI oozing
secondary to mucositis or underlying diverticulosis which may be
amplified by aggressive fluid repletion. His hematocrit was
trended closely and he received 2 unit of pRBCs.
.
# Hyponatremia: The patient has a long history of hyponatremia
which has been extensively evaluated by renal and found to be
consistent with SIADH with unclear underlying cause, possibly
due to his malignancy and worsened in the past (and this
admission) with chemotherapy session. Cisplatinum chemo is also
known to worsen hyponatremia and therefore the patient has been
repeatedly admitted for hyponatremia. During his last admission,
he was treated with lasix, salt tabs, and fluid restriction. On
admission his sodium was 119 and he was last discharged with a
Na=120. He was once again treated with Lasix, salt tabs, and
fluid restriction (although patient occasionally found drinking
fluids in the nutrition room with question of ability to
comply). His sodium was trended closely and was quite labile.
Renal followed the patient in-house.
.
# CXR Findings: He has a small infiltrate on imaging suggestive
of RLL PNA vs. atelectasis. Given his recent chemotherapy, as
well as current bandemia, chills, and cough with RLL crackles,
he was given azithromycin, ceftriaxone, and flagyl in the ED.
This regimen was changed to cefepime and azithromycin in the
ICU. He does not have a history of chronic cough, but he claims
to have "aspiration" due to cough with lying flat consistent
with GERD. After monitoring the patient overnight, it was felt
that pneumonia was very unlikely, and antibiotics were stopped.
The patient remained stable from a pulmonary standpoint for the
remainder of this hospital course.
# Altered mental status: Likely multifactorial from hyponatremia
and possibly toxicity from his chemotherapy may be contributing.
He was near his recent baseline per his wife who has noted
subtle memory changes since he started his chemo regimen. Recent
MRI head imaging had not revealed a likely cause. It was later
felt, also, once the patient started his next cycle of
chemotherapy that the steroids (dexamethasone) made him
emotionally labile, alternatively frustrated, anxious, tearful.
The patient wandered off the floor once looking for coffee. This
emotional lability improved once the steroids were discontinued.
# GERD: He described abdominal cramping followed by a feeling of
regurgitation and cough while supine which is consistent with
GERD. He was started on a [**Hospital1 **] PPI with improvmenet in his
symptoms.
# HTN: His home atenolol was held given hypotension. As his
pressures normalized, the patient's home beta blocker was
resumed. It was felt that the patient has a tendency to develop
vasovagal hypotension and bradycardia when his port site is
accessed. The patient has had vagal episodes in the past during
accessing his port. When the patient was prepared prior to port
site access, it is well tolerated.
Medications on Admission:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
9. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Ten (10) mL Mucous membrane four times a day.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet 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. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) as needed for pain.
Disp:*30 Troche(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for insomnia, anxiety.
Disp:*30 Tablet(s)* Refills:*0*
7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: [**2-4**] Capsules
PO every six (6) hours.
14. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Ten (10) mL Mucous membrane four times a day.
15. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
16. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
17. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Stage [**Doctor First Name 690**] squamous cell carcinoma of the right piriform
sinus, hyponatremia, slow lower GI bleed, altered mental status
Secondary: Hypertension, GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with mental slowing and cough. You were
initially in the ICU because of concerns about your low sodium
and a slow bleeding in your GI tract. You were treated briefly
with antibiotics for possible pneumonia and closely monitored
for the GI bleeding, which stopped. You also underwent your
third cycle of chemotherapy, which you tolerated well.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> RESUME Atenolol 50mg daily
--> INCREASE Lasix 20mg twice daily to 40mg twice daily
--> DECREASE your Atenolol 50mg daily to 25mg daily
--> CONTINUE Ciprofloxacin 500mg twice daily for 9 more days
--> START taking Enalapril 10mg daily
--> START Sodium Chloride (Salt) tablets 2mg three times daily
--> START Clotrimazole troches 10mg four times daily
-As we suspect you have bleeding in your intestinal tract, it is
very important that you see a Gastroenterologist about getting a
colonoscopy. This can be set up through your primary care
doctor. The number of the Gastroenterologist office here is
[**Telephone/Fax (1) 13246**].
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10351**] and Dr. [**First Name8 (NamePattern2) 916**]
[**Last Name (NamePattern1) **]. Their office will contact you with date/time of your
appointments next week in Hematology/[**Hospital **] clinic.
You also have an appointment with Dr. [**Last Name (STitle) **] (kidney doctor) to
follow up with your low sodium level. That appointment will be
on[**2197-6-20**] at 430pm. His office is located on the [**Location (un) 436**] of
the [**Hospital Ward Name 23**] Clinical CEnter. It is very important that you go to
this appointment.
As we suspect you have bleeding in your intestinal tract, it is
very important that you see a Gastroenterologist about getting a
colonoscopy. This can be set up through your primary care
doctor. The number of the Gastroenterologist office here is
[**Telephone/Fax (1) 13246**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-6-28**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-5**] 10:30
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
03812,48242,51881,5070,2866,5849,570,2762,2639,4271,2536,78551,1481,52800,28800,99592,78791,E9331,4019,42731 | 99,822 | 195,871 | Admission Date: [**2197-7-3**] Discharge Date: [**2197-7-8**]
Date of Birth: [**2136-3-17**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Watery, nonbloody diarrhea
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Arterial Line
Central Venous Line
History of Present Illness:
Mr. [**Known lastname 35716**] is a 61-year-old man with history of head and neck
cancer. He is currently on docetaxel, cisplatin, and 5-FU who
presented with diarrhea. The night before admission, he started
having multiple bowel movements with watery, non-bloody
diarrhea. Per his wife, he was also increasingly lethargic and
nodding off while sitting on the toilet. He denies fevers,
chills, or abdominal pain.
In ED, T 98.1, HR 110, BP 116/92, RR 16, 99% RA. Exam revealed a
macular rash on upper chest. WBC was 2.6 with 35% neutrophils,
21% lymphs, and 28% bandemia. Urinalysis was negative, and CXR
was reported as unremarkable. (However, subsequent [**Location (un) 1131**] of
CXR
revealed LLL opacity.) He received empiric levofloxacin and
metronidazole.
REVIEW OF SYSTEMS: no recent weight change, fevers, chills,
headache, visual changes, shortness of breath, cough, chest
pain,
abdominal pain, constipation, melena, BRBPR, hematuria, dysuria,
weakness, numbness, tingling
Past Medical History:
Oncologic history:
# Head and neck cancer:
- Mr. [**Known lastname 35716**] presented with a pain in his right neck. A lump
developed in the area and he was referred to Dr. [**Last Name (STitle) 1837**]
and laryngoscopy demonstrated a post-cricoid hypopharyngeal
lesion and was referred to have a CT scan of the neck. The CT
scan of the neck revealed an enhancing mass in the right
pyriform sinus with extensive conglomerate adenopathy in the
right level 2 and level 3 nodes. Biopsy of the mass was positive
for squamous cell carcinoma. On [**2197-4-13**] he underwent
direct laryngoscopy and biopsy of right pyriform sinus lesion
and rigid esophagoscopy. Pathology from this procedure revealed
squamous cell carcinoma, moderately differentiated. He was HPV
negative. Port was placed [**2197-5-5**]. He started C1D1 of cisplatin,
docetaxel, 5-FU on [**2197-5-5**].
# prostate cancer: status post radical prostatectomy
with Dr. [**Last Name (STitle) 79**] in [**2188**]. He had a biochemical recurrence in [**2194**],
status post salvage radiation therapy and has since followed
with Dr. [**Last Name (STitle) **] with anundetectable PSA in [**2196-11-3**].
Non-oncologic history:
- hypertension
- acid reflux disease with hiatal hernia
- hernia repair in [**2177**]
- appendectomy in [**2149**]
Social History:
Lives in [**Location **]. The patient is married with five children,
all local. He smoked half a pack per day for 10 years but quit
smoking 30 years ago. He had extensive second hand smoke
exposure working in a tavern. No alcohol use for the last 2
years. Previous drinking history. He is retired Navy and
currently works as a doorman/security.
.
Family History:
His mother died of CHF. Father died of a heart
attack. He has four siblings. His children are healthy.
.
Physical Exam:
Vitals: T 97.3, BP 122/90, HR 125, RR 16, 98%RA
Gen: Elderly Caucasian man in no acute distress, awake, alert,
oriented x 3 but slightly confused about recent history, very
talkative
HEENT: EOMI, moist mucus membranes with punctate oral sores
under tongue and on bilateral oral cavity, chocolate milk/boost
on lips, ruddy complexion (unchanged from last admission)
Neck: supple, no LAD, reticular/erythematous rash with clear
margins on chest
CV: Regular rate/rhythm, normal S1/S2, no murmur/gallops/rubs,
port site c/d/i
Lungs: CTAB, no wheezing/rhonchi/rales
Abd: soft, nontender, nondistended, bowel sounds present, no
hepatosplenomegaly
Ext: no c/c/e - previous admissions' edema of bilateral lower
extremiteis much improved
Pertinent Results:
[**2197-7-3**] 12:00AM PLT SMR-NORMAL PLT COUNT-254
[**2197-7-3**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2197-7-3**] 12:00AM NEUTS-35* BANDS-28* LYMPHS-21 MONOS-9 EOS-0
BASOS-0 ATYPS-2* METAS-3* MYELOS-2* NUC RBCS-1*
[**2197-7-3**] 12:00AM WBC-2.6*# RBC-3.99* HGB-12.1* HCT-35.7*
MCV-90 MCH-30.3 MCHC-33.8 RDW-17.4*
[**2197-7-3**] 12:00AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2197-7-3**] 12:00AM LIPASE-13
[**2197-7-3**] 12:00AM ALT(SGPT)-34 AST(SGOT)-16 ALK PHOS-135* TOT
BILI-0.7
[**2197-7-3**] 12:00AM UREA N-24* CREAT-1.0
[**2197-7-3**] 12:05AM freeCa-1.07*
[**2197-7-3**] 12:05AM GLUCOSE-125* LACTATE-2.6* NA+-131* K+-3.2*
CL--94* TCO2-23
[**2197-7-3**] 12:05AM PH-7.42 COMMENTS-GREEN TOP
[**2197-7-3**] 01:10AM URINE MUCOUS-RARE
[**2197-7-3**] 01:10AM URINE HYALINE-[**4-7**]*
[**2197-7-3**] 01:10AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2197-7-3**] 01:10AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2197-7-3**] 01:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
.
=
=
=
=
=
=
=
=
================================================================
MICRO DATA:
[**2197-7-4**] Sputum from BAL
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
.
[**2197-7-6**] Sputum:
GRAM STAIN (Final [**2197-7-6**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2197-7-8**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 298-6523S [**2197-7-4**].
.
.
[**2197-7-7**] Sputum:
[**2197-7-7**] 11:53 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2197-7-9**]**
GRAM STAIN (Final [**2197-7-7**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2197-7-9**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. HEAVY GROWTH.
.
=
=
=
=
=
=
=
=
================================================================
IMAGING
CXR - 1. Focal opacity at the left lung base, could be focal
consolidation;
however, cannot exclude nodule in a patient with cancer history,
although less likely. D/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Son [**Name (NI) **].
2. Nonspecific bowel gas pattern, with a few scattered air-fluid
levels in
the right upper abdominal quadrant.
.
[**2197-7-4**]: Chest X ray
IMPRESSION:
Increase of the left lung opacity consistent with worsening
pneumonia.
.
[**2197-7-5**] Chest X ray:
FINDINGS: As compared to the previous radiograph, the
endotracheal tube
projects 4 cm above the carina with its tip. The course of the
nasogastric
tube is unchanged. Also unchanged is the course of the right
pectoral
Port-A-Cath.
Newly appeared bilateral parenchymal opacities, notably in the
perihilar
areas, suggest pulmonary edema rather than pneumonia.
Progressing
retrocardiac atelectasis, the presence of a small left pleural
effusion cannot be excluded. No other relevant changes.
.
[**2197-7-6**] Chest X ray:
Comparison is made with multiple prior studies including all
performed the day before.
Cardiac size is top normal. Lines and tubes remain in place in
standard
position. There is no pneumothorax or enlarging pleural
effusions. Extensive bilateral parenchymal opacities worse in
the left lung have minimally improved in the right lower lobe.
These are a combination of pulmonary edema and preexisting left
lung pneumonia.
.
[**2197-7-7**] Chest X ray:
IMPRESSION: Worsening multifocal consolidation and increased
left lower lobe atelectasis.
.
[**2197-7-8**] Chest X ray:
Diffuse bilateral extensive opacities have minimally improved in
the left
lower lobe. Cardiomediastinal contours are unchanged. Cardiac
size is top
normal. Lines and tubes remain in place in standard position.
There is no
evident pneumothorax or large pleural effusion.
.
[**2197-7-8**] Trans thoracic Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = 20%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The
estimated cardiac index is depressed (<2.0L/min/m2). The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is probably moderate pulmonary
artery systolic hypertension. [RVSP 27 mmHg + RA pressure, with
the latter almost certainly very elevated in the setting of
significant tricuspid regurgitation]. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe left ventricular systolic dysfunction in the
setting of rapid atrial fibrillation. Markedly dilated and
severerly hypokinetic right ventricle with relative apical
sparing, consistent with acute pulmonary hypertension with a
chronically untrained RV (due to pulmonary embolism, hemorrhage,
ARDS, etc.). Moderate to severe tricuspid regurgitation. At
least moderate pulmonary hypertension.
Brief Hospital Course:
Mr. [**Known lastname 35716**] was a 61-year-old man with head and neck cancer
who presented with diarrhea. He ultimately developed a pneumonia
and passed due to complications of sepsis.
Septic Shock: Mr. [**Known lastname 35716**] was admitted on [**7-3**]. He was
initially started on levofloxacin for empiric coverage for a
pulmonary infection. Later that day his antibiotic coverage was
increased to vancomycin and cefepime. The following morning he
became hypoxic after eating/drinking. A respiratory code was
called. He was satting well on a non-rebreather. The decision
was made to intubate on the floor to prevent further
decompensation. After intubation, multiple secretions/food were
suctioned from his airway. He was transferred to the ICU for
further care. His antibiotic coverage was broadened to
vancomycin and zosyn. The following day his blood pressures
began to decrease. He was started on norepinephrine,
phenylephrine, and vasopressin. He received several fluid
boluses. On [**7-6**] micafungin was added for fungal coverage due to
persistent fevers. MRSA grew from BAL sputum on [**7-4**] and on
subsequent sputums on [**7-6**] and [**7-7**]. On [**7-7**] Zosyn was
discontinued. Meropenem and linezolid were started based on ID
recommendation. His primary source was felt to be from MRSA
pneumonia. The infectious disease team followed his course and
offered recommendations. Despite aggressive fluid resuscitation,
multiple pressors, and appropriate antibiotic coverage, he had
signs of end organ damage. An echo showed an EF of 15%, he had
elevated LFT's, elevated lactate to 12.1, increasing coags and
decreasing platelets indicating DIC, increasing WBC, and
increasing creatinine. Multiple family discussion were held
discussing Mr. [**Known lastname 35717**] poor prognosis. His family wanted an
aggressive approach. He lost his pulse and a code was initiated.
CPR was started, but his wife asked us the team to stop the
code.
Thrombocytopenia: Mr. [**Known lastname 35716**] was admitted with a platelet
count of 254. This decreased to a low of 25. A HIT antibody test
was sent and was negative. All heparin products were temporarily
discontinued pending results of the test. His thrombocytopenia
was ultimately thought to be due to his overwhelming infection
and possible medication effects.
Increased creatinine: Mr. [**Known lastname 35717**] kidney function remained
intact for most of his ICU stay with a creatinine of 0.9. The
day of his death his creatinine increased to 1.3 indicating
renal failure from his sepsis. The renal team was consulted.
There was no indication to for dialysis. His worsening renal
function was attributable to overwhelming infection.
Elevated LFT's: On [**7-7**] the patient's LFT's were significantly
elevated. This was thought to be due mainly to hypoperfusion of
the liver. Also in the differential was amiodarone toxicity as
this was recently started prior to the increase in LFTs. The
LFTs were monitored closely and continued to increase as we were
unable to maintain adequate tissue perfusion.
Head and neck cancer: No active treatment was given during this
hospitalization.
Atrial Fibrillation with RVR: Mr. [**Known lastname 35716**] [**Last Name (Titles) 35718**] went
into atrial fibrillation with RVR. His heart rate was initially
in the 200's. He was given metoprolol which slightly decreased
his rate to the 150-160's. His blood pressures then decreased to
systolics of 70-80's. He was cardioverted initially with 100 J,
then 200 J. Each cardioversion resulted in a return to sinus
rhythm. However, his heart rate went back into atrial
fibrillation after a few minutes. He was then loaded with
amiodarone. After a loading dose, an amiodarone gtt was started.
He was then successfully cardioverted. He maintained this rate
for several hours. However, throughout the next couple of days
he again went into atrial fibrillation with RVR. Each time his
blood pressure would drop. He was cardioverted multiple times
throughout the next 2-3 days. However, each time he remained in
sinus rhythm for a shorter period of time. His blood pressure
rebounded less often. An esmolol gtt was briefly started, but
this was discontinued for hypotension.
Diarrhea: His episode of diarrhea was thought related to a
chemotherapy side effect. C. diff and stool cultures were all
negative. He was given intravenous fluids to maintain volume
status.
Medications on Admission:
Atenolol 50 mg PO DAILY
Omeprazole 40 mg PO DAILY
Clotrimazole 10 mg Troche 4 times a day
Ondansetron 4 mg PO Q8H as needed for nausea
Lorazepam 0.5 mg PO Q6H as needed for nausea
Prochlorperazine 10 mg PO Q6H as needed for nausea
Multivitamin
Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q6H as needed
for pain
Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash 10 mL four times a day
Furosemide 20 mg PO BID
* Had just completed 10 day course of Cipro ppx
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
MRSA pneumonia/ARDS
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
20030,452,29281,7892,V6441,23871,2875,2800,V1582,E9379,2825 | 99,823 | 179,720 | Admission Date: [**2168-8-30**] Discharge Date: [**2168-9-8**]
Date of Birth: [**2086-9-30**] Sex: F
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
splenic marginal zone lymphoma
Major Surgical or Invasive Procedure:
laparoscopic converted to open splenectomy
History of Present Illness:
81-year-old woman who has been evaluated originally for abnormal
blood smear. She was further worked up with a bone marrow
biopsy and CAT scan and diagnosed with a low-grade lymphoma and
thought most consistent with a splenic marginal zone lymphoma.
In terms of symptoms, she has had right lower abdominal
"pressure pain" which is more prominent at night when just prior
to bed. Otherwise, she has had no symptoms, no nausea, vomiting,
no exacerbating or alleviating symptoms.
Past Medical History:
PMH:
1. Headaches.
2. Thalassemia minor.
3. Degenerative joint disease.
4. Question of tuberculosis.
PSH:
1. Total abdominal hysterectomy and bilateral salpingo-
oophorectomy for bleeding.
2. Cataract surgery, left eye.
3. Cesarean section x1.
4. Bartholin cyst surgery.
5. Thumb surgery.
Social History:
She is a former smoker but quit years ago. She does not drink
or use drugs. She is retired. She lives with her husband,
daughter, and son. She has eight grandchildren.
Family History:
Family history is significant for her father having had kidney
cancer. Her children have thalassemia, brother had thyroid
cancer, another brother had [**Name2 (NI) 499**] and prostate cancer.
Physical Exam:
VS: 97.0, 76, 126/52, 20, 96% RA
Gen: A&O, NAD
CV: RRR no m/r/g
Pulm: CTAB
Abd: soft, TTP over incision site, non-distended, incision c/d/i
with staples
Ext: warm, 2+dp/pt, 1+LE edema
Pertinent Results:
[**2168-9-8**] 11:50AM BLOOD WBC-12.9* RBC-3.71* Hgb-9.1* Hct-29.2*
MCV-79* MCH-24.6* MCHC-31.2 RDW-17.0* Plt Ct-840*
[**2168-9-8**] 11:50AM BLOOD PT-34.2* PTT-35.2* INR(PT)-3.4*
[**2168-9-8**] 11:50AM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-137
K-3.8 Cl-97 HCO3-32 AnGap-12
[**2168-9-6**] 07:20AM BLOOD ALT-34 AST-22 AlkPhos-74 TotBili-0.4
[**2168-9-8**] 11:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
Brief Hospital Course:
Date of Admission: [**2168-8-30**]
Date of Discharge: [**2168-9-8**]
Procedures: laparoscopic converted to open splenectomy, Epidural
placement x2
Imaging:
CXR ([**2168-9-1**]): No acute infiltrate. Bilateral lower lobe
atelectasis with small left pleural effusion. No cardiomegaly.
No pulmonary edema.
Abdominal U/S ([**2168-9-1**]): 1. Markedly abbreviated study due to
poor patient noncompliance. 2. Limited findings are concerning
for portal vein thrombus versus
undetectable flow, but cannot be further clarified with
ultrasound at the
present time. A contrast enhanced liver CT is advised to further
evaluate.
CT Abd/Pelv ([**2168-9-1**]): occlusive PV thrombus in intrahepatic R
and L branches of the PV. Non-occlusive thrombus in the main PV.
Thrombus in splenic vein remnant. Colonic wall thickening,
likely due to underdistention, but could
represent colitis in the right clinical setting. Multiple
hepatic and renal cysts.
Bilateral pleural effusions, greater on the left than the right.
CXR ([**2168-9-2**]): IJ is in proper position in the lower SVC.
Otherwise, bilateral
pancake atelectasis with small pleural effusions are unchanged.
CXR ([**2168-9-7**]): Neg for PNA or effusions
Pending labs: spleen for pathology
Medication changes: none
The patient was admitted for observation after laparoscopic
splenectomy that was converted to open. An epidural was placed
by the Acute Pains Service (APS) post-operatively for pain
control which provided moderate pain relief. This was removed
and was briefly started on a dilaudid PCA. However, she
developed confusion and this was d/c'd and started on vicodin
with IV morphine for breakthrough. APS was re-contact[**Name (NI) **] and
another epidural was placed. POD#2 she developed low grade
temperature with leukocytosis of 15,000 with a HCT drop from
29.6 to 26.8 and worsening abdominal pain. There was concern for
possible venous thrombosis so an abdominal U/S was performed.
However, this was suboptimal study limited views due to pain
but did demonstrate lack of flow through the portal vein. A
follow-up CT scan demonstrated an occlusive thrombus in the
portal vein and non-occlusive thrombus in the splenic vein
remnant. APS was paged and the epidural was removed and she was
transferred to the SICU for observation and was started on
Heparin drip. A right IJ CVL was placed for access. Her HCT
continued to drop to 22.4 and she was transfused 2 units PRBCs,
she responded appropriately with a HCT of 30. ID was consulted
who recommend checking blood cultures and UA which were
negative. She received pre-splenectomy vaccinations in [**Month (only) **].
Heme/Onc was consulted to assist with management and transfusion
requirements in patient post-splenectomy with history of
thalassemia minor. Their recommendations were to keep HCT
greater than 21 and to follow up as an outpatient with her
Oncologist and her scheduled f/u CT scan. POD#4 she was
transferred to the floor and was started on coumadin. She was
placed on regular diet and a morphine PCA for pain control.
POD#5 the foley was removed and she was voiding without
difficulty. She was transitioned to oxycodone and the PCA was
stopped. PT was consulted who recommend [**Hospital 3058**] rehab upon
discharge. POD#6 the heparin drip was stopped and she continued
on coumadin. POD#7 her INR returned as 6.6 and all
anticoagulation was held to allow her to drift back down. Her R
IJ was removed and sent for culture which was negative. She
continued to have mild O2 requirements via nasal cannula likely
due to decreased ambulation. IS was continued to be encouraged
and the O2 was then weaned. The oxycodone was stopped because
she was overly sedated and she was placed on scheduled Tylenol
and PRN tramadol of which she only needed 1 dose. POD#8 she did
have temperature of 101.0, CXR was negative for infiltrate and
UA was negative. She remained afebrile therafter, her WBC
continued to trend down and her INR trended down to 3.4, and she
developed post-splenectomy thrombocytosis with platelet count of
840 on discharge. She was ambulating, tolerating a regular diet,
voiding, and having BM's. She was discharged to rehab with
appropriate follow up appointments with Dr. [**Last Name (STitle) **] from
surgery and her oncologist. She is going to receive 1mg coumadin
tonight and should have her INR checked at rehab to titrate
coumadin.
Medications on Admission:
prilosec 20', Ca-Vit D 600 mg-400'', MVI'
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
3. M-Vit 27-1 mg Tablet Oral
4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
5. Coumadin. titrate to goal INR of [**3-3**].
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
splenic marginal zone lymphoma
portal vein thrombosis
splenic vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call the surgery clinic ([**Telephone/Fax (1) 3201**]) or go to the Emergency
Department for the following: Temperature greater than 101.4;
increasing redness, pain, swelling, or discharge from the
incision sites; blood in your stool or black tarry stools;
inability to tolerate food or drink; worsening abdominal pain;
or any other concerns.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drink alcohol, drive or operate heavy machinery while
taking narcotic analgesic medications. You may also take
acetaminophen (Tylenol) as directed, but do not exceed 4000 mg
in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2168-9-16**] 2:15
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-10-10**] 11:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2168-10-14**] 10:00
Completed by:[**2168-9-8**] |
86113,51851,86402,03844,9584,4233,8621,86132,5849,99592,E9654,8605,00845,99859,6822,2761,2851,9582,99832,E8788,4019,25000,5715,V1253,42731,70709,70725,88013,30500,30550 | 99,830 | 176,834 | Admission Date: [**2187-8-20**] Discharge Date: [**2187-9-14**]
Date of Birth: [**2138-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Pt is a 49 yo male transferred via med flight from OSH [**Hospital3 **] s/p GSW. Pt was brought directly to the OR.
Major Surgical or Invasive Procedure:
OPERATION:
1.Median sternotomy, multiple cardiac repairs as dictated by Dr.
[**Last Name (STitle) **], repair of right upper lobe parenchymal
laceration, exploratory laparotomy,chromic suturing and Argon
beam coagulation of 4 liver lacerations,abdominal packing, VAC
closure of abdomen.
2. Emergency median sternotomy.
3. Evacuation cardiac tamponade.
4. Repair of bullet injury to the right ventricle free wall.
5. Tricuspid valve replacement with a size 29 [**Company 1543**] Mosaic
tissue valve.
6. Repair of ventricular septal defect caused by the bullet with
Dacron patch.
7. Left ventriculotomy to remove the bullet.
8. Laparotomy and repair liver lacerations and also lung
parenchymal injury by Dr. [**Last Name (STitle) 16471**] as seen in her operation
dictation note.
9. Mediastinal exploration and washout.
10. Mediastinal exploration and closure of the sternotomy.
11.Exploratory laparotomy/reopening of recent laparotomy,
washout of the abdomen and closure, as well as exploration of
the right arm wounds, debridement and packing
12.Exploratory laparotomy and abdominal washout. Abdominal wall
debridement.Liver biopsy. Abdominal wall closure with retention
sutures.
History of Present Illness:
This is a 49-year-old patient who sustained a gunshot injury to
the right chest. He was apparently very unstable in the field
with multiple arrests resuscitated successfully and on reaching
the outside hospital at [**Hospital3 **] he was apparently
reasonably stable. There, further investigations with x-rays
revealed the bullet had traversed through the right
hemithorax(chest tubed placed) across the heart and lodged
itself into the left heart border and he was transferred
emergently to the [**Hospital3 **] Hospital for further exploration
and repair. On arrival to the [**Hospital3 **] Hospital, he was
actively resuscitated to maintain reasonable hemodynamics and
emergency surgery was carried out by [**Last Name (LF) **],[**First Name3 (LF) **] and the
trauma surgeon, Dr. [**Last Name (STitle) 16471**], and initially explored by Dr.
[**Last Name (STitle) **] as well.
Past Medical History:
+ETOH, DM, HTN, ? methadone user, s/p hit by train [**2180**]
Social History:
Heroin addict
Family History:
Non-contributory
Physical Exam:
Admission physical deferred- rushed emergently to O.R.
Pertinent Results:
TEE [**8-23**]
Focused Study for Chest Closure and Ongoing Pressor Requirement:
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
muscular ventricular septal defect (VSD) just below the
prosthetic tricuspid valve with left to right flow. This is
approximately 1 cm superior to the VSD observed on [**2187-8-21**] that
was repaired. The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal.. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. A bioprosthetic valve
is seen in the tricuspid position. There is a very small
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2187-8-23**] at 0830. Following chest closure
overall systolic function was unchanged from prior.
[**2187-8-31**] Chest and ABD CT Scan:
1.Small apical right pneumothorax.
2.Small bilateral pleural effusions with overlying atelectasis;
however,
infection cannot be excluded, especially at the left lung base.
Chest tube in appropriate position.
3.Small fluid collection inferior to the cecum with high density
material
concerning for extravasation of oral contrast. Associated focal
wall
thickening of the cecum which may be due to colitis: infections
or
inflammatory.
3. Wedge-shaped hypodense lesion within segment [**Doctor First Name 690**] of the
liver, likely
representing repaired liver laceration. Small amount of
perihepatic free
fluid.
4. Open anterior abdominal wall wound with a small amount of
fluid or
stranding inferiorly in the anterior abdominal wall.
5. Fractured left 1st and 2nd ribs.
Discharge labs:
[**2187-9-14**] 06:18AM BLOOD WBC-9.5 RBC-2.98* Hgb-8.4* Hct-27.0*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.5* Plt Ct-381
[**2187-9-14**] 06:18AM BLOOD Glucose-68* UreaN-28* Creat-1.8* Na-126*
K-4.8 Cl-93* HCO3-23 AnGap-15
[**2187-9-13**] 04:51AM BLOOD WBC-10.0 RBC-2.94* Hgb-8.4* Hct-26.8*
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.7* Plt Ct-401
[**2187-9-12**] 05:19AM BLOOD WBC-12.9* RBC-2.99* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.8 MCHC-32.1 RDW-16.6* Plt Ct-431
[**2187-9-13**] 04:51AM BLOOD Plt Ct-401
[**2187-9-12**] 05:19AM BLOOD Plt Ct-431
[**2187-9-5**] 02:53AM BLOOD PT-15.0* PTT-42.0* INR(PT)-1.4*
[**2187-9-13**] 04:51AM BLOOD Glucose-78 UreaN-30* Creat-2.1* Na-125*
K-4.2 Cl-93* HCO3-25 AnGap-11
[**2187-9-12**] 05:19AM BLOOD Glucose-96 UreaN-34* Creat-2.2* Na-122*
K-4.0 Cl-89* HCO3-23 AnGap-14
[**2187-9-7**] 05:50AM BLOOD ALT-72* AST-131* AlkPhos-108 Amylase-87
TotBili-1.9*
[**2187-9-3**] 02:01AM BLOOD ALT-62* AST-170* LD(LDH)-378* AlkPhos-97
TBili-2.6*
[**2187-9-7**] 05:50AM BLOOD Lipase-49
[**2187-9-1**] 02:07AM BLOOD Lipase-204*
[**2187-9-13**] 04:51AM BLOOD Mg-2.2
[**2187-9-12**] 05:19AM BLOOD Mg-2.1
[**2187-9-5**] 10:58 am STOOL **FINAL REPORT [**2187-9-6**]**
C. difficile DNA amplification assay (Final [**2187-9-6**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay. (Reference
Range-Negative).
[**2187-8-30**] 9:52 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2187-8-31**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2187-9-2**]):
RARE GROWTH Commensal Respiratory Flora.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 111925**]
[**2187-8-25**].
[**2187-8-25**] 3:12 pm BLOOD CULTURE Source: Line-IJ 2 OF 2.
Blood Culture, Routine (Final [**2187-8-28**]):
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
353-3223V
[**2187-8-27**].
Anaerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM NEGATIVE
ROD(S).
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2187-9-9**] 2:54 PM
Final Report: In comparison with study of [**9-7**], there has been
placement of a left subclavian PICC line that extends to the
lower portion of the SVC. Continued low lung volumes with
bibasilar effusions and atelectasis. No definite pulmonary
edema. Left apical pleural cap again is seen, representing a
loculated, possibly extrapleural fluid collection related to the
recent rib fracture.
Brief Hospital Course:
The patient was admitted from an outside hospital and went
emergently to the OR after sustaining gunshot wound to the
chest. He underwent extensive surgery to
repair trauma sustained to chest. He was brought from the OR
after undergoing Median sternotomy, TVR/VSD closure/RV repair by
Dr. [**Last Name (STitle) **], repair of right upper lobe parenchymal
laceration, exploratory laparotomy, chromic suturing and Argon
beam coagulation of 4 liver lacerations,abdominal packing, VAC
closure of abdomen .Please see multiple operative notes for
further details. He arrived from OR intubated, sedated,
paralyzed on Epi/Levo/vasopressin, open chest. He was bleeding
from his chest tubes and required multiple blood products and
returned to the OR for abd and chest washout, repair of
diaphragmatic bleeder. Returned from OR continued to be
hypotensive, elevated transaminases, chest and abd open and
wound vac in place. He developed Rapid afib and received
amiodarone with good effect. He returned to the OR on POD#2 for
chest closure which he tolerated well. Abdominal wound remained
open and packed. After chest closure pressors were weaned slowly
over the course of several days. On pod# 4 his abd was closed.
His sedation was weaned off, he remained neurologically intact
and his c-spine was cleared by ACS. He spiked fevers and became
bacteremic. He grew Serratia from his blood and STENOTROPHOMONAS
and ENTEROBACTER from sputum on [**8-28**]. He was covered with broad
coverage antibiotics, (vanc, fagyl, cefepime) ID were consulted
and Bactrim was added. He developed drainage upper aspect of abd
wound and was brought back to the OR by ACS. The abd was opened
and packed. He returned a few days later for abd wound closure
but the skin remained open. He was extubated on POD#7 but was
reintubated 3hr later 2nd to resp distress. Left chest tube was
placed for moderate to large effusion. He was again reextubated
on POD#10. Due to his current drug history he was seen by the
acute pain service for management of meds. He continued to
progress slowly and was transitioned off tube feeds, seen by
speech and swallow and cleared to eat regular diet. Appetite is
poor and he is on supplements. His tranaminases have continued
to improve. He developed acute renal failure peak creatinine
2.5. and was therefore gently diuresed. His creat continues to
be above normal. He was noted to have developed a pressure sore
to the back of his head for which he was seen by wound nurse and
place in foam mattress. Chest tubes and PW were remove without
incident. He eventually transitioned to the floor on POD#12. On
the floor he continued to progress. He has remained very weak
and deconditioned. He developed c-diff and was started on PO
Vanco which he had completed. He became hyponatremic which has
been slowly improving and was placed on fluid and free water
restriction and meds were adjusted. He has remained afebrile and
will continue on bactrim until [**9-14**]. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. At the time of discharge on POD 24 the patient was
requiring max assist and was screened for rehab. He is able to
sit and stand at the bedside he has a continued flat affect
requiring encouragement to partake in physical therapy. All his
wounds are healing well, his abdominal wound has several
retention sutures and a vac in place to assist with wound
healing. He was noted to be lethargic a few days prior to
discharge and pain meds were adjusted, he has tolerated the
adjustment and noted to be less lethargic.
The patient was discharged to [**Location (un) 511**] Sianai in [**Location (un) 86**] in
good condition with appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Metoprolol Tartrate 12.5 mg PO BID
hold and call HO for SBP<90
HR<55
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Nystatin Cream 1 Appl TP [**Hospital1 **] groin
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth
every four (4) hours Disp #*40 Tablet Refills:*0
12. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
13. Ranitidine 150 mg PO DAILY
14. Tizanidine 0.5 mg PO BID:PRN pain
15. Sodium Chloride 1 gm PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] at [**Hospital 3278**] Medical Center
Discharge Diagnosis:
1)Gunshot wound to chest with resultant injuries to heart,
diaphragm, lung and liver resulting in massive hemorrhage and
pericardial tamponade.
2)Bleeding from diaphragm.
3)Fascial dehiscence and evisceration
4)Serratia bacteremia
PMH: HTN, DM
Discharge Condition:
Alert and oriented x3 nonfocal
Bed to chair with assist(per PT)full assist-lift(per nursing)
pain managed with oral narcotics
Extremities:warm well perfused-no edema
Abd wound:with VAC, incision-clean
Occiput: pressure ulcer-keep on sponge pillow
Discharge Instructions:
look at your incisions daily
NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and in the evening take
your temperature, these should be written down on the chart
Vab dressing chnage to abdomin q 72hrs (last change [**2187-9-14**])
No driving for one month or while taking narcotics. Do not drive
until follow up with surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2187-10-16**]
1:00 in the [**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist:needs referral
Please call to schedule appointments with your:
Acute Care Surgery(ACS): call [**Telephone/Fax (1) 2537**] to schedule f/u appt
in 2 weeks
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 66039**] in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-9-14**] |
55221,9974,5601,6822,5680,27800,2440,V4586,32723,V1251,73300,4264,V4572,E8788 | 99,832 | 192,563 | Admission Date: [**2134-1-27**] Discharge Date: [**2134-2-5**]
Date of Birth: [**2073-8-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Admitted for repair of hernia.
Major Surgical or Invasive Procedure:
[**2134-1-27**]
1. Exploratory laparotomy with biopsy of mesenteric nodule.
2. Lysis of adhesions greater than 2 hours.
[**2134-2-2**] PICC line placement
History of Present Illness:
Mr. [**Known lastname 29215**] has the history of multiple
abdominal surgeries including hernia repairs with mesh. He
presented with very large abdominal wall hernias with
intermittent and recurrent obstruction. He was able to lose
weight preoperatively with the aid of the Lap-Band procedure
and now he required surgical repair of his hernias.
Past Medical History:
right bundle branch block
---Stress test in [**2124**] normal
osteoporosis
hypothyroidism s/p thyroid resection for thyroid nodule of
undetermined significance
sigmoid diverticulitis s/p Hartmann's with small bowel resection
([**2129-9-2**]) and takedown ([**2129-12-16**])
ventral hernia repaired with component separation ([**2131-5-2**])
Social History:
The patient quit tobacco 20 years ago, does drink one glass of
wine per night. No drugs. Works as mail carrier, lives with
wife.
Family History:
Non-contributory -- as per HPI no h/o blood clots,
coagulaopathies, or miscarriages
Physical Exam:
The BP is 116/74 and his pulse is 72 and regular. Resp is 14 and
unlabored after walking down the hallway. The temp is 98.2
orally.
There are no acute skin lesions. The hair and nails are normal
for his age. The ear canals are clear with benign TMs. The
sclera
are anicteric and w/o pallor. PERRL and A. The oral mucosa has
no
lesions; dentition is in good repair.
The neck is supple, and the thyroid is w/o enlargment or
nodularity. The neck veins are flat when he is about 30 degrees
from the fully supine position. The trachea is midline.
There is no pain with percussion of the vertebral bodies or the
CVAs. The thorax is resonant, and the BS are clear and symmetric
in all lung fields, including the apices, RML and the lingula.
The precordium is quiet and there is a soft and regular s1 and
s2
and no murmurs, no s3 or s4 when he is upright and supine. There
are no carotid bruits. No cardiac rubs.
The abdomen has active BS. The liver is 9 cm in span by
percussion and scratch. He has at least 2 very large ventral
hernias. No abdominal masses.
No peripheral edema, and no acute joint pathology. He is alert
and orientated.
Pertinent Results:
[**2134-1-27**] 09:25PM BLOOD WBC-6.2 RBC-3.34* Hgb-11.2* Hct-33.6*
MCV-101* MCH-33.7* MCHC-33.5 RDW-13.2 Plt Ct-302
[**2134-1-28**] 03:07AM BLOOD WBC-6.3 RBC-3.29* Hgb-10.6* Hct-32.6*
MCV-99* MCH-32.4* MCHC-32.6 RDW-13.5 Plt Ct-277
[**2134-1-27**] 08:13PM BLOOD Glucose-183* UreaN-13 Creat-0.8 Na-140
K-4.4 Cl-107 HCO3-26 AnGap-11
[**2134-1-28**] 03:07AM BLOOD Glucose-144* UreaN-13 Creat-0.9 Na-139
K-4.4 Cl-107 HCO3-27 AnGap-9
[**2134-1-27**] 08:13PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.5*
[**2134-1-28**] 03:07AM BLOOD Calcium-8.4 Phos-4.8*
Brief Hospital Course:
Pt underwent open heria repair on [**1-28**] with Dr. [**Last Name (STitle) **] and
then Dr. [**First Name (STitle) **] from Plastics did the reconstruction. Procedure
lasted over 10 hours and so pt was transfered to ICU after
surgery. Three JP drains were placed. Pt did well, made good
urine, vital signs were stable and so on [**1-28**] pt was transfered
to the floor. On [**1-29**] foley was removed diet was advanced.
Laboratory results and vital signs remained stable. JP drainage
was reduced.
Neuro - Patient's pain was well controlled with a dilaudid PCA
until the patient was tolerating POs at which point he was
transitioned to Percocet which offered good relief for his pain.
CV - The patient's vital signs were monitored per routine on the
floor after surgery. He was hemodynamically stable throughout
the entirety of his hospital course.
Pulm - After surgery the patient was encouraged to use his
incentive spirometer 10 times/hour; the patient was compliant
and had not postoperative complications with his pulmonary
function. He maintained his oxygen saturations in the mid-90s
on room air at the time of discharge.
GI - The patient underwent an open hernia repair on [**1-28**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] (plastic surgery). His post-operative
course was complicated by an ileus secondary to narcotics whichw
as relieved by a suppository. Prior to discharge the patient
was passing gas, defecating, and tolerating a Stage V diet
without nausea or vomiting.
Integumentary - The patient's incision was monitored for
cellulitis on a daily basis and showed no signs of infection
during his postoperative stay. He was kept on Ancef for
prophylaxis while his JP drains were in. All JPs and the Ancef
were discontinued on the day of discharge.
Medications on Admission:
1. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H
2.Levothyroxine Sodium 150 mcg
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day
Discharge Medications:
1. Verapamil 40 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ventral Hernia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* 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.
Activity:
No heavy lifting of items [**9-17**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call his
office at [**Telephone/Fax (1) 3201**] to make an appointment.
Please follow up with Dr. [**First Name (STitle) **], please call his office at
[**Telephone/Fax (1) 6742**] to make an appointment.
Please make an appointment with your primary care provider in
the next month to review your current health status.
Completed by:[**2134-2-8**] |
5523,570,5722,5070,1124,51881,0380,99592,5845,5724,5185,78959,99931,6823,1122,2867,2760,5601,5579,57142,5715,78097,319,53081,5305,53789,04119,45182,E8798,28860,V0981,2766,78722,28529,V667,34690,2720 | 99,836 | 101,018 | Admission Date: [**2116-5-21**] Discharge Date: [**2116-7-17**]
Date of Birth: [**2064-4-13**] Sex: F
Service: MEDICINE
Allergies:
Coconut Oil
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Altered mental status, hiatal hernia, hepatitis of unknown
etiology
Major Surgical or Invasive Procedure:
1. Several intubations for respiratory failure
2. [**2116-6-5**] laparoscopic reduction of hiatal hernia, repair of
diaphragmatic defect with pledgeted sutures, pexy of stomach to
diaphragm, and laparoscopic liver biopsy
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 85535**] is a 52 year old female with a history of
mental retardation and migraine headaches who is transfered from
[**Hospital 792**]Hospital for further management of hepatitis. She
originally presented to [**Hospital **] Hospital on [**2116-4-28**] with an
increase in the frequency of falls and confusion. Her sister and
[**Name2 (NI) 802**] noted subtle changes in her behavior as far back as
[**2115-10-13**] that became increasingly pronounced over the
following months, viral hepatitis work-up was reportedly
negative.
At [**Hospital **] Hospital, the patient had a prolonged and complicated
course with extensive evaluation of her elevated LFTs. She was
noted to have hyperammonemia and was treated with lactulose for
hepatic encephalopathy with some improvement in mental status.
MRI abdomen was unremarkable. Ceruloplasmin, [**Doctor First Name **], AMA, [**Last Name (un) 15412**] were
all normal. Viral hepatitis serologies were negative as was CMV
PCR. Alpha-1 antitrypsin was elevated at 385. She underwent a
liver biopsy on [**2116-4-5**] that showed "ongoing severe liver
injury with extensive hepatocyte damage and resulting collapse.
She underwent endoscopy that demonstrated a 10 cm hiatal hernia
and gastric volvulus with edema and erythema of the stomach and
an erosion at the GE junction. Colonoscopy showed grade IV
internal hemorrhoids and 2 colonic ulcerations that were
ischemic in nature and a 2 mm polyp that was resected. She
required antibiotics (vancomycin and zosyn) to treat HAP and
aspiration PNA. Her LFTs remained abnormal with AST of 146 and
ALT 103. AP peaked at 457. She was transferred, at the request
of her family, to [**Hospital1 18**] on [**2116-5-21**] for further evaluation as
they were still seeking a diagnosis for her illness.
The patient was admitted to the Medicine service on [**2116-5-21**] to
evaluate her liver disease. While on the medicine service, her
hospital course was complicated by ongoing aspiration events
felt to be a result of her large hiatal hernia and esophageal
dysmotility. On [**2116-5-28**], she was intubated and transferred to
the MICU for increasing dyspnea and acute respiratory failure.
She was extubated soon after on [**2116-5-29**] and was treated for
HAP/aspiration pneumonia, but antibiotics were stopped on
[**2116-6-1**]. On [**2116-6-5**], the patient was transferred to the
thoracic surgery service and underwent laparascopic hiatal
hernia reduction with percutaneous liver biospy.
Past Medical History:
- mental retardation of unknown etiology (some work-up at
[**Hospital **] Hosp of [**Location (un) 86**] that was of unclear consequence)
- history of migraine headaches that are associated with nausea
and vomiting and can be debilitating.
- hypercholesterolemia, was formerly on Lipitor.
- history of self-mutilization characterized by picking at skin.
- s/p right inner ear surgery x 2 with implant, [**2112**] and [**2107**]
- ATN, AIN at [**Hospital **] hospital [**4-/2116**]
Recent medical history during this hospitalization:
- Recurrent aspiration pneumonia ([**5-28**] - 18 intubated for ARDS)
- hiatal hernia s/p repair
- gastric volvulus s/p repair
- Right upper extremity phlebitis/cellulitis associated with
PICC
- NASH with Grade III-IV fibrosis
- ARDS and intubation post operatively [**Date range (1) 85536**]/10
- ATN, CVVH with oliguric renal failure (Cr peaked at 3.5)
- Coagulase negative staphylococcal bacteremia ([**6-16**])
- Persistent Leukocytosis of unclear etiology
- Elevated alpha 1 antitrypsin
Social History:
She lives with her sister [**Name (NI) 17**], her [**Name (NI) 802**], and a Burmese
mountain dog. She used to work at a daycare program where she
did manual labor but then was switched to a group that manages
dementia patients as it was thought she might be developing
dementia. She has had diminished ability to perform her ADLs
over the past few months. She has never smoked, no alcohol, and
no drug use.
Family History:
- mother: breast CA at 76
- father: colorectal CA in his 60s, MI
- 4 siblings: diabetes, hypertension, migraine headaches,
vertigo/Meniere's disease
Physical Exam:
Vitals: T 99.1, BP 149/89, HR 80, RR 20, O2 sat 96% RA
General: Morbidly obese, middle-aged, Caucasian female in NAD,
voice is difficult to understand
HEENT: dysmorphic facies, atraumatic, sclera anicteric,
disconjugate gaze, unable to completely assess EOM d/t
non-cooperation with exam, OP clear, MMM
Neck: supple, no lymphadenopathy or thyromegaly
Heart: RRR, normal s1 and s2, no murmurs
Lungs: CTA anteriorly, laterally, and superiorly in the back. No
w/r/r. Breathing comfortably without accessory muscle use.
Abdomen: +BS, soft, obese, mild RUQ tenderness without rebound
or guarding
Extremities: 3+ edema in feet and ankles bilaterally.
Neurological: Alert, oriented to self and family. Moves all 4
extremities. Difficult to assess due to lack of cooperation with
exam.
Pertinent Results:
ADMISSION LABS:
[**2116-5-21**] 09:32PM BLOOD WBC-14.5* RBC-3.89* Hgb-10.6* Hct-34.4*
MCV-88 MCH-27.2 MCHC-30.9* RDW-15.8* Plt Ct-236
[**2116-5-22**] 05:53AM BLOOD Neuts-85.2* Lymphs-7.8* Monos-4.6 Eos-2.1
Baso-0.2
[**2116-5-21**] 09:32PM BLOOD PT-15.6* PTT-32.5 INR(PT)-1.4*
[**2116-5-21**] 09:32PM BLOOD Glucose-101* UreaN-7 Creat-1.0 Na-140
K-3.9 Cl-108 HCO3-22 AnGap-14
[**2116-5-21**] 09:32PM BLOOD ALT-90* AST-145* LD(LDH)-229 AlkPhos-532*
TotBili-0.8
[**2116-5-21**] 09:32PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.3 Mg-1.8
LABS ON TRANSFER TO MICU:
[**2116-5-28**] 04:58AM BLOOD WBC-22.5* RBC-3.51* Hgb-10.0* Hct-31.6*
MCV-90 MCH-28.5 MCHC-31.7 RDW-15.9* Plt Ct-288#
[**2116-5-28**] 12:48PM BLOOD Neuts-91.5* Lymphs-5.0* Monos-2.9 Eos-0.2
Baso-0.4
[**2116-5-28**] 04:58AM BLOOD PT-16.2* PTT-30.6 INR(PT)-1.4*
[**2116-5-28**] 04:58AM BLOOD Glucose-124* UreaN-15 Creat-1.5* Na-146*
K-3.6 Cl-111* HCO3-21* AnGap-18
[**2116-5-28**] 04:58AM BLOOD ALT-94* AST-132* LD(LDH)-312*
AlkPhos-505* TotBili-0.8
[**2116-5-28**] 04:58AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.9 Mg-1.9
[**2116-5-28**] 10:26AM BLOOD Type-ART pO2-65* pCO2-30* pH-7.48*
calTCO2-23 Base XS-0
[**2116-5-28**] 10:26AM BLOOD Lactate-3.4*
BARIUM ESOPHAGRAM ([**2116-5-22**]):
1. Severe esophageal dysmotility and reflux.
2. Moderate hiatal hernia.
LIVER BIOPSY, PATHOLOGY ([**2116-5-26**]):
1. Advanced fibrosis (stage 3-4) with extensive bridging,
multifocal incomplete nodule formation (with a rare focus
suggestive of complete nodule formation) and a prominent
sinusoidal component.
2. Moderate lobular neutrophilic inflammation and mild portal
mixed inflammation (score 2).
3. Foci of hepatocyte ballooning degeneration with associated
intracytoplasmic hyalin (score 2).
4. Minimal steatosis (involving <5% of the core biopsy; score
0)
2D ECHO ([**2116-6-1**]):
Mild regional left ventricular systolic dysfunction consistent
with coronary artery disease.
MRI ABDOMEN & PELVIS ([**2116-6-3**]):
1. No evidence of biliary obstruction.
2. Small amount of perihepatic ascites.
3. Significant dependent body wall edema indicative of
"third-spacing".
RENAL ULTRASOUND ([**2116-6-6**]):
Essentially normal renal ultrasound. No evidence of
hydronephrosis.
DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US ([**2116-6-9**]):
Major intrahepatic vasculature patent with normal direction of
flow. Slightly coarsened and echogenic liver compatible with the
history of
autoimmune hepatitis. No intrahepatic or extrahepatic biliary
ductal
dilatation.
CT CHEST/ABDOMEN/PELVIS ([**2116-6-14**]):
1. Improved aeration of lung parenchyma, with persistent
predominantly basal consolidations and perihilar ground-glass
opacities.
2. Small bilateral pleural effusions.
3. Diffuse body wall edema with mild abdominal and pelvic
ascites without
focal fluid collection.
4. Persistent geographic area of hypoattenuation involving the
medial aspect of segment II and III of the liver of uncertain
etiology. Edema or infarcts could be considered. When clinically
appropriate, if the patient can have a contrast-enhanced CT or
MR examination, depending patient factors, this appearance could
be investigated further. Alternatively, a short-term follow-up
with ultrasound might be able to provide some information and
could provide a baseline for follow-up of the abnormality, if it
is later visualized. Doppler features could also be reassessed
in light of persistence of this abnormality.
5. Left PICC ends in the left brachiocephalic vein.
6. Thickening of the distal colon, involving the sigmoid and
through the
upper rectum, even allowing for underdistension. Differential
considerations include colitis in the appropriate setting or
sequelae of portal congestion. Since the upstream colon is
mildly prominent, the fact that the distal is mild to moderately
narrowed may be causing slight obstruction, although contrast
passes entirely through the area. The whole segment was
collapsed on the last examination, limiting assessment and
comparison. Correlation with clinical factors is recommended.
DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US ([**2116-6-16**]):
1. Patent hepatic vasculature
2. No focal liver lesion and no biliary dilatation seen.
3. Minimal ascites.
CT ABD/PELVIS ([**2116-6-25**]):
1. No evidence of abscess. Moderate amount of ascites, which has
increased
since the previous study.
2. Small bilateral pleural effusions, which have decreased in
size since the previous study. Adjacent bibasilar atelectasis in
addition to diffuse
ground-glass and patchy opacities at the bases have improved.
3. Small areas of hypoenhancement within segment II and III of
the liver with slight decrease in size of these segments likely
reflects evolving infarct and subsequent scarring corresponding
with the area of hypodensity noted on the previous noncontrast
CT studies.
4. Possible bowel wall thickening of the cecum, new since the
previous study. While this may be due to underdistended bowel,
focal colitis cannot be excluded. Previously described
thickening of the distal colon is not seen on today's study and
may have been due to underdistension on the previous study.
MR HEAD W/ & W/O CONTRAST ([**2116-6-28**]):
Non-specific, nonenhancing focus of high signal on FLAIR and T2
weighted images in the left parietal lobe. The differential
considerations are demyleination, vasculitis or sequlae of small
vessel disease.
MICROBIOLOGY:
[**5-27**] HD catheter - Coag neg staph
[**6-26**] HD catheter - Coag neg staph
[**6-28**] Blood cultures - VRE
Multiple sputum and urine cultures showing undifferentiated
yeast.
Brief Hospital Course:
HOSPICE CARE: Ms. [**Known lastname 85535**] was initially admitted to the
hospital from [**State 792**]after being diagnosed with hepatitis
that was found to be end stage liver disease (cirrhosis) from
NASH. Briefly, her hospitalization course was complicated by
intubation for aspiration pneumonia with subsequent respiratory
arrest. She also underwent a hiatal hernia repair to help
decrease the risk of aspiration, she was in the ICU for
transient shock liver and renal dysfunction. She also developed
VRE sepsis and was finally extubated several prior to her
transition to the floor. Unfortunately her course continued to
deteriorate, she was noted to again be in respiratory distress
likely a combination of aspiration from secretions and a
hypervolemic state. She was also not tolerating oral, NG tube
feeds. Following the onset of NGT feeding her abdomen would
become distended, she would have a fever. After a discussion
with health care proxy and family members the decision was made
for her to be comfort measures only. All non-essential,
non-comforting medications were discontinued. Pt was started on
oral Morphine for pain, oral Ativan for anxiety, Scopolamine
patch to minimize secretions from the Morphine.
- please continue with 5-10mg PO Morpine every 4 hours as needed
for comfort, this may need to be increased pending her
discomfort
- please continue with 1mg Ativan PO every 4 hours for anxiety
- please continue with 3 Scopolamine patches to the neck to
decrease secretions
- please continue with Bisacodyl 10mg PR as needed if the pt
does not have a bowel movement for several days and seems
uncomfortable from constipation
- please continue with Acetaminophen PR as needed for any fevers
PRIOR TO TRANSFER TO THORACIC SURGERY SERVICE/MICU:
# Elevated liver enzymes: liver biopsy pathology slides were
obtained from [**Hospital **] Hospital and reviewed by [**Hospital1 18**] pathology. Full
findings are above. Pathology was consistent with stage 3-4
fibrosis thought to be secondary to NASH.
# Dysphagia, hoarse voice: barium study evaluation revealed a
large hiatal hernia, and OSH upper endoscopy showed possible
gastric volvulus. Patient was continued on PPI [**Hospital1 **] and thoracic
surgery was consulted.
# Respiratory distress, aspiration pneumonia: a respiratory code
was called when patient became increasingly dyspneic and hypoxic
to 85% on the non-rebreather on [**5-28**]. Patient was then
transferred to the MICU and started on HAP coverage with
vancomycin and Zosyn. She was extubated on [**5-29**]. Bronchoscopy
specimens only grew yeast.
# Coag negative staph bacteremia: On [**5-29**] bottle grew GPCs
which turned out to be coag negative staph. Surveilance cultures
were negative, and this was felt to be likely a contaminant.
Patient was initially covered with vancomycin, but this was
stopped on [**6-2**].
# Candiduria: Patient grew [**Female First Name (un) **] from urine, as well as bronch
specimen. Patient received fluconazole IV x 3 days, and foley
catheter was changed.
# Nutrition: After above mentioned aspiration event, patient was
made NPO. Initial speech and swallow found esophageal
dismotility on barium swallow, without coughing and patient was
placed on diet of thin liquids and pureed solids.
# Cellulitis: she presented to the hospital from [**Hospital **] Hospital
with a right arm cellulitis at the site of her previous PICC. We
completed her 7-day course of antibiotics. There were no further
issues.
FROM TRANSFER TO THORACIC SURGERY SERVICE/SICU ([**2116-6-5**]):
KEY EVENTS:
[**6-6**]: Hepatology rec likely volume down, supportive care. Renal
recs likely ATN from hypotension. Renal US no source. TPN.
Vanco inc 1gm q48.
[**6-7**]: Placement of R subclavian CVL, started levo for sbp
support, adequate UO, one dose of lasix 20 mg IV in am, improved
liver function, rising creatinine
[**6-9**]: continues with minimal UOP. Started albumin 25g TID and
lasix drip with improvement in UOP, low dose levophed started to
increase renal perfusion. Fever, sent u/a, ucx, blood cx, cxr.
Ordered for RUQ ultrasound with doppler.
[**6-10**] started CVVH, CT torso, placed HD line, bedside ECHO
[**6-11**] CVVH at bedside, Cr / BUN / weight trending down, INR stable
at 1.5. started vanco, [**Last Name (un) 2830**], fluc.
[**6-12**] continues on CVVH. Now on PSV 10/10 with plan to extubate
[**6-13**]
[**6-13**] off CVVH since am, minimal urine production, improving past
midnight, no vasopressors, febrile to 103.2 -> Blcx, UClx,
sputum, on cpap. Sputum gram stain no organisms.
[**6-14**]: Paracentesis done, 1.5 L of transudative fluid removed.
RIGHT SC removed and new triple lumen placed in LEFT subclavian.
CT torso without obvious etiology of fevers. Increasing stools
overnight, c. diff sent.
[**6-15**]: had HD performed at bedside with 1.5 L removed. SBT with
5/0 settings. Patient did well for ~45 minutes, then became
tachypnic with desaturation. NO extubation. Became febrile to
104 and received ice packs and fan.
[**6-16**]: HD was cancelled [**1-14**] fever, HD planned for [**6-17**], may not
need renal recs albumin and lasix in interim; we gave lasix 40
mg once with adequate response, hepatology - f/u LFTs, no acute
events, afebrile > 24 hours, d/c'ed RIJ HD line. Patient
extubated.
[**6-17**]: Vancomycin started for coag neg staph on RIGHT IJ HD
catheter. UOP improving, lasix PRN. Overall, pt clinically
improving.
[**6-18**]: Urine output continues to improve. Received lasix with
good output, however, afternoon lytes with hypernatremia (147).
Evening lasix held.
[**6-19**]: we D/Ced Fluconazole given completion of course for yeast
cultures. She was cleared for thin liquids and pureed foods with
swallow eval.
[**6-22**]: repeat swallow study was performed demonstrating poor
interest in intake, no aspiration or mechanical issue with
deglutition.
[**6-23**]: last dose of Vancomycin was given in the AM. Blood
cultures were drawn x 2.
FROM TRANSFER TO MICU ON [**6-26**]:
# Respiratory failure: Pt was transferred to the MICU on [**6-26**]
for hypoxic respiratory failure and was intubated. Multiple
sputum cultures and a mini-BAL were negative except for
undifferentiated yeast. Her respiratory failure was
multifactorial, with contributions from her deconditioning after
a long hospital stay, increased intraabdominal pressure from
ileus and ascites, a component of ARDS during her immediate
post-op period, and significant fluid overload from aggressive
rehydration. She was initially >14L positive on arrival to the
MICU. With aggressive diuresis with lasix and metolazone her
respiratory status improved tremendously and she was extubated
to face mask on [**7-11**] and transferred to the floor on [**7-15**] on
nasal cannula.
# Fevers and persistent leukocytosis: Patient had multiple
infectious workups including repeat negative
blood/sputum/urine/catheter tip cultures, negative CT
chest/abdomen/pelvis, negative CT neck, cardiac echo negative
for vegetations. She did have one positive blood culture for
VRE early in her MICU stay. She received a long course of
multiple broad-spectrum antibiotics, including vancomycin,
meropenem, daptomycin, linezolid, flagyl and micafungin. It was
noted that her fevers appeared related temporally to tube feeds
and her fevers seemed to resolve when she was transitioned to
tpn.
# Renal failure: Patient's creatinine was 1.2 upon admission to
the MICU and improved without intervention.
# Constipation/ileus/abdominal distension: Patient had
difficulty with high residuals and persistent fevers seemingly
associated with tube feeds. She had intermittent increased
abdominal distension which was evaluated on multiple abdominal
KUBs, ultrasounds, CT scans which did not show acute abdominal
processes. Diagnostic paracenteses x2 did not demonstrate SBP
and ascites did not increase drastically during her MICU stay.
Thought likely due to ileus and the distension improved with tpn
(tube feeds held,) and erythromycin. Initially lactulose was
effective but this was also held as it was given per NGT and was
poorly absorbed.
# AMS: Presumably hepatic encephalopathy was the cause of
altered MS that led to pt's initial presentation to OSH in mid
[**Month (only) 116**], when pt was found to have elevated LFTs for the first time.
Apparently pt able to communicate with her sister at baseline,
but level/sophistication of this communication unclear. [**Name2 (NI) **]
had repeat negative head CTs and an MRI negative for acute
abnormalities. Her mental status improved only slightly after
extubation; however she never fully regained the ability to
communicate at her reported baseline.
# Anemia: First established at OSH, where EGD/[**Last Name (un) **] negative. Fe
studies consistent with anemia of chronic disease. Did decrease
once during her MICU stay requiring 1U PRBC but remained stable
throughout the rest of her stay in the low/mid 20s. Had one
episode of blood in ETT but no overt signs of significant
hemorrhage.
# Liver fibrosis/NASH: Transaminitis relatively stable during
MICU course, [**Name (NI) 3539**] actually improved while in the MICU.
Paracentesis on [**6-14**] and [**6-30**] negative for SBP. She was continued
on ursodiol and rifaximin for hepatic encephalopathy. She was
initially receiving lactulose, but this was discontinued due to
high residuals in her tube feeds and concern for worsening
abdominal distension.
# Coagulopathy: INR generally 1.5-1.8 with peak 2.1. Platelet
counts normal. Patient most likely had Vit K deficiency from
chronic antibiotics, NPO status, and malabsorption/ileus. There
was no need for reversal of anticoagulation during her MICU
stay.
Medications on Admission:
MEDICATIONS (pre-admission):
- propranolol 20mg qday
- atorvastatin 20mg qday
- fluoxetine 80 mg qday
- nortriptyline 75mg qday
- Ativan 1mg prn anxiety
.
MEDICATIONS (on transfer to MICU [**6-26**])
- Miconazole Powder 2% 1 Appl TP TID:PRN yeast
- Nortriptyline 75 mg PO/NG HS
- Acetaminophen 325-650 mg PO/NG Q6H:PRN pain or fever
- Olanzapine (Disintegrating Tablet) 5 mg PO TID:PRN anxiety
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
- Ondansetron 4 mg IV Q8H:PRN nausea Order
- Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing
- Potassium Chloride 40 mEq / 500 ml D5W IV
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
- Polyethylene Glycol 17 g NG [**Hospital1 **] constipation
- Bisacodyl 10 mg PR HS:PRN constipation
- Propranolol 20 mg PO/NG DAILY
- Docusate Sodium 100 mg PO BID
- Fluoxetine 80 mg PO/NG DAILY
- Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
- Heparin 5000 UNIT SC TID
- Ursodiol 300 mg PO BID
- traZODONE 50 mg PO/NG HS:PRN for sleep
- Lactulose 30 mL PO/NG TID
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72 hr Sig: Three (3) Patch 72
hr Transdermal ONCE (Once): to thin secretions.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: please place rectal suppository if constipated for
more than 3 days.
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H
(every 4 hours) as needed for pain/discomfort: Palliative Care.
Disp:*500 mg* Refills:*0*
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: place under tongue.
Disp:*30 Tablet(s)* Refills:*0*
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for fever.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] care and rehab
Discharge Diagnosis:
Hypoxemic Respiratory Failure
VRE Sepsis
Hiatal Hernia
Cirrhosis NASH
Mental Retardation
Hyperlipidemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic, intermittently arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were initially transferred to the hospital for management
for your hepatitis. After being transferred to the hospital we
noted that your hepatitis was actually end stage liver disease
called cirrhosis. You had a complicated hospitalization which
included several intubations after you developed a lung
infection after aspirating, you also had a severe infection
called sepsis and you were in the intensive care unit for a
prolonged time. After your breathing tube was removed you
unfortunately still remained very sick with difficulty
breathing. After talking with your family it was decided that
you should be comfortable and you transferred to comfort
measures only.
Followup Instructions:
Discharge to Hospice
|
8830,6824,E9687,30591,3004,3017 | 99,837 | 197,195 | Admission Date: [**2184-4-5**] Discharge Date: [**2184-4-9**]
Date of Birth: [**2158-11-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Intubation at outside hospital
Mechanical ventilation
Extubation
History of Present Illness:
25 year old male without any known medical problems but with
possible depression/anxiety/bipolar disease who was called out
from the ICU today after an extubation for violent and agitated
behavior. He was involved in a violent altercation with his
father two evenings ago, fueled a likely overdose of
dextrmethorphan combined with alcohol. Per report, he had nearly
strangled his father to unconsciousness, who required 30
stitches and now filed a restraining order. The [**Location (un) 7658**] police
arrived at the scene, and were unable to subdue the patient with
multiple taser shocks (3-5 times). He remained uncooperative. He
was eventually brought to LGH, though had apparently some
respiratory distress en route. Alcohol and marijuana were
detected in the [**Location (un) **]. He was so agitated that he apparently
required propofol/vecuronium sedation and was intubated. He was
transferred to [**Hospital1 18**] thereafter.
In the [**Hospital1 18**] ED, initial VS 97.3 100 140/80 18 100% unknown vent
settings. He was found to have an abrasion over his left hand
which was irrigated, and received amp/sulbactam. He was then
admitted to the MICU for further management.
In the MICU, he continued unasyn overnight and was extubated the
following day. He was continued on CIWA due to an elevated ETOH
level but he did not require additional benzos. A transition to
PO augmentin yesterday was short-lived, as he spiked fevers to
101 last evening, 100.4 this morning. He was seen by hand
surgery, who splinted the hand and recommended continued IV
unasyn.
Psychiatry and social work are both following. A warrant exists
in [**Location (un) 7658**] for his arrest, and [**Location (un) 7658**] police will be providing
a 1:1 sitter shortly. He has a long history of violent behavior,
which prompted his "other than honorable discharge" from the
marines several years ago. Per his mother, he tends to get
violent when under the influence of drugs.
Currently, he has a dry cough which has been present for about
24 hours. He denies shortness of breath. He denies malaise,
fatigue, weakness, nausea, vomiting, dysuria, hematuria, loose
stools.
Past Medical History:
- ADHD, not on meds
- possible depression/anxiety
- two psychiatric hospitalizations at [**Hospital3 **] in [**2183-5-17**]
from [**2183-5-29**] to [**2183-6-2**] and in [**2183-6-17**] from [**2183-6-24**] to6/11/10.
One hospitalization at least for suicide attempt.
- polysubstance abuse- ETOH, marijuana, dextromethorphan
- violent behavior
Social History:
Patient is unemployed since having a "other than honorable"
discharge from the marines. He had been living with his parents
recently. Smokes 1PPD cigarettes for 5 years. Denies alcohol or
illicit drug use, though per family members, he has been abusing
dextromethorphan and his admission tox screen positive for ETOH
and marijuana.
Family History:
NC
Physical Exam:
Admission Exam:
VS: 96.8 100 127/70 98% AC 550x20, 5, 0.4
Gen: Intubated, sedated
HEENT: Pupils 2->1mm
CV: Tachy S1+S2
Pulm: CTAB anteriorly
Abd: S/NT/ND +bs, -hsm
Ext: No c/c/e
Neuro: Sedated. Pupils as above.
Skin: 2 1 mm incision over left 4th finger consistent with tooth
marks.
Discharge Exam:
VS: T96.5 (tm 98.4) BP118/78 P76 RR18 Sat97RA
GENERAL: No acute distress
HEENT: MMM, OP clear
CARDS: tachy, normal S1 S2 no MRG
PULM: Clear to auscultation, no rhonchi or crackles appreciated
ABDOMEN: SNT ND +BS
EXT: Less edema of the left hand today. sensation intact,
suspended in stocking and splint.
Pertinent Results:
Admission Labs:
[**2184-4-5**] 06:10AM URINE HOURS-RANDOM CREAT-84 SODIUM-173
POTASSIUM-62 CHLORIDE-200
[**2184-4-5**] 06:10AM URINE OSMOLAL-738
[**2184-4-5**] 06:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2184-4-5**] 06:10AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2184-4-5**] 05:41AM GLUCOSE-63* UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-20* ANION GAP-12
[**2184-4-5**] 05:41AM ALT(SGPT)-32 AST(SGOT)-30 LD(LDH)-235
CK(CPK)-251 ALK PHOS-33* TOT BILI-0.3
[**2184-4-5**] 05:41AM ALBUMIN-3.5 CALCIUM-7.4* PHOSPHATE-2.7
MAGNESIUM-1.7
[**2184-4-5**] 05:41AM WBC-11.4* RBC-4.05* HGB-13.1* HCT-36.5*
MCV-90 MCH-32.4* MCHC-36.0* RDW-13.5
[**2184-4-5**] 05:41AM PLT COUNT-145*
[**2184-4-5**] 01:29AM TYPE-ART RATES-0/18 TIDAL VOL-550 O2-100
PO2-484* PCO2-43 PH-7.32* TOTAL CO2-23 BASE XS--3 AADO2-212 REQ
O2-42 -ASSIST/CON INTUBATED-INTUBATED
[**2184-4-5**] 01:29AM O2 SAT-99
[**2184-4-5**] 12:55AM GLUCOSE-85 UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13
[**2184-4-5**] 12:55AM CK(CPK)-256
[**2184-4-5**] 12:55AM ASA-NEG ETHANOL-111* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2184-4-5**] 12:55AM URINE HOURS-RANDOM
[**2184-4-5**] 12:55AM URINE HOURS-RANDOM
[**2184-4-5**] 12:55AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2184-4-5**] 12:55AM WBC-12.1* RBC-4.48* HGB-14.8 HCT-40.7 MCV-91
MCH-32.9* MCHC-36.2* RDW-13.1
[**2184-4-5**] 12:55AM NEUTS-71.0* LYMPHS-23.2 MONOS-4.7 EOS-0.4
BASOS-0.7
[**2184-4-5**] 12:55AM PLT COUNT-175
Discharge Labs:
[**2184-4-8**] 06:35AM [**Month/Day/Year 3143**] WBC-9.2 RBC-4.49* Hgb-14.4 Hct-41.0
MCV-91 MCH-32.0 MCHC-35.1* RDW-13.7 Plt Ct-182
[**2184-4-7**] 07:00AM [**Month/Day/Year 3143**] Glucose-95 UreaN-7 Creat-0.8 Na-141 K-4.4
Cl-105 HCO3-27 AnGap-13
[**2184-4-6**] 7:38 pm SWAB
Source: L hand ring finger fight bite wound.
GRAM STAIN (Final [**2184-4-6**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2184-4-8**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2184-4-5**] [**Month/Day/Year **] culture x 2: NTGD
[**2184-4-5**] Urine Culture Negative
EKG [**2184-4-5**]:
Sinus rhythm with borderline sinus tachycardia.
Prominent/modestly peaked T waves are non-specific and may be
within normal limits. Cannot exclude possible hyperkalemia.
Clinical correlation is suggested. No previous tracing available
for comparison.
CXR [**2184-4-5**]:
The lungs are well expanded and show bibasilar atelectasis. The
cardiac silhouette is top normal. The mediastinal silhouette,
hilar contours and pleural surfaces are normal. An ET tube
terminates 4.8 cm above the carina appropriately. An NG tube
terminates in the stomach.
IMPRESSION: Bibasilar atelectasis was much more pronounced on CT
torso two hours earlier.
LEFT HAND, 3 VIEWS [**2184-4-6**]: No specific localizing history is
available. Allowing for this, no fracture or dislocation is
detected about the left hand. No focal lytic or sclerotic lesion
is identified. There is soft tissue swelling along the dorsum of
the hand. No radiopaque foreign body or subcutaneous emphysema
is detected.
Brief Hospital Course:
Mr. [**Known lastname **] is a 25 year old male with a nonspecific history of
depression/anxiety/violence, polysubstance abuse, who was
involved in a violent altercation requiring significant sedation
and eventual intubation at an outside institution, who was
transferred to [**Hospital1 18**] for further management of mechanical
respiration and a left hand infected bite wound.
ACTIVE PROBLEMS:
1. MECHANICAL VENTILATION: He was intubated at an OSH for
agitation. CXR was clear without evidence of gas exchange
impairment. Patient extubated without difficulty. SW and Psych
evaluated the patient while in the ICU, with recommenadtion for
prn haldol, ativan, and benadryl for further agitation.
2. AGITATION/VIOLENCE: Social work and psychiatry teams were
immediately consulted for further management of his agitation.
His mother revealed a dextromethorphan overdose pattern which
causes euphoria and agitation, and the patient later confirmed
this fact. Psych initially recommended benadryl/haldol/ativan
for sedation, though was calm upon extubation and required no
further chemical sedation. He did not physically or verbally
abuse staff members. Psychiatry followed him throughout the
hospitalization. Per psych attending discharge recommendations:
Patient's history is suggestive of antisocial personality
disorder, although there are some inconsistencies in the
reported historical data (compare information from [**Hospital3 **] c
info patient later reported to Dr. [**Last Name (STitle) 3756**], so it is difficult
to say c certainy how accurate this diagnosis is. I don't
appreciate persuasive evidence for a major mood or anxiety
disorder, although patient does have some situational anxiety.
At present, there is no psychiatric contraindication to
patient's return to the legal system. Based on current data, I
do not see
an indication for a placement in a forensic psychiatric setting
for acute risk; however, appreciating that risk assessment is
dynamic, depending on the specific charges that patient is
facing (e.g., level of severity, which we do not know at this
time), his risk for impulsive self-harm might escalate in
proportion to
subjective sense of desperation & anxiety that is independent of
a major mental illness. Patient is able to voice a clear
understanding regarding his immediate future plans and an
apparent acceptance of the situation. We rev'd how to access
care
within the justice system.
3. LEFT HAND BITE WOUND: He sustained a left 4th MCP fight bite
which subsequently became infected. He developed fevers to 102
in the ICU with tachycardia. Received fluids and intravenous
unasyn. The hand surgery team was consulted and cleaned the
wound and splinted it. Swelling was intitially substantial, but
improved with elevation in stockignette. He required no
operative debridement. He continued 72 hours of intravenous
unasyn and was discharged to complete 10 additional days of PO
augmentin. He will follow up with the hand team in one week, at
which point he will likely have an extensor tendon repair, which
was partially torn in the fight. Will need daily dressing
changes. Elevation no longer necessary. Tylenol and ibuprofen
for pain.
4. ELECTRICAL INJURY: Patient received multiple electrical
shocks from Taser, putting him at risk for arrythmia,
rhabdomyolysis, and burns. CK stable without evidence of
rhabdomylolysis.
5. POLYSUBSTANCE ABUSE: Patient with EtOH level of 200 at OSH
with report of history of polysubstance abuse, particularly the
dextromethorphan that triggered his acute agitation.
Hyperstimulation and disassociation likely in setting of
dextromethorphan. PCP and ketamine labs were pending at the time
of discharge.
6. LEGAL: A warrant was issued for his arrest. Discharged into
[**Location (un) 7658**] police custody.
LABS PENDING AT DISCHARGE:
- ketamine and PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] cultures x2
TRANSITIONAL CARE ISSUES:
-follow up with hand surgery team in one week
-outpatient psychiatric care
Medications on Admission:
none
Discharge Medications:
1. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Cellulitis
Left hand laceration
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 after being intubated. You
were monitored in the intensive care unit, where you had your
breathing tube removed. You were noted to have an injury to your
hand, so you were seen by the hand surgeons. You were started on
antibiotics to treat an infection of your hand. You did not need
any surgery during this hospitalization, but you will need to
follow up in hand clinic next week for an injury to one of your
tendons.
The following changes were made to your medications:
#. START Augmentin 875mg by mouth every 12 hours for 10 days
Followup Instructions:
You have been scheduled the following appointment with the Hand
doctors:
Department: ORTHOPEDICS
When: TUESDAY [**2184-4-13**] at 10:30 AM
With: HAND CLINIC [**Telephone/Fax (1) 3009**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
4829,51881,42821,34831,0312,5849,4160,4259,1120,V4282,4280,5859,79092,28749,E9331,28803,42731,4240,7245,33829,2449,5533 | 99,847 | 155,024 | Admission Date: [**2191-4-12**] Discharge Date: [**2191-4-30**]
Date of Birth: [**2115-8-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Epinephrine / Levofloxacin /
Penicillins / Benadryl
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
75 yo W with recurrent/refractory multiple myeloma presenting
with several days of increased shortness of breath and
cough/chest congestion, transferred to the [**Hospital Unit Name 153**] for management
of hypoxia.
.
She was recently admitted to the BMT service from [**Date range (1) 20565**]
where she received a number of antimicrobials to treat fever,
cough, and URI symptoms ultimately attributed to parainflenza
virus III. The patient initially tested positive for
parainfluenza on [**3-16**] and failed outpatient treatment with a
Z-pack. During this last admission she also received IVIG and a
video swallow study to evaluate chronic aspiration attributed to
hiatal hernia. On [**2191-4-4**] she started Cytoxan/Velcade/Decadron
with D8 of Velcade on [**2191-4-11**].
.
According to the patient, she has not experienced any fevers,
chills, or night sweats since discharge. She felt her symptoms
had improved dramatically, but not entirely resolved. After
receiving chemo her symptoms returned and are now worse than
before. She endorses worsening sputum production, now pink and
occasional episodes of frank blood. No sick contacts or
significant outdoor exposures. Her dyspnea worsens with laying
flat and is associated with L-sided pleuritic chest pain. She
denies PND or LE swelling, hx of blood clots, hematuria, or
rash.
.
She contact[**Name (NI) **] her Oncologist and was sent to the ED for
evaluation of potential post-viral PNA. Her initial VS on
presentation were: 98.8, 76, 136/86, 20, 88% on RA. She was
placed on a NRB and her O2 sats rose to 98%. CXR revealed b/l
pleural effusions and opacification of the bases. She received
Vancomycin and Cefepime. They attempted to wean her supplemental
O2 to 40% FiO2 on Venturi mask; however, her oxygen saturations
again dropped to the 80s. Vitals prior to transfer were 141/94,
20, 99% NRB.
.
On admission to the [**Hospital Unit Name 153**], she appeared uncomfortable and
tachypneic. She was tired, but willing to converse. She answered
appropriately and expressed a need for pain medication to
control her "rib pain."
.
.
Review of sytems:
(+) Per HPI, + N/V/D attributed to recent chemotherapy
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness. Denied chest pain or palpitations. Denied
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias or rash.
Past Medical History:
Past Medical History:
- Vitiligo starting in [**2186**]
- Diverticulosis- found in colonoscopy [**2186**]. Last had
colonoscopy 6 months ago in [**Location (un) 47**].
- Atrial fibrillation
- History of thyroidectomy - for benign cyst
- History of radiation to her tonsils
- History of radiation to a left clavicle plasmacytoma after a
pathological fracture.
- History of mitral valve prolapse
- Allergies - since stem cell transplant
- Chronic back pain - s/p 9 compression fractures related to
multiple myeloma
- Restless leg syndrome - 30 yrs
- Auto. stem cell bone marrow transplant
- Multiple myeloma diagnosed in [**2184**].
.
Past Oncologic History:
"She is most recently status post five cycles of bendamustine
with her fifth cycle on [**2191-1-28**]. She was noted for increasing
lower back and right hip pain and underwent an MRI of the
thoracic and lumbar spine on [**2191-1-29**], which showed unchanged
extensive myelomatous involvement of the thoracic vertebrae with
no evidence of an epidural soft tissue mass. There were chronic
deformities of T7 through T12 and myelomatous involvement of the
lumbar spine, particularly the left anterior aspect of L4. Ms.
[**Known lastname **] developed increasing numbness of her right lower leg from
the anterior ankle and up the shin with some disruption of her
balance and gait due to this numbness. She had no changes in
bowel or bladder functioning.
She was initiated on Decadron 4 mg four times per day on
[**2191-2-4**], and began radiation therapy on [**2191-2-23**] to the
lower back in hopes of improving her symptoms. Her Decadron has
been decreased to 4 mg three times per day on [**2191-2-8**], 4 mg
twice per day as of [**2191-2-16**], 4 mg once per day on [**2191-2-25**],
and 2 mg daily as of [**2191-3-25**]. Radiation therapy completed on
[**2191-3-19**]. She also received weekly Velcade while she was
undergoing radiation therapy in order to continue to give her
some systemic therapy during her treatment. She received a dose
on [**2191-2-16**], [**2191-3-2**] and [**2191-3-9**]. She required periodic
platelet transfusions during this time.
Social History:
Retired former administrator for GTE. Lives in [**Location 932**]. 4
children who live in the [**Location (un) 86**] area. She is a widow, now has
male partner [**Name (NI) **] [**Name (NI) **], with whom she does not live. No tobacco
history. Occasional social drinking.
Family History:
No known family history of myeloma or other blood disorders.
Grandmother: breast cancer. Father: MI.
Physical Exam:
Admission Physical Exam:
Vitals: 98.2, 114, 151/96, 16, 95% on 4L NC and high flow mask
General: Alert, oriented, tachypneic, in no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi bilaterally
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge physical exam:
AFVSS
Gen: Well appearing, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, plasmacytoma
noted on scalp
Lungs: CTAB except for decreased BS in LLLF
Heart: Regular, no m/r, +S3
Abd: soft, NT, ND, with BS, no HSM
Ext: no c/c/e, WWP
Pertinent Results:
ADMISSION LABS
[**2191-4-11**]
-WBC-4.2 RBC-2.84* Hgb-9.1* Hct-27.8* MCV-98 MCH-32.1* MCHC-32.9
RDW-16.3* Plt Ct-24*# Neuts-92.8* Lymphs-2.5* Monos-3.7 Eos-0.2
Baso-0.8
[**2191-4-12**]
-WBC-1.6*# RBC-2.50* Hgb-8.4* Hct-23.6* MCV-94 MCH-33.8*
MCHC-35.8* RDW-17.0* Plt Ct-39* Neuts-91.1* Lymphs-5.6*
Monos-2.9 Eos-0.3 Baso-0.1
[**2191-4-13**]
-WBC-0.8* RBC-2.71* Hgb-8.9* Hct-26.1* MCV-96 MCH-32.8*
MCHC-34.1 RDW-16.7* Plt Ct-36* Neuts-88* Bands-1 Lymphs-7*
Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
.
[**2191-4-12**]
-PT-13.5* PTT-24.8 INR(PT)-1.2*
-Glucose-146* UreaN-25* Creat-1.4* Na-141 K-3.7 Cl-105 HCO3-24
AnGap-16
-ALT-19 AST-33 LD(LDH)-357* CK(CPK)-31 AlkPhos-112* TotBili-0.3
.
[**2191-4-13**]
-Glucose-186* UreaN-27* Creat-1.5* Na-141 K-4.2 Cl-104 HCO3-24
AnGap-17
-Glucose-153* UreaN-29* Creat-1.6* Na-140 K-4.0 Cl-102 HCO3-28
AnGap-14
.
[**2191-4-12**] CK-MB-4 cTropnT-0.09*
[**2191-4-13**] CK-MB-5 cTropnT-0.27* proBNP-[**Numeric Identifier 20566**]*
[**2191-4-12**] IgG-632*
IMAGING
[**4-13**] Final CT Chest
1. Multifocal consolidations throughout all lung lobes. While
consolidations in the right and left lower lobes are more
consistent with bacterial pneumonia, the other consolidations
are concerning for fungal infection, specifically invasive
aspergillosis.
2. Small bilateral pleural effusions, increased since CT of
[**2191-3-21**].
3. Prominent main pulmonary artery which may be seen with
pulmonary
hypertension.
4. Large hiatal hernia.
CXR [**4-15**]
IMPRESSION: AP chest compared to [**3-24**] and [**2191-4-12**]:
Pulmonary vascular congestion and mild pulmonary edema have
improved since
[**4-12**]. Large area of consolidation at the right lung base and
a smaller
one at the left lateral to the large hiatus hernia have
worsened, consistent with progressive pneumonia.
Moderate-to-severe cardiomegaly is longstanding. Small bilateral
pleural effusions are presumed. No pneumothorax. Right
subclavian infusion port ends in the SVC.
[**2191-4-16**]
MR head
IMPRESSION:
No acute infarcts. Small vessel disease. Bony abnormalities in
the skull and cervical vertebrae as well as the clivus
indicative of multiple myeloma. No significant epidural disease
is seen, although evaluation is limited without gadolinium
administration.
[**2191-4-19**] CT chest
IMPRESSION: Improving bilateral bronchocentric ground-glass
opacities, right pulmonary consolidation and bilateral pleural
effusions, consistent with a responding multifocal
consolidation, angioinvasive aspergillosis is considered a
probable explanation for the appearance on the prior CT.
[**4-20**] Cardiac MR
Impression:
1. Moderately dilated left ventricle with global left
ventricular systolic
dysfunction. The LVEF was mildly depressed at 45%. The effective
forward LVEF was moderately depressed at 35%. No CMR evidence of
myocardial edema.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 57%.
3. Moderate mitral regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Mild right atrial enlargement.
6. A note is made of bilateral pleural effusions and a hiatal
hernia.
MICROBIOLOGY
RESPIRATORY VIRUS SCREEN [**4-28**]
[**2191-4-28**] 4:00 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Final [**2191-4-29**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
MYCOLYTIC BLOOD CX
[**2191-4-26**] 7:06 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-poc.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
BAL [**4-15**]
[**2191-4-15**] 10:15 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
VIC WILL ALSO R/O CMV.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20567**] [**2191-4-15**] AT
1320.
GRAM STAIN (Final [**2191-4-15**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2191-4-17**]):
~[**2180**]/ML Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2191-4-22**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2191-4-15**]):
NO FUNGAL ELEMENTS SEEN.
This is a low yield procedure based on our in-house
studies.
KOH PERFORMED PER [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6401**] [**2191-4-15**].
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2191-4-15**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2191-4-29**]):
YEAST.
ACID FAST SMEAR (Final [**2191-4-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2191-4-15**]):
TEST CANCELLED, PATIENT CREDITED.
PLEASE REFER TO VIRAL CULTURE FOR RESULT.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
SPUTUM CX [**4-13**]
[**2191-4-13**] 12:25 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2191-4-13**]):
[**10-25**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2191-4-15**]):
SPARSE GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2191-4-13**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2191-4-29**]):
YEAST.
ACID FAST SMEAR (Final [**2191-4-14**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Reported to and read back by DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] AND
[**Last Name (LF) 20568**],[**First Name3 (LF) 20569**] @
15:30, [**2191-4-22**].
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
SENT TO STATE LAB FOR FURTHER IDENTIFICATION
[**2191-4-24**].
- per verbal report from state lab, probe of plated organism
+[**Doctor First Name **]
[**4-13**] Legionella negative
[**4-13**]
**FINAL REPORT [**2191-4-15**]**
CMV IgG ANTIBODY (Final [**2191-4-15**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
35 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2191-4-15**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**2-3**]
weeks.
Greatly elevated serum protein with IgG levels >[**2180**] mg/dl
may cause
interference with CMV IgM results.
All Blood Cxs no growth/pending.
DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2191-4-30**] 05:26 5.0 2.84* 9.2* 27.3* 96 32.3* 33.6 17.9* 23*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2191-4-30**] 05:26 85* 0 4* 11 0 0 0 0 0
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2191-4-30**] 05:26 901 29* 1.7* 141 4.2 107 23 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2191-4-30**] 05:26 24 23 243 142* 0.5
Free kappa/lambda light chains pending
Brief Hospital Course:
75 yo W with recurrent/refractory multiple myeloma, recent
parainfluenza virus infection, presenting with increased
dyspnea, transferred to [**Hospital Unit Name 153**] for management of hypoxia
.
# Dyspnea/Hypoxia: Likely multifactorial in etiology. Patient
has an element of volume overload from acute congestive heart
failure, supported by BNP of 33k, bilateral pleural effusions,
and improvement with initial BiPAP and IV Lasix boluses. She
also demonstrated multifocal opacities on CT chest, concerning
for bacterial PNA (and potentially invasive Aspergillus). Given
her immunocompromised state she was immediately started on broad
antimicrobials (Vancomycin, Cefepime, and Azithromycin) and
extensive studies for bacterial, viral, and fungal pathogens
were sent. Respiratory culture was positive for Parainfluenza
III. Sputum grew gram positive cocci from one induced culture
that were further speciated to respiratory flora. A bronchoscopy
was performed and revealed alveolar hemorrhage. Per infection
control, pt needs to stay on droplet precautions until
parainfluenza negative.
.
After stabilization, she was called out to the BMT floor. she
received IVIG x1 for the paraflu, and we continued her abx for a
14 day course. She did well and her oxygenation improved to the
point that her ambulatory saturation did not dip below 91. The
patient then started to have AFB + cultures (x 3), and ID was
consulted. She was empirically started on a brief course of
linezolid, imipenem, and clarithromycin as she will likely
require chemotherapy soon for her myeloma. However, the state
lab probed her cx which was + for [**Doctor First Name **], and her regimen was
changed to rifabutin, ethambutol, and clarithromycin. She will
require a baseline eye exam as an outpatient, and she has close
f/u with oncology and infectious disease.
.
# Acute Congestive Heart Failure: Patient presented with dyspnea
and hypoxia (as above). CXR revealed b/l pleural effusions. BNP
was elevated at 33k. Echocardiogram revealed EF of 30% with
severe hypokinesis of the inferior wall and basal 2/3rds of the
septum and anterior wall, which was new from her prior echo in
[**6-10**]. Cardiac biomarkers did not support acute coronary
syndrome. Cardiology was consulted and recommended starting low
dose beta-blocker and uptitrating as needed to provide rate
control and augment cardiac output. Initiation of ace-inhibitor
was deferred until hemodynamic stability was assured. The
etiology of her cardiomyopathy is unclear. Amyloid was
considered (SPEP negative, UPEP was +), as well as [**2-2**]
Parainfluenza virus, Velcade (very rare), or a missed ischemic
cardiac event.
.
Out of concern that the echo showed coronary distribution
hypokinesis, a cardiac MR was done which was c/w chemo induced
cardiomyopathy, not a coronary issue. The repeat study showed
an EF of ~ 45%. The CMR also did not show any signs of amyloid
involvement. A cardiology c/s was recalled to assist with CM
management, and metop was uptitrated to 37.5 POTID, and
lisinopril was started and titrated to 5 mg PO daily, which she
tolerated well. On discharge, her Metop was changed to long
acting Toprol XL 100 mg PO daily.
.
# Multiple Myeloma: Diagnosed in [**2184**] and s/p Auto SCT in [**2184**].
Currently on C1D1 of Cytoxan/Velcade/Decadron on [**2191-4-4**]. Had
increase of lytic lesions while on prior Bendamustine. ANC on
admission was approaching neutropenia, so the patient was placed
on neutropenic precautions. Hematolog/Oncology followed closely
and provided daily recommendations. We transfused to maintain
platlets >20 and Hct >25. She was continued on her prophylactic
Acyclovir, inhaled Pentamidine (last dose 3/17), and current
Dexamethasone. Per onc recs, her pentamidine was held. Her pain
and other symptoms were controlled. Given the need for
chemotherapy soon, she was placed on tx for MAC (see above).
She has close f/u with oncology scheduled.
.
# Word finding difficulty: Pt endorsed word finding difficulty a
few hours after bronchoscopy. Given concern for possible
pulmonary/systemic fungal infection, aspergillosis or even
mucor, vs acute embolic event, she was sent for MRI wo contrast.
Neurological exam was negative for any focal findings.
Preliminary read on MRI was negative for acute infarct, notable
for chronic small vessel disease, mild atrophy, and skull
deformities in L frontal/parietal/clivus/cervical vertebrae c/w
known multiple myeloma. A neuro c/s was called, and as the
patient improved, the thought was that this was [**2-2**]
toxic/metabolic causes from acute infection. The word finding
difficulty resolved over time, and she was set up for outpatient
f/u appointment in Neurology.
.
# Chronic kidney injury: Related to multiple myeloma. Cr
currently uptrending in the setting of diuresis. Baseline
1.4-1.8. Trended and was stble throughout stay. All
medications were renally dosed.
.
# Prolonged PT: Likely secondary to nutritional deficiency
and/or recent antibiotic use. She was given 1 dose of PO vitamin
K 5 mg for repletion and INR improved.
.
# Paroxysmal Atrial Fibrillation: Held ASA 81 daily given low
plts and monitored on telemetry. Pt was tachycardic and not on
nodal blocking [**Doctor Last Name 360**] as outpatient. Last EKG shows ST with
frequent PACs. Troponins peaked (othwer biomarkers flat), likely
[**2-2**] heart failure/demand in setting of CKI. Per Cards, started
low dose BB.
Metoprolol 12.5 TID was started with subsequent improvement in
rate and uptitrated to 25mg TID per cards rec. They attribute
cardiomyopathy to chemotherapy and anticipate improvement w
time. As above, these medications were continued to be titrated
to metop succinate 100 po daily as well as lisinopril 5 mg for
afterload reduction
.
# Hypothyroidism: Continued outpatient Levothyroxine 112mcg
daily.
.
# Hiatal Hernia: Continued Ranitidine 150 mg daily (home dosage
unknown), to restart home dose at discharge (25 mg effervescent
tab).
Medications on Admission:
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-EMLA 2.5 %-2.5 % Topical Cream Apply to POC site prior to blood
draw
-Caltrate 600+D Plus Minerals 600 mg-400 unit Tab 1 Tablet(s) by
mouth once a day
-Nystatin 100,000 unit/mL Oral Susp 5 cc(s) by mouth four times
a day swish and spit as needed
-Vitamin C 500 mg Tab
1 Tablet(s) by mouth once a day will hold during radiation
treatment
-Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected
area twice per day Do not use on face.
-Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth once a day
-Acetaminophen 325 mg Tab 1 to 2 Tablet(s) by mouth every [**4-6**]
hours as needed
-Ativan 0.5 mg Tab [**1-2**] Tablet(s) by mouth q4-6 as needed for
nausea, insomnia
-Milk of Magnesia 400 mg/5 mL Oral Susp Suspension(s) by mouth
as needed for constipation
-Furosemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day in the morning. presently on hold per patient
-Alprazolam 0.5 mg Tab 2 Tablet(s) by mouth one hour before
procedure. [**Month (only) 116**] take additional 0.5 mg tablet if needed.
-Dexamethasone 4 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day ICD-9 code: 203.00
-Prochlorperazine Maleate 5 mg Tab [**1-2**] Tablet(s) by mouth every
eight (8) hours as needed for nausea
-Promethazine 12.5 mg Tab [**1-2**] Tablet(s) by mouth q 8 hours as
needed for nausuea
-Anti-Itch 0.5 %-0.5 % Lotion apply to affected areas three
times a day as needed for itching
-Colace 100 mg Cap 1 Capsule(s)(s) by mouth twice a day as
needed for constipation
Levothyroxine 112 mcg Tab 1 Tablet(s) by mouth once a day
-Nebupent 300 mg Solution for Inhalation 300 mg(s) inhaled every
month for 6 months Diluted in 6 ml sterile water administered
via aerosol. Please administer 2 puffs of albuterol prior to
treatment as needed.
-OxyContin 10 mg 12 hr Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours
-oxycodone 5 mg Cap 1 - 2 Capsule(s) by mouth every four (4)
hours as needed for breakthrough pain
-B Complex Cap one Capsule(s) by mouth daily
-Acyclovir 400 mg Tab 1 Tablet(s) by mouth two times a day
-Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day
-ranitidine 25 mg Effervescent Tab
-Ondansetron HCl 4 mg Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours as needed for nausea ICD-9 code: 203.00
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. rifabutin 150 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. ethambutol 400 mg Tablet Sig: Two (2) Tablet PO DAYS
(MO,WE,FR).
Disp:*24 Tablet(s)* Refills:*2*
3. clarithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. Caltrate 600 + D Oral
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four
times a day as needed for thrush.
8. Vitamin C Oral
9. triamcinolone acetonide 0.1 % Cream Sig: One (1) appl Topical
twice a day as needed for rash.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for nausea or anxiety.
12. Milk of Magnesia 400 mg/5 mL Suspension Oral
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. EMLA Topical
15. alprazolam 0.5 mg Tablet Sig: Two (2) Tablet PO asdir as
needed for before procedure: take 1 hr before procedure.
16. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for nausea.
17. promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea.
18. Sarna Anti-Itch Topical
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
20. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Nebupent 300 mg Recon Soln Inhalation
22. oxycodone 10 mg Tablet Extended Release 12 hr Sig: [**1-2**]
Tablet Extended Release 12 hrs PO every eight (8) hours.
23. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
24. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
25. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
27. ranitidine HCl 25 mg Tablet, Effervescent Sig: One (1)
Tablet, Effervescent PO once a day.
28. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
29. cetirizine 10 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Pneumonia
Secondary Diagnoses
Mycobacterium Avium Intracellulare
Multiple Myeloma
Parainfluenza
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You were admitted to [**Hospital1 18**] with shortness of
breath and were in the ICU because you needed to have assistance
with your breathing. You were treated with antibiotics for 14
days for a bacterial pneumonia, and you were given IVIG because
you were para-influenza positive. Finally, we found acid-fast
bacilli in your sputum multiple times which required you to stay
on precautions while here. Infectious Disease saw you while you
were here and they felt you could be discharged with three drugs
to treat MAC before your next round of chemo. We also had our
cardiologists see you who added on medicine to keep your heart
healthy. We also had our neurologists see you because of some
word-finding difficulty, and they would like to see you in
clinic.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP TAKING LASIX
- STOP taking ASPIRIN
- DECREASE your ACYCLOVIR to 400 mg by mouth daily
- START taking RIFABUTIN 150 mg by mouth daily
- START taking ETHAMBUTOL 800 mg by mouth every MON, WED, FRI
- START taking CLARITHROMYCIN 250 mg by mouth daily
- START taking METOPROLOL SUCCINATE (TOPROL XL) 100 mg by mouth
daily
- START taking LISINOPRIL 5 mg by mouth daily
Please follow up with you physicians as indicated below
Followup Instructions:
You will be contact[**Name (NI) **] by the [**Name (NI) **]/BMT department regarding
an appointment on Monday with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
**You should also schedule an eye exam in the next week since
you are on ETHAMBUTOL **
Otherwise, these are the appointments for your follow up:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2191-5-4**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20564**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2191-5-5**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2191-5-17**] at 1:30 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 20570**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2191-4-30**] |
29181,85220,30301,E8881,3569,78321,28529,9100,9160,4019,7850 | 99,849 | 197,873 | Admission Date: [**2189-2-14**] Discharge Date: [**2189-2-17**]
Date of Birth: [**2134-7-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
tremulous
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54M with chronic alcohol use presenting with symptoms of
withdrawal, his last drink was reported to be last night.
Patient drinks approximately 1.75L of EtOH per day. He reports
that he felt unable to walk today and had to sit down because
his "legs were going to give out". Had a fall 2 days ago w/
apparenty head trauma. Apparently he had a similar problem last
week and was admitted to [**Hospital1 2177**] for withdrawal. Patient states that
his withdrawal usually manifests as shakiness, no history of
withdrawal seizures. The patient has dried blood on face,
unclear when trauma, ct head demonstrates miniscule SDH.
.
Patient's last drink was [**2-13**] afternoon.
.
Patient was admitted to the ICU because the patient will need
frequent monitoring.
.
In the ED inital vitals were, 98.6 112 161/101 18 98% RA. Pt
received Head CT - negative on initial read (? small SDH on
attending read).
Pt received Ativan per CIWA scale, pt received 6mg PO ativan
(shaky). Pt received PO Thiamine, MVI, Folate.
.
On arrival to the ICU, afebrile, 110, 160/86, 96%RA. Patient
tremulous, able to provide a reliable history.
.
Review of systems:
(+) Per HPI: diarrhea, night sweats, 20lb weight loss in past 2
years, cough.
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-EtOH abuse
-neuropathy lower extremities (past month)
-Hit head on curb 1 year ago --> residual L leg pain
Social History:
Has had alcohol abuse for many years. Many rehabs, many
withdrawals.
Pt does not smoke.
Pt does not use illicit drugs currently -- had used IV drugs in
70s.
Pt unemployed currently, used to be a wholesale representative.
Lives near symphony, alone. Has a girlfriend. [**Name (NI) **] a son,
daughter and one grandchild. Divorced.
Family History:
Father alcoholic. Died of lymphoma.
Mother died of multiple myeloma.
Brother with MS
Brother w/ morbid obesity, alcohol abuse.
Physical Exam:
Admission Physical Exam:
afebrile, 110, 160/86, 96%RA
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PE - tremulous, dried blood on face under L eye, tachycardic
with small systolic ejection murmur, lungs CTA bilaterally, abd
SNTND, 5/5 strength x 4 extremities. mildly decreased sensation
to soft touch in lower extremities, b/l.
Pertinent Results:
Admission Labs:
[**2189-2-14**] 02:15PM BLOOD WBC-5.9 RBC-3.80* Hgb-13.8* Hct-39.1*
MCV-103* MCH-36.4* MCHC-35.3* RDW-13.3 Plt Ct-228
[**2189-2-14**] 02:15PM BLOOD Neuts-81.1* Lymphs-11.5* Monos-5.7
Eos-0.9 Baso-0.8
[**2189-2-14**] 06:30PM BLOOD PT-9.7 PTT-30.8 INR(PT)-0.9
[**2189-2-14**] 02:15PM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-141
K-4.7 Cl-96 HCO3-24 AnGap-26*
[**2189-2-14**] 02:15PM BLOOD ALT-39 AST-61* AlkPhos-78 TotBili-0.5
[**2189-2-14**] 02:15PM BLOOD Lipase-67*
[**2189-2-14**] 02:15PM BLOOD Albumin-4.6 Calcium-9.6 Phos-3.9 Mg-1.5*
[**2189-2-14**] 02:15PM BLOOD ASA-NEG Ethanol-30* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
IMPRESSION: No acute intracranial process; mild left maxillary
sinus disease.
NOTE ON ATTENDING REVIEW:
There is a small dense focus along the convexity in the right
frontal/parietal regions likely representing a small acute
subdural hemorrhage. A small venous
tribuatry is noted adjacent and underneath. Small amount of
scalp soft tissue swelling is noted overlying. ( se 601b, im43;
se 2, im 15) No obvious fracture noted. Consider followup as
clinically indicated.
Prominent ventricles, sulci and extra-axial CSF spaces related
to volume loss-correlate for risk factors.
Brief Hospital Course:
54 yo M with chronic alcohol use presenting with EtOH
withdrawal.
.
# Alcohol Withdrawal: Last drink was less than 24 hours prior to
arrival. Very tremulous, requiring diazepam 10mg about every 2
hours for CIWA >10, fo total of 50mg in ICU. Received last 10mg
dose Valium [**2189-2-16**] on medical [**Hospital1 **], and was started on 2 days
of q6hr Librium to complete as outpatient as a natural benzo
taper for anxiety and mild tremors despite CIWA < 10. Also
received some ativan in the ED. Received multivitamin, thiamine
and folate. He met with social work who gave him list of day
programs. He plans on attending [**Hospital **] program because
of convenient location to his home, and his son's family.
.
# SDH: Per radiology, very small frontal R SDH, likely from most
recent fall. No symptoms and non-focal neurological exam.
Neurosurgery recommended repeat head CT. Repeat was unchanged.
.
# Amemia: macrocytosis (103), Hct 39.1. Likely [**1-29**] chronic
alcohol, marrow suppression, or B12. B12 level is normal,
patient was given folic acid.
.
# Neuropathy: pt w/ peripheral neuropathy, complaining of it for
a few months. Has worsened recently. Pt w/ full strength in
extremities, mildly decreased sensation. Etiologies include
EtOH neuropathy, B12 deficiency, DMII. A1C = 5.0%, B12 level
is pending. He was empirically started on 100mcg B12 for 1
month.
.
# Weight Loss: 10-20lb over last 6 months, coincides with heavy
drinking. He will seek support for abstinence, and was referred
to primary care for further evaluation and health maintenance
issues. CXR was normal.
.
# He was set up with PCP f/u apptmt at [**Company 191**] for [**2189-2-24**], and
indicated he will keep appoitment.
Medications on Admission:
none
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
5. chlordiazepoxide HCl 25 mg Capsule Sig: One (1) Capsule PO
four times a day for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Alcohol dependency
Mild anemia - likely alcohol related
Peripheral Neurophathy - likely alcohol related
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for alcohol withdrawal. You had a recent fall
with abrasions to the face and knee. You indicated you have
been driking 1-2liters vodka daily for past 6 months. You were
admitted to ICU for monitoring, and then to the medical [**Hospital1 **].
You had 2 Head CTs which showed a stable, small subdural
hematoma which does not need follow-up (per neurosurgical
evaluation). You are tolerating a full diet. You were seen by
physical therapy and deemed safe for home, to continue using
your cane. B12, TSH, and HgbA1C were all normal.
.
You were started on Metoprolol for high heart rate and high
blood pressure. You tolerated this well.
.
You indicated you have not been eating well because of the heavy
drinking, and that you have lost weight. A Chest xray was
normal. You indicated you did not wast to follow-up with your
current [**Hospital1 2177**] primary care physician and have requested a referral
to [**Hospital1 18**]. I recommend you see your PCP [**Last Name (NamePattern4) **] [**1-31**] weeks (new or
old) for further evaluation of your overall health, including
weight loss, age appropriate cancer screening and other
preventive health measures.
Please take the medications as prescribed. Vitamin B12 levels
and evaluation for diabetes was normal. The neuropathy is likely
from chronic alcohol use. Please follow up with your primary
care physician for further evaluation.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2189-2-24**] at 1:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Dr [**First Name (STitle) **] [**Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely
with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care.**
|
6826,34982,2384,4011,V4987,7226,5718,33829,7892,78901,30000,42789,45829,E9426,E8497 | 99,862 | 178,839 | Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-6**]
Date of Birth: [**2112-2-27**] Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Ceclor / clindamycin / ibuprofen /
Erythromycin Base / naproxen
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 82967**] is a 59-year-old female with a history of
polycythemia [**Doctor First Name **], hypertension and chronic pain who is
presenting with altered mental status. She was in her usual
state of health the morning of admission when her wife left her
at home. In the afternoon, the patient's wife found her
confused, lethargic, and having vomited. Otherwise, the patient
is unable to provide much history; however, she did have some
pain with palpation of her right upper quadrant. Neither the
patient nor her wife can remember any trauma to her left leg
(though she had a recent fall with a fracture of her left
humerus).
In the ED, initial VS were: 102.9 108 189/81 16 98%. She was
noted to have a large area of erythema and tenderness to
palpation of the left lower extremity that was marked which
involved a large portions of her calf as well as her distal
thigh. She was given Tylenol 1g, Vancomycin 1g IV, levofloxacin,
and Zofran. CT scan of her abdomen showed a small gallbladder,
making cholecystitis unlikely although not completely excluded;
with hyperdense contents which suggest stones or sludge. Fatty
liver and splenomegaly: although splenomegaly is not specific,
concern is raised for steatohepatitis or cirrhosis. Marked fatty
replacement of pancreas. Large right adnexal cyst; ultrasound
assessment recommended when appropriate. RUQ ultrasound was
unable to be completed due to significant patient discomfort.
.
On arrival to the MICU, the patient was somewhat agitated. She
became more calm in the presence of her wife, but still removed
an IV and needed to be restrained. Vitals T 97.9 HR 109 BP
124/51 RR 16 97% on room air.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Hypertension
2. Degenerative disc disease
3. chronic pain
4. Polycythemia [**Doctor First Name **] followed by [**Last Name (LF) 1852**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Social History:
Ms. [**Known lastname 82967**] lives with her wife in [**Location (un) 83264**], [**State 350**]. She is on disability. She has a cat,
dog, and birds at home. Tobacco: Remote history of smoking for
about five years at age 15. Alcohol: None. Illicits: None.
Also no chemical or secondhand smoking exposure.
Family History:
Not known. The patient's mother and father are
deceased. She has three brothers, six sisters and two
daughters.
She is estranged from all family members and does not know their
medical history.
Physical Exam:
Admission to MICU exam:
General: Oriented x 2 (person, place), agitated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not appreciated due to habitus, no LAD
CV: S1, S2, 3/6 SEM heard best at upper sternal border
Lungs: Clear to anterior auscultation bilaterally
Abdomen: Soft, non-tender, obese, bowel sounds present, striae
Ext: Warm, well perfused
Skin: Left lower leg with significant erythem from just below
the knee to foot, especially on medial side.
Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities,
sppech incoherent but intelligible
Call out to Medicine Exam:
GENERAL - Chronically ill appearing 59yo F who appears older
than her stated age. She has an odd affect with tangential
thinking. She is lethargic but arousable, oriented to person,
place and time. Inattentive and unable to do months of the year
in reverse
HEENT - NC/AT, EOMI, sclerae anicteric, Adentulous, MMM, OP
clear
NECK - supple, no [**Doctor First Name **], no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilaterally, moving air well and symmetrically
HEART - S1 S2 clear and of good quality, tachycardic, 3/6 SEM
RUSB
ABDOMEN - NABS, Obese, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs). Chronic
venous stasis skin changed on bilateral LE. Left lower leg with
significant erythema from knee to groing along medial aspect
tracking in a linear pattern along medial aspect of thigh. Warm
to touch.
NEURO - Awake but lethargic, A&Ox3, Facial asymmetric but CNs
II-XII grossly intact, muscle strength 5/5 throughout, sensation
grossly intact throughout. Speech slurred at times though
adentulous may be contributing. Tangential thought processes
Pertinent Results:
Trends:
[**2171-4-2**] 06:38PM BLOOD WBC-29.7* RBC-7.68*# Hgb-17.3* Hct-57.0*
MCV-76* MCH-22.2* MCHC-29.3* RDW-18.7* Plt Ct-490*
[**2171-4-4**] 05:18AM BLOOD WBC-21.5* RBC-7.26* Hgb-16.0 Hct-54.8*
MCV-76* MCH-22.1* MCHC-29.2* RDW-19.0* Plt Ct-366
[**2171-4-2**] 06:38PM BLOOD Neuts-89.7* Lymphs-6.6* Monos-2.6 Eos-0.4
Baso-0.7
[**2171-4-4**] 05:18AM BLOOD PT-13.5* INR(PT)-1.3*
[**2171-4-2**] 06:38PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-135
K-3.9 Cl-94* HCO3-27 AnGap-18
[**2171-4-4**] 05:18AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-137
K-3.8 Cl-97 HCO3-27 AnGap-17
[**2171-4-2**] 06:38PM BLOOD ALT-23 AST-43* AlkPhos-205* TotBili-1.2
[**2171-4-4**] 05:18AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
[**2171-4-3**] 04:12PM BLOOD Lactate-2.8*
[**2171-4-4**] 05:47AM BLOOD Lactate-1.8
[**2171-4-2**] 10:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2171-4-2**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Discharge Labs:
[**2171-4-5**] 08:20AM BLOOD WBC-17.3* RBC-7.24* Hgb-15.7 Hct-55.3*
MCV-77* MCH-21.6* MCHC-28.3* RDW-19.1* Plt Ct-416
[**2171-4-5**] 08:20AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-4 Eos-3
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2171-4-5**] 08:20AM BLOOD Glucose-152* UreaN-10 Creat-0.8 Na-139
K-4.1 Cl-99 HCO3-30 AnGap-14
[**2171-4-5**] 08:20AM BLOOD TSH-0.24*
BCx pending:
Imaging:
CT abd/pelvis w/:
IMPRESSION:
1. Mostly decompressed gallbladder which makes cholecystitis
unlikely,
although hyperdense contents could be seen with stones or
sludge.
2. Fatty infiltration of the liver.
3. Marked fatty infiltration of the pancreas, which can be seen
as a
manifestation of chronic pancreatic inflammation, although other
etiologies
such as cystic fibrosis could generate such an appearance.
4. Mild-to-moderate splenomegaly including small infarcts.
Splenomegaly in
association with fatty liver may raise concern for
steatohepatitis or
cirrhosis with portal hypertension as the etiology for
splenomegaly, although the appearance is not entirely specific.
5. Large right adnexal cyst. Although no complex features are
apparent based on CT imaging, particularly based on size and the
limitations of CT
assessment, when clinically appropriate, evaluation with
ultrasound is
recommended. If the lesion is not accessible to visualization
with
ultrasound, then MR is recommended.
6. Mild left inguinal lymphadenopathy, likely reactive;
correlation with
physical findings involving the left lower extremity is
recommended.
LENI [**4-3**]
IMPRESSION: No evidence of deep vein thrombosis either right or
left lower
extremity.
CT LE [**4-2**]:
IMPRESSION:
1. Findings above of subcutaneous edema and circumferential skin
thickening,
which in the right clinical setting may represent [**Month/Year (2) **].
2. No focal fluid collections to suggest abscess. No
subcutaneous emphysema.
3. Scattered degenerative changes of the left lower extremity.
CXR [**4-3**]:
FINDINGS: In comparison with the study of [**2168-8-25**], there is
little change.
Continued low lung volumes most likely account for the
prominence of the
cardiac silhouette. No pneumonia, vascular congestion, or
pleural effusion.
Brief Hospital Course:
Ms. [**Known lastname 82967**] is a 59 y/o female with a history of polycythemia
[**Doctor First Name **], hypertension and chronic pain who presented with altered
mental status and [**Doctor First Name **]. Treated with IV antibiotics in
the MICU with improvement in MS [**First Name (Titles) **] [**Last Name (Titles) **] and transferred
to [**Hospital1 **] on HD2.
# [**Hospital1 **]. Non-purulent, no necrosis on CT. Tx initially
with Vancomycin/Levofloxacin given allergy profile (anaphylaxis
to PCNs and Clindamycin). Levofloxacin d/ced on HD2 as pt.
improved. LENI was negative for DVT. Although cephalosporin
regimen would be most optimal, due to severe reaction type and
potential crossreactivity, vancomycin was selected for
treatment. In preparation for discharge antibiotics changed to
Bactrim 2DS tabs PO BID to complete 5 more days for total 10 day
course.
# Altered mental status. Toxic-metabolic encephalopathy
secondary to the patient's left leg [**Hospital1 **]. Head CT not
suggestive of hemorrhage. UA negative. CT abdomen demonstrated
no site of infection. Utox/Stox negative. Improved with
treatment of [**Hospital1 **]. Initially held sedating medications but
restarted prior to discharge with improvement in mental status.
# LFTs: Isolated ALP elevation associated with slightly elevated
T.Bili to 1.2 from 0.5. AST also elevated but ALT flat would
suspect mitochondrial dysfunction. Tox screen only positive for
Methadone so ingestion less likely especially while rising in
MICU. In ED patient complained of RUQ pain and nausea consitent
with cholecystitis. RUQ ultrasound incomplete/limited given
patient agitation. CT scan could not definitely rule out
cholecystitis. Patient has habitus and epidemiology for
cholelithiasis but with improved mental status she has no RUQ
pain or [**Doctor Last Name **] sign on exam with improvement in mental status so
did not pursue a second RUQ US. Fever curve also improved on
only Vancomycin without GNR or anaerobic coverage.
# Tachycardia: Sinus tachycardia to 120s consistently in the
MICU. Initially thought related to sepsis but did not improve
with downtrend of fever curve or improvement in [**Doctor Last Name **].
Volume status euvolumic and patient with good urine output.
Tachycardia did dip to 90s when wife is around and so there may
be a psychologic component. Patient with chronic pain on
Methadone so pain may be contributing as well. Outpatient HRs in
90s per record. Low likelihood for PE without hypoxia,
tachypnea, chest pain and LENIs negative for DVT. Tachycardia
resolved prior to discharge.
# Hypertension: Chronic, Lisinopril recently restarted with
resolution of sepsis but she remained hypertensive. Amlodipine
started prior to discharge. Asymptomatic on floor. TSH checked
and was low. Continued Lisinopril 40mg PO BID and added
Amlodipine 5 mg PO/NG DAILY to augment BP control. Day of
discharge she became hypotensive and orthostatic which, per
patient's wife, usually happens when increasing BP meds.
Amlodipine was discontinued, and lisinopril to 40mg po daily and
patient discharged after BPs stabilized.
# Anxiety: Continued home regimen of Ativan.
# DJD/chronic pain: Continue methadone but tizanidine and
gabapentin were initially held in setting of delirium but
restarted prior to discharge
# [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Stable. Plavix was continued.
# Incidentalomas: Splenic infarcts likely PCV related in
addition to splenomegaly. Large right adenexal cyst can be
worked up as outpatient
TRANSITIONAL ISSUES:
- Follow up incidentalomas, patient should have adenexal cyst
monitored as an outpatient
- Better control of hypertension is essential in this patient
- Careful with BP meds given profound orthostasis when starting
CCB
- CODE STATUS: Presumed Full
- CONTACT: Wife and HCP [**Name (NI) 636**] [**Name (NI) 82967**] [**0-0-**]
Medications on Admission:
- lisinopril 40 mg PO BID
- methadone 20 mg PO QID
- methadone 10 mg PO Daily
- tizanidine 4 mg PO TID
- tizanidine 2 mg PO BID
- gabapentin 600 mg PO Q4H
- lorazepam 0.5 mgPO Q4H as needed for anxiety
- Plavix 75 mg Tablet PO once a day
- Colace 100 mg PO twice a day as needed for constipation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2
times a day).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
5. methadone 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
7. gabapentin 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. tizanidine 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check chemistry panel including sodium, potassium,
creatinine on Mon [**4-8**] and fax results to Dr. [**Last Name (STitle) 70557**]
[**Telephone/Fax (1) 83265**].
Discharge Disposition:
Home
Discharge Diagnosis:
[**Telephone/Fax (1) **]
Encephalopathy
Polycythemia [**Doctor First Name **]
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 82967**],
It was a pleasure treating you during this hospitalization. You
were admitted to [**Hospital1 69**] because of
confusion and an infection in the skin of your thigh. You were
initially admitted to the ICU because of concern for sepsis and
you were treated with IV antibiotics with improvement in mental
status and skin infection. You were switched to by mouth
medications with continued improvement in skin infection
clearing. Your mental status also improved back to baseline. You
should have a blood lab checked on Monday, which will be faxed
to your doctor and discuss the results when you see Dr. [**Last Name (STitle) **]
on Friday. Some of your medications may need to be adjusted
further.
The following changes to your medications were made:
- START Bactrim 2 DS tablets twice daily until [**2171-4-11**]
- DECREASE your lisinopril to 40mg tabs, 1 tab daily
- No other changes were made, please continue taking your home
medications as previously prescribed
Followup Instructions:
Name: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 83266**], MD
Specialty: Primary Care
When: Friday [**4-12**] at 11:30am
Location: [**Hospital3 **] HEALTH CENTER
Address: [**Street Address(2) 83267**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**0-0-**]
|
43331,3484,431,5070,5849,3314,25012,514,99731,51881,34200,43301,4019,2724,27669,37230,04119,E8798,78720 | 99,863 | 100,749 | Admission Date: [**2142-4-2**] Discharge Date: [**2142-5-8**]
Date of Birth: [**2099-7-23**] Sex: M
Service: NEUROLOGY
Allergies:
Nifedipine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
[**2142-4-4**] intubation
suboccipital craniectomy and R venticulostomy - [**2142-4-6**]
ventriculostomy - VP shunt- [**2142-4-16**]
trach and PEG
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 2 minutes
Time (and date) the patient was last known well: 12:30 on [**4-2**]
NIH Stroke Scale Score: 10
t-[**MD Number(3) 6360**]: --- Yes Time t-PA was given ------:------ (24h
clock)
-X- No Reason t-PA was not given or considered: out of window
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 2
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 0
10. Dysarthria: 2
11. Extinction and Neglect: 0
HPI:
Mr. [**Known lastname 110219**] is a 42 yo Portuguese-speaking man with h/o DM2,
HTN,
HL who presents with L facial droop, R sided numbness, and
slurred speech. History is somewhat limited due to language
barrier and acute code stroke setting.
The patient developed nausea/vomiting at 12:30 am today. Over
the
next several hours, he worsened, developing difficulty with
balance and right sided numbness and weakness. At 4:00pm, wife
noticed L facial droop. Patient was brought to [**Hospital 4199**] Hospital.
NCHCT was interpreted as normal. [**Hospital1 2025**] neurology was consulted
over
the phone. NIHSS 8. Received IV labetalol 20 mg total, Zofran
and
ASA 325 mg. He was transferred to [**Hospital1 18**] without any thrombolysis
(unclear if [**Name (NI) 2025**] on-call stroke line thought he was out of
window).
In [**Hospital1 18**], patient had NIHSS 9. BP was elevated at 254/125.
He was started on nicardipine drip for BP control.
According to patient's wife, he has been stable to slightly
improving over past few hours. He was quite restless because he
is bothered by the absence of sensation on his right side. He
has
no pain or headache. No nausea. No diplopia in primary gaze, and
no vertigo.
On limited ROS, no fever, cough, SOB, chest pain.
Past Medical History:
DM2
HTN
HL
Social History:
married, no tobacco. Speaks Portuguese. Understands very limited
English
Family History:
h/o CAD
Physical Exam:
ADMISSION EXAM
Physical Exam:
Vitals: T: afeb P:100 R: 16 BP:215/135 SaO2:96/ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive and cooperative.
Language is fluent with intact naming and comprehension. Speech
was moderately dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil 6mm, L pupil 4mm, both briskly reactive both direct
and consensual responses. VFF to confrontation with blink to
threat.
III, IV, VI: In primary gaze, L eye deviated inward. Complete L
gaze palsy b/l. On R gaze there is horizontal nystagmus.
Vertical
gaze and convergence intact.
V: Facial sensation intact to light touch.
VII: Upper and lower facial musculature weakness.
VIII: Hearing intact to voice grossly.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. Decreased tone in right side. R pronator
drift present.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 3 4- 4- 4 4-
-Sensory: Decreased light touch and pinch on right upper and
lower extremities (now intact on face though previously right
face numb). No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on left, extensor on right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred
[**2142-5-1**] On transfer out of ICU:
Spontaneously awake, follows commands, shows thumbs-up for yes
and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L
gaze palsy, R eye abducens weakness (R beating nystagmus when
looking R). No blink to threat. No corneals. L upper/lower face
weakness. +gag. +cough. LUE/LLE 4+ to 5/5 strength. RUE/RLE
hemiplegia but R fingers/wrist/elbow extending/flexing now and R
quad contracts (almost antigravity). Inconsistent with R side
depending on exhaustion level. R toe up.
DISCHARGE EXAM:
Spontaneously awake, follows commands, shows thumbs-up for yes
and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L
gaze palsy, R eye abducens weakness (R beating nystagmus when
looking R). L upper/lower face weakness. LUE/LLE 5/5 strength.
RUE/RLE hemiplegia but R fingers/wrist/elbow extending/flexing
now, can move R quad anti-gravity and dorsi/plantar flex foot
with good strength. R toe upgoing.
Pertinent Results:
[**2142-4-2**] 07:15PM WBC-11.6* RBC-5.87 HGB-17.8 HCT-52.3* MCV-89
MCH-30.3 MCHC-34.1 RDW-13.0
[**2142-4-2**] 07:15PM PLT COUNT-278
[**2142-4-2**] 07:15PM PT-9.8 PTT-26.9 INR(PT)-0.9
[**2142-4-2**] 07:15PM UREA N-16
[**2142-4-2**] 07:26PM GLUCOSE-353* NA+-141 K+-4.1 CL--100 TCO2-23
[**2142-4-2**] 08:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2142-4-2**] 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2142-4-2**] 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2142-4-2**] 10:58PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2142-4-2**] 10:58PM CK-MB-3
[**2142-4-2**] 10:58PM CK(CPK)-171
[**2142-4-2**] 10:58PM GLUCOSE-313* UREA N-14 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2142-4-4**] 3:41 pm BRONCHOALVEOLAR LAVAGE LEFT LUNG.
**FINAL REPORT [**2142-4-20**]**
GRAM STAIN (Final [**2142-4-4**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2142-4-8**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110220**] FROM
[**2142-4-4**].
FUNGAL CULTURE (Final [**2142-4-20**]): NO FUNGUS ISOLATED.
[**2142-4-24**] 7:48 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2142-4-29**]**
GRAM STAIN (Final [**2142-4-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2142-4-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
GARDNERELLA VAGINALIS. MODERATE GROWTH.
[**2142-4-24**] 10:01 pm Mini-BAL BRONCHIAL LAVAGE.
**FINAL REPORT [**2142-4-27**]**
GRAM STAIN (Final [**2142-4-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2142-4-27**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2142-4-25**] 2:16 pm Blood (Toxo) Source: Venipuncture.
**FINAL REPORT [**2142-4-27**]**
TOXOPLASMA IgG ANTIBODY (Final [**2142-4-27**]):
POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
53 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2142-4-27**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with Toxoplasma once contracted remains latent
and may
reactivate when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**2-16**]
weeks.
ECG [**4-2**]
Normal sinus rhythm. Q waves in leads III and aVF consistent
with prior
inferior myocardial infarction. No previous tracing available
for comparison.
CTA Head/Neck [**4-2**]
IMPRESSION:
1. Unremarkable head CT without evidence of infarct or
hemorrhage. MRI is
suggested if clinically warranted.
2. Hypoplastic right vertebral and small left vertebral
arteries, likely
developmental. Both vertebral arteries end as PICA with
reconstitution of the right vertebral artery from the right
superior cerebellar.
[**4-3**] CXR
IMPRESSION:
1. Unremarkable head CT without evidence of infarct or
hemorrhage. MRI is
suggested if clinically warranted.
2. Hypoplastic right vertebral and small left vertebral
arteries, likely
developmental. Both vertebral arteries end as PICA with
reconstitution of the right vertebral artery from the right
superior cerebellar.
[**4-4**] CXR
As compared to the previous radiograph, there is no relevant
change. Minimal atelectasis at the right lung base. Borderline
size of the
cardiac silhouette. No pneumonia, no pulmonary edema. The
nasogastric tube
is in constant position.
[**4-6**] MRI/A Brain
FINDINGS: There is an acute infarct with hemorrhagic conversion
identified in the left cerebellum in the region of posterior
inferior and anterior inferior cerebellar arteries extending to
the left side of the pons. There is mass effect on the fourth
ventricle. There has been a craniectomy identified in the region
for decompression. There is mild indentation of the lateral
ventricles and there is presence of a right frontal approach
ventricular drain with the tip in the region of left lateral
ventricle. The temporal horns are mildly dilated indicating some
degree of obstructive hydrocephalus. There is signal change
within the anterior portion of corpus callosum related to the
tract of the ventricular drain. The flow void of the distal left
vertebral artery is not well visualized.
On the MRA of the head no abnormalities are seen in the anterior
circulation. Both vertebral arteries are not visualized beyond
posterior arch of C1. Subtle flow signal is identified in the
distal basilar artery but flow signal is not seen in the
proximal basal artery nor the distal vertebral arteries. There
are fluid levels within the left maxillary sinus which could be
related to intubation.
IMPRESSION: Postoperative changes for decompression secondary to
hemorrhagic left cerebellar infarct. There remains mass effect
on the fourth ventricle and some dilatation of the lateral
ventricle. A ventricular drain is in position. Both vertebral
arteries are not visualized distal to the posterior arch of C1
level. The proximal basal artery is not visualized as well.
There abnormalities on the anterior circulation on MRA.
[**4-7**] NCHCT
IMPRESSION:
1. Known left cerebellar infarct with hemorrhage, with mass
effect on the 4th ventricle and basal cisterns, stable in
appearance since the earlier study of [**2142-4-6**].
2. Stable positioning of the ventricular drain, coursing through
the frontal [**Doctor Last Name 534**] of the left lateral ventricle, terminating at
its lateral margin. Minimal interval increase in the ventricular
size since [**2142-4-5**] CT study.
[**4-8**] NCHCT
IMPRESSION:
1. Interval repositioning of the right external ventricular
drain with tip
now projecting anterior to the frontal [**Doctor Last Name 534**] of the right lateral
ventricle
adjacent to the falx, outside the ventricular system.
2. Otherwise similar exam with left cerebellar infarct with
hemorrhagic
conversion, adjacent mass effect, and stable ventricular size.
[**4-9**] NCHCT
IMPRESSION:
1. Interval repositioning of right frontal external ventricular
drain, now
terminating in the left putamen or internal capsule. Ventricles
have
decreased in size since the prior exam.
2. Left cerebellar infarction with stable posterior fossa mass
effect and
hypodensity extending into the pons.
[**4-10**] NCHCT
IMPRESSION:
1. Significant interval decrease in size of left lateral
ventricle is likely related to over shunting through the right
frontal approach EVD, as there is no associated sulcal
effacement or new edema. Correlate with catheter function and
close f/u. Assessment of the position of the tip of the catheter
is difficult due to the significant decompression of the
ventricle- it is either outside the ventricular margin or
within. Pl. review the images to decide on further management.
2. Left cerebellar infarct with stable posterior fossa mass
effect and
suboccipital craniectomy.
[**4-13**] NCHCT
IMPRESSION:
1. Right frontal approach EVD terminates in the left lateral
ventricle. Left lateral ventricle has increased in size since
the prior exam, with ventricles and sulci now similar in size
and configuration to [**2142-4-2**].
2. Status post suboccipital craniectomy with unchanged posterior
low-density fluid collection. Left cerebellar infarction and
pontine infarction are stable. Slight improvement in effacement
of fourth ventricle.
[**2142-4-15**] R Lower Ext - Doppler US:
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common
femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins were
performed. There is normal compressibility, flow and
augmentation.
IMPRESSION: No evidence of deep venous thrombosis in the right
lower
extremity.
[**2142-4-16**] NCHCT
IMPRESSION:
1. Repositioning of the EVD with the tip in the third ventricle.
2. Continued effacement of the fourth ventricle by mass effect
in the left
cerebellar hemisphere. Status post suboccipital craniectomy.
[**2142-4-17**] Renal Son[**Name (NI) **]:
RENAL SON[**Name (NI) **]:
The right kidney measures 12.8 cm, and the left kidney measures
13.6 cm.
There is no hydronephrosis, stones, or mass. Bladder is
collapsed with a
Foley in place.
IMPRESSION: Normal renal son[**Name (NI) **].
[**2142-4-23**] TEE:
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast at
rest x 4 injections (central line x 2; peripheral line x 2).
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch (clip [**Clip Number (Radiology) **]) and the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion.
IMPRESSION: No valvular vegetation, intracardiac mass/thrombus
seen. No evidence for an atrial septal defect or patent foramen
ovale by color flow Doppler or saline injection at rest. Simple
thoracic atheroma.
Brief Hospital Course:
42yo M with h/o DM2, HTN who presented with L lower face
weakness, dysarthria, R sided sensory loss and hemiparesis,
nausea/emesis, found to have L vertebral and proximal basilar
artery occlusion resulting in L cerebellar / L pontine infarct.
.
[] Acute Ischemic Stroke, Vertebrobasilar Occlusion - The
patient was found to have a clinical syndrome consistent with a
brainstem stroke and was found on imaging to have stenosis of
both vertebral arteries and the proximal basilar artery. He
arrived at the hospital outside the window for intravenous tPA
or intra-arterial therapies. He has two fetal PCAs coming from
his anterior circulation which would preclude him from being
able to have a mechanical thrombectomy. He was started on a
Heparin infusion with goal PTT 60-80 to aid the dissolution of
the thrombus. After hemorrhagic conversion was found on a repeat
MRI, this was switched to Aspirin 81 mg daily. A TTE was
performed which was unrevealing for thrombus, wall motion
abnormalities, or intracardiac shunt, but the suspicion for
venous hypercoagulability causing paradoxical embolism remained
high given the history of a brother of similar age with
bilateral lower extremity DVTs. Hypercoagulability labs (except
for genetic studies) were obtained and were normal. A TEE was
obtained that failed to show an intracardiac shunt and showed
only aortic arch simple atheroma. The patient will have genetic
hypercoagulability studies as an outpatient.
.
He was transferred to the stroke step-down unit on [**2142-5-1**] and
remained stable. His exam has continued to improve, as he is
more alert and following commands well. He has begun to use a
Passy-Muir valve to speak and is tolerating this well. His right
hemiparesis is also improving, and he is currently able to lift
his R arm over his head, can extend his leg anti-gravity, and
dorsi/plantarflex his foot.
.
[] Increased Intracranial Pressure - On [**2142-4-4**], he transiently
developed worsening neurologic deficits including losing his
corneal, cough and gag reflexes. A repeat NCHCT showed worsening
infarction of the left cerebellum and compression of the fourth
ventricle. He was taken to the OR by Neurosurgery for emergent
decompression/occipital craniectomy and placement of a
ventriculostomy. The ventriculostomy was revised/replaced twice
for improved placement. Due to mildly elevated ICP and CSF
drainage, this was converted to a ventriculoperitoneal shunt on
[**2142-4-16**]. He had no complications and no further signs of
increased ICP after the procedure.
.
[] Pulmonary Edema/Volume Overload - In the setting of receiving
IVF, he became net positive in his fluid balance, tachypneic,
and hypoxic. Furosemide did not sufficiently improve his
respiratory status. He was also noted to have worsening
leukocytosis and extensive secretions concerning for infection.
He subsequently was electively intubated to provide further
respirator support. He was unable to wean from the ventilator
and failed an extubation trial. An endotracheal tube was placed
on [**2142-4-20**]. He succeeded in tolerating the trach mask for 36-48
hours on [**2142-5-1**] and was subsequently transferred to the stroke
step-down unit. His secretions have improved with a scopolamine
patch. He continues to have intermittent tachypnea of unclear
etiology without desaturation or any compromise of his
respiratory status.
.
[] Pneumonia - He had recurrent fevers shortly after admission.
Cultures were obtained and revealed MSSA in the sputum. He was
treated with IV antibiotics for 10 days for this. He also had
proprionobacterium acnes in the blood. Later he again began
having fevers and increased sputum production. He underwent
bronchoscopy again on [**2142-4-24**] and was treated with VAP protocol
(Cefepime, Cipro, and Vanc) from [**Date range (1) 92895**], during which time
his fever curve and sputum improved.
He had transient low grade fevers to 99.8 axillary on [**5-3**];
repeat infectious work-up including UA/UCx/Blood cultures/CXR as
well as LENI's was negative. He subsequently remeained afebrile
with no signs of infection.
.
[] Diabetes - His HgbA1c was 11.9, and his blood sugars were
initially difficult to control. He was placed on an insulin GTT
and then transferred to long acting insulin. Blood sugars
remained well-controlled on this regimen.
.
[] Hyperlipidemia - Initial LDL was 109. He was restarted on
statin therapy and this improved to 59. He will continue on
atorvastatin 20mg daily for his hyperlipidemia.
.
[] Nutrition - He was maintained on tube feeds. Due to the
likelihood of an inability to swallow based on the area of his
stroke, a gastrostomy was placed on [**2142-4-20**]. Our speech/swallow
team continue to follow for progress. His phos has been running
a little high; please check a chem-10 in the next week to
re-evaluate.
.
.
TRANSITIONAL CARE ISSUES:
[ ] He will need intensive PT, OT, and speech therapy.
[ ] Please check chem-10 at least once in next week to
re-evaluate his bun/creatinine and phos.
[ ] Hypercoagulability - Prothrombin and Factor V Leiden gene
mutation tests should be obtained as an outpatient.
[ ] He has a follow-up appointment scheduled with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] in our stroke clinic on [**2142-6-26**]. He also has an
appointment to establish care with a new PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on
[**2142-5-18**].
Medications on Admission:
asa 81
atenolol 50 mg daily
chlorthalidone 10 mg daily
HCTZ 25 mg daily
lisinopril 40 mg daily
amlodipine 10 mg daily
pravastatin 40 mg daily
metformin 1000 mg daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. erythromycin 5 mg/gram (0.5 %) Ointment Sig: see
instructions Ophthalmic QID (4 times a day): apply to both eyes
QID.
12. labetalol 100 mg Tablet Sig: Five (5) Tablet PO Q6H (every 6
hours).
13. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
unit Subcutaneous twice a day: 35u with breakfast and dinner.
14. insulin aspart 100 unit/mL Solution Sig: as instructed
Subcutaneous ACHS: Give ACHS as per insulin sliding scale.
15. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
17. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day): Left eye.
18. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID
(4 times a day).
19. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q 3 DAYS (): for increased secretions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Left cerebellar/pontine stroke
Occlusion of the left vertebral and basilar arteries
Hypertension
Hyperlipidemia
Diabetes type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 110219**],
You were admitted to [**Hospital1 69**] on
[**2142-4-2**] due to nausea/vomiting, right sided weakness, and a left
facial droop. You were found to have a stroke in the left side
of your cerebellum as well as part of your brainstem. This
stroke likely resulted from a clot in your vertebral artery in
your neck. This may be related to your high blood pressure, high
cholesterol, and diabetes. You had tests to look at your heart
as well as to look for any disorders of blood clotting and these
were normal.
You had tracheostomy and gastrostomy tubes placed while in the
intensive care unit. You will need intensive physical therapy to
help regain your strength. You were started on some new
medications to better control your blood pressure and
cholesterol.
We made the following changes to your medications:
Increased amlodipine to 20mg daily
Started clonidine 0.3mg 3 times a day and labetalol 500mg 4
times a day to help control your bloood pressure
Held atenolol 50mg daily and HCTZ 25mg daily
Continued lisinopril 40mg daily
Changed from pravastatin to atorvastatin 20mg daily to help
control your cholesterol
Changed from metformin to lantus 35mg twice a day in addition to
insulin sliding scale injections to better control your diabetes
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You have the following appointment scheduled with a new primary
care physician at [**Hospital1 69**]:
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2142-5-18**] 2:15
You also have the following appointment scheduled with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] in stroke clinic:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2142-6-26**] 3:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
5780,43820,78791,7873,V441,7921,9916,29040,4370,43882,25040,40390,5853,V5867,41401,4264,2724,53081,33394,33182,29410,3331,V641 | 99,864 | 111,512 | Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-25**]
Date of Birth: [**2045-3-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 41957**] is an 81 yo Russian speaking male with dementia,
h/o CVA previously on coumadin, left sided weakness, dysphyagia
s/p Gtube, HTN, hyperlipidemia transferred from [**Hospital **] rehab
with coffee ground emesis. Reportedly has had several days of
diarrhea and abdominal distention and then developed acute
vomiting of coffee ground emesis on the day of admission. He
also has history of constipation with recent reports of
hypoactive bowel sounds and abdominal distention.
.
In the ED T95.3 BP 130/80 HR 90 97% 2L RA. During EMS transport
he was noted to have large amount of coffee ground emesis. On
arrival in the ED he was given 3L NS, 16 gauge PIV placed and he
was given protonix 40mg IV and a protonix gtt was started. NG
lavage of G tube reportedly with coffee grounds with streaks of
red blood. GI fellow was notified and tentative plan for scope
in the morning unless concern for acute bleeding.
Past Medical History:
h/o CVA with left hemiparesis - previously on coumadin however
d/c'd due to falls
Dysphagia s/p G tube
Vascular dementia
Parkinson's Disease
type 2 diabetes
coronary artery disease
stage III chronic kidney disease
Left ankle decubitus ulcer
hypertension
hyperlipidemia
GERD
BPH
essential tremor
herpes zoster
constipation
Right Lung calcified granuloma
Restless leg syndrome
Pruritis
Social History:
lives at [**Hospital **] rehab facility
Family History:
n/c
Physical Exam:
On admission:
VS:BP 133/48 HR 77 RR 20 93% on 3L NC
Gen: sleeping quietly, awakens to voice, answers yes to russian
interpreter on the phone but no other verbal communication,
appears frightened
HEENT: NC AT
CV: regualr rate and rhythm, 2/6 systolic murmur
Lungs: bibasilar crackles, right > left otherwise CTAB no
wheezing
Abd: distended, firm to palpation, gtube in place with coffee
ground emesis on suction, hypoactive bowel sounds
Rectal: Guaiac positive in ED
Ext: warm, no pedal edema, DP's palpable bilaterally
Neur: contracted, lying on right side, only verbalizes yes with
the russian interpreter
.
On discharge:
T99.1 HR65 - 92 BP109/46 - 182/107 RR 20 SpO2: 97%
Gen: sleeping quietly, awakens to voice,
HEENT: NC AT
CV: regualr rate and rhythm, 2/6 systolic murmur
Lungs: bibasilar crackles, right > left otherwise CTAB no
wheezing
Abd: ABD; soft, NT/ND, G-tube in place, no coffee grounds in or
around G-tube, NABS
Ext: warm, no pedal edema, DP's palpable bilaterally
Neur: contracted, lying on right side, only verbalizes yes with
the russian interpreter
Pertinent Results:
EKG: NSR at 85 bpm, normal axis, RBBB, st segment depressions in
v2-v6 compared with prior from [**2125-7-12**]
.
[**2128-5-24**] 02:10AM BLOOD WBC-9.3 RBC-3.84* Hgb-12.0* Hct-36.3*
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-357
[**2128-5-24**] 06:39AM BLOOD WBC-6.3 RBC-3.40* Hgb-10.8* Hct-32.4*
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.9 Plt Ct-299
[**2128-5-24**] 12:28PM BLOOD Hct-31.0*
[**2128-5-24**] 06:08PM BLOOD Hct-32.3*
[**2128-5-25**] 12:56AM BLOOD Hct-30.8*
[**2128-5-25**] 03:45AM BLOOD WBC-5.6 RBC-3.22* Hgb-10.5* Hct-30.7*
MCV-96 MCH-32.5* MCHC-34.1 RDW-14.2 Plt Ct-296
[**2128-5-24**] 02:10AM BLOOD Glucose-144* UreaN-47* Creat-1.3* Na-142
K-4.5 Cl-103 HCO3-26 AnGap-18
[**2128-5-24**] 06:39AM BLOOD Glucose-114* UreaN-46* Creat-1.1 Na-141
K-4.5 Cl-109* HCO3-26 AnGap-11
[**2128-5-25**] 03:45AM BLOOD Glucose-101 UreaN-29* Creat-1.2 Na-147*
K-4.0 Cl-114* HCO3-24 AnGap-13
[**2128-5-24**] 02:10AM BLOOD ALT-6 AST-14 CK(CPK)-39 AlkPhos-45
TotBili-0.4
[**2128-5-24**] 06:39AM BLOOD CK(CPK)-34*
[**2128-5-24**] 06:08PM BLOOD CK(CPK)-32*
[**2128-5-24**] 02:10AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2128-5-24**] 06:39AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2128-5-24**] 06:08PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2128-5-25**] 03:45AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2
Brief Hospital Course:
Pt was admitted with concern for GIB given coffee ground
material from G-tube. The patient was admitted to the ICU for
monitoring, but remained hemodynamically stable throught his
hospital stay. Initially, metoprolol, lisinopril and isosorbide
were held, but metoprolol and lisinopril were restarted once the
patient became slightly hypertensive. Isosorbide should be
restarted in [**2-6**] days if his BP remains stable. His aspirin was
also held and should be held for 7-10 days and can then be
restarted on a baby aspirin (rather than 325mg). The patient was
also placed on a pantoprozole drip and will need to be on the
drip for 72 hrs, until the morning of [**2128-5-27**] per
gasteroenterology consult. He can then be transitioned to a high
dose PPI [**Hospital1 **] for a month. The patient did not receive an EGD as
it was determined that the patient would require intubation and
as he is DNR/DNI. The decision not to perform EGD was discussed
with the patient's niece. On admission, the patient's HCT did
come down from 36->32 with fluids, but then remained stable at
30-32.
Medications on Admission:
Glargine 18 units qhs
simvastatin 20mg qhs
acetaminophen 975mg TID
citalopram 40mg daily
famotidine 20mg qpm
hydrocortisone cream
gabapentin 200mg [**Hospital1 **]
zinc oxide topical
metoprolol 25mg [**Hospital1 **]
terazosin 4mg qhs
lisinopril 2.5mg daily
aspirin 325mg daily
bisacodyl suppository prn
cetirizine 5mg daily
isosorbide dinitrate 10mg TID
lactulose 15 ml TID
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO three
times a day.
4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Hydrocortisone 1 % Cream Sig: AS DIRECTED Topical AS NEEDED.
7. Gabapentin 100 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Zinc Oxide Lotion Sig: AS DIRECTED Topical AS NEEDED.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
10. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO at bedtime.
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
13. Cetirizine 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day.
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
16. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
three times a day.
17. Pantoprazole 8 mg/hr IV INFUSION until [**2128-5-27**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
1. Coffee-ground emesis
Discharge Condition:
afebrile, vital signs stable, hematocrit stable.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
bleeding in your G-tube, likely from your stomach. You were
treated with IV medications, and your hematocrit dropped to the
low 30s but remained stable. You did not require any blood
transfusions. The GI specialists were consulted, who recommended
medical management given the stable blood count. Your
medications and tube-feeds are being restarted now. The
following changes are being made to your medications:
.
1. CHANGE Famotidine to Omeprazole 40mg [**Hospital1 **].
1. HOLD Aspirin for 1 week before restarting.
2. HOLD Isosorbide mononitrate for 1-2 days before restarting,
as tolerated by blood pressure.
.
You should follow-up with your primary care physician. [**Name10 (NameIs) **] there
is further bleeding, you should call your doctor. You should
also call your doctor or return to the Emergency Room for:
* fevers, chills
* chest pain, shortness of breath
* abdominal pain, bloody stools or black tarry stools
Followup Instructions:
Primary Care Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**]
.
Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-6-7**] 11:20
|
1550,0389,5762,99592,2762,5119,99811,2869,2930,2851,5990,78959,41401,412,4439,4019,2724,4414,3051,V1044,E8786,6930,E9479,27661,78551 | 99,865 | 189,346 | Admission Date: [**2184-12-10**] Discharge Date: [**2184-12-30**]
Date of Birth: [**2107-6-25**] Sex: F
Service: SURGERY
Allergies:
Codeine / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatocellular CA
Major Surgical or Invasive Procedure:
right hepatecomy [**2184-12-10**]
History of Present Illness:
77-year-old female who was recently diagnosed with a right lobe
hepatocellular carcinoma. This was initially diagnosed during
routine imaging follow-up for renal cell carcinoma of her
right kidney which is now status post RFA. She has had prior
imaging from [**Hospital6 2561**] dating back to [**2182**] that
showed a liver lesion of 2.3 cm. Most recently, a CT scan and
PET scan both demonstrated enlargement of the liver lesion to
greater than 9 cm. A biopsy demonstrated hepatocellular
carcinoma. The kidney lesion has been noted to be stable. A
CT scan of the chest demonstrated no evidence of pulmonary
metastases. A triphasic CT scan demonstrated a large arterial
and hyper-enhancing mass involving segments 5 and 6 of the
liver consistent with a biopsy-proven HCC with no further
concerning lesions being identified. Preoperative liver
function tests included AST 66, alkaline phosphatase
116, total bilirubin 0.4, albumin 4.7, CEA 2.7, CA-125 9.3,
CA19-9 6. She has undergone thorough preoperative evaluation
of her cardiac and cerebrovascular vasculature and has been
cleared for surgery. She has provided informed consent and is
brought to the operating room for right hepatic lobectomy.
Past Medical History:
The patient has a history of coronary artery disease and had a
heart attack in [**2165**]. Peripheral vascular disease s/p R external
iliac stent and angioplasty. Hypertension, hyperlipidemia,
depression, osteoarthritis, anemia, cataracts, 3 cm abdominal
aortic aneurysm, vulvar cancer, R renal cell cancer s/p
radiofrequency ablation.
PSurgHx;
R LE angioplasty, bilateral cataract surgery, vulvar cancer
resection and bilateral inguinal lymph node biopsy, hip
replacement x2, right knee replacement, and appendectomy as a
child.
Social History:
She smokes one pack of cigarettes a day and has
done so for 54 years. She denies alcohol or drug use.
Family History:
Mother died of SBO, father died of cerebral hemorrhage, sister
died of leukemia, sister with bladder cancer, brother with
prostate cancer
Physical Exam:
Post-op exam:
T 98.3 HR 71, BP 119/51, RR 18, SpO2 98%
gen: sedated, difficult to arouse, opens eyes to painful stimuli
but not voice, intubated
cardiac: RRR
chest: CTAB, upper airway sounds
abd: decreased breath sounds, mildly distended, clean dressings,
sanguinous drainage in JP
GU: Foley, urine concentrated
ext: warm and well-perfused, decreased pedal pulses
Pertinent Results:
[**2184-12-10**] 11:52AM BLOOD WBC-3.1*# RBC-3.77* Hgb-9.9* Hct-30.1*
MCV-80* MCH-26.2* MCHC-32.9 RDW-16.3* Plt Ct-120*
[**2184-12-11**] 04:28AM BLOOD WBC-9.0# RBC-4.58 Hgb-12.8 Hct-37.2
MCV-81* MCH-28.0 MCHC-34.5 RDW-16.1* Plt Ct-92*
[**2184-12-13**] 04:57AM BLOOD WBC-13.0* RBC-5.22 Hgb-14.3 Hct-43.5
MCV-83 MCH-27.4 MCHC-32.9 RDW-16.7* Plt Ct-76*
[**2184-12-16**] 04:50AM BLOOD PT-17.3* INR(PT)-1.5*
[**2184-12-16**] 04:50AM BLOOD Glucose-54* UreaN-24* Creat-0.8 Na-133
K-4.1 Cl-100 HCO3-26 AnGap-11
[**2184-12-10**] intraoperative liver U/S: Large right lobe liver mass
which is lobulated in contour but appears to be solitary.
[**2184-12-10**] pathology: pT1N0Mx G2 Greatest dimension: 11 cm.
Additional dimensions: 10 cm x 7 cm.
[**2184-12-11**] liver U/S: No large fluid collections are
seen. Normal color flow and Doppler waveforms were noted in the
main hepatic artery, hepatic vein, and portal vein. The common
duct measures 3 mm.
[**2184-12-17**] MRCP: Status post right hepatectomy. The liver
demonstrates moderate dropout of signal intensity on
out-of-phase imaging consistent with fatty infiltration. There
is no evidence of other worrisome lesions. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. Small amount
of perihepatic fluid is noted, without evidence of organized
fluid collection. The portal vein is patent. The hepatic artery
is patent.
[**2184-12-20**] CT abdomen/pelvis: 1. Extensive perihepatic hematoma
with mass effect upon the liver, portal vein and stomach. 2.
Small bilateral pleural effusions, right greater than left.
[**2184-12-20**] liver U/S: 1. Stable appearance of the resection bed
hematoma (heterogeneous collection measuring 9.5 x 6.4 x 7.3 cm)
as compared to the CT from [**2184-12-20**]. 2. Normal flow in
the main portal vein, left hepatic vein, and hepatic
artery.
[**2184-12-23**] liver bx: 1. Severe hepatocellular and canalicular
cholestasis, primarily involving zone 3 with prominent
hepatocellular swelling. 2. Mild lobular and focal portal
neutrophilic infiltration with neutrophilic aggregates and
infiltration of bile ducts. No bile duct proliferation is seen.
3. Mild to focally moderate steatosis (not seen on previous
resection).
[**2184-12-24**] CXR: Interval increase in bilateral right greater than
left small pleural effusions with associated atelectasis without
evidence of pneumonia.
[**2184-12-30**] CXR: As compared to the previous radiograph from
[**12-25**], there is improvement with decrease in extent of the
right-sided pleural effusion. The clips, the drains projecting
over the liver and the monitoring and support devices are in
unchanged position. No newly appeared focal parenchymal opacity
suggesting pneumonia. No evidence of pneumothorax.
[**2184-12-30**] liver U/S: 1. Resolving collection in the right hepatic
surgical bed. 2. No biliary dilatation and appropriate vascular
waveforms seen in the left lobe of the liver. 3. Right pleural
effusion.
[**2184-12-30**] LE U/S: No lower extremity deep venous thrombosis.
Brief Hospital Course:
On [**2184-12-10**], she underwent right hepatic lobectomy and
cholecystectomy, with intraoperative ultrasound. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for complete
details. Postop, patient was transferred intubated to the PACU
due to episodes of apnea on CPAP accompanied by respiratory
acidosis, likely related to the earlier administration of
intrathecal morphine. Consequently, further opiate medication
was limited. Patient was successfully extubated [**2184-12-11**] and
transferred to the floor. On [**12-14**] was tolerating a regular diet
and started on Lasix for weight gain and edema. Total bilirubin
and alkaline phosphatase increased post-op: alk phos peaked at
614 on [**12-18**] and T bili at 23.4 on [**12-22**] before starting to
decline. For this reason, an MRCP was obtained on [**2184-12-17**] that
demonstrated no biliary obstruction. On [**2184-12-20**] WBC rose to
29.3 from 19.0 the day before. Patient was afebrile; cultures
were obtained and were negative. Drain output had 10,000 WBCs
but fluid culture was negative. She was empirically started on
vancomycin, levofloxacin, and flagyl for the leukocytosis.
Sanguinous output was noted from JP. Patient received 2u pRBC on
[**12-20**] after a decline in HCT to 24.4 as well as 2 u FFP for an
INR of 2.7. A Dobhoff was placed and tube feeds were started for
poor oral intake.
On [**12-23**] L blood was noted from JP drain with a decline in
HCT to 28.9 from prior 32.8 and was taken to OR for hematoma
evacuation. Hematoma was observed but no active bleeding was
identified. Please refer to Dr.[**Name (NI) 1369**] operative note from
[**12-23**] for further detail. Two JP drains were placed. Patient was
kept in SICU following surgery for monitoring. She required
albumin and a fluid bolus for hypotension/low UO, pRBCs for HCT
27.5, and 1 u plts for platelets of 66. She had an episode of
delerium treated with Seroquel. Liver biopsy obtained
intra-operatively demonstrated severe cholestasis. Cultures
obtained from the hematoma intra-op grew sparse coag neg staph
aureus. On [**12-25**] she was hemodynamically stable and was
transferred to the floor, but still had confused mental status
despite withholding of sedating medications. On [**12-27**] 1 FFP, 1
plt, and vitamin K were given for an INR of 2.1, but there was
no evidence of bleeding from the JP drains, which had decreased
output.
On [**12-29**] dermatology was consulted for a worsening rash over her
flanks and lower abdomen and suggested a drug reaction versus
contact dermatitis. That afternoon, she was noted to have
worsening mental status and complaint of shortness of breath for
which albuterol nebs were given. Chest xray demonstrated right
greater than left pleural effusion but mild vascular congestion.
She was maintaining her saturations at 96% on 2L NC and appeared
more awake and responsive by the late afternoon. The morning of
[**12-30**] patient was transferred to the SICU for increased confusion
and tachypnea with concern over airway protection. Ammonia level
was 51. Patient was closely monitored in the ICU and was
maintaining her airway until 17:15, when she was found to be in
respiratory arrest and was subsequently intubated. At this time
patient went into cardiac arrest and ACLS was initiated with
pressor drip. Bleeding was noted from drains accompanied by
abdominal distension, with drop in HCT from 41 to 20, rise in
INR from 1.6 to >3, and platelets of 33. Massive transfusion
protocol was initiated and patient underwent exploratory
laparotomy at bedside by Dr. [**Last Name (STitle) **], but bleeding was unable to
be controlled and patient required CPR and external pacing.
Patient expired at 20:29 after discussion with daughter to
withdraw care. For details, see death pronouncement note of
[**2184-12-30**].
Medications on Admission:
Atenolol 50 mg daily
Omeprazole 20 mg [**Hospital1 **]
Isosorbide Mononitrate 40 mg [**Hospital1 **]
Lovastatin 40 mg daily
Amitriptyline 125 qHS
Ferrous Sulfate 325 mg [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatocellular CA s/p resection
intra-abdominal hematoma s/p evacuation
delirium
respiratory depression
cardiac arrest
hemorrhage/coagulopathy
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
9654,2762,28249,27650,2769,2768,96909,9651,9800,311,2753,78701,7850,E9500,E9503,E9509 | 99,868 | 177,777 | Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-10**]
Date of Birth: [**2122-3-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
tylenol PM and naproxen overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20 yo F, with hx of depression w/ SI on Effexor, no previously
established care here at [**Hospital1 18**], p/w tynenol / NASIADS overdose
in setting of a suidical attempt.
.
Of note, night prior to admission pt heard from her boyfriend
that his friends do not like her and don't want her around
anymore. At 10pm, pt took 50 tylenol PM, 30 naproxen and an
unknown amount of excedrin and a bottle of wine. Pt called the
suicidal hotline and was sent to [**Hospital1 18**] by ambulance.
.
In the ED, initial VS were: Initial ASA 7.3 and tylenol 14 and
EtOH 158. Two hours later, her ASA increased to 22.4, tylenol
increased to 76. Toxicology was consulted and decided to admit
to MICU for NAC protocol.
.
On arrival to the MICU, 98.6, 109, 109/48, 18, 98% on RA
Past Medical History:
History of SI attempt at age 15 per her mother, pt denies.
Depression
Social History:
[**University/College 5130**] 3rd year student, digital arts major. History of SI
attempt at age 15 per her mother, pt denies. Drinks alcohol [**11-26**]
times per week, 3 drinks per time. Denies tobacco or drug use.
Family History:
Mother and aunts have depression
Physical Exam:
ADMISSION EXAM
General: Lying in bed, breathing comfortably, interactive,
stable.
HEENT: PERRL, anicteric sclera, OP clear.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA bilaterally w/o crackles or wheezing. Good air
movement.
Ab: Positive BS??????s, mild diffuse tenderness with deep palpation,
non-distended, no HSM.
Ext: No c/c/e.
Neuro: Awake, alert, appropriately oriented, no focal motor
deficits noted. No asterixis.
DISCHARGE EXAM:
VS: 97.3 103 110/80 20 99% RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no lymphadenopathy. neck supple.
Cards: RRR, no murmurs/gallops/rubs.
Pulm: CTAB, no crackles or wheezes
Abd: soft, NT ND
Extremities: wwp, no edema.
Skin: warm and dry
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities
with sensation intact.
Pertinent Results:
ADMISSION LABS
[**2142-9-7**] 01:53AM BLOOD WBC-8.1 RBC-5.45* Hgb-11.7* Hct-34.6*
MCV-63* MCH-21.4* MCHC-33.7 RDW-14.8 Plt Ct-308
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-7**] 01:53AM BLOOD PT-11.5 PTT-25.1 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Glucose-113* UreaN-10 Creat-0.7 Na-139
K-3.1* Cl-105 HCO3-19* AnGap-18
[**2142-9-7**] 01:53AM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.2
[**2142-9-7**] 01:53AM BLOOD Albumin-5.0 Calcium-9.6 Phos-2.0* Mg-2.0
PERTINENT LABS
[**2142-9-7**] 01:53AM BLOOD ASA-7.3 Ethanol-158* Acetmnp-14
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-9-7**] 04:24AM BLOOD ASA-22.4 Acetmnp-76*
[**2142-9-7**] 07:05AM BLOOD ASA-22.4 Acetmnp-55*
[**2142-9-7**] 09:50AM BLOOD ASA-18.4 Acetmnp-26
[**2142-9-7**] 12:20PM BLOOD ASA-16.0 Acetmnp-15
[**2142-9-7**] 03:01PM BLOOD ASA-11.9 Acetmnp-7*
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
PERTINENT STUDIES
CXR ([**9-7**])
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
[**2142-9-9**] 07:05AM BLOOD WBC-8.4 RBC-4.95 Hgb-10.6* Hct-31.4*
MCV-63* MCH-21.4* MCHC-33.8 RDW-15.0 Plt Ct-244
[**2142-9-9**] 07:05AM BLOOD PT-11.7 PTT-24.2 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-9**] 07:05AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-137 K-4.3
Cl-104 HCO3-27 AnGap-10
[**2142-9-9**] 07:05AM BLOOD ALT-14 AST-17 AlkPhos-43 TotBili-0.5
[**2142-9-9**] 07:05AM BLOOD Calcium-9.7 Phos-4.5# Mg-2.0
[**2142-9-7**] 09:50AM BLOOD calTIBC-321 Ferritn-58 TRF-247
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
Brief Hospital Course:
20 yo F with hx of depression and suicidal ideation, currently
on Effexor, no previously established care here at [**Hospital1 18**], p/w
tynenol / ASA overdose in setting of a suidical attempt.
.
ACTIVE ISSUES
# Tylenol intoxication: Pt self-reported an overdose of large
quantity of acetominophen (>25 gram). The low tylenol level and
lack of elevation in LFT does not support overdose of such
extent. However, the benadryl in Tylenol PM could potentially
delay the absorption and administration of alcohol in the same
time could be hepatic protective by competing with tylenol for
cytochrome C. An N-acetylcysteine protocol was initiated at ED
and continued initially in the MICU. Her Tylenol level was
trended till non-detectable.
.
# ASA intoxication: The elevated ASA level is likely a result
from Excedrin overdose. Pt was treated conservative with fluid
hydration, and monitored closely on the rising ASA level. There
was an anion gap initially, which was closed shortly after
treatment. Her ASA level was trended till non-detectable.
.
# SI: Pt had a history of depression and suicidal ideation. She
was evaluated by on-call psychiatrist in the ED. The
psychiatrist at her college was notified. We restarted her
effexor after her nausea resolved. Medically cleared for
transfer to psychiatric facility.
.
CHRONIC ISSUES
# Anemia: Pt has known anemia from thalassemia. No transfusion
given. No evidence of iron deficiency.
.
Transitions of care:
Outpatient management of anemia.
Medications on Admission:
Venlafaxine XR 225 mg PO
altavera
Discharge Medications:
1. venlafaxine 225 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. Altavera (28) 0.15-30 mg-mcg Tablet Sig: as directed
previously Tablet PO Daily ().
Discharge Disposition:
Extended Care
Facility:
Four Winds Saratoga
Discharge Diagnosis:
Primary:
tylenol / aspirin overdose
Secondary:
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for taking too much tylenol and
aspirin. You were treated for this and improved and were deemed
medically clear for transfer to a facility that specializes in
psychiatric care.
REGARDING YOUR MEDICATIONS...
no changes were made to your medications
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Followup Instructions:
Otherwise, please followup with your primary care physician
[**Name Initial (PRE) 176**] 7-10 days regarding the course of this hospitalization.
Completed by:[**2142-9-10**] |
41401,4111,4142,2724,4019,32723,49390,3004,25060,3572,71941 | 99,870 | 124,555 | Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2123-1-29**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent to left anterior
descending artery and balloon angioplasty to Diagonal artery
History of Present Illness:
43 year female with h/o DMT2, OSA, Asthma, and Dyslipidemia
presents from OSH for ASA desensitization before PCI. Patient
has had 6 month history of Left Chest Pain/Pressure that lasts
for a couple of minutes and is a [**7-23**]. It radiates to the right
chest. Associated with shortness of breath and recently some
diaphoresis and nausea. She states she used to walk about 2
blocks before the CP starts, but it has been progressively
getting worse as she must stop and rest quite a bit more with
progressively shorter distances. She also states that this chest
pain has begun to occur at rest. Prior to 6 months, she has
never had this episode before. She went to her PCP who then
referred her to get a Exercise Tolerance Test: she walked 6
minutes according to a standard [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her isotope
study showed lateral ischemia.
She was then admitted yesterday to [**Hospital 487**] Hospital for a
cardiac cath performed today. ([**9-2**]) Her cath revealed a
proximal 80% long lesion, totally occluded Cx, occluded
diagnoal, mild RCA disease. LVEF reportedly 55%. Since the
patient has an ASA allergy associated with rash/angioedema/and
questionable wheezing (per patient), she was loaded with 600 mg
of plavix, 50 mg of atenolol and transferred here for asa
desensitization and further intervention.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: + Diabetes (complicated by peripheral
neuropathy, + Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Obesity
Asthma
Obstructive Sleep Apnea: Recent Sleep Study shows indication for
CPAP, although not currently using
Anxiety/Depression
Social History:
SOCIAL HISTORY
-Tobacco history: Never
-ETOH: None
-Illicit drugs: NOne
Lives with family in [**Hospital1 487**]
Family History:
2 aunts with "big heart", Father died of CVA, uncertain of age;
sister has h/o tachycardia?
Physical Exam:
VS: T=97.6 BP=160/70 HR= 66RR=20 O2 sat= 97% 2LNC
GENERAL: Well nourished obese female in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of cm. Hepatojugular reflux
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, obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right Femoral sheeth in place; TTP in
bilateral calves
SKIN: Discoloration of BLE
PULSES:
Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2166-9-4**] 07:15AM BLOOD WBC-11.9* RBC-4.49 Hgb-12.9 Hct-37.7
MCV-84 MCH-28.7 MCHC-34.2 RDW-13.4 Plt Ct-288
[**2166-9-4**] 07:15AM BLOOD Glucose-189* UreaN-10 Creat-0.5 Na-138
K-4.4 Cl-104 HCO3-25 AnGap-13
[**2166-9-4**] 07:15AM BLOOD CK(CPK)-66
[**2166-9-3**] 09:55PM BLOOD CK(CPK)-71
[**2166-9-2**] 12:43PM BLOOD ALT-32 AST-20 AlkPhos-88 TotBili-0.4
[**2166-9-2**] 12:43PM BLOOD CK-MB-3 cTropnT-<0.01
[**2166-9-4**] 07:15AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2
[**2166-9-2**] 12:43PM BLOOD HDL-37 CHOL/HD-5.3 LDLmeas-130*
.
ECHO: [**2166-9-4**]
The left atrium is dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen.
.
Cardiac catheterization [**2166-9-3**]:
COMMENTS:
1- Limited selective coronary angiography confirmed the presence
of a
long mid LAD 80% stenosis with a totally and chronically
occluded long
diagonal branch (originates from the diseased LAD segment). The
LMCA had
mild plaquing and the LCX was chronically occluded in mid vessel
with
collaterals filling the OM2. The RCA was not engaged as it was
found to
be patent on earlier cath performed at OSH.
2- Limited resting hemodynamic assessment showed normal systemic
arterial BP (130/70).
3- Successful PTCA of the chronically and totally occluded
diagonal
branch with 20% residual ostial stenosis, TIMI 3 flow and no
dissection
or distal emboli.
4- Successful PTCA and stenting of the mid LAD with a 2.5x23 mm
Cypher
DES, postdilated to 2.75 mm. Final angiography whosed no
residual
stenosis with TIMI 3 flow and no dissection or distal emboli.
5- Sucecssful closure of the LCFA with a perclose Proglide
closure
device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Sucecssful stenting of the mid LAD with a Cypher DES.
3. Successful POBA of the diagonal branch.
4. Sucecssful closure of the LCFA with a Perclose Proglide
closure
device.
5. Dual antiplatelet therapy (ASA and Plavix) for a minimum of
12 months
then ASA indefinitely.
.
CXR: [**2166-9-2**]
REASON FOR EXAMINATION: Chest pain after breast surgery.
The portable AP chest radiograph was reviewed with no prior
studies available for comparison.
The study was obtained in lordotic projection. The heart size
is mildly
enlarged, which might be exaggerated by the lordotic projection
of the study.
The lungs are essentially clear. There is no pleural effusion or
pneumothorax. Mediastinal position, contour and width are
unremarkable. Impression: No acute cardiopulmonary findings.
Brief Hospital Course:
#ACS/CAD: Pt admitted for aspirin desensitization. No signs of
wheezes, rash or pruritis with aspirin dose. S/P cath with
Diffuse 3VD with DES to mid LAD and POBA to Diagonal. No further
SOB during hospital stay, pt was able to ambulate in halls
without difficuty prior to discharge. CK's flat, no evidence of
prior MI or wall motion abnormality on ECHO. Started on
clopodigrel, metoprolol, simvastatin and full dose ASA. Pt will
need to take Aspirin and clopodigrel every day for at least one
year because of her drug eluting stent.
#Pump:No hx or symptoms of CHF. CXR clear, LS without crackles
and no peripheral edema. ECHO [**Last Name (un) **] preserved EF.
# Right Shoulder pain: Unclear precipitant. Developed after
cardiac catheterization. No similar pain PTA, no obvious trauma
or strain. Worse with movement and palpation at bicep area.
Right shoulder somewhat diffusely swollen and tender but [**Male First Name (un) **] and
pain decreased prior to discharge. Better with narcotics and
ice. Right shoulder films showed no fracture. EKG and CK's
stable, not thought to be cardiac related.
Pt told to f/u with her PCP if right shoulder pain continues.
# Dyslipidemia: Not on statin on admission, started on 80 mg
Simvastatin. See lipid panel above. pt will need LFT's checked
in 2 months and then at 6 months to assess for transaminitis.
Low fat diet discussed with pt. She will need reinforcement.
#Type 2 Diabetes :Glargine and Humalog cont, metformin held
because of contrast load. Pt told to restart metformin on
[**2166-9-6**]. No changes at d/c.
#Asthma: Home medications of Singulair and Abluterol continued.
No wheezes on exam or O2 requirement. No exacerbation with ASA.
# OSA: Per pt, is being worked up as outpt. CPAP machine offered
to pt but mask did not fit well and pt ref to use.
Medications on Admission:
Singulair 10 mg daily
Flovent prn
Prventil nebulized with albuterol 2 puffs QID
Metformin 1000mg [**Hospital1 **]
Risperdal 1 mg qhs
Trazadone 50 mg qhs
Omeprazole 20 mg [**Hospital1 **]
Docusate 100 mg PRN
Cialopram 40 mg daily
Gabapentin 400 mg [**Hospital1 **]
Novolog 10 units in AM
Lantus 70 units qhs
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous once a day.
3. Insulin Lispro 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1-3 tablets
Tablet, Sublinguals Sublingual PRN (as needed) as needed for
chest pain: Take 5 mintues apart. If still have chest pain after
3 tablets, call 911.
Disp:*1 bottle* Refills:*1*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day as needed for pain, discomfort: for right shoulder
pain.
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Metformin Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Diabetes Mellitus Type 2
Obstructive Sleep Apnea
Asthma
Depression/anxiety
Discharge Condition:
stable
Discharge Instructions:
You had a cardiac catheterization that showed blockages in
multiple coronary arteries. A drug eluting stent that was placed
in your left coronary artery and a balloon procedure was used to
open a blockage in your diagonal artery. It is very important
that you call your cardiologist, Dr. [**Last Name (STitle) 29070**], if you have any
more chest pain or trouble breathing. You did not have a heart
attack. You can now take aspirin safely but you need to take it
every day for the rest of your life, don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. You
also have to take clopodigrel (PLavix) every day for one year.
Don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 29070**]
tells you to. You may not drive for 48 hours. Please let Dr.
[**Last Name (STitle) 29070**] know if you have any increased tenderness, bleeding,
swelling or redness at your groin sites. No pools or baths for
one week, you may shower.
New Medicines:
1. Clopodigrel (Plavix): a blood thinner to keep the stent in
your heart open
2. Aspirin: a blood thinner to keep the stent open
3. Metoprolol: a beta blocker medicine to prevent a heart attack
4. Lisinopril: an ACE inhibitor medicine to lower your blood
pressure
5. Do not take your Metformin until Saturday
6. Your omeprazole was changed to Ranitidine
7. You were started on simvastatin for your cholesterol
8. You were given a prescription for nitroglycerin, to take if
you had chest pain or trouble breathing again. Please refer to
the spanish information on how to take nitroglycerin.
.
Please call Dr. [**Last Name (STitle) 29070**] for any chest pain, trouble breathing,
dizziness or fainting, dark or bloody stools or any other
concerning symptopms.
.
please come in to the walk in clinic on Monday [**9-8**] with
your discharge papers, your doctor is on an extended leave of
absence but you can be seen by another provider [**Name Initial (PRE) **].
Followup Instructions:
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 37284**]
Date/time: [**9-30**] at 3:00pm at the [**Doctor First Name 5987**] office
.
Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63099**]
Phone: [**Telephone/Fax (1) 63099**] Date/time: please go to the walk in clinic
tomorrow.
|
5789,27651,2851,2112,56984,4550,2809,4019,311 | 99,872 | 108,939 | Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-16**]
Date of Birth: [**2083-1-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 54y/o woman with a PMH of H. pylori and
depression admitted with DOE and anemia with HCT of 19. The
patient noted onset of DOE 2 days prior to presentation, with
worsening so that she was unable to ambulate without significant
difficultly over the past 24 hours. She noted black stools 24
hours prior to presentation. Denies previous recent history of
bleeding. She underwent a routine screening colonoscopy in [**2134**]
which demonstrated grade 1 internal hemorrhoids. She denies any
other bleeding (urine, gums). She denies weight changes, fevers,
chills, night sweats. She has nto had any bowel movements since
admission.
In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2
100% RA. On exam she was found to have dark, guaiac + stools. NG
lavage negative. 2 18 guage PIV were placed. She was transfused
1U PRBC.
On arrival to the MICU, the patient is resting comfortably, in
NAD. Denies current CP/SOB. The GI performed an upper endoscopy
on arrival to the MICU which demonstrated a large polyp with no
evidence of current bleeding. Intervention was deferred
overnight for planned excision and biopsy with EUS. She was
transfused 3 units PRBC's with appropriate improvement in her
hct and has been hemodynamically stable in the ICU.
10 point review of systems otherwise negative except as noted
above.
Past Medical History:
Melanoma in-situ, lentigo maligna type - L cheeck [**2133**]
Depression
H. Pylori
Social History:
The patient is married and has one teenage son. She runs the
Gift Shop at [**Hospital1 18**]. The patient denies tobacco, EtOH, IVDU.
Denies over the counter herbal supplements.
Family History:
Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19839**] deficiency
Physical Exam:
VS: T 97.3 HR 59 BP 102/69 RR 18 Sat 99% RA
Gen: wll appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates,
conjunctiva pink
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis
bilaterally, babinski down-going bilaterally
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
[**2137-8-12**] 05:57PM COMMENTS-GREEN TOP
[**2137-8-12**] 05:57PM HGB-7.8* calcHCT-23
[**2137-8-12**] 05:50PM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2137-8-12**] 05:50PM WBC-5.5 RBC-2.22* HGB-6.8* HCT-20.4* MCV-92
MCH-30.8 MCHC-33.4 RDW-14.0
[**2137-8-12**] 05:50PM NEUTS-68.4 LYMPHS-24.4 MONOS-5.5 EOS-1.4
BASOS-0.2
[**2137-8-12**] 05:50PM PLT COUNT-211
[**2137-8-12**] 05:50PM PT-11.3 PTT-21.8* INR(PT)-0.9
[**2137-8-12**] 01:46PM GLUCOSE-95
[**2137-8-12**] 01:46PM UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.4
CHLORIDE-109* TOTAL CO2-29 ANION GAP-7*
[**2137-8-12**] 01:46PM estGFR-Using this
[**2137-8-12**] 01:46PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-57 TOT
BILI-0.2
[**2137-8-12**] 01:46PM WBC-3.9* RBC-2.13*# HGB-6.4*# HCT-18.9*#
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.1
[**2137-8-12**] 01:46PM NEUTS-64.6 LYMPHS-24.2 MONOS-8.8 EOS-1.9
BASOS-0.5
[**2137-8-12**] 01:46PM PLT COUNT-177
[**2137-8-12**] 01:46PM PT-11.9 PTT-23.5 INR(PT)-1.0
[**2137-8-12**] 01:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-8-12**] 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
EGD [**2137-8-12**]: Impression: Polyp in the second part of the
duodenum on wall opposite ampulla Otherwise normal EGD to third
part of the duodenum
Recommendations: Patient will require polypectomy of this polyp.
We do not have the equipment to perform this as an emergency
procedure. Can have clear liquids. give Protonix 40 mg twice
daily.
Colonoscopy [**2137-8-12**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
This is a 54y/o woman with a h/o H. pylori and depression with
acute blood loss anemia, GIB, duodenal polyp.
1. Acute blood loss anemia due to GI bleeding: She presented
with blood loss anemia, secondary to slow GI bleed. She had an
emergent EGD which showed a duodenal polyp. She improved with
transfusion of 3 units of blood with stable hematocrit. She
will need to restart an [**Month/Day/Year **] supplement on discharge.
.
2. Duodenal polyp: Underwent EUS on [**8-15**] for evaluation of polyp
found on initial EGD. EUS showed 3 cm pedunculated polyp in the
second part of the duodenum. The ampulla was identified and was
separate from the mass. The ampulla appeared normal.
On EUS, this lesion appeared as a pedunculated polyp. No
extension of the lesion beyond the submucosa was noted. The
muscularis was clearly identified and was intact. She went for
removal on [**2137-8-16**]. During that EGD, EGD on she was found to
have angioectasia in the stomach (treated with thermal therapy),
a polyp in the second part of the duodenum (treated with
polypectomy, endoclip, and otherwise normal EGD to third part of
the duodenum. She was discharged home after the polypectomy,
with advise to return in the event of pain, hematemesis, or
worsening melena. She will have a CBC approximately 5 days post
discharge, results to her PCP.
.
3. Depression: continuee wellbutrin and celexa.
.
OUTSTANDING TESTS:
Polyp, pathology pending
Medications on Admission:
On Admission:
Bupropion HCl 200 mg Tablet SR daily
Citalopram 20 mg Tablet daily
Lorazepam 0.5 mg Tablet one half to one Tablet(s) by mouth @ hs
no more than 3 nights per week
Ferrous Sulfate 325 mg (65 mg [**Date Range **]) Tablet [**Hospital1 **]
Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC)
On transfer:
BuPROPion (Sustained Release) 200 mg PO QAM
Citalopram Hydrobromide 20 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. [**Hospital1 **] (Ferrous Sulfate) 325 mg (65 mg [**Hospital1 **]) Tablet Sig: One
(1) Tablet PO once a day.
4. Outpatient Lab Work
CBC, [**2137-8-21**]. Results to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] phone
[**Telephone/Fax (1) 250**].
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Acute blood loss anemia
Duodenal polyp
Depression
Discharge Condition:
Stable, hematocrit 31.5, no active bleeding, ambulating without
shortness of breath
Discharge Instructions:
You were admitted with anemia, due to blood loss. The most
likely cause was the polyp in your duodenum, which was slowly
oozing. You improved with transfusions with a stable blood
count throughout your stay after the transfusion. You had the
polyp removed on the day before discharge.
.
No aspirin, or NSAIDs. You do not need to take protonix.
.
Return to the ED if you get short of breath or dizzy. Your
stool will probably turn black from the [**Last Name (LF) **], [**First Name3 (LF) **] that is
expected.
.
Start eating solid food tonight. Stay well hydrated in the next
few days.
Followup Instructions:
Call the GI department to make an appointment with [**Doctor First Name 4370**] [**Doctor Last Name **] in
the next 2-3 weeks. The phone number is [**Telephone/Fax (1) 9557**]. They
will give you the results of your polyp removal.
.
Provider: [**Name10 (NameIs) **] [**Name6 (MD) **] [**Name8 (MD) 19840**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-9-3**] 3:00 (resident working with Dr. [**Last Name (STitle) 5263**]
.
Blood count check next week.
|
41401,42831,4111,4280,4240,42769,2724,4552,34690,V173,3051,2982,E9352 | 99,873 | 143,544 | Admission Date: [**2103-12-19**] Discharge Date: [**2103-12-24**]
Date of Birth: [**2058-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
left & right heart catheterization, coronary angiogram [**2103-12-19**]
Insertion of intraaortic balloon [**2103-12-19**]
urgent Mitral valve repair (P2 triangular resection),ring
annuloplasty(34mm [**Doctor Last Name **] Physio II annuloplasty ring, model
number 5200,serial number [**Serial Number 92293**])/ Coronary artery bypass
grafting times 3 LIMA-LAD,SVG-D1,SVG-OM1) [**2103-12-20**]
History of Present Illness:
This 45 year old white male began about one and a half months
ago to notice chest discomfort "like indigestion", across the
entire chest when exerting himself. He is avid walker and has
noticed this discomfort when going up
any type of incline and resolving with rest. He has not noticed
this discomfort when walking on a level surface. It is easily
reproducible. He underwent a stress echo which revealed mild LV
enlargement with preserved LV function. The left atrium was
moderately dilated. There was moderate mitral valve prolapse
involving the posterior leaflet with severe mitral insuffiency
and pulmonary vein flow reversal. Mild TR and borderline aortic
root dilation were seen. He exercised 6 minutes and developed
chest pain at peak exercise along with lateral ST depression.
PVC's were noted. Echo imaging showed anteroseptal ischemia. He
was referred for cardiac catheterization to further evaluate. He
was found to have coronary artery disease upon cardiac
catheterization and referred to cardiac surgery. He continued to
complain of chest pain on a nitro drip and morphine. He had an
intraaortic balloon placed with stabilization and was taken the
following day to the Operating Room for an urgent operation.
enzymes were flat.
Past Medical History:
Mitral prolapse/regurgitation
Mild hyperlipidemia, recently started on statin
Non sustained VT 13 years ago, on Atenolol since
Hemorrhoids with occasional rectal bleeding
Bone spurs s/p surgery
Remote history of migraines
Social History:
Race:caucasian
Last Dental Exam:
Lives with:Wife and three kids
Contact:[**Name (NI) **] [**Name (NI) 1024**] (Wife) #[**Telephone/Fax (1) 92294**]
Occupation:works at a bank as a temporary worker doing booking
Cigarettes: Smoked no [] yes [x] Hx:occasional cigarette/cigar
(none in 2 months)
Other Tobacco use:denies
ETOH: 2 glasses of wine per day
Illicit drug use:denies
Family History:
Adopted. Patient does not know his family history.
Physical Exam:
Height:6'2" Weight:228 lbs
Unable to assess patient due to emergent nature of case.
NO H&P in chart.
Pertinent Results:
[**2103-12-23**] 05:35AM BLOOD WBC-5.8 RBC-3.08* Hgb-9.1* Hct-27.0*
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.0 Plt Ct-138*
[**2103-12-22**] 04:30AM BLOOD WBC-6.0 RBC-3.27* Hgb-10.2* Hct-28.9*
MCV-88 MCH-31.1 MCHC-35.2* RDW-12.8 Plt Ct-133*
[**2103-12-21**] 02:11AM BLOOD WBC-6.7 RBC-3.68* Hgb-11.2* Hct-32.0*
MCV-87 MCH-30.3 MCHC-34.9 RDW-13.3 Plt Ct-148*
[**2103-12-23**] 05:35AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2103-12-22**] 04:30AM BLOOD Glucose-142* UreaN-10 Creat-0.9 Na-138
K-4.0 Cl-105 HCO3-25 AnGap-12
[**2103-12-21**] 02:11AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-137
K-3.8 Cl-110* HCO3-23 AnGap-8
[**2103-12-20**] 02:16PM BLOOD UreaN-14 Creat-1.0 Na-138 K-4.1 Cl-106
HCO3-24 AnGap-12
[**2103-12-20**] TTE
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: 0.45 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 113 ml/beat
Left Ventricle - Cardiac Output: 8.48 L/min
Left Ventricle - Cardiac Index: 3.69 >= 2.0 L/min/M2
Aorta - Annulus: 2.7 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 2.4 cm
LEFT ATRIUM: Dilated LA. LA not well visualized. No spontaneous
echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the body of the RA or RAA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Low normal LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta. Normal aortic arch diameter. No atheroma in descending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate/severe MVP. Partial mitral leaflet flail. Moderate to
severe (3+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the body of
the right atrium or right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The descending aorta appears
free from atherosclerotic plaque with some limitation in the
study due to the presence of an intraaortic balloon pump. The
distal tip of the IABP appears end prior to the subclavian
artery takeoff.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
moderate/severe posterior leaflet mitral valve prolapse. There
is partial posterior (P2) mitral leaflet flail. Moderate to
severe (3+) mitral regurgitation is seen.
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect).
There is no pericardial effusion.
POSTBYPASS:
The patient is in sinus tachycardia on low dose epinephrine &
moderate dose phenylephrine infusions. The biventricular
function is maintained. There is a well seated annuloplasty ring
in the mitral position. There is trace MR. There are peak and
mean gradients of 11 & 5mmHg, respectively. The remaining valves
are unchanged. The aorta appears intact, though the descending
aorta has suboptimal imaging due to the presence of an IABP. The
IABP continues to remain with the distal tip in appropriate
position.
[**2103-12-24**] 04:40AM BLOOD WBC-6.0 RBC-3.00* Hgb-9.0* Hct-26.3*
MCV-88 MCH-30.2 MCHC-34.4 RDW-12.9 Plt Ct-217#
[**2103-12-24**] 04:40AM BLOOD Na-141 K-4.0 Cl-105
Brief Hospital Course:
This is a 45-year-old male referred from Dr. [**Last Name (STitle) **] for
consideration of coronary artery bypass grafting as well as
mitral valve repair. The patient developed severe angina
after his diagnostic cardiac cath which revealed moderate left
main disease and high-grade LAD and diagonal stenoses. The
patient was not responsive to nitroglycerin and therefore was
brought to the Operating Room and an intra-aortic balloon pump
inserted. This abated his chest pain.
A stat echo in the Operating Room showed severe mitral
regurgitation. It was felt that the patient should proceed with
mitral valve repair or replacement and coronary artery bypass
grafting the next morning. The patient had a stable night and
did not rule in for a myocardial infarction by serial enzyme
analysis.
On [**2103-12-20**] he was taken to the Operating Room and underwent
mitral repair and coronary artery bypass grafting times 3.
CARDIOPULMONARY BYPASS TIME: 155 minutes CROSS-CLAMP TIME: 126
minutes. See operative note for full details.
The operation went without complication and the patient was
transferred to the CVICU in stable condition. He was initially
hypoxic which improved with recruitment maneuvers. The
intraaortic balloon pump was removed on the night of surgery and
he remained hemodynamically stable off all vasoactive
medications. He was started on Precedex and extubated on his
post operative night.
On POD1 beta blockers were started and he was gently diuresed
with Lasix. Chest tubes were removed per cardiac surgery
protocol and follow up CXR showed no pneumothorax. He was
transferred to the step down unit in stable condition. Pacing
wires were removed on POD3 per cardiac surgery protocol without
difficulty. He was changed from Percocet to Ultram due to
confusion and lethargy.
He worked with Physical Therapy for strength and mobility. He
was kept an extra day due to unsteadiness with ambulation. On
POD 5 he was ambulating with assistance, tolerating a full oral
diet and his incisions were healing well. It was felt that he
was safe for discharge home with visiting nurse services. There
was a tiny amount of serosanguinous drainage on the sternal
dressing the morning of discharge, however, the sternum was
stable, no further drainage could be expressed and he was
afebrile with a normal white blood cell count. All follow up
appointments were arranged.
Medications on Admission:
ATENOLOL 50 mg Tablet - 2 Tablets by mouth daily
ATORVASTATIN 40 mg Tablet - 2 Tablets by mouth every evening
ASPIRIN 81 mg Daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Severe mitral regurgitation
Unstable angina with left main stenosis
s/p insertion of intra aortic balloon
s/p urgent mitral valve repair and coronary artery bypass grafts
s/p left & right heart catheterization, coronary angiogram
hyperlipidemia
hemorrhoids
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right- healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2104-1-28**] at 1:45 pm
Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]([**Telephone/Fax (1) 4475**]) [**2104-1-15**] at 1:30pm
wound check at Cardiac Surgery office on [**1-1**]/ at 10:00am
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32651**] in [**3-6**] weeks
([**Telephone/Fax (1) **])
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2103-12-24**] |
4241,7464,4260,4019,79319,2800 | 99,880 | 179,507 | Admission Date: [**2162-4-16**] Discharge Date: [**2162-4-27**]
Service: CARDIOTHORACIC
Allergies:
Vasotec
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic Stenosis
Major Surgical or Invasive Procedure:
[**2162-4-19**] Aortic Valve Replacement (21 StJude porcine)
History of Present Illness:
87 year old woman with hypertension presented to [**Hospital3 110856**] after awakening with chest discomfort on [**4-12**]. She had
had several months of progressive DOE and fatigue. She lives
alone and at baseline is self-sufficient. She had never had
chest pain before. She denied any history of syncope. At LGH,
she was found to have severe AS and was transferred to [**Hospital1 18**] On
[**2162-4-16**] for AVR.
Past Medical History:
Aortic Stenosis
Hypertension
Status post cholecystectomy 40yrs ago
Social History:
Lives alone(5 sons near by, one in ajoining unit)
Occupation:homemaker
Cigarettes: never
ETOH: less than 1 drink/week
Illicit drug use none
Family History:
non-contributory
Physical Exam:
Pulse: Resp:14 O2 sat: 98% RA
B/P Right:134/78 Left:
Height:61" Weight:164
General:WDWN
Skin: Dry [] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur [x] grade _4/6 SEM -> neck
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [n] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:m Left:m
Pertinent Results:
[**2162-4-25**] WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3* MCV-95 MCH-29.5
MCHC-31.2 RDW-14.8 Plt Ct-196
[**2162-4-16**] WBC-4.1 RBC-3.59* Hgb-10.4* Hct-33.6* MCV-94 MCH-29.0
MCHC-31.0 RDW-14.2 Plt Ct-151
[**2162-4-25**] Glucose-183* UreaN-16 Creat-0.7 Na-139 K-4.5 Cl-96
HCO3-35
[**2162-4-16**] Glucose-176* UreaN-18 Creat-1.0 Na-141 K-4.3 Cl-104
HCO3-26
[**2162-4-16**] ALT-37 AST-55* LD(LDH)-233 AlkPhos-40 TotBili-0.3
[**2162-4-25**] Mg-1.9
MRSA SCREEN (Final [**2162-4-21**]): No MRSA isolated.
CXR: [**2162-4-24**]: There is cardiomegaly which is stable. There are
bilateral pleural effusions, right side worse than left as well
as a left retrocardiac opacity. No overt pulmonary edema or
pneumothoraces are seen. The tip of the right IJ Cordis is in
the superior SVC.
Echo: [**2162-4-19**]
PRE-CPB:
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
No thoracic aortic dissection is seen. The aortic valve is
bicuspid with horizontal commissure. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST-CPB:
A bioprosthetic valve is seen in the aortic position. The valve
appears well-seated with normally mobile leaflets. A tiny
filamentous mass is seen in the LVOT side of the aortic valve,
possibly debris from debridement or a suture. There are no
paravalvular leaks, there is no AI. The peak gradient across the
aortic valve is 21mmHg, the mean gradient is 9mmHg with CO of
3.5L/min.
Biventricular systolic function remain normal. Other valvular
function remain unchanged from pre-bypass.
There is no evidence of aortic dissection.
[**2162-4-26**] 05:40AM BLOOD WBC-5.4 RBC-3.33* Hgb-9.5* Hct-30.2*
MCV-91 MCH-28.6 MCHC-31.5 RDW-14.3 Plt Ct-181
[**2162-4-25**] 09:30AM BLOOD WBC-5.0 RBC-3.53* Hgb-10.4* Hct-33.3*
MCV-95 MCH-29.5 MCHC-31.2 RDW-14.8 Plt Ct-196
[**2162-4-26**] 05:40AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-138
K-4.4 Cl-96 HCO3-36* AnGap-10
[**2162-4-25**] 09:30AM BLOOD Glucose-183* UreaN-16 Creat-0.7 Na-139
K-4.5 Cl-96 HCO3-35* AnGap-13
Brief Hospital Course:
The patient was brought to the Operating Room on [**2162-4-19**] where
the patient underwent Aortic valve replacement with a 21-mm
Biocor tissue valve. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. The
patient was gently diuresed toward the preoperative weight. She
exhibited a high degree AV block initially, which would show
signs of recovery prior to discharge. EP was consulted and made
recommendations. Beta blockade was attempted, however this
compromised her normal sinus rhythm. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. She will not be
discharged on a beta blocker, and nodal agents should not be
initiated in the future. By the time of discharge on POD 8 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**Hospital **] Rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
Lisinopril 40mg daily, Aldactone 25mg daily, nadolol 160mg daily
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
5 days.
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
11. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane four times a day as needed for sore throat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab Center
Discharge Diagnosis:
Aortic Stenosis
Hypertension
status post cholecystectomy [**90**] yrs ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 1:15 in the
[**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A
Please call to schedule the following:
Cardiologist Dr. [**Last Name (STitle) 5017**]
Primary Care Dr. [**First Name4 (NamePattern1) 9097**] [**Last Name (NamePattern1) 110857**] [**Doctor Last Name 110858**] [**Telephone/Fax (1) 66039**] in [**4-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2162-4-27**] |
51881,5845,42832,49322,42732,2851,2762,515,4280,4019,42731,V5861,56210,2662,4168,2767,2753,E9478 | 99,881 | 172,327 | Admission Date: [**2174-1-20**] Discharge Date: [**2174-1-22**]
Date of Birth: [**2096-4-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 77 y.o. Male w/ h.o. diastolic dysfunction, A.
fib/flutter s/p recent PVI, COPD, asthma, ?IPF, HTN, initially
presented to [**Hospital1 **] [**Location (un) 620**] w/ [**1-8**] week h.o of lower extremity
edema, shortness of breath. Intubated for hypercapneic
respiratory distress. Transferred for further hypoxic work-up
whether this is COPD exacerbation, PNA, CHF exacerbation.
.
On review of pt's outside medical records it appears he was
initially admitted to [**Hospital1 18**] [**Location (un) 620**] on [**2173-1-18**] w/ a 2 week h.o.
progressive lower extremity edema, several days of SOB. Day
prior to admission pt was seen by his PCP who prescribed Steroid
taper, Azithromycin for possible COPD exacerbation. Upon
assessment in the ED it appears his oxygen saturation was 52% on
RA, HR 120, RR 32, BP 157/99. His labs at that time were
significant for a Leukocytosis of 22.0 (attributed to steroids).
Pt was given IV diuresis 100mg with poor urine output response.
A CXR was obtained which showed extesnive alveolar edema. Pt was
given repetitive Furosemide doses with little to no response in
urine output, pt was noted to have increase Creatinine,
decreased urine output. His admission labs also showed +CK-MB,
MBI, Troponins but negative CKS, am Echo which was obtained 3
days later, however, showed normal LV function, RV dilatation,
no MR, trivial TR. Pul HTN 37.
.
During the evening of [**1-19**] pt was noted to become hypoxic to
the 70% and was placed on a NRB where his O2 sat was ntoed to be
86-88%. He was titrated up to BiPAP with no reoslution in his
hypoxia, he was noted to be more lethargic. ABG showed pH of
7.17, pO2 66, pCO2 82-101, HCO 30.6, pt was intubated. His
initial ABG showed CO2 49, HCO3 30.4, pH 7.40. Sputum cx were
sent which showed . He was also noted to be anemic in the low
20s on admission. Surgery and GI were consulted and he underwent
a CT scan of his abdomen to check for an RP bld given his recent
PVI which was negative. Stools were guaiac negative as were NG
lavage. He was transfused 2 units with stable Hcts. Prior to him
leaving [**Location (un) 620**] he received Cefepime, Levofloxacin, IV
Solumedrol. A Femoral line was placed for central access. He was
influenza neg, Sputum cx showed [**10-31**] PMNs, GPC chains, rare. GP
bacili.
.
Of note pt was admitted to [**Hospital3 **] last year with similar
presentation, was initially diuresed for ?CHF exacerbation and
went into [**Last Name (un) **]. Eventually was diagnosed with Influenza A. He has
been noted to have CT changes in his chest suggesting IPF though
he has not seen a Pulmonologist. He was also admitted to [**Hospital **] in [**Month (only) 1096**] with new onset A. fib/flutter and underwent
pulmonary vein isolation. He was discharged on Coumadin as well
as a course of steroids. Per his wife he has been on a
requirement of 5L n.c. over the past month or so. Over the past
week he has been noted to desaturate to mid 80s on 5L n.c. with
movement.
.
REVIEW OF SYSTEMS:
Unable to obtain
Past Medical History:
1. He has a chronic history of asthma and a possible
COPD/chronic obstructive lung disease.
2. Possible pulmonary fibrosis that was diagnosed on a CT of
the chest but per wife he never had any further evaluation of
this fibrosis and never had any lung biopsies.
3. Atrial flutter status post ablation on [**2173-12-21**], and
started on Coumadin.
4. History of anemia that required blood transfusion around 1
year ago. No clear origin for the anemia. Previous workup for
retroperitoneal bleed. Guaiacs were all negative.
5. Hypertension.
6. Steroid-induced hyperglycemia.
7. Low vitamin B12.
8. Diastolic congestive heart failure, chronic lower limb edema
with an EF of 65%.
9. Diverticulosis as noted above.
10. Previous admissions for ARDS, CHF, COPD exacerbation,
Influenza A, A flutter.
Social History:
SOCIAL HISTORY: He lives at home. He is independent in his ADL,
IADLs but over the last year he had a big decline in his
functional status. He denies any drug abuse. No history of
smoking. He has a history of alcohol intake three to four
beers.
Family History:
non-contributory
Physical Exam:
GENERAL: Elderly Caucasian Male intubated laying down in bed
HEENT: PERRLA, MMM.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
GROIN: Femoral central noted in rt groin with pulsatile wave
form.
EXTREMITIES: 2+ edema noted b/l LE to calf.
SKIN: Multiple ecchymoses noted.
NEURO: Intubated, sedated.
Pertinent Results:
[**2174-1-20**] 02:30PM PT-32.4* PTT-33.6 INR(PT)-3.3*
[**2174-1-20**] 02:30PM PLT COUNT-264
[**2174-1-20**] 02:30PM WBC-16.7* RBC-2.72* HGB-8.0* HCT-25.4* MCV-93
MCH-29.4 MCHC-31.5 RDW-15.7*
[**2174-1-20**] 02:30PM ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-7.4*
MAGNESIUM-2.6
[**2174-1-20**] 02:30PM ALT(SGPT)-19 AST(SGOT)-34 LD(LDH)-592* ALK
PHOS-53 TOT BILI-0.4
[**2174-1-20**] 02:30PM estGFR-Using this
[**2174-1-20**] 02:30PM GLUCOSE-149* UREA N-80* CREAT-3.0* SODIUM-135
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
[**2174-1-20**] 02:40PM LACTATE-1.1
[**2174-1-20**] 02:40PM TYPE-ART PO2-147* PCO2-79* PH-7.17* TOTAL
CO2-30 BASE XS--1
[**2174-1-20**] 04:12PM CK-MB-11* MB INDX-6.3* cTropnT-0.06*
[**2174-1-20**] 04:12PM CK(CPK)-175
[**2174-1-20**] 04:34PM TYPE-ART TEMP-35.6 RATES-24/6 TIDAL VOL-400
PEEP-7 O2-70 PO2-74* PCO2-73* PH-7.20* TOTAL CO2-30 BASE XS--1
-ASSIST/CON INTUBATED-INTUBATED
[**2174-1-20**] 04:55PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-97*
LYMPHS-1* MONOS-1* OTHER-1*
[**2174-1-20**] 05:25PM URINE MUCOUS-OCC
[**2174-1-20**] 05:25PM URINE HYALINE-6*
[**2174-1-20**] 05:25PM URINE RBC-70* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-0
[**2174-1-20**] 05:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2174-1-20**] 05:25PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2174-1-20**] 05:25PM URINE HOURS-RANDOM UREA N-380 CREAT-63
SODIUM-25
[**2174-1-20**] 11:35PM freeCa-1.12
[**2174-1-20**] 11:35PM GLUCOSE-117* K+-5.2
[**2174-1-20**] 11:35PM TYPE-ART PO2-83* PCO2-76* PH-7.21* TOTAL
CO2-32* BASE XS-0
[**2174-1-21**] 12:00AM PT-21.5* PTT-31.5 INR(PT)-2.0*
Original CXR:
AP single view of the chest has been obtained with patient in
supine position. The patient is intubated, the ETT is seen to
terminate in
the trachea some 3 cm above the level of the carina. Heart size
is difficult to determine because of obscuring pulmonary
abnormalities. There exist extensive bilateral pulmonary
parenchymal densities occupying practically all lung fields in
this single view examination. There exist undoubtedly some
coinciding perivascular haze with blurred-out vascular contours.
The pleural spaces on the other hand are grossly free and in
particular the lateral pleural sinuses are not blunted. There is
no pneumothorax identified, nor is there any chest wall
emphysema.
IMPRESSION: Not having any clinical history available,
conclusive diagnosis cannot be established. Findings as
presented here are compatible with acute left-sided heart
failure and extensive pulmonary edema or ARDS. Severe pulmonary
edema related to left-sided heart failure is a likelihood.
Differential diagnosis must rely on clinical presentation.
Comparison with possibly available previous examinations is
essential
TTE:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. The right ventricular cavity
is mildly dilated with normal free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is mild functional mitral stenosis (mean
gradient 3 mmHg) due to mitral annular calcification. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild right ventricular dilation. Diastolic dysfunction. Moderate
pulmonary hypertension.
Brief Hospital Course:
##. Hypoxic Respiratory Failure: Pt has had underlying hypoxia
of unknown etiology over the past month with a requirement of 5L
O2 particularly during activity. Pt noted to be hypoxic at
outside hospital eventually requiring intubation. Etiology of
hypoxic respiratory failure includes possible infection,
cardiogenic pulmonary edema, COPD, IPF exacerbation. TTE was
repeated and was significant for moderate diastolic dysfunction
and pulmonary hypertension. Bronchoscopy and BAL was done,
bacterial, viral, fungal and PCP were negative. [**Last Name (un) **] revealed
bloody sputum and friable airway. Patient was initiated on
empiric high dose steroids, broad spectrum antibiotics and
nebulizers. Vent settings were maintained for ARDs-like picture,
given high plateua pressures suggesting very poor compliance.
Given [**Last Name (un) **] and worsening electrolytes, patient was also started
on CVVH and diuresed aggressively. Patient continued to be
acidotic and with no improvement in weaning off vent. He was
made CMO on [**2174-1-22**] (see below).
.
##. [**Last Name (un) **]: On admission pt noted to have a Creatinine of 1.8 which
trended up to 3.0 in the setting of diuresis. Etiology was
likely contrast induced. Cr continued to trend up, with
worsening hyperkalemia, elevated calcium-phos product and
evidence of volume overload. Patient was started on CVVH for
dialysis and fluid removal.
.
##. Femoral Line: Placed at OSH prior to transfer. Appears to be
placed in artery as opposed to vein given blood gas draw from
line and wave form when transduced. Pt has elevated INR of 3.3.
Line was pulled after patient was given FFP. Pt was checked for
femoral bruit, hematoma, and distal pulses q6 hours after line
pulled.
.
##. A. Flutter: Pt recently underwent PVI for new onset A.
flutter, currently in sinus rhythm. INR was noted to be
supratherapeutic, coumadin was held and pt given FFP. Continued
on diltiazem.
.
##. HL: Continued on home regimen of Simvastatin
.
[**2174-1-23**]:
16:00 pt??????s family verbalizing decision to make pt comfort care.
CRRT stopped and pt switched from fentanyl and versed drip to
morphine drip. Pt appearing very comfortable. Pt??????s ett remained
in placed and pt remaining on vent titrated down to rm air by
resp therapist. Morphine drip titrated to comfort. At 17:22 pt
pulseless. Cyanotic. Dr. [**Last Name (STitle) **] pronounced pt at 5:27pm. Pt??????s
wife [**Name (NI) **] requesting autopsy. Emotional support provided to
family. Post mortem care provided. All lines left in for
autopsy.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Propofol gtt
Furosemide 60mg [**Hospital1 **]
Albuterol/Ipratropium INH
Esomeprazole 40mg IV qday
ASA 81mg daily
Clonidine 0.1mg [**Hospital1 **]
Simvastatin 20mg qHS
Levothyroxine 37.5mcg daily
Methylprednisolone 80mg q8hrs
Flunisolide 1 puff [**Hospital1 **]
Diltiazem 180mg daily
Monteluekast 10mg daily
Colace
Vancomycin 1gm
Cefepime
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
41401,42823,5185,49322,9994,4280,99527,E9353,42731,E9478 | 99,883 | 150,755 | Admission Date: [**2131-12-24**] Discharge Date: [**2131-12-27**]
Date of Birth: [**2058-2-4**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ASA desensitization
Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2131-12-24**])
Intubation ([**2131-12-25**])
History of Present Illness:
The pt is a 73-yo man w/ severe COPD and recently-diagnosed
cardiomyopathy with EF 30% who presented to OSH on [**2131-12-21**]
with complaints of increasing SOB, DOE, orthopnea, PND, chest
tightness, and wheezing. He denied any chest pain, palpitations,
lightheadedness, syncope, lower extremity edema, fevers, chills,
cough, or sputum production. He was treated as an acute on
chronic CHF exacerbation with diuresis as well as a COPD
exacerbation with steroids and nebulizers. He was seen by
Cardiology and Pulmonology consults, and repeat TTE showed an
LVEF of 20-25% with global LV hypokinesis and chamber
dilatation, and the possibility of an apical thrombus could not
be ruled out. He was started on weight-based heparin gtt and
transferred to the [**Hospital1 18**] Cardiac Cath Lab for catheterization.
Catheterization here showed diffuse 20-30% stenosis with
mid-vessel 80% stenosis of the LAD and mild luminal
irregularities with mid-vessel 60% eccentric stenosis of the
LCx. Given his ASA allergy, he is admitted to the CCU for ASA
desensitization and investigation of viability of the
anteroapical wall in anticipation of probable PCI of the LAD
lesion.
.
On arrival to the CCU: VS - Temp 97.6F, BP 125/93, HR 94, R 22,
SaO2 97% 2L NC. He complains of mild left groin pain at the
catheterization site.
.
ROS: He acknowledges a prior history of TIA but denies any
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, hemoptysis, black
stools or red stools. All of the other review of systems were
negative.
.
Past Medical History:
- severe COPD / bronchial asthma
- cardiomyopathy w/ EF 30-35%, cause unknown
- suspected TIA
- h/o recent pneumonia
- LBBB on ECG
- nephrolithiasis
- s/p cataract surgery
- s/p hernia repair
Social History:
Lives with his wife, fairly independent until symptomatic w/
SOB.
-Tobacco history: x15-20years, Quit smoking: [**2104**]
-ETOH: Quit in [**2105**].
-Illicit drugs: None.
Family History:
Mother had a stroke, Father had CAD. No early CAD.
Physical Exam:
VS: T = 97.6 F, BP = 125/93, HR = 94, RR = 22, O2 sat = 97% 2L
NC
GENERAL: WA middle-aged man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL/EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm. No LAD or thyromegaly.
CARDIAC: PMI located in 5th intercostal space, non-displaced.
RRR w/ freq APCs and PVCs. Normal S1, S2. +[**2-1**] HSM at apex. No
r/g, thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
mildly labored, tachypneic, no accessory muscle use. +Bibasilar
crackles and scattered wheezes, prolonged expiratory phase.
ABDOMEN: +BS, soft/NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: WWP, no c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2131-12-24**] 08:26PM BLOOD WBC-8.2 RBC-4.02* Hgb-11.8* Hct-35.0*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.0 Plt Ct-293
[**2131-12-24**] 08:26PM BLOOD Neuts-84.6* Lymphs-9.4* Monos-5.9 Eos-0.1
Baso-0
[**2131-12-24**] 08:26PM BLOOD PT-12.7 PTT-25.9 INR(PT)-1.1
[**2131-12-24**] 08:26PM BLOOD Glucose-106* UreaN-26* Creat-0.9 Na-141
K-4.7 Cl-103 HCO3-31 AnGap-12
[**2131-12-26**] 05:31AM BLOOD LD(LDH)-333*
[**2131-12-26**] 05:31AM BLOOD cTropnT-0.08*
[**2131-12-24**] 08:26PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3
.
.
ECG ([**2131-12-24**]): Sinus rhythm with atrial premature beats and
possible first beat being a ventricular premature beat. Left
bundle-branch block. No previous tracing available for
comparison.
.
CARDIAC CATH ([**2131-12-24**]):
1. Selective coronary angiography of this left dominant system
revealed
one vessel coronary artery disease. The LMCA had no
angiographically
apparent disease. The LAD had diffuse 20-30% lesions throughout
with a
mid vessel 80% stenosis. The Lcx had mild luminal irregularities
with a
mid vessel 60% eccentric stenosis. The RCA was small and
nondominant
without any angiographically apparent stenosis.
2. Resting hemodynamics revealed elevated right sided filling
pressures
with an RVEDP of 17 mmHg. There was moderate pulmonary
hypertension with
a pulmonary artery pressure of 47/21 mmHg. There were moderately
elevated left sided filling pressures with a PCWP mean of 24
mmHg. There
was normal central aortic pressures of 126/77 mmHg. The cardiac
index
was normal at 2.9 L/min/m2.
3. Left vetriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Moderate diastolic dysfunction.
4. Elevated RVEDP
.
CXR ([**2131-12-24**]):
1. Hazy opacity in the lingula and left lower lobe, concerning
for early pneumonia versus asymmetric edema.
2. Cardiomegaly. Mild vascular congestion with interstitial
edema.
3. Right retrocardiac density, atelectasis versus pneumonia. PA
and lateral views are recommended for better assessment of this
area.
.
TTE ([**2131-12-25**]):
The left atrium is normal in size. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = [**10-9**] %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricular cavity with severe global
hypokinesis. Preserved right ventricular cavity size and
systolic function. Moderate mitral regurgitation. Mild pulmonary
hypertension.
.
CT Abdomen/Pelvis ([**2131-12-26**]):
1. There is no evidence of a retroperitoneal hematoma.
2. Marked asymmetric enlargement of the proximal right thigh
musculature, consistent with the patient's history of a known
hematoma.
3. Small left greater than right pleural effusions with
associated compressive atelectasis of the posterior lung bases.
4. Cholelithiasis.
5. Extensive colonic diverticulosis without evidence of
diverticulitis.
.
Femoral Vascular U/S ([**2131-12-26**]):
FINDINGS: There is no evidence of pseudoaneurysm or A-V fistula,
as questioned. There is a large right groin/thigh hematoma as
seen on CT, measuring at least 13.0 cm in greatest dimension.
IMPRESSION: No evidence of pseudoaneurysm of AVF. Large right
groin/thigh hematoma.
.
Brief Hospital Course:
The patient is a 73-year-old man with severe COPD and
recently-diagnosed cardiomyopathy with EF 30%, who presented to
an OSH on [**2131-12-21**] with symptoms of acute on chronic systolic
heart failure, transferred to [**Hospital1 18**] for cardiac catheterization
to assess for ischemic cardiomyopathy, which showed LAD disease.
He was admitted to the CCU for aspirin desensitization with plan
for repeat cardiac catheterization and PCI.
.
#. Aspirin desensitization - The patient was admitted to the CCU
overnight for aspirin desensitization. He completed the protocol
overnight, but approximately 1 hour after completion he suffered
from acute-onset of severe respiratory distress with chest
tightness and wheezing, consistent with anaphylaxis. He was
treated with steroids, H1- and H2-blockers, as well as
treatments directed at his COPD, CHF, and anxiety, with no
improvement, so he was intubated for respiratory failure. He was
extubated later that day with significant improvement. He was
seen by the Allergy consult service, who felt that this was
consistent with anaphylaxis, and recommended repeat
desensitization after a couple weeks if needed. He is stable for
discharge.
.
#. Acute on chronic systolic CHF - The patient was recently
diagnosed with a cardiomyopathy of unknown etiology, and was
being treated for acute on chronic systolic heart failure prior
to transfer. On transfer, he was still mildly fluid overloaded,
so diuresis was continued with Lasix and spironolactone. Repeat
TTE here revealed EF 15% with global LV dysfunction and no
wall-motion-abnormalities to suggest ischemic cardiomyopathy. He
is being discharged on Lasix and spironolactone, as well as a
beta-blocker and an ACE-inhibitor.
.
#. Coronary artery disease - The patient underwent cardiac
catheterization that showed a left-dominant system, an LAD with
diffuse 20-30% lesions throughout and mid-vessel 80% stenosis,
and a LCx with mild luminal irregularities and mid-vessel
eccentric 60% stenosis. He was admitted for the aspirin
desensitization protocol as above, but given his anaphylaxis he
is not being discharged on aspirin. It was also suggested that
he would need a viability study to assess for antero-apical
myocardial viability in preparation for a potential PCI of his
mid-LAD lesion, but his TTE showed no wall-motion-abnormalities
to suggest ischemia as the reason for his cardiomyopathy, so
there was felt to be no indication for viability study at this
time. He is being discharged home on Plavix, beta-blocker, and
lisinopril.
.
# ? Apical thrombus - The patient was transferred to [**Hospital1 18**] for
evaluation for apical thrombus as the TTE done at OSH was unable
to properly assess the apex. He was transferred on an IV heparin
gtt, but TTE here showed no evidence of apical thrombus, so this
was discontinued. He is being discharged off of anticoagulation.
.
# COPD - The patient has a history of severe COPD, with mild
wheezes on exam on admission. This was significantly worsened
after his intubation for anaphylaxis as above, so he was treated
with IV Solu-Medrol and then quickly transitioned to Prednisone
for a rapid taper. He was otherwise continued on Advair,
Spiriva, and nebulizers as needed, and showed significant
improvement by discharge.
Medications on Admission:
HOME MEDICATIONS:
- Plavix 75mg PO daily
- Nexium 40mg PO daily
- Lisinopril 10mg PO daily
- Toprol XL 37.5mg PO daily
- Salmeterol 50mcg 1puff INH [**Hospital1 **]
- Spironolactone 25mg PO daily
- Tiotropium 18mcg 1puff INH daily
- Docusate 100mg PO daily
.
.
TRANSFER MEDICATIONS:
- Plavix 75mg PO daily
- Lisinopril 10mg PO daily
- Advair Diskus 250/50 1puff INH [**Hospital1 **]
- Guaifenesin syrup 200mg QID PRN
- SL NTG PRN
- Tylenol PRN
- Nexium 40mg PO daily
- Solu-Medrol 60mg IV daily
- Tiotropium 18mcg 1puff INH daily
- Spironolactone 25mg PO daily
- Toprol XL 37.5mg PO daily
- Lasix 20mg IV BID
- Xopenex nebs PRN
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
Disp:*1 Diskus* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Puff Inhalation once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: ([**12-28**]) One-Half Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours.
Disp:*1 Inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aspirin allergy: anaphylaxis
2. Non-ischemic cardiomyopathy (EF 15%)
3. Coronary artery disease
4. Severe COPD
5. Atrial fibrillation
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for cardiac catheterization, and you
were found to have a blockage in one of the arteries of your
heart. Since you are allergic to Aspirin, you were admitted to
the CCU for Aspirin desensitization. At the end of the
desensitization you had an anaphylactic reaction that required
intubation. You were extubated quickly and have done well since.
You do have an exacerbation of your COPD (chronic lung disease)
and are being treated for it with steroids. You will need to
continue to take your medications as prescribed below. You also
have atrial fibrillation but were not treated with blood
thinners because you were not on this medication at home. You
should discuss starting blood thinners (Coumadin) with your
cardiologist at home. You should follow-up with your primary
care doctor and your cardiologist within 1 week.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You should call your doctor or return to the Emergency Room for
any concerning symptoms, including:
- chest pain, shortness of breath, wheezing, palpitations
- allergic reaction
- leg swelling, feeling faint
- fevers or chills
- any other concerning symptoms.
Followup Instructions:
You should follow-up with your cardiologist at home within 1
week.
You should follow-up wiht your PCP (Dr. [**Last Name (STitle) 77512**] within [**12-28**]
weeks.
You should discuss blood thinners with your cardiologist for
your atrial fibrillation.
|
41401,42822,4139,4254,4280,49320,4263,V1251,V5861,V1254 | 99,883 | 198,523 | Admission Date: [**2132-9-15**] Discharge Date: [**2132-9-21**]
Date of Birth: [**2058-2-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Ibuprofen
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2132-9-16**] - Coronary artery bypass grafting x3 with left internal
mammary artery grafted to the left anterior descending, reverse
saphenous vein graft to the posterior descending artery and the
marginal branch.
History of Present Illness:
74 yo M with known 2vCAD who presents
to clinic for evaluation for possible surgical
revascularization.
Pt was admitted to [**Hospital3 417**] Hospital on [**2131-12-21**] with
increasing SOB and chest pain. He was treated for CHF as well as
COPD flare. He was then transferred to [**Hospital1 18**] for ASA
desensitization and cardiac cath. Pt developed anaphylactic
reaction shortly after desensitization procedure complete and
required short intubation for respiratory failure. Cath during
that admission showed small, nondominant right coronary artery
with 80% LAD lesion and 60% lesion in the circumflex. Of note,
his chest discomfort has improved dramatically with the
initiation of Imdur.
Past Medical History:
- severe COPD / bronchial asthma
- cardiomyopathy w/ EF 30-35%, cause unknown
- suspected TIA
- h/o recent pneumonia
- LBBB on ECG
- nephrolithiasis
- s/p cataract surgery
- s/p hernia repair
- chronic systolic heart failure
Social History:
Lives with his wife, fairly independent until symptomatic w/
SOB.
-Tobacco history: x15-20years, Quit smoking: [**2104**]
-ETOH: Quit in [**2105**].
-Illicit drugs: None.
Family History:
Mother had a stroke, Father had CAD. No early CAD.
Physical Exam:
Physical Exam:
VS: T 97 HR:100 Resp:20 O2 sat:96% RA
B/P Right: 137/60 Left: 134/56
Ht 64" Wt 59.6K
General: Elderly gentleman in no acute distress
Skin: Dry [x] intact [x] - well healed abd incision, mesh
palpable from prior hernia operation
HEENT: PERRLA [x] EOMI [x] anicteric, MMM, OP benign
Neck: Supple [x] Full ROM [x] no Lymphadenopathy
Chest: diffuse inspiratory and exp wheezing Heart: RRR [x]
Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, A&Ox3, MAE, follows commands
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: decreased Left: decreased
PT [**Name (NI) 167**]: decreased Left: decreased
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none appreciated Left: none appreciated
++ Femoral Bruits noted bilaterally
Pertinent Results:
[**2132-9-16**] ECHO
Pre-bypass:
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is severely depressed (LVEF= 20 %).
Right ventricular chamber size is normal. with borderline normal
free wall function.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened.
Torn mitral chordae are present. Mild to moderate ([**12-28**]+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-bypass:
The patient is AV-Paced and receiving 0.02 mcg/kg/min of
epinephrine post-CPB.
The LV - EF is approximately 30%.
There is mild mitral regurgitation.
All other findings are consistent with pre-bypass findings.
The aorta is intact post-decannulation. All findings
communicated to [**Month/Day (2) 5059**].
[**2132-9-21**] 06:45AM BLOOD WBC-9.8 RBC-3.87* Hgb-11.3* Hct-35.0*
MCV-90 MCH-29.2 MCHC-32.3 RDW-14.6 Plt Ct-294
[**2132-9-21**] 06:45AM BLOOD PT-14.4* INR(PT)-1.2*
[**2132-9-21**] 06:45AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-139
K-3.9 Cl-99 HCO3-28 AnGap-16
Brief Hospital Course:
Mr. [**Known lastname 1001**] was admitted to the [**Hospital1 18**] on [**2132-9-15**] for surgical
management of his coronary artery disease. He was taken to the
Operating Room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Within the next 24 hours, he awoke
neurologically intact and was extubated. Hew as then transferred
to the step down unit on postoperative day one. He was gently
diuresed towards his preoperative weight. He was started on an
ACE-I due to a low ejection fraction. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. Chest tubes and pacing wires were
removed per cardiac surgery protocol. His narcotics were
discontinued due to visual hallucinations and he was using
Ultram sparingly for pain control. His visual haalucinations
abated. He benefited from vigorous pulmonary therapy. He has an
allergy to ASA and therefore was not started on it. He is being
anticoagulated with Plavix and Coumadin for a history of DVT.
First INR draw to be done Mon [**9-22**] with results to be called to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8725**] or faxed to [**Telephone/Fax (1) 8719**] for
further instructions for coumadin dosing. Goal INR [**1-29**] for
history of DVT. He was deemed safe for discharge home with
services on POD#5.
Medications on Admission:
Plavix 75 mg daily
Spiriva 18 mcg daily
Lisinopril 10 mg daily
Advair 500/50 ipuff [**Hospital1 **] PRN
ALbuterol inh ii puffs daily PRN
Xopenex neb 1.25mg
Spironolactone 25 mg daily
Lasix 40mg daily
Digoxin 0.125mcg tablet daily
Simvastatin 40mg daily
Warfarin daily
Metoprolol daily
Imdur 30 daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*30 * Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
dosing per the office of Dr. [**Last Name (STitle) **]. .
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
INR to be drawn on [**2132-9-22**] with results sent to the offie of Dr.
[**Last Name (STitle) **]. Fax number ([**Telephone/Fax (1) 81642**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABGx3
Aspirin Allergy
Severe COPD, Lifelong Asthma
Coronary Artery Disease, Ischemic Cardiomyopathy
Hypertension
Dyslipidemia
History of TIA [**2130**] - no residual deficit
History of DVT/significant groin hematoma(post-cath) - right
lower extremity, on coumadin
Left bundle branch block
Nephrolithiasis
Nasal polyposis
Recurrent sinusitis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) First INR/Potassium blood draw [**9-22**] with results to be faxed
to [**Telephone/Fax (1) 8719**] or called to [**Telephone/Fax (1) 8725**] with instructions for
coumadin dosing to be given-Goal INR [**1-29**]
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 81643**] [**Name (STitle) **] in [**1-29**] weeks ([**Telephone/Fax (1) 18658**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 10381**]
Please call all providers for appointments.
Completed by:[**2132-9-21**] |
42823,51882,5849,3371,4280,41400,4148,V4581,V4582,V462,3320,V4986,7802,E8846,25050,36201,V5867,2724,40390,5859,43889,72989,V1582 | 99,893 | 128,349 | Admission Date: [**2193-3-31**] Discharge Date: [**2193-4-7**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 1968**] is an 88 year-old man with CAD s/p CABG in [**2162**] and
PCI at [**Hospital1 2025**] in [**2192**], mild AS, Parkinsons with autonomic
instability, CHF with EF 30% with multiple recent admissions for
exacerbations ([**3-8**], [**1-31**], [**1-18**]) presents with acute onset
dyspnea.
.
Patient reports acute onset tachypnea and chest pressure after
having large BM this afternoon. Of note, he is DNR/DNI and the
family has explicit wishes not to escalate care or have invasive
procedures, including cardiac catheterization. The patient was
previously discharged with palliative care and CHF nurse, with
morphine and metolazone as rescue medications (which have not
been used to date.) During his previous admission, he
experianced significant orthostasis with SBPs in the 70s
following potentiation of lasix with 5mg of metolazone. The
patient's daughter considered using metolazone this afternoon,
but was unable to communicate with his outpatient physcians and
therefore elected to bring him to the ED instead.
.
In ED, initial VS: 96.8 72 160/51 20 and SaO2 70% on RA. Initial
exam was notable for tachypnea and wet rales throughout lung
fields. Labs notable for Cr of 1.8. EKG showed LBBB, unchanged
from previous. CXR c/w pulmonary edema. Patient placed on CPAP,
nitro gtt and given 80mg IV lasix with 420cc UOP with SaO2
rising to 100%. He was subsequently admitted to the CCU for
further managment.
.
On initial evaluation in the CCU, he is wearing a BiPAP mask and
appears comfortable. He is without addition complaint.
.
On review of systems, he denies deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,
Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2162**]
-PERCUTANEOUS CORONARY INTERVENTIONS: stenting x in [**3-/2192**]
3. OTHER PAST MEDICAL HISTORY:
- Parkinson's disease
- Diabetic retinopathy
- s/p Carotid endarterectomy
- systolic CHF
- mild Aortic stenosis
- L CVA in [**2179**] with residual R sided weakness
Social History:
Widowed, has 3 adult children, lives with daughter who cares for
him at baseline. He has a night aide from 8:00 pm until 8:00 am
and goes to adult daycare. Needs walker + assistance for
ambulation. He requires assistance with showering. He feeds
himself.
-Tobacco history: prior use, quit several years ago
-ETOH: moderate use, many years ago, currently none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: T=99.4 BP=133/59 HR=82 RR=20 O2 sat=100% on BiPap 50% FiO2
with PEEP 5 PS 8
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm. Marked kyphosis evedent on exam.
CARDIAC: Well healed sternotomy notable on exam. Heart sounds
are faint [**2-20**] to CPAP noise, no m/r/g. No thrills or lifts.
LUNGS: Significant kyphosis. Crackles noted in BL lower lobes
with minimal wheezes and no rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Discharge Exam:
Gen: alert, oriented, NAD, joking with examiner
HEENT: supple, difficult to assess JVD [**2-20**] upright position
CV: RRR, [**Month (only) **] HS, no M/R/G
RESP: [**Month (only) **] BS, no obvious crackles.
ABD: soft, NT
EXTR: no edema
NEURO: A/O, weak [**2-20**] hospitalization but no obvious unilateral
defects
Extremeties:
Pulses: palpable.
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Pertinent Results:
Admission Labs:
[**2193-4-1**] 04:35AM BLOOD WBC-8.5 RBC-3.56* Hgb-10.2* Hct-30.6*
MCV-86 MCH-28.7 MCHC-33.4 RDW-16.1* Plt Ct-200
[**2193-4-1**] 04:35AM BLOOD Glucose-136* UreaN-47* Creat-1.6* Na-135
K-4.3 Cl-94* HCO3-31 AnGap-14
[**2193-3-31**] 07:59PM BLOOD Glucose-258* UreaN-49* Creat-1.8* Na-132*
K-5.2* Cl-92* HCO3-24 AnGap-21*
[**2193-4-1**] 04:35AM BLOOD CK(CPK)-47
[**2193-3-31**] 07:59PM BLOOD CK(CPK)-56
[**2193-4-1**] 04:35AM BLOOD CK-MB-3 cTropnT-0.02*
[**2193-3-31**] 07:59PM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-5630*
[**2193-4-1**] 04:35AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3
[**2193-3-31**] 07:59PM BLOOD Digoxin-0.3*
[**2193-3-31**]: CXR:
SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median
sternotomy. The cardiac silhouette is normal in size. Diffuse
airspace opacities are noted, more pronounced on the right
compared to the left, with vascular indistinctness compatible
with moderate pulmonary edema. Bilateral pleural effusions are
small. More focal opacities in the retrocardiac region and right
lung base may reflect atelectasis. There is no pneumothorax. No
acute osseous findings are seen.
IMPRESSION: Moderate pulmonary edema with small bilateral
pleural effusions and bibasilar atelectasis.
Discharge Labs:
[**2193-4-6**] 09:15AM BLOOD WBC-6.6 RBC-4.09* Hgb-11.5* Hct-34.9*
MCV-86 MCH-28.1 MCHC-32.9 RDW-15.7* Plt Ct-261
[**2193-4-6**] 09:15AM BLOOD Glucose-168* UreaN-67* Creat-1.8* Na-135
K-4.0 Cl-89* HCO3-33* AnGap-17
[**2193-4-5**] 06:05AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.7*
Brief Hospital Course:
Patient is an 88 year-old man with CAD s/p CABG in [**2162**] and PCI
at [**Hospital1 2025**] in [**2192**], mild AS, Parkinsons with autonomic instability,
CHF with EF 30% with multiple recent admissions for
exacerbations ([**3-8**], [**1-31**], [**1-18**]) who presented with acute on
chronic systolic CHF.
# PUMP: Patient has known brittle choronic systolic congesitive
heart failure that has been exacerbated on numerous occasions
over the past year. He presented with an acute exacerbation that
appears to have been precipitated by the a straining episode
while having a bowel movement. It is also possible that more
strenous PT over the two days prior to admission contributed to
his decompensation by transiently increasing his blood pressure.
He had previously been feeling well and was well compensated. He
responded well IV lasix and an attempt was made to transition
him to lasix po on hospital day 2. However, he did not respond
as expected to the oral lasix and he reaccumulated fluid and had
to be given lasix 80 mg iv x2 plus a lasix gtt with BiPAP for a
few hours for respiratory distress. This episode seemed to be
triggered by being moved for nursing care further enforcing how
brittle his heart failure is at this point. After recovering
from this episode he was then transitioned to po torsemide and
was discharged home on 20mg PO torsemide daily with instructions
to increase torsemide if worsened SOB at home and PRN metolazone
to be taken at home if more SOB. Pt [**Last Name (un) **] been stable for 2 days
on current diuretic regimen at time of discharge. He was
continued on his home dose of digoxin 0.125mg QOD.
# Goals of Care: Due to severity of heart failure and how
tenuous patient status appears to be, pt's daughters had
multiple conversations with the palliative care service during
the hospitalization. Palliative care had been consulted at the
request of the palliative service who was aware of the patient.
They followed during hospitalization and continued to give recs
about care. They are currently working with daughters to develop
a plan for possible outpatient hospice. For now, pt going home
with palliative care NP home visits planned but not definitive
hospice plans yet made.
# Respiratory distress: Patient presented with hypoxia, likely
in the setting of CHF exacerbation. He was appropriately
diuressed in the ED with stabilization of his oxygenation on
BiPAP. He was transitioned to nasal cannula on arrival to the
CCU. He was continued on 2 L NC prn and patient has 2L home O2
requirment occasionally for comfort and sleep. On hospital day
2, he reaccumulated fluid on po lasix and was on BiPAP for a
short time. After response to iv lasix (including lasix gtt), he
was transitioned back to face mask and then nasal cannula when
sats improved. At time of discharge pt was satting in mid 90s on
RA and was comfortable.
.
# CORONARIES: Patient has known coronary disease s/p CABG and
PCI on clopidigrel and ASA daily. He had no evidence of ACS on
symptoms or CEs. His EKG was unchaged from 2/[**2193**]. He was
continued on clopidigrel 75mg daily, Aspirin 81mg daily,
Atrovastatin 20mg daily, Carvidolol 3.125mg [**Hospital1 **]. He was not
started on an ACE-inhibitor as it was stopped during the last
admission for orthostatic hypotension.
.
# RHYTHM: LBBB was known from prior admission with no
significant change noted on EKG. He was monitored on telemetry
with no rhythm changes noted.
.
# Type 2 diabetes: Well controlled on current regimen. He was
continued on NPH 70/30 [**Hospital1 **] with humalog sliding scale. Some
alterations were briefly made while pt not eating due to BiPAP
but went back to home regimen when diet restarted. Blood sugars
ranged from 80-200s on home regimen during hospitalization.
.
# Chronic renal insuficiency: Creatinine was initially elevated
to 1.8 (recent baseline of 1.6). His creatinine came back down
to 1.6 on hospital day two and remained stable in the 1.5-1.8
range while in the hospital. Cr was 1.8 on day before discharge.
# Parkinson's disease: Stable. He was continued on home
carbidopa, levodopa, entacapone, selegiline, home requip XL. Pt
was having some groin pain thought [**2-20**] to cramping from
Parkinson's and was started on tylenol to help with this while
inpt.
.
Medications on Admission:
- Home O2 1-2L continuous O2, pulse dose for portability.
- pantoprazole 40 mg Tablet 0.5 tab q 24hrs.
- entacapone 200 mg Tablet QID
- selegiline HCl 5 mg Capsule [**Hospital1 **]
- clopidogrel 75 mg Tablet DAILY
- Requip XL 12 mg Tablet Extended Release 24 hr qam
- carvedilol 3.125 mg Tablet [**Hospital1 **]
- polyethylene glycol 3350 17 gram/dose Powder daily
- docusate sodium 100 mg Capsule [**Hospital1 **]
- donepezil 5 mg 2 tabs QHS
- aspirin 81 mg Tablet daily
- atorvastatin 20 mg Tablet QHS
- calcium carbonate 200 mg (500 mg) Tablet, [**Hospital1 **]
- cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]
- carbidopa-levodopa 25-100 mg Tablet 1.5 Tablets PO QID
- Humulin 70/30 18U qam, 11U qpm (prior to dinner)
- Lasix 80 mg Tablet daily
- morphine 10 mg/5 mL Solution 2.5mg PO prn chest pain
- metolazone 2.5 mg Tablet Sig: 0.5 Tablet PO prn SOB
- digoxin 125mg QOD
Discharge Medications:
1. Home equipment
- [**Hospital 485**] hospital bed for CHF- medically necessary for
body positioning for shortness of breath
- commode
- wheelchair
- bedside table
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: 0.5
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Requip XL 12 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO qam ().
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO twice a day.
9. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QID
(4 times a day).
16. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous once a day: 11 units at
night.
17. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO three times a
day as needed for chest pain.
19. metolazone 2.5 mg Tablet Sig: 0.5 Tablet PO once a day as
needed for shortness of breath or wheezing.
20. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Can increase to 2 pills twice daily if needed.
22. lactulose 10 gram/15 mL Solution Sig: Ten (10) grams PO
twice a day as needed for constipation: Only take if you have
not had a BM in [**2-21**] days. .
Disp:*30 cups* Refills:*2*
23. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once as needed for shortness of breath or wheezing:
Please call your cardiologist before taking this medication. You
must be lying down in bed when you take this medication. .
Disp:*10 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure
Parkinson's syndrome
Coronary artery disease
Diabetes mellitus type 2
Acute on chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had an acute exacerbation of your congestive heart failure
and required diuretics to remove extra fluid. We have adjusted
your medicines to minimize a drop in your blood pressure and to
try to keep the fluid off. Weigh yourself every morning, call
Dr. [**First Name (STitle) 2920**] if weight goes up more than 1 lbs in 1 day or 3 pounds
in 3 days. This is very important to prevent episodes of
congestive heart failure. You may also be asked to use
metolazone or increase the dose of torsemide if additional
diuresis is needed at home. Please also follow a low sodium
diet. You also have morphine liquid to use at the first sign
that you may be having difficulty breathing. Draw up 2.5 cc (a 5
mg dose) and take 1.25cc first (2.5mg). If your breathing does
not improve in 10 minutes, you can take an additional 1.25cc.
Please call Dr.[**Name (NI) 17793**] office right away if you take any
morphine. You have nitroglycerin at home but don't use that
unless Dr. [**First Name (STitle) 2920**] or other health provider tells you it is OK to do
so. If you use the nitroglycerin, you should be laying in bed at
home as your blood pressure may get lower after you take this
medication.
An appt was made with a PA who works with Dr. [**First Name (STitle) 2920**], please cancel
this if you are unable to get there. A palliative care nurse
practitioner will visit you at home and help you sort out
decisions about further hospitalizations and care at home.
.
We made the following changes to your medicines:
1. Decrease the torsemide to 20 mg daily. Dr. [**First Name (STitle) 2920**] may tell you
to take more if your weight rises or take additional metolazone
at home.
2. STOP taking Carvedilol, take metoprolol instead to help your
heart pump better.
3. Increase the colace to 200mg twice daily to prevent
constipation
4. Increase the miralax to twice daily
5. Start senna one tablet twice daily, you can increase to 2
tablets twice daily if needed.
6. Start lactulose twice daily if all of the above fails to
initiate a bowel movement in [**2-21**] days.
7. Nitroglycerin sub-lingual 0.3mg once if short of breath.
Please call your cardiologist before using this medication and
you must be lying in bed when you take this medication because
your blood pressure may fall.
Followup Instructions:
Dr. [**First Name (STitle) 2920**]:
Name: PA [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**]
Location: [**Location (un) 2274**] [**University/College **]
Address: [**University/College 88277**], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 72622**]
Appointment: Wednesday [**2193-4-10**] 1:30pm
|
5789,5990,45829,5849,2762,E9452,04104,340,2724,2449,56409,92410,E9179 | 99,894 | 127,380 | Admission Date: [**2129-7-4**] Discharge Date: [**2129-7-15**]
Date of Birth: [**2069-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
The patient is a 60 year old female with a history of MS who
presents with complaints of weakness. Patient has significant
debilitation from her MS, with the use of a wheel chair at
baseline. She is followed by Dr. [**Last Name (STitle) **] of neurology at [**Hospital1 18**],
but hasn't been seen by her in over 3 years.
6 weeks prior, the patient developed shingles. Since that time,
she has felt continued malaise and fatigue. She denies any
weight loss, weight gain, fevers, chills, cough, chest pain, or
shortness of breath. In the few days prior to presentation, the
patient felt a dramatic increase in her fatigue, such that she
couldn't transfer from bed to chair. She also felt confused,
not recognizing her own kitchen. She denies any headahes,
blurred vision, or worsening motor/sensory deficit. She was
told by her care taker that her urine may be smelly. She called
Dr. [**Last Name (STitle) **], who recommended evaluation in our ED. Of note, she
has not noted any blood in her stools, and last scope was 2
years prior.
In the ED, initial vs were: T 97.9 P 76 BP 85/50 R 19 O2 sat 99%
on 2L NC. The patieng triggered on arrival for hypotention,
although all remainin BP in ED was > 100 systolic over a 4.5hr
time perior, and SBP on time of transfer was 145/71. With
complaints of generalized weakness and foul smelling urine, the
patient was given vanc/ceftaz/levo with concern of urosepsis.
She was given 3L of NS. The patient was then found to be
grossly guaic positive w/ reports of dark stool. She had a
negative NG lavage. A FAST u/s was optained and was negative.
She was given 40mg IV protonix, had a CVL placed for access, and
was admitted to the MICU for further manegment.
Past Medical History:
Secondary Progressive MS
[**First Name (Titles) 49099**]
[**Last Name (Titles) 49100**]
Rectal discomfort
Hypothyroidism
Social History:
Patient is divorced and lives alone, with the assistance of a
care taker. Ex-husband active in routine. Son would be HCP.
Does not smoke or drink
Family History:
No family history of colon cancer or colonic polyps.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2129-7-4**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2129-7-4**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-7-4**] 05:33PM LACTATE-1.4
[**2129-7-4**] 05:21PM GLUCOSE-122* UREA N-45* CREAT-1.5* SODIUM-142
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
[**2129-7-4**] 05:21PM ALT(SGPT)-21 AST(SGOT)-26 CK(CPK)-135 ALK
PHOS-101 TOT BILI-0.3
[**2129-7-4**] 05:21PM LIPASE-31
[**2129-7-4**] 05:21PM cTropnT-0.03*
[**2129-7-4**] 05:21PM CK-MB-6
[**2129-7-4**] 05:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2129-7-4**] 05:21PM WBC-10.7 RBC-3.27* HGB-10.3* HCT-30.5* MCV-93
MCH-31.7 MCHC-33.9 RDW-13.5
[**2129-7-4**] 05:21PM NEUTS-83.5* LYMPHS-12.1* MONOS-3.6 EOS-0.5
BASOS-0.2
[**2129-7-4**] 05:21PM PLT COUNT-277
[**2129-7-4**] 05:21PM PT-11.9 PTT-24.4 INR(PT)-1.0
Labs during admission:
[**2129-7-7**] 04:14AM BLOOD CK-MB-5 cTropnT-0.01
[**2129-7-7**] 04:29PM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-7-8**] 01:10AM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-7-4**] 05:21PM BLOOD ALT-21 AST-26 CK(CPK)-135 AlkPhos-101
TotBili-0.3
[**2129-7-7**] 04:14AM BLOOD CK(CPK)-204*
[**2129-7-7**] 04:29PM BLOOD CK(CPK)-140
[**2129-7-8**] 01:10AM BLOOD CK(CPK)-123
[**2129-7-4**] 05:21PM BLOOD cTropnT-0.03*
[**2129-7-6**] 02:39AM BLOOD freeCa-1.20
[**2129-7-6**] 02:13AM BLOOD Free T4-1.2
[**2129-7-5**] 04:20AM BLOOD TSH-0.18*
[**2129-7-5**] 04:20AM BLOOD calTIBC-280 Ferritn-72 TRF-215
[**2129-7-5**] 10:00AM BLOOD Hapto-173
[**2129-7-4**] 7:50 pm URINE Site: CATHETER
**FINAL REPORT [**2129-7-7**]**
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
VIRIDANS STREPTOCOCCI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
Labs on discharge:
[**2129-7-13**] 06:10AM BLOOD WBC-7.4 RBC-3.36* Hgb-10.6* Hct-30.8*
MCV-92 MCH-31.6 MCHC-34.4 RDW-14.5 Plt Ct-379
[**2129-7-13**] 06:10AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-144 K-4.3
Cl-111* HCO3-24 AnGap-13
[**2129-7-13**] 06:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
STUDIES:
CT ABD [**2129-7-5**]:
1. Inflammatory wall thickening in 12 cm loop of proximal
transverse colon.
Differential diagnosis includes inflammatory, infectious, or
ischemic. No
focal abscess or fluid collection. Although there are scattered
colonic
diverticula this does not appear to be the source of this
problem.
2. Multiple liver cysts.
.
CXR [**2129-7-4**]: Overall findings are suggestive of mild/early CHF.
Prominence of the left paratracheal stripe in the configuration
of aortic arch suggests unfolding. If a dissection is suspected
clinically, CT of the chest is warranted.
.
CXR [**2129-7-12**]:
Since [**2129-7-5**], right internal jugular catheter was removed.
Lungs are
clear. The cardiomediastinal silhouette and hilar contours are
normal. There is no pleural effusion.
Brief Hospital Course:
# [**Year (4 digits) **]: Her [**Year (4 digits) **] was likely due to a combination
of urosepsis and tizanidine induced [**Year (4 digits) **]. There was
initial concern for GI bleed given strongly guaiac positive BM
in ED. However, pt with no further evidence of GI bleed and her
lactate was normal. She was treated broadly for infection with
Vanc/Zosyn given [**Year (4 digits) **] in setting of T>98 (considered
fever in MS patients) and leukocytosis. Urine cultures grew out
>100,000 pan-sensitive Enterococcus; also with 10,000-100,000
Strep viridans, and her antibiotics were narrowed to ampicillin.
She was also started on on midodrine due to concern for
autonomic dysfunction with MS. [**First Name (Titles) **] [**Last Name (Titles) 4246**] and
midodrine was discontinued. Her blood cx and c diff were all
negative. She was transferred to the medical floor and had
episodes of [**Last Name (Titles) **] to the high 70s and low 80s which were
responsive to fluid. It was discovered to be tizanidine (in
combination with baclofen) induced [**Last Name (Titles) **] and her
tizanidine was decreased in dose from 8mg and tapered down to
2mg. She was told not to take tizanidine within 2 hours of your
baclofen or within one hour of lisinopril. Outpatient
antihypertensives were held and then lisinopril was later
restarted at a decreased dose of 5mg daily. Her HCTZ was not
restarted prior to discharge. Her amitriptyline dose was
decreased as well to prevent [**Last Name (Titles) **].
# GI Bleed: Per report, the patient had a BM in ED that was dark
and strongly guaiac positive. That with the combination of
[**Last Name (Titles) **] was concerning for significant bleed. Hct on
presentation was 30. She reported a prior cscope 2 years prior
w/o abnormalities. She had a negative NG lavage. In the ICU
her SBP dropped to the 80s and she was transfused 1 unit.
Hemolysis labs were negative. She was started on levophed. An
A-line was placed. She was continued on IV PPI [**Hospital1 **]. GI was
consulted and felt there was no need for emergent scope. Her Hct
remained stable for the rest of the admission with no further
bloody stools. She did have a with proximal transverse colon
thickening that was thought to more consistent with ischemic
rather than infectious or inflammatory processs. Initial
hematochezia may have been secondary to mild bowel ischemia from
[**Hospital1 **] in a pt with low reserve. She should have an
outpatient colonoscopy.
.
# Weakness/confusion: Given her complicated neurologic history,
her complaints of muscle weakness and confusion were likely due
to both her MS, UTI, and transient [**Hospital1 **]. Her TSH was low
but her T4 was normall. Provigil was held and her outpatient
neurologist was contact[**Name (NI) **] and agreed. She should follow up with
neurology as an outpatient.
# MS: Patient was continued on baclofen, amitriptilene,
copaxone, keppra, and tizanidine (at a decreased dose as
detailed above). She was transiently on midodrine as detailed
above.
# Renal failure: She initially presented with ARF which was
likely hypovolemic in the setting of [**Name (NI) **], UTI, and ?GI.
Her creatinine [**Name (NI) 4246**] with transfusion and fluids.
# Anion gap acidosis: She had a normal lactate with no evidence
of uremia. Her anion gap acidosis was likely secondary to
ketosis in setting of NPO status. This improved with IV fluids
and diet restarted.
# Hypothyroidism: TSH was low but T4 was normal. She was
continued on Synthroid.
# Hyperlipidemia: Continued Zocor.
# Prophylaxis: continued on home famotidine and heparin sc.
# Code: Full Code
Medications on Admission:
Baclofen 20mg qid
Simvastatin 20mg daily
HCTZ 50mg daily
Famotidine 20mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Lisinopril 10mg daily
Provigil 100mg [**Hospital1 **]
Tizanidine 8mg TID
Colace 100mg ID
Amitriptyline 10mg qhs
Arginine 500mg daily
MVI daily
ASA 81mg daily
Copaxone 20mg daily
Keppra 500mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Glatiramer 20 mg Kit Sig: Twenty (20) mg injection Kit
Subcutaneous daily ().
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Amitriptyline 10 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for skin rash/fungal infection.
Disp:*1 bottle* Refills:*0*
12. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Provigil 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
Urinary tract infection with question of resulting [**Hospital3 **]
[**Hospital3 **] likely secondary to drug effect of combination of
tizanidine and baclofen
.
Secondary Diagnosis:
Secondary Progressive MS
[**First Name (Titles) 49101**]
[**Last Name (Titles) 49100**]
Rectal discomfort
Hypothyroidism
Discharge Condition:
Stable. Normotensive.
Discharge Instructions:
You were admitted with a urinary tract infection and decreased
blood pressure. In the intensive care unit you required
pressors to maintain your blood pressure. On the normal medical
floor your blood pressure dropped several times and it responded
to IV fluids. We think your blood pressure dropped due to a
combination of tizanidine and baclofen. We spaced out these
medications and we decreased your dose of tizanidine. You
should not take tizanidine within 2 hours of your baclofen.
Please do not take your lisinopril within 1 hour of your
tizanidine. You were treated for a urinary track infection and
you have completed your course of treatment. You also had a
decreased hematocrit and we do not know whether you had a bleed
in your GI tract but we do know that your hematocrit is stable
now. You should have a colonoscopy as an outpatient. Please
talk to your primary care doctor about arranging this.
.
The following medications were started:
-miconazole powder for your rash
.
The following medications were stopped:
-hydrochlorothiazide is being temporarily stopped to ensure you
do not become hypotensive. Please discuss with your primary care
doctor when to restart this.
.
The following medications were changed in dose:
-Lisinopril was decreased to 5mg po daily to ensure you do not
become hypotensive. Please discuss with your primary care doctor
when to restart this.
-amirtiptyline was decreased to 5mg po daily to ensure you do
not become hypotensive.
-tizanidine was decreased to 2mg po TID
-aspirin was decreased to 81mg po daily
.
Please return to the hospital if you develop fatigue, dizziness,
lighteheadedness, pain with urination, blood in your urine,
diarrhea, blood in your stool, chest pain, shortness of breath,
or any new concerning symptom.
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 6707**]
Specialty: Primary Care
Date and time: [**7-28**] at 12pm
Location: [**Street Address(2) **], [**Location (un) 5110**]
Phone number: [**Telephone/Fax (1) 14214**]
.
Appointment #2
MD: Dr [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **]
Specialty: Neurology
Location: [**Hospital Ward Name 23**] clinical Center
Phone number: [**Telephone/Fax (1) 5434**]
Scheduler will call you with appointment. Please call the above
number if you do not hear by next Tuesday.
Completed by:[**2129-10-19**] |
25020,5849,42832,4280,2762,5855,40391,3572,2767,2761,25040,25050,25060,V5867,7801,3659,28521,36201,V1581 | 99,897 | 162,913 | Admission Date: [**2181-8-6**] Discharge Date: [**2181-8-7**]
Date of Birth: [**2128-1-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / simvastatin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Hyperglycemia, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mr. [**Known lastname **] is a 53 M with a history
of type II diabetes on insulin, hypertension, chronic kidney
disease, diastolic CHF who presents with malaise and confusion
following a barbeque this afternoon. He reports feeling fine in
the morning and attending a barbeque where he ate a significant
amount of food and drank soda. Afterward, he became confused and
reports hearing background noise "like voices on a radio." He
reports that he took his QHS insulin last night, however he did
not bring his insulin pen with him today to the barbeque.
In the ED, initial vs were: T 98.8, HR 82, BP 179/83, RR 16,
100% on RA. His fingerstick on arrival was noted to be
critically high and initial labs were notable for glucose > 1200
with anion gap of 15. He received 8 units of regular insulin SQ
with improvement after two hours to glucose > 1000. He then
received another 8 units SQ regular insulin. He also received 2L
of IVF with NS. He was noted to have K elevated to 6.6 and did
have some peaking of T waves on EKG, though no QRS widening.
Given that he will receive additional insulin, no further
intervention was taken to control his K, which came down to 5.0
on repeat BMP. He was transferred to the ICU for further
management of hyperglycemia. Vitals on admission were T 97.2, BP
137/56, HR 80, RR 18, O2 sat 100% on RA.
On the floor, he arrived on an insulin drip, was awake, alert
and cooperative. He denied symptoms, endorsing only hunger and
thirst.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Medical History:
1) CKD Grade 5, currently being evaluated for transplant
2) Diabetes. He says he has had this for 23 years and has been
on insulin for seven years. He has a history of retinopathy and
is status post laser surgery, and has some mild neuropathy. He
says his sugars are relatively well controlled.
3) Hypertension. He has had this about five years.
4) High cholesterol.
5) History of small CVA in [**2174**]. He said it was characterized
by tongue heaviness and he has no residual.
6) History of congestive heart failure requiring admission in
[**2181-1-10**].
7) History of latent TB by PPD that was treated 15 yrs ago and
then again he was started on INH in [**2180-10-11**]. He says he
has planned to take for six or seven months total at this time.
8) History of right Charcot joint surgery with hardware in
place
9) Glaucoma
Social History:
Social History:
Married, lives in [**Location 686**] with his wife and 2 sons, ages
17 and 6 who are both up-to-date on vaccinations. They have no
pets. He presently works as a driver for a food-services
company. In [**Country 2045**], he was the director of social services
programs for the Ministry of Health, and spent a significant
amount of time in the Health Department interfacing with
numerous
clients.
Family History:
Family History:
His family history is significant for HTN secondary to DM; no
CAD. Both parents passed away from what he feels were
complications from DM. He has had a brother and sister both
pass
away in [**2174**] from DM related complciations. He has 2 other
brothers and 2 other sisters who are alive.
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Exam on Discharge:
Pertinent Results:
[**2181-8-5**] 11:15PM PLT COUNT-474*
[**2181-8-5**] 11:15PM NEUTS-82.9* LYMPHS-10.6* MONOS-3.2 EOS-2.4
BASOS-1.0
[**2181-8-5**] 11:15PM WBC-11.7* RBC-3.26* HGB-9.4* HCT-29.5*
MCV-91# MCH-28.9 MCHC-31.9 RDW-14.8
[**2181-8-5**] 11:15PM CK-MB-3 cTropnT-0.06*
[**2181-8-5**] 11:15PM CK(CPK)-129
[**2181-8-5**] 11:15PM GLUCOSE-1267* UREA N-76* CREAT-5.3*
SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION
GAP-22*
[**2181-8-5**] 11:20PM GLUCOSE->500 K+-5.7*
[**2181-8-5**] 11:15PM GLUCOSE-1267* UREA N-76* CREAT-5.3*
SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION
GAP-22*
[**2181-8-5**] 11:20PM GLUCOSE->500 K+-5.7*
[**2181-8-5**] 11:30PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2181-8-5**] 11:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2181-8-5**] 11:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2181-8-6**] 01:50AM GLUCOSE-1004* UREA N-76* CREAT-5.0*
SODIUM-120* POTASSIUM-5.0 CHLORIDE-85* TOTAL CO2-21* ANION
GAP-19
[**2181-8-6**] 06:12AM PLT COUNT-505*
[**2181-8-6**] 06:12AM WBC-12.1* RBC-3.28* HGB-9.6* HCT-26.6*
MCV-81*# MCH-29.3 MCHC-36.1*# RDW-14.1
[**2181-8-6**] 09:57AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2181-8-7**] 04:00AM BLOOD Glucose-218* UreaN-64* Creat-4.5* Na-132*
K-3.9 Cl-101 HCO3-20* AnGap-15
[**2181-8-5**] CXR
UPRIGHT FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart size is
normal. The hilar and mediastinal contours are within normal
limits. The central pulmonary vessels are prominent, however,
there is no overt edema. Mild bronchial wall thickening appears
chronic. There is no pneumothorax, focal consolidation, or
pleural effusion. IMPRESSION: No acute intrathoracic process.
[**2181-8-5**] EKG
Normal sinus rhythm. Marked peaking of T waves in leads V2-V4.
No other diagnostic abnormality. Compared to the previous
tracing of [**2181-1-31**] peaked T waves are new. Consider electrolyte
abnormality (hyperkalemia).
Brief Hospital Course:
Hospital Summary:
Mr. [**Known lastname **] was admitted [**8-5**] with confusion, hyperglycemia after
a barbecue in which he took in a copious amount of food and
[**Company 19015**]. He was started on an insulin gtt, progressed to a
diabetic diet, SSI w/ Lantus qhs. Hospital course was
complicated by, altered mental status and hyperkalemia.
#Nonketotic Hyperosmolar Hypoglycemia.
Pt. presented with a glucose of 1200 and an anion gap of 16 w/o
ketonuria, and patient was started on an insulin gtt. Gap closed
to 12 within 4 hours on gtt. On the first day of admission, BS
dropped to 200's and the insulin gtt was discontinued. Mr.
[**Known lastname **] was seen by the [**Last Name (un) **] diabetes service and they
recommended the following changes to his sliding scale diabetic
regimen:
Range Meal QHS
0-70 juice
70-120 4 0
120-160 6 0
160-200 8 0
200-240 10 2
240-280 12 3
280-320 13 4
320-360 14 5
360-400 16 6
[**Last Name (un) **] also recommended 16 units lantus qhs. By [**8-7**], Mr.
[**Known lastname 88088**] glucose had improved to 100's and [**Last Name (un) **] fellow agreed
with discharge. Diabetes education is of major concern with Mr.
[**Known lastname **] and the nursing staff spent ~30-45 minutes educating Mr.
[**Known lastname **] and his wife.
#Altered Mental Status.
Upon presentation, Mr. [**Known lastname **] was confused and complaining of
auditory hallucinations and was found to have waxing and [**Doctor Last Name 688**]
of consciousness. Delirium and auditory hallucinations resolved
upon normalization of glucose.
#Mr. [**Known lastname **] initially experienced hyperkalemia to 6.6 on
admission with an EKG demonstrating peaked T waves. Following
insulin therapy, hyperkalemia resolved to 4.3 on the day of
discharge [**8-7**].
Medications on Admission:
Confirmed with PCP
[**Name Initial (PRE) **] - 10mg qd
CALCITRIOL - 0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE - 25 mg Tablet qd
FUROSEMIDE - 80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen -
per sl sc
INSULIN GLARGINE [LANTUS] - 16 units qhs
Toprol XL - 200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily
Discharge Medications:
Confirmed with PCP
[**Name Initial (PRE) **] - 10mg qd
CALCITRIOL - 0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE - 25 mg Tablet qd
FUROSEMIDE - 80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen -
per new sliding scale outlined in brief hospital course.
INSULIN GLARGINE [LANTUS] - 16 units qhs
Toprol XL - 200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hyperosmolar Nonketotic Hyperglycemic Episode
Acute on Chronic Renal Failure (stage 5)
Secondary Diagnosis:
Hypertension
Diabetes Type II (Insulin Dependent)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with high blood sugar levels. These
levels were dangerously high. While you were in the hospital,
you were given insulin and intravenous fluids to help control
your blood sugars. It is very important to control your blood
sugars at home. You should check your blood sugars several times
per day.
We made adjustments to your insulin sliding scale. Please check
your blood sugar before meals and before bed and use the new
scale to determine how much Novolog insulin to use. You should
continue to take your glargine (Lantus) insulin 16 units before
bed. Please take your other medications as prescribed.
Please follow up with your primary care doctor as well as the
endocrinology specialist as detailed below.
Until you see your primary care doctor to review your case, you
should not drive as these high blood sugars and confusion pose a
serious risk to your health. Please keep a record of your blood
sugar readings and bring it to your next appointments with your
PCP and endocrinologist. You should also call your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 86505**] tomorrow to report your blood sugar readings to make
sure that your sugars stay well-controlled.
Followup Instructions:
We have scheduled the following appointments for you to follow
up on your diabetes:
Name: [**Last Name (STitle) **],SHANTHY
Location: [**Location (un) 2274**] [**Location (un) **], Primary Care
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appt: [**8-16**] at 11am
Name: [**Last Name (LF) 88089**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**]-[**Location (un) **], Endocrinology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 88090**]
Appt: [**8-21**] at 10:30am
You have the following appointments scheduled at [**Hospital1 18**]:
Department: RADIOLOGY
When: THURSDAY [**2181-8-23**] at 1:30 PM
With: VASCULAR STUDY [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2181-8-23**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
25012,40391,5855,42832,5849,V5867,25062,3572,25052,36201,25042,2720,V1581,4280,V1254,79551,3659 | 99,897 | 181,057 | Admission Date: [**2182-7-3**] Discharge Date: [**2182-7-8**]
Date of Birth: [**2128-1-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / simvastatin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 54 year old male with PMH of type II diabetes on
insulin(previous presentation for hyperglycemic, hyperosmolar
state), hypertension, chronic kidney disease, and diastolic
congestive heart failure presenting with hyperglycemia in the
setting of not taking his insulin for 4 days. Patient states
that he normally take 16 units insulin in the evening, but
forgot the last few days. He glucometer broke and he got a new
one that he did not know how to use. He says that over the last
few days he has felt weak with poor po intake. Also on day prior
to admission experienced abdominal pain and then n/v on morning
of presentation. Patient denies fevers, cough, chest pain. He
does report some nausea. He denies dysuria but does report
urinary frequency and thirst. EMS initial blood sugar report was
>600.
.
In the ED, initial vital signs were 98.0 83 165/76 16 100%.
Glucose was noted to be >1000. Patient was noted to be drowsy,
but arousable to voice. His lungs were clear to auscultation
bilaterally. His abdomen was tender diffusely. Potassium was
4.4 with a creatinine of 5.9. Anion gap was noted to be 20.
Chest X-ray was performed and showed no acute process.
Urinalysis showed no evidence of infection, and no ketones. VBG
was performed and showed 7.35/48/58/28 with a lactate of 1.7.
Insulin 10 units IV were given and patient was started on an
insulin gtt at 7 units per hour. He received 2 liters NS in the
ED. Renal was consulted and requested urine electrolytes.
.
On arrival to the MICU, patient feels improved from presentation
but still weak.
Past Medical History:
1) CKD Grade 5, currently being evaluated for transplant
2) Diabetes. He says he has had this for 23 years and has been
on insulin for several years. He has a history of retinopathy
and
is status post laser surgery, and has some mild neuropathy.
3) Hypertension. He has had this about five years.
4) High cholesterol.
5) History of small CVA in [**2174**]. He said it was characterized
by tongue heaviness and he has no residual.
6) History of congestive heart failure requiring admission in
[**2181-1-10**].
7) History of latent TB by PPD that was treated 15 yrs ago and
then again he was started on INH in [**2180-10-11**].
8) History of right Charcot joint surgery with hardware in
place
9) Glaucoma
Social History:
From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for
meals on wheels. Denies tobacco, etoh, illicits.
Family History:
Family History:
His family history is significant for HTN secondary to DM; no
CAD. Both parents passed away from what he feels were
complications from DM. He has had a brother and sister both
pass
away in [**2174**] from DM related complciations. He has 2 other
brothers and 2 other sisters who are alive.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
.
Pertinent Results:
Admission Labs:
[**2182-7-3**] 06:00PM BLOOD WBC-14.7* RBC-3.77* Hgb-10.5* Hct-33.8*#
MCV-90# MCH-27.8 MCHC-31.0# RDW-14.5 Plt Ct-455*
[**2182-7-3**] 06:00PM BLOOD Neuts-92.2* Lymphs-5.0* Monos-2.1 Eos-0.3
Baso-0.4
[**2182-7-3**] 06:00PM BLOOD Glucose-1092* UreaN-68* Creat-5.9*#
Na-121* K-4.4 Cl-81* HCO3-20* AnGap-24*
[**2182-7-3**] 09:23PM BLOOD CK(CPK)-176
[**2182-7-3**] 09:23PM BLOOD CK-MB-2 cTropnT-0.04*
[**2182-7-3**] 09:23PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.7*
[**2182-7-3**] 06:35PM BLOOD Osmolal-349*
[**2182-7-3**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-58* pCO2-48* pH-7.35
calTCO2-28 Base XS-0 Comment-GREEN
[**2182-7-3**] 06:41PM BLOOD Lactate-1.4
.
urine
[**2182-7-3**] 07:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2182-7-3**] 07:40PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2182-7-3**] 07:40PM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
[**2182-7-3**] 08:23PM URINE Hours-RANDOM UreaN-214 Creat-32 Na-30
K-16 Cl-24
[**2182-7-3**] 08:23PM URINE Osmolal-411
.
micro:
blood culture pending
urine culture pending
.
IMAGING:
Radiology Report CHEST (PA & LAT) Study Date of [**2182-7-3**] 7:20 PM
IMPRESSION: No acute intrathoracic process
.
EKG: Sinus rhythm. LVH. TWI in I, II, avL, V4-V6 (new in II,
V4-V6)
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 54yo male with
PMH of T2DM, CHF, and CKD5 who presents with hyperglycemic,
hyperosmolar state. He was admitted to the ICU on an insulin gtt
and had correction of blood sugar with resolution of elevated
anion gap overnight. He was transferred to the general medical
floor.
.
# Non-ketotic hyperglycemic hyperosmolar state: Patient reports
not having taken his insulin in the past 4 days. He experienced
general malaise, abdominal pain, n/v and presented with blood
sugar in the low 1000's. On admission, he was placed on an
insulin drip and had blood sugars reduced to 100's overnight
following admission. He receieved IVF resuscitation and D5 as
FSBS fell. Lantus was overlapped with the drip and the drip was
discontinued. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was obtained and recommended that
his out pt insulin regimen be uptitrated to Glargine 30U at
night and an insulin sliding scale with humalog. His dinner time
sliding scale was made more aggressive due to his persistent
elevated glucose levels after dinner.
.
# Altered mental status: Patient's mental status on admission
was reported to be drousy but arousable, however upon reaching
the floor mental status was much improved. This is likely
explained by the non-ketotic hyperglycemic, hyperosmolar state,
but also would consider toxic metabolic encephalopathy from
infection given leukocytosis. His hyperglycemia was corrected
and mental status remained normal.
# Troponin elevation: Patient presented with ECG with TWI and
troponin to 0.04 in the setting of CKD-5. Previous labs have
shown troponin in the range of 0.03. Three sets of troponins
were obtained and each was 0.04. The pt was asymptomatic and
this was determined to not be ACS.
.
# Leukocytosis: Unclear etiology. Stress response vs. underlying
infection. CXR clear and rest of infectious workup including UA,
Blood and urine cultures were negative. The pt was afebrile
during this hospitalization. His WBC trended down without
treatment.
.
#T2DM: Patient has been non-adherent to insulin for four days
prior to admission. He has had [**Last Name (un) **] consult on previous
similar presentation. Will treat the hyperglycemia as above with
additional education and aid of the [**Hospital **] clinic.
.
#Acute on CKD5: CKD [**3-14**] DM and HTN. Patient has a bump in his
creatinine to 5.9 from last known baseline of around 5.0.
Pre-renal etiology is most likely considering his kidney
function improved with IVF administration. He was followed by
renal during this hospitalization who did not recommend any
changes to his current regimen. He had no acute indication for
dialysis.
.
#Hypertension:
- continued amlodipine
- continued metoprolol 200mg daily
- continued Lisinopril 20mg daily
.
#Chronic Diastolic CHF: The pt was not volume overloaded on exam
even after volume resuscitation due to hyperglycemia. We
continued his ACEi and Beta Blocker but initially held
diurectics as pt was severely dehydrated due to hyperglycemia on
admission. His diurectics were added back to his regimen at time
of discharge.
.
#TRANSITIONAL:
1. F/U appointments were made with his primary care and
nephrology
Medications on Admission:
AMLODIPINE - 10mg qd
CALCITRIOL - 0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE - 25 mg Tablet qd
FUROSEMIDE - 80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen -
per new sliding scale outlined in brief hospital course.
INSULIN GLARGINE [LANTUS] - 16 units qhs
Toprol XL - 200 mg qd
Lisinopril 20 mg daily
Niacin PO daily
Fish oil PO daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
4. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. niacin 1,000 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
7. Fish Oil 1,000 mg Capsule Sig: Two (2) Capsule PO once a day.
8. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Solution Subcutaneous
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyperosmolar non ketotic hyperglycemia
Secondary:
Chronic kidney disease
Diabetes
Hypertension
Hyperlipidemia
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with high
blood sugar levels after not taking your insulin for several
days. It is very important that you continue to take all of your
medications everyday to keep your blood sugar under better
control. You were seen by the [**Last Name (un) **] consultants, who approved
the recommended insulin changes.
The following changes have been made to your medications:
CHANGE Insulin dosing; you should take 30 units of glargine
every evening, and please see attached new insulin sliding scale
DISCONTINUE your FUROSEMIDE and CHLORTHALIDONE; please discuss
when to restart this medications with your regular doctors at
your follow up appointments (see below for details).
Please see below for follow up appointments that have been made
on your behalf.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Name8 (MD) **],SHANTHY
Location: [**Hospital1 641**]
Department: Internal Medicine
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2182-7-9**] 1:00pm
Name: NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 26581**]
Location: [**Hospital1 641**]
Department: Nephrology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2263**]
Appointment: Tuesday [**2182-7-9**] 2:30pm
|
185,51881,34982,1985,591,1628,5990,5849,514,5119,7994,4275,42731,41401,78097,40390,5859,2724,25000,28522,70703,70722,V5861,V1046,V446,V4986,V667 | 99,899 | 188,409 | Admission Date: [**2113-6-4**] Discharge Date: [**2113-6-13**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
central venous catheter placement
cardiopulmonary resuscitation
endotracheal intubation
History of Present Illness:
86 yo M with history of metastatic prostate cancer with
bilateral nephrostomy tube and recent diagnosis of malignancy in
chest, initially presenting with altered mentatl status, who had
an asystolic cardiac arrest in the ED, and is now transferred to
MICU post-arrest.
.
The patient was diagnosed with a UTI 2 days ago, and was started
on antibiotics (unclear what antibiotic). He took 2 doses of the
antibiotic and presented this a.m. with confusion. He was
following commands, but more confused that his baseline, which
is A+Ox3.
,
In the ED, the patient was taken for CT head and CXR, and was
noted to be non-responsive after the imaging studies. He was
found to be in asystole, and received 2 minutes of CPR. During
the resuscitation, he was given atropine 1 mg, epinephrine 1 mg,
and amiodarone 300 mg. He was subsequently intubated, receiving
etomidate and succinylcholine peri-intubation. He was started on
peripheral dopamine, switched to levophed. A central line was
placed ED prior to transfer to the MICU.
The CXR that was done pre-arrest showed bilateral plerual
effusions and interstitial edema. A bedside echo showed no RV
strain. FAST scan negative. Only exam finding before code was
mild abdominal pain. Vital signs on transfer pulse 59 BP 137/51
RR 18 100%/RA.
.
In MICU, the patient was initially non-responsive, with only
corneal reflexes present. Subsequently, he withdrew to pain in
all extremities.
Past Medical History:
- Metastatic prostate adenocarcinoma to bone with local
extension to bladder and rectum also complicated by bilateral
hydronephrosis s/p nephrostomy tubes. He has been treated with
Casodex, Lupron, and most recently, Ketoconazole. He has
declined chemotherapy.
- Recently diagnosed extensive intrathoracic malignancy
- Coronary artery disease
- Atrial fibrillation (previously on coumadin)
- Hyperlipidemia
- Hypertension
- Type 2 Diabetes
- Pleural effusion s/p right thoracenteses x 2 in the past month
Social History:
Mr. [**Known lastname **] has 8 children who live nearby and are involved in
his care. Previously worked at [**Hospital1 18**] as a transporter. Reports
no smoking, ETOH, or illicits. He is a Jehovah's Witness and
notes that his faith plays a central role in his life.
Family History:
His mother 'may' have had diabetes.
Physical Exam:
Vitals: T 98.2: BP 164/57: P 79: R 11: Sat: 100% O2:
General: Intubated, not on sedation. Non-responsive.
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: Clear ventillated breath sounds bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: bilateral nephrostomy tubes in place
Ext: warm, well perfused, 1+ bilateral LE edema
Neuro: Non-responsive to sternal rub or painful stimuli. Pupils
3 mm and non-reactive. Corneal reflex present bilaterally. Does
not move any extremity initially. Subsequently withdrew to pain.
Pertinent Results:
Admission labs:
[**2113-6-4**] 01:30PM BLOOD WBC-11.4* RBC-2.84* Hgb-6.6* Hct-20.3*
MCV-72* MCH-23.3* MCHC-32.6 RDW-17.8* Plt Ct-232
[**2113-6-4**] 01:30PM BLOOD Neuts-83* Bands-0 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2113-6-4**] 01:30PM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2*
[**2113-6-4**] 01:30PM BLOOD Glucose-163* UreaN-42* Creat-1.7* Na-125*
K-5.7* Cl-88* HCO3-25 AnGap-18
[**2113-6-4**] 01:30PM BLOOD ALT-12 AST-28 AlkPhos-214* TotBili-0.3
[**2113-6-4**] 01:30PM BLOOD Lipase-27
[**2113-6-4**] 11:44PM BLOOD CK-MB-5 cTropnT-0.11*
[**2113-6-4**] 01:30PM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.1 Mg-2.2
.
CT head w/o contrast [**2113-6-4**]:
1. No acute intracranial process.
2. Opacification of the left mastoid air cells . Clinical
correlation is
recommended to assess for mastoiditis.
.
CXR (portable AP) [**2113-6-4**]:
1. Worsening bilateral pleural effusions. Increased opacity at
the lung bases bilaterally may be a combination of pleural
effusions and atelectasis. However, underlying pneumonia cannot
be excluded.
2. Bilateral hilar lymphadenopathy. Stable right paratracheal
mass.
3. Mild pulmonary edema.
Brief Hospital Course:
86 yo M with metastatic prostate cancer and recent diagnosis of
extensive intrathoracic malignancy, initially presenting with
altered mental status, who had
asystolic cardiac arrest in the emergency department. The pt
arrived to the MICU intubated and on blood pressure support.
However given his extensive comorbidity combined with grave
prognosis and failure to respond to supportive measures, it was
ultimately decided by the family to focus on comfort measures
and the patient was terminally extubated and died on [**2113-6-13**].
Please see below for further details by problem.
# Goals of care: Per recent OMR notes, the patient elected a
hospice approach and was DNR/DNI. However, per family request,
this was reversed in the ED and the patient was resuscitated and
intubated. After discuss with family, patient was made full code
but CPR not indicated. Family meeting on [**6-9**] demonstrated that
they were not ready to withdraw life support and were hoping for
a miracle. On [**6-11**], the family expressed some desires to not
escalate care. On [**6-13**] family meeting, it was decided to withdraw
care and focus on comfort.
# s/p asystolic cardiac arrest: His initial rhythm was asystole
in the ER with underlying etiology unclear. Patient's FAST exam
was negative in the ER and blood cultures on admission were
positive which suggests septic shock as possible cause of
asystole. He was not cooled, and MRI the following day did not
show any signs of anoxic brain injury. However, the EEG showed
epileptiform activity and keppra was started. He had another
episode on [**6-6**] when on pressure support on the vent and turning
where is HR decreased, he desatted and his BPs dropped. He
responded to atropine, and levophed was restarted. Family
meeting established the CPR was not indicated. Neurology used
EEG, clinical exam, and somatosensory evoked potentials to
monitor the patient's neurologic status. The SSEP were present
which did not change the overall poor neurologic status as he
was not improving.
.
# Hypotension: Vital signs were normal on initial presentation
but he became hypotensive requiring Levophed for blood pressure
support s/p arrest. His hypotension could be related to cardiac
stunning in setting of recent arrest but was more likely related
to underlying sepsis. Echo was orderd in the ICU which showed
focal regional left ventricular systolic dysfunction c/w CAD.
Aneurysmal interatrial septum. Moderate pulmonary hypertension
with at least moderate tricuspid regurgitation and mildly
dilated right ventricle. Very small pericardial effusion. The
patient continued to require norepinephrine for blood pressure
support. With acute renal failure and poor urine output, and
hypervolemia on exam, the patient was transitioned to low dose
dopamine gtt with lasix boluses on [**2113-6-8**], which improved his
blood pressures and his creatinine 1.8 --> 1.7 with good urine
output (100cc/hr X2-3 hours with each bolus). Lasix gtt was
started however his Cr rose and this was discontinued.
# Respiratory failure: He was intubated in the ER and has been
ventilating well on the ventilator. He did have a near arrest on
CPAP and required reinitiation of full vent support. The patient
was gradually transitioned back from Assist Control to PSV with
thoughts that intermittent tachypnea due to central process and
some discomfort that responded to Fentanyl 25mcg boluses. He was
unable to be weaned from the vent and ultimately terminally
extubated.
# Altered mental status: Initially likely toxic-metabolic
process in setting of medical illness/UTI. CT head was
non-focal, and MRI after arrest without signs of hypoxic brain
injury. His underlying toxic-metabolic encephalopathy is likely
contributing as well. Neurology followed and recommended
continuing EEG with somatosensory potential evaluation from [**6-4**]
and [**6-7**] respectively.
.
# Urinary tract infection: U/A consistent with infection. He was
broadly covered with vanc/zosyn, and urine culture was sent.
Urostomy tubes bilaterally continued to put out purulent fluid
although right urostomy tube output was persistently ~half that
of left urostomy tube. Both tubes gradually had decreased output
.
# Bacteremia: Grew strep viridans from BCx. The patient was also
CDiff negative.
.
# Extensive intrathoracic malignancy: Invades mediastinum and
encases SVC, brachiocephalic, jugular, esophagus, and all major
airways. Mechanical complications of this malignancy could
underlie arrest, although echo in ED does not support this, and
hypoxemia seems more likely given rapid return of spontaneous
circulation. If patient improved, would have considered CT
chest.
.
# Metastatic prostate cancer: Currently not on any treatment.
.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for loose stools.
Disp:*60 Tablet(s)* Refills:*0*
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*200 Tablet(s)* Refills:*2*
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Home Oxygen
Home Oxygen 2-3L Nasal Cannula Continuous
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2113-6-21**] |
42823,5990,2764,45829,42731,25000,40390,515,V4509,7295,V4581,412,4280,5852,2809,2449,4148,2724,53081,79902,56400,311,V5867,04104 | 99,901 | 131,711 | Admission Date: [**2173-1-6**] Discharge Date: [**2173-1-19**]
Date of Birth: [**2104-3-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
PICC line placement
DC cardioversion
History of Present Illness:
Mr. [**Known lastname **] is a 68 yo gentleman with hx CABG, MI x2, of stage
IV heart failure, multiple admissions for CHF exacerbation who
was transferred for further management of his heart failure. Pt
states that most recently he has been in rehab and has been
doing well with increased exercise tolerance, until
approximately a week ago when he felt weak all over and slowly
fell to the ground, no LOC. Since that time, pt states that he
has been feeling progressively weak. While he denies worsening
SOB, nursing noted labored breathing and low BPs to the 80s
systolic for the last two days. Pt also denies CP, palpitations
or worsening LE edema. He requested transfer to [**Hospital1 18**] for
further management of his heart failure.
His most recent hospitalization was in [**12-8**] for SOB. At that
time, pressures were in the 80s/90s and pt was satting 89-95% on
RA. He was treated with diuresis and ciprofloxacin for a UTI. At
that time, pt was offered hospice but refused. He was
transferred to rehab facility on discharge
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, recent syncope or presyncope. Pt does state that
he had one episode of syncope over [**Holiday **], but none since.
Also states that he has trouble lying flat but cannot articulate
why.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
1. Ischemic CMP, with an EF of 25%. s/p MI at age 37 and 52. s/p
CABG in [**2146**] with LIMA to LAD, SVG to D1, SVG to OM, and SVG to
PDA. s/p stent placement to the RCA graft in 08/00.
2. s/p BiV. ICD implant in [**5-/2167**] for primary prevention of
SCD, in the setting of CAD, low EF, and inducible VT on EPS.
Also had prolonged HV and bifascicular block (RBBB/LAHB).
3. Paroxysmal atrial fibrillation, s/p AV node ablation [**10-7**],
now pacemaker dependent. At this time, he was taken off of
quinidine, started on dofetilide which was subsequently dc'd as
the pt reverted into A-fib, and the pt was dc'd on an increased
dose of coreg.
.
3. OTHER PAST MEDICAL HISTORY:
- Diabetes mellitus type 2, on insulin
- osteoarthritis
- pulmonary fibrosis?
- asthma
- seasonal allergies
- stage II CKD
- htn
- dyslipidemia
- hx of multiple MIs, most recent episode [**8-6**], anginal
equivalent is back pain
.
PSHx: cholecystectomy ([**2164**]), TURP, "benign tumor excision"
Social History:
He is married, and lives with his wife but has been in rehab for
the past month. He is retired, former businessman. He is a
former smoker and quit in [**2156**]. He denies alcohol or illicit
drug use.
Family History:
Father with MI at 51, mother with MI age 84, sister with MI age
76, brother with MI age 79.
Physical Exam:
VS: T=96.0 BP=90/66 HR=79 RR=24 O2 sat=100% 3L
GENERAL: chronically ill appear in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD to the earlobe
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. Crackles bilaterally in
bases approx 1/3 up the lung fields.
ABDOMEN: Soft, NTND, +BS. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ LE edema to the knees. Cool UEs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On Admission:
[**2173-1-6**] 06:49PM BLOOD WBC-7.2 RBC-3.97* Hgb-9.2*# Hct-31.9*#
MCV-80* MCH-23.3* MCHC-29.0* RDW-18.8* Plt Ct-145*
[**2173-1-6**] 06:49PM BLOOD PT-29.9* PTT-50.4* INR(PT)-3.0*
[**2173-1-6**] 06:49PM BLOOD Glucose-155* UreaN-54* Creat-1.7* Na-131*
K-4.0 Cl-86* HCO3-39* AnGap-10
[**2173-1-6**] 06:49PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3 Iron-19*
.
On Discharge:
[**2173-1-19**] 05:34AM BLOOD WBC-11.7* RBC-4.44* Hgb-10.8* Hct-34.3*
MCV-77* MCH-24.3* MCHC-31.4 RDW-19.9* Plt Ct-168
[**2173-1-19**] 05:34AM BLOOD WBC-11.7* RBC-4.44* Hgb-10.8* Hct-34.3*
MCV-77* MCH-24.3* MCHC-31.4 RDW-19.9* Plt Ct-168
[**2173-1-19**] 05:34AM BLOOD PT-31.6* PTT-45.2* INR(PT)-3.2*
[**2173-1-18**] 08:30PM BLOOD Neuts-81.6* Lymphs-10.8* Monos-6.0
Eos-1.0 Baso-0.7
[**2173-1-18**] 08:30PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Spheroc-OCCASIONAL
Ovalocy-1+ Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2173-1-19**] 05:34AM BLOOD Glucose-151* UreaN-45* Creat-1.8* Na-129*
K-3.5 Cl-85* HCO3-32 AnGap-16
[**2173-1-19**] 05:34AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.5
.
While inpatient: + WBCs and blood in urine, urine cx with
ampicillin sensitive enterococci
TSH 13
T4 5.3
TIBC 441 Ferritin 54 TRF 339
.
[**1-6**] EKG: Ventricular paced rhythm with ventricular couplets.
Atrial mechanism is uncertain. Since the previous tracing of
[**2172-9-23**] atrial activity/question pacing is more difficult to
assess.
.
[**1-6**] CXR: Mild cardiomegaly is stable. Left transvenous
pacemaker leads terminating in standard position in the right
atrium, right ventricle and through the coronary sinus. There is
haziness of the perihilar regions minimally increased from prior
study consistent with chronic CHF. There is no strong evidence
of pneumonia. There is no pneumothorax. There is no large
pleural effusion. Sternal wires are aligned.
.
[**2173-1-7**] TTE: The left atrium is markedly dilated. The right
atrium is moderately dilated. There is mild (non-obstructive)
focal hypertrophy of the basal septum. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The estimated cardiac index
is depressed (<2.0L/min/m2). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. The
right ventricular cavity is markedly dilated with severe global
free wall hypokinesis. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate to severe (3+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
.
IMPRESSION: Severely dilated and hypokinetic right and left
ventricles with moderate to severe mitral and tricupsid
regurgitation and mild pulmonary artery systolic hypertension.
The inferior and inferior septum are severely hypokinetic
akinetic with the other segments being moderately hypokinetic.
.
Compared with the prior study (images reviewed) of [**2172-7-9**],
the function of the lateral wall is probably worse on the
current study. The degrees of mitral and tricuspid regurgitation
have increased. The estimated pulmonary artery systolic
pressures are slightly lower but are probably UNDERestimated
given the severity of tricuspid regurgitation.
.
[**1-12**] CXR
Chronic CHF. The patient with biventricular pacing, but no
significant interval change since next preceding portable chest
examination of [**2173-1-6**].
.
[**1-18**] CXR
The pacemaker leads terminate in right atrium and right
ventricle, unchanged in appearance. Cardiomediastinal silhouette
is unchanged including severe cardiomegaly involving mostly the
left ventricle. The left ventricular pacer is unchanged as well.
The patient is in mild vascular engorgement as well as there is
no change in bibasal interstitial abnormalities. Note is made
that the lung apices were not included in the field of view. The
broken third sternal wire is unchanged as well. Repeated
radiograph is highly recommended including the lung apices for
precise evaluation of the abnormalities.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68 yo gentleman with hx CABG, MI x2, of stage
IV heart failure, multiple admissions for CHF exacerbation (EF
20%) who was transferred for further management of his heart
failure. Resp status initally improved since admission with
diuresis, however required ICU transfer for hypotension and
respiratory distress concerning for pulmonary edema. He was
made DNR/DNI while in the ICU, transferred back to the floor in
stable condition with request for no further escalation of care,
medical management only.
.
# PUMP: Most recent ECHO showed LVEF of 15-20%. Mr [**Known lastname **] was
treated with aggressive diuresis with a lasix gtt and metolazone
while on the floor. Also received acetazolamide for treatment
of elevated bicarb in the setting of aggressive diuresis. On
transfer to the ICU, Mr [**Known lastname **] was below dry wt of 204 lbs
however continued to have evidence of volume overload on exam
with elevated JVP, crackles, LE edema. Pt required transfer to
the ICU as he was unable to maintain pressures while on
aggressive diuresis. He was treated with Milrinone and Lasix gtt
while in the CCU with Phenylephrine for pressure support. He was
diuresed several liters of fluid and approached euvolemia.
Phenylephrine and Milrinone were weaned off, and the pt was
switched to PO diuretic regimen of Torsemide 40mg PO daily and
aldactone 25mg PO daily. Pt should have daily lytes checked and
adequate repletion with potassium. BB and ACEI were held in the
setting of hypotension and end of life care.
.
# CORONARIES: known 3 V disease based on [**6-1**] cardiac cath,
however patent LIMA and SMG grafts, low concern for ACS at this
time. The patient is on ASA and Plavix. BB, ACEi and statin held
for hypotension and end of life care. If patient's pressures
increase and his blood pressure tolerates, a low dose BB and/or
ACEI would be indicated.
.
# RHYTHM: hx afib, previously on 2.5 mg/day of warfarin. Pt was
cardioverted on previous admission in [**2172-8-29**] and started
on warfarin at that time. On arrival, afib was not clearly
identified on ECG, but evident on ECHO. He was loaded on
amiodarone and cardioverted in attempt to restore atrial kick
and improve forward flow. Digoxin was held [**3-2**] to high levels,
and Metoprolol was held [**3-2**] to hypotension. The patient was rate
controlled on Amiodarone - he will be discharged on a taper:
200mg PO BID x2 weeks (through [**1-25**]), 200mg PO daily
thereafter. INR was supratherapeutic, up to 4.6. Warfarin has
been discontinued as the patient had supratherapeutic INR on low
dose of Warfarin, and the risks outweigh the benefits, as the
patient is in the end stage of his heart disease.
.
# Hypotension: pt runs in the 80s-90s systolic at baseline,
likely due to poor systolic function. While in the hospital he
was asymptomatic until day 6 of his admission when pressures
dropped to <80. At this time he had increasing difficulty with
attention, some SOB, no CP, was transferred to the ICU given
need for aggressive diuresis given his worsening respiratory
status and volume overload. He was started on Phenylephrine for
pressure support and weaned off. He maintained SBP >100 after
diuresis.
.
# Hypoxia: improved with diuresis, but new cough developed on
the day of transfer to the ICU possibly due to aspiration event.
Pt also with ? underlying lung disease (COPD, pulm fibrosis)
which may be contributing. The patient was not febrile in the
CCU and maintained sats in mid-90s on 2LNC.
.
# CKD: Pt with history of stage II CKD, creatinine trended up to
2.1 with lasix, but improved to 1.9 prior to discharge.
.
# Anemia: no evidence of active bleed, however significantly
decreased from baseline. Iron studies suggest iron deficiency
anemia, pt started on iron supplementation. Haptoglobin WNL,
guaiac negative. Crit stable for several days now.
.
# Leukocytosis: concerning for infection in the setting of amp
sensitive enterococci in urine and worsening pulmononary exam.
Pt was treated with ampicillin for UTI. Blood cxs were drawn
and are NTD. Leukocytosis improved, pt remained afebrile.
.
# Metabolic alkaloisis: appears to be chronic, most likely due
to contraction alkalosis in the setting of aggressive diuresis.
Also likely a component of respiratory acidosis from CO2
retention in the setting of ?COPD/pulmonary fibrosis.
.
# Hypothyroidism: TSH elevated but levothyroxine recently
increased as an outpatient. Pt was continued on levothyroxine,
will hold on dose adjustment for now given recent increase.
Thyroid function tests should be repeated as an outpatient.
.
# GERD: continue on ranitidine
.
# Diabetes: stable on Levemir as an outpatient. Sugars stable on
glargine and ISS.
.
# Depressed mood: Pt was seen by SW and palliative care. Pt is
aware that this is end-stage of his disease.
.
# Seasonal allergies: continued on fexofenadine, montelukast
.
# Constipation: BM uptitrated while on the floor. Regimen
decreased in CCU as the patient had 2 episodes of bowel
incontinence. Rectal tone was intact and there were no other
neurologic deficits.
.
# GOALS OF CARE: The patient was seen by Social Work and
Palliative Care during this hospitalization. It was decided that
he would be maintained on the current medical therapy with minor
changes if they would be helpful in the short-term. He
understands that this is the end-stage of his heart disease.
There is to be no escalation of care beyond the
medications/treatments outlined in this discharge summary aside
from minor changes if they would be helpful in the short-term.
While in the ICU, decision was made not to re-hospitalize. The
patient is DNR/DNI. If he decompensates on these medications, he
should be transferred to hospice for end of life care.
Medications on Admission:
-Albuterol 0.083% Neb Soln
-Ipratropium Bromide Neb
-Artificial Tears
-Levothyroxine Sodium 75 mcg PO/NG DAILY
-Aspirin 325 mg PO/NG DAILY
-Metoprolol XL 25 mg q day
-Atorvastatin 40 mg PO/NG DAILY
-Montelukast Sodium 10 mg PO DAILY
-Clopidogrel 75 mg PO/NG DAILY
-Mupirocin Cream 2% 1 Appl TP [**Hospital1 **]
-Nitroglycerin SL 0.4 mg SL PRN cp
-Digoxin 0.125 mg PO/NG DAILY
-Potassium Chloride 20 mEq PO TID
-Docusate Sodium 200 mg PO HS
-Ranitidine 150 mg PO/NG DAILY
-Fexofenadine 60 mg PO BID
-Senna 2 TAB PO/NG HS
-Furosemide 160 mg PO/NG DAILY
-Gabapentin 100 mg PO/NG TID
-Sodium Chloride Nasal
-Tamsulosin 0.4 mg PO HS
-TraMADOL (Ultram) 50 mg PO
-Levemir 26 units at dinnertime
Discharge Medications:
1. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
Please take 200 mg twice a day through [**1-25**], then take one tab
once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob, wheezing.
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dryness.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry mucosa.
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
17. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
20. Outpatient Lab Work
Please check daily lytes and replete until a stable repletion
regimen is determined.
21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
22. Levemir 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous at dinnertime.
23. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
25. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
q4 hrs as needed for SOB/CP: Hold for oversedation, RR<12; 5mg
should equal 0.25 mL.
26. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
Life Care of [**Location (un) 2199**]
Discharge Diagnosis:
Primary:
acute on chronic decompensated congestive heart failure
atrial fibrillation
microcytic anemia
Secondary:
coronary artery disease
chronic kidney disease
Discharge Condition:
Activity Status:Out of Bed with assistance to chair or
wheelchair
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Discharge Instructions:
You were admitted to the hospital with fluid overload from
worsening of your heart failure. Several liters of fluid were
removed with intravenous Lasix.
.
You also had an abnormal heart rhythm called atrial
fibrillation. Your heart was converted back into a normal
rhythm. You are on medications to help control your heart rate
and prevent it from going back into the abnormal rhythm.
.
We made several changes to your medication regimen. We changed
the doses of your diuretic medications and stopped some of your
nonessential medications including your metoprolol, warfarin,
atorvostatin and digoxin.
Followup Instructions:
Please follow-up with your primary care physician after
discharge from rehab.
|
74782,4010,3051,25000,V643 | 99,903 | 135,939 | Admission Date: [**2146-1-6**] Discharge Date: [**2146-1-10**]
Date of Birth: [**2095-11-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Spinal AVM
Major Surgical or Invasive Procedure:
[**1-6**]:Angiogram, partial embolization of Spinal AVM
History of Present Illness:
50M with elective admission for embolization of spinal AVM
Past Medical History:
HTN / non-compliant with outpt regime, LE weakness
Social History:
Resides at home with wife
+tobacco use
Family History:
non-contributory
Physical Exam:
On Discharge:
AOx3, strength full except LE's [**5-1**] with exception of DF left
3-/5, right DF 4-/5. Rectal tone sl. diminished
Pertinent Results:
Labs on Admission:
[**2146-1-6**] 08:00AM BLOOD WBC-5.1 RBC-5.36 Hgb-14.9 Hct-41.8
MCV-78* MCH-27.8 MCHC-35.7* RDW-13.3 Plt Ct-216
[**2146-1-6**] 08:00AM BLOOD PT-13.0 INR(PT)-1.1
[**2146-1-6**] 05:30PM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-143
K-3.1* Cl-111* HCO3-25 AnGap-10
[**2146-1-6**] 05:30PM BLOOD CK(CPK)-72
[**2146-1-6**] 05:30PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.3 Mg-1.9
UricAcd-5.6
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**]
Radiology Report CARDIAC PERFUSION PERSANTINE Study Date of
[**2146-1-10**]
[**2146-1-10**]
CARDIAC PERFUSION PERSANTINE Clip # [**Clip Number (Radiology) 81531**]
Reason: 50YR OLD NEEDS CARDIAC CLEARANCE FOR OR.
Final Report
RADIOPHARMACEUTICAL DATA:
3.1 mCi Tl-201 Thallous Chloride ([**2146-1-10**]);
19.7 mCi Tc-[**Age over 90 **]m Tetrofosmin Stress ([**2146-1-10**]);
HISTORY: 50 year-old male with history of NIDDM and HTN with
abnormal ECG prior
to surgery.
SUMMARY FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
IMAGING METHOD:
Resting perfusion images were obtained with Thallium. Tracer was
injected
approximately 30 minutes prior to obtaining the resting images.
Following resting images and two minutes following intravenous
dipyridamole,
approximately three times the resting dose of Tc-[**Age over 90 **]m tetrofosmin
was
administered intravenously. Stress images were obtained
approximately 30 minutes
following tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction (LVEF) is 51%.
There is no prior for comparison.
IMPRESSION: Normal myocardial perfusion study. LVEF is 51%.
[**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **], M.D.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D.
Approved: MON [**2146-1-10**] 5:17 PM
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**]
Cardiology Report STRESS Study Date of [**2146-1-10**]
EXERCISE RESULTS
RESTING DATA
EKG: SINUS, LAE, LVH WITH ST-T ABNLS, PRWP
HEART RATE: 71 BLOOD PRESSURE: 146/108
PROTOCOL /
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 [**1-29**] 0.142MG/ KG/MIN 80 122/86 9760
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 47
SYMPTOMS: ATYPICAL
ST DEPRESSION: NONE
INTERPRETATION: This 50 yo NIDDM man with a h/o hypertension was
referred to the lab for the evaluation of an abnormal EKG prior
to
surgery. The patient was infused with 0.142 mg/kg/min of IV
Dipyridamole
over 4 minutes. Early post-infusion, the patient reported a
nonprogressive [**5-6**] central "chest heaviness" which resolved
quickly
with administration of 125 mg IV Aminophylline. No significant
ST
segment changes were noted during the infusion or in recovery.
The
rhythm was sinus with no ectopy. Systolic and diastolic
hypertension
noted at rest (146/108mmHg) with an appropriate hemodynamic
response to
the infusion.
IMPRESSION: Questionable persantine-induced symptoms with no
significant
ST segment changes. Atypical symptoms. Nuclear report sent
separately.
SIGNED: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81532**]TTE (Complete)
Done [**2146-1-10**] at 9:53:13 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] J.
[**Hospital1 18**] - Division of Neurosurger
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2095-11-27**]
Age (years): 50 M Hgt (in): 68
BP (mm Hg): 130/90 Wgt (lb): 200
HR (bpm): 70 BSA (m2): 2.05 m2
Indication: Abnormal ECG. Hypertension. Preoperative assessment.
Left ventricular function.
ICD-9 Codes: 402.90, 427.89
Test Information
Date/Time: [**2146-1-10**] at 09:53 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W058-0:20 Machine: Vivid [**8-3**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.8 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.32 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Stroke Volume: 103 ml/beat
Left Ventricle - Cardiac Output: 7.21 L/min
Left Ventricle - Cardiac Index: 3.52 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Arch: *3.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.7 cm
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 0.83
Mitral Valve - E Wave deceleration time: *303 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm)
with 35-50% decrease during respiration (estimated RA pressure
(0-10mmHg). Prominent Eustachian valve (normal variant).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Estimated cardiac
index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal
PCWP (<12mmHg). No resting or Valsalva inducible LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated aortic arch.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. There is
mild-moderate symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic arch is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild-moderate symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Dilated thoracic aorta.
CLINICAL IMPLICATIONS:
Based on [**2144**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-1-10**] 11:45
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81530**] M 50 [**2095-11-27**]
Radiology Report SPINAL ART Study Date of [**2146-1-6**] 2:39 PM
[**Last Name (LF) 81533**],[**First Name7 (NamePattern1) 177**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 81534**] [**2146-1-6**] SCHED
SPINAL ART Clip # [**Clip Number (Radiology) 81535**]
Reason: spinal embolization of dural AVM., AVM seen on angiogram
tod
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
dural spinal AVM, left lower extremity weakness
REASON FOR THIS EXAMINATION:
spinal embolization of dural AVM.
AVM seen on angiogram today - plan embo today as well
Preliminary Report
Preliminary reports are not available for viewing.
DR. [**First Name11 (Name Pattern1) 58372**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
PreliminaryApproved: MON [**2146-1-10**] 1:02 PM
Imaging Lab
Brief Hospital Course:
Patient was electively admitted on [**1-6**] for embolization of
spinal AVM. Post-operatively, in the PACU; he developed T-wave
inversion in the setting of hypertension. Cardiology was
consulted and made recommendations to start lisinopril, HCTZ,
Norvasc. His cardiac work-up/EKG was negative for acute MI.
Persantine stress test and Echo were done for cardiac clearance
- he was deemed safe for d/c home per cards on medications
previously recommended. He agrees with this plan and is to see
his PCP [**Name Initial (PRE) 503**]. Dr [**First Name (STitle) **] will call pt tomorrow with a formal
neurosurgical plan for the spinal avm.
Medications on Admission:
Hydralizine, HCTZ
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Spinal AVM
Discharge Condition:
Neurologically stable
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedule follow-up with Dr. [**First Name (STitle) **]
on [**1-11**] in the office. He will call you - if you don't hear
from his office by 3pm - call them at the above number.
You must also arrange for follow up with your PCP [**Name Initial (PRE) **]/
cardiology at [**Hospital1 69**] in the
[**Hospital Ward Name 23**] building call [**Telephone/Fax (1) 70484**] for the managment of your HTN
within the next 2 weeks.
Completed by:[**2146-1-10**] |
0389,51881,48242,78552,9972,45381,2764,99592,4414,53081,2720,7804,60000,2859,72887,56409,V1582,V1204 | 99,912 | 189,380 | Admission Date: [**2153-4-13**] Discharge Date: [**2153-4-27**]
Date of Birth: [**2068-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname 25816**] is an 84 year old patient of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25817**] who
presented to the ED today after 2 episodes vomiting and
diarrhea. Per his son, he lives independently and was doing well
until he woke up this morning with nausea, a single episode of
vomiting, a loose nonbloody stool, chills, and general malaise.
He called his son who brought him to the [**Name (NI) **].
.
In the waiting room, he had an episode of possible syncope. He
felt SOB and looked ill, and his family noticed that he seemed
confused. He was taken to the core area where he was found to
have 80% on RA. EKG showed no ischemic changes. CXR was
unremarkable. Labs notable for lactic acidosis with lactate 8.
CT torso was done to rule out PE. This showed diffuse ground
glass opacities in the lungs and AAA. Vascular Surgery service
saw him.
.
In the ED waiting room, patient had a brief episode of near
syncope during which he was feeling SOB and confused and "looked
bad." He was tachycardic and tachypneic. O2 Sat was 80% on RA
with venous pH 7.1, prompting intubation. Serial EKGs were
without ischemic changes. He was noted to be acidotic with
lactate 8. CT torso was done to rule out PE. No PE was
demonstrated, but there were diffuse ground glass opacities
concerning for multifocal pneumonia. He was given vancomycin,
zosyn, levofloxacin. CT also showed 3.8 cm infrarenal AAA.
Vascular Surgery service saw him in the ED. He was intubated and
admitted to the MICU for further managemenet.
Past Medical History:
GERD
Hyperlipidemia
Vertigo
BPH
Social History:
Lives with wife. [**Name (NI) **] is her primary care taker as she has
suffered a recent stroke. Remote smoking history (30 pkyr).
Occasional alcohol use. No history of illicit drug use.
Family History:
The patient has a mother who had HTN and father who had a
stroke.
Physical Exam:
Admission exam:
VS: T 100.0, HR 88, BP 130/70RR 32, O2 100% on PSV with 100%
FiO2, [**6-20**]
Gen: intubated, sedated, doesn't open eyes to voice or follow
commands
HEENT: NCAT. Sclera anicteric. EOMI. OP clear, no exudates or
ulceration.
Neck: JVP flat, RIJ in place
CV: RRR, normal S1, S2. No m/r/g.
Chest: diffuse crackles.
Abd: Soft, NTND. No HSM or tenderness.
Ext: no edema
Skin: No stasis dermatitis, ulcers, scars.
Neuro: PERRL, does not follow commands
Pertinent Results:
Admission labs:
[**2153-4-13**] 01:30PM WBC-3.7* RBC-4.82 HGB-14.4 HCT-45.2 MCV-94
MCH-29.9 MCHC-31.9 RDW-13.0
[**2153-4-13**] 01:30PM NEUTS-47* BANDS-17* LYMPHS-26 MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-2*
[**2153-4-13**] 01:30PM GLUCOSE-229* UREA N-26* CREAT-1.2 SODIUM-138
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-22*
[**2153-4-13**] 01:30PM CALCIUM-9.3 PHOSPHATE-4.6*# MAGNESIUM-2.0
Brief Hospital Course:
An 84 year-old man presents with likely sepsis secondary to
pneumonia.
.
# Respiratory failure: patient was intubated in ED for hypoxemic
respiratory failure, likely secondary to pneumonia. Due to
initial aggressive fluid resuscitation, patient had to be
diuresed over several days before extubation. During the course
of intubation, patient intermittently hyperventilated regardless
of ventilator settings and failed repeated SBTs. Benzodiazepenes
and opiates briefly brought down respiratory rate. At one point,
family considered making patient CMO and terminal extubation.
However, patient was gradually more alert and once asked
declined terminal extubation and agreed that if extubation was
unsuccessful, re-intubation would be okay. Patient was
successfully extubated on [**2153-4-24**] and called out to the medicine
floor. Patient remained comfortable on 4L with improved breath
sounds.
.
# MRSA pneumonia: Patient presented with bandemia and
leukopenia, fevers, and CT with multilobar infiltrates
diagnostic of severe pneumonia. Vancomycin, zosyn, and
levofloxacin were started. He initially required levophed to
maintain MAP >65. Sputum cultures grew MRSA. Antibiotics were
narrowed to vancomycin. Levophed was weaned, and BP remained
normal to hypertensive. However, a few days into his MICU
course, he was again febrile and clinically tenuous, so
antibiotic regimen was broadened back to include cefepime and
ciprofloxacin in addition to the IV vancomycin. He finished his
course of antibiotics on [**2153-4-24**] and he has been stable on 4L of
O2 with gradually improving breath sounds.
.
# RUE edema/weakness - upper extremity ultrasound showed an age
indeterminate midcephalic vein clot with signs of distal flow.
Vascular surgery was consulted, recommended no anticoagulation.
Warm packs, elevation, and NSAIDS were used. Head CT was
performed with no signs of intracranial process to explain
weakness. Patient will require physical rehabilitation of right
arm.
.
# Hct drop: Hct fell from 35 on admission to 27, likely
secondary to fluids, and was subsequently stable.
.
# Hyperlipidemia: Atorvastatin was continued.
.
# AAA: 3 cm, newly discovered. Patient was seen by vascular in
ED who recommended repeat US in 6 months
.
CODE STATUS: Full code
Medications on Admission:
Aspirin 81 mg daily
lipitor 20 mg daily
omeprazole 20 mg daily
Multivitamin
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice
a day.
3. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB, wheezing.
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
8. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
12. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary Diagnosis:
MRSA pneumonia
Secondary Diagnosis:
GERD
Hyperlipidemia
Vertigo
BPH
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
respiratory distress. You were found to have a MRSA pneumonia,
and you needed to be admitted to the ICU and required intubation
to help with your breathing. You received a course of
antibiotics to help clear your infection. You are being
transferred to a rehabilitation facility to help you improve
your breathing functions.
Your medications have changed. Please take only the medications
as listed below:
Aspirin 81 mg daily
Albuterol nebulizer every 6 hours as needed for shortness of
breath or wheezing
Atorvastatin 20 mg daily
Docusate sodium 100 mg twice a day
Heparin 5000 units injected under the skin three times a day
Ipratropium nebulizer every 6 hours as needed for shortness of
breath and wheezing
Lansoprazole 30 mg daily
Multivitamin 1 tablet daily
Ibuprofen 400 mg every 8 hours as needed for pain
Tylenol 325-650 mg every 6 hours as needed for pain, fever
Quetiapine 25 mg three times a day
If you experience chest pain, worsening shortness of breath, or
any other worrisome symptoms please return to the emergency room
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**]
([**Telephone/Fax (1) 10492**]), after discharge from the pulmonary
rehabilitation facility
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
41401,34831,7801,4241,42731,78829,78009,4019,2724,25000,44020,V5867 | 99,913 | 175,989 | Admission Date: [**2141-5-10**] Discharge Date: [**2141-5-18**]
Date of Birth: [**2070-4-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain and dyspnea
Major Surgical or Invasive Procedure:
[**2141-5-12**] 1. Urgent coronary artery bypass graft x3 -- left
internal mammary artery to the diagonal, vein graft to the
distal left anterior descending artery, and vein graft to the
right coronary artery. 2. Aortic valve replacement with a size
23 mm [**Doctor Last Name **] Magna Ease tissue valve.
History of Present Illness:
71 y/o Hispanic male with PMH significant for PVD, DM, and
hypertension who presented with fatigue after walking 2 to 3
blocks. Presented with chest
discomfort in upper chest unrelated to activity. ECHO on [**2141-4-11**]
showed mild concentric LVH with EF of 60-65%, sever AS with mean
gradient of 53 mm HG and [**Location (un) 109**] of .63 cm2. Cardiac cath today
showed severe AS with mean gradient of 54 mm Hg and [**Location (un) 109**] of .77
cm2, 50% ostial lesion of RCA, 70% D1 and diffuse disease of
LCx. Transferred to [**Hospital1 18**] for further evaluation and treatment
Past Medical History:
Coronary artery disease
IDDM
hyperlipidemia
moderate aortic valve stenosis with a valve area of [**12-4**].2 cm2
psoriasis
Social History:
The patient lives with his wife in an apartment complex. He is
primarly Spanish speaking and denies tobacco, alcohol, or
illicit drug use.
Family History:
N/C
Physical Exam:
General: NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []x
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _3-4/6 SEM across
precordium_____
Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds
+
[x]
Extremities: Warm [], well-perfused [] Edema [] _____
Varicosities: None [][**12-5**]+ left pretibial edema with stasis
dermatitis and amputation of rightsecond and third toes
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+2
Carotid Bruit Right:murmur transmits to carotid
Left:murmur transmits to carotid
Pertinent Results:
[**2141-5-11**] Carotid ultrasound
Impression: Right ICA less than 40% stenosis. Left ICA less than
40% stenosis
.
[**2141-5-11**] CTA
1. No evidence of aortic aneurysm. No ascending aortic
calcifications with calcifications seen only at the level of the
aortic valve.
2. Extensive calcifications of the aortic valve itself
consistent with known aortic valve stenosis. Extensive coronary
calcifications.
3. Right lower lobe 6 mm spiculated nodule that should be
reassessed in three months for assessment of stability to
exclude the possibility of neoplastic growth. Additional
pulmonary nodules mentioned in the body of the report can be
reassessed at the same time.
[**2141-5-12**] ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Preserved biventricular systolic functin.
LVEF 55%.
Intact thoracic aorta.
The bioprosthetic valve in the native aortic position is well
seated and moving well. The peak is 15 and mean is 5 mm of Hg.
Trivial MR>
.
[**2141-5-13**] Head CT
Arterial calcifications and signs of chronic sphenoid sinus
inflammation, otherwise normal study.
CXR [**5-17**]:
Intact sternomy wires. Aortic valve prosthesis. Unchanged L
hemidiaphragm
elevation and atelectasis.
[**2141-5-17**] 06:02AM BLOOD WBC-6.4 RBC-3.37* Hgb-9.3* Hct-29.7*
MCV-88 MCH-27.7 MCHC-31.4 RDW-13.6 Plt Ct-113*
[**2141-5-17**] 06:02AM BLOOD Plt Ct-113*
[**2141-5-13**] 02:58AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4*
[**2141-5-17**] 06:02AM BLOOD Glucose-148* UreaN-21* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
[**2141-5-12**] 04:30AM BLOOD ALT-117* AST-133* LD(LDH)-310*
AlkPhos-130 TotBili-1.0
Brief Hospital Course:
Mr. [**Known lastname 13621**] was transferred to the [**Hospital1 18**] on [**2141-5-10**] for surgical
management of his aortic valve and coronary artery disease. He
was worked-up in the usual preoperative manner. A carotid duplex
ultrasound was obtained which showed less then a 40% bilateral
internal carotid artery stenosis. A dental consult was obtained
which found no contraindication for surgery after obtaining a
Panorex x-ray of his teeth. A chest CT scan was performed which
showed no significant aortic calcifications but did note a right
lower lobe 6 mm spiculated nodule that should be reassessed in
three months for assessment of stability to exclude the
possibility of neoplastic growth. Labs showed that he had
elevated liver function studies. On [**2141-5-12**], Mr. [**Known lastname 13621**] was taken
to the operating room where he underwent coronary artery bypass
grafting to three vessels and replacement of his aortic valve
with a tissue valve. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours he awoke and was
extubated. He was noted to have some confusion, hallucinations
and somnolence. A head CT scan was obtained which was negative.
The stroke service was consulted who suspected a metabolic or
possible infectious etiology to his confusion- no acute
infection was detected. All narcotics were discontinued and his
pain was managed with Tylenol only. Over the next day, his
mental status cleared. Aspirin, beta blocker, statin therapy and
diabetic management were continued. Mild confusion noted again
on POD#4 and Ultram was discontinued.. Confusion improved. POD#5
he went into rapid a-fib and remained in it for several hours,
was started on Amio and returned to SR for 24 hours prior to
discharge. He failed first and second voiding trial, urology was
consulted and it was determined that he would be discharged to
home with the foley in place and will follow up with urology as
an outpatient. After second foley placement his urine was noted
to be cloudy. A UA C&S was sent and he was started on Cipro.
Cultures were negative and Cipro was discontinued. He was noted
to have some serosanguinous drainage from his mid sternal pole.
He was afebrile, CXR showed intact wires, and WBC was normal. He
was sent home on no antibiotics and will return for a wound
check on [**5-23**]. He was seen by the physical therapy department
and cleared for discharge. By time of discharge on POD #6 he was
deemed safe for discharge to home. Follow-up appointments were
advised.
Medications on Admission:
aspirin 81 mg QD, glipizide 5 mg QD, glucophage 1000 mg [**Hospital1 **],
lisinopril 5 mg QD, metoprolol extended release 50 mg QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
RX *acetaminophen 325 mg q 6 hours Disp #*60 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg daily Disp #*30 Tablet
Refills:*2
3. MetFORMIN (Glucophage) 1000 mg PO BID
RX *Glucophage 1,000 mg twice daily Disp #*90 Tablet Refills:*0
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg daily Disp #*60 Tablet Refills:*2
5. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg bedtime Disp #*30 Tablet Refills:*0
6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
Hold for K+ > 4.5
RX *K-Tab 10 mEq twice daily Disp #*28 Tablet Refills:*0
7. Glargine 24 Units Bedtime
8. Amiodarone 400 mg PO BID
for 6 more days starting [**5-18**] then 400mg daily for 1 week, then
200mg daily
RX *amiodarone 200 mg twice a day Disp #*90 Tablet Refills:*2
9. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg daily Disp #*60 Tablet Refills:*2
10. Metoprolol Tartrate 50 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *Lopressor 50 mg twice a day Disp #*90 Tablet Refills:*2
11. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg daily Disp #*7 Tablet Refills:*0
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K >
RX *potassium chloride 20 mEq daily Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
Coronary artery disease
Diabetes
Peripheral [**Location (un) 1106**] disease
Hypertension
post-op urinary retention
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol only
Incisions:
Sternal - Healing well, no erythema, no tenderness - minimal
serosanginous drainage from mid sternal pole
Leg Left - healing well, no erythema or drainage.
Edema trace lower extremity edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Keep your urine catheter in place until you are advised by the
VNA or your primary care doctor to remove it.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The office will call you and schedule the following appointments
your Surgeon:
Dr. [**First Name (STitle) **]:[**2141-6-20**] at 2:15p
Cardiologist: [**Doctor Last Name 29070**] [**2141-6-9**] at 8:45a
Wound check: [**2141-5-23**] 10:45
[**Hospital 159**] Clinic for voiding trial: [**Last Name (LF) 5929**], [**5-25**] at 4:00 PM with
[**Name6 (MD) **] Crohn, NP - Shipiro Building [**Location (un) 470**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-9**] weeks
***Nodular opacity of CT scan seen on this admission - NEEDS
FOLLOW UP CT SCAN IN 6 MONTHS***
Scheduled appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2141-6-2**]
9:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2141-6-2**] 10:30
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2141-5-18**] |
4241,2761,42731,41401,2724,53081,V153,V1582,V1021 | 99,922 | 123,563 | Admission Date: [**2107-4-7**] Discharge Date: [**2107-4-11**]
Date of Birth: [**2037-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] tissue) [**2107-4-7**]
History of Present Illness:
69 year old male with no prior cardiac history who was recently
treated for squamous cell carcinoma of the left vocal cord. Over
the last several months, he has noted dyspnea on exertion and
chest pain while walking. He noted this to his oncologist during
a follow-up appointment who referred him to Dr. [**Last Name (STitle) 5310**]. An
exercise tolerance test was done which was stopped due to near
syncope. An echocardiogram showed severe aortic stenosis. In
preparation for surgery, a cardiac catheterization was performed
which showed mild non-obstuctive coronary artery disease.
Currently he denies syncope, pre-syncope, orthopnea, PND and
pedal edema. He had prviously never been told he had a heart
mumrur. He presents for surgical evaluation.
Past Medical History:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
mild coronary artery disease
- squamous cell carcinoma of the left vocal cord, s/p
chemotherapy/radiation
- dyslipidemia
- GERD
Past Surgical History:
- Tonsillectomy
- Appendectomy
- Repair of anal fissure
- Feeding tube during chemo/radiation. This has been removed.
Social History:
Lives with: Wife in [**Name2 (NI) 3320**], MA
Contact: Phone #
Occupation: Retired
Cigarettes: Smoked no [] yes [X] last cigarette 1.5 years ago
Hx:
[**12-20**] ppd for 50 years.
Other Tobacco use:
ETOH: < 1 drink/week [] [**1-25**] drinks/week [X] >8 drinks/week []
Illicit drug use
Family History:
Denies premature coronary artery disease. Mother died of
aneurysm at age 74
Physical Exam:
Vital Signs sheet entries for [**2107-3-16**]:
BP: 152/79. Heart Rate: 73. Resp. Rate: 16. O2 Saturation%: 100.
Height: 72" Weight: 170lb
General: WDWNI in NAD. Voice is hoarse.
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Edentulous
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] III/VI SEM, Nl S1-S2
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit - Tranmitted murmur vs. bruit
Pertinent Results:
Intra-op TEE [**2107-4-7**]
Conclusions
Pre Bypass: 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. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Phenylepherine. Patient
is AV paced. A well-seated bioprosthetic valve is seen in the
aortic position with normal leaflet motion and gradients (mean
gradient = 19-20 mmHg). No aortic regurgitation is seen.
Regional and global left ventricular systolic function are
normal. Aortic contours intact. All findings discussed with
surgeons at the time of the exam.
[**2107-4-11**] 04:32AM BLOOD WBC-7.7 RBC-3.60* Hgb-11.2* Hct-33.6*
MCV-93 MCH-31.2 MCHC-33.4 RDW-13.1 Plt Ct-190
[**2107-4-10**] 06:00AM BLOOD WBC-9.3 RBC-3.48* Hgb-11.1* Hct-32.5*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 Plt Ct-130*
[**2107-4-9**] 04:50AM BLOOD WBC-12.5* RBC-3.38* Hgb-10.6* Hct-31.3*
MCV-93 MCH-31.4 MCHC-33.9 RDW-13.2 Plt Ct-107*
[**2107-4-11**] 04:32AM BLOOD PT-12.3 INR(PT)-1.1
[**2107-4-8**] 01:45AM BLOOD PT-12.9* PTT-24.2* INR(PT)-1.2*
[**2107-4-7**] 12:23PM BLOOD PT-13.5* PTT-26.7 INR(PT)-1.3*
[**2107-4-7**] 10:48AM BLOOD PT-16.5* PTT-30.3 INR(PT)-1.6*
[**2107-4-11**] 04:32AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-136
K-4.4 Cl-99 HCO3-27 AnGap-14
[**2107-4-10**] 06:00AM BLOOD Na-134 K-4.2 Cl-96
[**2107-4-9**] 04:50AM BLOOD Glucose-150* UreaN-14 Creat-0.8 Na-129*
K-4.4 Cl-95* HCO3-27 AnGap-11
[**2107-4-8**] 01:45AM BLOOD Glucose-102* UreaN-7 Creat-0.7 Na-133
K-4.2 Cl-104 HCO3-21* AnGap-12
Brief Hospital Course:
The patient was brought to the Operating Room on [**2107-4-7**] where
the patient underwent Aortic Valve Replacement with Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. He
demonstrated a few episodes of brief, rate-controlled atrial
fibrillation. He converted to sinus rhythm with amiodarone and
was in sinus rhythm at the time of discharge. Anti-coagulation
was initiated with coumadin. He has received 3 mg on POD3 and
was to receive 5 mg on [**2107-4-11**] for an INR of 1.1. INR to be
checked on [**4-12**] by VNA. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home in good condition with appropriate follow up instructions.
Medications on Admission:
OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*30 ML(s)* Refills:*0*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 1 week then 400 mg daily x 1 week then 200 mg daily x
1 month.
Disp:*80 Tablet(s)* Refills:*0*
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed for INR goal 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
mild coronary artery disease
- squamous cell carcinoma of the left vocal cord, s/p
chemotherapy/radiation
- dyslipidemia
- GERD
Past Surgical History:
- Tonsillectomy
- Appendectomy
- Repair of anal fissure
- Feeding tube during chemo/radiation. This has been removed.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] at [**2107-4-19**]
at 10:00a
Cardiologist: Dr. [**Last Name (STitle) 5310**] [**2107-5-2**] at 12:00p
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] at [**2107-5-11**] at 1:30p
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 84368**] in [**3-24**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Atrial fibrillation
Goal INR 2.0-2.5
First draw day after discharge [**2107-4-12**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 5310**] [**Telephone/Fax (1) 5315**]
Completed by:[**2107-4-11**] |
45829,4532,2761,5723,4561,45621,5849,7455,E9394,5712,30393,V1582,5859 | 99,923 | 164,914 | Admission Date: [**2201-2-23**] Discharge Date: [**2201-3-3**]
Date of Birth: [**2146-10-4**] Sex: M
Service: MEDICINE
Allergies:
OxyContin
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Hypotension in setting of ativan administration
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
History of Present Illness:
Mr. [**Known lastname 1124**] is a 54 year old gentlamen with EtOH cirrhosis
complicated by ascites and encephalopathy admitted for transient
hypotension. The patient was scheduled for outpatient MRI liver
today, for which he was prescribed 0.5 mg po ativan taken 1 hour
prior to arrival. While awaiting MRI in the waiting room, the
patient became dizzy and states that he "couldn't see" and that
he "lost focus." At that time, he lay down on the floor and was
noted to have an SBP 70s from a baseline SBP 90-100s. He
received 1L IVF, and was transferred to the ED for further
evaluation. Of note, the patient reports that he last ate at 8
am this morning, with his meal consisting of a bowl of cereal.
He does report that he had assocaited nausea, but denies any CP,
f/c/s, HA, diaphoresis, palpitations, orthopnea, PND, LE
swelling, pain in his legs. He does report chronic diarrhea
since starting lactulose. Of note, the patient was admitted to
[**Doctor Last Name **] County Hospital ([**Location (un) 50909**] RI) from [**Date range (1) 78183**] for hepatic
encephalopathy, during which he was treated with lactulose and
had a large volume paracentesis. In addition, the patient
underwent RHC on [**2-10**] with [**Doctor First Name **] 21 mmHg.
.
In the [**Hospital1 18**] ED, initial VS 98.0 74 92/58 16 100%RA. He received
1 L NS, had a negative CXR, with labs notable for hyponatremia
to 118 and creatinine 2.9, with only prior creatinine 2.6 on
[**1-13**]. He had a diagnostic paracentesis that was negative for SBP,
and was admitted to the MICU at the request of Liver.
.
Currently, the patient is resting comfortably. He does state on
ROS that he has had worsening SOB over the past 3 days such that
he is unable to walk 20 feet without feeling fatigued.
Past Medical History:
1. EtOH cirrhosis complicated by diuretic refractory ascites and
encephalopathy currently undergoing transplant eval. Reports
having large volume paracentesis Q2Wks since [**11-21**].
2. EtOH abuse
3. Acute kidney injury.
4. Hypertension.
Social History:
He denies a history of intravenous drug use. He has a 25- pack
year history of tobacco use quitting 15 years ago. He has a
history of extensive alcohol use in the past quitting 7 months
ago (EtOH - last drink [**6-21**]). He is married and has 2 daughters
ages 24 and 28.
Family History:
A grandparent had alcoholism. His mother died at age 75 and his
father at age 77. There is a history of diabetes and colon
cancer in the family.
Physical Exam:
On admission:
VS - Temp 97.3F, 100/63 BP , 90HR , 18R , O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Obese, no fluid waves, soft, NABS, soft/NT/ND, 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
Pertinent Results:
On admission:
[**2201-2-23**] 08:00PM ASCITES GLUCOSE-125 LD(LDH)-37 ALBUMIN-LESS
THAN
[**2201-2-23**] 08:00PM ASCITES WBC-240* RBC-670* POLYS-10* LYMPHS-55*
MONOS-28* EOS-1* MESOTHELI-1* MACROPHAG-5*
[**2201-2-23**] 04:20PM GLUCOSE-99 UREA N-77* CREAT-2.9* SODIUM-118*
POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-19* ANION GAP-14
[**2201-2-23**] 04:20PM ALT(SGPT)-83* AST(SGOT)-144* LD(LDH)-235 TOT
BILI-2.0*
[**2201-2-23**] 04:20PM LIPASE-182*
[**2201-2-23**] 04:20PM ALBUMIN-1.8*
[**2201-2-23**] 04:20PM WBC-8.4 RBC-3.09* HGB-11.1* HCT-31.9*
MCV-103* MCH-35.9* MCHC-34.8 RDW-14.0
[**2201-2-23**] 04:20PM PLT COUNT-130*
[**2201-2-23**] 04:20PM PLT COUNT-130*
[**2201-2-23**] 03:04PM CREAT-2.9*
[**2201-2-23**] 03:04PM estGFR-Using this
.
CXR:
FINDINGS: Frontal and lateral views of the chest are obtained.
Blunting of
the right posterior costophrenic angles raises concern for small
pleural
effusion. Minimal left mid-to-lower lung atelectasis is noted.
No discrete
focal consolidation is seen. The cardiac and mediastinal
silhouettes are
unremarkable.
IMPRESSION: Small right pleural effusion. Mild left base
atelectasis.
.
Echo:
No atrial septal defect is seen by 2D or color Doppler but a
patent foramen ovale is suggested with premature appearance of
saline contrast in the left heart with cough. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The estimated pulmonary artery
systolic pressure is normal. There is a small to moderate sized
pericardial effusion around the right atrium. There is a
prominent pleural effusion.
IMPRESSION: Patent foramen ovale. Loculated pericardial effusion
suggestive of a pericardial cyst.
.
Renal U/S:
IMPRESSION:
1. Technically limited study, however patent bilateral main
renal arteries
and veins.
2. Large amount of ascites.
.
MRI/MRV:
IMPRESSION:
Non-obstructive infrarenal partial thrombus in IVC, without
extension beyond
the bifurcation.
.
LENIs: Negative for DVT
.
EGD:
Esophagus:
Protruding Lesions 1 cords of grade I varices were seen in the
gastroesophageal junction. The varices were not bleeding.
Stomach:
Contents: Food was found in the stomach
Mucosa: Diffuse erythema, congestion and mosaic appearance of
the mucosa with no bleeding were noted in the stomach. These
findings are compatible with portal gastropathy.
.
On discharge:
[**2201-3-3**] 04:50AM BLOOD WBC-5.3 RBC-2.50* Hgb-9.1* Hct-25.9*
MCV-104* MCH-36.2* MCHC-35.0 RDW-13.9 Plt Ct-112*
[**2201-3-3**] 04:50AM BLOOD PT-17.1* PTT-97.3* INR(PT)-1.5*
[**2201-3-3**] 04:50AM BLOOD Glucose-105* UreaN-58* Creat-2.4* Na-132*
K-4.0 Cl-100 HCO3-21* AnGap-15
[**2201-3-3**] 04:50AM BLOOD ALT-28 AST-57* AlkPhos-241* TotBili-1.7*
[**2201-2-23**] 08:00PM ASCITES WBC-240* RBC-670* Polys-10* Lymphs-55*
Monos-28* Eos-1* Mesothe-1* Macroph-5*
.
MELD = 19
Brief Hospital Course:
Mr. [**Known lastname 1124**] is a 54 year old gentleman with EtOH cirrhosis
complicated by refractory
ascites and encephalopathy admitted for transient hypotension.
.
# Hypotension: The patient became hypotensive after taking
ativan prior to receiving his outpatient MRI for HCC screening.
He was briefly dizzy but that felt normal within minutes. He was
transported to the ED where he was given NS boluses. He was then
admitted to the ICU overnight for observation. Blood pressures
remained stable with SBP in the 80s-90s overnight. The patient
was then transferred to the floor where orthostatics were
neagative. The patient was asymptomatic with systolics in the
80s-90s.
.
# Hyponatremia: Na was 118 on admission. The patient reported
having been drinking lots of fluid because he was told it would
help his kidneys. He was placed on salt restriction and 1500 -
2L fluid restriction. His sodium gradually improved and was 132
on the day of discharge. He was taught about the importance of
salt-restriction in his diet. Urine osm/Na showed perceived
decreased effective circulating volume secondary to cirrhosis.
.
# Prolonged PR: New 1st degree AVB compared to prior ECG. He was
kept briefly on telemetry without events.
.
# Acute on chronic renal failure: Creatinine was 2.9 on
admission; past [**Hospital1 18**] labs revealed a Cr of 2.6 on [**2201-1-13**]. The
patient reported having frequent large volume paracenteses
without the administration of albumin. He also reported that he
thought his creatinine was usually ~2. He was briefly treated
for hepatorenal syndrome (with albumin, octreotide, and
midodrine) without much improvement in his Creatinine. He had
normal urine output. On discharge, Cr was 2.4. He was scheduled
to see [**Hospital1 18**] nephrology for consultation for possible renal
transplant in addition to liver transplant.
.
# EtOH Cirrhosis c/b portal hypertension with ascites and recent
admission at OSH for hepatic encephalopathy: The patient's
transplant evaluation was completed with Echo, MRI, and EGD. EGD
showed grade I varices and portal hypertensive gastropathy. He
was presented to the transplant committee and was listed for
transplant. Unfortunately, the MRI showed an incidental IVC
thrombus (see below). He was also scheduled for renal follow-up
for possible renal transplant listing. Rifaximin and lactulose
were continued on discharge. A diagnostic paracentesis on
admission was negative for SBP.
.
# IVF thrombus: Infrarenal, non-occlusive thrombus was seen on
MRI. Occupying 30% vessel. Likely a result of cirrhosis and
decreased anticoagulant proteins. Heparin gtt was initially
started and was continued for 3 days. Coumadin was started. INR
was 1.5 on discharge with plans for repeat INR check in 2 days
at PCP [**Name Initial (PRE) 3726**]. Goal INR 2-2.5 with anticoagulation for at least
6 weeks.
.
# EtOH abuse: Patient reports his last drink was in [**6-21**]. He was
scheduled to begin substance relapse prevention program at Kodak
shortly after discharge.
.
Transitional Issues:
- sodium monitoring
- renal function monitoring, possible listing for renal/liver
transplant
- anticoagulation for IVC thrombus
- substance relapse prevention
Medications on Admission:
Rifaxamin 550 mg [**Hospital1 **]
Dexilant 60 mg daily
Ciprofloxacin 250 mg daily
Vicodin prn
Vitamin D 50,000 units weekly
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain or fever: Do not exceed 2g in
24 hours (caution: as vicodin contains acetaminophen).
2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
7. Dexilant 60 mg Cap, Delayed Rel., Multiphasic Sig: One (1)
Cap, Delayed Rel., Multiphasic PO once a day.
8. Vicodin 5-500 mg Tablet Oral
9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day:
daily at 4pm; requires frequent monitoring of INR; goal INR
2-2.5.
Disp:*150 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please draw INR on [**2201-3-5**] and provide results to Dr. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) 5456**] (ph: [**Telephone/Fax (1) 90437**]). Patient should have twice weekly INRs
with goal 2-2.5.
11. lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO three
times a day: Please titrate to [**1-15**] soft bowel movements per day.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension
Inferior vena cava thrombus
Cirrhosis - alcoholic
Acute vs. chronic kidney disease
.
Secondary:
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted after you became hypotensive
prior to your MRI. We completed your liver transplant evaluation
and you were presented to the transplant committee. Dr. [**Last Name (STitle) **]
would also like for you to see a transplant nephrologist to be
evaluated for a possible kidney transplant as your kidney
function is abnormal. We incidentally discovered a small
thrombus in your inferior vena cava for which you will need to
be anticoagulated for at least 6 weeks. Coumadin requires very
close monitoring with twice weekly INRs - your goal INR is
2-2.5.
.
We made the following changes to your medications:
We STARTED Coumadin (Warfarin) 5 mg per day; you will need to
have your INR checked twice per week - first check this Thursday
on [**2201-3-5**].
We CONTINUED lactulose, which you should use to titrate to [**1-15**]
soft bowel movements per day
.
We called Dr.[**Name (NI) 56701**] office and he is willing to manage your
coumadin.
.
Your follow-up information is listed below.
Followup Instructions:
Department: TRANSPLANT CENTER
When: FRIDAY [**2201-3-6**] at 9:20 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ECHO LAB
When: FRIDAY [**2201-3-6**] at 1 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: THURSDAY [**2201-3-19**] at 9:00 AM
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
5712,5856,5724,40391,9974,5601,30393,V1251,V5861,V1582,4580,27669,4168,E8780,E8497,2859,79902,78701 | 99,923 | 192,053 | Admission Date: [**2201-5-15**] Discharge Date: [**2201-5-25**]
Date of Birth: [**2146-10-4**] Sex: M
Service: SURGERY
Allergies:
OxyContin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
EtOH cirrhosis, ESRD
Major Surgical or Invasive Procedure:
liver transplant [**2201-5-16**]
History of Present Illness:
Mr. [**Known lastname 1124**] is a 54M with EtOH cirrhosis, ESRD not on HD, hx
of IVC thrombus on coumadin presenting for liver and kidney
transplantation. He was recently hospitalized for worsening
renal
function, however he continues to not require hemodialysis. The
patient states that he continues to have baseline urine output
and denies lower extremity swelling. He continues to require
frequent therapeutic paracentesis; last performed 2 weeks ago at
which time 14L were drained; planned on next tap in 1 week. Pt
received 2 units of PRBC this past Tuesday. He states that he
feels "great" and denies any specific symptoms or complaints.
He
denies nausea, vomiting, diarrhea, constipation, hematemesis, or
melena.
.
Past Medical History:
- EtOH cirrhosis complicated by diuretic refractory ascites and
encephalopathy currently undergoing transplant evaluation.
Frequent large volume paracentesis
- EtOH abuse
- Acute kidney injury recent baseline 3.0, multifactorial HTN
and HRS
- IVC thrombus, on coumadin
Social History:
He denies a history of intravenous drug use. He has a
25-pack-year history of tobacco use quitting 15 years ago. He
has a history of extensive alcohol use in the past quitting
[**6-21**]. He is married and has 2 daughters ages 24 and 28.
Family History:
A grandparent had alcoholism. His mother died at age 75 and his
father at age 77. There is a history of diabetes and colon
cancer in the family.
Physical Exam:
Vitals: 96.8, 68, 121/86, 16, 100% RA
Wt: 88.1 kg
General: Alert, oriented, no acute distress
HEENT: NCAT, minimal scleral icterus, lateral nystagmus noted
bilaterally; moderately dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, distended with ascites, bowel sounds present, no
rebound tenderness or guarding
Ext: warm, no clubbing, cyanosis or edema; eschar noted on R
forearm, minimal ecchymosis
.
Labs:
WBC-9.1 RBC-3.77* Hgb-12.7* Hct-37.8* MCV-100* MCH-33.8*
MCHC-33.7 RDW-15.2 Plt Ct-162
PT-40.5* PTT-41.8* INR(PT)-4.2*
Fibrino-230
ALT-45* AST-93* AlkPhos-419* TotBili-2.8*
Albumin-3.6 Calcium-9.3 Phos-4.5 Mg-2.4
.
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
URINE CastHy-29*
URINE Mucous-RARE
.
HEPATITIS HBsAg HBsAb HBcAb HAV Ab
[**2201-5-15**] PND PND PND PND
[**2201-4-29**] 05:10 NEGATIVE NEGATIVE NEGATIVE
[**2201-1-13**] 12:55 NEGATIVE NEGATIVE NEGATIVE POSITIVE
.
HEPATITIS C SEROLOGY HCV Ab
[**2201-5-15**] 16:45 PND
[**2201-4-29**] 05:10 NEGATIVE
[**2201-1-13**] 12:55 NEGATIVE
.
HIV SEROLOGY HIV Ab
[**2201-5-15**] 16:45 PND
[**2201-1-13**] 12:55 NEGATIVE
.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB ([**2201-1-15**]): POSITIVE
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB ([**2201-1-15**]):POSITIVE
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB ([**2201-1-15**]):NEGATIVE
.
TOXOPLASMA IgG ANTIBODY ([**2201-1-20**]): POSITIVE
.
CMV IgG ANTIBODY ([**2201-1-16**]): NEGATIVE
CMV IgM ANTIBODY ([**2201-1-16**]): NEGATIVE
.
VARICELLA-ZOSTER IgG SEROLOGY ([**2201-1-16**]): POSITIVE
.
Rubella IgG/IgM Antibody ([**2201-1-14**]): POSITIVE
.
RAPID PLASMA REAGIN TEST ([**2201-1-14**]): NONREACTIVE
.
RUBEOLA ANTIBODY, IgG ([**2201-1-14**]): POSITIVE
.
EKG: NSR at 87, poor R wave progression; no ST-T changes, no TWI
.
CXR: pre-lim - Right pleural effusion, similar to [**2201-4-18**].
Trace/minimal left pleural effusion. No PTX or new findings
compared to prior imaging.
.
[**2201-4-19**] Renal US: Echogenic kidneys suggestive of medical renal
disease. No calculi or hydronephrosis noted. Splenomegaly with
moderate amount of ascites.
.
[**2201-3-24**] Cardiac stress: No anginal symptoms or ischemic ST
segment changes. Appropriate hemodynamic response to the
Persantine infusion. Nuclear report sent separately.
.
[**2201-3-2**] ECHO: No atrial septal defect is seen by 2D or color
Doppler but a patent foramen ovale is suggested with premature
appearance of saline contrast in the left heart with cough. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The estimated
pulmonary artery systolic pressure is normal. There is a small
to
moderate sized pericardial effusion around the right atrium.
There is a prominent pleural effusion.
IMPRESSION: Patent foramen ovale. Loculated pericardial effusion
suggestive of a pericardial cyst.
.
[**2-27**] MRV ABD/PELVIS:
Non-obstructive infrarenal partial thrombus in IVC, without
extension beyond the bifurcation.
.
Pertinent Results:
[**2201-5-25**] 05:22AM BLOOD WBC-5.3 RBC-3.17* Hgb-10.1* Hct-29.1*
MCV-92 MCH-32.0 MCHC-34.9 RDW-16.2* Plt Ct-176
[**2201-5-25**] 05:22AM BLOOD PT-16.4* PTT-85.3* INR(PT)-1.4*
[**2201-5-25**] 05:22AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-137
K-4.2 Cl-105 HCO3-23 AnGap-13
[**2201-5-25**] 05:22AM BLOOD ALT-26 AST-11 AlkPhos-107 TotBili-0.5
[**2201-5-25**] 05:22AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.8 Mg-1.7
[**2201-5-25**] 05:22AM BLOOD tacroFK-7.8
Brief Hospital Course:
On [**2201-5-15**], he underwent kidney and liver transplant. Surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details.
He was sent to the SICU for management. Postop duplex of liver
and kidney demonstrated patent vasculature, no hydro or biliary
ductal dilatation. He was hypotensive on postop day 1 and
required IV hydration and blood products. Hct remained stable.
LFTs and creatinine improved daily. Urine output was excellent.
JP drainage was non-bilious.
He developed an ileus. NG remained in place until [**5-22**] when
ileus resolved. Diet was slowly advanced and tolerated. Pain
medication was switched to oral Dilaudid. Lateral JP drain was
removed on [**5-23**] and medial on [**5-25**].
Generalized anasarca improved daily and he only required only
Lasix x1. Weight decreased to 85.8 (down 10 kg from admission
wt). In fact, he developed orthostatic hypotension. Midodrine
was started with improvement.
Heparin drip was started for h/o IVC thrombus. A few days later,
Coumadin was started a 1mg daily. Dose was increased to 2mg
[**5-24**]. On [**5-25**], INR was 1.4. Dose was increased to 3mg and
patient was instructed to get PT/INR done as an outpatient on
[**5-27**] and [**5-30**].
PT worked with him and recommended home PT. VNA Care of [**Location (un) 4368**] was arranged. He was ambulating with a walker.
He tolerated steroid taper to 20mg daily, cellcept [**Hospital1 **] and
prograf dosing. Prograf levels increased to 15.2 on [**5-24**]. Dose
was held and decreased to 1mg [**Hospital1 **].
He will go to stay at his sister's home in [**Location (un) 50909**] RI with f/u
on [**5-28**]. Of note, a TTE was done when he was in SICU for
hypotension. Mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the distal half of the anterior
septum and anterior walls, distal septum were noted with EF of
50%. Cardiology recommended ASA, BB and statin. Given
orthostatic hypotension, metoprolol was stopped on [**5-22**]. ASA was
on hold as patient was switched from IV heparin to Lovenox on
day of discharge to home. A f/u cardiology appointment was
scheduled for [**5-29**].
He will also f/u with hematology given h/o IVC thrombus. He was
found to have 60% activity of antithrombin III. Recommendation
was to continue anticoagulation and follow-up with Dr. [**Last Name (STitle) 6944**]
to determine the optimal length of anticoagulation. See note
from [**5-20**].
He was discharged to home in stable condition.
Medications on Admission:
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth once a day
DEXLANSOPRAZOLE [DEXILANT] - (Prescribed by Other Provider) -
60
mg Cap, Delayed Rel., Multiphasic - 1 Cap(s) by mouth daily
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth qweek
HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-500 mg Tablet - 1 Tablet(s) by mouth as needed
LACTULOSE - (Prescribed upon d/c) - 10 gram/15 mL Solution -
15-30 Solution(s) by mouth three times a day Please titrate to
[**1-15**] soft bowel movements per day
MIDODRINE - 7.5 mg by mouth three times a day
RIFAXIMIN [XIFAXAN] - 550 mg by mouth twice a day
WARFARIN - 5mg by mouth daily
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU).
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
10. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
11. Outpatient Lab Work
Wednesday [**5-27**] then Every [**Month/Year (2) 766**] and Thursday
12. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Folow transplant clinic taper.
13. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
14. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous [**Hospital1 **] (2 times a day).
15. Outpatient Lab Work
Wednesday [**5-27**] and Saturday [**5-30**] for stat PT/INR with results
called to [**Telephone/Fax (1) 673**] attn: Transplant Coordinator
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
ETOH cirrhosis
s/p liver and kidney transplant [**2201-5-16**]
ileus
orthostatic hypotension
h/o IVC thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever, chills, nausea, vomiting, jaundice, inability to take any
of your medications, increased abdominal distension or pain,
incision redness/bleeding/drainage, decreased urine output,
weight gain of 3 pounds in a day or any concerns
You will need to have blood drawn on Wednesday [**5-27**] at Quest
then every [**Month/Year (2) 766**] and Thursday for labs
No heavy lifting
No driving if taking narcotic pain medications
You may shower, no tub baths or swimming
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2201-5-28**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT SOCIAL WORK
When: THURSDAY [**2201-5-28**] at 3:00 PM
With: TRANSPLANT SOCIAL WORKER [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2201-5-29**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: [**Hospital Ward Name **] [**2201-6-8**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Hematology
When: WEDNESDAY [**2201-7-15**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 6946**]
Completed by:[**2201-5-25**] |
25013,V5867,V1581,311,2720 | 99,928 | 104,802 | Admission Date: [**2181-11-16**] Discharge Date: [**2181-11-18**]
Date of Birth: [**2161-1-2**] Sex: F
Service: MEDICINE
Allergies:
Radioactive Diagnostics, General Classif
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"Nausea."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20F with DMI previously on insulin pump but now on HISS alone
due to dislike of pump who is now admitted to [**Hospital Unit Name 153**] with DKA. She
presented to ED due to nausea in the setting of being unable to
find her insulin this am. Patient reports poorly controlled
blood sugars 200s-400s since [**2181-5-9**] with no recent
significant change who last took her insulin at her friend's
house last night around 11pm per her usual sliding scale. This
am, she awoke at home around 11am with slight nausea and could
not find her insulin. She subsequently developed abdominal pain
and had her father bring her to [**Name (NI) **]. She reports multiple recent
stressors discussed below but denies sick contacts, CP, dysuria,
urinary frequency, vomiting, cough, fever, chills, change in
weight or recent illnesses. Her symptoms of nausea and
abdominal pain were consistent with her previous DKA episodes.
Last DKA was [**2181-5-9**] which occurred in the setting of her
getting upset with her mother and breaking all of her insulin
vials and refusing to take her insulin.
In the ED inital vitals were, 98.2 84 127/82 16 100% RA. Labs
remarkable for Glucose 600s, AG 23 and + urine ketones. UA
otherwise negative and urine and blood cultures were sent. She
was given 5 units of IV insulin and started on 5 unit/hr insulin
drip which was decreased to 2 units/hr. She received 2L NS and
40 mEq of KCl in 1L of NS and was trasnferred to [**Hospital Unit Name 153**]
On arrival to the ICU, she reports feeling much better and back
to baseline. Denies further nausea or abdominal pain. FSBS 185.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- Type I DM - diagnosed at age 3, last episode of DKA 6/[**2180**].
She has been prescribed insulin pump but doesn't like to use and
has only been consistently using HISS at home
- Hypercholesterolemia
- History of seizures, none since [**2172**] and off meds
- Depression and h/o cutting
Social History:
Works at [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] now living with her brother and his
girlfriend in [**Name (NI) 392**] since lease recently up on Section 8
housing in [**Location (un) **] so had to move 1 week ago. Denies cigarettes
or ETOH but used to smoke occasionally in past. Reports
occasional marijuana use. recent stess related to being witness
to her friend's stabbing. Sister lives in [**Name (NI) 108**] and was
recently diagnosed with breast cancer.
Family History:
Grandmother had diabetes.
Physical Exam:
Admission Exam:
Vitals: Afebrile HR 91 BP 107/72 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam
VS: Tm: 98.3 Tc: 97.9 BP:120/86 HR:79 RR:18 O2 Sats 100% on RA
.
pain: none
GEN: AAOX3 in NAD
HEENT: CN 2-12 grossly intact, MMM
NECK: no lad
CV: RRR, no RMG
RESP: CTAB, no WRR
ABD: abdomen flat, active BS, no TTP, no HSM
EXTR: WWP, 5/5 strength, sensation, pulses intact and equal
DERM: no obvious rashes
neuro: CN intact, strength, sensation wnl
PSYCH: mood and affect wnl
Pertinent Results:
Admission labs:
[**2181-11-16**] 03:00PM BLOOD WBC-11.6* RBC-4.46 Hgb-14.6 Hct-45.4
MCV-102*# MCH-32.7* MCHC-32.1 RDW-12.5 Plt Ct-379
[**2181-11-16**] 03:00PM BLOOD Neuts-82.0* Lymphs-14.8* Monos-2.4
Eos-0.5 Baso-0.4
[**2181-11-16**] 03:00PM BLOOD Plt Ct-379
[**2181-11-16**] 03:00PM BLOOD Glucose-625* UreaN-19 Creat-0.8 Na-127*
K-5.0 Cl-85* HCO3-19* AnGap-28*
[**2181-11-16**] 06:21PM BLOOD CK(CPK)-305*
[**2181-11-16**] 06:21PM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-11-17**] 05:51AM BLOOD CK-MB-1 cTropnT-<0.01
[**2181-11-16**] 06:21PM BLOOD Calcium-8.5 Phos-2.1* Mg-1.6
[**2181-11-16**] 06:21PM BLOOD VitB12-696 Folate-16.8
[**2181-11-16**] 03:00PM BLOOD %HbA1c-11.5* eAG-283*
Brief Hospital Course:
20 y/o F with DMI presenting with DKA likely secondary to missed
medications.
# DKA- Patient has Type 1 DM and reports poorly controlled DM
recently on HISS alone. HbA1C 11.5. She presents with symptoms
of nausea and abdominal pain. DKA with AG>20 and ketonuria. DKA
likely secondary to missed insulin on morning of admission. She
denies symptoms of infection but has mildly elevated WBC 11.6
which resolved without antibiotics. She currently denies CP and
cardiac enzymes negative. AG resolved with fluids and insulin
drip, and patient transitioned to insulin SS + Lantus 15 units
with [**Last Name (un) **] input. The patient was sent out on lantus 25 units
QHS and humalog sliding scale. The patient will following up
with a female provider at [**Name9 (PRE) **] in addition to her PCP.
[**Name10 (NameIs) **] has means to call and make follow up appointments and
can afford her medications. The patient said she had test
strips and a glucometer at home and she was also written for
insulin syringes.
.
# Social stress - Pt with h/o depression and multiple recent
stressors but not depressed currently. Poorly controlled DM
suggests poor insight into chronic disease process. SW consulted
for poor coping and insight.
.
Transitional Issues:
-Follow up at [**Hospital1 **] in [**12-10**] weeks
-Follow up with PCP [**Last Name (NamePattern4) **] [**12-10**] weeks
Medications on Admission:
Humalog insulin sliding scale; not on any long acting
medications. States she was told she should take lantus but was
not given pescription last admission so has not been on
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime: Please take this dose of lantus
unless otherwise instructed by a physician.
[**Name Initial (NameIs) **]:*6 bottles (QS for 1 month supply)* Refills:*2*
2. Humalog 100 unit/mL Solution Sig: Variable per sliding scale
Subcutaneous AC and HS: please dose humalog per sliding scale.
[**Name Initial (NameIs) **]:*6 vials (QS for 1 month supply)* Refills:*2*
3. syringe (disposable) 1 mL Syringe Sig: One (1) syringe
Miscellaneous fives times a day as needed for for injection of
insulin.
[**Name Initial (NameIs) **]:*120 syringes* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
diabetic ketoacidosis secondary to insulin non-compliance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with nausea. Your blood sugars were
found to be very high and had laboratory values consistent with
diabetic ketoacidosis. This was likely because you were not
taking enough insulin at home. You were intially treated in the
ICU and then transfered to the floor. You will be sent home on
long acting insulin and short acting insulin. You should follow
up closely with your PCP and [**Name9 (PRE) **].
Medication changes:
latus 25 units before bedtime
Humalog sliding scale (please see attached sheet)
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-80 mg/dL 3 Units 3 Units 3 Units 0 Units
81-130 mg/dL 5 Units 5 Units 5 Units 0 Units
131-180 mg/dL 6 Units 6 Units 6 Units 0 Units
181-230 mg/dL 7 Units 7 Units 7 Units 0 Units
231-280 mg/dL 8 Units 8 Units 8 Units 2 Units
281-330 mg/dL 9 Units 9 Units 9 Units 3 Units
331-380 mg/dL 10 Units 10 Units 10 Units 4 Units
381-400 mg/dL 12 Units 12 Units 12 Units 5 Units
Followup Instructions:
1) Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73829**] within [**12-10**]
weeks of discharge. Please call to make this appointment on
Monday. Phone number is [**Telephone/Fax (1) 50305**]
2) Please follow up at [**Hospital6 **] in [**12-10**] weeks.
You requested a women provider. [**Name10 (NameIs) **] suggestions are Dr. [**First Name8 (NamePattern2) 3692**]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **]. Please call [**Hospital1 **] at [**Telephone/Fax (1) 3402**] to make
an appointment Monday morning
-You need to see one of the two physicians within a week of your
discharge from the hospital
|
99859,56722,486,11289,5119,27900,75683,04104,E8786,V552,49390 | 99,934 | 176,121 | Admission Date: [**2110-2-28**] Discharge Date: [**2110-3-6**]
Date of Birth: [**2092-3-18**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
wound infection, intra-abdominal abscess
Major Surgical or Invasive Procedure:
CT guided drainage of abscess with pigtail drain placement
History of Present Illness:
17 M s/p appendectomy at [**Hospital3 2737**] on [**2-17**] for
perforated appendicitis. The patient recovered well and had an
initial improvement in his symptoms and leukocytosis. On POD2
the
patient started experiencing worsening abdominal pain, nausea
and
vomiting and was transferred to the OSH ICU where a CT was
obtained showing postoperative changes and continued
inflammation
but no clear abscess. He was taken to the operating room for a
exploratory laporotomy on [**2-21**] where, per report, an enterotomy
or
perforation was identified in the terminal ileum. An ileal
resection was performed and an end ileostomy was placed, and the
patient was taken to the ICU for further recovery. Following the
procedure the patient continued to have abdominal pain and
increasing leukocytosis up to [**Numeric Identifier 3301**]. His midline laparotomy
wound
was opened [**1-22**] wound infection. The patient had been receiving
Zosyn and Flagyl and was then switched to Imipenem per ID
recommendation. A repeat CT was obtained on [**2-27**] and
demonstrated
multiple fluid collections and the patient was transferred to
[**Hospital1 18**] for further management.
Past Medical History:
PMH: Hypogammaglobulinemia
PSH: Appendectomy [**2110-2-17**], ex-lap LOA, end ileostomy [**2110-2-21**]
Social History:
senior in high school, no ETOH, tobacco or drugs, active
football player
Family History:
no immunodeficiencies, 2 siblings - one with ? diagnosis of SLE,
other healthy
Physical Exam:
On Discharge:
AVSS
GEN: resting comfortably, NAD
CV: RRR
Lungs: CTAB
ABD: Open midline abdominal wound with wet/dry dressing in
place. Appropriately tender around the wound. Ostomy
pink/viable.
EXT: warm, well perfused
Pertinent Results:
[**2110-2-28**] 04:05AM BLOOD WBC-18.0* RBC-3.82* Hgb-11.3* Hct-34.3*
MCV-90 MCH-29.7 MCHC-33.0 RDW-13.9 Plt Ct-543*
[**2110-3-4**] 06:35AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.6* Hct-32.2*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.9 Plt Ct-642*
[**2110-2-28**] 04:05AM BLOOD Glucose-106 UreaN-11 Creat-0.9 Na-137
K-5.1 Cl-101 HCO3-27 AnGap-14
[**2110-3-4**] 06:35AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-139 K-4.8
Cl-102 HCO3-28 AnGap-14
CT abd/pel ([**3-5**]):
IMPRESSION:
1. Two discrete collections are again visualized throughout the
abdomen and pelvis. The previously aspirated, but not drained
collection along the right paracolic gutter appears relatively
unchanged with a focus of air consistent with prior
instrumentation. The right lower quadrant collection with
extension to pelvis which was aspirated and had a drain placed
appears smaller with resolution of the lateral and superficial
portion of the collection anterior to the right psoas muscle.
2. Moderate left pleural effusion, which is increased in size in
comparison to prior study with adjacent atelectasis. Small right
pleural effusion with adjacent atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 89930**] was transferred to our trauma surgical intensive
care unit from [**Hospital3 **] early in the AM of [**2110-2-28**]. He
was seen by Dr [**Last Name (STitle) **] and his team, and based on the fluid
collections seen on OSH CT scan, he was sent to IR for
percutaneous drainage. The IR team aspirated the right paracolic
gutter collection and left a drain in the pelvic collection.
This fluid was sent for culture. The patient was initially
tachycardic upon admission to the ICU, but was otherwise
hemodynamically stable. He was transferred to the floor on HD4
in good condition.
Neuro: His pain was initially well controlled on intermittent IV
dilaudid. When tolerating po intake, the patient was switched to
vicodin, which was well tolerated.
CV: He arrived tachycardic with stable blood pressure. This
improved quickly during his hospital stay, and he had no other
issues.
Resp: He had significant oxygen demand upon arrival and CXR
showed bilateral effusions and atelectasis. Sputum cultures were
drawn that were insufficient. Patient was concurrently being
treated with vancomycin and meropenem for his intra-abdominal
abscesses, which was determined to be sufficient for presumed
pneumonia as well. The patient was also given intermittent lasix
to improve his respiratory status as his lungs looked fluid
overloaded. These effusions were followed with serial CXRs and
improved throughout his stay. He was weaned off of oxygen on the
floor and his breathing remained comfortable.
GI/GU/FEN: The patient was initially NPO/IVF upon admission. His
diet was advanced to regular by HD3 and this was well tolerated.
Ostomy output was nearly 2 liters the first 24 hours of
admission. The output remained high the first few days of his
hospital stay, but then decreased on its own to an appropriate
level without medical intervention. His electrolytes and fluid
status were closely monitored and patient was repleted as
needed. His open abdominal wound was treated with wet/dry
dressing changes TID, and showed continued healing and
improvement during his stay.
ID: He was seen by our ID team upon arrival who recommended
switching imipenem to meropenem. He was also started on
vancomycin at arrival for presumed PNA. His abdominal wound was
packed with wet to dry dressings. Abdominal fluid collections
showed vanc sensitive enterococcus and [**Female First Name (un) **], so fluconazole
was added as well. The patient was kept on this antibiotic
regimen during his hospital stay. PICC line was placed on [**3-3**]
to continue atbx as an outpatient. Repeat CT scan was performed
on [**3-5**] that showed persistent abscesses in the pelvis and R
pericolic gutter. However, after patient's drain was adequately
flushed, the drain began to put out purulent material. Radiology
felt the drain was in good position and did not need to be
re-adjusted. The patient was sent home on meropenem, vancomycin,
and fluconazole per ID's recommendations.
Prophylaxis: Patient was started on SQH and encouraged to
ambulate often.
Dispo: Patient received ostomy teaching, Picc line teaching, and
wound care teaching. He understood all of this and agreed with
the plan. He was given discharge instructions and told to keep
all follow up appointments as scheduled.
Medications on Admission:
zyrtec
Discharge Medications:
1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. vancomycin 500 mg Recon Soln Sig: 1.5g Recon Solns
Intravenous Q 8H (Every 8 Hours): Through [**3-8**].
Disp:*12 Grams* Refills:*0*
4. meropenem 500 mg Recon Soln Sig: 500mg Recon Solns
Intravenous Q6H (every 6 hours): Through [**3-17**].
Disp:*23 grams* Refills:*0*
5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Through [**3-17**].
Disp:*22 Tablet(s)* Refills:*0*
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringes* Refills:*0*
7. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe
Injection PRN as needed for drain or PICC line flush.
Disp:*100 * Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
9. loperamide 2 mg Capsule Sig: [**12-22**] Capsules PO With meals and
at bedtime as needed for ostomy output greater than 1200cc/day.
Disp:*30 Capsule(s)* Refills:*0*
10. Outpatient Lab Work
LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Home With Service
Facility:
[**Telephone/Fax (1) 269**] of Southeastern Mass.
Discharge Diagnosis:
wound infection, intra-abdominal abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*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.
.
General Discharge Instructions:
*Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
*Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
*Avoid driving or operating heavy machinery while taking pain
medications.
*Please do not engage in any strenous activity until instructed
to do so by your surgeon.
.
Wound Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the wound
site.
*No showering, tub baths, or swimming until cleared by Dr.
[**Last Name (STitle) **] at your follow-up appointment. You may sponge bath
until then.
*Please perform wet-to-dry dressing changes three times daily.
You will have a visiting nurse come to help assist you with
dressing changes, and they will teach you how to perform these
dressing changes yourself.
.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Last Name (STitle) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output
daily.
*Keep the insertion site clean and dry otherwise.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Monitoring ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*If ostomy output is greater than 1200mL in one day, please use
Immodium to slow down the output: 2-4mg with meals and at
bedtime, as needed. Do not exceed 16mg/24 hours.
.
PICC Line Care:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.
*Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse
if the dressing comes undone or is significantly soiled for
further instructions.
.
Antibiotic Instructions:
*You will be receiving IV antibiotic therapy through your PICC
line. Per Infectious Disease recommendations, you will be on the
following regimen:
Vancomycin 1.5g IV every 8 hrs
Start date: [**2110-2-28**]
Stop date: [**2110-3-8**]
Meropenem 500mg IV every 6 hrs
Start date: [**2110-2-27**]
Stop date: [**2110-3-17**]
Fluconazole 400mg PO daily
Start date: [**2110-2-27**]
Stop date: [**2110-3-17**]
Required laboratory monitoring while on IV antibiotics:
LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP
FREQUENCY: Weekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**]
MD in when clinic is closed.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-3-20**].
Please come to Dr.[**Name (NI) 1482**] clinic at 8:15am to receive the
contrast for your scan. You will then have the CAT scan at
9:30am.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2110-3-20**] 10:45am. You will see Dr. [**Last Name (STitle) **] after
your CAT scan to go over the results.
3. Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2110-3-25**] 9:30am
Completed by:[**2110-3-7**] |
43411,34830,34291,42731,71690,5859,E8809,V5883,V5861,9110,7802 | 99,936 | 107,913 | Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-18**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed Lithuanian only speaking
woman with no significant PMH save for arthritis (per HCP who
goes to [**Name (NI) 48924**] visits with her)who initially presented at
around 11am after taking a fall at home at around 10:30. She
was brought in by EMS and was felt to be neurologically intact
when examined with a Lithuanian interpreter at around 2pm. She
had said "Hospital" in english. She didn't initally know the
date or time. The nurse caring for her did not feel that even
with the interpreter that the patient could ever produce 5
consecutive words. At 2:20pm her BP was 204/60 and she was
given 10mg IV labetolol. Her BP decreased to 180s/60s. She was
then noted by the niece (who just arrived - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79715**] -
1-[**Telephone/Fax (1) 79716**]) at around 2:30 to be weak in the right hand and
not paying attention to her right. Her verbal output was also
diminished. The nurse was called and the ED physician
[**Name9 (PRE) 31042**] calling [**Name Initial (PRE) **] code stroke at 2:39.
Past Medical History:
Arthritis.
Per the HCP [**First Name5 (NamePattern1) **] [**Name (NI) 79717**] - 1-[**Telephone/Fax (1) 79718**]) the patient had
a major medical workup 1 year ago that didn't reveal CAD (as was
once thought in the ED.) He also denied HTN (also mentioned in
the ED). In fact Mr. [**Name14 (STitle) 79717**] said she has low blood pressure.
Social History:
Lives in [**Location **] with Mr. [**Last Name (Titles) 79717**]. No ETOH, Drugs or tobacco.
Family History:
NC
Physical Exam:
On admission:
Temp: 99.2; BP: 204/60 -> 183/61; HR: 70s; RR: [**10-26**];
SaO2:100%RA
Gen: Alert, elder woman in C-collar. Sclerae anicteric. MMM. No
meningismus.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Neuro:
>>MS??????Alert. With niece translating could follow intermittent
commands (looking l/r; lifting left arm; indicating whether she
felt light touch). English speech limited to "ouch" and "yes".
In Lithuanian, pt would repeat questions but not name or follow
multi-step commands.
>>CN??????PERRL. No threat blink on right. No ptosis. EOMI w/ smooth
pursuit. Facial sensation and pterygoid strength intact. Facial
mm intact. Tongue protrudes midline.
>>Motor??????LEFT UE/LE [**5-13**] w/ nl tone. RIGHT UE postures to nox
stim; no spontaneous movement; tone increased. RIGHT LE
withdraws (MRC 3+) to nox stime; no spont movement; tone normal.
>>Sensory??????withdraws/grimaces briskly to nox stim throughout.
>>DTRs??????L/R: bic [**2-9**]+, br [**2-9**], tri [**2-9**]; pat [**2-9**], Ach 0/0. Right
plantar extensor.
>>Coord/Gait??????Not tested.
NIHSS: At : 2:50 pm in the admission - performed with the Niece
in Lithuanian.
Total score 21-22
1a =2
1b =2
1c =2
2 =1
3 =[**1-9**] - unclear if complete or partial hemianopia with blink
only.
4 =0
5a =4
5b =0
6a =3
6b =0
7 =0
8 =0
9 =3
10 =2
11 =1
Repeat NIHSS at 4pm. - performed with the Niece in Lithuanian.
Total score 13-14
1a =2
1b =1
1c =0
2 =0
3 =[**1-9**] - unclear if complete or partial hemianopia with blink
only.
4 =0
5a =4
5b =0
6a =3
6b =0
7 =0
8 =0
9 =2
10 =0
11 =0
Discharge physical exam: awake, interactive, following simple
commands. Simple english naming is intact, answers
appropriately. Dense right hemiplegia, sparing the face.
Pertinent Results:
[**2182-10-10**] 11:30AM BLOOD WBC-5.4 RBC-4.09* Hgb-12.8 Hct-36.9
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.3 Plt Ct-343
[**2182-10-10**] 11:30AM BLOOD PT-13.9* PTT-26.2 INR(PT)-1.2*
[**2182-10-11**] 02:59AM BLOOD Glucose-103 UreaN-23* Creat-1.1 Na-142
K-3.7 Cl-107 HCO3-26 AnGap-13
[**2182-10-11**] 12:05PM BLOOD ALT-14 AST-19 LD(LDH)-202 AlkPhos-73
Amylase-18 TotBili-0.5
[**2182-10-10**] 11:30AM BLOOD Lipase-11
[**2182-10-10**] 09:31PM BLOOD cTropnT-<0.01
[**2182-10-11**] 02:59AM BLOOD cTropnT-<0.01
[**2182-10-11**] 12:05PM BLOOD cTropnT-<0.01
[**2182-10-11**] 02:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.6 Cholest-184
[**2182-10-11**] 02:59AM BLOOD %HbA1c-6.5*
[**2182-10-11**] 02:59AM BLOOD Triglyc-107 HDL-42 CHOL/HD-4.4
LDLcalc-121
[**2182-10-10**] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Relevant lab results for discharge:
[**2182-10-15**] 06:35AM BLOOD WBC-7.5 RBC-3.61* Hgb-11.5* Hct-32.8*
MCV-91 MCH-31.8 MCHC-35.0 RDW-13.7 Plt Ct-345
[**2182-10-15**] 06:35AM BLOOD Plt Ct-345
[**2182-10-15**] 06:35AM BLOOD PT-41.5* PTT-41.6* INR(PT)-4.5*
[**2182-10-14**] 03:29AM BLOOD PT-23.5* PTT-63.9* INR(PT)-2.3*
[**2182-10-13**] 05:13PM BLOOD PT-18.6* PTT-65.7* INR(PT)-1.7*
[**2182-10-15**] 06:35AM BLOOD Glucose-98 UreaN-20 Creat-1.2* Na-139
K-4.3 Cl-106 HCO3-26 AnGap-11
[**2182-10-14**] 03:29AM BLOOD Glucose-143* UreaN-15 Creat-1.1 Na-138
K-4.1 Cl-105 HCO3-26 AnGap-11
[**2182-10-13**] 05:13PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-142
K-3.5 Cl-112* HCO3-22 AnGap-12
[**2182-10-12**] 10:10AM BLOOD CK(CPK)-101
[**2182-10-15**] 06:35AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9
Trauma XRay: The examination is limited due to overlying spinal
board and fixators. Within these limitations, there is no
displaced rib fracture or pneumothorax. The lungs are clear. The
cardiomediastinal silhouette appears unremarkable.
Limited assesment due to spinal board. Degenerative changes are
seen at the hip joints. There is no definite fracture
identified.
CTA/CTP [**10-10**]:
CTA: Attenuationa nd markedly decreased caliber of the M1
segment of the left middle cerebral artery with attenuation and
paucity of the M2 branches.
CTP: Large area of elevated MTT in the left MCA territory with
relatively well preserved blood volume in the periphery
indicating ischemia. However, the abnormality extends beyond the
area included on the present study.
Area of low blood volume in the left parasagittal parenchyma in
the higher
slices is not adequately assessed as the abnormality is in the
watershed
zone. Acute infarcts in this location or in areas not included
on the present study cannot be excluded. To consider MR head
with DWI for better assessment.
Echo: Suboptimal image quality - poor echo windows. The rhythm
appears to be atrial fibrillation. The left atrium is mildly
dilated. The right atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Repeat CT of head [**10-12**]: Evolving left anterior cerebral artery
territory infarction without evidence of hemorrhagic
transformation. No new abnormalities identified.
Brief Hospital Course:
Ms. [**Known lastname 79719**] is a [**Age over 90 **]yo Lithuanian speaking RHW without
significant PMH who presented with fall and transient right
sided weakness with recrudescence of weakness noted ~4h later.
It is unclear whether vessel occlusion/weakness prompted the
fall. She was found to have a left ACA occlusion with some left
MCA involvement. Her family declined intervention with IA tPA.
She was admitted to the Neuro ICU initially with a heparin drip
with PTT goal 50~70. She went into atrial fibrillation on HD #2
and thus was maintained on heparin and bridged to coumadin.
There was no past documentation of Afib per history and there
was no evidence of myocardial infarction per EKG or cardiac
enzymes. On [**10-14**], INR was 2.3 and heparin drip was discontinued.
She was started on Diltiazem 30mg [**Hospital1 **] for rate control since
there was a question of severe bradycardia with metoprolol. She
had sustained afib with elevated heart rate up to 160. Diltiazem
was changed to extended release 120mg daily. She received a
couple extra doses on [**10-17**] and had one 3.4sec pause on
telemetry; she then flipped back into sinus rhythm. [**10-15**] INR =
4.5, [**10-16**] INR = 3.5, so coumadin was held; [**2182-10-17**] INR = 3,
coumadin 2.5mg was restarted, but her most recent ([**2182-10-18**])
INR=3.7 and coumadin was again held. INR needs to be followed
and coumadin adjusted in order to establish the correct dose of
coumadin. Her right sided weakness remained unchanged during her
hospitalization.
Medications on Admission:
ASA, meclizine, vicodin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left ACA/MCA stroke
Atrial fibrillation
Discharge Condition:
stable, however with dense hemiplegia over the right side
(excluding the face), not walking
Discharge Instructions:
You were admitted to this hospital because you presented with
weakness over the right side of your body. You had a brain MRI
which showed signs of stroke at the left side of the brain.
While in the hospital we noticed irregularity of your heart beat
called atrial fibrillation, and this is a risk factor for
stroke.
To prevent further episodes of embolism and stroke you neeed to
take coumadin and you need to have your blood checked every
couple of days.
Please return to the emergency department if you have new onset
of weakness, mental status changes, loss of consciousness,
dizziness, loss of balance, or any other concerning symptoms.
Followup Instructions:
You will need to call your primary care physician in [**Name9 (PRE) **] to
set up a follow up appointment with Neurology after your
discharge from Rehabilitation. We sent a copy of your Duscharge
summary to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79720**] in [**Location (un) **]. Telephone #
[**Telephone/Fax (1) 79721**] Fax# [**Telephone/Fax (1) 79722**].
While in [**Location (un) 86**] you can contact [**Name2 (NI) 79723**] office [**Telephone/Fax (1) 657**]
for recommendations if necessary.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
486,1120,515,79902,4019,2720,53550,71690,311,V103 | 99,937 | 129,380 | Admission Date: [**2128-5-11**] Discharge Date: [**2128-5-20**]
Date of Birth: [**2062-9-6**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 65-yo woman with interstitial lung disease on
chronic immunosuppression, and h/o left breast Ca s/p partial
mastectomy + adjuvant chemo-XRT, who presented to the ED with
dyspnea. Pt has been feeling unwell since Thursday of last week,
when she initially developed symptoms of headache, dizziness,
body aches, decreased appetite, and inability to get out of bed.
These symptoms have continued since, and since Sunday she has
had significant dyspnea as well. She has been using her home O2
continuously since Sunday (at baseline she only uses 2L NC as
needed for dyspnea). She denies any associated cough or sputum
production, but endorses mild wheeze, stating it feels like a
bronchitis or pneumonia. Overnight last night she developed
subjective chills and sweats, and this morning she found her
temperature to be 101.7F, so she was brought to the ED for
evaluation.
In the ED, VS - Temp 98.0F, BP 128/57, HR 102, R 34, SaO2 78% on
2L NC. Labs were remarkable for an elevated WBC at 11.6 with 90%
PMNs, and lactate 3.6, and negative UA. Blood Cx sent x2. CXR
showed low lung volumes, increased interstitial markings c/w
chronic fibrotic changes, and interstitial edema; an underlying
atypical pneumonia cannot be ruled out. She was given Solumedrol
125mg IV x1, Levofloxacin 750mg IV x1, Vancomycin 1g IV x1, and
2L NS IVF for SBPs ~100. She seemed to improve and was changed
from NRB to 3L NC, but desaturated to 85% on 3L so was restarted
back on the NRB, with good response. CTA was done to r/o PE,
which showed no PE or acute aortic syndrome; lung fibrotic
changes, increased in left lung at site of radiation tx; and no
underlying pneumonia. She is being admitted to the MICU for
further care.
On the floor, pt feels significantly improved. She has been on
daily steroids and azathioprine for several months, with a
recent decrease in her methylprednisolone dose and corresponding
increase in her azathioprine dose on her last visit with Dr.
[**Last Name (STitle) **] on [**2128-4-7**]. She also complains of mildly painful "pimples"
on the sides of her tongue, which she relates to the increase in
her azathioprine. She also endorses having stopped her Bactrim
PCP [**Name9 (PRE) 5**], but was unsure as to when this was stopped.
Past Medical History:
- Interstitial lung disease, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], last
seen [**4-/2128**], with increase in Azathioprine to 150mg daily and
decrease in methylprednisolone to 16mg daily
- Left breast carcinoma grade 3, T1c, N0, ER positive, PR
negative, HER-2/neu negative, s/p partial mastectomy, sentinel
node dissection, adjuvant chemotherapy and radiation therapy
- Hypertension
- Hypercholesterolemia
- Depression
- Gastritis
- Arthritis
- H/o low positive [**Doctor First Name **]
Social History:
Married, lives with husband and three children. Originally from
El [**Country 19118**], Spanish-speaking only. No history of smoking or
drinking.
Family History:
No family history of lung disease. No early CAD. Sister with
breast cancer at 50. No other cancers in the family.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2128-5-11**] 12:00PM WBC-11.6* RBC-4.29 HGB-13.4 HCT-40.1 MCV-93
MCH-31.3 MCHC-33.6 RDW-15.2
[**2128-5-11**] 12:00PM NEUTS-90.3* LYMPHS-5.9* MONOS-3.2 EOS-0.4
BASOS-0.3
[**2128-5-11**] 12:00PM PLT COUNT-246
[**2128-5-11**] 12:00PM PT-12.5 PTT-20.6* INR(PT)-1.1
[**2128-5-11**] 12:00PM ALBUMIN-4.0
[**2128-5-11**] 12:00PM CK-MB-1 cTropnT-<0.01
[**2128-5-11**] 12:00PM LIPASE-50
[**2128-5-11**] 12:00PM ALT(SGPT)-23 AST(SGOT)-46* LD(LDH)-700*
CK(CPK)-60 ALK PHOS-66 TOT BILI-0.6
[**2128-5-11**] 12:00PM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
[**2128-5-11**] 12:11PM LACTATE-3.6*
[**2128-5-11**] 09:35PM CK-MB-1 cTropnT-<0.01
[**2128-5-11**] 09:35PM LD(LDH)-292* CK(CPK)-26*
[**2128-5-18**] Respiratory Viral Antigen Screen (Final [**2128-5-19**]):
Negative for Respiratory Viral Antigen. Specimen screened for:
Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by
immunofluorescence.
[**2128-5-18**] BAL Gram Stain: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
Studies:
[**2128-5-11**] ECG: Normal sinus rhythm. Axis at 0 degrees. Poor R wave
progression. Non-specific ST-T wave changes in leads V1-V3.
Compared to the previous tracing of [**6-12**]-109 the Q-T interval
prolongation is no longer present. The T wave inversions in
leads V1-V3 persist unchanged. The prior T wave inversions in
leads V4-V5 are no longer present. Otherwise, no diagnostic
interval change. These T wave changes are non-specific.
[**2128-5-11**] CXR: Low lung volumes with increased interstitial
markings consistent with chronic fibrotic changes with some
component of interstitial edema; an underlying atypical
pneumonia cannot be ruled out, so repeat radiograph after
diuresis is recommended.
[**2128-5-11**] CT Chest: 1. No PE or acute aortic syndrome.
2. Chronic interstitial fibrotic changes in the lungs with
increased fibrosis and bronchiectasis of the lingula with
subpleural fat consistent with post-radiation changes.
[**2128-5-13**] TTE: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Mild to
moderate ([**12-6**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad. IMPRESSION: Preserved global and regional
biventricular systolic function. Mild to moderate aortic
regurgitation. Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
65-yo woman with ILD on chronic immunosuppression and PRN home
O2 for symptoms of dyspnea, also with h/o left breast Ca s/p
partial mastectomy and adjuvant chemo-XRT, admitted to the MICU
with respiratory distress and hypoxia.
#. Hypoxia, respiratory distress: Pt admitted with worsened
hypoxia from baseline, somewhat acute and in setting of recent
systemic symptoms. She was also febrile on admission. CXR and
CTA had a faint suggestion of possible pneumonia, with diffuse
faint ground glass opacities new compared to prior CTA from 1
year ago, making multifocal pneumonia a possibility. She
continued to have O2 sats in the high-90s on 6L NC, but with
desaturations to the 60s-70's even with small movements in bed.
She was initially started on ceftriaxone and levofloxacin to
cover for community acquired pneumonia, and was continued on
levofloxacin for a total 5 day course. She was also placed on
IV steroids (125mg IV methylprednisolone q6h) for three days and
then given high-dose prednisone. She was also started on NAC
and continued on her home azathioprine. Her respiratory status
minimally improved with this treatment. She underwent
bronchoscopy to rule out occult infection. At the time of
discharge, her only positive culture was yeast in the fungal
culture that hadn't been speciated. The pulmonary team planned
to follow this culture and contact the rehab after discharge if
an organism grew that needed treatment. It was not felt that
this was likely to be aspergillus. Ultimately, it was felt that
she likely had an infection on admission that caused a flare of
her underlying ILD and her persistent hypoxia was a result of
worsening of ILD. She was discharged still requiring 5L NC and
on 40mg prednisone daily.
#. Interstitial lung disease: She is followed closely by Dr.
[**Last Name (STitle) **]. Her PFTs have declined considerably over time. She
received steroids as above and was continued on azathioprine.
It was felt that this presentation resulted from worsening of
her ILD in the setting of acute infection. It was discussed
with the patient that her degree of ILD is severe and her
oxygenation is unlikely to substantially improve in the future.
#. Left breast cancer: Grade 3, T1C, N0, ER positive, PR
negative, HER-2/neu negative, s/p partial mastectomy with
sentinel node dissection and adjuvant chemotherapy and radiation
therapy. She was maintained on daily Tamoxifen.
#. Hypertension: She was slightly hypertensive during her stay
and is not on any antihypertensives at home.
#. Gastritis: Continued home PPI
#. Hypercholesterolemia: Continued on her home statin
#. Depression: Continued on her home celexa
#. Thrush: She was started on fluconazole for thrush for a total
14 day course.
#. Code Status and Goals of Care: She was full code initially
during this admission but she decided to change to DNR/DNI
status during this admission. A long goals of care discussion
was held and the patient was also interested in exploring any
services that will help her to spend more time with her family.
She is being discharged to a rehab facility with plans to
possibly transition to hospice depending on her clinical course.
Medications on Admission:
- Azathioprine 150mg PO daily
- Chlorpheniramine-Hydrocodone 10mg-8mg/5ml [**12-6**] tsp PO Q12hr PRN
severe cough
- Celexa [dosage uncertain]
- Methylprednisolone 16mg PO daily
- Omeprazole 20mg PO daily
- Simvastatin 20mg PO daily
- Sulfamethoxazole-Trimethoprim 800mg-160mg PO 3x/week - pt
states this was stopped
- Tamoxifen 20mg PO daily
- Acetaminophen 500mg PO PRN
- Ergocalciferol [Vitamin D2]
- Loratadine
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
6. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Last day [**2128-5-30**].
10. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
while on steroids Subcutaneous ASDIR (AS DIRECTED).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous TID (3 times a day).
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnoses:
- Interstitial lung disease
- Community acquired pneumonia
Secondary Diagnosis:
- History of breast cancer
- Left breast carcinoma
- Hypertension
- Hypercholesterolemia
- Depression
- Gastritis
- Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
O2 Sats: 93-97% on 5L NC, desats to 60's-70's with ambulation
but recovers when rests. Needs oxygen supplementation at all
times.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
increasing oxygen requirements. You were treated for a
pneumonia and for a worsening of your interstitial lung disease.
You continued to require a large amount of oxygen
supplementation and you are being discharged to a rehabilitation
facility.
Changes to your medications:
ADDED fluconazole 100mg by mouth daily for 10 more days (last
day [**2128-5-30**])
RESTARTED Bactrim 1 double strength tablet 3 times weekly
INCREASED prednisone to 40mg by mouth daily
ADDED trazodone 25mg by mouth at bedtime as needed for sleep
INCREASED omeprazole to 20mg by mouth twice daily
ADDED acetylcysteine 20% 600mg po by mouth three times daily
ADDED guaifenesin 100mg/5mL syrup: 5-10ml by mouth every 6
hours as needed for cough
Followup Instructions:
You have the following appointments scheduled:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2128-6-28**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
42841,2761,4240,41401,4280,25000,4019,2859,5859,501,V1301,7231,73300 | 99,938 | 103,815 | Admission Date: [**2200-10-24**] Discharge Date: [**2200-11-11**]
Date of Birth: [**2119-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath, exertional dyspnea
Major Surgical or Invasive Procedure:
[**2200-10-27**] Mitral Valve Replacement (33mm St. [**Male First Name (un) 923**] tissue)/
Coronary artery bypass grafts x 4 (LIMA-LAD, SVG-OM, SVG-Dg,
SVG-PDA)
[**2200-10-24**] Left and right heart catheterization, coronary
angiography
History of Present Illness:
80M with history of coaornary disease who was in usual health
until two weeks ago when he noted progressively worsening
dyspnea and orthopnea. His symptoms progressively worsened and
he presented to [**Hospital3 3583**] on [**10-23**] and was found to be in
heart failre with a BNP of 2351 and a borderline troponin of
0.15. An ECHO was performed and showed LVEF of 25%. He was
diuresed with IV lasix and was oxygenating well on 2L NC but
still had dyspnea. Of note, the patient's last stress test was
in [**2199**] and was unremarkable with preserved LVEF. He received
metformin and lovenox on morning of transfer and was not given
plavix. He was transferred to [**Hospital1 18**] for catheterization.
At cath, he was found to have severe three vessel coronary
artery disease, moderate to severely elevated right and left
sided filling pressures and depressed cardiac index and
ejection fraction with diffusely hypokinetic left ventricle.
He was referred for surgical revascularization.
Past Medical History:
osteoporosis
spinal stenosis
hx of asbestos exposure
kidney stones- s/p lithotripsy colon polyps
hyperlipidemia
glaucoma
peripheral vascular disease.
diverticulosis
colonic polyps
Hypertension
diabetes
Social History:
Quit smoking 44 years ago, previously had a 15 pack-year
history. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died of CVA. No other known FH of CVD.
Pertinent Results:
[**2200-10-24**] Cardiac Cath:
1. Coronary angiography of this right dominant system revealed
severe, calcific three vessel coronary artery disease. The LMCA
did not have focal stenoses. The LAD had a 90% stenosis in the
mid-vessel. The proximal portion of the major diagonal branch
had a 70% stenosis. The LCx had a 99% stenosis at the origin,
with left to left collaterals. The RCA was totally occluded
proximally, with left to right collaterals.
2. Resting hemodynamics revealed moderate to severely elevated
right and left sided filling pressures (RVEDP 19 mm Hg, LVEDP 25
mm Hg, respectively). The PCWP mean was elevated at 28 mm Hg.
There was moderate pulmonary artery hypertension (PASP 59 mm
Hg). The systemic arterial blood pressure was low-normal (SBP
105 mm Hg). The cardiac index was depressed at 1.7 L/min/m2. The
systemic and pulmonary vascular resistances were mildly elevated
at 1697 dynes-sec/cm5 and 315 dynes-sec/cm5, respectively.
3. Left ventriculography demonstrated a dilated left ventricle
with global, severe hypokinesis to akinesis, with estimated
ejection fraction of 25%. There was moderate to severe mitral
regurgitation.
[**2200-10-25**] ECHO:
The left atrium is dilated. The right atrium is markedly
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
inferior/inferolateral and inferoseptal akinesis. Overall left
ventricular systolic function is moderately depressed (LVEF= 30
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] with
borderline normal free wall function. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, medially directed jet of at
least moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] was found to have triple vessel disease on
catheterization, with right heart pressure elevated and mitral
regurgitation. He was taken to the operating room on [**10-27**] where
coronary bypass grafting and mitral valve replacement were
performed. See operative note for details. He weaned from
bypass on Milrinone,epinephrine and neosynephrine.
Postoperatively he was relatively stable and was extubated on
[**Name (NI) 80108**]. His epinephrine was weaned and discontinued as was his
neosynephrine by POD 2. The Milrinone was then slowly weaned
and he remained stable.
He was gently diuresed, however, he became hypotensive each time
he received a Lasix bolus. A Lasix drip was instituted with a
good diuresis and stable blood pressure. Consult was obtained
from the CHF service-- we appreciate their recommendations. The
patient was transitioned from the lasix gtt to bolus treatment,
which he tolerated well.
He made good progress with physical therapy before discharge.
By the time of discharge, the patient was ambulating with
assistance, the pain was controlled with oral analgesics, and
the woundf was healing. He was discharged on POD 15 to The
Rehab of [**Location (un) **] and Islands for further recovery.
Medications on Admission:
Prilosec 20 qd
Altace 10 qd
Metformin 1000 qam, 500 qpm
Crestor 10 qd
ASA 81
MVI
Ca Vit D
Actonel 35 qFriday
Lasix
Timolol 0.5% to L eye [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) 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. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
5. Furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2
times a day).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
17. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
congestive heart failure
coronary artery disease
Diabetes Mellitus
Dyslipidemia
Hypertension
peripheral vascular disease
h/o nephrolithiasis
chronic anemia
spinal stenosis
glaucoma
osteoporosis
diverticulosis
colonic polyps
Discharge Condition:
good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
report any temperature greater than 100.5
report any redness or drainage from incisions
shower daily, no baths or swimming
take all medications as directed
no lotions, powders or creams to incisions
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58201**] in 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] in [**3-2**] weeks
Completed by:[**2200-11-11**] |
51881,5849,40391,5856,99812,5990,5839,2875,2859 | 99,939 | 159,023 | Admission Date: [**2110-3-22**] Discharge Date: [**2110-4-2**]
Date of Birth: [**2083-4-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Respiratory Failure, Acute Renal Failure, Emergent Dialysis
Major Surgical or Invasive Procedure:
HD catheter placement
Femoral Line placement
Hemodialysis x 6
History of Present Illness:
This is a 26 yo Spanish speaking M, otherwise healthy, who
presented initially to the [**Hospital3 15402**] ED with a history of couple
of weeks of cough, more recently n/v, blurry vision in the last
few days which then developed into acute dyspnea with pink
frothy sputum. At [**Hospital3 15402**], he was found to have a low grade
fever, and multiple electrolyte abnormalities, most notably a
creatinine of 21.6, Hct 16, plts 88, and K 6.0. He was given
blood, kayexalate, insulin, D50, amp bicarb x 1, protonix, and
was sent to the [**Hospital1 18**] ED for further management.
.
On arrival here, he was tachypneic with lots of pink frothy
sputum, and was satting 92% on a 100%nrb. His other vitals were
AF 98.7 240/110 80's. On exam, he was diffusely rhonchorous and
crackly on exam. He was started on a nitro gtt which quickly
became maxed without benefit to either his blood pressure or his
breathing. He was initially tried on CPAP but did not tolerate
the mask [**3-17**] secretions and was intubated with etom/succ. 2
large bore IV's. Propofol gtt started. Bedside u/s showed
hyperdynamic heart function, no effusion.
He is undergoing a head CT for headache and elevated BP's and
will be sent to the ICU for emergent dialysis and respiratory
failure. Pressure 220's currently.
.
On arrival to the ICU, the patient is intubated and sedated,
maxed on nitro gtt with BP's in the 170's, tachycardic.
Past Medical History:
none
Social History:
per OSH ED notes, no EtOH, tobacco or illicits. Has a
brother/cousin who was with him there. Lives with a friend.
Has a spot for ongoing hemodialysis treatments in [**Location (un) 5503**],
Ma but needs to have his Essential Mass Health status upgraded
to Limited, before they will accept him. They will not accept
him with the "Limited" number still pending.
Family History:
per patient's brother, family is healthy, there are no renal or
pulmonary problems and he denies bleeding dyscrasias, joint or
heart disease.
Physical Exam:
Vitals: T: BP: 177/110 P: 114 Sat 100% A/C 500x14 Peep 10 FiO2
0.5
General: Intubated and sedated
HEENT: PERRL, pupils pinpoint. Sclerae anicteric, MMM,
oropharynx clear; nares with crusted blood. Unable to visualize
discs at this time.
Neck: supple, JVP to 9cm, no LAD
Lungs: Rhonchorous diffusely with scattered rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: +clonus at ankles
Pertinent Results:
[**2110-3-22**] 03:14AM WBC-10.7 RBC-2.45* HGB-7.5* HCT-21.0* MCV-86
MCH-30.6 MCHC-35.5* RDW-14.4
[**2110-3-22**] 03:14AM NEUTS-85.5* LYMPHS-9.5* MONOS-3.7 EOS-1.0
BASOS-0.3
[**2110-3-22**] 03:14AM GLUCOSE-146* UREA N-161* CREAT-21.3*
SODIUM-148* POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION
GAP-24*
[**2110-3-22**] 03:14AM ALT(SGPT)-26 AST(SGOT)-24 CK(CPK)-543* ALK
PHOS-75 TOT BILI-0.6
[**2110-3-22**] 03:14AM cTropnT-0.20*
[**2110-3-22**] 05:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2110-3-22**] 05:35AM HCV Ab-NEGATIVE
[**2110-3-22**] 05:35AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2110-3-22**] 05:35AM [**Doctor First Name **]-NEGATIVE
[**2110-3-22**] 05:35AM ANCA-NEGATIVE B
[**2110-3-22**] 05:35AM C3-108 C4-27
[**2110-3-22**] 01:25PM dsDNA-NEGATIVE
[**2110-3-22**] 01:25PM PTH-424*
[**2110-3-22**] 01:25PM LD(LDH)-758* CK(CPK)-476*
[**2110-3-22**] 01:25PM HAPTOGLOB-<20*
[**2110-3-22**] 04:27PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL Stipple-OCCASIONAL Bite-1+ Acantho-OCCASIONAL
Fragmen-OCCASIONAL
[**2110-3-22**] 04:27PM BLOOD Plt Ct-76*
[**2110-3-31**] 07:45AM BLOOD Plt Ct-225
[**2110-3-22**] 01:25PM BLOOD PT-14.2* PTT-73.5* INR(PT)-1.2*
[**2110-3-23**] 08:10AM BLOOD Ret Aut-2.0
[**2110-3-22**] 01:25PM BLOOD ACA IgG-2.5 ACA IgM-7.2
[**2110-3-22**] 03:14AM BLOOD Glucose-146* UreaN-161* Creat-21.3*
Na-148* K-4.2 Cl-108 HCO3-20* AnGap-24*
[**2110-3-31**] 07:45AM BLOOD Glucose-121* UreaN-102* Creat-13.8*
Na-137 K-6.1* Cl-100 HCO3-15* AnGap-28*
[**2110-3-22**] 05:35AM BLOOD LD(LDH)-788* TotBili-0.6 DirBili-0.2
IndBili-0.4
[**2110-3-23**] 06:45PM BLOOD LD(LDH)-595* TotBili-1.4
[**2110-3-22**] 03:14AM BLOOD cTropnT-0.20*
[**2110-3-23**] 08:10AM BLOOD CK-MB-4 cTropnT-0.41*
[**2110-3-22**] 03:14AM BLOOD Calcium-6.2* Phos-7.3* Mg-3.6*
[**2110-3-31**] 07:45AM BLOOD Calcium-9.1 Phos-7.8* Mg-3.0*
[**2110-3-23**] 06:45PM BLOOD Hapto-52
[**2110-3-28**] 08:55AM BLOOD HIV Ab-NEGATIVE
[**2110-3-22**] 05:35AM BLOOD ANTI-GBM-Test -
Test Result Reference
Range/Units
GBM AB 4 U/ML (High) <3
NEGATIVE
>=3
POSITIVE
Cardiology Report ECG Study Date of [**2110-3-22**] 3:10:36 AM
Sinus tachycardia. Modest ST junctional depression which is
non-diagnostic.
No previous tracing available for comparison.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 108 82 318/424 71 -3 65
[**Last Name (LF) **],[**First Name3 (LF) **] A. EU [**2110-3-22**] 3:16 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80775**]
Reason: r/o chf
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with desats, pink sputum with new ARFand low
plt.
REASON FOR THIS EXAMINATION:
r/o chf
Final Report
INDICATION: 26-year-old male with desaturation, pink sputum, and
new acute
renal failure. Evaluate for CHF.
Single AP chest radiograph demonstrates bilateral diffuse
airspace opacity.
Differential consideration include non-cardiogenic pulmonary
edema, multifocal
pneumonia or possibly diffuse hemorrhage. There is no pleural
effusion or
pneumothorax. The cardiomediastinal contour is normal.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2110-3-22**] 11:25 AM
[**Last Name (LF) **],[**First Name3 (LF) **] P. MED FA2 [**2110-3-31**] 5:22 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 80776**]
Reason: patient with new tenderness in left flank s/p renal
biopsy ?
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with IgA nepropathy in ESRD on HD, receiving
dialysis.
REASON FOR THIS EXAMINATION:
patient with new tenderness in left flank s/p renal biopsy ?
perinephric
hematoma
CONTRAINDICATIONS FOR IV CONTRAST:
End stage renal disease;end stage renal disease
Final Report
STUDY: CT of the abdomen and pelvis.
HISTORY: 26-year-old male with IGA nephropathy on hemodialysis.
New
tenderness of left flank. Assess for hematoma.
TECHNIQUE: Non-contrast MDCT axial images of the abdomen and
pelvis were
acquired. Coronal and sagittal reformatted images were then
obtained.
CT OF THE ABDOMEN WITHOUT CONTRAST: The lung bases are clear.
The liver,
gallbladder, spleen, adrenal glands, stomach, pancreas, and
abdominal portions
of the large and small bowel appear unremarkable. The right
kidney is normal
in size and there is no perinephric stranding. There is a
moderate sized left
perinephric hematoma with heterogeneous internal density
including a few areas
of higher attenuation within the lower pole of the left kidney
(2:22, 23,
300B:36). The largest dense area within the lower pole seen best
on coronal
images measures 2.8 x 2.4 cm (300B:36). The hematoma tracks
along the
capsule without evidence of large subcapsular component, and
tracks
within Gerota's fascia on the left, extending to the psoas
medially. Along
the inferior margin of the left kidney, the collection measures
approximately
5.8 x 6.3 cm (300B:30). The right kidney is unremarkable. There
is no free
fluid or free air within the abdomen.
CT OF THE PELVIS WITHOUT IV CONTRAST: The prostate, bladder,
rectum, sigmoid
colon, and intrapelvic loops of small bowel appear unremarkable.
There is no
free fluid within the pelvis.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic
lesions.
IMPRESSION: Moderate left perinephric hematoma, status post
recent biopsy.
Brief Hospital Course:
26 yo M with no PMH admitted with respiratory failure and marked
acute renal failure of unknown etiology.
# Respiratory Failure: Likely secondary to flash pulmonary edema
in the setting of malignant hypertension. Mostly pink frothy
sputum and not hemoptysis, but on admission, a pulmonary-renal
syndrome was within the ddx. CXR showed diffuse infiltrates
characteristic of pulmonary edema and BNP was very elevated.
Mini BAL did not show evidence of eosinophilia. Due to unstable
shortness of breath with decompensating O2 sats, the patient was
intubated in the ER, started on a propafol drip and transfered
to the MICU. Once dialyzed, the patient was weaned and extubated
quickly with no further respiratory issues. Throughout the
remainder of his stay he was kept on PRN Albuterol and
Ipratropium, and never complained of shortness of breath, nor
did he suffer and desaturation incidents.
.
# Acute Renal Failure: In the emergency department the patient's
creatinine was elevated to 21.3 and a his BUN of 161. The
patient met all but one of the indications for dialysis
(acidosis, electrolyte derangements, overload and uremia)
underwent emergent line placement and HD. Etiologies initially
considered were TTP/HUS (although thrombocytopenia was not
profound), vasculitic process including Wegener's, microscopic
polyangiitis, Churg-[**Doctor Last Name 3532**] (but no eos on peripheral smear),
HSP (no skin findings on exam), Cryoglobulinemia (but he is
young for this dx), anti-GBM, and Goodpasture's. SLE was also on
the differential initially. A broad work up was initiated, but
UA with large blood and 500 protein without dyspmorphic red
cells/red cell casts on sediment seemed to direct away from
acute GN or vasculitis, and peripheral smear had relatively few
schistocytes with normal bili, and with fairly high platelet
count, so TTP also seemed unlikely. Renal u/s showed atrophic
kidneys and elevated PTH, suggesting chronic renal failure.
Anca, [**Doctor First Name **], dsDNA, hepatitis serologies were all negative, and C3
and C4 levels were wnl. Renal bx was done on [**2110-3-24**]. The patient
had HIV, Hepatitis, and PPD tests that were negative. An anti
GBM antibody study came back high at 4 (upper limit of 3)
assumed a likely false positive given that biopsy results
revealed IgA nephropathy with profoundly sclerosed glomeruli.
The patient had a tunneled hemodialysis catheter placed and was
started on dialysis. Over the course of his hospitalization,
with dialysis treatments, his weight was reduced from 62.6 kg to
56.4 kg. His symptoms of nausea/vomiting abated early. 6 days
post biopsy, the patient developed a 6cm x 6cm perinephric
hematoma. The bleeding was contained and his pain treated.
.
# Hypertensive Emergency: on nitro gtt initially, but weaned off
on arrival to MICU with fent/versed. Received HD for acute
management. CT head without obvious bleed. BP between 140 and
170 systolic in unit. On floor managed with Amlodipine 10mg po
daily until BP controlled only with HD. Final BP of 118/87. Had
one episode of hypertension post dialysis on HD#5 treated with
10mg IV Hydralazine. Blurry vision and HA both resolved
following first dialysis treatment. No evidence of ongoing end
organ damage present.
.
# Anion Gap Metabolic Acidosis - AG was 20, and delta-delta was
1.6 on admission indicating a pure AG metabolic acidosis
(although given the renal failure there is likely a component of
NG acidosis as well). This was most likely due to uremia; the
patients acidosis corrected with regular dialysis treatment.
.
# Elevated CE's: patient was very volume overloaded and with ARF
so the likely etiology was significant strain; however, we
considered myocarditis in the setting of vasculitis,
specifically Wegener's. EKG had nonspecific findings but no
evidence of acute ischemia. These trended downward over the
course of admission without the patient complaining of chest
pain or difficulty breathing.
.
# Anemia/Thrombocytopenia: Unclear why platelet count was low as
this is not characteristic of uremia, but anemia initially
considered to be secondary to malignant HTN. Hematology was
consulted given the possibility of a TTP/HUS picture, though
there were too few schistocytes, and primitive platelet forms on
the peripheral smear to warrant this diagnosis. Following the
renal biopsy, and the discovery of change more consistent with a
chronic etiology to his renal failure, the anemia was believed
to be secondary to poor epo output. On HD#7 he received 2 units
of packed red blood cells prior to dialysis, however, his
hematocrit continued to fall gradually. On HD#9 a 6 cm x 6 cm
perinephric hematoma was discovered on CT. The patient's Hct was
32 and bleeding was well controlled upon discharge. His platelet
count was within normal by time of discharge.
.
# UTI, on hospital day 7 the patient began spiking low grade
fevers to the 100.4 range. Urinalysis revealed a pattern
consistent with a UTI and the patient was started on 500mg of PO
BID Ciprofloxacin for treatment. Given his hemodialysis this
was considered to be safe.
.
# FEN: The patient was intubated at first and kept NPO while in
the MICU, after transfer to the floor, he was placed on a renal
diet. He did not enjoy the renal diet. Nutrition was consulted
to provide him with an appropriate modification of his usual
diet at home.
.
# Code: patient is full code
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three
times a day.
Disp:*270 Tablet(s)* Refills:*2*
4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
IgA nephropathy
Acute on Chronic renal failure.
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile, and
with appropriate follow up.
Discharge Instructions:
You were admitted to the hospital because of your shortness of
breath, cough productive of pink frothy sputum, nausea,
vomiting, inability to eat, and lab tests that suggested that
you had acute kidney failure. Because of your pink frothy
sputum you could not breathe and had to have a tube placed down
your throat to help you. After you received your first dialysis
treatment, this tube was removed. Afterward, you received an
ultrasound of your kidneys which revealed them to be smaller
than they should have been. You then had a CT scan that
confirmed this. A biopsy was taken of your kidney that revealed
the cause of your symptoms to be a condition called IgA
nephropathy. This condition has likely been present for a very
long time and has been damaging your kidneys during that time
period without you even being aware of it. Because of your
kidney failure, you had a hemodialysis catheter(tube for
dialysis) placed in your chest, and began to receive
hemodialysis treatments every other day.
During your hospitalization you were treated with a number of
medications: Amlodipine for your blood pressure, Albuterol and
Iprotropium for your breathing, Sevelamer to remove phosphate
from your blood, and pantoprazole to prevent the burning feeling
in your stomach.
On your 9th day of hospitalization, you experienced some left
sided flank pain for which you were evaluated with a CT scan of
your abdomen and pelvis. The CT scan showed that you had a small
bleed to the side of your kidney where your biopsy had been
taken. You were given medication for the pain.
Please take the sevelamer medication, three pills, three times
daily to prevent buildup of phosphate in your blood.
Please continue to take the antibiotic Ciprofloxacin twice a day
for 7 days.
Please take the nephrocaps 1 pill once a day.
You have been given some pills for pain, please take one or two
every 6 hours for pain.
You do not need to take Amlodipine.
Please keep your follow up appointments as listed below.
Should you experience further nausea, vomiting, headache with
blurry vision, coughing up blood, or any other concerning
symptoms, please return to the hospital at once.
Followup Instructions:
Please return to the hospital for dialysis treatment 11:30am
[**Hospital Ward Name 121**] [**Location (un) 436**], every Monday, Wednesday, and Friday.
|
42833,486,41071,5781,2851,4240,5859,4280,41401,40390,725,42731,2749,2689,78791,V5865 | 99,944 | 185,654 | Admission Date: [**2161-2-16**] Discharge Date: [**2161-2-21**]
Service: MEDICINE
Allergies:
Demerol / Morphine / Hydrocodone / Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
85 yo F with HTN, polymyalgia rheumatica, transferred from [**Hospital1 18**]
[**Location (un) 620**] for cardiac catheterization. The patient was in her
usual state of health until Wednesday [**2-11**], when she developed
black diarrhea, occuring 5 times daily. The patient attributes
the black color to her iron supplements. Along with diarrhea,
the patient also experienced 2 episodes of vomiting (clear, no
blood or coffee grounds). The patient also had fever to as high
as 100.6 on Friday [**2-13**] and Saturday [**2-14**].
On Sunday [**2-15**], the patient became lightheaded when getting up
from the toilet and fell, hitting her head and right elbow. She
presented to [**Hospital1 18**] [**Location (un) 620**], where head and c-spine CT were
negative. She developed chest pain after admission, relieved
with metoprolol and nitroglycerin. She received 1 unit of RBCs
for Hct 27, and became short of breath. She was given 40mg IV
lasix and diuresed 500cc. She ruled in for MI with third set of
troponins peaking at 0.26. She was transferred to [**Hospital1 18**] for
cardiac catheterization on 100% non-rebreather and a heparin
gtt. Of note, pt was guaiac positive on admission.
On arrival to [**Hospital1 18**], the patient was taken to the cardiac
catherization lab, where she was found to have severe 3-vessel
disease and an elevated LVEDP (see below for details). She was
transferred to the CCU on a non-rebreather for further
management. In the CCU, the patient was weaned to a
non-rebreather. She reported that her breathing was improved and
had no other complaints.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. She denies
sore throat, sinus congestion, dysuria. She denies weakness,
tingling, or numbness. All of the other review of systems were
negative.
Cardiac review of systems is notable for chest pain and
lightheadedness as above and two pillow orthopnea. No syncope.
The patient reports a recent decrease in exercise tolerance from
100 feet on a flat surface to 50 feet on a flat surface.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Diastolic CHF
Chronic Kidney Disease (Baseline 1.5-1.7)
Right BBB
MRSA in nares
Atrial Fibrillation
Gout
Cellulitus
Polymyalgia Rheumatica
Diverticulosis
Depression and Anxiety
S/p cholecystecomty/appendectomy
S/p tonsillectomy
S/p surgery for anal fissure
Social History:
Retired. Worked as secretary. Lives alone at [**Location (un) 582**].
-Tobacco history: quit 40 yrs ago; smoked 1 ppd x 30 years
-ETOH: denies
-Illicit drugs: denies
Family History:
Father with stroke at 68. Mother with MI at 65. Two brothers
with HTN. Had 4 children (one died).
Physical Exam:
(Per Admitting Resident)
VS: T=97.5 BP=129/54 HR=69 RR=18 O2 sat=96%/6L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR, 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. CTA anteriorly (could
not sit up due to recent cath).
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2161-2-16**] 05:30PM BLOOD WBC-13.7* RBC-3.60* Hgb-9.7* Hct-29.4*
MCV-82 MCH-27.0 MCHC-33.0 RDW-14.9 Plt Ct-311
[**2161-2-16**] 05:30PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.3
Baso-0
[**2161-2-16**] 11:01PM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0
[**2161-2-16**] 11:01PM BLOOD Glucose-174* UreaN-31* Creat-1.5* Na-141
K-3.3 Cl-105 HCO3-22 AnGap-17
[**2161-2-16**] 11:01PM BLOOD CK(CPK)-110
[**2161-2-16**] 11:01PM BLOOD CK-MB-3 cTropnT-0.14*
[**2161-2-16**] 11:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9
[**2161-2-16**] 05:33PM BLOOD Type-ART O2 Flow-15 pO2-75* pCO2-34*
pH-7.46* calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Discharge Labs
[**2161-2-21**] 05:42AM BLOOD WBC-14.9* RBC-3.43* Hgb-9.8* Hct-29.3*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.2 Plt Ct-360
[**2161-2-21**] 05:42AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.0
[**2161-2-21**] 05:42AM BLOOD Glucose-103* UreaN-36* Creat-1.4* Na-139
K-4.2 Cl-98 HCO3-32 AnGap-13
[**2161-2-21**] 05:42AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1
[**2161-2-18**] 04:05AM BLOOD %HbA1c-6.1* eAG-128*
CXR ([**2161-2-18**]) - The size of the cardiac silhouette is at the
upper range of normal, there is no evidence for overt pulmonary
edema. In the right upper lobe as well as in the entire left
lung, the interstitial markings are increased, there are patchy
areas of opacities, that are ill-defined and distributed in a
mainly peribronchial pattern. In addition, a small left basilar
atelectasis and a small left pleural effusion is seen. Overall,
the morphology and distribution of the changes suggests
multifocal pneumonia rather than pulmonary edema. No evidence of
right basal changes, no evidence of right-sided pleural
effusion.
CXR ([**2161-2-20**]) - In comparison with study of [**2-18**], there has been
placement of left subclavian PICC line extends to the mid
portion of the SVC. There has been some decrease in the
bilateral patchy areas of opacification, most likely consistent
with improving pneumonia.
Cardiac Cath ([**2161-2-16**]) -
1. Coronary angiography in this right dominant system
demonstrated severe three vessel CAD. The LCx was the least
stenosed and there was no obvious single culprit stenosis. The
LMCA had distal calcification with a hazy 30% stenosis. The LAD
was heavily calcified with diffuse disease throughout with
serial 60% stenoses just before a major D4 with a distal 85%
stenosis and an 80% apical stenosis. There was a high D1,
functionally a large septal branch which was patent. A large D2
and D4 were also patent. The LCx was tortuous proximally with
slow flow and mild diffuse disease in the AV groove LCx. OM
branch had a proximal 50% stenosis with a tortuous upper pole
and mild diffuse disease in the lower pole. The distal AV groove
LCx supplied collaterals to the distal RCA system. The RCA was
heavily calcified with a 40% ostial stenosis without pressure
dampening. There was proximal diffuse disease up to 75% and
distal diffuse disease before the RPDA up to 45%. There was
moderate diffuse disease throughout the RPDA with severe diffuse
disease in the distal AV groove RCA supplying the RPLs with slow
flow (? severe disease vs. competitive flow from collaterals).
Septal collaterals from the LAD fill the RPDA.
2. Limited resting hemodynamics revealed mildly elevated RA
pressure
with a mean RAP of 9 mmHg. There was severely elevated left
sided filling pressures with an LVEDP of 29 mmHg. There was
moderate systemic arterial systolic hypertension with an SBP of
160 mmHg. No cardiac index could be calculated as unable to
float PWP catheter beyond RA.
3. Modest hypoxemia (O2 sat 93% on 15L NRB mask) improved to 96%
with the addition of 2L via nasal cannula arguing against
significant shunt physiology.
FINAL DIAGNOSIS:
1. Severe three vessel CAD.
2. Severe left ventricular diastolic dysfunction.
Brief Hospital Course:
85 yo F with HTN, Afib, dCHF, CKD, h/o guaiac-positive stools,
transferred from [**Hospital1 **] [**Location (un) 620**] for cardiac catheterization in the
setting of elevated cardiac enzymes, new focal wall motion
abnormalities, and worsened MR. [**Name13 (STitle) **] to have extensive 3-vessel
disease.
# Coronary Artery Disease: Pt noted to have a troponin leak at
an OSH, with peak of 0.26. Was transferred to [**Hospital1 18**] for cardiac
catheterization, which revealed three-vessel disease. Given
this, pt is a poor candidate for PCI. After much discussion, pt
decided that she would not want cardiac surgery. [**Hospital 49578**]
medical management was pursued. During her hospitalization, she
experienced episodes of chest discomfort, particularly at night.
She did not exhibit any ECG changes during these episodes. Her
metoprolol was uptitrated, and she was started on a long-acting
nitrate for further antianginal activity. By the time of
discharge, she had been free of chest pain for several days.
# Acute on Chronic Diastolic HF / Worsened Ritral Regurgitation:
Echo at OSH showing new focal wall motion abnormalities and
worsened MR, likely of ischemic etiology. On presentation, she
was thought to be hypervolemic. Metoprolol and amlodipine were
tirated for optimum BP control / afterload reduction. The option
of mitral valvular surgery was addressed, but the patient was
not interested in cardiac surgery. She was diuresed with bolus
IV lasix, which was converted to PO lasix prior to discharge.
# Pneumonia: CXR performed on [**2161-2-18**] was suspicious for
multifocal pneumonia. Pt was initially started on broad-spectrum
coverage with vancomycin, cefepime, levofloxacin. She was noted
to spike a fever on the night of [**2161-2-18**]; however, she remained
afebrile after that. She did also have a leukocytosis throughout
her hospitalization, which was improving at the time of
discharge. On [**2161-2-20**], her antibiotics were narrowed to
levofloxacin, as she had no positive cultures and appeared
improved clinically. Of note, at the time of discharge, she did
continue to have an oxygen requirement, which was likely
multifactorial in etiology (see below).
# GI Bleeding: The patient was noted to have guaiac positive
stools during her hospitalization. She did have one episode of a
hematocrit drop, for which she received a unit of PRBCs. Her
hematocrit remained stable after that. She also complained of
some episodes of dysphagia, with food getting "stuck" in her
throat. She states that this has been occuring for some time.
She was seen by GI for both of these issues. Further evaluation
with a barium swallow was recommended as an outpatient. Further
work-up of her GI bleeding should also be pursued as an
outpatient. Of note, in the setting of this GI bleeding, her
aspirin dose was decreased and her PPI dose was increased. Her
iron was also discontinued.
# Oxygen Requirment: Likely multifactorial in the setting of the
patient's pneumonia and severe MR. Treatment as above.
# Positive Blood Cx: One blood cx positive for GPR's. Likely a
contaminant. Speciation pending and not further cultures
positive at the time of d/c.
# Pre-Diabets: Pt was noted to have elevated blood sugars in the
CCU. A1C was 6.1, consistent with pre-diabetic state. This
should be further followed as an outpatient.
# Chronic Kidney Disease: Baseline creatinine 1.5 to 1.7. The
patient remained at her baseline throughout the hospitalization.
ACE inhibitors was held in the setting of her kidney disease.
# Diarrhea: Pt presented with some recent diarrhea in the
setting of recent fever and chills. Stool cultures were sent,
including C.diff, and were negative. Her diarrhea improved.
# Vitamin D Repletion: Pt's previous vitamin D regimen was not
entirely clear. She is being discharged on 1000 units of Vitamin
D3 daily. This may be adjusted as an outpatient if more
significant vitamin supplementation is desired.
# Polymyalgia Rheumatica: Continued on home prednisone dose.
# Anxiety/Depression: Continued on nortriptyline and zyprexa at
home dose.
Medications on Admission:
Ativan 0.5 mg daily PRN
Tylenol 650 mg Q4H PRN
Prochlorperidzine 10 mg Q6H PRN
Lidoderm 5% patch apply to left hip for 12 hours on 12 hours off
Norvasc 5 mg daily
Prilosec 20 mg daily
Nortriptyline 10 mg daily
Metoprolol ER 100 mg daily
Vitamin D 50,000 units weekly for 4 weeks, then monthy
prednisone 10 mg daily
Drisdol once a month
ferrous sulfate 325 mg [**Hospital1 **]
Tylenol 1000 mg PO BID
Calcium carbonate 500 mg TID
acidophilus 1 capsule [**Hospital1 **]
Zyprexa 5 mg daily
Trazodone 12.5 mg PO QHS
Senna 1 tab [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea .
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: to right hip, 12 hrs on, 12 hrs
off.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
14. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed for insomnia.
17. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual x3 as needed for CP : Up to three doses
separated by 5 min. If not resolved after three, call physician.
19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Start [**2-22**] am.
20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux.
21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Pneumonia
Coronary artery disease
Secondary:
Chronic kidney disease
Guaiac positive stool
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance
Discharge Instructions:
You were admitted to [**Hospital1 18**] for a heart catheterization to
evaluate for coronary disease. We found disease in all 3 blood
vessels as well as a leaky mitral valve. You declined to have
heart surgery to repair these problems. We removed extra fluid
with medications called diuretics and treated you for a
pneumonia.
Please take all medications as prescribed. We have made the
following medication changes:
STOPPED:
Lorazepam (Ativan)
Ferrous sulfate (iron)
CHANGED:
Increased metoprolol succinate to 225mg daily
Vitamin D to 1000 units daily
STARTED:
Atorvastatin for cholesterol
Levofloxacin for 4 days (antibiotic for pneumonia)
Isosorbide mononitrate for chest pain
Aspirin for blood thinning
Furosemide to prevent fluid buildup
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with the physician at your nursing facility.
Please call [**Telephone/Fax (1) 62**] on Monday to set up a follow up
appointment for 2-3 weeks with one of our cardiologists.
|
5770,5307,2763,5180,5990,0416,3441,V1251,78720,V441,30000,53081,2724,3019,43811,43882,79902,43813,43853,5758 | 99,946 | 157,197 | Admission Date: [**2161-7-14**] Discharge Date: [**2161-7-21**]
Date of Birth: [**2111-11-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 y.o male with pmhx of multiple CVAs, multiple dvts (s/p IVC
filter), aphasia, G-tube for dysphagia presents with abdominal
pain, nausea and vomiting. The abdominal pain started yesterday
and was accompanied by nausea and vomiting (last episode
yesterday) nonbloody bilious. Last BM was yesterday after he
received ducolax and was brown, formed and nonbloody. He was
also noted to have temperature up to 100, and WBC of 13 (from 8
yesterday) today at his care facility.
.
Of note per rehab notes: Yesterday dulc. supp given and patient
had large BM with KUB revealing no ileus or obstruction.
.
Of note the patient had a G tube placed several months ago and a
replacement inserted in [**2161-5-22**] due to leakage around the
tube.
.
Initial ED vitals: 99.7 102 147/100 18 95% ra. Given 2mg Zofran
IV and 5mg Morphine IV for pain and nausea.Because of increasing
oxygen requirements in the ED transferred to the ICU, 92% on
non-rebreather; and did abg which revealed resp alkalosis,CTA
revealed no PE.Of note the patient recieved no IV fluid.
.
Prior to transfer vitals were: BP-147/104, HR 103, RR 13, 94%
NRB
.
On arrival to the MICU, the patient denies dyspnea and is
satting 96% on 4L NC, he also denies chest pain, back pain,
confusion, vision changes,headache, recent vomiting. He does
have persisting nausea and abdominal pain which is diffuse and
not worse in any particular area.
Review of systems:
Obtained from patient
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Constipation
Anxiety
GERD
Generalized pain
HLD
Insomnia
Multiple CVA's [**Month (only) **] first in [**2152**] of the brain stem related to
aneurysmal dilation of basilar artery w/ b/l hemiparesis
especially right hand, b/l facial plegia, partial 6th nerve
palsy, dysarthyria, and dysphagia.
[**2152**] Basilar artery dissection several basilar artery aneurysyms
(11mm) after was put on plavix, calcified mural thrombus
suggestive of chronic dissection [**10-1**] ([**Last Name (un) 74591**] [**Hospital1 107**])
Back pain s/p lumbar disectomy L4-L5, L5-S1 [**2135**]
Multiple DVT s/p IVC filter [**3-/2160**]
Dysphagia s/p G tube being used for meds only
+ [**Doctor First Name **] [**2160-3-21**]
Personality disorder- rapidly becomes verbally abusive
periodically makes false accusations against staff
Social History:
Former professor, patient estranged from family who lives in
[**State 8842**] . Currently living in [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
LF Denies alcohol, tobacco and illicit drug abuse.
Family History:
NC
Physical Exam:
ADMISSION
Vitals: T:99.0 BP: 140/90 P: 90 R:13 18 O2:98% 4L NC
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, distended, bowel sounds present though hypoactive
in all quadrants, no organomegaly .G tube in place in epigastric
area with no erythema or drainage around the site of the tube.
Diffuse abdominal pain to palpation, neg [**Doctor Last Name **], and no rebound
tenderness or guarding.
GU: foley placed with dark amber urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact,EOMI, sym smile, can raise forehead sym,
tongue midline, EOMI, pupils equal and reactive to light, [**3-26**]
hand grip strength b/l, [**3-26**] UE extension, [**2-23**] UE flexion to only
40 degrees, cannot flex knees or pick up thighs off bed b/l, but
has [**3-26**] plantarflexion b/l, downgoing babinski b/l, grossly
normal sensation, cannot illicit achilles and patellar reflexes
bilaterally, gait deferred.
DISCHARGE
Abdomen: soft, NT/ND,NABS x4. minimal diffuse TTP, no
rebound/guarding
Pertinent Results:
ADMISSION LABS:
[**2161-7-14**] 05:45PM BLOOD WBC-16.5* RBC-5.83 Hgb-18.1* Hct-51.1
MCV-88 MCH-31.1 MCHC-35.4* RDW-13.5 Plt Ct-255
[**2161-7-14**] 05:45PM BLOOD Neuts-89.5* Lymphs-4.1* Monos-6.0 Eos-0.3
Baso-0.2
[**2161-7-15**] 02:05AM BLOOD PT-30.9* PTT-39.0* INR(PT)-3.0*
[**2161-7-14**] 05:45PM BLOOD Glucose-132* UreaN-22* Creat-0.8 Na-142
K-3.2* Cl-101 HCO3-29 AnGap-15
[**2161-7-14**] 05:45PM BLOOD ALT-23 AST-13 AlkPhos-62 TotBili-1.7*
[**2161-7-14**] 05:45PM BLOOD Lipase-1576*
[**2161-7-14**] 05:45PM BLOOD Albumin-4.9 Calcium-9.8 Phos-3.4 Mg-2.2
[**2161-7-14**] 05:45PM BLOOD Triglyc-67
[**2161-7-14**] 08:10PM BLOOD Type-ART pO2-363* pCO2-38 pH-7.50*
calTCO2-31* Base XS-6 Intubat-NOT INTUBA
[**2161-7-15**] 02:23AM BLOOD Type-[**Last Name (un) **] Temp-38.2 pO2-94 pCO2-42 pH-7.45
calTCO2-30 Base XS-4 Comment-AXILLARY T
[**2161-7-14**] 05:47PM BLOOD Lactate-2.1*
[**2161-7-15**] 02:23AM BLOOD Lactate-1.1
DISCHARGE
[**2161-7-20**] 06:55AM BLOOD WBC-9.6 RBC-4.54* Hgb-13.8* Hct-40.0
MCV-88 MCH-30.5 MCHC-34.6 RDW-13.3 Plt Ct-283
[**2161-7-20**] 03:10PM BLOOD Hct-39.1*
[**2161-7-20**] 06:55AM BLOOD PT-34.7* PTT-41.0* INR(PT)-3.4*
[**2161-7-20**] 06:55AM BLOOD Glucose-96 UreaN-6 Creat-0.8 Na-143 K-3.3
Cl-107 HCO3-28 AnGap-11
[**2161-7-20**] 06:55AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.2
PERTINENT
[**2161-7-15**] 02:05AM BLOOD PT-30.9* PTT-39.0* INR(PT)-3.0*
[**2161-7-19**] 07:25AM BLOOD PT-38.3* PTT-37.8* INR(PT)-3.7*
[**2161-7-20**] 06:55AM BLOOD PT-34.7* PTT-41.0* INR(PT)-3.4*
[**2161-7-14**] 05:45PM BLOOD Lipase-1576*
[**2161-7-15**] 02:05AM BLOOD Lipase-1196*
[**2161-7-17**] 07:10AM BLOOD Lipase-50
[**2161-7-14**] 05:45PM BLOOD ALT-23 AST-13 AlkPhos-62 TotBili-1.7*
[**2161-7-15**] 02:05AM BLOOD ALT-19 AST-9 LD(LDH)-163 AlkPhos-58
Amylase-1044* TotBili-1.8*
[**2161-7-16**] 07:15AM BLOOD ALT-18 AST-12 LD(LDH)-224 AlkPhos-52
TotBili-2.0* DirBili-0.5* IndBili-1.5
[**2161-7-19**] 07:25AM BLOOD ALT-17 AST-10 LD(LDH)-210 AlkPhos-58
TotBili-1.1 DirBili-0.4* IndBili-0.7
IMAGING:
RUQ U/S: Distended gallbladder containing a few sludge balls. No
specific
signs for acute cholecystitis.
CXR: Low lung volumes with bibasilar atelectasis.
CTA CHEST: 1. No pulmonary embolism. Bibasilar atelectasis.
2. Coronary artery atherosclerotic calcification, significant
in this age group.
Brief Hospital Course:
49 y.o male with pmhx of multiple CVAs, multiple dvts (currently
has IVC filter), aphasia, s/p G-tube for dysphagia presents with
abdominal pain, nausea and vomiting found to have elevated
lipase concerning for pancreatitis.
#Pancreatitis- Felt ultimately secondary to biliary obstruction,
although ultrasound revealed only distended gallbladder with
biliary sludge. Hypertriglyceridemia ruled out, and patient
denied recent ETOH or trauma. Statin initially considered as
potential etiology so held in this setting. His BISAP score was
1 with no significant uremia, clear mental status, very small
left pleural effusion/atelectasis on imaging, and
hemodynamically stable. calcium level normal. Lactate mildly
elevated in ED so admitted to MICU. He was treated with IVF
repletion and bowel rest with improvement. Upon initial
reinitiation of fluids patient did not tolerate well and had
episode of emesis leading to UGI bleed with coffee ground emesis
ultimately suctioned from Gtube. Resumed bowel rest and patient
improved and eventually tolerating regular diet w/o abdominal
discomfort.
#Hypoxemia- No ARDS or significant pleural effusion seen on
imaging. No PE on CTA. The patient denied cough, chest pain,
fevers, chills and recent dyspnea. He was euvolemic/hypovolemic
on exam with no evidence of heart failure. Imaging only
remarkable for mild bronchial wall thikening compatible with
chronic airway disease. Per nursing facility Baseline oxygen
sats 92-94 (<95). Patient likely w/ component of hypoventilation
and atelectasis. Oxygen saturations remained w/in baseline
throughout course.
#Leukocytosis -Likely related to pancreatitis described above.
The patient denies cough, dysuria, diarrhea. Blood cultures and
urine cultures obtained which showed were negative. Resolved
with management of pancreatitis. No antibiotics administered.
#Past CVA- according to records due to basilar artery dissection
and subsequent basilar artery aneurysyms, was on plavix which he
was intolerant of for unknown reason at this time. Currently on
Coumadin,current neurologic exam at baseline per records and
patient denies any new numbness or paralysis. INR 3.0 on
admission and uptrending although patient did not get any doses
of warfarin during his inpatient courese.
TRANSITION OF CARE
- maintained full code status
- studies pending at discharge: urine culture [**2161-7-20**]
- patient to follow up with PCP, [**Name10 (NameIs) **], GI
Medications on Admission:
NaCl nasal spray
Chlorhexidine Gluconate 0.12% mouthwash Qdaily
Fluticasone 50mcg nasal spray [**Hospital1 **]
Glucosamine Chondroitin 500-400mg daily
Lotrimin AF 1% Topical cream daily
Nystatin 100,000 unit/ml oral suspension
Prevident 5000 1.1 % Cream apply on teeth and gum line
senna 8.6mg tab Q daily
Famotidine 20mg [**Hospital1 **]
Tylenol 650mg/20.3 cc oral solution PRN Pain
Pyridoxine 100mg daily
Niacin 100mg daily
Lorazepam 0.5mg p.o Q4H PRN anxiety
Mag oxide 400mg Tab [**Hospital1 **]
Trazodone 50mg [**12-22**] tab QHS
Baclofen 10mg tab Q8H PRN spasm of the muscle
Colace 100mg [**Hospital1 **]
Vitamin D 3 TID
Simvastatin 40mg daily
Loratidine 10mg tab daily
Baclofen 20mg [**Hospital1 **]
Refresh Liquigel 1% eye drops each eye Q2H PRN eye dryness
Dulcolax 10mg supp PRN
Fish oil 1 cap daily
Coumadin 4mg daily
Compazine 5 mg Q4H PRN nausea
Compro supp 25mg [**Hospital1 **]
Senokot 218mg/5ml syrup 10ml Q dPRN
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL DAILY
2. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
3. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP [**Hospital1 **]
apply on teeth and gum line
4. Senna 1 TAB PO BID Constipation
hold for loose stools
5. Famotidine 20 mg PO BID
6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
7. Pyridoxine 100 mg PO DAILY
8. Niacin 100 mg PO DAILY
9. Lorazepam 0.5 mg PO Q4H:PRN anxiety
10. Magnesium Oxide 400 mg PO BID
11. traZODONE 25 mg PO HS:PRN insomnia
12. Baclofen 10 mg PO Q8H:PRN spasm, hiccups
13. Docusate Sodium (Liquid) 100 mg PO BID
14. Vitamin D 400 UNIT PO TID
15. Loratadine *NF* 10 mg Oral daily
16. Baclofen 20 mg PO BID
17. Artificial Tears 1-2 DROP BOTH EYES PRN dry eye
18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
19. Fish Oil (Omega 3) 1000 mg PO DAILY
20. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
21. Prochlorperazine 5 mg PO Q6H:PRN nausea
22. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
23. THERAPY
Please resume PT, OT, and speech therapy
Discharge Disposition:
Extended Care
Facility:
[**First Name9 (NamePattern2) 112207**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
PRIMARY
acute pancreatitis
upper gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 112208**],
You were admitted to the hospital for abdominal pain and found
to have pancreatitis. You were treated conservatively with bowel
rest and IV fluids and you improved. Your pancreatitis was
probably caused by a very small gallstone, so it is important
that you follow up with surgery because you will need your
gallbladder removed. You did have an episode of nausea and
vomiting that likely caused a small tear in the lining of your
stomach and you had some bleeding in your stomach. However, this
stopped on its own and your blood counts remained stable
thereafter.
MEDICATION CHANGES
STOP simvasatin
STOP warfarin
START pantoprazole
Please continue all other medications as previously prescribed.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: MONDAY [**2161-7-27**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2161-8-6**] at 4:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2161-8-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
4321,3484,3485,78003,2760,25060,3572,99659,9982,E8708,4019 | 99,955 | 108,494 | Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-19**]
Date of Birth: [**2076-5-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache and unresponsive
Major Surgical or Invasive Procedure:
intubation by OSH prior to arrival.
extubation with trach placement.
History of Present Illness:
Mr. [**Known lastname 89692**] is a 63 yo Haitian man with history of DM and
HTN
who presented with severe headache and vomiting to [**Hospital3 9683**].
The patient was at home with his wife, when he suddenly
developed
the worst headache of his life at 11pm. He had previously been
in
his normal state of health, and his daughter spoke to him at
8pm.
The patient apparently did have headache 1 day prior to
presentation, but had no other symptoms.
When his headache became severe on the night of admission, he
was taken to [**Hospital3 9683**]. Upon arrival he was vomiting and becoming increasingly
somnolent, so
was intubated for airway protection. This was a traumatic
intubation causing some oral bleeding, most likely because the
intubation had punctured the soft palate. NCHCT showed 19mm R
SDH. Patient was transferred to [**Hospital1 18**] for surgical eval.
On arrival to [**Hospital1 18**] ED, patient was intubated and on propofol.
Head CT showed significant enlargement of R SDH to 21mm, with
19mm L midline shift and compression of the brainstem pushing
the brainstem to the left
c/w uncal herniation. Initial exam showed pupils fixed and
dilated, no corneals, not responding to noxious stimuli.
Neurosurgical consult did
not feel that patient would benefit from surgery since pupils
were fixed and there was no change in his neurological
examination in particular in his pupillary reactions and
cornealreflex after he had received a 100g Mannitol challenge.
Pt continued to receive a high dose of mannitol, nicardipine gtt
for HTN and Dilantin for seizure prophylaxis.
Per patient's family, he had not been ill, no recent trauma or
falls, no changes to medications. He takes ASA 81 mg daily but
no
other blood thinning medications. He has never had profuse
bleeding with surgery/dental work/injuries/etc, and there is no
family history of bleeding disorders.
Past Medical History:
HTN
HL
DM for decades c/b peripheral neuropathy
Social History:
lives with wife, no tobacco, EtOH or illicits.
Family History:
NC
Physical Exam:
At admission:
VS: T afebrile HR 80s BP 130s/60s
General: intubated, no responding to verbal commands or noxious
stimuli even without sedating agents turned off.
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
NEURO:
Off propfol approx 1 hour:
Eyes closed. Eyes do not open to sternal rub, no response to
noxious stimuli. No spontaneous limb movements.
Pupils 8mm and nonreactive. No VORs, very sluggish right corneal
reflex noted, no corneal reflex on the left; vestibulo-ocular
reflex absent; +strong cough
and gag.
Tone decreased. Intermittently a decerebrate posturing in his UE
with very severe noxious stimuli.
DTR 2+ in bilateral [**Hospital1 **], tri, brachiorad, absent in LEs, toes
mute.
At discharge: deceased
Pertinent Results:
At admission:
[**2139-7-14**] 01:50AM PT-13.2 PTT-22.4 INR(PT)-1.1
[**2139-7-14**] 01:50AM WBC-14.7* RBC-5.29 HGB-15.8 HCT-44.2 MCV-84
MCH-29.8 MCHC-35.7* RDW-13.5
[**2139-7-14**] 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-7-14**] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-7-14**] 01:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2139-7-14**] 01:50AM URINE RBC->182* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-0
[**7-14**] CTA with and without Recon
IMPRESSION:
1. Right-sided subdural fluid collection with acute hemorrhage
along with
hypodense areas which may related to ongoing
hemorrhage/coagulopathy. Maximum transverse dimension of 23 mm
with mass effect on the right erebral hemisphere, lateral
ventricles and shift of the midline structures to the left side
by approximately 21.3 mm. Hypodense appearance of the cerebral
hemispheres may relate to a component of cerebral edema.
Right sided uncal herniation; brain stem compression and
distortion with
leftward shift. Assessment for osseous structures/fractures is
limited on the present study. Please see the outside study for
additional details. To
correlate clinically, for trauma/coagulopathy and close followup
as clinically necessary.
2. Patent major intra- and extra-cranial arteries as described
above with
decreased caliber of the Basilar artery, A1 and A2 segments of
the anterior cerebral arteries on both sides, part of which may
relate to mass effect/spasm from cerebral edema.
3. Small focus of enhancement in the right-sided subdural
hemorrhagic
collection may relate to contrast extravasation. No abnormally
dilated
vessels to suggest an obvious vascular malformation in this
location.
Recommended review of the images by neurosurgery to decide on
further workup.
4. Multilevel degenerative changes in the cervical spine along
with a focus of prominent posterior disc osteophyte complex at
C5-6 resulting in moderate canal stenosis and varying degrees of
foraminal narrowing. MR can be considered if not CI and if
clinically necessary.
[**2139-7-19**] Nuclear Brain Scan:
INTERPRETATION:
Following injection of tracer, SPECT images of the brain were
obtained in
multiple projections and show no evidence of perfusion to the
cerebral cortex.
IMPRESSION:
The perfusion abnormalities are consistent with brain death.
Findings discussed with Dr [**Last Name (STitle) **] via phone at [**Pager number **] on [**2139-7-19**].
Brief Hospital Course:
The patient was admitted to the NeuroICU for subdural hematoma.
Patient was intubated at OSH prior to transfer. Neurological
exam showed patient to be nonresponsive, with pupils fixed and
dilated 6mm bilaterally. Right corneal reflex could be
elicited, but was very sluggish; no left cornealreflex; cough
intact, and extensor posturing on applying severe noxious
stimuli in the UE. CTA showed 23 mm mass effect on the right
cerebral hemisphere, lateral ventricles and shift of the midline
structures to the left side by approximately 21.3 mm, as well as
right sided uncal herniation, brain stem compression and
distortion with leftward shift. Neurosurgery saw the patient but
did not feel there was any surgical intervention that they could
offer that would be of benefit given the patient's presenting
neuro exam, in particular his fixed pupils and the lack of any
change in his neurological exam after he got a Mannitol
challenge of 100g.
Neuro:
The patient was continued to be treated with mannitol after the
initial Mannitol challenge to decrease cerebral edema and
herniation. Administration was limited by checking for
hypernatremia and serum hyperosmolality. He was continued on
fosphenytoin for seizure prophylaxis. Neuro exam initially
slight worsened, since he lost a cough and gag reflex and he did
not breath over the vent anymore. He continue to have a very
sluggish right corneal reflex and some extensor posturing to
severe noxious stimuli in his UE. All other brainstem reflexes
were absent. His neurological exam worsened on [**2139-7-19**]. He no
longer had any brain stem reflexes on exam and no posturing to
noxious stimuli. Given his hemodynamic instability, apnea test
was forgoed for fear of worsening hemodymanics. Instead a
nuclear brain scan was done to evaluate for brain death. The
scan showed no activity and subsequently the patient was
pronounced brain dead.
Pulmonary:
The patient arrived intubated from the OSH. It was discovered
that the endotracheal tube was traversing the right tonsillar
pillar and ENT was consulted. They evaluated the patient and
then took the patient for trach in order to remove the
endotracheal tube. The trach was placed without complication.
The patient was started on Unasyn for empiric coverage given the
tonsil perforation.
Infectious disease:
The patient was febrile throughout the majority of his stay.
Initial culture data failed to show any infection. Sputum
culture on [**7-16**] grew staph aureus coag positive and H.
influnzae.
Cardiovascular:
The patient became hypotensive on HD 5 and required pressor
support.
Renal:
The patient was maintained on IVF as well as free water through
his NG tube to maintain hydration with care not to worsen ICP.
GI:
NG tube was placed and tube feeds were started [**7-16**].
Code:
Multiple family meetings were had with the patient's wife and
daughters who shared that based on previous, specific
discussions they had held with him in the past, they felt that
he would want all heroic measures done. The patient remained
full code through out his hospital course.
Medications on Admission:
ASA 81 mg daily
Metformin
Sitagliptin
Lisinopril
Lantus
Lispro
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma with midline shift, uncal herniation and
brainstem compression leading to brain death
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
3202,3240,7907,04109,3839,78039,7813,2858,79092,2724,25092,4019,41401,412,V1582 | 99,957 | 148,574 | Admission Date: [**2157-2-20**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2089-2-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
OSH transfer for pneumococcal meningitis and cerebritis
Major Surgical or Invasive Procedure:
Stereotactic Burr hole drainage of subdural empyema.
History of Present Illness:
68M with PMH of DM, HTN, HL, CAD s/p distant MI, who is
transferred from [**Hospital **] Hospital, where he presented on [**2157-2-13**]
with fever, cough, and sore throat. He was initially treated for
pneumonia with ceftriaxone and azithromycin. On the afternoon of
admission, he was noted to be acutely aphasic, with word finding
difficulty. There was concern for acute stroke. Neurology was
consulted, he was transferred to the ICU, and a stat head CT was
performed. Given that he was also febrile with an elevated WBC
count to 27 with 27% bands, an LP was performed. This revealed
7800 WBCs with 94% polys, a glucose of 5, and a protein of 447.
He was initially covered with vanc/CTX/ampicillin/acyclovir. CSF
and blood cultures from [**2-13**] grew strep pneumo. ID was consulted,
and recommended PCN G and rifampin, which were started on
[**2157-2-13**]. He was followed by neurology and ID. He steadily
improved and was transferred out fo the ICU on [**2157-2-15**]. An MRI
performed [**2157-2-16**] showed right cerebral meningeal enhancement c/w
his h/o meningitis, as well as concern for mastoiditis
(non-communicating with the meninges). There was no evidence of
abscess or hemorrhage, but a small frontal hygroma vs. subdural
empyema. Nsurg was consulted, and there was NTD per them.
On [**2-19**], ENT performed a right myringotomy, and a copious amount
of seromucoid purulent material was aspirated; tubes were
placed. Per his report, later that day he developed tingling of
both upper extremities and the LLE, as well as left hand
weakness and general poor coordination. Neurology was
re-consulted, and exam revealed left sided neglect and poor
coordination without frank dysmetria. A repeat MRI was
performed, the preliminary report of which showed evidence of
cerebritis. Plans were initiated tranfer him to the [**Hospital1 18**] neuro
ICU, but they refused. He was instead accepted by the MICU.
Prior to transfer, rifampin was resumed, and keppra was begun
for seizure ppx. His temp was 100.2 and he was hemodynamically
stable.
On arrival to the [**Hospital1 18**] MICU, he complained of nausea. He
endorsed ongoing numbness in his hands and feet since
yesterday's ear operation.
Past Medical History:
PMH:
1. CAD - s/p MI in [**2138**], [**2151**] tx with angioplasty
2. HTN - currently managed w/ toprol XL 200mg
3. DM2 - managed on glucophage 1000mg [**Hospital1 **], glyburide 3.75
4. Hyperlipidemia - on lipitor 40mg
5. S/p ORIF for R zygomatic fx, and orbital fx with 2 plate
insertion
6. Atypical pneumonia in [**2144**], complicated by bronchocentric
granulomatosis and cold agglutinins hemolytic anemia
7. Cystic pancreatic disease
8. BPH s/p TURP
9. Appendicitis s/p appendectomy
10. S/p bladder polypectomy
Social History:
Mr. [**Known lastname 410**] is a retired immunologist at the [**Hospital3 328**] whose
research interest was in monoclonal antibodies. He and his wife
live in [**Name (NI) 1439**], MA. He has at least one son and one daughter.
Daughter is an OB/Gyn at [**Hospital1 18**]. Denies EtOH. Tob use: 20 pack
year hx, d/c in [**2136**].
Family History:
Non-contributory
Physical Exam:
Upon transfer to medical service:
VS: 98.9 120/54 106 w/ PVCs 24 95RA
Gen: Well-nourished elderly man, lying in bed, talking to son,
not SOB, in pain, or otherwise distressed.
HEENT: H: R eye palpabral fissure slightly smaller than L (9mm
vs. 12mm), no signs of trauma. E: PERRLA 3mm->2mm, conjunctiva
not pale, anicteric. E: Slightly tender to palpation. No
drainage appreciated. N: No signs of epistaxis. T: Moist
mucous membranes, no erythema or exudate.
Neck: Soft, supple. No LAD at pre/post auricular, ant/post
cervical, submandibular, supraclavicular nodes. No carotid
bruits. No mastoid tenderness.
CV: Tachycardic, reg rhythm with nl S1, S2. No m/r/g. Pulses 2+
in all 4 extremities (DP and PT on feet). No splinter
hemorrhages.
Lungs: Nl excursion on inspiration. No dullness to percussion.
No tactile fremitus. Lungs clear to auscult, bilat and ant/post.
No crackles, wheezes or rhonchi. Diaphragms symmetric.
Abd: Soft, non-tender. Slightly distended, but not tympanic.
Hypoactive bowel sounds. Liver percussed at 8cm. No renal
bruits.
Back: No spinal tenderness. No CVA tenderness. No paraspinal
tenderness.
Ext: No edema, erythema. WWP.
Neuro: AAOx3. Gives identifiers without prompting. Able to name
past 2 presidents only. Can multiply 6x7. Cannot subtract 17
from 81. Able to talk briefly about his research. Three word
recall intact at 2min. Full strength (unable to break) in
deltoids, biceps, triceps, IPs, and gastrocs, bilaterally. R
does seem slightly stronger however. Able to hold pen in L
hand, but trouble re-capping. Dysmetria w/ finger to nose on
the L. CN II: Lower left quadrant cut bilaterally. III, IV,
VI:EOMS intact. (son notes no ptosis as compared to baseline) V:
Sensation intact to light touch. VII/VIII: Face symmetric aside
from eyes as mentioned above. Hearing intact to snaps, not light
rustle. IX/X: coughs. XII:SCM intact, trap intact. XII:tongue
midline.
Upon Discharge:
c/o sl. HA controlled
A&Ox3, PERRL, follows commands, 5/5 strength, wound C/D/I
Pertinent Results:
FROM OUTSIDE HOSPITAL PRIOR TO TRANSFER:
MICRO:
[**2-13**] CSF HSV PCR: negative
[**2-13**] CSF gram stain: GPCs in P+C, culture neg
[**2-13**] BCx + pansenstive strep PNA
[**2-13**] UCx: <10,000 CFU, mixed flora
No right ear fluid cultures sent from OR on [**2-19**]
.
OSH IMAGING:
[**2-13**] CT-A:
no evidence of PE. Calcified right costophrenic sulcus plaque
with associated.
.
[**2-15**] Head CT without contrast
new small amound of hypodense fluid in the right frontal
subdural space/ While this may represent a subdural hygroma,
given the patient's h/o bacterial meningitis, a subdural empyema
should be considered. Complete opacification of the right
mastoid air cells with fluid int he right middle ear, as seen
previously.
.
[**2157-2-15**] Temporal Bone CT
bilateral cerumen plugs, extensive opacifiaction of the right
mastoid air cells, antrum, and middle ear suggesting
otomastoiditis. No bony destruction.
.
[**2-16**] MRI Brain:
extra-axial collection right cerebral hemisphere suggestive of
meningeal enchancement c/w clinical hx of bacterial meningitis.
No abscess or hemorrhage is seen.Non-aeration of mastoid air
cells with fluid signal c/w mastoiditis. However, this does not
appear to have broken through the subjacent meninges. Normal
venous sinuses.
.
[**2-16**] B/L carotid U/S:
< 20% ICA stenosis on both sides
.
[**2-16**] TTE
LVEF 40-45%, with inferior and posterior akinesis. Normla RV. 2+
MR, 1+ TR. Negative bubble study.
.
[**2-17**] CXR
fibrosis and scarring at the right base, small right pleural
effusion. PICC line at jxn of SVC and RA.
.
[**2-21**] CT Head w/ and w/o contrast:
"1. Right otomastoiditis.
2. Unchanged small right parietal subdural collection,
concerning for a
subdural empyema.
3. Persistent cortical swelling in the right parietal, posterior
frontal, and temporal lobes, compatible with known cerebritis."
.
[**2-21**] CT Orbits, Sella w/ contrast:
"Findings compatible with severe right otomastoiditis with
possible coalescence of the mastoid septae. There is also
thinning and demineralization of the tegmen tympani. Would
recommend MRI with skull base protocol to assess for meningeal
extension of infection.
Additionally, there is a tiny subdural collection on the
right, again
recommend MRI for further evaluation and to exclude a subdural
empyema."
.
[**2-22**] MR [**Name13 (STitle) 430**] w/ and w/o contrast, MRV Head:
"1. Unchanged small right parietal subdural empyema.
2. Right cortical edema consistent with cerebritis is again
seen. New mild
slow diffusion suggests interval worsening.
3. Mild right-sided leptomeningeal enhancement, consistent with
meningitis.
4. Right otomastoiditis again seen.
5. No evidence of venous sinus thrombosis. "
.
[**2-24**] CT Head:
"No significant change from prior studies, with unchanged right-
sided subdural collection, consistent with previously
characterized subdural empyema. Persistent opacification of
right mastoid air cells and middle ear cavity. "
.
[**2-26**] CT Head:
"Stable examination demonstrating unchanged right subdural
collection consistent with previously characterized subdural
empyema. No
interval change in opacification of right mastoid air cells and
middle ear
cavity.
"
.
[**2-28**] MR [**Name13 (STitle) 430**]:
"Stable appearance since [**2157-2-22**]. Evidence of right
mastoiditis with adjacent subdural empyema, extensive dural
enhancement,
leptomeningeal enhancement, and no evidence of infarction or
sinus
thrombosis. "
.
CBC:
[**2157-2-20**] 11:14PM WBC-14.5*# RBC-3.88* HGB-13.0*# HCT-35.7*#
MCV-92 MCH-33.4* MCHC-36.3* RDW-13.1
[**2157-2-20**] 11:14PM NEUTS-87.7* LYMPHS-9.3* MONOS-1.9* EOS-1.0
BASOS-0
[**2157-2-20**] 11:14PM PLT COUNT-399#
[**2157-3-3**] 04:50AM 7.9 4.12* 13.5* 37.6* 91 32.8* 36.0* 13.7
328
Coags:
[**2157-2-20**] 11:14PM PT-15.2* PTT-33.9 INR(PT)-1.3*
[**2157-3-3**] 04:50AM 16.2* 33.7 1.4*
Chem 7:
[**2157-2-20**] 11:14PM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2157-3-3**] 04:50AM 128* 18 1.0 139 4.1 101 28 14
LFTs:
[**2157-2-27**] 06:17AM 29 18 186 66 0.3
Head CT [**3-3**]
There is a new posterior parietal burr hole, and pneumocephalus
overlying the left posterior frontal and parietal lobes. Small
low-density extra-axial collection layers dependently, and
appears slightly more dense in comparison to [**2156-2-26**]. Effacement
of the underlying sulci is unchanged.
There is no hydrocephalus or shift of normally midline
structures. No
intracranial hemorrhage is identified. [**Doctor Last Name **]-white matter
differentiation
remains normally preserved.
Complete opacification of the right mastoid air cells persist.
Brief Hospital Course:
68M with PMH of DM, HTN, CAD s/p MI, who is transferred from an
OSH with resolving pneumococcal meningitis and new neurological
deficits, found to have mastoiditis, cerebritis, and subdural
empyema.
.
# Meningitis: Mr. [**Known lastname 410**] was treated with IV Ceftriaxone 2mg IV
q12, in addition to 50mg [**Hospital1 **] Metronidazole upon arrival.
Metronidazole was replaced with Clindamycin following a seizure,
but was changed back to metronidazole following the start of
levetiracem. Since his transfer here, Mr. [**Known lastname 410**] has remained
afebrile, with a WBC trending down. Clinically, Mr. [**Known lastname 410**]
improved dramatically over the course of his stay to the point
where no neurological deficits can be noted noted. He has no
meningeal signs at present.
.
#Cerebritis - Empyema was followed serially by CT and MR imaging
without any change over his stay. There was no involvement of
the sinuses. The decision was made on [**2156-2-29**] by medicine,
neurosurgery, and ID to surgically drain the fluid collection
via stereotactic biopsy.
.
# Mastoiditis- Patient has ear tubes bilaterally that have
drained minimally. He has remained afebrile since his arrival
and w/o pain. Hearing remains sensitive to loud snaps only. He
continues on Ciprofloxicin ear drops 0.3% Ophth Soln 4-10 drops
to the right ear.
.
# Seizure - Patient had a single generalized, tonic clonic
seizure in the MICU on [**2156-2-20**] while on Keppra 500mg.
Metronidazole was stopped temporarily and the patient was loaded
with additional Keppra. Pt has not seized since MICU stay. He
remains on Keppra, now tritrated up to 1g for neurosurgical
intervention.
.
# HTN - Mr. [**Known lastname 410**] was never hypotensive during his stay and his
pressures largely ranged in the 130s sytolic. Metoprolol was
started at 25 mg [**Hospital1 **] and titrated up to 50 mg tid, with the
discharge goal of home dosing of 200mg qd.
.
#Diabetes - Mr. [**Known lastname 410**] was initially covered under a sliding
scale. When full diet was resumed, his glucose values were in
the high 200s. Medication was changed to pt's home PO metformin
and glyburide, with modest effect. Hyperglycemia thought to be
resultant of stress and illness.
.
#CAD, hx of MI - Stable, no events. Continued statin. Given
possibility of intervention, ASA was held throughout the stay.
.
#Anemia - Pt was down from baseline of 47.7 in [**2155**] to 37.8.
Because of history of cold agglutinin hemolysis, patient was
worked up for anemia. Haptoglobin was within normal limits.
Iron labs were consistent with anemia of inflammation, with
normal MCV, lower transferrin, and lower TIBC.
On [**3-2**] he was brought to the OR by Dr. [**Last Name (STitle) **] for a
steriotactic burr hole placement and washout of subdural
empyema. He tolerated the procedure and was transferred to the
floor where he ambulated with nursing and tolerated a regular
diet. He was then safe to be d/c'd home with services and follow
up appointment
Medications on Admission:
Home Meds:
Lipitor 40 mg
ASA 650 mg daily
Glucophage 1000mg [**Hospital1 **]
Glyburide 3.75mg [**Hospital1 **]
Toprol XL 200 mg
MVI
.
Transfer Meds:
Rifampin
Keppra 250mg po bid ([**2-20**] - )
RISS
Floxin otic gtt to right ear [**Hospital1 **]
PCN G 4 million units q4h IV
metformin 1000mg [**Hospital1 **]
tylenol q4h prn prn
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ciprofloxacin 0.3 % Drops Sig: 4-10 Drops Ophthalmic TID (3
times a day): Right ear only.
Disp:*1 1* Refills:*2*
5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 13 days: Do not consume alcohol while taking this
medication.
Disp:*40 Tablet(s)* Refills:*0*
7. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours) for 13 days.
Disp:*26 IV Piggyback* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: Please do not exceed 4 grams per day. .
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache: Please do not drink or drive
while taking this medication.
Disp:*50 Tablet(s)* Refills:*0*
12. PICC Line Care
Saline flush 10cc SASH PRN
Heparin flush 10u/ml 3cc SASH PRN
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary: Streptococcus pneumoniae meningitis, cerebritis, and
mastoiditis.
Secondary:
Diabetes Mellitus, Type II, non-insulin dependent
Coronary artery disease
HTN
Discharge Condition:
Stable.
Discharge Instructions:
You were transferred from [**Hospital **] Hospital with an infection of
your brain and your mastoid bone. While you were here, you
received intravenous antibiotics, anti-seizure medication, and
repeated imaging of your brain. The medicine, [**Hospital 1083**]
disease, and neurosurgery teams decided that having surgical
drainage of the [**Hospital 1083**] collection around your brain would
best help clear the infection.
You were started on the following NEW medications, all of which
you will continue:
1. Ceftriaxone 2 g IV Q12H
2. Metronigazole (Flagyl) 500 mg PO Q8H
3. Ciprofloxicin Ear Drops
4. Levitracetam 1g PO BID
The first medication will be given through the picc line in your
arm. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] this. The flagyl will be
an oral medication, in the same amount, to be taken three times
a day. [**Last Name (Titles) **] disease will determine the length of your
antibiotics.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for CBCs,
Chem 7, and LFTs each week and send the results to the
[**Last Name (Titles) 1083**] disease clinic at ([**Telephone/Fax (1) 1353**].
If you should become febrile, confused, lose bowel or bladder
function, have a strong headache, experience any loss in vision,
or lose conciousness, please return to the emergency room
immediately.
You will need follow-up appointments with your PCP, [**Name10 (NameIs) **]
Disease, Neurology, Neurosurgery, and ENT.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
-You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
*******You may resume your Asprin on [**2157-3-12**]******
Followup Instructions:
Please be sure to follow up with the following physicians:
1. [**Date Range **] Disease - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
[**2157-3-22**] 11:30am
2. Ear, Nose and Throat - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**]
[**Apartment Address(1) 96381**], [**Location (un) 55**]
[**3-8**] @ 10:15 am, Tuesday
[**Telephone/Fax (1) 2349**]
4. PCP
[**2157-3-8**] at 10am
Dr [**First Name4 (NamePattern1) 449**] [**Known lastname 410**]
[**Location (un) **], [**Location (un) **], MA.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for LFTs each
week and send the results to the [**Location (un) 1083**] disease clinic at
FAX number [**Telephone/Fax (1) 11959**].
Neurosurgical Follow-Up Appointment Instructions
??????Please return to the office [**2157-3-11**] for removal of your sutures
and a wound check. This appointment can be made with the Nurse
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment with Dr. [**Last Name (STitle) **] on [**2157-3-15**] at 9a at [**Hospital Unit Name **], [**Hospital Unit Name **]
If you have any questions please call ([**Telephone/Fax (1) 88**]
??????You are scheduled for an MRI of the brain with and without
gadolinium contrast on [**3-15**] at 730 am in the [**Hospital Ward Name 517**]
Basement.
Completed by:[**2157-3-4**] |
99811,2851,185,4019,49320 | 99,965 | 101,083 | Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-16**]
Date of Birth: [**2125-3-29**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 y/o male with [**Doctor Last Name **] 6 prostate cancer. He had a 26 core
prostate needle biopsy this afternoon with Dr. [**Last Name (STitle) **]. He had
rectal bleeding shortly after going home from the clinic this
afternoon, and was brought to the ED by ambulance after feeling
lightheaded with continuous rectal bleeding. He had a syncopal
episode on admission to the ED. He denies nausea, vomiting,
fevers, chills, chest pain, dyspnea, hematuria, urinary urgency,
frequency. The patient had discontinued his aspirin one week
prior to the biopsy as instructed.
Past Medical History:
HTN
Hyperlipidemia
Mild COPD/Asthma
Colonic polyps
Social History:
Past tobacco use (quit 3-4 years ago), +EtOH use (approx 4
drinks per day)
Family History:
Father, mother: [**Name2 (NI) 499**] cancer
Physical Exam:
VS: Afebrile, HR 65, BP 139/49, R 16, 100%RA
NAD, A&Ox3, lying in Trendelenburg
RRR, No respiratory distress
Abd: Soft, nondistended, nontender
GU: No active rectal bleeding on initial exam. On DRE, pressure
and surgicel were applied to the prostate, and there was no
active bleeding or clots after pressure applied.
Ext: No cyanosis/clubbing/edema.
Pertinent Results:
[**2191-7-15**] 02:41AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.1* Hct-26.6*
MCV-91 MCH-31.2 MCHC-34.4 RDW-12.6 Plt Ct-226
[**2191-7-14**] 02:59AM BLOOD PT-15.9* PTT-23.5 INR(PT)-1.4*
[**2191-7-14**] 02:59AM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-108 HCO3-26 AnGap-9
[**2191-7-15**] 02:41AM BLOOD CK-MB-5 cTropnT-<0.01
Brief Hospital Course:
On [**2191-7-13**], the patient was admitted to Dr.[**Doctor Last Name **] Urology
service/SICU from the ED with rectal bleeding and syncope after
prostate needle biopsy. In the ED, surgicel and pressure were
applied to the prostate and the acute bleeding stopped. The
patient was placed in trendelenburg and serial Hct's were
checked. GI consult was requested by the ICU team, and they
recommended Vit K for elevated INR 1.5. Cardiac enzymes were
negative. On HD 2, the patient had several bloody bowel
movements and remained in the ICU for monitoring. Hematocrits
were stable at 26-27 without transfusion on HD 2. On HD 3, the
patient was seen by general surgery, who performed an anoscope.
The anoscopy showed old clot, no active bleeding. Also on HD 3,
the patient was transferred to the floor from the ICU in stable
condition. Serial Hct's were monitored, which continued to be
stable at 24-26. He received peri-operative antibiotic
prophylaxis, and he remained afebrile throughout his hospital
stay. At discharge, patient denied pain, was tolerating a
regular diet, ambulating without assistance, and voiding without
difficulty. He denied chest pain, dyspnea, abdominal pain at
discharge. He was given explicit instructions to call Dr. [**Doctor Last Name 5752**] office to schedule follow-up appointment.
Medications on Admission:
Levoxyl 75mcg
Fluoxetine 20mg
Simvastatin 10mg
Levaquin (perioperative)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal bleeding status post ultrasound guided prostate needle
biopsy
Discharge Condition:
Stable
Discharge Instructions:
-Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up
appointment.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-If you have fevers > 101.5 F, abdominal pain, nausea or
vomitting, bright red blood per rectum, call your doctor or go
to the nearest emergency room.
Followup Instructions:
Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up
appointment.
Completed by:[**2191-7-16**] |
4260,42789,7802,9100,4019,2724,53081,V1046,V1254,E8889 | 99,966 | 167,228 | Admission Date: [**2191-8-23**] Discharge Date: [**2191-8-25**]
Date of Birth: [**2114-2-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
CHIEF COMPLAINT: Syncope
Major Surgical or Invasive Procedure:
Dual Chamber pacemaker placement
History of Present Illness:
77 y/o man with a PMH significant for prostate cancer (T2a,
[**Doctor Last Name **] score 9), HTN and hyperlipidemia transferred from [**Hospital1 **]
s/p syncopal episode this morning found to be in complete heart
block with ventricular escape. By report, in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] he
was asymptomatic with a SBP 110 and HR in the 30s.
Transcutaneous pacing pads were placed with good capture at 50mA
and a CT head was negative for mass/shift/bleed. He received
0.5mg atropine and was sent to [**Hospital1 18**] for further management.
.
In the ED, he was in complete heart block with a ventricular
escape rhythm in the 20s. He was given 5mg IV glucagon [**3-2**]
concern for Atenolol overdose in the setting of Cr 1.3 (baseline
unknown). Labs were notable for trop <0.01. Cardiology was
consulted and he was admitted to the CCU for temp pacer wire
placement.
.
The pt states that he had been in his normal state of health
this morning until rising from his car and walking towards a
conveniece store. Approximately 2 seconds after rising from his
car he fell, hit his head and briefly lost consciouness. There
was no prodrome of lightheadedness, nausea, vomiting,
diaphoresis, palpitations or changes in vision. He also denies
ever experiencing CP/SOB and does not recall tripping or any
mechanical aspect to the event. He has never had a seizure and
was not post-ictal. He is followed by his PCP, [**Name10 (NameIs) 1023**] he last saw 1
month ago. His last EKG was 1 year ago, and there is a
questionable history of pre-existing LBBB per family (pt
unaware). He denies any cardiac history and has never been
diagnosed with AS or other valvular or structural heart disease.
.
On review of systems, he endoses a stroke in [**2180**] with no
residual neuro deficits. He denies deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema or palpitation.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: as per HPI
- PACING/ICD: trans venous pacer in place
3. OTHER PAST MEDICAL HISTORY:
1. Prostate cancer
2. GERD
3. BPH
4. CVA ([**2180**]), no residual deficits
Social History:
The patient quit smoking 32 years ago. He does not drink
excessively. He lives with his wife and his daughter who is a
nurse.
Family History:
No FH of premature death, cardiac disease, early MI. Father died
of colon cancer, mother died in her 80s of unknown cause.
Physical Exam:
Admission
VS: T 96.3 BP 150/57 HR 60 (paced) RR 18 O2 Sat 98% RA
Weight: 207.3. Height: 68.75. BMI: 30.8.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVP difficult to asses [**3-2**] R IJ
CARDIAC: PMI not palpable. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Superficial abrasion on the R scalp, hand and knee
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge:
General Appearance: Well nourished, No acute distress
Head, Ears, Nose, Throat: Bandage on forehead intact.
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : Bilaterally)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: None, Left lower
extremity edema: none
Skin: Left chest dressing clean/dry/intact
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2191-8-25**] 05:14AM BLOOD WBC-9.0 RBC-4.11* Hgb-12.4* Hct-35.3*
MCV-86 MCH-30.2 MCHC-35.2* RDW-15.5 Plt Ct-138*
[**2191-8-23**] 10:30PM BLOOD WBC-11.0 RBC-4.17* Hgb-12.6* Hct-35.6*
MCV-85 MCH-30.2 MCHC-35.5* RDW-15.3 Plt Ct-185
[**2191-8-23**] 10:30PM BLOOD Glucose-103* UreaN-21* Creat-1.3* Na-135
K-4.9 Cl-105 HCO3-21* AnGap-14
[**2191-8-25**] 05:14AM BLOOD Glucose-114* UreaN-22* Creat-1.3* Na-142
K-4.3 Cl-109* HCO3-27 AnGap-10
[**2191-8-23**] 10:30PM BLOOD cTropnT-<0.01
[**2191-8-24**] 06:10AM BLOOD CK-MB-3 cTropnT-0.03*
[**2191-8-24**] 01:29PM BLOOD CK-MB-3 cTropnT-0.01
[**2191-8-24**] 06:10AM BLOOD TotProt-5.4* Albumin-3.9 Globuln-1.5*
Calcium-8.8 Phos-3.4 Mg-2.0
EKG
[**2191-8-23**]
Sinus rhythm with slow idioventricular rhythm, complete heart
block. No
previous tracing available for comparison.
[**2191-8-24**]
Sinus rhythm with atrial sensed and ventricular paced rhythm and
capture, newas compared to the previous tracing of [**2191-8-23**].
Echo [**2191-8-24**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No cardiac cause of syncope identified. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Mild tricuspid and
mitral regurgitation.
CXR [**2191-8-25**]:
Cardiomediastinal contours are normal. Left transvenous
pacemaker leads
terminate in standard position in the right atrium and right
ventricle. Thereis no pneumothorax. Left pleural effusion is
small. Right lower lobe
atelectasis has improved. Left lower lobe atelectasis is stable.
LYME SEROLOGY (Final [**2191-8-25**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
[**3-3**] weeks.
Brief Hospital Course:
# Bradycardia s/p Pacer placement: Patient presented with
complete heart block and a slow idioventricular rhythm. His
troponins peaked at 0.03 but were negative at discharge. His
lyme serologies returned negative. He had successful placement
of a St. [**Male First Name (un) 923**] dual chamber pacemaker. Follow up chest x-ray was
unremarkable and EKG demonstrated atrial sensed and ventricular
paced rhythm. Following pacemaker placement, atenolol and
irbesartan were started. Patient tolerated the procedure well
and was discharged without incident.
# Syncopal episode with fall. Patient sustained abrasions on
the top of his head which were bandaged and cared for. Head CT
from outside hospital was negative. Patient was stable upon
discharge.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - Dosage uncertain
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - Dosage
uncertain
FOLIC ACID - (Prescribed by Other Provider) - Dosage uncertain
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - Dosage
uncertain
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - Dosage
uncertain
Medications - OTC
ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) -
Dosage uncertain
CALCIUM CARBONATE [CALTRATE 600] - (Prescribed by Other
Provider) - Dosage uncertain
L.ACIDOPH & SALI-B.BIF-S.THERM [ACIDOPHILUS] - (Prescribed by
Other Provider) - Dosage uncertain
MULTIVITAMIN [MULTI-DAY] - (Prescribed by Other Provider) -
Dosage uncertain
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - Dosage uncertain
.
Chemotherapy/Anti-androgens:
([**2191-8-16**]) LUPRON 7.5mg IM
([**2191-8-16**]) CASODEX 50mg po daily
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
8. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO once a day. Capsule, Ext Release
24 hr(s)
10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
11. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
12. lactobacillus acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
13. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Chemotherapy/Anti-androgens:
([**2191-8-16**]) LUPRON 7.5mg IM monthly
([**2191-8-16**]) CASODEX 50mg po daily
Discharge Disposition:
Home
Discharge Diagnosis:
3rd Degree heart block
Syncope [**3-2**] bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
You were admitted to the hospital after a fall related to your
heart rate going too slowly. We have given you a St. [**First Name8 (NamePattern2) 923**]
[**Last Name (NamePattern1) 10661**] XL 5826 pacemaker which will keep the heart rate going at
an acceptable rate. We would like you to please follow up with
the electrophysiology clinic team to evaluate the pacemaker.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2191-8-31**] at 1 PM
With: ONCOLOGY DIETITIAN [**Telephone/Fax (1) 3681**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2191-9-15**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **]
Location: [**Hospital **] MEDICAL ASSOCIATES, PC
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 70678**]
Phone: [**Telephone/Fax (1) 60570**]
Appointment: Friday [**2191-9-2**] 10:45am
Department: CARDIAC SERVICES
When: WEDNESDAY [**2191-8-31**] at 9:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2191-9-30**] at 12:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
00845,5849,5990,83500,27651,27652,E8889,32723,28860 | 99,973 | 150,202 | Admission Date: [**2180-11-27**] Discharge Date: [**2180-12-1**]
Date of Birth: [**2115-5-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypotension, Diarrhea
Major Surgical or Invasive Procedure:
Placement of a central venous line
History of Present Illness:
This is a 65 year-old female with past medical history
significant for R hip replacement post multiple disclocations
and reductions and history of C. diff colitis in [**2177**] who
presents with profuse watery diarrhea x1 week, hypotension and
syncope.
She was transfered from [**Hospital **] hospital after a syncopal event
at home. Per records, she had been intermittently confused with
decreased oxygen saturations. Of note, per report, the patient
was started on dilaudid 4 mg prn at the time of her laminectomy
and has apparently had several episodes of confusion and
incoherent speech since starting this medication. The patient
states she had been having significant diarrhea for over one
week, and in fact took kayopectate which stopped the diarrhea
for 2 days. It has been constant for the last week. She had been
resting at home, and as she got up to stand last pm, she felt
the room spinning and then had a syncopal episode. Her husband
caught her before she fell. She then presented to [**Location (un) **] for
evaluation.
There, she had evidence of a right hip dislocation and
hypotension and received around 9 L of NS as well as
levoflox/flagyl. Given persisent hypotension, she was transfered
here for further management. Of note, the patient has had
multiple courses of antibiotics over the last 2 months, first
for a UTI in [**Month (only) **], then at the time of her laminectomy, and
most recently completed a course for pneumonia last week.
In the ED, initial VS 99.2 101/50 87 18 98% on 4L. She received
1 gm ctx, 500 mg flagyl, ativan 1 mg IV and fentanyl (for hip
reduction). A RIJ was placed given concern for shock, though no
levophed was required. She rec'd 2 L NS in the ED. R hip was
reduced by orthopedics and knee immobilzer placed prior to
transfer to ICU.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, constipation, melena, hematochezia, chest
pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes. She does report
decreased urine output over the last 24 hours prior to admission
as well as abdominal discomfort that is new today.
Past Medical History:
Depression
Anxiety
Fibromyalgia
Recent laminectomy in [**9-30**] at NEBMC
R hip replacement in [**10-27**]
RLS
Sleep apnea
Arthritis
Social History:
Quit smoking prior to surgery, smoked one pack per 3 days for
many years prior, rare etoh, independent ADLS at home.
Family History:
No recent sick contacts, non-contributory
Physical Exam:
On Presentation:
Vitals: T: 97.3 BP:101/50 HR:88 RR: 22 O2Sat:100% on 3L NC
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mildly distended, tender diffusely to deep palpation
only, no HSM, no masses
EXT: No C/C/E, no palpable cords, knee immobilizer in place, R
hip without ecchymoses
NEURO: alert, oriented to person, place, and time. Poor
historian
Skin: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2180-11-26**] 09:30PM BLOOD WBC-17.2* RBC-3.25* Hgb-9.6* Hct-28.0*
MCV-86 MCH-29.7 MCHC-34.4 RDW-15.5 Plt Ct-323
[**2180-11-27**] 04:41AM BLOOD WBC-16.9* RBC-3.25* Hgb-9.3* Hct-29.3*
MCV-90 MCH-28.5 MCHC-31.6 RDW-15.4 Plt Ct-312
[**2180-11-27**] 04:41AM BLOOD Neuts-82.8* Lymphs-12.1* Monos-4.1
Eos-0.9 Baso-0.1
[**2180-11-27**] 04:41AM BLOOD PT-14.6* PTT-29.9 INR(PT)-1.3*
[**2180-11-26**] 09:30PM BLOOD Glucose-94 UreaN-21* Creat-1.5* Na-140
K-3.5 Cl-118* HCO3-13* AnGap-13
[**2180-11-27**] 04:41AM BLOOD Glucose-88 UreaN-18 Creat-1.4* Na-140
K-3.4 Cl-117* HCO3-12* AnGap-14
[**2180-11-27**] 04:41AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.6
[**2180-11-26**] 09:46PM BLOOD Lactate-0.9
[**2180-11-27**] 04:56AM BLOOD Lactate-0.6
Brief Hospital Course:
This is a 65 year old female with recent history of C. diff
colitis (06') and recent mult abx use for UTI/PNA past couple
months who presented after a syncopal episode in the setting of
diarrhea/dehydration with c. diff colitis with a R hip
dislocation as result of synocopal episode and also noted ARF
(pre-renal). Tx from OSH for persistant hypotension - admitted
to MICU - mgmt only with aggressive IVF resusitation (no
pressors were required), tx with po vanc/IV flagyl.
.
# Leukocytosis: Pt presented with a leukocytosis of 17.2, most
likely due to C. diff colitis given her diarrhea and clinical
history. CXR at the OSH prior to admission in the [**Hospital Unit Name 153**] showed
resolution of prior pna. Patient denied cough or fevers at home,
though there was a report of hypoxia as noted above.
Differential shows left shift without bandemia, no recent WBC
for comparison. UA negative initially. Following onset of Flagly
and Vancomycin regimen pt's leukocytosis started to trend down,
however prior to transfer from the ICU to the medical floor her
WBC increased to 19. Given her improving colitis signs as well
as a clear pulmonary examination a U/A was sent and noted to be
suspicious for infection. Pt was then started on a 3 day course
of Ciprofloxacin by MICU. Importantly, pt's R IJ and foley were
the day of transfer from the MICU.
The patient's leukocystosis remained stable at 19K over the next
72 hours and given good clinical status and no significant
documented fevers or symtoms while being observed in the
hospital over that time, the patient was discharged to f/u with
a repeat cbc the next week at her PCP office to monitor.
.
# C. diff colitis/Diarrhea: Vastly improved during her
hospitalization. The patient was discharged to complete a
prolonged course of po vanc and flagyl.
.
# OSA/OHA (sleep apnea): Restarted home CPAP here (patientused
prior but then self d/c 1 mo prior but willing to re-try now).
.
# Hypotension/syncope: Likely due to profound dehydration from
ongoing severe diarrhea. Patient had been unable to maintain
hydration and had required upwards of 10 L of IVF since her
admission to the OSH ED. Never required pressors.
.
# Syncope: Likely result of orthostatic hypotension secondary to
her diarrhea from C. diff colitis.
.
# Hip dislocation: Status post reduction in the ED by ED staff
and orthopedics. Hip had dislocated multiple times in the past,
usually reduced in OR. Patient is currently in knee immbolizer,
no plans for surgical intervention at this time. Pt was seen by
Orthopaedics who recommended seeing her as an outpatient given
that she was able to ambulate on her hip.
.
# Acute Renal Failure: On admission pt was noted to be in ARF
with a reported elevated Creatinine of 2.17 at an OSH. During
hospitalization course pt was given IV hyrdration (7 L in the
ICU) and her creatinine was noted to trend down back to normal.
Creatinine elevation most likely pre-renal secondary to her
diarrhea.
.
# Depression/Anxiety - controlled with pt's home regime.
Medications on Admission:
Nexium 40 mg daily
Prozac 40 mg daily
ASA 81 mg daily
Lunesta 2 mg QHS
Celebrex 200 mg [**Hospital1 **]
Oxazepam 10 mg TID
Lisinopril 10 mg daily
Buproprion 150 mg TID
Requip 2 mg daily
MVI
Neurontin 600 mg QID
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Celebrex 200 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO three times a
day.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)): TAKE
PRIOR HOME DOSE.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Eszopiclone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 20 days.
Disp:*80 Capsule(s)* Refills:*0*
13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
Disp:*20 Lozenge(s)* Refills:*2*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 20 days.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Clostridium Difficile Colitis
Hypotension
Syncope
Leukocystosis, Persistent
Discharge Condition:
Vitals Signs Stable
Discharge Instructions:
Return to ED if having fevers, chills, worsening abdominal pain,
worsening diarrhea, rigors, significant lethargy.
You have a white blood cell count of 19,000 on day of discharge.
This elevated white blood cell count has been stable over the
past three days and has not worsened. Clinically, you are
vastly improved. You should have your white blood cell count
followed up next week by your PCP.
Followup Instructions:
Patient to f/u with her PCP and have her wbc checked and
monitored next week. Patient to schedule appointment with her
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**].
|
42823,5849,4254,2763,4280,42731,78729,53081,V422,V5861,4168,56400,2768 | 99,982 | 112,748 | Admission Date: [**2157-1-5**] Discharge Date: [**2157-1-12**]
Date of Birth: [**2091-10-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a 65 yo M who is 5 weeks s/p tricuspid valve replacement
for severe nonischemic cardiomyopathy with h/o [**Hospital1 **]-V IVCD (lead
causing wide open TR) and chronic afib on coumadin, who p/w one
day history of worsening DOE and orthopnea. Pt has noted DOE
with walking since his operation on [**2156-11-28**]. Three days ago his
DOE increased. Two nights ago, he noted increased orthopnea and
had 2 episodes of PND. He saw his cardiologist, Dr. [**First Name (STitle) 437**], for
f/u yesterday, at which point he had no complaints. After the
appointment he noted increased DOE, occurring after a few steps.
All of these were acute changes from the past few weeks. No
appreciable increase in edema. Denies prior PND. Denies CP. Has
had nonproductive cough since leaving hospital on [**12-29**] for
constipation. No f/c. No n/v/d. Came in today because of acute
change in symptoms.
.
On [**Hospital1 1516**] this AM, pt received 100mg IV lasix. Went for RHC after
which swan was placed. Now being admitted to CCU for milrinone
+/- lasix gtt for fluid management.
.
On arrival to CCU, pt was comfortable without complaints.
Past Medical History:
s/p Tricuspid valve replacement for TR
s/p biventricular pacer/ICD placement [**2155-8-10**]
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
Social History:
Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**]. Never
smoked. Denies illicits. Drank EtOH only rarely after diagnosed
with CHF; quit in [**2156-4-9**].
Family History:
Mother with renal failure. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION
VS - HR 70 BP 89/59 97%RA
GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD 1/2 up neck @30 degrees
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted.
Heart sounds distant.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ bilateral pitting edema.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, grossly non-focal
.
DISCHARGE
GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD appreciated
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no edema.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, grossly non-focal
Pertinent Results:
ADMISSION LABS
[**2157-1-5**] 03:25PM BLOOD WBC-6.1 RBC-3.48* Hgb-11.2* Hct-33.6*
MCV-96 MCH-32.3* MCHC-33.5 RDW-16.5* Plt Ct-145*#
[**2157-1-5**] 03:25PM BLOOD Neuts-77.9* Lymphs-15.0* Monos-4.8
Eos-1.8 Baso-0.5
[**2157-1-5**] 03:25PM BLOOD PT-24.8* PTT-40.0* INR(PT)-2.4*
[**2157-1-5**] 03:25PM BLOOD Glucose-90 UreaN-47* Creat-1.7* Na-138
K-4.7 Cl-94* HCO3-34* AnGap-15
[**2157-1-7**] 05:39AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2.
.
CARDIAC ENZYMES
[**2157-1-5**] 03:25PM BLOOD cTropnT-0.03*
[**2157-1-6**] 07:25AM BLOOD CK-MB-3 cTropnT-0.03*
[**2157-1-6**] 07:25AM BLOOD CK(CPK)-33*
.
DISCHARGE LABS
.
PERTINENT LABS
.
PERTINENT STUDIES
CXR [**2157-1-5**]
FINDINGS: Frontal and lateral views of the chest were obtained.
The patient is status post median sternotomy. There are small
bilateral pleural effusions with overlying atelectasis. No overt
pulmonary edema is seen. The cardiac silhouette remains top
normal to mildly enlarged.
IMPRESSION: Small bilateral pleural effusions with overlying
atelectasis.
.
CARDIAC CATH [**2157-1-6**]
COMMENTS:
1. Resting hemodynamics revealed right and left filling
pressures with
RVEDP of 20 mmHg and PCW 27 mmHg. There was moderate pulmonary
artery
systoic hypertension with PASP of 53 mmHg. The cardiac index was
low at
1.9 L/min/m2.
.
FINAL DIAGNOSIS:
1. Biventricular elevated filling pressures.
2. Moderate pulmonary arterial hypertension.
.
ECHO [**2157-1-6**]
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is at least
15 mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. The left ventricular cavity
is dilated. Systolic function of apical segments is relatively
preserved. Overall left ventricular systolic function is
severely depressed (LVEF= 15%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The right ventricular free wall
thickness is normal. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Moderate to severe (3+)
mitral regurgitation is seen. A bioprosthetic tricuspid valve is
present. The tricuspid prosthesis appears well seated, with
normal leaflet motion and transvalvular gradients. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
IMPRESSION: Biatrial enlargement. Dilated, severely hypokinetic
left ventricle with relative preservation of the apical
segments. Dilated, hypokinetic right ventricle. Mild aortic
regurgitation. Moderate to severe mitral regurgitation.
Well-seated, normally functioning tricuspid annuloplasty ring.
Mild pulmonary artery systolic pressure.
.
Compared with the prior study (images reviewed) of [**2156-12-20**],
there is worsening left ventricular global and regional systolic
function with a decrease in ejection fraction from 25% to 15%.
The severity of mitral regurgitation has increased minimally.
Mild pulmonary artery systolic hypertension is now appreciated;
its presence could not be determined previously.
[**2157-1-11**] TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 25 %). The right ventricular
free wall thickness is normal. The right ventricular cavity is
mildly dilated with depressed free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. A bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients.
Compared with the findings of the prior study (images reviewed)
of [**2157-1-6**], systolic function of both ventricles is
improved.
Brief Hospital Course:
Mr. [**Known lastname 85439**] is a 65-year-old-man who is five weeks status post
tricuspid valve replacement for severe tricuspid regurgitation,
severe right ventricular enlargement, and severe right heart
failure, with recent removal of defibrillator coil that revealed
a massively dilated right atrium and right ventricle who is
presenting with worsening dyspnea on exertion.
.
#. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC):
patient is 5 weeks s/p tricuspid valve replacement, now with
worsening right heart failure symptoms. TTE with worsening
systolic function as well with depressed EF. Attempts were made
with IV diuresis, but ultimately he required CCU admission for
milrinone. Initially he was started on milrinone alone and his
UOP was measured, and ultimately he required a lasix drip as
well to maintain good UOP. His cardiac output doubled with
milrinone therapy. Length of stay he was out approximately
9-10L net negative, his edema cleared, his lungs remained clear
and his JVP was no longer elevated. Symptomatically, he felt
much better, having improved exercise tolerance and a greatly
increased appetite. Milrinone was on for approximately 3.5
days, after which it and the lasix were stopped. He had a
repeat ECHO ~14 hours after cessation of his milrinone, showing
improved global function. He was started back on his home
torsemide without metolazone and maintained euvolemia.
.
#. AFIB/ectopy: patient therapeutic on warfarin with INR of 2.4.
Also rate-controlled with home digoxin and metoprolol. These
medications were continued throughout the admission. His afib
was rate controlled well, never having a rapid ventricular rate.
He did have a few episodes of ventricular ectopy with small
runs of NSVT although these were likely related to hypokalemia
and electrolyte shifts rather than the milrinone or other
intrinsic cardiac etiology.
.
#. ACUTE KIDNEY INJURY: Creatinine at 1.7 from a baseline in
late [**Month (only) **] of 1.0. Etiology is likely secondary to poor
forward flow rather than overdiuresis as his diuretics had
actually been decreased recently 1.5 weeks ago. His renal
function quickly improved with milrinone and at the time of
discharge was at his baseline.
Medications on Admission:
Omeprazole 20 mg EC PO BID
Aspirin 81 mg PO daily
Warfarin 5mg PO daily at 4pm
Trazodone 50mg PO qHS PRN insomnia
Polyethylene glycol 3350 17 gram/dose Powder one packet daily
Senna 8.6 mg Tablet PO BID
Docusate sodium 100 mg PO BID
Digoxin 125 mcg PO daily
Potassium chloride 10 mEq Tablet ER PO TID
Metoprolol succinate 12.5 mg PO daily
Torsemide 40mg PO daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. warfarin 5 mg Tablet Sig: 1-1.5 Tablets PO once a day.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO three times a day.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
11. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Nonischemic cardiomyoapthy s/p ICD [**8-19**] later removed
Chronic AF
Chronic dysphagia
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 with shortness of breath and
found to be in acute heart failure. You were given medication to
take off the extra fluid and no longer appear to be fluid
overloaded.
In the future- please call Dr. [**First Name (STitle) 437**] or the heartline right away
if you have symptoms of too much fluid: shortness of breath,
swelling in your feet or ankles, weight gain.
You should increase your Torsemide to 60mg daily. You will need
to have your electrolytes repeated in 1 week (you can have it
all done on Monday when you see Dr. [**Last Name (STitle) 4469**].
Your INR has been low. You should increase your Coumadin to 5mg
alternating with 7.5mg daily. You should take 7.5mg tonight. You
will need to have your INR checked on Monday [**2157-1-17**].
You should resume your Digoxin (seems like you may have been on
and off this medication in the past).
Medication changes:
-INCREASE Coumadin to 7.5mg alternating with 5mg daily (take
7.5mg tonight)
-INCREASE Torsemide to 60mg daily
-ADD Losartan 12.5mg daily
-RESUME Digoxin 125mcg daily
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days. Follow a low salt diet and a fluid restriction of 1500
ml/ day.
Patient offered VNA services at home, declines the need for them
at this time. Please let us know if you reconsider.
Followup Instructions:
Dr. [**Last Name (STitle) 4469**] ([**Telephone/Fax (1) 4475**]) Monday [**1-17**] 1:45pm
*have your blood work repeated at this visit*
Department: CARDIAC SERVICES
When: TUESDAY [**2157-1-18**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2157-3-11**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
42823,4254,2875,42731,3970,5303,4280,V5861,45829 | 99,982 | 151,454 | Admission Date: [**2156-11-28**] Discharge Date: [**2156-12-8**]
Date of Birth: [**2091-10-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Tricuspid regurgitation
Major Surgical or Invasive Procedure:
Tricuspid valve replacement(33mm St. [**Male First Name (un) 923**] tissue) [**2156-11-29**]
History of Present Illness:
This 65 year old white male has known nonischemic dilated
cardiomyopathy for years. he has previously undergone
biventricular pacemeker/ICD placement and has had progressive
tricuspid regurgitation. The device was recently explanted due
to concern for the lead interfering with the tricuspid valve.
He has continued to have worsening symptoms and was referred for
surgical intervention. Catheterization previously demonstarted
no obstructive coronary disease, severely depressed LV
function(15-20%) and elevated right heart pressures.
Past Medical History:
s/p biventricular pacer/ICD placement [**2155-8-10**]
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
Social History:
Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**].
-Tobacco history: Never smoker
-ETOH: Quit when diagnosed with heart failure
-Illicit drugs: Denies
Family History:
Mother: Renal failure
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse 80
B/P 85/57 cuff 95/60 by Aline
O2sat: 100% RA Resp: 18
Height: 71" Weight: 77.2 kgs
General: NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] mild JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] [**3-14**] holosystolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [X] Trace
Varicosities: LLE
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2156-12-6**] 03:40AM BLOOD WBC-5.5 RBC-3.30* Hgb-10.5* Hct-31.6*
MCV-96 MCH-31.8 MCHC-33.2 RDW-16.0* Plt Ct-131*
[**2156-11-28**] 03:29PM BLOOD WBC-3.8* RBC-3.18* Hgb-10.5* Hct-31.1*
MCV-98 MCH-33.0* MCHC-33.8 RDW-15.2 Plt Ct-113*
[**2156-12-6**] 03:40AM BLOOD PT-17.3* PTT-33.6 INR(PT)-1.5*
[**2156-12-5**] 03:59AM BLOOD PT-16.2* PTT-33.3 INR(PT)-1.4*
[**2156-12-4**] 04:13AM BLOOD PT-15.0* PTT-33.1 INR(PT)-1.3*
[**2156-12-3**] 01:26AM BLOOD PT-14.6* PTT-34.2 INR(PT)-1.3*
[**2156-12-2**] 03:00AM BLOOD PT-14.8* PTT-36.5* INR(PT)-1.3*
[**2156-11-28**] 03:29PM BLOOD Glucose-106* UreaN-29* Creat-1.5* Na-137
K-3.8 Cl-98 HCO3-30 AnGap-13
[**2156-11-29**] 01:49AM BLOOD ALT-19 AST-25 AlkPhos-76 TotBili-1.4
ECHO [**2156-12-3**]
The right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal.
with depressed free wall contractility. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen. A bioprosthetic
tricuspid valve is present. The prosthetic tricuspid leaflets
appear normal. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2156-11-23**], the tricuspid valve has been replaced by a
bioprosthesis. The right ventricle is no longer dilated.
Trace-to-mild tricuspid regurgitation is present. Left
ventricular function is improved due to reduction of right
ventricular size, as well as reduction of ventricular
interaction.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2156-12-3**] 16:10
Brief Hospital Course:
He was admitted a day early for PA catheter placement and
diuresis. Despite ultrasound visualization and an hour's time,
the catheter could not be passed across the valve due to the
regurgitant jet. Diuresis was undertaken.
On [**11-29**] he went to the Operating Room where valve replacement
was performed (see operative note for details). He weaned from
bypass on Levophed and Milrinone. The PA catheter was placed at
the end of the case, with great difficulty. He remained
stable,and was extubated the day of surgery. Over the next few
days the Milrinone was weaned off and he did well. He was
diuresed toward his pre-operative weight and Coumadin was
started for atrial fibrillation.
Carvedilol was started for his cardiomyopathy and the Torsemide
he was on at home resumed after stopping Lasix. Wires were
removed as were CTs. He ambulated in the ICU and progressed
well. Physical Therapy was consulted for strength as well.
He was cleared for discharge to home on POD# 9 with VNA
services, on medications as listed with appropriate follow up
appointments. Coumadin will continue to be managed by Dr.
[**Last Name (STitle) 4469**] his primary cardiologist.
Medications on Admission:
Losartan 25 mg daily
2. Metoprolol succinate 12.5 mg daily
3. omeprazole 20mg daily [**Hospital1 **]
4. Torsemide 20mg daily
5. Coumadin 5mg daily 6 days per week, 7.5mg on tuesday
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
6. Outpatient Lab Work
INR/PT on [**2156-12-9**] and mon/wed and friday's until INR stable.
Results to Dr. [**Last Name (STitle) 4469**]
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
indication afib-
INR goal 2.0-2.5
.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*80 Tablet(s)* Refills:*2*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
Disp:*120 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Tricuspid regurgitation
s/p Tricuspid valve replacement
nonischemic, dilated cardiomyopathy
s/p Biventricular pacemaker/ICD placement
s/p removal of Biventricular pacemaker/ICD
chronic atrial fibrillation
s/p Achilles Tendon repair
chronic dysphagia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2156-12-28**] at 1pm in the
[**Hospital **] Medical office building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist:Dr. [**Last Name (STitle) 4469**] on [**2156-12-27**] at 1:30pm
Heart failure: Dr [**First Name (STitle) 437**] [**2156-12-27**] 11:00am in [**Hospital Ward Name 23**] 7
Echocardiogram [**Telephone/Fax (1) 62**] Date/Time:[**2156-12-27**] 9:00 in [**Hospital Ward Name 23**] 7
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0-2.5
First draw [**2156-12-9**] then mon/wed/friday's until stable
Results to Dr. [**Last Name (STitle) 4469**]
phone:[**Telephone/Fax (1) 4475**] fax :[**Telephone/Fax (1) 23978**]
Completed by:[**2156-12-9**] |
42823,78551,4254,7994,5849,42731,4280,2875,59689,53081,56400,78720,V5861,V422,60001,78820 | 99,982 | 183,791 | Admission Date: [**2157-2-16**] Discharge Date: [**2157-2-22**]
Date of Birth: [**2091-10-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
right heart catheterization, PICC line placement
History of Present Illness:
Mr. [**Known lastname 85439**] is a 65 year old man with a PMHx s/f sCHF (EF 25%),
and AF who initially presented to [**Hospital 20338**] Hospital in [**State 108**] on
[**2157-2-7**] with five days of gradually worsening weakness,
dyspnea on exertion, orthopnea, decreased appetite. He declines
any dietary or medication nonadherance. Initially he declined
any change in weight. Whilst in [**Location (un) 20338**], he was treated for a CHF
exacerbation with diuresis and milrinone. Over the course of his
first week, he became increasingly hypotensive requiring
increasing doses of milrinone. On [**2-13**] following a fall with near
syncope while walking, Mr. [**Known lastname 85439**] was found to be hypotensive
to SBPs in the 50s requiring transfer to the CCU. Note his only
injury suffered with this fall was an excoriation of his left
knee. He was maintained on dopamine and milrinone early in his
ICU course, but this was able to be weaned on [**2-14**]. LE US
demonstrated no DVT. Throughout his course, when BP would allow
he was gently diuresed with IV boluses of bumex (2mg) and
torsemide (10-20mg), but given his low BP this occurred only
every other day.
Troponin I peaked at 0.27 on [**2-14**].12 on transfer. MB remained
flat throughout his admission. Ischemic etiology was not
entertained.
Echo was performed on [**2157-2-10**] demonstrated EF 22%, severe RV
dysfunction, dilated LA, moderate to severe MR.
Initial CXR demonstrated RML and LLL pneumonia with bilateral
pleural effusions, but CT at the OSH demonstrated large b/l
pleural effusions, several rib fractures on the right, with no
evidence of pneumonia. Of note, he was afebrile throughout his
admission without leukocytosis.
Labs on day of transfer: Na 128, K 3.5, Cl 86, Bicarb 30, BUN
62, Cr 1.9. MG 2.3, Ca 8.6, PT 16.3, INR 1.7.
Also of note, Mr. [**Known lastname 85439**] was initiated on megace for poor
appetite and cachexia.
Past Medical History:
CHF (EF 25% in [**1-/2157**])
s/p Tricuspid valve replacement for TR
s/p biventricular pacer/ICD placement [**2155-8-10**]
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
Social History:
Retired pipe fitter. Lives with wife [**Name (NI) **] in [**Name (NI) 392**]. Never
smoked. Denies illicits. Drank EtOH only rarely after diagnosed
with CHF; quit in [**2156-4-9**].
Family History:
Mother with renal failure. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Physical Exam on Admission:
GENERAL - cachectic elderly M in NAD, comfortable, appropriate,
AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD 1/2 up neck @30 degrees
LUNGS - rales in RLB, otherwise CTAB good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted.
Heart sounds distant.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ bilateral pitting edema up to thighs.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, grossly non-focal
Physical Exam on Discharge:
GENERAL - cachectic elderly M in NAD, comfortable, appropriate,
AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
JVP much improved at 12.
NECK - supple, no thyromegaly, JVD at level of the mandible at
60 degrees
LUNGS ?????? faint bibasilar crackles R>L, improved from prior, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, no murmurs. Heart
sounds distant.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ bilateral pitting edema up to knees and in
dependent aspect of thighs
Pertinent Results:
Admission Labs:
[**2157-2-16**] 06:45PM BLOOD WBC-7.1 RBC-3.83* Hgb-11.9* Hct-36.1*
MCV-94 MCH-31.0 MCHC-32.8 RDW-15.7* Plt Ct-163
[**2157-2-16**] 06:45PM BLOOD Neuts-73.8* Lymphs-17.4* Monos-6.5
Eos-1.4 Baso-0.8
[**2157-2-16**] 06:45PM BLOOD PT-13.9* PTT-34.3 INR(PT)-1.3*
[**2157-2-16**] 06:45PM BLOOD Glucose-106* UreaN-42* Creat-1.3* Na-131*
K-3.8 Cl-91* HCO3-35* AnGap-9
[**2157-2-16**] 06:45PM BLOOD Calcium-9.3 Phos-2.3* Mg-2.0
[**2157-2-16**] 06:45PM BLOOD Digoxin-0.8*
[**2157-2-18**] 04:11AM BLOOD Hgb-11.1* calcHCT-33 O2 Sat-69
Pertinent Studies:
Echo
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position. 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. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. A bioprosthetic tricuspid
valve is present. The tricuspid prosthesis appears well seated,
with normal leaflet motion and transvalvular gradients. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2157-1-11**], LV
systolic function appears slightly less vigorous.
Cardiac Catheterization [**2-17**]:
1. Hemodynamic catheterization in this patient demonstrates
decreased
cardiac output at baseline with moderately elevated left
ventricular
filling pressures. Following milrinone infusion the cardiac
index
signficantly increased from 2.1 to 2.5 L/min/m2 without a change
in left
ventricular filling pressures.
FINAL DIAGNOSIS:
1. Severe systolic and diastolic ventricular dysfunction.
2. Significant improvement in hemodynamic parameters following
milrinone
infusion.
TTE [**2-18**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position. 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. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. A bioprosthetic tricuspid
valve is present. The tricuspid prosthesis appears well seated,
with normal leaflet motion and transvalvular gradients. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Labs on Discharge:
[**2157-2-22**] 03:32AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.3* Hct-31.1*
MCV-93 MCH-31.0 MCHC-33.2 RDW-16.1* Plt Ct-132*
[**2157-2-22**] 03:32AM BLOOD PT-22.1* PTT-35.2 INR(PT)-2.1*
[**2157-2-22**] 03:32AM BLOOD Glucose-110* UreaN-37* Creat-1.5* Na-133
K-3.5 Cl-86* HCO3-34* AnGap-17
[**2157-2-22**] 03:32AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 85439**] is a 65 year old man with a past medical history
significant for non-ischemic cardiomyopathy with an EF of 25%
who presented with a CHF exacerbation and was initiated on
homegoing dopamine.
Active Diagnoses:
#. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC):Mr.
[**Known lastname 85439**] was initially managed in [**Location (un) 20338**], FL for a CHF
exacerbation with milrinone and dopamine. Diuresis was deferred
due to hypotension. Weight on admission of 158 was above
discharge weight from [**1-/2157**] of 138. Heart failure is primarily
driven by dilated RV in the setting of long term wide open TR
which had only been repaired 6 weeks earlier. RHC demonstrated
improvement in CO with milrinone (3.8 to 4.2), but to a less
extent than would be inferred by his improvement in clinical
status during his last admission. On his second day of
admission, support with Milrinone only was attempted, but was
aborted due to persistent hypotension (MAPs of 55). Dopamine was
attempted at 6 mcg/kg/hr with improvement in BP with MAPs > 60,
and improvement in CO 5.8 and CI 3.0. A PICC was placed for home
dopamine infusions. However, diuresis was tapering off even
though patient was on lasix 20 and dopamine 10. Patient was not
maintaining good O2 sats and felt cold in his peripheries and
short of breath when talking. A decision was made to transfer
him to [**Hospital 3278**] Medical Center for heart transplant evaluation.
Upon discharge, he was 10.8L negative. His discharge weight was
.
#. AFIB: Patient is anticoagulated for Afib, goal [**2-11**]. INR 2.1
today. Patient was continued on warfarin 7.5mg daily.
.
#. ACUTE KIDNEY INJURY: Baseline Cr 1.0, Cr at OSH is 1.9 likely
secondary to decompensated CHF. With continued diuresis, Cr
initially came downt o 1.2, but then bumped up to 1.5 on
transfer. Despite further increases in dopamine and lasix
drips, his urine output continued to taper off. Patient had
diuresed -800cc since midnight of the day of transfer.
.
# Thrombocyteopenia: Plts slowly downtrending to 132 from 163 on
admission. DDx includes malnutrition, marrow suppression, drug
effect. HIT was thought to be less likely, as there was a less
than 50% fall, no evidence of thrombosis.
.
#.SKIN DISCOLORATION: patient noted to have yellowish skin
discoloration on [**2157-2-22**], initially concerning for congestive
hepatopathy. However, LFTs were normal. Most likely etiology is
pyridium use (started for bladder spasm). Pyridium was
discontinued.
.
#. GERD: Patient was continued on home lansoprazole.
.
#. CONSTIPATION: Patient was maintained on an aggressive bowel
regimen with senna, colace, miralax. At one point, patient had
not had bowel movement in 3 days, so was given lactulose and
fleet enema, to which he responded with a bowel movement.
.
#. DYSPHAGIA: Patient has a history of dysphagea and cannot
swallow while supine. He tolerated a regular diet, but was
willing to consider a soft diet if he was unable to swallow
regular food.
.
# BPH: Patient had low UOP one day and bladder scan confirmed
urinary retention. Prostate exam revealed enlarged bladder, and
patient is known to have hx of BPH. He was started on
phenazopyridine and tamsulosin.
Transitional Issues:
Patient was transferred to [**Hospital 3278**] Medical Center for heart
transplant evaluation. He will be sent with this discharge
summary, several recent TTE and RHC reports, and several of his
outpatient cardiology appointment notes.
At [**Hospital1 18**], he was evaluated for a LifeVest, and most of the
paperwork was filled out, but this was deemed no longer
necessary upon transfer. If patient is deemed at [**Hospital1 3278**] to still
need LifeVest, can contact [**Name (NI) 13764**] Case Manager at [**Hospital1 18**] for
additional details.
Medications on Admission:
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth once a day
LOSARTAN - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth once
a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider: [**Name Initial (NameIs) 4469**]) -
25 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s)
by
mouth once a day
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a
day
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram/dose Powder - 1 by mouth daily
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq
Capsule, Extended Release - 1 Capsule(s) by mouth at breakfast,
lunch & supper
TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 3
Tablet(s) by mouth once a day
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 5 mg
Tablet - 1-2 tablets as directed. Tablet(s) by mouth take as
directed
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for constipation
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
solution Injection TID (3 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO BID (2 times a day) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q48H (every 48
hours).
10. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
16. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Congestive Heart Failure
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 85439**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for diuresis for your heart
failure. While you were here, we started you on two pressors
(milrinone and dopamine) and a lasix drip to help you with urine
output. While you were here, you diuresed 10.8L. We ultimately
decided to transfer you to [**Hospital1 3278**] for cardiac transplant
evaluation because you were not maintaining adequate urine
output despite high doses of dopamine and lasix drip.
Followup Instructions:
Please follow-up with your outpatient cardiologist, Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 437**], when you are discharged from [**Hospital1 3278**].
|
41001,5849,41401,60001,2724,4019,V4582,78820 | 99,983 | 117,390 | Admission Date: [**2193-4-26**] Discharge Date: [**2193-4-29**]
Date of Birth: [**2114-9-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
transfer for c. cath/STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug-eluting stent placed in the
left anterior descending artery
History of Present Illness:
79-year-old male with history of CAD and prior PCI with DES to
OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**2192-2-8**]
chest pain. The night prior to presentation he experienced
indigestion. He then awoke with a "rope-like" non-radiating
chest discomfort with no associated symptoms except perhaps
chills that resolving except the portion "over the heart." He
continued to have this discomfort. His wife called his PCP and
told him to report to the nearest ER. EKG on presentation showed
ST elevation in leads V3,4, and 5. Troponin was 12.483.
He was given 81 mg ASA x 4, 4500 units heparin bolus with drip
at 1800 units/hr and 5 mg IV lopressor. He was given plavix 600
mg PO x 1 prior to transfer to [**Hospital1 18**] for c. cath. He was chest
pain free prior to transfer. Vitals at transfer were BP 145/87
HR 63 SR pOx 100 % on 3 L O2 and RR 20.
He was taken to the c. cath lab showing subtotally occluded LAD
with successful PTCA/stenting with 2.5 x 18 promus stent. LCx
and RCA were patent.
On the floor, patient in NAD without any complaints.
Of note, he was recently hospitalized at [**Name (NI) 75328**] [**Hospital 18806**] Medical
[**Name2 (NI) **] in early [**Name (NI) 547**] for sepsis from a urinary source secondary
to BPH. He completed a course of levofloxacin, was placed on
flomax, and is scheduled to follow-up with urology.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope. + palpitations two days before the event
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
CAD s/p prior PCI
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**Hospital1 2025**] ([**2185**]): Has stent placed to OM2 with ? MI in setting of
shoulder pain. At that time, he was placed on ASA/plavix.
3. OTHER PAST MEDICAL HISTORY:
- BPH with urinary retention
- History of HL
- History of UTI
- Esophageal Dilitation
Social History:
He lives with his wife.
- Tobacco history: none
- ETOH: [**1-6**] glasses of wine/week
- Illicit drugs: none
Family History:
- Brother died of MI at age 60 (sudden death) while shoveling
snow.
- Mother: unknown cancer at age [**Age over 90 **]
- Father: COPD at age 85
Physical Exam:
Tmax: 35.9 ??????C (96.6 ??????F)
Tcurrent: 35.9 ??????C (96.6 ??????F)
HR: 69 (69 - 69) bpm
BP: 125/73(82) {125/73(82) - 125/73(82)} mmHg
RR: 21 (21 - 21) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx2 (not to date fully), Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
I. Cardiology
A. Cath ([**2193-4-26**]) ** PRELIM REPORT **
BRIEF HISTORY: 78 M presented to OSH with chest pain and [**Hospital **]
transferred to [**Hospital1 18**] for emergent cardiac catheterization.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, STEMI transfer
PROCEDURE:
Coronary angiography
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
**PTCA RESULTS
LAD
PTCA COMMENTS: Initial angiography reveald a mid LAD 95%
subacute
thrombus. We planned to treat this thrombus with aspiration
thrombectomy/PTCA/stenting and heparin/integrilin given
prophylactically. An XB LAD 4.0 guiding catheter provided good
support
for the procedure and a Prowater wire was advanced into the
distal LAD
with moderate difficulty. We then proceed with an Export AP
aspiration
thrombectomy but unable to deliver device distal to subacute
thrombus.
We then predilated the mid LAD thrombus with an Apex OTW 2.0x8
mm
balloon inflated at 8 atm. We then noted an acute cut-off in the
distal
LAD after flow was re-established and proceeded with cautious
dotting of
the cut-off area with the balloon and distal delivery of NTG via
balloon
with minimal improvement of distal LAD flow. We then stented the
mid LAD
with a Promus Rx 2.5x18 mm drug-eluting stent (DES) post-dilated
with an
NC Quantum Apex MR 2.75x12 mm balloon inflated at 20 atm for 20
sec.
Final angiography revealed normal TIMI 3 flow in the vessel, no
angiographically apparent dissection and 0% residual stenosis in
the
newly deployed stent but acute cut-off in distal LAD showed
diffusely
diseased small apical vesswel that remained unchanged despite
mechanical
dottering and distal NTG delivery via balloon. The R 6Fr femoral
artery
sheath was removed post limited groin angiography and an
Angioseal
closure device was deployed without complications with distal
pulses
confirmed post deployment. The patient left the cath lab
angina-free and
in hemodynamically stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 59 minutes.
Arterial time = 56 minutes.
Fluoro time = 15.2 minutes.
IRP dose = 733 mGy.
Contrast injected:
Omnipaque 175 cc total contrast during procedure
Anesthesia:
1% Lidocaine SC, fentanyl 25 mcg IV, versed 0.5 mg IV
total
Anticoagulation:
Heparin [**2182**] units, integrilin bolus and infusion
COMMENTS:
1. Emergent coronary angiography revealed a right dominant
systemt. The
LMCA, LCx and RCA were all patent. The LAD revealed a mid 95%
occlusion
with thrombus.
2. Limited resting hemodynamics revealed a SBP of 142 mmHg and a
DBP of
80 mmHg.
3. Successful aspiration thrombectomy/PTCA/stenting of the mid
LAD with
a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm
balloon. Final
angiography revealed normal TIMI 3 flow, no angiographically
apparent
dissection and 0% residual stenosis in the newly deployed stent
with an
abrupt cut-off in the distal LAD unchagned despite mechanical
balloon
dottering and distal NTG delivery via balloon. (see PTCA
comments)
4. R 6Fr femoral artery Angioseal closure device deployed
without
complicatons (see PTCA comments)
FINAL DIAGNOSIS:
1. Severe coronary artery disease with subtotally occluded mid
LAD: see
comments section.
2. Successful aspiration thrombectomy/PTCA/stenting of the mid
LAD with
a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm
balloon. (see
PTCA comments)
3. R 6Fr femoral artery Angioseal closure device deployed
without
complications (see PTCA comments)
4. ASA indefinitely; plavix (clopidogrel) 75 mg daily for at
least 12
months for DES
5. Integrilin gtt for 18 hours post PCI for thrombus and abrupt
cut-off
of distal small vessel apical LAD unchanged despite mechanical
balloon
dottering and distal NTG delivery via balloon
B. TTE ([**2193-4-26**])
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild to moderate regional left ventricular systolic
dysfunction with basal to mid lateral hypokinesis and distal
septal/distal anterior and apical septal hypokinesis. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
C. ECG
No prior ECG available for comparison.
OSH ECG dated [**2193-4-26**] at 9:01 showing ?ectopic atrial rhythm,
NI, leftward axis. STE in V3, V4, and V5.
II. Labs
A. Admission
[**2193-4-26**] 03:15PM BLOOD WBC-7.5 RBC-4.21* Hgb-13.6* Hct-38.9*
MCV-92 MCH-32.3* MCHC-34.9 RDW-12.7 Plt Ct-253
[**2193-4-26**] 03:15PM BLOOD PT-13.4 PTT-27.0 INR(PT)-1.1
[**2193-4-26**] 03:15PM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
[**2193-4-26**] 03:15PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 Cholest-204*
B. Cardiac
[**2193-4-27**] 05:57AM BLOOD CK(CPK)-426*
[**2193-4-26**] 11:13PM BLOOD CK(CPK)-675*
[**2193-4-27**] 05:57AM BLOOD CK-MB-22* MB Indx-5.2 cTropnT-1.36*
[**2193-4-26**] 11:13PM BLOOD CK-MB-41* MB Indx-6.1*
[**2193-4-26**] 03:15PM BLOOD CK-MB-96* MB Indx-9.2* cTropnT-3.21*
C. Misc
[**2193-4-26**] 03:15PM BLOOD %HbA1c-6.0* eAG-126*
[**2193-4-26**] 03:15PM BLOOD Triglyc-135 HDL-44 CHOL/HD-4.6
LDLcalc-133*
D. Discharge
WBC 4.5 Hgb 11.2 Plt 181 INR 1.2 Na 141 K 4.4 Cl 108 HCO3 29 BUN
20 Cr 1.4 Ca 9.1 Ph 3.2 Mg 2.1
Brief Hospital Course:
79-year-old male with history of CAD and prior PCI with DES to
OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**Hospital **]
transferred to [**Hospital1 18**], and now s/p successful PTCA/stenting with
DES for LAD lesion.
# STEMI
Patient has known history of CAD given prior stent placement in
OM2. It is uncertain why the patient is not on any cardiac
medications for risk reduction. He presented with chest
discomfort. OSH ECG notable for ectopic atrial rhythm and ST
elevations in V3, V4, and V5 and initial troponin 12.483
(unknown if I or T) and CK-MB 68.5. Cardiac biomarkers indicated
CK-MB 22 and cTrop 1.36. He was transferred to [**Hospital1 18**] for c. cath
with successful PTCA/stenting with DES for 95 % subacute mid-LAD
thrombus. Final angiography revealed normal TIMI 3 flow and no
angiographically apparent dissection. See cardiac cath report
for full details. Cardiac biomarkers indicated CK-MB 22 and
cTrop 1.36. Post-MI ECHO indicated LVEF 35-40 % withmild to
moderate regional left ventricular systolic dysfunction with
basal to mid lateral hypokinesis and distal septal/distal
anterior and apical septal hypokinesis. This may be suggestive
of another MI given that these wall motion abnormalities do not
necessarily correspond to his LAD lesion.
He was continued on an integrilin infusion for 18 hours post PCI
for thrombus and abrupt cut-off of distal small vessel apical
LAD unchanged despite mechanical balloon dottering and distal
NTG delivery via balloon.
He was placed on aspirin 325 mg PO qD indefinitely, clopidogrel
75 PO qD for at least 12 months for DES. He was started on
crestor given concern for myalgias. He was also started on
metoprolol and lisinopril.
# Hyperlipidemia
Patient was not on lipid-lowering therapy on admission.
Cholesterol panel showing total cholesterol 204, TG 135, HDL 44,
and LDL 133. He was started on statin as above and advised to
initiate lifestyle modifications.
A1c was 6 suggestive of pre-diabetic state.
# RHYTHM: Patient remained in NSR during hospitalization with
telemetry showing bradycardia to low 40s during sleep.
# BPH with urinary retention
Patient was recently hospitalized at [**Name (NI) 75328**] Brothers in the
state of [**Name (NI) 531**] for sepsis from a urinary source in the
setting of urinary retention per provided records from family.
He was continued on flomax during hospitalization and will
follow-up with urology after hospitalization.
CODE: Full
COMM: patient, wife [**Name (NI) **] [**Telephone/Fax (1) 88873**] (H) [**Telephone/Fax (1) 88874**] (C)
Medications on Admission:
- flomax 0.4 mg PO qD
- Multivitamin
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check Chem-7 and CBC on [**4-1**] at Dr.[**Name (NI) **] office.
7. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
ST elevation myocardial infarction
Coronary Artery Disease
Acute Kidney Injury
.
Secondary Diagnosis:
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 26762**],
It was a pleasure taking part in your care at [**Hospital1 18**]. You were
transferred here after it was determined that you had suffered a
heart attack prior to arriving at hospital. You underwent a
cardiac catheterization procedure where a drug eluting stent was
placed in one your heart arteries and you did very well after
this.
You will need to take a number of medications to keep your heart
healthy and make sure the stent stays open.
We have made the following changes to your medications:
START taking aspirin 325 mg and Plavix daily. These medicines
work together to prevent the stent from clotting off. YOu will
need to take these medicines daily for the next year and
possibly longer. Do not stop taking aspirin and Plavix unless
Dr. [**Last Name (STitle) **] says that it is OK.
START taking Rosuvastatin (Crestor) to lower your cholesterol.
YOu will need to have your liver function tested with blood
tests on a regular hasis on this medicine. If you develop muscle
cramps on this medicine, please call Dr. [**Last Name (STitle) **].
START taking Lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
START taking Metoprolol to lower your heart rate and help your
heart recover from the heart attack.
START taking nitroglycerin if you have chest pain at home. Take
one tablet under your tongue, sit down and wait 5 minutes. You
can take another tablet if you still have chest pain but please
call Dr. [**Last Name (STitle) **] if you take any nitroglycerin.
Continue to take Flomax as before.
Followup Instructions:
D'[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 22235**]
Appointment already made on [**2193-5-2**] at 11:00 AM
.
Name: [**Last Name (LF) 7526**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] BLDG
Address: 131 ORNAC, [**Apartment Address(1) 88875**], [**Location (un) **],[**Numeric Identifier 17125**]
Phone: [**Telephone/Fax (1) 88876**]
Appt: [**5-16**] at 3:30pm
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
0389,51881,48241,4870,78552,V4281,99592,2449,2724,2859,53081,V1072,23871 | 99,985 | 176,670 | Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-12**]
Date of Birth: [**2127-4-8**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt's a 53-year-old male patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is here
for evaluation of fever. The patient states fever began two
days ago along with a mild dry cough, fever was low-grade at
that time. Day of admission, pt noticed to be 101.8 has some
chills as well. No shortness of breath, no chest pain. Denies
any headache, ear aches, and some scratchy throat. The patient
denied any change in stools, ab pain, urinary sx, has some mild
nausea on [**1-27**] but thought it more due to fever. No arthralgias
or myalgias or rashes. The patient says cough is nonproductive.
He did recently have URI symptoms beginning of the month which
abated shortely . He then came on the 22nd for routine medical
examination and was found to be in pretty good health and stated
remains until these last two days. Of important note - pts kids
had been sick earlier this week (both) - similiar sx - lasting
just 3 days. Pt reports having the flu shot earlier this week.
Noted poor po intake past few days.
<br>
Review of systems:
<br>
Constitutional: No weight loss/gain, fatigue, malaise, +
fevers, +chills, NO rigors, night sweats, or anorexia.
HEENT: No blurry vision, diplopia, loss of vision, photophobia.
No dry motuh, oral ulcers, bleeding nose or [**Male First Name (un) **], tinnitus, sinus
pain.
Cardiac: No chest pain, palpitations, LE edema, orthopnea, PND,
DOE.
Respiratory: No SOB, pleuritic pain, hemoptysis, does have mild
DRY-cough as above.
GI: + mild nausea but NO vomiting, abdominal pain, abdominal
swelling, diarrhea, constiatpion, hematemesis, hematochezia, or
melena.
Heme: No bleeding, bruising.
Lymph: No lymphadenopathy.
GU: No incontinence, urinary retention, dysuria, hematuria.
Skin: No rashes, pruritius.
Endocrine: No change in skin or hair (has chronic hair loss),
no heat or cold intolerance (noted thyroid meds recently
adjusted).
MS: No myalgias, arthralgias, or back or nec pain.
Neuro: No numbness, weakness or parasthesias. No dizziness,
lightheadedness, vertigo. No confusion or headache.
Psychiatric: No depression, anxiety.
Allergy: No seasonal or medication allergies.
Past Medical History:
-splenectomy
-pericarditis
-Hodgkin's disease, and bone marrow transplant in [**2164**],
Hodgkin's treatment was in [**2157**]
Social History:
No tob, etoh, or drugs. Lives with wife and 2 kids, -
employment - real estate developer.
Family History:
Mother with Breast CA/Uterine CA
Physical Exam:
Vitals: 99.5 138/80 95 18 96%RA
Pain: denies
Access: RUE PICC
Gen: nad, thin man
HEENT: anicteric, mmm
CV: RRR, no m
Resp: CTAB, improved L sided crackles, no wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: appropriate
Pertinent Results:
WBC 20-->15.4-->12.4 (peak 26 [**2-6**])
Hgb [**7-4**]-->8.8 stable s/p 1U [**2-9**]
plt 800s
INR 1.3
retic 4.7
Chem panel unremarkable BUN 11/creat 0.9
LFTs normalized except alk phos 214, downtrending (peak 385 on
[**2-2**], normal prior), albumin 2.8
.
.
Influenza swab +B Ag
Sputum cx MSSA X2
Blood cx all NTD
Urine Cx NTD
Stool Cx NTD
.
.
Imaging/results:
CXR [**2-8**]: LUL consolidation, mod pulm edema, R PICC
.
.
RUQ US [**2-4**]:
1. Unchanged appearance of mildly distended gallbladder
containing layering sludge, without evidence of acute
cholecystitis.
2. No focal liver lesions or biliary ductal dilatation.
3. Right pleural effusion.
.
[**2-4**] CT Chest:
1. Interval decrease in right-sided pleural effusion. Left-
sided pleural effusion is unchanged.
2. Persistent multifocal pneumonia with interval worsening
consolidation in the lingula and left upper lobe.
3. Nonspecific soft tissue stranding in the left upper quadrant,
new from prior study but difficult to assess without oral
contrast. Consider CT of the abdomen for more complete
assessment, if warranted clinically.
.
.
[**2-2**] Echo: EF 55%, mod pulm HTN.
[**1-28**] CTA, no PE
.
.
Brief Hospital Course:
53-year-old male patient with h/o of hodgkins lymphoma in BMT
'[**64**], h/o splenectomy, h/o pericarditis, hypothyroidism was
initially admitted for fever in setting +sick contacts. In ER,
confirmed Influenza B + (Rx with Tamiflu X7days). Pt initially
did well first night, but then had rapidly worsened hypoxia am
of [**2181-1-28**] with CT chest showing new multilobar consolidations.
Developed septic shock and ARDS, started broad Abx
(vanc/cefepime/azithromycin), transfered to MICU, was intubated
for hypoxemic resp failure [**1-28**]. Resp cultures grew MSSA and Abx
changed to nafcillin to complete 3week course per ID (until [**2-18**]
via R PICC). Was finally extubated [**2-7**] and transfered to Gen
Med on [**2-9**]. On Gen Med, continued with rapid improvement,
weaned off O2. There was some concern initially with persistant
leukocytosis in 20s with fevers and imaging with pleural
effusions that raised concern for parapneumonic efffuisons or
empyema. However, WBC did start to trend down so [**Female First Name (un) 576**] was
deferred. He will have ID f/u after Abx and needs repeat
imaging. Still having low grade fevers and imaging with L>R
infiltrates but clinically much better. Other infectious w/u
negative.
Of note, during hospitalization, pt had some LFT elevation with
US/CT showing sludge but no evidence of cholecystitis and this
was likely [**1-29**] acute illness and possible TPN which he recieved
for few days (improving by time of discharge). Also developed
Anemia 12-->8 w/o gross evidence of bleeding or hemolysis, s/p
1U prbc [**2-9**] with hgb stable 9s thereafter. this can be followed
up as outpt.
.
.
See progress note below for details according to each problem:
53 year-old male with a history of hodgkin's s/p BMT in 93, s/p
splenectomy, h/o pericarditis, hypothyroidism, anemia, admitted
[**1-27**] with influenza B (received antiviral treatment in ICU)
complciated by severe MSSA bacterial
superinfection-->ARDS/intubation, extubated [**2-7**], t/f to floor
[**2-9**], doing very well, ambulating, tolerating PO, plan to d/c
home today
.
.
MSSA CAP, superinfection (Influenza B): ARDS, extubated [**2-7**].
Doing well, off oxygen. Some concern initially with persistant
leukocytosis/fevers and CT with persistant L>>R pleural
effusions concerning for parapneumonic effusions but white count
finally down. Pt has been afebrile (low grade temps)
- continue Nafcillin 2 gm IV q 4hr through [**2-18**] for total of 3
weeks per ID (confirmed plan)
-since downtrending wbc, can hold off on [**Female First Name (un) 576**], but needs repeat
imaging to ensure resolved effusions, f/u [**Hospital **] clinic in [**2181-3-6**]
- continue incentive spirometry
- guiafenisin prn, duonebs
-note, pt is post splenectomy, asked to confirm pneumovax and
meningitis vaccine, but none here while PNA
.
.
Leukocytosis: as above, 20s for several days, today down to 12,
as above, concern for parapneumonic effusions but holding [**Female First Name (un) 576**]
as above with repeat CXR in 1week. Currently with low grade
temps, no fevers. As for other sources, LIJ tip not sent, PICC
site looks good, no urinary complaints, no diarrhea. note,
baseline elevated wbc partly due to post-splenectomy.
.
.
Anemia and thrombocytosis: baseline hgb 12s, here 9-->7s s/p 1U
prbc [**2-9**], now 9s. No obvious bleeding or hemolysis but was
acutely ill.
-Fe studies will be unreliable since got blood t/f, hold supp
since Fe load with transfusion
-will need to be followed as outpt
-as for thrombocytosis, likely reactive (anemia, illness) and
post-splenectomy
.
.
Hodgkins disease s/p BMT'[**64**], no issues
.
.
Hypothyroidism: cont levothyroxine 88mcg
.
.
GERD: protonix 40-->prilosec at home
.
.
Dyslipidemia; resume lipitor 10
.
.
Elevated Alk phos: RUQ [**2-4**] with sludge, no dilation, bili
normal, no RUQ pain
-slow trend down, monitor, follow as outpt
.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet - 1 Tablet(s) by mouth
once a day
OMEPRAZOLE [PRILOSEC] - 10 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. PICC care per protocol
2. Nafcillin 2 gram Piggyback Sig: Two (2) Intravenous every
four (4) hours for 6 days: total 4g. continue until [**2-18**].
Disp:*qs doses* Refills:*0*
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**12-29**]
MLs PO Q6H (every 6 hours) as needed for cough.
5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Influenza type B
Severe MSSA multilobar pneumonia as superinfection causing ARDS
Anemia s/p blood transfusion
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted with influeza with superimposed severe
bilateral pneumonia due to staph.
YOu will need to complete IV antibiotics until [**2-18**]. If you have
worsening of fevers/cough/shortness of breath, call your doctor
or come to ER. Your PICC line will be removed after the
antibiotics are complete. Please follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**3-6**] as scheduled so that she can make sure you are
stable, you will need repeat Chest xray as well.
Confirm with your primary doctor that you are up to date with
your vaccination since you have your spleen removed.
Your medications are otherwise kept the same.
You had anemia during this hospitalization likely from your
severe illness, please follow this with your doctor to make sure
this is getting better. You recieved 1 unit of blood for this.
You can take daily Fe supplement to help with this.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-3-6**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2181-5-29**] 10:45
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 5647**], M.D. Date/Time:[**2182-1-24**] 10:40
|
56211,0389,5570,5849,99592,56081,78959,5538,7885,40291,4280,71947,5644,25000,V0254,E8788,27651 | 99,991 | 151,118 | Admission Date: [**2184-12-24**] Discharge Date: [**2185-1-5**]
Date of Birth: [**2137-4-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Recurrent diverticulitis
Major Surgical or Invasive Procedure:
[**2184-12-24**]: Laparoscopic sigmoid colectomy, splenic flexure
takedown, rigid sigmoidoscopy.
.
[**2184-12-28**]: Exploratory laparotomy, lysis of adhesions,
omentectomy, washout of abdomen, drain placement and abdominal
closure.
History of Present Illness:
Mr. [**Known lastname **] is a 47-year-old gentleman with a history of
diverticulitis in [**2177**] and again in [**2184-9-9**]. His last
episode required a seven day hospital stay on intravenous
antibiotics. Subsequently, his symptoms resolved and he was
discharged on an oral regimen. He had a colonoscopy after his
first attack of [**2177**]. He has no colonoscopies within our
system. He feels well now and has no further symptoms. He was
admitted for prophylactic operation to prevent recurrence.
Past Medical History:
PMHx: Type II DM, HTN, Diverticulitis
.
PSHx: Negative
Social History:
He lives in [**Location 4628**]. He is in a same sex marriage. Rarely
drinks alcohol. Smokes very rarely and at that time smoked four
to five cigarettes per day. He is a registered nurse [**First Name (Titles) **] [**Last Name (Titles) 3278**].
Family History:
Family history is significant for grandmother with lung cancer,
grandfather with strokes, and other family members with
hypertension and diabetes.
Physical Exam:
Pre-Admission Examination:
On physical exam, he is afebrile. Vital signs are normal.
Sclerae are nonicteric. Chest is clear. Heart is regular.
Abdomen is soft without rebound or guarding. There is
nofullness. Testicles are symmetric and descended. He is
circumcised. Extremities are warm without edema. Rectal exam
is heme negative, normal tone.
.
At Discharge:
AVSS/afebrile
GEN: Well appearing male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR; no m/c/r.
ABD: Midline incision with staples c/d/i. BSx4. Appropriately
tender along incision, otherwise soft/NT/ND.
EXTREM: No c/c/e
NEURO: A+Ox3. Comfortable. Non-focal/grossly intact.
Pertinent Results:
On Admission:
[**2184-12-24**] 07:28PM POTASSIUM-4.1
[**2184-12-24**] 07:28PM MAGNESIUM-1.9
[**2184-12-24**] 07:28PM HCT-39.6*
.
IMAGING:
[**2184-12-27**] CXR:
Aside from several regions of subsegmental atelectasis at the
right base, lungs are clear, though low in volume. There is no
pleural effusion or evidence of central adenopathy. Severe
gastrointestinal gaseous distension present in the upper abdomen
raises concern for small-bowel obstruction.
.
[**2184-12-31**] AP CXR:
In the interval there has been improvement in the degree of
vascular engorgement with the lungs appearing clear.
Nasogastric tube has been removed. Right-sided jugular central
venous catheter is in unchanged position.
.
[**2185-1-1**] HEEL (AXIAL & LATERAL) LEFT:
There is a large dorsal calcaneal enthesophyte. No discrete
fracture is identified. There is mild fragmentation within the
enthesophyte but there appears to be cortication in the
fragment.
.
MICROBIOLOGY:
[**2185-1-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-
NEGATIVE.
[**2185-1-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-
NEGATIVE.
[**2184-12-28**] URINE URINE CULTURE- NO GROWTH.
[**2184-12-28**] BLOOD CULTURE: No GROWTH.
[**2184-12-28**] BLOOD CULTURE NOT PROCESSED.
[**2184-12-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS).
[**2184-12-27**] BLOOD CULTURE: NO GROWTH.
[**2184-12-27**] BLOOD CULTURE: NO GROWTH.
[**2184-12-27**] URINE URINE CULTURE- <10,000 organisms/ml.
[**2184-12-27**] BLOOD CULTURE: NO GROWTH.
[**2184-12-27**] BLOOD CULTURE: NO GROWTH.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2184-12-24**] for prophylactic operation to prevent recurrence of
diverticulitis. The patient underwent laparoscopic sigmoid
colectomy, splenic flexure takedown, rigid sigmoidoscopy, which
initially went well (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO on IV fluids, with a foley
catheter in place, and a Dialudid PCA and Toradol IV for pain
control. The patient was hemodynamically stable.
.
Postoperatively, initially he did well, but he began spiking
fevers. His white blood cell count dropped, his urine output
dropped, and he began to have a septic etiology. He was
pan-cultured, started on empiric antibiotic therapy, and given
aggressive IV fluid rescusitation. Concern for an anastomotic
leak was raised. A chest x-ray showed evidence of
pneumoperitoneum. The patient was [**Last Name (un) 4662**] back to the Operating
Room on [**2184-12-28**] and underwent exploratory laparotomy, lysis of
adhesions,
omentectomy, washout of abdomen, drain placement and abdominal
closure, which went well without complication (see Operative
Note). After a prolonged PACU stay where he was extubated, he
was transferred to the TICU. He arrived NPO with an NG tube, on
IV fluids and IV Zosyn and Vancomycin, a foley catheter and 2 JP
drains to bulb suction were in place, and he recived Fentanyl
for pain control with good effect. Post-operative fluid overload
and associated hypertension was treated with IV Lasix for
diuresis as well as Metoprolol and Hydralazine with good effect.
He was transitioned back to home Labetolol and Clonidine was
started. The NG tube was removed. While in the TICU, he began to
notice some (L) ankle pain.
.
On [**2184-12-31**], the patient was transferred back to [**Hospital Ward Name 121**] 9. Pain
was initially well controlled with a Dilaudid PCA, which was
converted to oral pain medication when tolerating clear liquids.
The patient was started on sips of clears upon transfer, which
was progressively advanced as tolerated to a low fat, heart
healthy regular diet by [**2185-1-3**] with good tolerability. The
foley catheter was discontinued the morning of [**1-2**]. The patient
subsequently voided without problem. IV antibiotics were
discontinued on [**2185-1-1**]. Both JP drains were discontinued on
[**1-4**] as their output was low. The incision with staples remained
clean and intact. He was transitioned back to his home
anti-hypertensive medications with good BP control.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. By discharge, he was started back
on home Metformin for diabetes. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his diet,
ambulating, voiding without assistance, and pain was well
controlled. He was discharged home wihtout services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Viagra 50 mg 1 tab PO as directed for ED.
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: Over-the-counter.
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety/insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Recurrent diverticulitis.
2. Sepsis with acute abdomen and internal hernia secondary to
infarcted omentum with small bowel obstruction.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) 2819**] (Surgery) in 2 weeks.
.
Please call ([**Telephone/Fax (1) 1577**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-12**] weeks.
Completed by:[**2185-1-5**] |
9999,56881,5772,2851,5849,5799,72992,53081,4019,2721,5699,3004 | 99,992 | 197,084 | Admission Date: [**2144-7-25**] Discharge Date: [**2144-7-28**]
Date of Birth: [**2078-10-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Norvasc / Lipitor / Cortisone
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Chief Complaint: anemia
.
Reason for MICU transfer: retroperitoneal bleed
Major Surgical or Invasive Procedure:
Coiling of superior gluteal artery
History of Present Illness:
Ms. [**Known lastname 91180**] is a 65 YOF with history of GERD, HTN, and
hypertriglyceridemia who was recently admitted from [**7-9**] to [**7-22**]
after being transferred from an OSH for intractable diarrhea.
This hospital course was complicated by PEA arrest in the
setting of pH 6.98 and she was intubated and had a right femoral
CVL placed and was started on a bicarb drip. She was diagnosed
with postviral autoimmune enteropathy and was treated with TPN
and eventually discharged on budesonide and methylprednisolone
with improvement in her diarrhea. Notably her hospital course
was complicated by hypertensive urgency with SBP above 200,
volume overload in the setting of steroids, and an enterococcus
UTI. She was discharged to rehab 4 days ago.
.
The following day, she developed some mild pain in her medial
knee up her thigh to the groin. This was in the setting of
increased mobility - as she had previously been limited by
rectal tube during her admission. She had a f/u appointment
with her gastroenterologist the following day and when she
returned to rehab she complained of the pain and had LENIs that
were negative for DVT. The following morning (today) she was
turing and had increased pain in her right hip and flank. She
films and checked a Hct that was 14 (down from 27 on [**7-22**]). She
denied dizziness, chest pain, or dyspnea. She denied history of
trauma and was only on heparin subq for DVT prophylaxis but
otherwise no anticoagulation. She was sent to the ED for
further eval.
.
In the ED, VS 97.9 88 85/39 18 99% 3L. She was given
fentanyl for pain and hydrocortisone 100 mg (stress doese).
She had guiac + brown stool, NG lavage was negative. CT scan
showed large RP hematoma. IR rec CTA - which showed a small
focus at right psoas muscle, concerning for active bleed. She
was given 2 units uncrossmatched blood for the hypotension,
followed by a unit of cross matched blood and a L of NS. BP
remained 100-110 over several hours.
.
The patient went straight to IR where no active extravasation
was seen, but there was an irregular smaller branch that was
embolized with 2 small coils. A second arteriogram revealed no
more bleeding
Past Medical History:
Anxiety
GERD
Hypertension
Anemia of chornic disease
malnutrition
euthyroid sick
s/p hysterectomy
Social History:
Patient used to work part-time as a secretary. She is married
and has one son. Denies tobacco, etoh, or other drug use.
Family History:
Mother died at 78, father at 71 from MI.
Physical Exam:
Admission Exam:
Vitals: T: 97.6 BP: 133/61 P: 65 R: 18 O2: 95%
General: Alert, oriented, no acute distress
HEENT: slightly pale, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: multiple echymosis from heparin shots, firmness to
palpatio over the right abdomen, mild tenderness to palpation in
that region, no guarding, + BS
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Admission Labs:
[**2144-7-25**] 02:04PM BLOOD WBC-21.4*# RBC-1.35*# Hgb-4.7*#
Hct-12.9*# MCV-95 MCH-34.5* MCHC-36.4* RDW-16.3* Plt Ct-188
[**2144-7-25**] 02:04PM BLOOD Neuts-84.9* Lymphs-9.1* Monos-5.0 Eos-0.7
Baso-0.3
[**2144-7-25**] 02:04PM BLOOD PT-12.9 PTT-43.9* INR(PT)-1.1
[**2144-7-25**] 02:04PM BLOOD Glucose-206* UreaN-56* Creat-1.2* Na-136
K-4.9 Cl-105 HCO3-22 AnGap-14
[**2144-7-25**] 02:04PM BLOOD ALT-32 AST-20 AlkPhos-55 TotBili-0.2
DirBili-0.1 IndBili-0.1
[**2144-7-25**] 02:04PM BLOOD Albumin-2.0* Calcium-7.1* Phos-6.0*#
Mg-1.8
[**2144-7-25**] 02:04PM BLOOD Hapto-160
[**2144-7-25**] 02:04PM BLOOD D-Dimer-664*
.
CXR [**2144-7-25**]
1. Minimal right basilar atelectasis. Otherwise, no acute
intrathoracic
process.
2. Small bilateral pleural effusions as seen on subsequent CT.
.
CT AP [**2144-7-25**]
1. Large right iliopsoas intramuscular hematoma with associated
retroperitoneal hematoma. Further evaluation with CTA is
recommended to
assess for active bleeding.
2. Diverticulosis without evidence of diverticulitis.
.
CTA AP [**2144-7-25**]
1. Tiny focus of active arterial extravasation within the right
psoas muscle (2:124). Overall stable size of large right
retroperitoneal hematoma.
2. Hypodense 3-mm lesion in the body of the pancreas, more fully
characterized on the MRCP dated [**2144-7-11**].
Brief Hospital Course:
Ms. [**Known lastname 91180**] is a 65 YOF with recent diagnosis of postviral
autoimmune enteropathy requiring prolonged hospitalization
complicated by acidosis and PEA arrest who represented from
rehab with acute Hct drop and was found to have a
retroperitoneal bleed, now s/p coiling by IR with stable Hct.
# Retroperitoneal bleed:
Unclear etiology. Pt was instrumented 3 weeks ag during PEA
arrest with right femoral line, however, likely not related to
bleed as pt was noted to have a stable hct 3 prior to admission
(27) and femoral lines do not typically travel far enough to
cause a psoas bleed. Possible pt had heparin shot into a vessel
which caused bleeding? Symptoms began wednesday night and she
was not symptomatic despite her profound anemia, making a slow
bleed most likely. S/p IR coiling of small artery though unclear
if it was actually bleeding. Hct stable after the procedure
around 27. Lasix and valsartan were held in setting of IV
contrast load during IR procedure. Coreg was also held to
monitor for tachycardia as sign of re-bleed. Blood pressure
medications were slowly restarted as blood pressure and blood
counts stabilized.
# Autoimmune enteropathy:
Continued budesonide and methylprednisolone taper and monitored
fingersticks. Should continue methylprednisolone 15 mg [**Hospital1 **] x 1
day, 12.5 mg [**Hospital1 **] x 3 days, 10 mg [**Hospital1 **] x 3 days, 7.5 mg [**Hospital1 **] x 3
days, 5 mg [**Hospital1 **] x 3 days, then off. Should follow up with GI as
scheduled.
# Hypertension:
Has history of poorly controlled BP. Pt was hypotensive in ED in
setting of anemia and had one episode of BP 80s overnight the
night of admission, but was otherwise was normotensive. Her home
isosorbide mononitrate was continued with holding parameters;
and clonidine patch replaced to prevent withdrawal. Held
valsartan, lasix, and coreg initially as above which were slowly
restarted.
# GERD:
Omeprazole instead of esomeprazole while inpatient.
# Depression/anxiety:
Continued citalopram and Ativan during hospitalization.
Restarted both on discharge.
# 4-mm pancreatic cystic lesion:
Found within the neck / body of the pancreas during previous
hospitalization. Concern for IPMN (intrapapillary mucinous
neoplasm) of pancreas. Will need follow up with MRI as
outpatient.
# Hypoxia:
Likely atelectatis, but may have a component of pleural effusion
from hypoalbuminemia. CHF possible, but no history of echo in
our system. Echo done this admission showed normal systolic
function and mild pulmonary artery hypertension.
Incentive spirometer use encouraged.
Transitional Issues:
- monitor O2 status
- monitor Hct daily for 2 days, then again on [**Hospital1 2974**] [**2144-7-31**] to
ensure stable
- monitor BPs
- outpatient MRI
- continue methylprednisolone taper as above
FULL CODE during this admission.
Medications on Admission:
[**Last Name (un) **] 5000 TID
Trazodone 25 mg HS
Valsartan 320 mg Q day
Conjugated estrogen 0.625 Q day
Esmompreazole 40 mg Q day
Lorazepam 0.5 mg Q 8 PRN
Citalopram 40 mg Q day
Vitamin D 400 units Q day
Acetaminophen 650 mh Q 6 PRN
Folic acid 1 mg Q day
Tiamine 100 mg Q day
Budesonide 9 mg Q day
Gemfibrozil 600 mg Q day
clonidine 0.2 mg patch Q thursday
furosemide 40 mg Q day
Carvedilol 25 mg [**Hospital1 **]
isosorbide mononitrate 30 mg Q day
Lidocaine patch Q day
methylprednisolone 17.5 mg [**Hospital1 **] until [**7-27**] --> 15 mg [**Hospital1 **] x 3 days
--> 12.5 mg [**Hospital1 **] x 3 days --> 10 mg [**Hospital1 **] x 3 days --> 7.5 mg [**Hospital1 **] x
3 days --> 5 mg [**Hospital1 **] x 3 days
Discharge Medications:
1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
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. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Three (3)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
10. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: change on Thursday.
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. methylprednisolone 8 mg Tablet Sig: One (1) taper PO BID (2
times a day) for 13 days: taper as below:
15mg [**Hospital1 **] x 1 days 12.5mg [**Hospital1 **] x 3 days 10mg [**Hospital1 **] x 3 days 7.5 mg
[**Hospital1 **] x 3 days 5 mg [**Hospital1 **] x 3 days
.
15. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
16. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
18. insulin lispro 100 unit/mL Solution Sig: One (1) sliding
scale Subcutaneous ASDIR (AS DIRECTED): follow insulin sliding
scale enclosed.
19. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
20. dextrose 50% in water (D50W) Syringe Sig: One (1)
syringe Intravenous PRN (as needed) as needed for hypoglycemia
protocol.
21. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
22. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
23. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] Skilled Nursing Center
Discharge Diagnosis:
Retroperitoneal bleed
Autoimmune enteropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 91180**],
You were admitted to [**Hospital1 18**] for a bleed in your right lower
abdomen/back, called a retroperitoneal bleed. It is not clear
why this has happened, but it may have been spontaneous (for no
apparent reason). You were transfused with blood products to
improve your blood counts. Interventional radiology doctors
placed a [**Name5 (PTitle) 91181**] in the blood vessel that appeared to be bleeding
and you did not have any subsequent problems.
You were restarted on your most of your home blood pressure
medications after the bleeding was felt to be stable. For your
diarrhea and autoimmune enteropathy we continued your steroid
regimen which will be tapered down as planned by the
gastroenterology doctors.
We also discontinued your foley catheter.
The following changes were made to your medications:
STARTED Atovaquone to prevent fungal pneumonia while you are on
steroids
STARTED calcium supplement
INCREASED vitamin D supplement
CONTINUE methylprednisolone taper for additional 15 days as
follows:
- 15 mg [**Hospital1 **] x 1 days
- 12.5 mg [**Hospital1 **] x 3 days
- 10 mg [**Hospital1 **] x 3 days
- 7.5 mg [**Hospital1 **] x 3 days
- 5 mg [**Hospital1 **] x 3 days
Your blood pressure medications were initially stopped when you
came in because you were bleeding significantly, but after your
blood pressure and your blood counts were stable, we slowly
restarted your blood pressure medications.
Please be sure to discuss with your primary care doctor the
possibility of again trying to very slowly taper down your
conjugated estrogens because of potential risks of being on
these medications.
Please be sure to keep your followup appointment with your GI
doctor as below.
Followup Instructions:
Department: DIVISION OF GI
When: [**Hospital1 **] [**2144-8-7**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Please follow up with your primary care doctor once you are
discharged from [**Hospital **] rehab. They can assist you with this
function once you are ready for discharge to home.
|
4414,42833,99812,2851,4241,25000,99811,9961,E8798,2724,V4581,4280,V103,V1582,V5861,4400,41401 | 99,995 | 137,810 | Admission Date: [**2147-2-8**] Discharge Date: [**2147-2-11**]
Service: SURGERY
Allergies:
Zantac
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Abdominal Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2147-2-8**]: groin cutdown with mass excision and endovascular
repair of an aortic aneurysm
History of Present Illness:
Ms. [**Known lastname **] is an 88-year-old female who is currently being
evaluated for percutaneous aortic valve replacement due to
severe
aortic stenosis. She has a known infrarenal aortic aneurysm.
This was in the 4-5 cm range when it was first discovered
approximately eight years ago. In [**Month (only) **] of this past year, she
was evaluated at the [**Hospital3 2358**] and was judged not to be an
endovascular candidate. For that reason, repair was deferred.
She was recently hospitalized in [**Month (only) 956**] of this year for flash
pulmonary edema and back pain related to vertebral compression
fracture. CAT at that time demonstrated a 7.5-cm infrarenal
aortic aneurysm. She presents for elective endovascular repair.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
CAD
Diabetes
Dyslipidemia
Hypertension
CABG
afib on coumadin
dCHF (EF 60%)
severe AS
breast cancer s/p right partial mastectomy
s/p hysterectomy
Social History:
Remote smoking history (quit 30 years ago). lives in [**Hospital 4382**] with her husband. walks with a walker. has four children,
one died from MI. no etoh use. no illicit drug use
Family History:
one child died from MI as above, two brother died of MI in 40s,
one sister died of cancer, one sister of heart disease, father
died of heart problems, mother died of breast cancer
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 138/58 HR 72 Carotids: 2+, no bruits or JVD
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral palp , DP dop ,PT dop
Right Femoral palp , DP dop ,PT dop
Bilateral groin Dressing clean dry and intact. Soft, no hematoma
or ecchymosis.
Pertinent Results:
[**2147-2-10**] 02:05AM BLOOD WBC-6.4 RBC-2.99* Hgb-8.9* Hct-28.1*
MCV-94 MCH-29.8 MCHC-31.7 RDW-18.0* Plt Ct-124*
[**2147-2-10**] 02:05AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.5
Brief Hospital Course:
The patient was brought to the operating room on [**2147-2-8**] and
underwent a right groin cutdown and mass excision and EVAR. The
procedure was without complications. She was closely monitored
in the PACU and then transferred to the floor where she
remained hemodynamically stable. Her diet was gradually
advanced. She is ambulatory with ad lib. She was discharged to
home on POD # 2 in stable condition. Follow-up has been
arranged with Dr. [**Last Name (STitle) **] with surveillance CTA in one month.
Medications on Admission:
Metoprolol 50', Lasix 40', Simvastatin 20', Lisinopril 10',
Amiodarone 200', Coumadin 2.5'(on hold), Magnesium 120', MVI,
Ca/Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: as
per PCP.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. magnesium 120 mg daily
10.calcium/vit d
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Aortic Aneurysm
Aortic Stenosis
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 after an endovascular repair
of an abdominal aortic aneurym.
Please restart your coumadin at your home dose of 2.5 mg
starting tonight. Have your INR checked at your PCPs office on
[**2-13**].
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2147-3-16**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2147-3-16**] at 1:30 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2147-2-11**] |
75612,7861,4019,25000,4139 | 99,999 | 113,369 | Admission Date: [**2117-12-30**] Discharge Date: [**2118-1-4**]
Date of Birth: [**2054-1-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Neurogenic claudication
Major Surgical or Invasive Procedure:
[**2117-12-30**] PLIF L4-5
History of Present Illness:
63-year-old woman who complains of bilateral lower extremity
symptoms that are exacerbated by walking. She receives some
amelioration with rest. She denies difficulty with bowel or
bladder function.
Past Medical History:
HTN
Diabetes
Angina
Social History:
NC
Family History:
NC
Physical Exam:
Pre-Op on clinic visit:
On examination, her motor strength was [**3-30**] in hip flexion,
extension, quadriceps, hamstrings, dorsiflexion, and plantar
flexion bilaterally. Her sensory examination was intact with
respect to the modality of light touch. Her reflexes were
normal
and symmetric in the patellar and absent in the Achilles
bilaterally. Her pulses were palpable bilaterally. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
sign was positive on the left and not on the right, but weekly
so.
Upon Discharge:
A&OX3
PERRL
EOMs: intact
Motor: IP [**Initials (NamePattern5) 12643**] [**Last Name (NamePattern5) **] AT [**Last Name (un) 938**]
R 5 5 5 5 4 4
L 5 5 5 5 5 5
Incision: c/d/i- STAPLES
Pertinent Results:
CT L-SPINE W/O CONTRAST [**2118-1-1**]
1. Postoperative changes in the lumbar spine including posterior
fusion of
L4-L5. Grade 1 anterolisthesis of L4 on L5.
2. Drain is identified within the postoperative bed. No evidence
of
immediate hardware complication.
LUMBO-SACRAL SPINE (AP & LAT) [**2118-1-1**]
Status post L4-L5 stabilization. The stabilization material is
in
correct position. No evidence of complications.
Brief Hospital Course:
[**2117-12-30**] s/p PLIF L4-5 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]. Surgery was
uneventful and immediately post-operatively she remained stable.
POD 1 [**12-31**] she had an episode of stridor and feeling like she
could not breath, desat to 84-86% - she received an albuterol
and racemic neb with good effect, CXR was negative. Later that
morning she experienced a second episode of stridor and feeling
like she could not breath but OS sat was 100% and was
transferred to the ICU for observation. Etiology is unclear but
appeared to be upper respiratory. SQ Heparin was started on
[**2117-12-31**].
On [**1-1**] she was transferred to the floor and her JP drain was
discontinued. On [**1-3**], patient complained of pain in her back
that radiated down both legs. Her R IP and [**Last Name (un) 938**] were both [**2-28**] on
exam. She was started on neurontin and a medrol dose pack to
help alleviate pain. PT is working with patient to determine if
she needs to go to a rehab facility.
On [**1-4**], patient reported that her pain was much more controlled.
Her exam is improved with her R IP [**3-30**], but [**Last Name (un) 938**] is [**2-28**]. Patient
will be discharged to [**Location (un) 86**] Center for rehabilitation.
Medications on Admission:
Atenolol
Metformin
Lisinopril
Nortriptyline
Hydroxychloroquine [Plaquenil]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever > 100.4, pain.
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
6. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO
breakfast/lunch/dinner () for 1 days.
15. Methylprednisolone 8 mg Tablet Sig: Two (2) Tablet PO
bedtime () for 1 days.
16. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) for 1 days: start on [**2118-1-5**].
17. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 days: start on [**2118-1-6**].
18. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: start on [**2118-1-7**].
19. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO QD ()
for 1 days: start on [**2118-1-8**].
20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
22. Magnesium Citrate 1.745 g/30mL Solution Sig: Three Hundred
(300) ML PO ONCE (Once) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Lumbar Spondylolisthesis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2118-1-3**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**6-4**] DAYS FOR REMOVAL OF YOUR
STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2118-1-4**] |