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20,000 | 41401,4111,43310,4439,4401,4019 | 136,817 | Admission Date: [**2192-2-1**] Discharge Date: [**2192-2-6**]
Date of Birth: [**2136-2-3**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 55-year-old male
who presents with atypical chest pain for several weeks. Has
a history of known carotid disease, left 80-90%, right
70-80%, and he is scheduled for a left CEA on [**2192-2-1**], and
has been undergoing a preoperative evaluation.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Bilateral carotid disease.
3. Hypertension.
4. Hyperlipidemia.
5. Left renal artery stenosis.
PREOPERATIVE MEDICATIONS:
1. Norvasc 10 mg q day.
2. Lipitor 10 mg q day.
3. Folate 1 mg q day.
4. Toprol 25 mg q day.
ALLERGIES: Mussels and shellfish.
SOCIAL HISTORY: Positive smoker x40 years.
PHYSICAL EXAMINATION: At the time of admission, vital signs
are a heart rate 65 sinus rhythm, 130/67 blood pressure,
respiratory rate 16, and 97% on room air sat. Alert and
oriented times three. Extraocular movements are intact.
Neck is supple. Lungs are clear to auscultation.
Cardiovascular: Regular, rate, and rhythm, distant heart
sounds. Abdomen positive bowel sounds, tender in the left
upper quadrant. Extremities: No edema noted.
LABORATORIES: On [**1-20**], BUN is 18, creatinine 1.0, white
blood cells 8.0, hematocrit 41, platelets 244. PT 12.0, PTT
27.4, INR of 1.0. Urinalysis is negative. Total cholesterol
239, LDL 157, HDL 67, TGL 107. Homocysteine level 19.3.
Vitamin B12 level 328. LFTs within normal limits. Enzymes
were cycled and were flat. Troponin-I less than 0.3 and CPKs
were 61.
ELECTROCARDIOGRAM: Showed ectopic atrial rhythm in the 70s.
On [**1-26**], an echocardiogram was done showed an ejection
fraction of 44%, normal perfusion, and mild cavity
enlargement. No anginal or ischemic electrocardiogram
changes noted.
On [**2-1**] cardiac catheterization was done: Left ventricular
ejection fraction of 60%, and mitral regurgitation noted,
LMCA 90% ostial to the left anterior descending artery, the
left anterior descending artery mid vessel is 60% tubular,
left circumflex 40-50% proximal, right coronary artery small
vessel tortuous irregularities, 70% proximal disease.
An AIBP was placed in the catheterization laboratory
secondary to uncontrolled pain in order to assist the balloon
pump insertion, a stent was placed in the right iliac artery.
The patient was placed on Heparin and transferred to the CCU
pain free. Cardiac Surgery was consulted.
HOSPITAL COURSE: On [**2-1**], the patient was taken emergently
to the operating room, where he had left CEA and a CABG x3,
LIMA to the LAD, SVG to the distal RCA, SVG to the OM. IBP
was discontinued in the operating room. No intraoperative
complications. See the operative note for complete details.
The patient was transferred to the Intensive Care Unit.
Anesthesia was reversed and the patient was successfully
weaned from the ventilator early on postoperative day #1. He
remained in the Intensive Care Unit due to slow weaning from
vasopressor, eventually discontinued on postoperative day #3.
Chest tubes were also discontinued on postoperative day #3,
and patient was transferred to the floor for continued
cardiac rehabilitation and recovery.
He received 1 unit of packed red blood cells on the floor for
a low hematocrit. Physical Therapy was consulted, and
assisted patient with rehabilitation and determined to be
stable. Mr. [**Known lastname **] continues to do well, ambulating
independently, tolerating po, full strength in all
extremities. Neurologically intact and hematocrit stable.
PHYSICAL EXAM AT TIME OF DISCHARGE: Alert and oriented times
three. Pupils are equal, round, and reactive to light.
Follows commands. Neck is supple. No bleeding, oozing noted
at the incision site at the left neck. Lungs are decreased
bilateral bases, but otherwise clear to auscultation.
Cardiovascular: Regular, rate, and rhythm, S1, S2, no
murmurs, rubs, or gallops. Abdomen is soft, nontender, and
nondistended, and positive bowel sounds, [**1-1**] pulses bilateral
radial and femorals, and +[**12-1**] dorsalis pedis and PT. Sternal
incision is clean, dry, and intact. No drainage noted. The
patient has full strength bilaterally.
LABORATORIES AT TIME OF DISCHARGE: White count of 6.7,
hematocrit 27.7, platelets 140. BUN 11, creatinine 0.9,
calcium 7.5, phosphorus was 1.8.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg q day.
2. Potassium chloride 20 mEq q day.
3. Metoprolol 12.5 mg po bid.
4. Ranitidine 150 mg po bid.
5. Enteric coated aspirin 325 mg q day.
6. Plavix 75 mg q day.
7. Ibuprofen 400 mg q6 prn.
8. Percocet 1-2 tablets po q4-6 prn.
9. Tylenol 650 mg q4 prn.
DISPOSITION: The patient is stable and discharged to home.
FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 70**] in six
weeks with a primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17399**] in [**12-1**] weeks
and Vascular surgeon, Dr. [**Last Name (STitle) 1391**] in two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 17400**]
MEDQUIST36
D: [**2192-2-6**] 10:18
T: [**2192-2-6**] 10:18
JOB#: [**Job Number 17401**]
|
20,001 | 41071,486,1985,4280,41401,412,185,4019,2720 | 109,756 | Admission Date: [**2163-3-23**] Discharge Date: [**2163-3-26**]
Date of Birth: [**2088-9-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male who
was originally admitted to care for hypoxia, hypertension,
and mental status changes. Reportedly, the patient had
abrupt onset of dyspnea and was found to be hypoxic. At
outside hospital, the gas on 100% FIO2 of 85, pCO2 30, pH
7.47 with a systolic blood pressure of 70. He denies other
symptoms at that time. Chest x-ray revealed extensive
bilateral pulmonary disease consistent with lymphangitic
carcinomatosis and perhaps pulmonary edema.
Electrocardiogram demonstrated inferior ST elevation and ST
depression in V2 and Q waves in the inferior leads. He did
have a history of an old inferior myocardial infarction.
Troponin-I peak at 1.92, peak CK at 210. CT scan of the
chest was negative for pulmonary embolus. Echocardiogram
demonstrated ejection fraction of 50% with posterior wide
hypokinesis, mild MR and mild TR. He was then transferred to
the [**Hospital6 **], where he underwent catheterization
revealing 90% lesion in the mid right coronary artery with
thrombus. He was referred to [**Hospital1 188**] for PCI of the right coronary artery lesion.
Catheterization here revealed 60-70% lesion in the mid circ
and distal circ in addition to the right coronary artery
lesion. The right coronary artery lesion was stented in two
places with much difficulty.
In the holding area, he was noted to have decreased mental
status and increased confusion. O2 sat was found to be 70%.
He was given Lasix, intravenous nitroglycerin, and placed on
100% nonrebreather at which time his oxygen saturation
improved to 90-100%. He was then transferred to the CCU for
further evaluation.
PHYSICAL EXAMINATION: Vitals at that time included a heart
rate of 58, blood pressure 132/61, respirations 19, and he
was 96% on nonrebreather. He is a pleasant man in no acute
distress. Pupils are small but reactive. Heart: He had a
regular, rate, and rhythm with a II/VI crescendo systolic
murmur. His lungs have bibasilar dry, rhonchorous, coarse
throughout especially in the lower lobe. Abdomen was soft,
nontender, nondistended with positive bowel sounds with no
hepatosplenomegaly. He had no clubbing, cyanosis, or edema.
PAST MEDICAL HISTORY:
1. Metastatic prostate cancer with bone metastases to the
right humeral.
2. Coronary artery disease status post myocardial infarction
six years ago treated with medical therapy. A recent ETT
showed inferior fixed defects, ejection fraction of 50%.
3. Hypertension.
4. Zoster.
5. High cholesterol.
6. Status post appendectomy.
HOME MEDICATIONS:
1. Atenolol 50.
2. Zocor.
3. Neurontin.
4. Vicodin.
5. Levaquin.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He lives with his daughter. [**Name (NI) **] positive
alcohol 1-2 drinks. He quit smoking tobacco 50 years ago.
HOSPITAL COURSE: Hospital course is relatively
uncomplicated. He was admitted to CCU. He was gently
diuresed with Lasix and intravenous nitroglycerin. He was
gradually weaned. His oxygen was gradually weaned down to 2
liters nasal cannula, however, there was not much improvement
following this intervention. It was thought that his O2
requirement could possible be due to a primary pulmonary
process that could have been lymphangitic carcinomatosis or
fibrosis, perhaps from her Taxotere therapy.
Patient was transfused 1 unit of packed red blood cells to
maintain his hematocrit above 30 with a recent coronary
event. His laboratories on admission were 17.7, 32.4
hematocrit, platelets 189. Sodium 144, potassium 3.8,
chloride 110, bicarb 21, BUN 42, creatinine 0.8, glucose 157,
calcium 8.7, magnesium 2.0, phosphorus 3.9.
Cardiovascular: He had two stents placed to his RCA. He was
continued on Plavix, aspirin, beta blockers, and ACE
inhibitor. He was kept on Integrilin for 18 hours.
Reportedly at the outside hospital, the patient was found to
have an atypical pneumonia. He was continued on Levaquin.
His QTC was monitored because of the prepencity of Levaquin
to lengthen QTC.
Patient was seen by Physical Therapy who said that he was
safe to be discharged home and recommended PT visit to
maximize rehabilitation.
He was discharged home in good condition after speaking with
the patient's oncologist with close followup to further
workup the primary lung process causing him to have a new
oxygen requirement. The patient was discharged home with
home O2.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg po q day x4 days.
2. Simvastatin 2 mg po q day.
3. Gabapentin 400 mg po bid.
4. Protonix 40 mg po q day.
5. Lasix 40 mg po q day.
6. Atenolol 50 mg q am, 25 mg q pm.
7. Aspirin 325 mg po q day.
8. Home O2 by 2 liters nasal cannula continuous.
9. Plavix 75 mg po q day.
FOLLOW-UP INSTRUCTIONS: The patient was to followup with Dr.
[**Last Name (STitle) 2912**] in two weeks. In addition, he has an appointment
with his oncologist the following week.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D.
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2163-3-27**] 15:33
T: [**2163-3-29**] 08:00
JOB#: [**Job Number 45323**]
|
20,002 | V3001,76502,769,7485,76522,7470,V290 | 126,105 | Admission Date: [**2109-12-16**] Discharge Date: [**2109-12-17**]
Date of Birth: [**2109-12-16**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 59511**] is 709 gm
birth weight, a product of approximately 24 4/7 weeks
gestation. The infant was born at 18:42 on [**2109-12-16**]. The
exact gestation dates are uncertain because the mother was
not aware that she was pregnant until approximately one month
prior to delivery and had late onset of prenatal care. The
mother is a 23 year old G1 P0, blood type B positive,
antibody negative, RPR nonreactive, Rubella immune, hepatitis
B negative, GC negative, Chlamydia negative, GBS unknown.
Mother has a history of migraine headaches treated with
nortriptyline. She is a Jehovah's witness. The pregnancy was
complicated by anhydramnios of unclear duration and possible
IUGR. The mother presented to [**Hospital3 **] for
prenatal care. She was presumed to have ruptured membranes
and transferred to [**Hospital1 69**].
Mother was started on ampicillin and erythromycin seven days
prior to delivery. She had no fever, no signs of
chorioamnionitis clinically.
The infant was born by stat C-section on [**12-16**] because of non-
reassuring fetal heart rate tracing and prolonged fetal
tachycardia. The infant emerged in a breech position with
flexed hips, specifically the right leg more hyperextended
and externally rotated. The infant was intubated in the
Delivery Room. Apgar scores were 6 and 7. She was admitted to
the NICU.
SUMMARY OF HOSPITAL COURSE: The infant was placed on high
frequency ventilation. Over the course of the evening, she
was stable on high frequency ventilation. However, as of
approximately 12 hours of age, she had deterioration in her
oxygenation. Her chest x-ray showed no air leak, consistent
with respiratory insufficiency, ET tube in good position. The
infant had very low oxygen saturations, at best in the 80's.
At this point, I discussed with the mother and father that
the child's prognosis was very poor. Upon receiving volume
expansion, she transiently had oxygen saturations in the
90's, still on 100 percent FIO2 and mean airway pressures in
the 11-12 range. The infant was also initiated on
indomethacin and dopamine for treatment of a patent ductus
arteriosus. The infant then had a repeat occurrence of
progressive desaturations that were unresponsive to hand
bagging, switching to mechanical ventilation. The infant had
progressive deterioration in her cardiorespiratory status
despite maximal ventilatory support. There was further
discussion with the family regarding the futility of
continuing treatment in an infant who is having no response
to maximal ventilatory support in terms of oxygenation. The
etiology of her respiratory failure is thought to be related
to her extreme prematurity and potential pulmonary hypoplasia
given the mother's several day interval of prolonged ruptured
membranes and oligohydramnios. The infant had ventilatory
support withheld as of 1400 hours on [**2109-12-17**]. The infant
was pronounced dead by [**Doctor First Name **] Zacharini, neonatal nurse
practitioner at 1532 hours. I discussed autopsy permission
with the parents. They have signed permission by telephone
consent for autopsy with no restrictions. That packet will be
taken to the Admission Office.
CONDITION ON DISCHARGE: Death. The infant will be cremated
as per parents' wishes at [**Hospital1 188**]. Dr. [**Last Name (STitle) **], obstetrician, has been notified.
DISCHARGE DIAGNOSIS: Cardiorespiratory failure secondary to
extreme prematurity and possible pulmonary hypoplasia.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 50-ABP
Dictated By:[**Last Name (NamePattern1) 56577**]
MEDQUIST36
D: [**2109-12-17**] 19:48:22
T: [**2109-12-19**] 09:25:16
Job#: [**Job Number 59512**]
|
20,004 | 41091,25001,41401,4019,43820,53081 | 126,550 | Admission Date: [**2139-6-22**] Discharge Date: [**2139-7-1**]
Date of Birth: [**2066-2-17**] Sex: M
Service: CARD [**Doctor First Name 147**]
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73 year old
gentleman who was transferred from an outside hospital for
cardiac catheterization. He presented with fatigue at
[**Hospital3 15174**] with inverted T waves in the
precordial leads. Denies chest pain but ruled in for an
acute myocardial infarction.
Cardiac catheterization at [**Hospital1 188**] revealed LM 30%, left anterior descending 70%, obtuse
marginal 1 70%, mid-circumflex 40%, right coronary artery
100%, and non-dominant. He had preserved left ventricular
function. He was subsequently evaluated for cardiac surgery.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident in [**2127**] with residual left
weakness.
2. Abdominal aortic aneurysm.
3. Status post right cerebrovascular accident in [**2127**];
status post left cerebrovascular accident in [**2136**].
4. Cataract surgery.
5. Insulin dependent diabetes mellitus.
6. Hypertension.
7. Hyperlipidemia.
8. Chronic renal insufficiency.
9. Gastroesophageal reflux disease.
SOCIAL HISTORY: Mr. [**Known lastname **] quit smoking in [**2127**].
ALLERGIES: Prednisone causes swelling.
MEDICATIONS:
1. Atenolol 25 mg q. day.
2. Lasix 40 mg q. day.
3. Aspirin 81 mg q. day.
4. Plavix 75 mg q. day.
5. Nifedipine 60 mg q. day.
6. Protonix 30 mg q. day.
7. Terazosin 2 mg q. h.s.
8. NPH 44 units q. a.m., 20 units q. p.m.
REVIEW OF SYSTEMS: Denies melena, orthopnea, dyspnea, edema,
dizziness or palpitations. Positive for right hip pain.
PHYSICAL EXAMINATION: Blood pressure 170/80; heart rate 84.
His head is normocephalic, atraumatic. Neck is supple with
left carotid bruit with incisional scars bilaterally. Heart
is regular rate and rhythm with a systolic ejection murmur.
Lungs are clear to auscultation bilaterally. Abdomen is
soft, nontender, nondistended, with normoactive bowel sounds.
Extremities are without cyanosis, clubbing or edema.
HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the Operating Room on
[**2139-6-26**] for a coronary artery bypass graft times two.
Graft included a left internal mammary artery to left
anterior descending and saphenous vein graft to obtuse
marginal. The operation was performed without complication
and Mr. [**Known lastname **] was then transferred to the Cardiac Surgical
Intensive Care Unit. There he was extubated, weaned off
drips and fluid resuscitated.
His stay in the Intensive Care Unit was remarkable for
elevated blood sugars. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained
who recommended NPH dosing changes as well as changes in the
Humalog sliding scale. His blood sugar have been better
controlled over the last several days. Otherwise, Mr. [**Known lastname **]
continued to improve. He was transferred to the Floor where
he tolerated an oral diet and his pain was controlled with
oral medications.
He was able to ambulate some with Physical Therapy and on
[**2139-7-1**], he was felt stable for transfer to a
rehabilitation facility.
PHYSICAL EXAMINATION: On discharge, temperature 98.9 F.;
pulse 78; blood pressure 143/67; respirations 20; O2
saturation 93% on three liters. Heart was regular rate and
rhythm. Lungs were coarse at the left base, but he was
moving air well. Abdomen was soft, nontender, nondistended,
with normoactive bowel sounds. Extremities were without
cyanosis, clubbing or edema. Incision was clean, dry and
intact.
DISCHARGE MEDICATIONS:
1. [**Last Name (LF) **], [**First Name3 (LF) **]-saccharide complex 150 mg q. day.
2. Terazosin 2 mg p.o. h.s.
3. Amlodipine 5 mg q. day.
4. Pantoprazole 40 mg q. day.
5. Aspirin 325 mg q. day.
6. Calcium carbonate 1000 mg twice a day.
7. Metoprolol 37.5 mg twice a day.
8. Docusate 100 mg twice a day p.r.n.
9. Ipratropium two puffs i.h. q. four to six hours p.r.n.
10. Acetaminophen 325 to 650 mg q. four to six hours p.r.n.
11. Albuterol one to two puffs i.h. q. six hours p.r.n.
12. NPH 45 units at breakfast, 22 units at bedtime.
13. Potassium chloride 20 mEq p.o. twice a day.
14. Furosemide 60 mg p.o. twice a day times two weeks, then
40 mg q. day.
15. Humalog sliding scale: For glucoses 0 to 100, give zero
units at breakfast, lunch, dinner and bedtime; for 101 to
150, 4 at breakfast, zero at lunch, 4 at dinner, zero at
bedtime; 151 to 200, 6 at breakfast, 2 at lunch, 6 at dinner,
zero at bedtime; 201 to 250, 8 units at breakfast, 4 at
lunch, 8 at dinner and 2 at bedtime; 251 to 300, 10 units at
breakfast, 6 at lunch, 10 at dinner, 4 at bedtime; 301 to
350, 14 at breakfast and 8 at lunch, 14 at dinner, and 6 at
bedtime, and greater than 350, 16 units at breakfast, 10 at
lunch, 16 at dinner and 8 at bedtime. For glucose less than
60, give juice.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname **] should follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks.
2. He should follow-up with his primary care physician in
three to four weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged to
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times two.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2139-7-1**] 10:32
T: [**2139-7-1**] 13:40
JOB#: [**Job Number 22996**]
|
20,005 | 5849,2765,78039,431,5990,41071,41519,51882,42731 | 145,132 | Admission Date: [**2138-1-5**] Discharge Date: [**2138-1-18**]
HISTORY OF PRESENT ILLNESS: This is an 83-year-old Caucasian
female with history of dementia, hypertension, chronic renal
insufficiency, who was initially admitted to [**Hospital1 346**] on [**1-5**] for acute mental
metabolic toxic encephalopathy from acute and chronic renal
failure, questionable Tylenol overdose with transaminitis,
and an untreated urinary tract infection superimposed on her
underlying dementia.
On the night of admission, the patient acutely decompensated
with an increased heart rate, increased respiratory rate,
requiring an immediate transfer to the Intensive Care Unit.
There she was found to have multiple pulmonary emboli, and
was started on a Heparin drip for adequate anticoagulation.
Unfortunately, this resulted in a massive intracranial
hemorrhage within the occipital horns and the patient has had
severe cognitive decline ever since to the point of
unresponsiveness. Her hospital course has been marked by
worsening renal and hepatic dysfunction associated with
multiple metabolic derangements requiring intubation, blood
loss anemia requiring multiple transfusions, a renal mass
suspicious for malignancy, and an acute myocardial
infarction, event associated pneumonia.
Since the patient was without friends or family, a legal
guardian was appointed by the state and the patient's code
status was changed to DNR/DNI. The patient was transferred
out of the Intensive Care Unit on [**1-17**] once her code
status was finalized, and passed away the next
day ([**1-18**]) at 12:45 pm. An autopsy was granted by
her guardian, Ms. [**First Name4 (NamePattern1) 8214**] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**]
Dictated By:[**First Name (STitle) 35062**]
MEDQUIST36
D: [**2138-2-24**] 12:37
T: [**2138-2-25**] 07:30
JOB#: [**Job Number **]
|
20,006 | 0389,51881,78552,41071,43411,5070,4280,5849,4241,42731,2765,99592,V1046,2720,7455 | 151,980 | Admission Date: [**2194-5-4**] Discharge Date: [**2194-5-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
asp pna, CVA, MI
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
[**Age over 90 **] yo M w/ hx prostate ca, s/p recent d/c from [**Hospital1 18**] in [**3-15**] s/p
CVA, newly dx'ed AF, hyperchol, glucose intolerance and AS was
doing well at home after a rehab stay, when his family came to
see him the day of admission and found him unresponsive.
.
They had last talked to him at 930pm the night prior to
admission when he reported feeling short of breath with a stuffy
nose, which he attributed to seasonal allergies, as well as some
"upset stomach," which he attributed to taking [**Doctor First Name 130**]. He then
said he had to go to make dinner. He didn't report any F/C/N/V
or have any other complaints.
.
The day of admission, his family became worried because they had
not heard from him and his great nephew came over to his house
and found him unresponsive, cold and w/ yellow-white sputum
around his mouth. He called the ambulance and pt was brought in
to [**Hospital 882**] Hospital.
.
At [**Name (NI) 882**], pt was found to have an elevated troponin, an
elevated wbc and a NCHCT showed a new CVA w/out a bleed. His CXR
showed a L consolidation. He received 600mg IV clinda and
albuterol nebs and he was transferred to [**Hospital1 18**] for futher
treatment and management.
.
On arrival to [**Hospital1 18**] ED, his BP was 150/59, HR 120s (AF), RR
30s-40s 82% NRB. He was found to be gurgling w/ audible wheezing
and crackles in respiratory distress. He had a short trial of
CPAP while his code status was being clarified. He also received
100mg IV lasix and put out ~ 200cc urine.
.
When it was determined that pt was not DNR/DNI, pt was intubated
and received 20mg etomidate and 120mg succinate. He was started
on a propofol gtt and a nitro gtt. His BP's subsequently dropped
to SPB 40-50's and his nitro gtt was turned off and he received
IVF (~ 3L total of IV NS). His pressure came back up (he was
briefly on neosynephrine). In the ED he also received 500mg IV
levofloxacin and a central line was placed.
.
On arrival to the [**Name (NI) 153**], pt was hypotensive to the 70s/40s with
HR in 140s-160s in atrial fibrillation. EKG consistent with old
LBBB. He was given 1L NS wide open, his propofol was stopped and
his SBP increased to 120s. He was given 10mg IV Diltiazem with
HR in the 90s-110s with SBP 90s.
Past Medical History:
1. Prostate ca
2. s/p CVA L frontal lobe [**3-15**]
3. AF recently diagnosed [**3-15**]
4. AS
5. hypercholesterolemia
6. glucose intolerance
7. CHF: Echo ([**3-15**]) EF< 20%, mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mod-severe AS, PFO
with left-to-right shunt, mild pulm HTN
Social History:
Lives alone at home, s/p recent stay at rehab after his CVA.
Semi-retired carpenter, and still does odd jobs to help his
family at home. He has 3 sisters and one brother in the area. He
is a widower since [**2171**], no children. He never smoked, drinks
wine with dinner, and has no hx of illicit drug use.
Family History:
sisters died of cancer (? type), father died of CVA, mother w/
[**Name2 (NI) 2320**]
Physical Exam:
101.2 PR HR 126 (110-130's) BP 148/87 (50-140/P-80's)
AC 600 x 16 (overbreathing to 18-30) PEEP 5 100% FIO2 96-100%
sat;
Gen: thin cauc M lying in stretcher, intubated, arousable,
following commands
HEENT: dry mucous membranes
Neck: no JVD appreciated but difficult exam
Heart: very distant HS, irreg irreg, no m/r/g appreciated
Lungs: diffuse coarse crackles, expiratory wheezing
Abd: S/NT/ND/no masses
Ext; 2+ pitting edema b/l
Neuro: 0/5 motor on LUE and LLE, 4+/5 RUE and RLE;
Pertinent Results:
LABS:
lact 7.5
wbc 10 hct 43 trop T 0.48
INR 1.9 creat 1.9 AG 16
.
OSH:
wbc 17.7 creat 1.8 BUN 33 glu 149 hct 46.3 plt 290 INR 2.1 PTT
26
alb 3.4 ALT/AST 61/72 alk phos 167
CK 612 CK-MB 62.6 MBIndex 10 [ref <3.5]
trop I 4.10 [ref < 0.10 ng/ml]
U/A tr prot, o/w negative;
RAD:
CXR: LUL pna, no effusion
NCHCT from OSH per report: R frontal infarct, no bleed;
.
EKG:
AF @ 130bpm, LAD, LVH, LBBB qrs 120msec, c/w baseline [**2194-3-19**], no
change;
.
Cards:
[**2194-3-21**] TTE EF < 20%, + PFO and L->R shunt at rest across
interatrial septum; mod-severe AS, severe mitral annular
calcification;
Brief Hospital Course:
On arrival to the [**Hospital Unit Name 153**], the patient was hypotensive and
tachycardic. In addition, he was in respiratory failure and
therefore intubated and sedated. CXR revealed LUL infiltrate. He
was put on vancomycin and levofloxacin for sepsis, and
levophedrine to keep his blood pressure elevated. Multiple
cultures were sent. He was given fluid boluses. Troponins were
checked which were elevated, suggesting myocardial damage, so he
was given aspirin and diltiazem and lopressor for rate control.
He was ventilated on AC with 60% oxygen and stable O2 sats.
The patient's status declined as he became dependent on
increasing doses of pressors throughout the first day of
admission. The patient's family visited the patient on the day
after admission and made a joint decision that the patient would
not have wanted aggressive measures to keep him alive. The
decision was made to discontinue all treatment except comfort
measures and to extubate him. The patient died within 2 hours of
withdrawl of care at 4:00 pm on [**2194-5-4**] with his family at the
bedside.
Medications on Admission:
lisinopril 2.5mg po q24h
toprol 12.5mg po bid
warfarin for goal INR [**3-13**]
atorvastatin 40mg po q24h
lasix 20mg po q24h
tylenol prn
colace
senna
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
respiratory failure
sepsis
stroke
myocardial infarction/troponin leak
glucose intolerance
atrial fibrillation
Discharge Condition:
dead
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
20,007 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 | 188,442 | Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]
Date of Birth: 04/[**Numeric Identifier 5590**] Sex: F
Service: [**Hospital **] MEDICAL INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
female with multiple medical problems and a prolonged recent
Intensive Care Unit stay. She was readmitted with prepped
and draped. In [**Month (only) **] of this year, she had gallstone
pancreatitis requiring open cholecystectomy, and her course
congestive heart failure, atrial fibrillation, C-diff,
respiratory failure followed by failure to wean, and because
of this, she had a tracheostomy, the placement of which was
complicated by tracheal tear requiring placement of a
specialized trachea and urgent repair. Additionally, she has
an unclear myopathic, neuropathic process resulting in
generalized total body weakness. She was sent to [**Location (un) 511**]
admission after respiratory distress and reported granulation
tissue in her tracheal site. Plans were made for a
bronchoscopy in the morning. She denied shortness of breath,
chest pain, or cough.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial
fibrillation. 3. Vent dependent believed to be secondary to
myopathy neuropathy. 4. Recent C-diff. 5. Volume
overload. 6. Malnutrition. 7. Status post tracheal
perforation. 8. Goiter hypothyroid. 9. Right IJ clot.
10. Gastroesophageal reflux disease. 11. Status post
cholecystectomy. 12. Status post intra-abdominal abscess.
ALLERGIES: ASPIRIN, LEVOFLOXACIN, VANCOMYCIN, GENTAMICIN.
MEDICATIONS ON ADMISSION: Synthroid 75 q.d., Metoprolol 25
b.i.d., Prilosec 40 q.d., Flagyl 500 t.i.d., Paxil 20 q.d.,
Vitamin C 500 b.i.d., Zinc 220 q.d., Trazodone 25 q.h.s.,
Zofran p.r.n., Coumadin, Lasix 20 q.d., Promote tube feeds 65
cc/hr.
PHYSICAL EXAMINATION: Vital signs: Pulse 100, blood
pressure 109/65, oxygen saturation 99% on room air. General:
She was an elderly white female in no acute distress. HEENT:
Unremarkable. Lungs: Coarse breath sounds throughout.
Cardiovascular: Irregularly, irregular with normal S1 and
S2. Abdomen: Benign. Extremities: There was 3+ diffuse
pitting edema. Neurological: She was alert and oriented
with intact motor exam but generalized weakness.
LABORATORY DATA: Chest x-ray pending. Electrocardiogram
revealed atrial fibrillation at 125.
HOSPITAL COURSE: This was a 79-year-old female with multiple
medical problems, with prolonged Intensive Care Unit stay,
admitted with respiratory distress to the Medical Intensive
Care Unit.
1. Pulmonary: The patient was admitted with worsening
respiratory status, breathing through a tracheostomy
ventilator dependence believed to be secondary to
myopathic process. On hospital day #2, bronchoscopy was
performed which was negative for obstruction or vocal cord
dysfunction. She was noticed to have a redundant trachea,
and her episode of shortness of breath at the skilled nursing
facility was likely secondary to her trach hitting the back
of her trachea. Interventional Pulmonary and Thoracic
Surgery evaluated her airway, and they recommended not
changing her trach at this time. They felt that the current
trach was appropriate and more likely to obstruct than any
other.
On hospital day #3, Neurology was consulted to evaluate her
neuropathic process. The result of this will be dictated
subsequently.
The patient was rested on AC mode with plans to start her on
pressure support trials on hospital day #4. By her fifth
hospital day, the patient was tolerating pressure support
mode well. At this point, the consensus thinking was that
all of her respiratory failure was due to her muscular
weakness. Pressure support was weaned as tolerated.
On [**10-8**], after consultation with the Interventional
Pulmonology Service, it was deemed that the patient was a
candidate for change to a new trach which would allow her to
speak from time to time. This was successfully performed
without incident on [**10-8**]. The patient tolerated the
procedure well. Following this through the remainder of her
hospital stay, the patient was kept in pressure support mode
with periodic T-piece trials. On the day prior to
discharge, she was able to tolerate a trache mask
trial for approximately three hours.
We will discharge her to [**Hospital3 4419**] where she
can be continued on pressure support mode with
trache mask trials as tolerated. Of note at the time
of discharge, she had not required AC ventilation mode for
greater than two weeks. At the time of discharge when on the
ventilator, the patient was in IMV mode with pressure support
with an FIO2 of 40%, a set tidal volume of 500, a set rate of
5. She was overbreathing at a rate of 17 total. Her PEEP
was set at 5.0, and her pressure support was set at 5.0 as
well.
2. Cardiovascular: The patient came in with chronic atrial
fibrillation, therapeutic on Coumadin. Her anticoagulation
was stopped. In order for her to have her bronchoscopy, she
was subsequently put on Heparin and reloaded with Coumadin.
At the time of discharge, her INR was 2.5 on a dose of 3 mg a
day, and this will need to be adjusted at the outside
hospital at an appropriate stable dose. Additionally she was
maintained on her Digoxin. Multiple Digoxin levels were
checked and were all 1.0 which was deemed acceptable.
3. GI: The patient was on tube feeds. At the time of
discharge she was tolerating tube feeds at a rate of 40
cc/hr. Of note, on two separated occasions approximately one
week before discharge, the patient had complaints of nausea
and vomiting for which her tube feeds had to be stopped. CT
scan was performed on the day prior to discharge which
revealed no intra-abdominal abscesses or evidence of bowel
obstruction; however, the patient did appeared to have a mild
ileus, the exact etiology of which is unclear at this time,
although we speculated it may be related to her neuromuscular
process. She was tolerating tube feeds and able to move her
bowels with laxatives. We recommend continuing this at this
time. At the rehabilitation facility, low-dose Erythromycin
can be considered as a GI motility [**Doctor Last Name 360**] if she continues to
have problems tolerating tube feeds and with nausea and
vomiting.
4. Neurology: The patient was seen by the Neuromuscular
Team who recommended muscle biopsy which was subsequently
performed, the results of which are still pending at the time
of this dictation and her discharge. She has a follow-up
appointment with the Neurology Service on Monday, [**11-6**],
at 4 p.m. on the [**Location (un) 858**] of the [**Hospital Ward Name 23**] Building, [**Telephone/Fax (1) **].
At that time, results of the biopsy should be back. In the
meantime, they recommended a four-week trial of Prednisone 60
mg a day, of which she is currently on. She will continue
this until the end of the four weeks in late [**Month (only) 359**], or
until she is directed to stop from the Neurology Service.
5. Infectious disease: The patient had a urine culture come
back positive for pseudomonas sensitive to Bactrim. At the
time of dictation, she is on her fifth day of Bactrim. She
will need to complete a 14-day course. She should also have
her urine tested for clearing of the bacteria at the outside
facility.
6. Endocrine: The patient was placed on a regular Insulin
sliding scale for control of her blood sugars while on
Prednisone.
7. Psychiatric: In order to help with sleeping, the patient
was given 40 mg Paxil q.h.s. which seemed to work well.
8. Prophylaxis: For prophylaxis, the patient was placed on
Prevacid q.d.
9. Fluids: The patient was very edematous at the
time of her admission. She was started on Captopril which
was titrated up to 37.5 t.i.d. This seemed to greatly
improve her urine output. Additionally she was initially
given a Lasix drip and subsequently switched over to daily
Lasix dose. Her current dose is 60 mg IV t.i.d. With this,
she has been diuresing approximately 500 cc to 1 L per day.
We recommend continuing to do this until she clinically shows
no evidence of fluid overload. On exam at the time of
discharge, she has approximately 1+ pitting edema in her
lower extremities.
10. Communication: Dr. [**Last Name (STitle) **], the patient's primary care
physician, [**Name10 (NameIs) **] [**Name (NI) 653**] routinely throughout the course of
her care. There are plans to have follow-up discussions with
the family, as course evolved. Additionally as mentioned
above, she has a follow-up appointment with the Neuromuscular
Service regarding her diffuse myopathy.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2183-10-15**] 10:52
T: [**2183-10-15**] 11:12
JOB#: [**Job Number 5591**]
|
20,007 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 | 188,442 | Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]
Service:
HISTORY OF PRESENT ILLNESS: The following discharge summary
will cover the time period from [**10-15**] through [**2183-10-28**].
Please see previous discharge summary for information on
patient's admission diagnosis and medications.
HOSPITAL COURSE:
1. Gastrointestinal. On [**10-16**] the patient developed nausea,
vomiting and abdominal pain. Because of this she was not
discharged to rehabilitation at [**Location (un) 511**] Center Hospital
as had been previously planned. Due to her symptoms a CT
scan was obtained which revealed the patient had an ileus.
There were no abscesses or other processes that could be
identified. The neurology service was consulted regarding
possibility of this ileus being related to the patient's
myopathy but felt this was unlikely since skeletal muscle
myopathies typically do not also involve smooth muscle of the
Gastrointestinal tract. A Gastrointestinal consult was
obtained who had no additional thoughts on what could be
causing the patient's ileus and recommended bowel rest. The
patient was kept off tube feeds for two days after which time
they were restarted at a low rate of 20 cc's an hour as
compared to her goal rate of 65 cc's per hour. The patient
appeared to tolerate this reasonably well and the tube feeds
were increased. When they reached the rate of 30 cc's an
hour however the patient developed nausea and vomiting a
second time. Tube feeds were again stopped and her bowel was
rested for several days.
On [**10-24**] it was decided that because the patient was unable
to tolerate tube feeds at a reasonable rate she would be
started on TPN for nutrition. At the time of this dictation
on [**10-27**] the patient was reporting decreased abdominal pain
and no further nausea or vomiting. She additionally had been
successful in moving her bowels and treated with Colace,
Senokot and Fleet enemas. The suspicion of the team at this
point in time is that her ileus is resolving however, very
slowly. Her tube feeds will need to be started at a very
slow rate, advanced extremely gently as tolerated with
caution being taken because when the rate is increased to
abruptly she does tend to develop nausea and vomiting. She
will be discharged out on no tube feeds, they can be started
when she arrives at [**Location (un) 511**] Center for rehabilitation.
She will be discharged out on TPN which she can continue.
Additionally we will maintain her on [**Doctor Last Name **] and Colace.
2. Pulmonary. The patient continued to do well on a trach
mask and in fact tolerated trach mask ventilation for five
days in a row with no support from mechanical ventilator.
Because of this she was deemed safe to go to the floor
something which the team and the patient's family were very
happy with as it was thought this could be a trial
preliminary to transferring her to rehabilitation home. On
[**10-21**] she was transferred to the floor. Unfortunately however,
on [**10-22**] she was found to be hypoxic to the low 80's on the
floor. She was suctioned with thick tenacious dark
secretions came out, her O2 sats increased to the mid-80's.
Chest x-ray was consistent with a left sided opacity
throughout which was new. She was transferred back to the
Intensive Care Unit with ventilatory support and bronchoscopy
was performed which revealed purulent drainage from the left
mainstem, sample was sent. Chest x-ray after bronchoscopy
revealed markedly improved air space. O2 saturations
increased to 98% on only .4 FIO2. Following this episode the
patient was rested in IMV for several days. At the time of
this admission she was feeling better and feeling strong
enough to try pressor support ventilation again.
The teams thinking is that perhaps the patient needs to be
rested each night in an MV mode letting her use only a trach
mask for five days may have been to much to soon and in the
future we will get her to tolerate pressor support and rest
her on the night and possibly during the day allowing her to
breath through the trach mask. Currently she is being
weaned, this will need to be continued at [**Hospital1 **].
Per discussion with the family the pulmonary attending is
planning to call the pulmonary attending at [**Hospital1 **]
to communicate the patient's need regarding ventilatory
management.
3. Infectious disease. On [**10-16**] the patient's urine grew out
Enterobacter which was sensitive only to Mirpenum and one
other [**Doctor Last Name 360**]. She was treated with Mirpenum for seven days.
At approximate completion of the 7 days course the patient's
BAL sample from her bronch grew out pseudomonas which was
resistant to Mirpenum. Because of this switched to Zosyn
which the pseudomonas was sensitive to. She will be
discharged on this and need to complete a 10 to 14 day
course. Additionally she was started on Flagyl for possible
C. diff given that she was complaining of abdominal pain and
was feeling extremely weak. Of note, she did not have
diarrhea. She did seem to get better after starting the
Flagyl so she will need to complete a 14 day course of this
as well for empiric therapy for C. diff.
Also of note the patient had one set of blood cultures
positive for coag negative staph however, it was deemed that
this was a contaminant and the decision was made not to treat
after consultation with Infectious Disease service.
4. Neurological. The patient continued to show improvement
in her strength while on 60 mg of Prednisone a day. The
original plan had been for her to be treated for 4 weeks with
60 mg of Prednisone empirically and then follow-up with the
neuromuscular service for a decision as to whether or not to
continue this. However, after approximately 2-1/2 weeks of
therapy the patient had issues with infectious disease as
detailed above including urinary tract infection and
pulmonary infection. Because of these issues, with highly
resistant bacteria it was deemed that the best thing to do
would be to taper the steroids.
On approximately [**10-22**] the patient was cut from 60 to 40 mg of
Prednisone a day and on [**10-27**] the day of this dictation the
patient was cut to 20 mg a day. She will need to continue
this slow taper until the steroids had been weaned to off.
If her improvement in neurologic function continues even off
the steroids then she can probably never start on steroids
again however, if she shows a decline once she is off
steroids this will further enforce the theory that the
steroids are what has been treating her myopathy and once she
is clear for infectious issues she should be restarted on
steroids in the future. She will follow-up with the
neuromuscular service as detailed in her previous discharge
summary.
5. Psychiatric. On one occasion the patient during the
night the patient became quite despondent and request that
she did not wish to continue with this therapy as she was
incredibly frustrated. However, the team had multiple
discussions on their rounds and at the time of this dictation
the patient's mood had significantly improved and her will to
fight on actually seemed quite remarkable. She is continued
on her Paxil and at the present time the team did not see any
need for additional psychiatric intervention.
6. Communication. A family meeting was held on [**2183-10-27**]
with the patient's two daughters, son and husband as well as
the attending physician in the Intensive Care Unit Dr. [**First Name (STitle) **],
Dr. [**First Name (STitle) **] the former Intensive Care Unit attending, myself
Dr. [**First Name (STitle) 916**] and the patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Discussion was held
as to the patient's status. We discussed the fact that the
family had previously wished for the patient to have
resolution of all her issues prior to going to
rehabilitation. However, we explained that her issues seemed
to be taking quite sometime the resolve and that we will have
to accept the fact that her issues are stable and improving
although not completely resolved. Additionally was discussed
the fact that the patient was clearly ready for
rehabilitation now and likely many of her problems including
her pulmonary and gastrointestinal problems may benefit from
getting her out of bed and having her go to rehabilitation.
The family was open to this and grateful for our assistance.
Tentative plans were made to arrange for discharge to [**Hospital1 5593**] on [**2183-10-29**].
An addendum to this discharge summary will be dictated
following this detailing the events of the 15th and 16th.
Please refer to that discharge summary for the exact meds at
discharge and discharge diagnosis.
DIAGNOSIS AT TIME OF THIS DICTATION:
1. Respiratory failure resulting in ventilatory dependence.
2. Myopathy of unclear etiology.
3. Ileus of unclear etiology.
4. Pseudomonas pneumonia.
5. Enterobacter urinary tract infection.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2183-10-27**] 20:51
T: [**2183-10-27**] 21:10
JOB#: [**Job Number 5594**]
|
20,007 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 | 188,442 | Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]
Service:
DISCHARGE DIAGNOSES:
1. Ventilatory dependence.
2. Atrial fibrillation.
3. Neuropathy and weakness.
4. Hyperthyroidism.
5. Gastroesophageal reflux disease.
6. Status post gallbladder removal.
KNOWN ALLERGIES AT THE TIME OF DISCHARGE: 1. Levofloxacin
causes a rash. 2. Vancomycin causes hearing loss. 3.
Aspirin, Celebrex and non-steroidal anti-inflammatory drugs
the patient cannot tolerate. 4. Gentamycin cannot tolerate
per the patient's son.
MEDICATIONS ON DISCHARGE: 1. Vitamin C 500 q.d. 2. Paxil
40 mg q.h.s. 3. Bactrim double strength one tab b.i.d.
until [**2183-10-21**]. 4. Prednisone 60 mg q.d. until
[**2183-11-4**] per neurology request. 5. Coumadin 3 mg po
q.h.s. adjust to goal INR of 2.0 to 3.0. 6. Regular insulin
per sliding scale. 7. Captopril 37.5 mg t.i.d. 8. Colace
100 b.i.d. 9. Prevacid 30 mg q.d. 10. Senna two tabs
b.i.d. 11. Digoxin 0.125 mg q.d. 12. Synthroid 75
micrograms q.d. 13. Trazodone 25 mg q.h.s. prn for sleep.
NUTRITIONAL NEEDS: The patient is lactose intolerant.
VENTILATORY SETTINGS: Mrs. [**Known lastname 5579**] has been attempted to
use a ____________ daily for as long as she can tolerate
usually one to four hours. She has not required a C mode for
the past two weeks. When she gets fatigued she has been
rested comfortably in IMV mode FI2 40%, PEEP of 5, pressure
support of 5 with a set rate of 5.
FOLLOW UP: Dr. [**Last Name (STitle) **] her primary care physician as arranged
by Dr. [**Last Name (STitle) **] and the Neurology Service as dictated above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2183-10-15**] 10:56
T: [**2183-10-15**] 11:32
JOB#: [**Job Number 5592**]
|
20,007 | 51881,9982,5121,5180,496,42731,4280,5119,4820 | 192,297 | Admission Date: [**2183-8-6**] Discharge Date:
Service: ICU
CHIEF COMPLAINT: Hypercarbic hypoxemic respiratory failure
HISTORY OF PRESENT ILLNESS: 79-year-old white female with a
history of chronic obstructive pulmonary disease,
hypertension, paroxysmal atrial fibrillation, presents from
rehabilitation facility following an episode of tachypnea,
hypoxia and obtundation requiring endotracheal intubation.
The patient is status post a recent prolonged hospitalization
from [**7-4**] to [**7-25**] for gallstone pancreatitis requiring
open cholecystectomy and choledochoduodenostomy on [**7-3**] by
Dr. [**Last Name (STitle) 1305**] with a long hospitalization complicated by E. coli
sepsis, a lower gastrointestinal bleed, with negative
colonoscopy, volume overload, and a postoperative abdominal
abscess, culture positive for vancomycin-resistant
enterococcus requiring CT-guided drainage. The patient also
suffered C. difficile colitis during this admission. Toward
the end of her hospitalization, the patient was noted to have
acute tachypnea, pH 7.27, CO2 70, which resolved with minimal
intervention the following day. The patient was discharged
to a skilled nursing facility on [**7-25**] on a plan for
linezolid for four weeks for her VRE abscess, and Flagyl for
two weeks for her C. difficile colitis.
At the skilled nursing facility, the patient has done poorly,
with continued lethargy, anorexia and depression. She was
noted to have decreased sodium to 119 on [**8-3**], which was
question of serum-inappropriate antidiuretic hormone. The
patient developed cough on [**7-29**], for which she was started
on Robitussin, and yesterday she was noted to have hypoxia
with an oxygen saturation of 93% on 2 liters nasal cannula.
This morning, shortly after breakfast, the patient was noted
to become more tachypneic and somnolent, having an oxygen
saturation in the 60s on 2 liters, improving to 97% on 100%
non-rebreather. She became increasingly somnolent, and
became completely unresponsive. The patient was bag mask
ventilated and referred to [**Hospital1 188**] for further evaluation.
In the Emergency Department, she was afebrile, with heart
rate in the 80s, blood pressure 140/80, oxygen saturation 90%
on 100% non-rebreather. She was unresponsive to voice and
pain. The patient was subsequently intubated, with
improvement in her mental status following intubation. A CTA
of the chest was performed, without evidence of pulmonary
embolism, with scattered ground-glass opacities, slightly
increased right greater than left. Electrocardiogram was
without significant change. A head CT was negative for acute
bleed or cerebrovascular accident. After receiving 4 liters
of normal saline, ceftriaxone, Flagyl and lasix, the patient
was transferred to the Intensive Care Unit.
Upon arrival to the Intensive Care Unit, the patient spiked a
temperature to 101, and dropped her systolic blood pressure
from 130s to the 80s. The patient received a 1 liter fluid
bolus without significant change. She was subsequently
started on dopamine.
PAST MEDICAL HISTORY:
1. Hypertension
2. Chronic obstructive pulmonary disease, FEV-1 1.74 in [**2176**]
3. Atrial fibrillation
4. Congestive heart failure with an ejection fraction of
60%, basal septal hypertrophy, 1 to 2+ aortic regurgitation,
and 1 to 2+ mitral regurgitation
5. History of gastrointestinal bleed on aspirin
6. Degenerative joint disease
7. Migraine headaches
8. Cataracts
9. Large substernal goiter and hypothyroidism
ALLERGIES: Aspirin
MEDICATIONS ON TRANSFER: Linezolid 200 mg twice a day,
Flagyl 500 mg by mouth three times a day, Darvocet as needed,
atenolol 100 mg by mouth once daily, Ranitidine 150 mg by
mouth once daily, Levothyroxine 75 mcg by mouth once daily,
lasix 40 mg by mouth once daily, amiodarone 200 mg by mouth
once daily, Zoloft, Mycostatin, Florinef, and prednisone
SOCIAL HISTORY: The patient is married and has her children
very involved with her care. Her son, [**Name (NI) **], is a
cardiologist in [**Name (NI) 5583**], [**State 350**]. She has a 20
pack year smoking history.
PHYSICAL EXAMINATION: Temperature 101, heart rate 70s to
80s, blood pressure 170/48 on 16 mcg/kg/minute of dopamine.
Skin: Dry, cool feet. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, pupils equal, round and reactive
to light and accommodation, extraocular movements intact,
oropharynx dry. Neck: Prominent external jugular vein.
Lungs: Bilateral inspiratory and expiratory rhonchi.
Cardiovascular: S1 and S2, no murmurs, gallops or rubs.
Abdomen: Surgical scar healing well, hypoactive bowel
sounds, soft, nontender, nondistended. Extremities: No
edema, peripheral pulses intact. Neurological: Moving upper
extremities and lower extremities.
LABORATORY DATA: White blood count 17.3, hematocrit 33.5,
platelets 187. INR 1.4, PTT 30. Sodium 130, potassium 3.7,
chloride 94, bicarbonate 26, BUN 13, creatinine 0.3. CPK 75,
troponin-i 0.3. Urinalysis was unremarkable. Chest x-ray
revealed increasing left-sided effusion, consolidation at the
left base, a large mediastinal mass without tracheal
deviation that was unchanged from that on [**7-22**]. CT of the
chest was negative for pulmonary embolism, moderate bilateral
pleural effusion, slightly increased from [**7-23**]. Bilateral
atelectasis, partial collapse adjacent to pleural effusions,
large superior mediastinal mass with calcific density
consistent with thyroid goiter. Deviated trachea and
esophagus, deviated anterior and to the right. Calcification
of the coronary arteries, ground-glass opacifications in both
lungs, with central lobular emphysematous changes mostly at
the bases. CT of the head: No acute bleed, chronic small
vessel ischemic changes.
HOSPITAL COURSE:
1. Pulmonary/thoracic: The patient was initially admitted
with hypoxic and hypercarbic respiratory failure. As stated
above, CTA showed no evidence for pulmonary embolism. The
patient was gradually weaned from the ventilator. The
patient's left-sided pleural effusion was tapped on [**8-7**],
which revealed a 700 cc pleural effusion which was
transudative and sterile. The patient was extubated on [**8-10**]. However, on [**8-15**], while receiving a bath, the
patient again developed sudden acute hypoxia, respiratory
acidosis, apnea, and generalized unresponsiveness, requiring
emergent reintubation on [**8-15**].
On [**8-18**], the patient underwent a percutaneous
tracheostomy, complicated by a tear of the posterior trachea.
The patient was taken emergently to the operating room, and
required open sternotomy with surgical repair of her trachea,
along with placement of bilateral chest tubes and mediastinal
tubes. Because of the tortuosity of her large substernal
goiter, she had a partial thyroid resection.
Following this procedure, the patient was managed on AC
ventilation, with eventual removal of her chest and
mediastinal tubes. The patient continued to wean from the
ventilator on AC and, at the time of this dictation, is
tolerating pressure support for approximately 12 hours per
day. The patient was bronchoscoped on an almost daily
regimen by Dr. [**First Name (STitle) **] [**Name (STitle) **] of Interventional Pulmonology both
for secretion clearing and checking placement of the
endotracheal tube. The endotracheal tube position was
changed multiple times.
At the time of this dictation, the patient is scheduled to
undergo placement of a customized tracheostomy tube obtained
by Dr. [**Last Name (STitle) **] on [**9-3**].
2. Cardiovascular/hemodynamics: The patient was weaned off
pressors by [**8-9**]. The patient's amiodarone was
discontinued secondary to concerns for precipitating a
myopathy. An echocardiogram in late [**Month (only) 205**] revealed basal
septal left ventricular hypertrophy with ejection fraction
greater than 55%, 2+ mitral regurgitation, 2+ tricuspid
regurgitation, and moderate pulmonary hypertension. The
patient was restarted on her outpatient doses of Captopril,
on low doses of ACE inhibitors and beta blockers. In the
second week of [**Month (only) 216**], the patient's blood pressure began to
trend to the 90s, with heart rate in the 110s, along with
poor urine output. There were no electrocardiogram changes,
and the patient did not complain of chest pain or shortness
of breath. The patient's poor urine output is currently
being managed with aggressive fluid boluses and
resuscitation. She remains otherwise hemodynamically stable.
3. Infectious Disease: The patient was initially covered
with broad spectrum antibiotics, including ceftazidime,
Flagyl, as well as linezolid. All blood cultures remained
negative, though her sputum did grow Klebsiella pneumoniae,
with urine showing pseudomonas. Her antibiotic therapy was
tailored to Zosyn, for which she received a seven day course.
The patient did develop a rash on Levaquin, which she was
being treated for a urinary tract infection. Following the
tear of her trachea, the patient was begun on a 14 day course
of empiric vancomycin for coverage of her history of
methicillin resistant staphylococcus aureus, as per Dr.
[**Last Name (STitle) 952**], the Thoracic Surgery attending.
4. Neurological: The etiology of the patient's recurrent
respiratory decompensations was unclear. [**Name2 (NI) 227**] the fact that
her chronic obstructive pulmonary disease was not felt to be
very severe, a diagnosis of a potential respiratory muscle
myopathy was entertained. While CKs were negative, the
patient was evaluated by Neurology. The patient had a
negative tensilon test. An electromyogram was also
consistent with a myopathic process with a moderate to severe
axonal polyneuropathy noted. At the time of this dictation,
the differential diagnosis includes critical care myopathy
vs. drug-induced myopathy. Because of concern for
drug-induced myopathy, linezolid and amiodarone were
discontinued. All other medications were longstanding. The
patient is currently scheduled to undergo a muscle biopsy by
Dr. [**Last Name (STitle) 1338**] in a combined operating room procedure on [**9-3**].
5. Gastroenterology: The patient has a history of lower
gastrointestinal bleed during her last hospitalization, with
a negative colonoscopy. The patient has remained OB negative
during this hospitalization. She had multiple C. difficile
screens, which have been negative. An abdominal CT done on
[**8-26**] revealed no change in her abdominal fluid
collection.
6. Hematology: The patient developed thrombocytopenia to
the 100s during the early part of her hospitalization. The
etiology was unclear, but was felt to either be drug-related
vs. thrombocytopenia sepsis. It has since resolved. The
patient required intermittent transfusions of several units
of packed red blood cells.
7. Endocrine: The patient was continued on Synthroid.
Given her periods of hypotension, an ACTH stimulation test
was performed, which was negative.
8. Renal: The patient's creatinine remained well within
normal limits. However, as stated in the cardiovascular
section, her urine output continued to be poor through the
second week of [**Month (only) 216**]. She was given aggressive fluid
resuscitation with some improvement in her urine output but,
at the time of this dictation, is currently receiving
intravenous fluid boluses. A fractional excretion of sodium
was calculated and was found to be 0.1 and negative of
pre-renal insufficiency.
9. Fluids, electrolytes and nutrition: The patient was
briefly on total parenteral nutrition at the time of her
tracheal seal, but is currently now tolerating tube feeds.
She will need to undergo placement of a percutaneous
endoscopic gastrostomy tube either by Radiology or by Dr.
[**Last Name (STitle) **].
An addendum will be completed for this hospitalization at the
time of discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 5584**]
MEDQUIST36
D: [**2183-8-29**] 20:53
T: [**2183-8-30**] 00:00
JOB#: [**Job Number 5585**]
|
20,007 | 51881,9982,5121,5180,496,42731,4280,5119,4820 | 192,297 | Admission Date: [**2183-8-6**] Discharge Date: [**2183-9-15**]
Service:
PRIMARY DIAGNOSIS:
1. Volume overload anasarca.
2. Status post posterior trach perforation and repair.
3. Respiratory failure with ventilatory dependence.
Mechanical ventilatory dependence.
4. Atrial fibrillation.
5. Clostridium difficile infection.
6. Malnourishment.
7. Sepsis. Status post treatment and resolution.
8. Pneumonia, ventilatory associated status post
resolution and treatment.
9. Anemia.
10. Pleural effusions.
11. Goiter.
12. Hypothyroidism
13. Urinary tract infection, numerous including pseudomonas.
14. Questionable myopathy.
15. Yeast infection of the urinary tract.
16. Thrombocytopenia subsequent resolution.
17. Right internal jugular, non-occlusive clot.
18. Hyponatremia subsequently resolved.
19. Tracheostomy.
20. Hypothyroidism.
21. Gastroesophageal reflux disease.
SECONDARY DIAGNOSIS:
1. Status post cholecystectomy and choledochoduodenostomy.
2. Vancomycin resistant enterococcus bacteremia in abscess.
3. History of lower gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname 5579**] is a
79-year-old female with chronic obstructive pulmonary
disease, hypertension, paroxysmal atrial fibrillation, who
presents from Shore House Rehabilitation following episodes
of tachypnea, hypoxemia and obtundation requiring
endotracheal intubation. The patient is status post recent
hospitalization from [**7-4**] to [**2183-7-25**] for gallstone
pancreatitis requiring open cholecystectomy and
choledochoduodenostomy on [**2183-7-11**] by Dr. [**Last Name (STitle) 1305**] with
hospitalization complicated by E. coli sepsis, volume
overload and bilateral pleural effusion, atrial fibrillation
and postop abdominal abscess which grew out Vancomycin
Resistant Enterococcus.
The patient subsequently had a gallbladder drainage by CT
guidance on [**2183-7-18**]. The patient suffered C. diff colitis at
prior hospitalization. Towards the end of hospitalization
was noted to have acute tachypnea. She was subsequently
discharged to Shore House on [**2183-7-25**] on antibiotics
Linezolide for four week course for her Vancomycin resistant
enterococcus abscess and Flagyl for 14 day course for C. diff
colitis.
At the Shore House however, the patient was doing poorly with
continued lethargy, anorexia and depression. The patient was
noted to develop hyponatremia. She apparently developed
cough on [**7-29**] for which she was treated with Robitussin and
the day prior to admission was noted to have hypoxemia with
O2 saturations 90% on two liters nasal cannula.
On the morning of presentation to [**Hospital1 190**] the patient shortly was noted to become more
tachypneic and somnolent with oxygen saturation in the 60's
and requiring 100% non-rebreather. The patient subsequently
then became unresponsive and was subsequently started manual
artificial respirations and was sent to [**Hospital1 190**] for further evaluation.
In the Emergency Room she was afebrile, heart rate in the 80s
and blood pressure 140/80, oxygen saturation 90% on 100%
non-rebreather, unresponsive. The patient subsequently
intubated at the Emergency Room at [**Hospital1 190**]. She was admitted to the Intensive Care Unit
for further treatment.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastroesophageal reflux disease, FEV 1 of 1.74, 70%
predicted.
3. Atrial fibrillation.
4. Congestive heart failure with ejection fraction of
60% Basal septal hypokinesis.
5. History of Gastrointestinal bleed secondary to aspirin.
6. Degenerative joint disease.
7. Migraine headaches.
8. Cataracts.
9. Substernal goiter with hypothyroidism status post
biopsy.
ALLERGIES: Aspirin which causes gastrointestinal bleed.
MEDICATIONS ON PRESENTATION:
1. Linezolide 200 mg p.o. b.i.d.
2. Flagyl 500 mg p.o. q 8 hours.
3. Percocet
4. Atenolol 100 mg q day.
5. Ranitidine 150 mg p.o. q day.
6. Levoxyl 75 mcg q day.
7. Lasix 40 mg p.o. q day.
8. Amiodarone 200 mg p.o. q day.
9. Florinef 0.1 mg p.o. q day.
10. Prednisone 30 mg p.o. q day.
PHYSICAL EXAMINATION: Upon presentation the patient was
subsequently intubated, temperature 101, heart rate 70 to 80
and atrial fibrillation. Blood pressure 107/48 on Dopamine.
Skin was dry. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation. Oropharynx dry. Neck:
Prominent external jugular veins. Lungs: Bilaterally coarse
breath sounds. Cardiac: Irregular rate and rhythm, no
murmurs, rubs or gallops. Abdomen: Surgical site healing
well. Hyperactive bowel sounds, soft, nontender to
palpation. Extremities: No edema, peripheral pulses 2+.
Neurological: Moving all extremities. On vent setting,
assist control 500, tidal volume, respiratory rate of 17,
FIO2 0.7, PEEP of 5.
LABS ON PRESENTATION: White count 17,300, hematocrit 33.5,
platelets 187,000. Prothrombin time of 14, PTT 30, sodium
130, potassium 2.7, chloride 94, bicarbonate 26, BUN 13,
creatinine 0.3, glucose 81. Calcium 7.1, magnesium 1.2,
albumin 2.2, CK 75, troponin less than 0.3.
Chest x-ray revealed left effusion, questionable
consolidation left base with mass with tracheal deviation
which is unchanged from [**7-22**]. CT of the chest revealed
no pulmonary embolism, moderate bilateral pleural effusions
slightly increased from [**2183-7-23**]. Left sided atelectasis,
partial collapse adjacent to pleural effusion. Superior
mediastinal mass calcific densities consistent with right
goiter with deviation of the trachea. Scattered ground glass
opacities in both lungs. CT of the head revealed no
bleeding. Chronic small vessels with ischemic changes.
Fluid in the mastoid ear cells, right greater than left,
right middle ear.
IMPRESSION AND PLAN: The patient was subsequently admitted
to the Medical Intensive Care Unit for further treatment.
She is a 79-year-old person with chronic obstructive
pulmonary disease, hypertension, congestive heart failure
presents from rehabilitation on [**2183-8-6**] following episode of
tachypnea, hypoxia, obtundation requiring intubation with
presumed sepsis. The patient is status post recent
hospitalization [**7-4**] to [**7-25**] for gallstone pancreatitis
requiring open cholecystectomy and choledochoduodenostomy
with hospitalization complicated by sepsis, volume overload
and bilateral effusions, atrial fibrillation, C. diff colitis
and postoperative intra-abdominal abscess at the
port-a-hepatis requiring CT guidance drainage and extended
therapeutic use of Linezolid. The patient had one episode of
unexplained respiratory decompensation at hospitalization
characterized by respiratory acidosis and hypoxemia. She had
a negative CT angio of the chest and episode resolved on its
own after treatment with high flow oxygen. The patient had
been failing to thrive at rehabilitation with poor p.o.
intake, unable to fully participate in rehabilitation
activities.
THE patient presented on [**2183-8-6**] in ventilatory failure and
hypertension requiring volume resuscitation and temple
posterior support. Sputum grew out Klebsiella and urine grew
out pseudomonas. All blood cultures were surprisingly
negative. The initial impression was that the patient may
have aspirated however, further workup revealed a
questionable myopathy and we suspected she is unable to
effectively clear her secretions. She has since undergone a
complicated tracheostomy requiring tracheal repair and open
sternotomy.
SUMMARY OF HOSPITAL COURSE BY SYSTEM AND PLAN:
1. Pulmonary. Infectious disease. The patient initially
presented with hypoxemia, hypercarbia, respiratory failure
requiring intubation. The patient originally spiked to 102.8
and developed leukocytosis to 37,000. Chest x-ray showed
bilateral moderate effusions with ill defined opacification
in the right lung. CT angio of the chest revealed no
evidence of pulmonary embolism, scattered ground glass
opacity, emphysematous changes and moderate bilateral
effusions, slightly increased since last hospitalization.
She also demonstrated a large substernal goiter which was
unchanged. She was covered with broad spectrum antibiotics
initially with Ceftazidime, Flagyl as well as Linazolid which
she has been scheduled to be on through mid-[**Month (only) 216**] for
intra-abdominal Vancomycin Resistant Enterococcus abscess.
Her left sided effusion was subsequently tapped by
interventional pulmonology which removed 700 cc's of fluid on
[**8-7**] which was transudative and sterile. All blood cultures
proved negative. Her sputum did show Klebsiella with urine
showing pseudomonas. Her antibiotic therapy was changed to
Zosyn, Piperacillin, Bactrim for which she received a 7 day
course. The patient was weaned off chemical process on [**8-9**],
extubated on [**8-10**]. She initially did well though developed
sudden acute hypoxemia, respiratory acidosis, apnea and
generalized unresponsiveness requiring emergent re-intubation
on [**2183-8-15**]. This occurred while receiving a bath. The
feeling is that she had an underlying questionable myopathic
process which caused the patient to be unable to clear her
secretions.
The patient improved rapidly following re-intubation with
excellent oxygenation though required chemical process
transiently, Levophed.
On [**2183-8-18**] the patient underwent percutaneous tracheostomy,
which was complicated by tear of the posterior trachea. She
was taken emergently to the operating room and required open
sternotomy. She had a large substernal goiter making her
airway tortuous. Bilateral thoracostomy tubes were placed
which were eventually discontinued on [**2183-8-22**]. She
had a mediastinal tube with drainage, was subsequently
discontinued several days afterwards. During that period she
required daily bronchoscopies to check placement of the
endotracheal tube for suctioning. She was allowed to have a
mild cuff leak so as not to produce tension on the suture
line. On [**2183-9-8**] the patient underwent a tracheostomy change
to a Bivoner tracheostomy flexible trach with a foam cuff.
The patient tolerated the procedure well. The patient
currently is being weaned off vents. The patient is
currently requiring assist control 500, tidal volume,
respiratory rate of 12, FIO2 of 0.4% and PEEP of 5 at night
time. During the day the patient is able to tolerate
pressure support of 8 and PEEP of 5 with FIO2 of 0.4% for
extended periods of time.
The patient was given multiple trials of pressure support.
however, the longest that the patient is able to tolerate
pressure support was approximately 36 hours before she
subsequently had respiratory decompensation including low
tidal volumes and decreased oxygen saturation. Ever since
the tracheostomy changed to the Bivoner valve the patient is
unable to tolerate trach mask trial. It is thought that the
patient's respiratory failure to wean may be secondary to a
myopathic process. Will be discussed later in Neurological
component of this dictation.
The patient will benefit from pulmonary rehabilitation for
vent weaning. Ultimately once the patient is tolerating more
pressure support on her Bivoner valve the patient will be
changed over to Shiley which is fenestrated tracheostomy in
transition to removal of trach. This trach change will be
performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 5586**] at a later date. Dr. [**First Name (STitle) 5586**]
telephone number is [**Telephone/Fax (1) 3020**]. Arrangements should be
made once the patient is able to tolerate pressure support
for extended periods of time. No passine valve should be
placed on the Bivoner valve as her cuff is a foam cuff and
does not display completely.
2. Cardiovascular. The patient has a history of paroxysmal
atrial fibrillation since her last hospitalization. She has
been on Amiodarone which has since subsequently discontinued
given a question of contributing to her myopathy. She has
required DC cardioversion for atrial fibrillation shortly
after her initial presentation at [**Hospital1 190**] though subsequently reverted to constant
atrial fibrillation. She is currently being rate controlled
with Lopressor 25 mg p.o. b.i.d. She had an echo in Late
[**2183-7-14**] which showed basilar septal left ventricular
hypertrophy, ejection fraction of greater than 55% 2+ MR, 2+
TR, moderate pulmonary hypertension. She was also given a
trial of low dose Captopril however, her blood pressures
subsequently were to low systolically, 80's to 90's systolic
so Captopril was subsequently discontinued. She required
persistent diuresis with Lasix however, with aggressive
diuresis the patient's bicarbonate increased to 40 and she
developed contraction alkalosis and relatively oliguria.
The patient was subsequently rebolused with intravenous
fluids and her urine output improved and contraction
alkalosis subsequently resolved. The patient's urine output
subsequently began to pick up, 50 cc's an hour without
aggressive Lasix diuretic treatment.
3. Renal. Her BUN and creatinine has remained stable
throughout her hospitalization. Her 24 hour urine estimates
for creatinine clearance approximately 50 to 60. In regards
to urine output the patient was aggressively diuresed during
hospital course however, subsequently became intravascularly
dry and her urine output subsequently dropped to 5 to 10 cc's
an hour which responded to intravenous fluid boluses. It is
thought the patient would start to mobilize her extravascular
space once her nutritional status improved. The patient may
tolerate gentle diuresis at this point however, will run the
risk of volume contraction alkalosis and intravascular
depletion and anuria requiring further intravenous fluid
boluses and further worsening of her anasarca.
4. Neurology. The patient was originally evaluated by
Neurology, felt to have a myopathy with possible muscle
weakness. The patient had a negative Tensilon test. An EEG
was also consistent with mild pathic process, MR to severe
axonal polyneuropathy was also noted. It is unclear what is
the cause of her myopathy. Differential includes critical
care myopathy versus dry induced myopathy. Potential
offenders include Amiodarone and Lanazolide. She also had
normal CK laboratory test. Her thyroid and renal functions
have been measured and are normal.
Originally there was a planned biopsy by Neurosurgery during
the trach change in the operating room however, the biopsy of
the muscle was not performed as Dr. [**Last Name (STitle) **] was unavailable
for the muscle biopsy. However, given her recurrent status
will defer muscle biopsy to a later date. Her prognosis is
unclear at this point. It is unclear whether or not the
patient will benefit from steroids.
5. Gastrointestinal. The patient has a history of lower
gastrointestinal bleed with bright red blood per rectum
during her last hospitalization which was a negative
colonoscopy. She has been occult blood negative for most
part during hospitalization. She did screens which have been
negative. However, the most recent C. diff colitis screen
was positive for C. diff colitis. The patient was started on
Metronidazole per percutaneous endoscopic gastrostomy tube
for treatment, complete a 14 day course. She had an
abdominal CT without contrast done earlier in the hospital
which showed basically resolution of her former abdominal
abscess. Her Linazolide was discontinued on [**8-19**] with
Infectious Disease's recommendations. She currently has a
percutaneous endoscopic gastrostomy tube placed and was
receiving tube feeds and most of her medications through the
percutaneous endoscopic gastrostomy tube.
6. Genitourinary. The patient had multiple numerous urinary
tract infections with bacteria and yeast and on [**2183-8-19**] Foley
was subsequently changed. The patient received two days of
Levofloxacin discontinued following development of a fine
erythematous rash involving upper chest, back and thighs.
The patient subsequently development of a urinary tract
infection is being treated with Bactrim DS tablets p.o.
b.i.d., will complete a 7 day course. The patient has
subsequently had multiple yeast infections as well treated
with Diflucan and Foley changes.
7. Heme. The patient developed thrombocytopenia with a drop
in her platelets down to 100,000 during earlier part of her
hospitalization the etiology was unclear. It is thought to
be drug related verses thrombocytopenia with sepsis. Her
Thrombocytopenia has subsequently resolved. She has required
intermittent transfusions of packed red blood cells during
hospitalization without clear source of bleeding. The
patient may have anemia of chronic disease at this point.
During the later part of her hospitalization the patient's
hematocrit has subsequently stable around 30. The patient
has been on Heparin during a portion of her hospitalization
for catheter related thrombosis of the right anterior
jugular, partial non-occlusive clot. The line was
subsequently discontinued and was started on Heparin for
earlier part of her hospitalization and subsequently held
prior to her procedures of tracheostomy. Heparin was
restarted during the later part of her hospital course and
Coumadin was subsequently started. INR should be checked and
Heparin should be discontinued once her INR is greater than
2.0. Goal INR is greater than 2, less than 3.0. The patient
tolerating Coumadin 5 mg p.o. q h.s.
8. Endocrine. The patient was maintained on Synthroid
throughout her entire hospital course. Random Cortisol
during her hospital course revealed measurement of 20, the
patient was not adrenal insufficient. The patient's
hypothyroidism was subsequently treated with hormone
replacement.
9. FEN. The patient had unexplained hyponatremia as an
outpatient at the rehabilitation and upon presentation at
[**Hospital1 69**] questionable whether or
not the patient has inappropriate NIDH also, responded with
intravenous fluid resuscitation. The hyponatremia
subsequently resolved. The patient was briefly on total
parenteral nutrition around the time of her tracheal repair.
The patient was subsequently tolerating tube feeds and
subsequently had percutaneous gastrostomy tube placed and
performed by Interventional Radiology and has been receiving
tube feeds Promod without fiber and subsequently been doing
well. Currently at goal of 70 cc's per hour. During her
entire hospital course the patient had episodes of
hypocalcemia, hypokalemia which was subsequently repleted and
with resolution. The patient received approximately 250 cc's
of free water boluses through her percutaneous endoscopic
gastrostomy tube b.i.d.
10. Prophylaxis. The patient currently on Pneumo boots, on
Heparin GGT and is in the process of transition to Coumadin.
The patient receives Prevacid through her percutaneous
endoscopic gastrostomy tube.
11. Lines: The patient currently has a right single lumen
PICC line for access. The patient has Foley and a
Percutaneous endoscopic gastrostomy tube placed as well.
DISCHARGE MEDICATION:
1. Lopressor 25 mg per G-tube b.i.d.
2. Synthroid 75 mcg per G-tube q day.
3. Prevacid suspension 30 mg per G-tube q day.
4. Paxil 20 mg per G-tube q day.
5. Heparin GGT.
6. Promod without fiber, goal of 70 cc's per hour through
the percutaneous endoscopic gastrostomy tube.
7. Bactrim DS tablets p.o. b.i.d. times seven day course
to finish on [**2183-9-17**].
8. Metronidazole 500 mg per G-tube q 8 hours times 14
days to finish on [**2183-9-25**].
9. Coumadin 5 mg per G-tube q h.s.
10. Lactulose 30 cc's per G-tube q day p.r.n.
constipation.
11. Albuterol MDI 2 puffs q 4 to 6 hours p.r.n.
shortness of breath and wheezing.
12. Atrovent MDI 2 puffs q 4 to 6 hours p.r.n. shortness
of breath and wheezing.
13. Tylenol 650 mg p.o. G-tube/per rectum q 4 to 6 hours
p.r.n. temperature.
14. Trazodone 25 to 50 mg per G-tube q h.s. p.r.n.
insomnia.
15. Nystatin Powder applied to effected area p.r.n.
16. Promod without fiber via percutaneous endoscopic
gastrostomy tube 70 cc's per hour at goal.
DISCHARGE CONDITION: Stable.
DISCHARGE ACTIVITIES: Bedrest and per physical therapy.
Discharged to physical and pulmonary rehabilitation for vent
weaning.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2183-9-15**] 18:50
T: [**2183-9-15**] 18:56
JOB#: [**Job Number 5589**]
1
1
1
R
|
20,007 | 486,51881,5990,42731,2761,2767,2639,496,4019 | 193,793 | Admission Date: [**2184-1-16**] Discharge Date: [**2184-1-20**]
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This 79-year-old woman is
admitted for respiratory distress, hyponatremia and
hyperkalemia. This woman has had a complicated medical
course over the past six months which has included several
episodes of respiratory failure, difficulty to wean off a
ventilator, tracheostomy placement complicated by tracheal
tear (requiring open sternotomy), anasarca, atrial
fibrillation, E.coli sepsis, pseudomonas urinary tract
infection, VRE intraabdominal abscess and Clostridium
difficile colitis. Her ventilatory difficulties were thought
to be perhaps secondary to a myopathic process, although
muscle biopsy results were inconclusive and not demonstrative
of inflammatory changes.
Patient was admitted to [**Hospital1 **] [**10-28**]
through [**2183-12-18**] and successfully weaned from the
ventilator there. She was transferred to [**Hospital1 5595**] [**2183-12-18**] where she was gradually reintroduced to p.o. feed and
weaned from PEG feeds. She currently tolerates a pureed
diet. Her atrial fibrillation has been managed via rate
control as the Amiodarone she was previous on was felt to
possibly contribute to her myopathy. She had been on Lasix
(40 mg b.i.d.) on transfer from [**Hospital1 **] and
nonetheless gained 12 pounds from [**12-28**] through
[**1-15**]. Lasix was decreased to 20 mg q. day on [**1-12**] because her sodium was noted to be 129.
On [**1-15**], the patient was noted to have increased
dyspnea and tachypnea. She states she has had intermittent
dry cough for several days. No subjective fevers or chills.
She was transferred to [**Hospital1 69**]
today with still more dyspnea / tachypnea, sodium of 126 and
a potassium of 6.2.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Diastolic dysfunction (latest echo [**2183-9-30**] ejection
fraction of 70 to 80% (2+ aortic regurgitation, moderate
mitral regurgitation, moderate tricuspid regurgitation).
4. History of intubations, tracheal tear secondary to
tracheostomy, myopathic contribution to respiratory
difficulty.
5. E.coli sepsis.
6. VRE abscess.
7. Klebsiella pneumonia.
8. Pneumoniae pneumonia.
9. Clostridium difficile colitis.
10. Malnutrition.
11. PEG placement.
12. Gastroesophageal reflux disease.
13. Status post cholecystectomy.
14. Gallstone pancreatitis.
15. Hypothyroidism.
16. Retrosternal goiter.
MEDICATIONS ON ADMISSION:
1. Vitamin C 500 mg q. day.
2. Wellbutrin SR 150 mg q. day.
3. Ambien.
4. Warfarin 5 mg q.h.s.
5. Captopril 25 mg q. eight hours.
6. Metoprolol 25 mg q. 12 hours.
7. Levothyroxine 75 mcg q. day.
8. Digoxin 0.125 mg q. day.
9. Colace 100 mg p.o. b.i.d.
10. Senokot one tab b.i.d.
ALLERGIES:
1. Aspirin.
2. Gentamycin.
3. Vancomycin.
SOCIAL HISTORY: Twenty pack year smoking history. Son,
[**Name (NI) **], cardiologist in [**Location (un) 5583**].
REVIEW OF SYSTEMS: Positive for rash present since [**12-30**] at
[**Hospital1 5595**].
PHYSICAL EXAMINATION: On admission temperature 97.4 F, heart
rate 96, blood pressure 143/68, respirations 20 and oxygen
saturation 88% on room air. Head, eyes, ears, nose and
throat: Pupils 2 mm, light reactive. Sclerae anicteric.
Oropharynx dry. Lungs: Bilateral end expiratory wheezes.
Heart: Regular rate, irregularly irregular rhythm, II/VI
holosystolic murmur at the apex to the axilla. Abdomen:
Soft, mild diffuse tenderness, J tube site non-erythematous,
positive bowel sounds. Extremities: 2 cm bilateral pitting
edema to mid thigh bilaterally. Skin: Reticular
erythematous blanching and rash bilaterally upper extremities
and trunk. Neuro: Alert and appropriately interactive.
LABORATORY DATA ON ADMISSION: White count 9.7, hematocrit
34.0, platelets 319. INR 3.3, PTT 41.1. Sodium 125,
potassium 6.4, chloride 84, total CO2 31, BUN 25, creatinine
0.6, glucose 119.
Arterial blood gas: 7.38 / 58 / 91.
Chest x-ray: Dense left retrocardiac opacity, small
bilateral pleural effusions.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: The patient was admitted for
treatment of pneumonia. This was felt to be the main
etiology of her respiratory distress. She had a Levofloxacin
allergy on my medical record, but per patient and daughter,
she did not have an allergy. She was placed on Levofloxacin
500 mg p.o. q. day for a 10 day course. Her respiratory
status subsequently improved and returned to her baseline
level of saturating in the 90s on zero to two liters of
oxygen per nasal cannula. She was monitored for additional
rash and no rash appeared. Her previous rash symptomatically
improved throughout admission.
The patient had evidence of a urinary tract infection on
urinalysis. A culture was performed which was contaminated.
Additional culture and sensitivities are recommended if the
patient has continued symptoms despite her course of
Levofloxacin.
2. ELECTROLYTES: Aforementioned, the patient had
hyponatremia and hyperkalemia on admission. She was noted to
be extravascularly volume overloaded and intravascularly
depleted by physical examination. Potential etiologies of
this were felt to include diastolic cardiac dysfunction and
malnutrition with hypoalbuminemia. The patient received one
liter of normal saline at a slow rate. Thereafter, she was
fluid restricted. Her sodium improved to a level of 129 on
the day prior to discharge. The patient's potassium likewise
improved to a level under 5. A cosyntropin stimulation test
was performed to rule out adrenal insufficiency. The test
was negative.
3. CARDIOVASCULAR: Aforementioned, the patient was noted to
be in atrial fibrillation and possibly with diastolic
dysfunction. Her Metoprolol was increased to 37.5 mg p.o.
B.i.d. for improved rate control. Her Captopril was also
increased to 37.5 mg p.o. t.i.d. She was continued on
Digoxin as her son noted that the patient diuresis well in
response to this drug. She remained in atrial fibrillation
with good rate control throughout admission.
4. NUTRITION: The patient has a recent history of
malnutrition. A nutrition consult was obtained for tube feed
recommendations as the patient has had decreased p.o. intake
of late. She received nocturnal tube feedings with
encouraged p.o. intake throughout the day. It is recommended
that her nutritional status be closely monitored at [**Hospital1 5595**] as
this contributes to her general well-being.
5. ENDOCRINE: Patient has noted history of hypothyroidism.
TSH was pending at time of this dictation. She was continued
on her outpatient dose of Synthroid throughout admission.
6. PROPHYLAXIS: The patient was continued on Coumadin at
admission for her atrial fibrillation. She had an elevated
INR on day #1 of admission and her Coumadin was held. It is
recommended that her INR be monitored in an outpatient
setting with adjustments made to maintain an INR between 2
and 3.
7. PSYCH: Patient has apparent depression with depressed
mood and neurovegetative symptoms. She was continued on
Wellbutrin SR this admission. It is recommended that she
have a trial of Ritalin once she returns to [**Hospital1 5595**] for
activation and appetite stimulation.
DISCHARGE DIAGNOSIS:
1. Pneumonia.
2. Atrial fibrillation.
3. Diastolic dysfunction.
4. Depression.
5. Malnutrition.
6. Hypothyroidism.
7. Retrosternal goiter.
8. History of respiratory failure and multiple difficult
intubations.
9. History of tracheostomy complicated by tracheal tear.
CONDITION ON DISCHARGE: Fair.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. q. day through [**2184-1-25**].
2. Metoprolol 37.5 mg p.o. b.i.d.
3. Captopril 37.5 mg p.o. t.i.d.
4. Digoxin 0.125 mg p.o. q. day.
5. Levothyroxine 75 mcg p.o. q. day.
6. Wellbutrin SR 150 mg p.o. q. day.
7. Coumadin 3 mg p.o. q.h.s.
8. Multivitamin one tab p.o. q. day.
9. Vitamin C 500 mg p.o. q. day.
10. Colace 100 mg p.o. b.i.d.
11. Senna one tab p.o. b.i.d.
12. Atrovent one neb INH q. six hours.
DISCHARGE STATUS: To [**Hospital1 5595**].
FOLLOW UP: Patient is to be followed by her outpatient
physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
[**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2184-1-20**] 07:54
T: [**2184-1-20**] 09:56
JOB#: [**Job Number 5597**]
|
20,008 | V3401,76527,76516,7746 | 157,837 | Admission Date: [**2104-8-29**] Discharge Date: [**2104-9-11**]
Date of Birth: [**2104-8-29**] Sex: M
Service: NEONATOLOGY
[**Known lastname **] [**Known lastname 12056**]-[**Known lastname 51321**], triplet number two, was born at 34
weeks gestation by cesarean section, for a triplet gestation
and preterm labor. Mother is a 39-year-old G4, para 1, now
4, woman with previous obstetrical history remarkable for
spontaneous abortion in [**2100**] and [**2102**], a 38 week spontaneous
vaginal delivery in [**2097**], whose name is [**Name (NI) 6644**]. [**Name2 (NI) **] previous
medical history is remarkable for depression. She is
currently on fluoxetine, remote HSV (normal Pap smear, no active
lesions). The mother's prenatal screens are blood type A+,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
surface antigen negative, GC negative, Chlamydia negative and
Group B Strep unknown. This pregnancy is remarkable for
being a spontaneous triamniotic, trichorionic triplet
gestation. This pregnancy was complicated by preterm
contractions leading to admission one week prior to delivery
with tocolysis and betamethasone given at that time. The
elective cesarean section was performed without the
progression of labor. Rupture of membranes occurred at the
time of delivery with clear fluid. There were no antepartum
stressors or risk factors. This infant emerged with good
tone and spontaneous cry. Apgars were 8 at one minute and 8
at five minutes.
Birth weight was 1,615 grams (20th percentile). Birth length
was 42.5 cm (25th percentile) and birth head circumference
29.5 cm (25th percentile).
PHYSICAL EXAMINATION ON ADMISSION: Baby's admission physical
examination revealed a nondysmorphic vigorous preterm infant.
Anterior fontanelle soft and flat. Intact palate.
Comfortable respirations. Breath sounds clear and equal.
Heart was regular rate and rhythm. Pink and well perfused.
Femoral pulses normal. Abdomen soft, non-distended. Three
vessel umbilical cord. No organomegaly. Patent anus.
Normal preterm male genitalia with testes descended
bilaterally. Appropriate for age central nervous system
examination. Normal spine, hips and clavicles.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory status: Infant has remained in room air
throughout his Neonatal Intensive Care Unit stay. He has
never required any supplemental oxygen and he has never had
any apnea of prematurity. On examination, his respirations
are comfortable. Lung sounds are clear and equal.
2. Cardiovascular status: The infant has remained
normotensive throughout his Neonatal Intensive Care Unit
stay. There are no active cardiovascular issues.
3. Fluids, Electrolytes and Nutrition status: Enteral feeds
were begun on the day of delivery and were advanced without
difficulty to full volume feeding and calorie enhanced
formula or breast milk of 24 calories per ounce. The infant
is being discharged home on that nutrition plan eating
approximately every three to four hours. At the time of
discharge his weight is 1,810 grams, his length is 43 cm and
his head circumference is 29.7 cm.
4. Gastrointestinal status: The infant was treated with
phototherapy for hyperbilirubinemia of prematurity on day of
life three until day of life number five. Peak bilirubin
occurred on day of life three with total 8.2. Direct was
0.2.
5. Hematology status: The infant has received no blood
product transfusions during his Neonatal Intensive Care Unit
stay. He is receiving supplemental iron of 2 mg/kg/day of
elemental iron.
6. Urology: The infant was circumcised [**2104-9-11**],
without complication.
7. Infectious Disease status: The infant never required
evaluation for sepsis and never received any antibiotics
during his Neonatal Intensive Care Unit stay.
8. Neurology: Sensory: Hearing screening was performed
with automated auditory brain stem responses and the infant
passed in both ears.
9. Psychosocial: Parents have been very involved in the
infant's care throughout the Neonatal Intensive Care Unit
stay as has the 6-year-old brother, [**Name (NI) 6644**].
CONDITION AT DISCHARGE: The infant is discharged in good
condition.
DISCHARGE STATUS: The infant is discharged home with his
parents.
PRIMARY PEDIATRIC CARE: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital3 51322**], [**Hospital1 8**], [**Numeric Identifier 4293**], telephone [**Telephone/Fax (1) 43957**].
CARE AND RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings: Enfamil or breast milk 24 calories per ounce
made with Enfamil powder.
2. Medications: Iron sulfate (25 mg/mL 0.15 cc p.o. q.
day).
3. The infant has passed the car seat position screening
test.
4. State newborn screen was sent on [**2104-9-10**]. That
is the only state screen that was sent.
5. Parents have declined hepatitis C vaccine at this time
and will wait until all infants reach 2 kg of weight.
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born at 32 to
35 weeks and plan for day care during RSV season, with smoker
in the household or with preschool sibs or (3) With chronic
lung disease.
2. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
the care givers should be considered for immunization against
influenza to protect the infant.
FOLLOW-UP APPOINTMENTS:
1. The parents have a pediatrician appointment scheduled for
[**9-15**].
2. They will be followed by the Visiting Nurses of [**Location (un) 86**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Triplet Number Two.
3. Status post hyperbilirubinemia of prematurity.
4. Status post circumcision.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2104-9-11**] 13:16
T: [**2104-9-11**] 14:07
JOB#: [**Job Number 51323**]
|
20,009 | 78097,40391,5856,4280,42830,2767,25080,29040,4370,2819,7245,4389 | 126,068 | Admission Date: [**2190-12-11**] Discharge Date: [**2190-12-13**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
unresponsive at HD
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 77 yo man with h/o longstanding HTN c/b ESRD, several
lacunar strokes, multivascular dementia with poor baseline
cognitive function, limited verbal ability and comprehension, as
well as poor memory, who presented with AMS today from his
outpatient dialysis center.
.
Per pt's wife and Neurology resident, pt had some agitation last
night, talking with his wife and pacing with walker. He finally
fell asleep around 3AM, awoke at 4AM for dialysis at 6:30,
slightly groggy but responding appropriately to his wife before
HD. Her received his usual dose of 50mg benadryl before
dialysis, and then slept through the entire dialysis, which is
unusual for him (last known "awake" time was 6:30AM). Following
dialysis, staff tried to wake him up with verbal and tactile
stim and he was unresponsive. Staff tried applying cold packs to
head, no response. BP was "high" and RR was 12 (other VS
unavailable). Wife tried to move his head which felt heavy and
stiff, and entire body looked stiff with no spontaneous mvmt. At
one point, wife tried to move him and he slapped her hand away,
thus wife thought he was "alright." However, was again
unresponsive, eyes closed just after this.
.
When EMS arrived, he had his eyes open and was looking around
initially, though unresponsive. In ER, still unresponsive, BG
found to be 49 - given 1amp d50, with no return to BL, thus CODE
STROKE called. Neuro arrival within 5 minutes, and initial NIHSS
score high in every category as pt unresponsive; TPA not given
as last well-time was 6:30AM (5.5 hrs ago) and not clear to be
stroke. Per Neuro recommendation, pt underwent head CT followed
by head MRI, both of which were unrevealing for etiology of his
AMS. He initially had 1mg Ativan given for possible Sz, and when
no response, he was loaded on IV dilaudid. Had bedside EEG in
the ER that did not show definite Sz activity, but Neuro
recommends continuing Dilantin. Also notable, pt had SBP in the
250s while in ED.
.
Per wife, the patient's baseline is: limited speech and
comprehension, walks with walker, brushes teeth and feeds self
but wife helps him with most other adls, including transfers. He
has some urinary and bowel incontinence at baseline. He has
complained of no (and wife has noticed no) f/c/cp/sob/uri
sx/gi/gu sx; he has chronic LBP and as usual took vicodin this
am. No visual, hearing, sp/sw problems, no new
weakness/numbness; has fallen (falls occ. at BL) but no head
trauma.
Past Medical History:
-ESRD related to HTN nephropathy
-s/p avf in both arms, R arm is functional
-HTN x >20 yrs
-Multivascular dementia
-BPH
-Chronic LBP with DJD, spinal stenosis
-Macrocytic anemia, unclear if from ESRD
Social History:
Retired plumber; no tob, etoh or drugs; lives with wife; has 2
children.
Family History:
No strokes or CAD
Physical Exam:
Vitals: T 97.0, HR 51, BP 151/84, RR 18, Sat 100% on 2LNC, UO
78cc/3h
Gen: initially sleeping and intermittently apneic, aroused to
touch, poorly responsive and not following commands, withdraws
to pain
HEENT: PERRL (5 to 3 mm), EOMI with approp tracking, mouth
closed and not opening for exam
Neck: turning head with no apparent discomfort; tunnelled line
into L SCV
CV: bradycardic, regular, +s4, no s3, no m/r
Lungs: CTA
Abd: thin, soft, NT (no grimace or withdrawal), ND, no HSM
Ext:
UE -- L pulsatile AVF without bruit or thrill, 2+ radial pulse;
R AVF with overlying bandage, with thrill and bruit, 2+ radial
pulse
LE -- thin, no edema, cool bilaterally but with 2+ DP pulses
bilaterally
Neuro:
a) MS: Unresponsive to verbal, opens eyes to tactile stim,
withdraws to pain, not following commands, nonverbal
b) CN: perrla 5->3; +blink to threat bilat; could not look in
mouth or test gag as teeth clenched shut
c) Sensorimotor: moving all 4 ext and neck, resisting extension
of arm for ABG
d) DTRs: 1+ biceps bilaterally, 1+ at knees bilaterally, toes
upgoing with Babinski bilaterally
Pertinent Results:
[**2190-12-11**] 10:43PM POTASSIUM-6.1*
[**2190-12-11**] 08:53PM GLUCOSE-81 UREA N-33* CREAT-8.8* SODIUM-138
POTASSIUM-6.5* CHLORIDE-99 TOTAL CO2-28 ANION GAP-18
[**2190-12-11**] 08:53PM ALT(SGPT)-19 AST(SGOT)-54* CK(CPK)-198* ALK
PHOS-68 TOT BILI-0.4
[**2190-12-11**] 08:53PM CK-MB-7 cTropnT-0.22*
[**2190-12-11**] 08:53PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2190-12-11**] 08:53PM TSH-3.2
[**2190-12-11**] 08:53PM WBC-4.8 RBC-3.79* HGB-13.4* HCT-41.6 MCV-110*
MCH-35.3* MCHC-32.1 RDW-17.0*
[**2190-12-11**] 08:53PM PLT COUNT-148*
[**2190-12-11**] 08:53PM PT-11.7 PTT-29.3 INR(PT)-1.0
.
pCXR [**2190-12-11**]:
1. New retrocardiac opacity, which likely indicates pneumonia.
Atelectasis is a less likely diagnostic consideration.
2. Hypertensive configuration of the heart and aorta.
3. Indwelling dialysis catheter as above.
.
Brain MRI: No evidence of acute infarct.
MRA: Head MRA is somewhat limited by motion. There is no
evidence of vascular occlusion seen. There is diminished flow
signal intensity visualized in the intracranial arteries which
appears artifactual. The basilar artery flow void as well as the
basilar artery flow signal on source images is maintained.
IMPRESSION: Somewhat limited normal MRA of the head
.
head CT: No acute intracranial hemorrhage or mass effect. No
significant change from [**2190-9-27**].
.
EEG: This is an abnormal EEG in the waking and sleeping states
due to the low voltage slow posterior rhythm as well as bursts
of
bilateral frontal 4 Hz slowing. This suggests an encephalopathic
pattern which may be seen with medications or toxic metabolic
abnormalities.
.
pCXR: Mild CHF with left greater than right small pleural
effusions.
Brief Hospital Course:
MICU course:
- CT, MRI/MRA, EEG all negative for acute pathology. Etiology
of altered mental status thought to be multifactorial - 1)By
history patient took double of the usual dose of benadryl.
2)Patient found to be hypoglycemic. 3) Renal failure. 4)All
superimposed on baseline that per family is altered.
- Patient was intially started on dilantin but the etiology was
ultimately deemed not to be seizure. The patient should see his
behavioral neurologist, Dr. [**First Name (STitle) **], for whether he should
restart this medication.
- Plan to go to dialysis [**2190-12-13**] with possible removal of
tunneled catheter if dialysis through fistula is successful.
- Elevated potassium was treated with good effect with
kayexalate, insulin and D-50.
- Patient was incidentally found to have a retrocardiac opacity
but was not treated because of lack of fever and normal white
blood cell count.
- Home were held on admission, but were subsequently restarted
and the blood pressure remained stable.
# AMS: unclear etiology although possible precipitants include
hypoglycemia, seizure, altered BP; Neurology was consulted, EEG
was performed and showed no seizure. Head CT and MRI/A were
unremarkable. Benadryl/trazodone were held. Mental status
improved to baseline per his family. Trazodone was held. He
should try to avoid >25 mg at a time of benadryl. Blood sugars
returned to [**Location 213**].
.
# CV: Had slight TnT bump though with no change in ECG and known
ESRD; ruled out for MI, no CP/SOB.
# HTN: became very hypertensive to >200/100, not controlled on
home meds, so patient was changed to labetalol 400 mg tid in
addition to his norvasc for better BP control, his BP improved
to 140/90.
.
# ESRD: Had elevated Cr, K on admit. Dialyzed with improved K.
Will continue increased frequency of HD for a few days. Due for
another HD session the day after d/c. His fistula has matured as
was used for effective HD. He will need to follow up with Dr.
[**Last Name (STitle) 816**] as an outpatient to have his tunnelled HD cath removed. Pt.
did not want to stay in the hospital to have this removed. He
was restarted on his sensipar, renal caps, and fosrenal. He will
follow up with Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) **].
.
# Thrombocytopenia: plt count mildly low at 141k (recent bl
167k-190k) Follow up as an outpatient.
.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lopressor 12.5 mg [**Hospital1 **]
3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)*
Refills:*2*
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**]
hours as needed for agitation.
6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. Trazodone 50 mg hs.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**]
hours as needed for agitation.
6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
Hypoglycemia
End Stage Renal Failure
Hypertensive Urgency
Vascular Dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue medications as listed below. Please follow up
for dialysis tomorrow. Please also follow up with Dr. [**Last Name (STitle) 816**] to
have your tunnelled catheter removed.
Followup Instructions:
1. Please call Dr.[**Name (NI) 1381**] office tomorrow to schedule a follow
up appointment to have your tunnelled catheter removed.
2. Please follow up with your nephrologist in the next week.
3. Please go for dialysis tomorrow.
4. Follow up with your PCP [**Last Name (NamePattern4) **] [**1-18**] weeks.
|
20,009 | 99673,2767,5856,40391,E8782,2948,28521,60000 | 161,220 | Admission Date: [**2190-11-5**] Discharge Date: [**2190-11-10**]
Date of Birth: [**2112-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Thrombosed Access
Hyperkalemia
Major Surgical or Invasive Procedure:
Right arm arterio-venous hemodialysis graft placement [**2190-11-9**]
L tunneled cath placed under fluoroscopy. Placement right at the
vena caval-atrial junction
History of Present Illness:
Patient is a known Hemodialysis patient, ESRD since [**2187**] who
presented for thrombectomy of Left upper arm AVF. During pre-op
evaluation, Labwork revealed hyperkalemia, with a K of 9.3.
Femoral line placed for hemodialysis, admitted from the pre-op
holding area to the SICU where emergent hemodialysis was
performed.
Past Medical History:
ESRD on HD since [**5-19**] - Dr. [**Last Name (STitle) **], [**Hospital1 1426**] [**Location (un) 4265**] MWF
Dementia
Had transplant w/u and declined
Hypertensive nephrosclerosis
Hypertension x >20 years
BPH
MRSA Bacteremia
Chronic low back pain [**2-18**] spinal stenosis on vicodin PRN
Anemia in past with normal iron studies
Social History:
Pt. is right handed, a native of [**Doctor First Name 26692**], and has 15
years of education. He worked as a commercial plumber for many
years before retiring ten years ago. He lives with wife and 2
children in [**Location (un) 686**] in family owned home. Retired plumber.
His wife still works full time but she is primary caregiver. [**Name (NI) **]
h/o ETOH or tobacco or elicit drug use.
Family History:
no h/o CAD
Physical Exam:
On Admission:
VS: 96.1, 200/91, 61, 13, 97% RA
General: Agitated, combative
CV: RRR
Lungs: CTA bilaterally
Abd: + Bowel sounds, soft, non-distended, no rebound or
guarding.
Extr: feet warm, no edema, palpable DP and PT pulses
Pertinent Results:
[**2190-11-5**] 04:12PM GLUCOSE-146* UREA N-96* CREAT-15.9*#
SODIUM-135 POTASSIUM-5.9* CHLORIDE-87* TOTAL CO2-27 ANION
GAP-27*
[**2190-11-5**] 04:12PM CALCIUM-9.6 PHOSPHATE-4.9*# MAGNESIUM-2.7*
[**2190-11-5**] 04:12PM WBC-6.4 RBC-3.55* HGB-12.7* HCT-38.2*
MCV-108* MCH-35.8* MCHC-33.3 RDW-17.6*
[**2190-11-5**] 04:12PM PLT COUNT-174
[**2190-11-5**] 04:12PM PT-12.6 PTT-28.5 INR(PT)-1.1
[**2190-11-5**] 01:34PM K+-9.3*
[**2190-11-5**] 02:34PM K+-7.5*
Following HD:[**2190-11-5**] 07:17PM POTASSIUM-4.3
On D/C: Gluc 157* BUN: 62* Creat: 12.1 Na:134 K:4.9 Cl:95*
CO2:21*
Brief Hospital Course:
77 y/o male on hemodialysis T-TH-S with ESRD since [**2187**]
presented for thrombectomy to Left AVF when he was found to have
hyperkalemia on pre-op labs. K of 9.3 was treated with emergent
placement of femoral line and transfer to SICU for emergent
hemodialysis.
Patient received HD on [**11-6**] and [**11-8**] as well through the
femoral line.
On [**11-9**] the patient had a Right brachiocephalic loop AV Graft
placed which is + Bruit and thrill on assessment [**11-10**], as well
as a tunnelled hemodialysis catheter in the left chest under
fluoroscopy with placement right at the vena caval-atrial
junction.
HD performed on [**11-10**] using Left Catheter with consistent blood
flows of 300.
Next treatment will be at [**Location (un) **] [**Location (un) **] on Saturday.
Medications on Admission:
Lanthanum 1000''' with meals, cinacalcet 30', B complex-vit
C-folic acid 1', amlodipine 2.5', metoprolol 25'', levothyroxine
12.5'
Discharge Medications:
1. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Lanthanum 250 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Right arm arterio-venous hemodialysis graft placement [**2190-11-9**]
left tunnelled hemodialysis catheter placement
ESRD
hyperkalemia
Discharge Condition:
Stable
Discharge Instructions:
Please continue outpatient hemodialysis per your regular
schedule.
Continue medications at home as usual
Renal diet as recommended by your hemodialysis caregivers
Dialysis unit will change dressing to the chest dialysis
catheter.
Check the new left arm graft daily to make sure it has a thrill
("buzzing") If this is not present, please call [**Telephone/Fax (1) 673**] and
ask for [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-12-2**]
8:30
Completed by:[**2190-11-10**] |
20,009 | 0389,78552,6012,5990,5856,40391,51881,41091,5647,29041,V667,99592,4370 | 190,619 | Admission Date: [**2192-3-31**] Discharge Date: [**2192-4-2**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o M w/ baseline dementia, ESRD on HD, recurrent E coli
bacteremia of unclear source, recurrent prostatitis w/ possible
abscess, who p/w altered mental status, recent swallowing
difficulties, increasing abdominal distention, and brown thick
discharge from his penis.
.
In the ED, Labs showed normal WBC w/ left shift and floridly
positive U/A. ECG had question of lateral ST depressions.
Tropinin was below normal baseline. He had a CT abdomen
performed which showed distended stool loaded colon with
fecalization of the distal
small bowel. He received 1 dose of ceftriaxone. Also while in
the ED, he became agitated and received 2 mg of haldol w/
improved agitation. While awaiting transport to the floor, he
became hypertensive w/ SBPs in 190s and required IV hydralazine
with improvement to 140s.
.
He has had a [**Hospital 96531**] medical course of late w/ recurrent
hospital admissions for E coli bacteremia and prostatitis c/b
recurrent foley trauma. He was intitially admitted in [**1-23**] after
blood cultures drawn at HD grew E coli. During admission he was
also noted to have penile discharge. Since that time he has had
3 subsequent admissions for recurrent penile discharge and
bacteremia w/ E coli. He has undergone extensive work up for
both including CT abdomen/pelvis showing possible prostatic
abscess, TTE showing possible aortic valve vegetation(which was
not seen on subsequent TTE and wife refused [**Name2 (NI) **]), normal
colonscopy, CT cystogram negative for enterovesicular fistula,
and retrograde uretogram showing a large
hollowed out section of the prostate which may represent abscess
or fistula. He has completed multiple prolonged courses of
antibiotics under the guidance of ID and Urology consultations.
Following his last admission for the above problems in [**5-23**], he
completed a course of Zosyn in house and then followed up with
Urology as an outpt after which he was placed on Macrodantin x 3
months. He was most recently admitted [**Date range (1) 96532**]/08 for recurrent
seroma over dialysis access site in his R arm. He had recently
underwent a revision of the graft secondary to a large seroma.
He had excision of right upper arm arteriovenous graft [**2192-2-22**]
and a temporary HD line was placed and was scheduled for
permanent line placement by IR post-discharge. In addition,
blood cultures from presentation grew clostridium species.
However, subsequent blood cultures were negative. Wound cultures
from seroma also grew vanco sensitive enterococcus. He competed
a 14 day course of vanco and ceftazidime.
Past Medical History:
# ESRD related to HTN nephropathy s/p av graft in both arms, R
arm was functional until the past 24h
# HTN x >20 yrs
# Multivascular dementia
# BPH
# Chronic LBP with DJD, spinal stenosis
# Macrocytic anemia, unclear etiology
# h/o Bacteremia: [**12-22**]- Ecoli,B. Fragilis; [**3-23**] - Ecoli;
several Ecoli isolates w/ different sensitivities
- [**2191-4-4**] TTE: no vegetation seen.([**Month/Day/Year **] again refused)
- [**2191-3-26**] TTE: aortic valve echodensity is new and c/w possible
vegetation (wife and pt refused [**Month/Day/Year **]) but completed 4 wks of
ceftazidime
- outpt colonoscopy normal [**1-23**] w/o evidence of infectious
source
- CT [**12-23**] w/ hypodensity in prostate
.
# Prostatitis - multiple admissions w/ penile discharge, UTI,
prostatitis
- readmission [**5-/2191**]: w/ penile discharge
---CT cysto gram neg for enterovesicular fistula
---Retrograde uretogram was performed and showed a large
hollowed out section of the prostate which may represent abscess
or fistula.
--- tx'ed w/ Zosyn x 7 days
- readmission [**Date range (1) 96533**]: hematuria
- [**Date range (1) 96534**]/07: recurrent discharge w/ Ecoli bacteremia
---prostate MRI: cannot exclude abscess-> 4wks ceftazidime
---Daily bladder irrigation through the Foley with fluid
containing
Neomycin-Polymyxin
--- cytoscopy w/ purlent drainage from bladder
--- d/c on 4 wks ceftazidime
- [**1-23**]: penile discharge noted following foley catheter removal
- [**12-22**]: CT of prostate with hypodense area: per Urology, not
concerning for abscess when compared to prior imaging -> 4 wk
course of Cipro/Flagyl
Social History:
Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or
drugs;
Family History:
NC
Physical Exam:
Admission PE:
VS: 98.6, 136/72, 95, 98% RA
Gen: Responds briefly to questions, directs eyes appropriately,
moves to command occasionally
HEENT: No conjunctival pallor. No icterus. MMM. Will not open
mouth for OP exam.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Grossly distended, firm, tense, no tenderness to palpation
throughout, hypoactive bowel sounds, tympanitic
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: Will not answer A&O questions. Will not cooperate with
motor exam. States yes to sensation questions.
.
MICU transfer PE:
T: 99.4 BP: 91/53 HR:74 RR: 30 O2 99% bipap
Gen: elderly man, opens eyes to stimulus
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: Distant. RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Distended, firm, NT, no bowel sounds
EXT: WWP, NO CCE. 2+ DP pulses BL, fistula s/p surgical removal
SKIN: No rashes/lesions, ecchymoses.
NEURO: Moves all fours, opens eyes, Gait assessment deferred
Pertinent Results:
CT abdomen/pelvis [**3-30**]:
The lung bases are clear aside from mild bibasilar atelectasis.
The heart is enlarged. A central venous catheter is partially
visualized terminating in the cavoatrial junction. There are
aortic valvular calcifications. Allowing for the limitations of
a non-contrast
study, the liver, pancreas, spleen, stomach, adrenal glands, and
small bowel loops are normal. Multiple small layering
stone/sludge present in an otherwise normal-appearing
gallbladder. The kidneys are small and atrophic, containing
multiple small probable cysts consistent with history of
end-stage renal disease. There is no free air or free fluid.
CT PELVIS WITH CONTRAST: The entire colon is markedly distended
with stool including fecalization of the distal small bowel. The
prostate is enlarged. The bladder appears normal. There is no
free air, free fluid, or pathologic adenopathy.
BONE WINDOWS: There are multilevel degenerative changes, but no
suspicious lesions.
IMPRESSION: Distended stool loaded colon with fecalization of
the distal small bowel.
.
[**4-1**] KUB: The cecum and ascending colon are dilated, measuring
up to 10.1 cm. Specks of radiodense material are present within
the colon, which represent dense residual contrast from prior
administration. Small bowel does not appear to be dilated. There
is no supine evidence of free intraperitoneal air. Upper abdomen
is excluded from the radiograph. The osseous structures are
diffusely demineralized.
IMPRESSION: Persistent colonic dilatation, unchanged from scout
images of recent CT.
.
[**2192-3-31**] 09:20AM GLUCOSE-86 UREA N-47* CREAT-11.0* SODIUM-142
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-22*
[**2192-3-31**] 09:20AM CK(CPK)-104
[**2192-3-31**] 09:20AM CK-MB-7 cTropnT-0.19*
[**2192-3-31**] 09:20AM CALCIUM-9.8 PHOSPHATE-5.2* MAGNESIUM-2.3
[**2192-3-31**] 09:20AM WBC-6.6 RBC-3.33* HGB-11.9* HCT-39.0*
MCV-117* MCH-35.7* MCHC-30.5* RDW-16.9*
[**2192-3-31**] 09:20AM PLT COUNT-170
[**2192-3-31**] 01:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2192-3-31**] 01:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2192-3-31**] 01:30AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-<1
[**2192-3-31**] 01:30AM URINE AMORPH-MANY
[**2192-3-31**] 01:30AM URINE MUCOUS-MANY
[**2192-3-30**] 08:30PM GLUCOSE-119* UREA N-40* CREAT-10.3*#
SODIUM-142 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-22*
[**2192-3-30**] 08:30PM estGFR-Using this
[**2192-3-30**] 08:30PM ALT(SGPT)-21 AST(SGOT)-48* LD(LDH)-239 TOT
BILI-0.3
[**2192-3-30**] 08:30PM CK-MB-7 cTropnT-0.19*
[**2192-3-30**] 08:30PM ALBUMIN-4.9*
[**2192-3-30**] 08:30PM NEUTS-78.7* LYMPHS-13.0* MONOS-6.1 EOS-1.8
BASOS-0.3
[**2192-3-30**] 08:30PM PLT COUNT-193
[**2192-4-1**] 07:05AM BLOOD WBC-11.5*# RBC-3.45* Hgb-13.0* Hct-42.0
MCV-122* MCH-37.7* MCHC-31.0 RDW-16.7* Plt Ct-202
[**2192-4-1**] 05:47PM BLOOD WBC-9.1 RBC-3.24* Hgb-12.1* Hct-38.0*
MCV-118* MCH-37.4* MCHC-31.8 RDW-16.9* Plt Ct-201
[**2192-4-2**] 01:43AM BLOOD WBC-7.8 RBC-3.12* Hgb-11.8* Hct-36.4*
MCV-117* MCH-37.8* MCHC-32.4 RDW-17.0* Plt Ct-171
[**2192-4-1**] 07:05AM BLOOD Glucose-98 UreaN-45* Creat-9.5*# Na-146*
K-4.1 Cl-98 HCO3-16* AnGap-36*
[**2192-4-1**] 05:47PM BLOOD Glucose-143* UreaN-64* Creat-10.8*#
Na-142 K-4.1 Cl-98 HCO3-20* AnGap-28*
[**2192-4-2**] 01:43AM BLOOD Glucose-110* UreaN-72* Creat-11.0* Na-145
K-3.8 Cl-102 HCO3-17* AnGap-30*
[**2192-4-1**] 05:47PM BLOOD ALT-91* AST-233* LD(LDH)-316*
CK(CPK)-2695* AlkPhos-91 Amylase-119* TotBili-0.4
[**2192-4-2**] 01:43AM BLOOD ALT-107* AST-282* LD(LDH)-376*
CK(CPK)-3502* AlkPhos-92 Amylase-104* TotBili-0.4
[**2192-4-2**] 10:07AM BLOOD CK(CPK)-3291*
Brief Hospital Course:
80 M with dementia, HTN, ESRD on HD, recurrent Ecoli bacteremia,
prostate abscess, admitted with confusion, abdominal distension,
difficulty swallowing, copious purulent penile discharge.
.
Brief hospital course:
Patient was initially admitted to the floor and placed on
aggressive bowel regimen and urology was consulted. Plan was
for protate US to look for prostatic ascess. On [**4-1**] while on
the floor the patient developed hypotension and an acute change
in mental status. Pt was non-verbal with verbal baseline. MICU
evaluation revealed :ABG 7.23/54/82 with lactate 3.6. SBP was 84
with HR in the 70s. He appeared tachypneic. He received 500cc NS
as well as vancomycin, flagyl, Zosyn. He was transferred to the
MICU with a diagnosis of septic shock
EKG was unchanged from prior. Labs returned with CK of 2600.
Surgery was consulted. Of note patient was unable to complete
dialysis (0.5L off) the day prior to transfer secondary to
hypotension. Possible sources of infection included GU tract
given purulent penile discharge on admission or abdominal source
given distention and colonic dilitation seen on plain films. He
was aggressively hydated with IVF and continued on broad
spectrum antibiotics including Vanco, Zosyn, and Flagyl.
Bladder irrigation with Neomycin-Polymyxin was also continued.
A CVL was attemped x2 without ability to thread the wire and was
aborted. Given the abdominal distention surgery was consulted
for concern for ischemic colitis. An exploratory laparotomy was
offered to the patient's wife who declined surgical
intervention. An NG tube was placed for decompression. Over
the course of the next 24 hours in the ICU the patient's
condition continued to worsen with progressive hypotension and
the patient became unresponsive. His critical and deteriorating
condition was discussed with his family who did not want to
continue aggressive intervention. The decision was made to make
the patient CMO on the morning of [**4-2**]. Antibiotics were
discontinued and the patient expired at 2:20pm on [**4-2**] with his
family at the bedside. His wife declined a post-mortem exam.
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
[**Hospital1 **] (2 times a day) as needed for back pain.
Disp:*35 Tablet(s)* Refills:*0*
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DINNER
.
Medications on transfer to ICU:
1. IV access: Peripheral Order date: [**3-31**] @ 0643 9.
MetRONIDAZOLE (FLagyl) 500 mg IV Q12H Order date: [**4-1**] @ 1601
2. 500 mL NS Bolus 500 ml Over 20 mins Order date: [**4-1**] @ 1522
10. Piperacillin-Tazobactam Na 2.25 g IV Q12H *Awaiting ID
Approval* Order date: [**4-1**] @ 1455
3. Amlodipine 7.5 mg PO DAILY Order date: [**3-31**] @ [**2190**]
11. Piperacillin-Tazobactam Na 2.25 g IV ONCE Duration: 1 Doses
Start: [**2192-4-1**] Order date: [**4-1**] @ 1526
4. Cinacalcet HCl 30 mg PO Q DINNER Order date: [**3-31**] @ [**2190**]
12. Simethicone 120 mg PO QID Order date: [**3-31**] @ 2034
5. Fleet Phospho-Soda 45 ml NG ONCE Duration: 1 Doses
Please give by rectum. Order date: [**3-31**] @ 2230
13. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift Order date: [**3-31**] @
0643
6. Lanthanum 500 mg PO TID W/MEALS Order date: [**3-31**] @ [**2190**]
14. Vancomycin 1000 mg IV HD PROTOCOL
ID Approval will be required for this order in 71 hours. Order
date: [**4-1**] @ 1455
7. Lactulose 30 mL PO TID Order date: [**3-31**] @ 2034
15. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date:
[**4-1**] @ 1523
8. Metoprolol 12.5 mg PO BID Order date: [**3-31**] @ [**2190**]
(Dinner).
6. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
20,009 | 6011,7907,5997,40391,5856,0414,29040,4589,2819 | 192,836 | Admission Date: [**2191-4-2**] Discharge Date: [**2191-4-6**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hematuria, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP
p/w hematuria, chills. Pt was recently admitted [**Date range (1) 96389**]
for penile discharge. [**Date range (1) 159**] was consulted and placed a foley
which revealed purulent discharge. Pt was placed on daily
irrigation with abx, though this was discontinued at the time of
d/c with plans for out-pt f/u with [**Date range (1) **]. Also during that
admission, multiple [**Date range (1) **] cxs grew out E coli. Pt was discharged
with plans for tx with [**Date range (1) **] with HD X 4 weeks. Initially the
pt felt well after discharge and had no complaints. However,
yesterday pt noted mild "chills and sweats." This AM pt noted
large amount of hematuria, but he and his wife decided to go to
HD. Pt with worse chills and sweats at HD. Given persistent
symptoms and worsening hematuria, pt's wife brought him to [**Hospital1 18**]
[**Name (NI) **].
.
In ED, vitals: 96.1, hr 70, 110/50, rr 18, 96% RA. Lactate 1.8.
BUN 23, cr 5.6. Hct 35, baseline 41. CXR with patchy
retrocardiac opacity, likely atelectasis. EKG: nsr@78 bpm, LAD,
RBBB, TWF v2-3 (new). [**Name (NI) 159**] consulted and foley was palced.
Renal called for HD and elected to hold on dialysis today. LIJ
placed for access (white port not flushing). Pt given vanc 1
gram, gent 80 mg for ? endocarditis, flagyl 500 mg given for
prior h/o b frag bacteremia (on admission [**12-22**]), [**Month/Year (2) **] given
for prior e coli bacteremia, tylenol 325 mg. Home BP meds held.
Pt started on labetalol gtt for elevated sbps to 270s, which
were controlled. However, pt's sbps dropped to 70s. Drip turned
off and pt bolused with sbp to 120s. Pt transferred to MICU for
further management.
.
ROS: Denies chest pain, abdominal pain, nausea, vomiting, or
shortness of breath
Past Medical History:
-ESRD related to HTN nephropathy s/p av graft in both arms, R
arm was functional until the past 24h
-HTN x >20 yrs
-Multivascular dementia
-BPH
-Chronic LBP with DJD, spinal stenosis
-Macrocytic anemia, unclear etiology
-Bacteremia - [**12-22**]- Ecoli and B. Fragilis; [**3-23**] - Ecoli
-Prostatitis - [**3-23**] - CT of prostate with hypodense area and
Ecoli in penile discharge swab and [**Month/Year (2) **]. Daily bladder
irrigation through the Foley with fluid containing
Neomycin-Polymyxin was done. Pt discharged on 4 weeks of [**Month/Year (2) **]
as endocarditis not ruled out on TEE.
Social History:
Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or
drugs;
No recent sexual activity.
Family History:
NC
Physical Exam:
Vitals- 98.4, 158/p, 78, 20, 100% RA
Gen - Alert, no acute distress, but appears confused.
HEENT - PERRL, extraocular motions intact, anicteric, MMM
Neck - no JVD, no cervical lymphadenopathy, central line left
neck without erythema
Chest - Clear to auscultation bilaterally
CV - irregularly irregular, nml s1,s2. No murmurs noted.
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - 2+ DP, PT pulses bilaterally, no edema or cyanosis, warm
and well perfused.
Skin - No rashes or petechiae noted.
foley catheter in place. draining bright red [**Location (un) **].
Pertinent Results:
[**2191-4-2**] 02:10PM PLT COUNT-255
[**2191-4-2**] 02:10PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+
[**2191-4-2**] 02:10PM NEUTS-75.6* LYMPHS-16.1* MONOS-3.9 EOS-2.9
BASOS-1.6
[**2191-4-2**] 02:10PM WBC-6.6# RBC-3.49* HGB-11.4* HCT-35.8*
MCV-103* MCH-32.7* MCHC-31.9 RDW-17.2*
[**2191-4-2**] 02:10PM CALCIUM-9.2 PHOSPHATE-3.8# MAGNESIUM-2.0
[**2191-4-2**] 02:10PM CK-MB-NotDone cTropnT-0.28*
[**2191-4-2**] 02:10PM CK(CPK)-94
[**2191-4-2**] 02:10PM estGFR-Using this
[**2191-4-2**] 02:10PM GLUCOSE-136* UREA N-23* CREAT-5.6*#
SODIUM-142 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-36* ANION GAP-16
[**2191-4-2**] 02:27PM LACTATE-1.8
[**2191-4-2**] 02:27PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2191-4-3**] 12:00AM HCT-28.9*
.
CHEST (PORTABLE AP) [**2191-4-2**] 2:33 PM
UPRIGHT AP CHEST: Heart size is normal, though there is a left
ventricular configuration. Mediastinal and hilar contours are
unchanged. There is minimal patchy opacity in the retrocardiac
area which likely reflects atelectasis. There is no definite
consolidation. No evidence of failure. No pleural effusion or
pneumothorax. Flecks of dense material are seen within the
bowel, likely reflecting bits of retained barium from recent CT.
-Minimal patchy opacity in the retrocardiac region likely
reflects atelectasis. To better evaluate this area, a lateral
view could be obtained.
.
EKG [**2191-4-2**]
Baseline artifact. Sinus rhythm. Atrial ectopy. Left axis
deviation with left anterior fascicular block. Right
bundle-branch block. Compared to the previous tracing of [**2191-3-29**]
no significant diagnostic change.
.
[**2191-4-4**]- TTE
The left atrium is dilated. The right atrium is moderately
dilated. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2191-3-26**],
there is
sginificant change. No vegetation is seen on either study.
Brief Hospital Course:
79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP
p/w hematuria, chills.
.
In MICU continued [**Month/Day (2) 21347**], flagyl and vanc dosed by levels. Foley
with numerous clots, periodically flushed. Dialysis planned for
Tuesday as per renal, with [**Month/Day (2) **] 2 grams IV to be given during
hemodialysis. Stabilized BP on home meds. Question of vegetation
on TTE [**3-26**] admission.
.
#Fever/chills: Question of endocarditis (especially given
previous ECHO) vs. prostatic infection, abscess. Vanc and flagyl
DC'd shortly after initiation. Continued [**Month/Year (2) 21347**] 2 gm per
dialysis. TTE with no evidence of vegetation. Wife would not
like TEE at this time. E-coli bacteremia noted. Frequent bouts
of prostatis, but family not interested in TURP at this time. ~6
week course of [**Month/Year (2) **].
.
#hematuria: ddx includes prostatitis v abscess v prior trauma
from foley placement.
foley in place by [**Month/Year (2) **]. Monitored crit which were stable.
[**Month/Year (2) 159**] had replaced the 16F Coude catheter placed in ED,
numerous clots irrigated from the bladder. As patient did not
produce much urine, it was difficult to tell whether foley was
clotted vs. his baseline anuria. Irrigated the foley regularly
to clear out any residual clots. Clear urine at the time of
discharge. Patient denied any pain. No white count or fever,
hemodynamically stable. Transfused PRBC's last 2 units on
[**2191-4-5**]. [**Date Range 159**] follow up.
.
ESRD: on HD as an out-pt. Dialysis as per renal during
admission. Electrolytes stable. Continued sevelamer, nephrocaps,
CaCo3, cinacalcet.
.
#HTN urgency: transient HTN, resolved with gtt and now stable on
no meds. Transient hypotension, likely related to Labetolol
drip. No evidence of sepsis. Continue amlodipine and metoprolol
[**Hospital1 **]. Stable [**Hospital1 **] pressure on the floor up to discharge.
.
#elevated tpn: in setting of renal failure. Minimal non-specific
EKG changes. Pt asymptomatic. Pt was ruled out.
.
#FEN: renal/HH diet, IVF as above
#ppx: pneumo boots, po diet
#Full Code
Medications on Admission:
Amlodipine 7.5 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Cinacalcet 30 mg daily
nephrocaps
Ceftazidime 2 gm QHD X 4 weeks ([**Date range (3) 96388**]).
Sevelamer 800 mg tid
Calcium Carbonate 500 mg tid
.
MEDS on transfer to the floor:
Levothyroxine Sodium 25 mcg PO DAILY
Amlodipine 7.5 mg PO DAILY
Metoprolol 25 mg PO BID
Calcium Carbonate 500 mg PO TID W/MEALS
Nephrocaps 1 CAP PO DAILY
CeftazIDIME 2 gm IV QHD
Senna 1 TAB PO BID:PRN
Cinacalcet HCl 30 mg PO DAILY
Sevelamer 1600 mg PO TID
Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day). Tablet(s)
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. CeftazIDIME 2 gm IV QHD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
E-coli bacteremia
Prostatitis
Hematuria
Hypertension
ESRD secondary to hypertensive nephropathy
.
Secondary:
s/p av graft in both arms, R arm is functional
Multivascular dementia
BPH
Chronic LBP with DJD, spinal stenosis
Macrocytic anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with fever, chills, bleeding from urethra with
clots. Your [**Date range (3) **] pressure was also very elevated, and then
dropped after being placed on a Labetolol drip. You were given
dialysis, foley catheter placed and flushed. You were continued
on [**Last Name (LF) 21347**], [**First Name3 (LF) **] antibiotic given to you at dialysis. A repeat TTE
demonstrated no vegetation concerning for endocarditis, and your
wife would not like a TEE at this time.
-Please continue [**First Name3 (LF) 21347**] 2 grams every dialysis until ID follow
up on [**2191-4-25**]. A decision will be made at that time to continue
with [**Date Range 21347**] or to have course of cipro or bactrim.
-You will have a 6 week course of [**Date Range **] for your e-coli
bacteremia, prostatis.
-You will need your LFT's and CBC checked weekly at dialysis.
-Please maintain all appointments, with your [**Date Range 3390**], [**Name10 (NameIs) **] and kidney
doctors.
-Please return to the hospital if you are feverish, have
bleeding through your urethra, altered mental status, severely
elevated [**Name10 (NameIs) **] pressure, or any other symptoms concerning to you
or your wife.
.
Changes to your medications:
-Your Metoprolol was increased to 50 mg twice daily
-Sevelamer was increased to 1600 three times a day
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD. Phone [**Telephone/Fax (1) 133**]: Date/Time
[**2191-4-15**] 3:00 PM
-Will follow up on pending [**Month/Day/Year **] culture results.
.
Please follow up with Dr. [**Last Name (STitle) **] tomorrow at Dialysis in
[**Location (un) **]. Discussed with Mrs. [**Known lastname 24110**], and she will see Dr.
.
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2191-4-13**]
10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2191-4-25**] 9:30
|
20,010 | 41071,4280,99672,78551,9971,4275,5185,41401,4019,25000,2720,2948,311,V4581,V667 | 161,812 | Admission Date: [**2101-8-5**] Discharge Date: [**2101-8-15**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization, intubation
History of Present Illness:
86 yo F with h/o HTN, CAD s/p remote CABG, DM who presents from
NH with acute SOB and diaphoresis, transferred here for NSTEMI,
admitted to CCU s/p cath on IABP, pressors, and intubated. She
received lasix and NTG at [**Hospital1 18**] [**Location (un) 620**] and was transferred
here. Her ECG on arrival showed [**Street Address(2) 2051**] depressions in V4-V6,
II, avF. Cardiac enzymes were positive with CK 827/105/12.7 and
Trop 1.02. CXR showed edema and RUL infiltrate; she was given
ceftriaxone 1g, azithromycin 500, and clindamycin 600 and lasix
40IV. She received ASA, plavix 600, and heparin bolus. She
underwent catheterization, showing severely elevated left and
right-sided filling pressures (mean PCWP 30, giant v-waves).
Grafts from SVG-> LAD and SVG -> RCA were patent. LAD had
diffuse proximal disease. No prior LCx graft was found; LCx had
90% proximal occlusion and mid 70% which were stented. ACT
returned as 85 (later attributed to heparin infiltration in
peripheral IV). The patient became hypotensive and went into
respiratory distress. Her LCx was found to have a fresh
thrombus, as well as new thrombus in the LMCA. She was
intubated and placed on a balloon pump. Dopamine and levophed
were started. Integrillin was started. The LCx was restented
twice.
.
On arrival to the floor the patient was noted to be
significantly oozing from the groin. Vascular surgery was
consulted and applied Femstop to stop bleeding. She received 1
unit pRBCs. Integrillin gtt was stopped. dopa @ 5, levo @ 0.16
.
Past Medical History:
HTN
CAD s/p CABG: 15 yrs prior. SVG-> LAD and SVG -> RCA
DM
hypercholesterolemia
dementia
syncope
depression
Social History:
lives in [**Location **], has son who is HCP.
Family History:
unknown
Physical Exam:
Vitals: T: 97.3 P: 84 BP: 91/47 RR: 16 SaO2: 97% AC:
550/16/1.0/5
General: Intubated, sedated, NAD. exam limited by bedrest s/p
cath
HEENT: PERRL, sclera anicteric. MMM
Neck: supple, no JVD or carotid bruits appreciated
Pulm: lungs coarse
Cardiac: RRR, nl S1/S2
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Ext: 1+ edema b/t. L groin with FemStop in place. R groin
c/d/i. Right leg with 1+ dp. Left leg with mottled skin and nl
capillary refill, dopplerable dp.
Neurologic: intubated, sedated, MAE spontaneously.
Pertinent Results:
Echo [**2101-8-6**]:
1. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed. Inferior, lateral,
and apical akinesis with septal and anterior hypokinesis is
present. LVEF 30%
2. The aortic root is moderately dilated.
3. The aortic valve leaflets are mildly thickened.
4. The mitral valve leaflets are mildly thickened.
.
Admission Labs:
[**2101-8-5**] 09:42PM TYPE-MIX PH-7.32*
[**2101-8-5**] 09:42PM LACTATE-2.6*
[**2101-8-5**] 09:42PM O2 SAT-67
[**2101-8-5**] 09:42PM freeCa-1.00*
[**2101-8-5**] 09:30PM TYPE-ART PO2-174* PCO2-40 PH-7.37 TOTAL
CO2-24 BASE XS--1
[**2101-8-5**] 09:30PM O2 SAT-99
[**2101-8-5**] 09:12PM GLUCOSE-295* UREA N-24* CREAT-1.0 SODIUM-135
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
[**2101-8-5**] 09:12PM CK(CPK)-1275*
[**2101-8-5**] 09:12PM CK-MB-123* MB INDX-9.6*
[**2101-8-5**] 09:12PM MAGNESIUM-1.8
[**2101-8-5**] 09:12PM WBC-24.4*# RBC-3.88* HGB-10.8* HCT-32.0*
MCV-83 MCH-27.9 MCHC-33.7 RDW-14.9
[**2101-8-5**] 09:12PM PT-14.2* PTT-115.8* INR(PT)-1.3*
[**2101-8-5**] 07:21PM TYPE-ART RATES-13/ TIDAL VOL-500 PEEP-5
PO2-179* PCO2-52* PH-7.21* TOTAL CO2-22 BASE XS--7 -ASSIST/CON
INTUBATED-INTUBATED
[**2101-8-5**] 07:21PM O2 SAT-98
[**2101-8-5**] 05:38PM TYPE-ART RATES-/14 O2-99 O2 FLOW-15 PO2-198*
PCO2-41 PH-7.45 TOTAL CO2-29 BASE XS-4 AADO2-492 REQ O2-80
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2101-8-5**] 05:38PM O2 SAT-98
[**2101-8-5**] 02:24PM LACTATE-2.2*
[**2101-8-5**] 12:30PM GLUCOSE-161* UREA N-22* CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
[**2101-8-5**] 12:30PM CK(CPK)-827*
[**2101-8-5**] 12:30PM CK-MB-105* MB INDX-12.7* cTropnT-1.02*
[**2101-8-5**] 12:30PM WBC-14.1* RBC-4.38 HGB-12.5 HCT-37.3 MCV-85
MCH-28.6 MCHC-33.6 RDW-14.8
[**2101-8-5**] 12:30PM NEUTS-87.4* BANDS-0 LYMPHS-7.7* MONOS-3.6
EOS-1.2 BASOS-0.1
[**2101-8-5**] 12:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2101-8-5**] 12:30PM PLT SMR-NORMAL PLT COUNT-316
[**2101-8-5**] 12:30PM PT-12.2 PTT-21.4* INR(PT)-1.1
.
Labs at time of Expiration:
[**2101-8-15**] 04:00AM BLOOD WBC-16.5* RBC-3.14* Hgb-9.1* Hct-27.0*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.6*
[**2101-8-15**] 04:00AM BLOOD Neuts-73* Bands-5 Lymphs-7* Monos-9 Eos-4
Baso-1 Atyps-0 Metas-0 Myelos-1* NRBC-2*
[**2101-8-15**] 04:00AM BLOOD Plt Smr-UNABLE TO
[**2101-8-15**] 04:00AM BLOOD Glucose-49* UreaN-46* Creat-0.8 Na-148*
K-3.8 Cl-111* HCO3-31 AnGap-10
[**2101-8-15**] 04:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.6
[**2101-8-15**] 09:09AM BLOOD Type-ART Temp-37.6 pO2-89 pCO2-43
pH-7.48* calTCO2-33* Base XS-7
[**2101-8-15**] 04:35AM BLOOD Lactate-2.0
[**2101-8-15**] 09:09AM BLOOD O2 Sat-96
[**2101-8-15**] 04:35AM BLOOD freeCa-1.17
.
Micro:
Fungal Swab:
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
Chest X Ray [**2101-8-15**]:
Severe pulmonary edema has worsened again obscuring the cardiac
silhouette which is not particularly large. There is more
mediastinal vascular engorgement and at least small bilateral
pleural effusions are presumed. No pneumothorax. ET tube and
nasogastric tube in standard placements.
Brief Hospital Course:
<b>Assessment and Plan: 86 yo F with h/o HTN, CAD s/p remote
CABG, DM who presents from NH with acute SOB and diaphoresis,
transferred here for NSTEMI, admitted to CCU s/p cath on IABP,
pressors, and intubated.
.
Cardiac:
Pump: The patient developed cardiogenic shock while in the cath
lab, requiring placement of IABP and support with pressors. CI
and SVR gradually improved, allowing discontinuation of the IABP
and pressors. The patient remained volume overloaded and was
therefore diuresed with IV lasix and responded very well.
However, she continuously dropped her BP and required
intermittent fluid boluses to maintain her BP. Blood
transufions were also given during her episodes of hypotension
to encourage fluid mobilization and maintain her hematocrit.
Her CXR initially improved. However, she did continue to have
patchy infiltrates despite good duresis. At the time of her
death, she did have diffuse course breath sounds.
.
Ischemia: She had an infero/anterolateral MI, was s/p cath for
NSTEMI and LCx stenting. The patient was not treated with
intergrillin due to bleeding/oozing from groin sites. She was
continued on aspirin, and plavix. Atorvastatin 80 mg qday was
held for 2 days post cath for concern of drug fever, however, as
her fevers continued without the medication it was restarted.
She was started on a betablocker despite transient hypotension.
The CCU team stopped following her cardiac enzymes, and
continued her medical regimen up until the time of her death.
.
Rhythym: The patient had an episode of SVT (afib vs aflutter) on
[**2101-8-11**], which broke with metoprolol IV and PO. She was then
continued on metoprolol. She was monitored on telemetry
throughout her hospitalization. She maintained her rhythm up
until her death, eventually ending in asystole.
.
Respiratory failure: The patient was intubated in the cath lab.
She was thought to be in heart failure post cath, and so was
diuresed with IV lasix, however, ARDS was also on the
differential given her persistant high O2 requirement. The
patient then developed persistant fevers with elevated WBC
count, and so was treated empirically for pneumonia with
Zosyn/Vanco. Sputum cultures were unremarkable. An A-line was
placed for closer monitoring of ABG's. On the last day,
Fluconazole was added for possible yeast infection, although the
likelihood was low. She initially tolerated trials of pressure
support. However, she persistently dropped her 02 sats into the
80s. Her 02 requirement increased to an Fi02 of 0.6. Her PEEP
could not be lowered. She persistently failed her RSBIs. The
decision was made that extubation would be very difficult and
unlikely. With that in mind, the family decided to withdraw
care. She was made CMO and extubated. She persisted for 4
hours, with 02 sats in the 70's. She was comfortable at the
time of her death.
.
Fevers: Throughout admission, she continued to spike fevers to
101+. She was initially started on Levaquin/Flagyl for
aspiration pneumonia. However, her regimen was changed to
vancomycin/Zosyn for pseudomonal coverage. She continued to
spike fevers. Culture data remained negative. On the last day,
Fluconazole was added for yeast coverage.
.
Diabetes Mellitus: The patient had high insulin requirements on
tube feeds, therefore she was maintained on an insulin gtt. Her
home avandia was held. Thyroid: the patient was continued on her
home dose synthroid.
.
Psych: The patient was continued on her home dose zoloft.
.
Prophylaxis: PPI, bowel regimen
.
FEN: She was maintained on tube feeds. Electrolytes were
monitored and repleted PRN.
.
Code Status/Disposition: She was initially DNR/DNI. However,
this was reversed for catheterization. However, once her
condition worsened, the family decided to make her CMO, the
patient was then extubated and comforted with morphine/ativan
boluses. After 4 hours, the patient went into asystole. Pulses
could not be felt and we could not appreciate spontaneous
breaths or heart beats for over 2 minutes. She was pronounced
dead at 6:10PM. Her son and daughter were present. They did
not want an autopsy.
Medications on Admission:
lasix 20 PO QOD
ASA 325
avandia 8 mg
levothyroxine 100 mcg
lipitor 40 mg
zoloft 25 mg
detrol LA 4 mg QD
neurontin
Vitamin B12 1000 Qmonth
namenda
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Non-ST Elevation Myocardial Infarction complicated by cardiac
arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
20,011 | 4280,41091,486,42731,00845,2765,41401 | 100,281 | Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**]
Service:
ADDENDUM TO PREVIOUS DISCHARGE SUMMARY
Add to medication list: Lasix 40 mg p.o. q.d.
In regard to patient's congestive heart failure management,
patient apparently was on isosorbide dinitrate 10 mg p.o.
t.i.d. as an outpatient. This medication was tried prior to
discharge and patient experienced hypotension with a low dose
of this medication. Subsequently this medication was
discontinued. Patient did quite well with diuresis with 20
mg of intravenous Lasix and thus the patient was discharged
on a dosage of 40 mg daily p.o. q day.
Non-ST elevation myocardial infarction: The patient
frequently had rapid rate in the 110 range but her blood
pressure would not tolerate further increase in metoprolol as
she was already on a large dose of 50 mg p.o. t.i.d. which
should be continued as an outpatient and on further follow up
with her primary care physician this metoprolol dosage could
likely be changed to a q.d. dosing. This was not done
further prior to discharge since further titration of her
medications may be needed.
Eye issues: The patient has right conjunctival erythema most
likely secondary to Bell's palsy causing a droopy lower lid.
Patient apparently was on gatifloxacin eye drops for an
unknown reason and unknown duration of time per her
ophthalmologist, Dr. [**Last Name (STitle) 106470**]. Since Dr. [**Last Name (STitle) 106470**] could not be
reached, I suggested that patient's daughters follow up with
her outpatient ophthalmologist to make a follow up
appointment regarding further use of these eye drops, their
indication for use and any further follow up appointments
that area needed. Patient had no signs or symptoms of
infection, conjunctivitis and her eye apparently appeared
improved than one month ago per the patient and her family.
DISCHARGE MEDICATIONS: Addended should read aspirin 325 mg
p.o. q.d., atorvastatin 10 mg p.o. q.d., Lasix 40 mg p.o.
q.d., Atrovent inhaler q 6 hours p.r.n., nitroglycerine
sublingual 0.3 mg sublingual p.r.n., Protonix 40 mg p.o.
q.d., metoprolol 50 mg p.o. t.i.d., levofloxacin 250 mg p.o.
q.d. times six more days to complete a ten day course for
community acquired pneumonia, and last warfarin 3 mg p.o.
q.h.s.
Patient should follow up with her primary care doctor
regarding her Coumadin and INR levels. I also advised at the
rehabilitation facility that patient should have her
potassium checked as well as her INR checked at least every
other day to ensure therapeutic level of her Coumadin dosing
as well as electrolyte repletion for diuresis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2103-5-24**] 12:23
T: [**2103-5-24**] 12:11
JOB#: [**Job Number 106471**]
|
20,011 | 4280,41091,486,42731,00845,2765,41401 | 100,281 | Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**]
Service:
DISCHARGE SUMMARY ADDENDUM
HOSPITAL COURSE: Congestive heart failure: The patient was
placed on BiPAP temporarily overnight in the Intensive Care
Unit for eight hours and maintained stable oxygenation and
good O2 saturations. She showed good improvement with Lasix
20 mg intravenous and a nitro drip which was shortly
discontinued. It was thought that her episode of acute
pulmonary edema was most likely in the setting of
hypertension and tachycardia which was stabilized in the
Medicine Intensive Care Unit. Patient was restarted on her
beta blocker for improved rate control and at the time of
this dictation is currently at a dosage of metoprolol 50 mg
p.o. t.i.d. For further afterload reduction, patient was
also started briefly on an ACE inhibitor but did not tolerate
a low dose of 6.25 mg secondary to hypotension. Patient was
also diuresed with Lasix 20 mg intravenous as needed for goal
fluid balance of negative 500 cc per day. At the time of
this dictation, patient has been diuresing well to 20 mg of
intravenous Lasix per day but her chest x-ray still indicates
mild failure and bilateral pleural effusions. She could
likely use more diuresis and will likely be discharged on a
standing Lasix dose. In addition patient had a transthoracic
echocardiogram performed on [**5-21**] which revealed diastolic
dysfunction, ejection fraction greater than 55 percent with a
dilated left atrium and right atrium, mild symmetric left
ventricular hypertrophy, normal left ventricular cavity size
and normal left ventricular function, mild atrial
fibrillation, trace aortic regurgitation and mild to moderate
1 to 2 mitral regurgitation. There were no wall motion
abnormalities.
Coronary artery disease/Non-ST elevation myocardial
infarction: The patient did have an episode of chest pain
during her Medical Intensive Care Unit stay and described as
"indigestion" substernal pain for 30 minutes unrelated to
food with associated mild shortness of breath and light
headedness. Her EKG showed no new T wave inversions and [**Street Address(2) 28585**] depressions in V4 to V6. She was given one sublingual
nitroglycerine with relief of pain but her EKG remained
unchanged with persistent T wave inversions and [**Street Address(2) 4793**]
depressions in V4 to V6. Cardiology was called to ask
whether further intervention would be needed and cardiology
suggested that in this [**Age over 90 **] year-old woman with an elevated INR
cardiac catheterization would not be indicated. They
suggested medical management. Patient's cardiac enzymes
trended upward through her stay with a peak CK of 79, MB
fraction 11, troponin 0.17. Patient was continued on her
aspirin and was started on a low dose heparin drip with no
bolus given her history of GI bleed. Her metoprolol dose was
titrated up to control her heart rate to allow better filling
and better systolic blood pressures. Patient remained chest
pain free throughout the rest of her hospital course and her
enzymes trended downward. Her heparin drip was stopped the
day after her episode of chest pain she had some mild
hematuria and had no further indications for heparin drip.
She was also started on a statin 10 mg q day. The patient's
outpatient cardiologist, Dr. [**Last Name (STitle) **], was contact[**Name (NI) **] and patient
has refused a cardiac stress test in the past. Patient's
outpatient cardiologist agreed with starting low dose
Captopril (patient did not tolerate this in the hospital and
thus it was discontinued) and agreed also with titrating up
patient's beta blocker.
Pneumonia: Although patient initially did not show signs of
an infiltrate on chest x-ray and it was thought that patient
most likely had a bronchitis early on admission. Patient's
white count was trending upward to a peak of 15,000 and had
mild low grade fevers. In the Medical Intensive Care Unit
patient was started on empiric coverage for community
acquired pneumonia with levofloxacin and her white count has
been trending downward and she has remained afebrile. Her
chest x-ray shows a left basilar opacity which could be an
infiltrate versus atelectasis versus pleural effusion. She
should continue her Levaquin for a total ten day course.
Sputum culture was obtained during this hospitalization which
showed 3+ gram positive, 2+ gram positive cocci in pairs and
clusters and 1+ budding yeast but respiratory culture showed
only oropharyngeal flora and no specific organisms. Patient
also incidentally had a urine culture drawn which showed no
growth.
Atrial fibrillation: Patient remained in atrial fibrillation
with a rate of 90s to 100 throughout her hospital stay. Her
beta blocker dose was increased to 50 mg p.o. b.i.d. to
further control her rate. Patient was also briefly started
on heparin drip for a non-ST elevation myocardial infarction
and her Coumadin dose was held but at the time of this
dictation patient has been restarted on her Coumadin home
dose of 3 mg p.o. q.h.s. and patient will be discharged on
this dose.
Fluid, electrolytes and nutrition: Patient was maintained on
a 2 gram sodium diet. She developed a contraction alkalosis
likely secondary to diuresis but still appeared fluid
overloaded on examination and by chest x-ray. Her
electrolytes remained stable throughout her hospitalization.
Prophylaxis: The patient is on Coumadin with a therapeutic
INR and a PTI.
CODE: Patient is a full code which was readdressed with her
family.
DISPOSITION: Patient was evaluated by Physical Therapy who
felt that patient would benefit from rehabilitation. She
will likely be discharged from the Intensive Care Unit itself
or from a medicine floor as soon as a bed is available at
rehabilitation.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE CONDITION: Stable with O2 saturations 96 to 98
percent on 2 liters nasal cannula.
DISCHARGE MEDICATIONS: 1) Metoprolol 50 mg p.o. t.i.d., hold
for SBP less than 100 and heart rate less than 55. 2)
Coumadin 3 mg p.o. q.h.s. 3) Atorvastatin 10 mg p.o. q.d.
4) Levofloxacin 250 mg p.o. q day times six more days. 5)
Protonix 40 mg p.o. q.d. 6) Aspirin 325 mg p.o. q.d., 7)
Atrovent nebulizer inhaled q 6 hour p.r.n. wheezing. 8)
nitroglycerine sublingual 0.3 mg p.r.n. chest pain.
FOLLOW UP PLANS: 1) Patient should follow up with her
primary care physician or primary cardiologist in one to two
weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2103-5-23**] 15:20
T: [**2103-5-23**] 15:35
JOB#: [**Job Number 106469**]
cc:[**Hospital3 26500**] |
20,011 | 4280,41091,486,42731,00845,2765,41401 | 100,281 | Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**]
Service: MEDICINE
INTERIM SUMMARY - HISTORY OF PRESENT ILLNESS: The patient is
a [**Age over 90 **]-year-old female, with a history of coronary artery
disease without interventions, also with AFIB on Coumadin,
who was brought to the Emergency Department by EMT for chief
complaint of shortness of breath and chest pain. The patient
had been feeling these symptoms for the entire day. She
started to feel 5/10 chest pain, substernal in location,
around the time of her shortness of breath which was also
associated with dizziness.
In the ambulance, blood pressure 200/100, heart rate 110,
AFIB, with O2 sats 82% on room air. The patient was also
tachypneic and had diffuse expiratory wheezes on exam. She
was given oxygen, aspirin and Nitroglycerin x 3 without
relief.
In the Emergency Department, blood pressure was 184/128,
heart rate 99, and in AFIB. She was still tachypneic with a
respiratory rate of 35, 100% room air sats. Pedal edema was
noted. The patient was given 1 Combivent neb for audible
wheezing. A chest x-ray suggested failure, and the patient
was treated with lasix and Nitro drip, but blood pressure
decreased to the 90s, so Nitroglycerin drip was discontinued.
Urine output after 20 of IV lasix was approximately 300 cc,
and her symptoms improved. The patient was admitted to the
medicine team for rule out MI and CHF therapy.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Coronary artery disease, EF not known.
3. History of peptic ulcer disease.
4. Status post bilateral cataract surgery.
5. History of GI bleed.
6. History of carotid stenosis.
MEDICATIONS ON ADMISSION:
1. Propranolol 10 tid.
2. Lasix.
3. Coumadin 2 mg po q hs.
4. Albuterol prn.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Denies tobacco, alcohol or IV drug abuse.
PHYSICAL EXAMINATION: Temperature afebrile, BP 159/76, heart
rate 75, respirations 27, satting 97% on 3 liters. In
general, the patient was an elderly female, sitting
comfortably, in no apparent distress.
HEENT: Extraocular movements intact. Pupils equal, round
and reactive to light. Moist mucous membranes.
NECK: Positive jugulovenous distention to jaw level, no
bruits, no lymphadenopathy.
PULMONARY: Diffuse crackles throughout and expiratory
wheezes.
CARDIOVASCULAR: Irregularly irregular. S1 and S2 normal.
Positive systolic murmur at the apex.
ABDOMEN: Soft, nontender, nondistended with good bowel
sounds.
EXTREMITIES: 2+ edema bilateral lower extremities, no
clubbing or cyanosis, no calf tenderness.
NEURO: Nonfocal.
LABORATORIES ON ADMISSION: White blood cell count 12.8 with
a differential of 76% neutrophils, 16% lymphocytes, 7%
monocytes, 1% eosinophils, hematocrit 47, platelets 206.
Chem-7 - sodium 133, potassium 4.5, chloride 93, bicarb 32,
BUN 17, creatinine 0.9, glucose 166. Initial cardiac enzymes
- CK 491, MB 1, troponin less than 0.01. INR 1.8, PTT 31.1.
CHEST X-RAY (BY WET READ): Showed bilateral pleural
effusions consistent with [**2102-4-1**].
EKG: AFIB, at a heart rate of 89, normal axis and intervals,
poor R wave progression, no ST-T wave changes.
ASSESSMENT: This is a [**Age over 90 **]-year-old female admitted initially
for a CHF exacerbation, and with cardiac ischemia likely
related to her CHF.
HOSPITAL COURSE - 1) CONGESTIVE HEART FAILURE: The patient
was initially admitted with shortness of breath likely
secondary to CHF exacerbation. From a pulmonary standpoint,
her breathing had improved after nebulizer treatment
initially. On the day of admission and the day after
admission, however, on [**5-21**] the patient had an acute
episode of acute pulmonary edema. The patient's O2
saturation decreased to 84% on 2 liters. She appeared
diaphoretic and dyspneic with audible wheezes. Initially,
she was given albuterol nebs with minimal response. Vital
signs were 170/100, heart rate 120s, respiratory rate 30.
She was given lasix 20 mg IV x 1, nitropaste 0.5", morphine
0.5 mg x 1. After therapy, her blood pressure increased to
230/120 and a respiratory rate was in the 40s. She was given
hydralazine 20 mg IV x 1, another 1 mg of morphine, and 2
sublingual Nitros which brought her blood pressure down
slightly more to the 140s. The patient appeared lethargic
and less short of breath. She maintained sats in the
high-90s on 100% nonrebreather. EKG showed slight T wave
inversions in V5 and V6 which were a subtle change from her
prior EKG, and she was then transferred to the Fennard ICU
for BiPAP and Nitro drip. A discharge summary addendum will
accompany this discharge summary for further information on
the [**Hospital 228**] hospital course.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2103-5-23**] 13:42
T: [**2103-5-23**] 13:51
JOB#: [**Job Number 106468**]
|
20,011 | 4280,41091,486,42731,00845,2765,41401 | 100,281 | Admission Date: [**2103-5-24**] Discharge Date: [**2103-5-27**]
Service: [**Location (un) **]
NOTE: This is a partial dictation. The rest of the
dictation will be done in the Internal Service.
CHIEF COMPLAINT: Explosive diarrhea.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a past medical history significant for coronary
artery disease, atrial fibrillation (on Coumadin), and
congestive heart failure who now presents with severe
explosive diarrhea.
The patient was recently hospitalized at the [**Hospital1 346**] and was discharged on [**2103-5-24**]; the same day that she re-presented to the Emergency
Room with explosive diarrhea.
During her prior hospitalization, she was noted to have a
pneumonia and was started on antibiotic therapy. She was
discharged on levofloxacin. She was reportedly discharged in
good condition; however, during the ambulance ride to the
nursing home she developed explosive diarrhea and became
tachycardic. Upon arrival to the nursing home she was
redirected to the [**Hospital1 69**] for
further management.
In the Emergency Department, she was noted to be tachycardic
to 140 and dehydrated. She was treated with one liter of
intravenous fluids and 5 mg of intravenously Lopressor times
two. She was also started on Flagyl for empiric coverage of
Clostridium difficile. A chest x-ray was obtained and
revealed stable cardiomegaly with a tortuous and calcified
aorta. She was noted to have upper zone redistribution of
the pulmonary vasculature. This was consistent with
congestive heart failure. There were also bibasilar
effusions and consolidation at the left lung base. An
underlying pneumonia could not be excluded. The overall
impression was that this chest x-ray revealed improvement of
her underlying congestive heart failure.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Coronary artery disease; status post non-ST-elevation
segment myocardial infarction.
3. History of peptic ulcer disease.
4. Status post cataract surgery.
5. History of gastrointestinal bleed.
6. History of carotid stenosis.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Atorvastatin 10 mg by mouth once per day.
3. Ipratropium nebulizers as needed.
4. Levofloxacin 250 mg by mouth q.24h.
5. Metoprolol 50 mg by mouth three times per day.
6. Sublingual nitroglycerin.
7. Pantoprazole 40 mg by mouth once per day.
8. Psyllium by mouth as needed.
9. Warfarin 3 mg by mouth at hour of sleep.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies a history of tobacco.
The patient does not consume alcohol. No history of
intravenous drug use.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
temperature was 98.6 degrees Fahrenheit, her blood pressure
was 138/72, her heart rate was 93, her respiratory rate was
90, and she was saturating 94% on room air. In general, the
patient was an elderly female sitting comfortably in bed in
no apparent distress. Head, eyes, ears, nose, and throat
examination revealed the extraocular movements were intact.
The pupils were equal, round, and reactive to light. The
mucous membranes were dry. Neck revealed jugular venous
distention approximately 9 cm. There was no lymphadenopathy
appreciated on examination. Pulmonary examination revealed
diffuse crackles throughout and mild expiratory wheezes.
Cardiovascular examination revealed an irregularly irregular
rhythm. Normal first heart sounds and second heart sounds.
The abdomen was soft, nontender, and nondistended. There
were normal active bowel sounds. Extremities revealed no
clubbing, cyanosis, or edema. There was no calf tenderness.
BRIEF SUMMARY OF HOSPITAL COURSE: In the setting of
explosive diarrhea and tachycardic, it was felt that the
patient was mildly volume depleted. In addition, she had dry
mucous membranes.
She was resuscitated with approximately one liter of normal
saline. It was also felt that due to her recent antibiotic
therapy for pneumonia, a likely etiology of her diarrhea
could be Clostridium difficile. She was started on empiric
antibiotics with Flagyl. She reported subjective improvement
with intravenous hydration; however, she remained
tachycardic. She was then given 5 mg of intravenous
Lopressor times two 15 minutes apart. Her heart rate
stabilized to the middle 90s; which was down from 160 to 140.
The following day a cardiac echocardiogram was obtained which
showed mild left ventricular hypertrophy. The left
ventricular cavity size was normal and the left ventricular
ejection fraction was greater than 55%. There was mild
aortic valve stenosis and trace aortic regurgitation. There
was 1 to 2+ mitral regurgitation. There was moderate
pulmonary artery systolic hypertension.
An electrocardiogram was also obtained which demonstrated
atrial fibrillation with a rapid ventricular response. There
was mild left axis deviation. There were some nonspecific
extensive ST segment changes.
Cardiac enzymes were cycled. The patient was noted to have
an elevated troponin. However, this was believed to be
secondary to her non-ST-segment elevation myocardial
infarction which she reportedly had during her [**Hospital Ward Name 332**]
Intensive Care Unit stay. Her creatine kinase and CK/MB
remained within normal limits during her hospitalization.
The patient continued to support subjective improvement. She
was not discharged back to the nursing home, however, because
her white blood cell count remained elevated. At the time of
this dictation, the Clostridium difficile toxin assay was
still pending. The plan was to discharge the patient if her
white blood cell count improved on Flagyl therapy and if the
Clostridium difficile toxin assay was positive.
DR [**First Name8 (NamePattern2) 312**] [**Last Name (NamePattern1) 5408**] 12.766
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2103-5-26**] 09:54
T: [**2103-5-26**] 10:13
JOB#: [**Job Number 106490**]
|
20,012 | 43310,41401,V4581,53081,311,V433 | 148,002 | Admission Date: [**2150-4-10**] Discharge Date: [**2150-4-13**]
Date of Birth: [**2074-7-30**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
gentleman who had had coronary artery bypass grafting x 4 in
the past and aortic heart valve replacement, status post a GI
bleed. He is preangioplasty for stent angioplasty for left
internal carotid artery stenosis.
PHYSICAL EXAMINATION: Vital signs were stable. He was
afebrile. He was awake, alert and oriented x 3 in no
distress. Pupils were equal, round and reactive to light,
extraocular movements full. He was hard of hearing, and wore
glasses. Lungs were clear to auscultation. He had a clean,
dry and intact CABG incision. Cardiac was regular rate and
rhythm, S1 and S2, no murmurs. Abdomen was soft, nontender,
nondistended with positive bowel sounds. Extremities showed
trace edema in the bilateral lower extremities.
Neurologically cranial nerves two through 12 were intact.
Smile was symmetric with no drift. Extraocular movements
were full. Strength was [**4-20**] in all muscle groups.
HOSPITAL COURSE: He underwent the left carotid stenting
procedure on [**2150-4-10**] without complications. Postoperatively
he was monitored in the surgical intensive care unit. He was
awake, alert and oriented with extraocular movements full,
smile symmetric, no drift, strength was intact. He was
transferred to the regular floor on postprocedure day two.
The patient was transferred to the floor on [**2150-4-12**]. He
remained awake, alert and oriented x 3 with no drift. His
strength was [**4-20**] in all muscle groups. He had a small groin
hematoma. He had positive pedal pulses. He is going to have
an ultrasound of his left internal carotid artery today and
then will be discharged to home for work-up with Dr. [**Last Name (STitle) 1132**] in
two weeks' time, on Plavix, aspirin and Aggrenox.
DISCHARGE MEDICATIONS:
1. Venlafaxine 75 mg p.o. q.d.
2. Percocet 1-2 tablets p.o. q. 4 hours p.r.n.
3. Enteric-coated aspirin 325 p.o. q.d.
4. Simvastatin 20 mg p.o. q.d.
5. Protonix 40 mg q. day.
6. Metoprolol 25 mg p.o. b.i.d.
7. Aggrenox 1 capsule p.o. b.i.d.
8. Plavix 75 mg p.o. q. day.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2150-4-13**] 08:49
T: [**2150-4-13**] 09:26
JOB#: [**Job Number 49297**]
|
20,013 | 42731,9971,9982,5121,42732,4239,4019,2449,2720 | 116,051 | Admission Date: [**2177-4-2**] Discharge Date: [**2177-4-7**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a history of AFib that has been difficult to rate
control, who is scheduled for elective pacemaker placement
and AVJ ablation on day of admission. After completion of
pacemaker placement, patient's blood pressure dropped to
50/palpable. Volume resuscitation was begun and
echocardiogram showed a large effusion with tamponade.
Emergent pericardiocentesis was 300 cc of frank blood and
improved blood pressure.
Blood pressure decreased again and another 400 cc blood was
pulled off. Pacing wire was repositioned successfully in the
right ventricle and pacer was set at DDD at 90.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Atrial fibrillation.
5. Atrial flutter.
6. Status post right atrial isthmus ablation in summer of
[**2175**]. Was on amiodarone, but discontinued secondary to
nausea and headache. Status post several admissions with
AFib with RVR with rates in the 160s. Referred for pacer and
AVJ ablation. Stress echocardiogram in [**2175-4-17**] showed
an ejection fraction of 65%, mild AS and AI, mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
ALLERGIES: Amiodarone causes headache and nausea.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 b.i.d.
2. Univasc 15 mg q.d.
3. Lescol 80 mg p.o. q.d.
4. Cartia 120 mg p.o. b.i.d.
5. Coumadin.
6. Levoxyl 75 mg p.o. q.d.
7. Vitamin E.
8. Vitamin C.
9. Calcium.
10. Magnesium citrate.
11. Calcium citrate.
FAMILY HISTORY: Negative for diabetes and otherwise
noncontributory.
SOCIAL HISTORY: Denies drugs, tobacco, and alcohol. Lives
in [**Location **] with friend.
PHYSICAL EXAM ON ADMISSION: Temperature 97.3, blood pressure
120/59, heart rate 90, respiratory rate 16, and sats 100% on
room air. Height is 5'5.5", weight 128 pounds. HEENT was
moist mucous membranes. Clear oropharynx. Neck was supple.
Jugular venous pressure is 6 cm. Cardiovascularly: S1, S2
with a 2/6 systolic ejection murmur at the right upper
sternal border, and pericardial drain that was clean, dry,
and intact. Lungs were clear to auscultation bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities: No cyanosis, clubbing, or edema.
Neurologic examination: Awake, alert, and oriented times
three. Cranial nerves II through XII are grossly intact.
Intact strength and motor function, normal sensation. Skin:
No rashes or lesions.
LABORATORIES ON ADMISSION: White count 16.1, hematocrit
30.4, platelets 222. Potassium 4.2, creatinine 0.7, INR 1.3,
PTT 25.1.
Echocardiogram at 11:18 on day of admission showed
moderate-to-large sized pericardial effusion with RV
diastolic collapse. This is impaired filling and tamponade
physiology. At 11:21 a.m. status post pericardiocentesis,
just trivial physiologic pericardial effusion.
HOSPITAL COURSE: This was an 81-year-old woman with a
history of atrial fibrillation, atrial flutter, status post
right atrial isthmus ablation in the summer of [**2175**] admitted
for pacer placement. Procedure complicated by RV perforation
requiring pericardiocentesis with removal of 700 cc of blood.
1. Hemorrhagic pericardial effusion with tamponade: Patient's
drain output
continued to decline and patient's drain was eventually
removed with good results. Patient remained hemodynamically
stable. She got 2 units of packed red blood cells in the
Cath Lab, but was otherwise stable. Patient had follow-up
echocardiogram with no recurrence of the effusion even after
Coumadin was removed. Plans were to stay off Coumadin for at
least one month secondary to this bleed.
Otherwise, patient was started on Ancef 1 gram q.8 initially
and then titrated off.
2. Atrial fibrillation: Patient continued to have episodes
of tachycardia. Patient was continued on her outpatient
regimen eventually and titrated up as tolerated. Patient's
diltiazem dose was titrated up to 180 b.i.d. at time of
discharge. Her atenolol at her home b.i.d. dose regimen was
titrated up to 50 mg b.i.d. Patient was started on aspirin
to which she is to continue especially while she is off
Coumadin. Otherwise, patient was doing well and was planned
for EP study as an outpatient. Patient will follow up with
[**Hospital **] Clinic, on [**4-9**] for Device Clinic and then will
return on [**4-29**] for AVJ ablation.
3. Pneumothorax: Patient had a small pneumothorax after her pacer
placement. Leads were in place and pneumothorax had resolved by
the time of dischar ge on follow-up chest x-ray.
3. Hypothyroidism: The patient was continued on her home
dose of Levoxyl. Patient's TSH was elevated, but her free T4
was in the normal range, and this was likely secondary to
subacute hypothyroid picture. No changes were made during
this acute setting.
DISCHARGE DIAGNOSES:
1. Right ventricle perforation.
2. Atrial fibrillation.
3. Atrial flutter.
4. Hypertension.
5. Hypothyroidism.
6. Pericardial effusion and tamponade.
7. Pneumothorax.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. once a day.
2. Atenolol 50 mg p.o. b.i.d.
3. Diltiazem extended release 180 mg p.o. b.i.d.
4. Ascorbic acid 500 mg p.o. b.i.d.
5. Vitamin E 400 units p.o. q.d.
6. Levothyroxine 75 mcg p.o. q.d.
DISCHARGE CONDITION: Good. Patient is ambulating without
difficulty. Chest pain free at present, no oxygen
requirement.
DISCHARGE STATUS: Discharged to home with followup.
FOLLOW-UP INSTRUCTIONS: The patient is to see her PCP [**Last Name (NamePattern4) **] [**1-17**]
weeks. Patient is to followup in Device Clinic on [**4-9**]
at 9:30 and then for return on [**2177-4-29**] for an AVJ
ablation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2177-4-7**] 13:50
T: [**2177-4-8**] 08:58
JOB#: [**Job Number 26913**]
|
20,014 | V3000,2860,7670,7728,V053,7765,7746 | 142,842 | Admission Date: [**2153-4-17**] Discharge Date: [**2153-4-27**]
Date of Birth: [**2153-4-17**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 5253**] is a term infant admitted with
increasing head circumference and bruising. He was born to a
31-year-old G1 P0 now 1 mother with unremarkable prenatal
screens as follows: O positive, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, rubella immune,
PREGNANCY HISTORY: Estimated date of delivery was [**2153-4-23**] for estimated gestational age of 39-1/7 weeks.
Pregnancy was complicated by oligohydramnios with an AFI of
3.5 and by multiple evaluations for decreased fetal movement.
There was spontaneous onset of labor progressing through
vacuum assisted vaginal delivery under epidural anesthesia.
clear amniotic fluid, no antepartum maternal fever or fetal
tachycardia, no antepartum antibiotic prophylaxis.
Baby was vigorous at delivery, was bulb suction, dried, and
had free flow oxygen administered briefly. Apgars were
nine and nine. In the Newborn Nursery, he initially had a
caput which increased in the amount of swelling and bruising
in the subsequent 24 hours. He was then referred to the NICU
for assessment and management of the increased bleeding.
PHYSICAL EXAMINATION UPON ADMISSION TO THE NICU: Birth
weight was 3850 grams. Head circumference was 41 cm. HEENT
was significant for swelling of the scalp tissue in
generalized distribution with ecchymosis extending from the
occiput to the posterior auricular area and dorsal aspect of
the neck to the mid cervical level. Ears were displaced
forward. Eyes were normal. Neck and mouth were normal. No
nasal flaring. Chest: No retractions, good breath sounds
bilaterally, no crackles. Cardiovascular: Regular, rate,
and rhythm. Femoral pulses normal, S1, S2 were normal.
There was a 1/6 systolic ejection murmur in the upper left
sternal border without radiation. Abdomen was soft,
nontender, no organomegaly, no masses. Bowel sounds are
active and patent. CNS active, responsive to stimulation.
Pupils are reactive to light. Tone is normal, moving all
limbs symmetrically, irritable with palpation of the scalp.
Suck, root, gag, grasp, and morrow were normal. Skin: Pale
as above, nonicteric. Musculoskeletal: Normal spine, hip,
clavicles, small mass at the site of previous right
quadriceps intramuscular injection.
An initial head CT scan had revealed extracranial soft tissue
swelling most prominently at the right
frontal-parietal-occipital area extending to the left and to
the upper cervical region. Ventricles were symmetrical and
not compressed. No gross intraparenchymal hemorrhage. But
upon further radiology attending [**Location (un) 1131**], there was a small
bilateral occipital subdural hemorrhage noted.
The initial hematocrit was 21.2, platelets 186. PT was 14.6,
PTT 77 with an INR of 1.4. Fibrinogen was 192. D-dimer was
negative.
ASSESSMENT: This is a term infant with significant
subgaleal hematoma with apparent extension over the past six
hours. There was also elevation of the PTT suggesting
possible inborn coagulopathy. There is also critical anemia
secondary to the subgaleal hemorrhage. He was admitted to
the NICU for further management.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Patient has been on room air maintaining
sats above 95%. No apnea or bradycardia.
2. Cardiovascular: There was an initial murmur on admission
likely secondary to severe anemia which has since resolved.
He remained hemodynamically stable throughout this admission.
3. FEN: Patient was restarted on po feeds as of day of life
three after the bleeding had stabilized. He has been taking
breast milk or Enfamil 20 po adlib. His admission weight was
3850 grams. His weight on discharge was 4055.
4. GI: Given the significant amount of bleeding, baby was
started prophylactically on phototherapy. His bilirubin
peaked on day of life three at 5.4 with a subsequent
bilirubin of 4.6 at which time phototherapy was discontinued.
5. Hematology: Given the rapid extension of the subgaleal
bleed, coagulopathy workup was initiated revealing an
elevated PTT level of 77 as well as factor 8 level that was
below detection in the presence of normal factors 5, 9, 10,
and 11.
He was started on a 50 units/kg bolus of factor 8 followed by
continuous factor 8 infusions at 50 units/kg/day divided
until hourly infusion rates at [**4-19**]. Subsequent factor
8 levels varied with an initial factor 8 level of 18 after
the bolus with which he received another bolus of factor 8 of
50 units/kg and increased factor 8 infusion rate to 65
units/kg/day.
As of [**4-26**], he was switched over to bolus infusion in
preparation of continued home factor 8 administration. His
peak level after a bolus of 75 units/kg of factor 8 was 131.
A trough level at 20 hours after the bolus on day of
discharge was 29. He will continue to receive factor 8 bolus
q day for a total of [**3-12**] weeks in light of the intracranial
hemorrhage, and will be followed by Hematology visiting nurse [**First Name (Titles) **]
[**Last Name (Titles) 49178**] level checks at home.
Currently, the infusion of factor 8 are going through a
jugular Broviac which was placed on [**4-24**] for
administration of factor. His last PTT on [**4-25**] was
68.3. The last hematocrit was on [**4-25**] of 54.5.
6. Neurology: Baby [**Name (NI) **] [**Known lastname 5253**] initially presented with
significant subgaleal bleed as well as a small subdural
hemorrhage. A repeat head CT scan on [**4-24**] had shown
the resolution of the subdural hematoma and significant
improvement of the subgaleal bleed. His head ultrasound on
[**4-23**] reveals no interventricular hemorrhage. He had
remained neurologically stable. His head circumference on
[**4-27**] was 36.5 cm with a maximum head circumference on
admission of 40.5 cm.
7. Social: Both parents are very involved in the care of
Baby [**Name (NI) **] [**Known lastname 5253**]. They have been informed up to date on his
needs, discharge from the hospital. Teaching has been
completed on the care of the Boviak as well as administration
of factor 8.
8. Sensory: Audiology: Hearing screen was performed
automated auditory brain stem responses and Baby [**Name (NI) **] [**Known lastname 5253**]
passed bilaterally.
CONDITION ON DISCHARGE: Baby [**Name (NI) **] [**Known lastname 5253**] had been stable with
improvement of the subgaleal bleed and good peak and trough
factor 8 levels after the bolus infusion.
DISPOSITION: Baby [**Name (NI) **] [**Known lastname 5253**] is to be discharged home with
parents with close Hematology VNA followup.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 43197**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Breast milk Enfamil 20 po adlib as
tolerated.
2. Medications: Factor 8 boluses at 75 units/kg/day.
3. Car seat position screening passed.
4. State Newborn Screen sent.
5. Immunizations: Received hepatitis B vaccination on [**4-25**].
FOLLOW-UP APPOINTMENT: Scheduled for [**4-30**].
DISCHARGE DIAGNOSIS:
1. Factor 8 deficiency.
2. Subgaleal hemorrhage, resolved.
3. Small occipital subdural hemorrhage, resolved
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Name8 (MD) 47634**]
MEDQUIST36
D: [**2153-4-27**] 13:58
T: [**2153-4-27**] 14:22
JOB#: [**Job Number 49179**]
|
20,015 | V3000,7742,V290,V502,V053,76518,76527,7706 | 194,051 | Admission Date: [**2159-8-26**] Discharge Date: [**2159-9-1**]
Date of Birth: [**2159-8-26**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 6692**] was born at 34
5/7 weeks gestation to a 37 year old gravida III, para 0, now
I woman. The mother's prenatal screens are blood type B
negative, antibody negative, rubella immune, RPR nonreactive,
hepatitis surface antigen negative and group B strep unknown.
The mother was diagnosed with antiphospholipid antibodies
after having had two spontaneous losses. This pregnancy was
conceived with Clomid and intrauterine insemination. She was
treated with Lovenox daily during the pregnancy. She had
spontaneous rupture of membranes and labor was induced with
Pitocin. She had a spontaneous vaginal delivery. The Apgars
were 8 at one minute and 9 at five minutes.
The birth weight was 2,165 grams (30th percentile), the birth
length 43 cm (25th percentile), and the head circumference 32
cm (50th percentile.
ADMISSION PHYSICAL EXAMINATION: Revealed a preterm infant,
anterior fontanelle soft, open and flat, positive bilateral
red reflexes. Palate intact. Mild intercostal retractions.
The breath sounds were clear and equal. Heart was regular
rate and rhythm, no murmur. Abdomen benign. No
hepatosplenomegaly. Three vessel umbilical cord. Normal
back, stable hip examination. Normal male genitalia for
gestational age with testes descended bilaterally.
Appropriate tone and strength.
NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS: Respiratory:
The infant has always remained on room air. He had some
initial tachypnea and retractions which resolved in the first
few hours of life. He has had no episodes of apnea,
bradycardia or desaturation. On examination his respirations
are comfortable. Lung sounds are clear and equal.
Cardiovascular: He has remained normotensive throughout his
Neonatal Intensive Care Unit stay. There are no
cardiovascular issues.
Fluid, electrolyte and nutrition status: At the time of
discharge his weight is [**2184**] grams. Enteral feeds were begun
on the day of life number one and advanced without difficulty
to full volume feeding. At the time of discharge he is
eating breast feeding and supplementing with 20 calorie per
ounce formula on an ad lib schedule.
Gastrointestinal status: He never required any phototherapy.
His peak bilirubin on day of life number four was total 11.4,
direct 0.4.
Hematology: His hematocrit at the time of admission was
48.5. He has never received any blood product transfusions.
Infectious Disease Status: The infant was started on
ampicillin and Gentamicin at the time of admission for sepsis
risk factors. The antibiotics were discontinued after 48
hours when the infant was clinically well and the blood
cultures negative.
Genitourinary: The infant was circumcised on [**2159-8-31**]. The
area is healing nicely.
SENSORY:
Audiology screening: The hearing screening was performed
with automated auditory brain stem responses. The infant
passed in both areas.
PSYCHOSOCIAL: The parents have been very involved in the
infant's care during his Neonatal Intensive Care Unit stay.
The infant is discharged in good condition.
Primary pediatric care will be performed by Dr. [**Last Name (STitle) **] of
[**Hospital 57574**] Pediatrics. Telephone number is [**Telephone/Fax (1) 43701**].
RECOMMENDATIONS AFTER DISCHARGE: Feedings: Feeding and
moving toward exclusive breast-feeding is the mother's plan.
The infant is discharged on no medications.
The infant passed a car seat position screening test.
A State Newborn Screen was sent on [**2159-9-1**].
The infant received his first hepatitis B vaccine on [**2159-8-26**].
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis to be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria: 1) Born at less than 32 weeks, 2) born
between 32 and 35 weeks with two of the following: Day
care during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings or 3) With chronic lung disease.
1. Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before
this age and for the first 24 months of the child's live
immunization against influenza is recommended for
household contact and out of home care givers.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 5/7 weeks.
2. Sepsis ruled out.
3. Status post transitional respiratory distress.
4. Status post circumcision.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2159-9-3**] 01:55:21
T: [**2159-9-3**] 09:06:46
Job#: [**Job Number 57575**]
|
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This is the MIMIC III dataset used to evaluate Meta Llama3 finetuned model. The data is from MIMIC III's NoteEvents table and the DIAGNOSES_ICD table, containing all patients with ID in range 20000-21000.
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