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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**]
| 20,000 | 136,817 | 41401,4111,43310,4439,4401,4019 |
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**]
| 20,001 | 109,756 | 41071,486,1985,4280,41401,412,185,4019,2720 |
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**]
| 20,002 | 126,105 | V3001,76502,769,7485,76522,7470,V290 |
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**]
| 20,004 | 126,550 | 41091,25001,41401,4019,43820,53081 |
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 **]
| 20,005 | 145,132 | 5849,2765,78039,431,5990,41071,41519,51882,42731 |
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**]
| 20,006 | 151,980 | 0389,51881,78552,41071,43411,5070,4280,5849,4241,42731,2765,99592,V1046,2720,7455 |
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 | 188,442 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 |
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 | 188,442 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 |
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 | 188,442 | 51881,5601,42731,4821,5990,00845,4280,3599,V550 |
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 | 192,297 | 51881,9982,5121,5180,496,42731,4280,5119,4820 |
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 | 192,297 | 51881,9982,5121,5180,496,42731,4280,5119,4820 |
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**]
| 20,007 | 193,793 | 486,51881,5990,42731,2761,2767,2639,496,4019 |
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**]
| 20,008 | 157,837 | V3401,76527,76516,7746 |
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 | 126,068 | 78097,40391,5856,4280,42830,2767,25080,29040,4370,2819,7245,4389 |
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 | 161,220 | 99673,2767,5856,40391,E8782,2948,28521,60000 |
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 | 190,619 | 0389,78552,6012,5990,5856,40391,51881,41091,5647,29041,V667,99592,4370 |
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
| 20,009 | 192,836 | 6011,7907,5997,40391,5856,0414,29040,4589,2819 |
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
| 20,010 | 161,812 | 41071,4280,99672,78551,9971,4275,5185,41401,4019,25000,2720,2948,311,V4581,V667 |
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 | 100,281 | 4280,41091,486,42731,00845,2765,41401 |
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 | 100,281 | 4280,41091,486,42731,00845,2765,41401 |
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 | 100,281 | 4280,41091,486,42731,00845,2765,41401 |
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**]
| 20,011 | 100,281 | 4280,41091,486,42731,00845,2765,41401 |
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**]
| 20,012 | 148,002 | 43310,41401,V4581,53081,311,V433 |
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**]
| 20,013 | 116,051 | 42731,9971,9982,5121,42732,4239,4019,2449,2720 |
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**]
| 20,014 | 142,842 | V3000,2860,7670,7728,V053,7765,7746 |
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**]
| 20,015 | 194,051 | V3000,7742,V290,V502,V053,76518,76527,7706 |
Admission Date: [**2161-12-20**] Discharge Date: [**2161-12-23**]
Date of Birth: [**2107-6-7**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine; Iodine Containing / Naprosyn
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization and primary stent to distal RCA
History of Present Illness:
54yo man with pmh significant for CAD, h/o CABG [**2158**] (LIMA and
SVG to LAD, SVG to OM, SVG to PDA) presented to the ED c/o
midsternal chest pain radiating between shoulders. Pain [**7-28**],
sudden onset lasting for 30 minutes prior to arrival at ED,
associated with SOB, without
N/V/diaphoresis/parasthesias/fever/chills. EMS administered NTG
with subsequent BP drop. ECG revealed 1 mm STE inferiorly with
hyperdynamic T waves. In cath lab, LMCA with mild disease, LAD
totally occluded after second septal, graft to LAD not engaged,
presumed occluded. Left cx widely patent, SVG occluded, RCA
with patent proximal stent, total occlusion of mid RCA with left
to right collaterals to PL. All SVG occluded (to OM) or
presumed occluded (LAD, RCA). RCA was stented with cypher
stent, PL was dilated with balloon. Pt transferred to unit for
monitoring.
Social History:
Patient lives with his wife
and two daughters.
Physical Exam:
T 98.9 BP 112/67 HR 76 RR 18 O2Sat 98% 2L; General appearance:
no apparent distress. Head and neck is nonicteric, mucosa
moist. No JVD. Lungs are clear to auscultation
bilaterally.
Cardiac examination: Distant heart sounds, regular rate and
rhythm. Abdomen is obese, nontender, and nondistended.
Extremities had no clubbing, cyanosis, or edema. Neurologic
examination: Is alert and oriented times three, grossly
nonfocal exam. Groin: cath site without hematoma or bruit.
Pertinent Results:
Cardiac Cath - COMMENTS:
1. Selective coronary angiography revealed a right dominant
system
with acute occlusion of the RCA. THe LMCA had mild diffuse
disease. The
LAD was totally occluded after the second septal. The composite
SVG-LIMA graft to the LAD was not engaged or seen on aortography
and is
presumed occluded. The LCx had a widely patent stent in the
native OM1
artery. The SVG to OM is stump occluded. THe RCA had a patent
proximal
stent and total occlusion of the mid RCA with left to right
collaterals
to the PL branch. The SVG to RCA is known occluded from prior
cath.
2. Hemodynamics revealed significantly elevated left and right
heart
filling pressures, pulmonary hypertension and preserved cardiac
index.
3. Left ventriculography was note performed.
4. Successful PCI of the RCA with a 3.5 x 33 mm Cypher DES,
post-dilated with a 4.0 mm balloon. Successful balloon
angioplasty of
the RPL with a 2.5 x 15 mm balloon.
FINAL DIAGNOSIS:
1. Acute inferior myocardial infarction, managed by primary PCI.
2. Elevated left and right heart pressures with preserved
cardiac
output.
3. Successful PCI of the RCA.
.
.
Echo - Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is mildly dilated with mild
regional left
ventricular systolic dysfunction including severe hypokinesis of
the basal
half of the inferior and inferolateral walls. The remaining
segments contract
well. The ascending aorta is mildly dilated. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion. Trace
aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild
to moderate ([**12-20**]+) mitral regurgitation is seen. There is mild
pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with regional
systolic
dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild
pulmonary artery
systolic hypertension. Milldly dilated ascending aorta.
.
.
[**2161-12-20**] 10:51PM WBC-5.5 RBC-4.38* HGB-12.1* HCT-35.8* MCV-82
MCH-27.6 MCHC-33.8 RDW-13.0
Brief Hospital Course:
Pt was admitted and was taken to the cardiac catheterization lab
where he received a cypher stent to the RCA. His hospital
course was significant only for demonstrating several episodes
of junctional rhythm which responded to atropine. Routine post
myocardial infarction echo demonstrated an ejection fraction of
40 %. He was discharged to home to continue care with his
cardiologist on an outpatient basis.
Medications on Admission:
Aspirin 325 mg
Atorvastatin Calcium 80 mg
Metoprolol Tartrate 25 mg [**Hospital1 **]
Zetia 10 mg
Moexipril 7.5 mg [**Hospital1 **]
Celebrex 100 mg [**Hospital1 **]
Zoloft 100 mg
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Moexipril HCl 15 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
myocardial infarction
hypertension
hypercholesterolemia
gastro esophageal reflux disease
Discharge Condition:
stable
Discharge Instructions:
Adhere to 2 gm sodium diet
Followup Instructions:
1)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-12-28**] 9:40
2)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-1-5**] 1:20
3)Dr.[**Name (NI) 9388**] office will contact you to make an appointment
with him within the next several weeks
Completed by:[**2162-1-11**] | 20,018 | 139,528 | 41071,V4581,4019,53081,311,7291 |
Admission Date: [**2165-5-24**] Discharge Date: [**2165-5-27**]
Date of Birth: [**2107-12-9**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
right-handed woman who was evaluated by a neurologist for
vertigo.
She indicates she was in her usual state of good health until
approximately five days prior to her evaluation when she had
complaints of the acute onset of vertigo, a sensation of
being off balance, and vomiting. She also reports associated
blurry vision with no headache, tinnitus, sensory symptoms,
or speech difficulties. Her daughter, however, who was
present during the interview today indicates that her speech
was somewhat slurred.
She was taken to [**Hospital **] Hospital where a head computed
tomography showed "an abnormality." She had a magnetic
resonance imaging/magnetic resonance angiography of the brain
which showed evidence of a right posterior communicating
artery aneurysm.
She was referred to Dr. [**Last Name (STitle) 1132**] for endovascular vs. surgical
therapy. She was admitted on [**2165-5-24**] for a conventional
angiogram and consideration for endovascular treatment.
PHYSICAL EXAMINATION ON PRESENTATION: She was a
well-developed woman who appeared in mild discomfort. Her
blood pressure was 120/80, her pulse was 72, her respiratory
rate was 12, and she was afebrile. She was alert, awake, and
fully oriented. Speech and language function were intact.
Judgment, memory, and calculations were intact. Affect was
appropriate. There was no apraxia, agnosia, or neglect.
Cranial nerve examination revealed visual acuity was normal.
She had a slight anisocoria with the left pupil approximately
4 mm in diameter and the right 3 mm. Both were equal, round,
and reactive to light. There was no Horner syndrome or
ptosis. The visual fields were full. Extraocular movements
were full in all directions. Facial movement was intact.
There was decreased sensation to touch on the left side of
the face. Hearing was intact to rub. The palate elevated
symmetrically. Motor examination revealed normal tone and
muscle strength throughout. Cerebellar function was normal
except for subtle clumsiness of the finger-to-nose on the
left side. She also had slight difficulty drawing a figure
eight with the left foot compared to the right. Deep tendon
reflexes were 2+ throughout.
SUMMARY OF HOSPITAL COURSE: She was admitted for angiogram
for coiling of the right posterior communicating artery
aneurysm. There were no intraoperative complications.
Postoperatively, she was monitored in the Intensive Care Unit
for close neurologic observation. She was started on
heparin. The patient was in the Intensive Care Unit
recovering from the coiling when she had the onset of
unresponsiveness and bilateral pinpoint pupils. Her blood
pressure rose to greater than 180 for a few minutes and then
she had slight twitching of her head. She was immediately
intubated and sedated and brought to head computed tomography
which showed no evidence of bleeding or stroke. She was
loaded prophylactically with Dilantin and started on
Decadron. Her blood pressure was kept at less than 140.
On [**5-25**], the patient was alert, awake, and oriented times
three. She had some double vision in the left lateral gaze.
She had negative drift. She had a slight hematoma of the
right leg. Her iliopsoas were [**6-19**]. Her pulses were intact.
Her Decadron was decreased. She was continued on Dilantin.
She was out of bed to chair.
On [**5-26**], there was no seizure activity. She was alert,
awake, and oriented times three and moving all extremities
with good strength. No drift. She continued to have a left
lateral gaze minimal diplopia. She was stable, and she was
transferred to the regular floor.
On [**5-27**], she continued to be neurologically stable
without any evidence of seizures. Alert, awake, and oriented
times three. Moving all extremities. Her speech was fluent.
DISCHARGE DISPOSITION: She was discharged on [**5-27**] in
stable condition with followup with Dr. [**Last Name (STitle) 1132**] in one week.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets by mouth q.4h. as needed.
2. Decadron 2 mg by mouth q.6h. (for three days).
3. Famotidine 20 mg by mouth twice per day.
4. Dilantin 100 mg by mouth three times per day.
5. Aspirin 325 mg by mouth once per day.
CONDITION AT DISCHARGE: Stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2165-5-27**] 13:56
T: [**2165-5-29**] 14:13
JOB#: [**Job Number 54801**]
| 20,019 | 172,281 | 4373,99709,78039,3682,30000,E8788 |
Admission Date: [**2177-10-13**] Discharge Date: [**2177-11-17**]
Date of Birth: [**2177-10-13**] Sex: M
Service: NEONATOLOGY
HISTORY: This is the 1.315 kg product of a 28 [**1-9**] week twin
gestation, born to a 27-year-old GI P0-II mother. Prenatal
screens notable for maternal blood type A positive, antibody
surface antigen negative, group B strep unknown. This is a
Ultrasound at 23 weeks showed size discordance, attributed to
twin-twin transfusion syndrome. Subsequent ultrasound showed
increasing oligohydramnios but good biophysical profiles.
The mother completed steroid therapy. These patients were
delivered by cesarean section. Twin I emerged apneic but
minutes.
1. Respiratory: The child was intubated and given 2
doses of surfactant, and rapidly weaned to CPAP and then
nasal cannula. Intermittently the child had to go back on
CPAP for increased spelling. He was started on caffeine and
subsequently weaned onto nasal cannula on DOL #16 and onto RA on
DOL#34. He is currently on caffeine. He has occasional spells.
2. Fluids, electrolytes and nutrition: He was initially
nil by mouth and started on intravenous fluids. His
feeds were advanced as tolerated .He is currently tolerating
150 cc/kg of PE28 with ProMod po/pg.
3. Infectious Disease: The patient had started antibiotics.
Culture were negative at 48 hours, and these were
discontinued. When he had increased spells, repeat CBC and
blood cultures were done, but no further antibiotics were
started. He is currently off all antibiotic therapy.
4. Cardiovascular: He never required blood pressure
support, although he did have a murmur and was given a course
of indomethacin. His murmur persisted. An echocardiogram
was performed, which showed that he had a mild biventricular
outflow obstruction, probably secondary to hypovolemia, but
no structural heart disease and no duct. Repeat ECHO on DOL#28
revealed improved but mild biventricular hypertrophy, which will
need to be followed as an outpatient at the Cardiology Clinic.
5. Hematology: He received a blood transfusion of 50 cc/kg
since his hematocrit was relatively low and his
echocardiogram was consistent with hypovolemia. He did
require phototherapy for hyperbilirubinemia, however, at this
time, he is off of phototherapy, with normal bilirubin
levels.
6. Neurology: HUS on [**10-15**] and [**10-23**] were within normal limits
Follow up HUS on [**2177-11-13**] revealed caudothalamic groove cyst
PHYSICAL EXAMINATION: He is 2.170kg, he is non-dysmorphic.
His cardiac examination shows a II/VI systolic murmur, regular
rate and rhythm. His lung examination is clear bilaterally.
His abdomen is soft and nondistended. The rest of his physical
examination is within normal limits.
CONDITION AT THE TIME OF THIS SUMMARY: Stable.
FOLLOW UP
1. Paediatric Cardiology in mid [**Month (only) **] to F/U biventricular
hypertrophy- parents will need to call for appointment
2. ROP screen on [**2177-11-19**]
MEDICATION
Caffeine 15mg po/pg qd
Vit E 5 IU po/pg qd
Ferrinsol 0.15cc po/pg qd
DIAGNOSIS LIST:
1. Prematurity
2. Status post twin-twin transfusion
3. Mild apnea of prematurity
4. Status post rule out sepsis
5. Mild biventricular hypertrophy
6. Right subependymal cysts with resolved bilateral germinal
matrix haemorrhages
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477
Dictated By:[**Name8 (MD) 45197**]
MEDQUIST36
D: [**2177-10-31**] 17:56
T: [**2177-11-1**] 00:00
U: [**2177-11-17**] 09:00
JOB#: [**Job Number 35882**]
| 20,021 | 104,946 | V3101,76515,7742,77081,4293,74689 |
Admission Date: [**2136-12-21**] Discharge Date: [**2136-12-23**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old man
who presents with shortness of breath. He was recently
admitted to [**Hospital1 **] with chest pain on
[**2136-12-15**]. Patient ruled in for a myocardial infarction with
peak CK of over [**2135**]. Cardiac catheterization was done which
showed three-vessel disease with an ejection fraction around
30%. Decision was made to manage the patient medically. He
was also made DNR/DNI. He was discharged to rehab on
[**2136-12-18**].
Patient was sent back to the Emergency Department today
because of difficulty breathing. Patient was only able to
provide limited history, but states he is still short of
breath and is having cough. He denies chest pain.
PAST MEDICAL HISTORY: Hypertension, depression, three-vessel
coronary artery disease with an ejection fraction of 30%.
MEDICATIONS ON ADMISSION: Aspirin, Lopressor, captopril,
Lipitor, Protonix, Colace, Serzone, and Tylenol.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Patient has a father with coronary artery
disease.
PHYSICAL EXAMINATION AT TIME OF ADMISSION: Vital signs:
96.6, pulse 100, blood pressure 100/50, respiratory rate 40,
and sating 98% on 100% nonrebreather. Generally he was in
respiratory distress on 100% nonrebreather. HEENT: Pupils
are equal, round, and reactive to light. OP with dry mucous
membranes. Neck: Positive jugular venous distention. CVP
estimated around 10. Respirations: Diffuse rhonchi most
prominent in the right lower posterior lung fields. Coronary
examination: regular, rate, and rhythm, no murmurs, rubs, or
gallops. Abdomen was soft and nontender with positive bowel
sounds, mild diffuse tenderness. Extremities: He had trace
edema. Neurologic: He was alert and oriented times three.
LABORATORIES ON ADMISSION:
He had a white count of 19.0, hematocrit of 32.0, platelets
407,000. Sodium 134, potassium 6.2, chloride 100, bicarb 18,
BUN 63, creatinine 2.8.
His electrocardiogram showed a left bundle branch block.
Chest x-ray with a bilateral infiltrates right greater than
left and bilateral pleural effusions.
ASSESSMENT AND PLAN:
This is an 80-year-old man recently admitted with large
myocardial infarction and now presenting with shortness of
breath and increased respiratory rate. Chest x-ray
suggestive of pneumonia and possible congestive heart
failure.
1. Pulmonary. Plan to treat pneumonia with ceftriaxone and
azithromycin in this critically ill patient. Also plan to
continue oxygen, culture sputum, make him NPO. Pulmonary
edema may also be playing a role, but will hold on Lasix
given his hypotension.
2. Cardiovascular. Three-vessel coronary artery disease
holding his po medications. Will consider restarting aspirin
overall amount for myocardial infarction.
3. Renal. Creatinine increased. Check urine, electrolytes,
and Foley.
4. ID. Blood cultures times two. Urine cultures. Sputum
cultures. Ceftriaxone and azithromycin for pneumonia as
above.
5. Gastrointestinal. NPO.
6. Code status. DNR/DNI.
7. Communication. Discussed with son and told him the next
12-24 hours are critical.
HISTORY OF HOSPITAL COURSE:
The patient began to have evidence of a further myocardial
infarction with CK of 278 and a troponin of over 50. Patient
was made comfort measures only. He is not a candidate for an
invasive intervention. The patient continued to do poorly
and died at 1 pm on [**2136-12-23**] after extensive discussions with
the family. It was decided to discontinue oxygen.
CONDITION ON DISCHARGE:
Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36903**], M.D. [**MD Number(1) 36904**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1201**], M.D.
MEDQUIST36
D: [**2136-12-23**] 13:19
T: [**2136-12-27**] 06:06
JOB#: [**Job Number 32157**]
| 20,023 | 179,425 | 486,4280,41091,5849,51881,4019 |
Admission Date: [**2159-8-10**] Discharge Date: [**2159-8-27**]
Date of Birth: [**2097-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2159-8-13**] Two vessel coronary artery bypass grafting utlizing the
left internal mammary to left anterior descending with vein
graft from left internal mammary to obtuse marginal.
[**2159-8-10**] Cardiac catheterization with placement of IABP
History of Present Illness:
This is a 61 year old Portuguese speaking man with history of
hypertension and hyperlipidemia was admitted for an elective
catheterization after an increase in DOE and increasing CP with
walking. At present he is able to walk only 2 blocks before he
becomes short of breath.
He was previously quite active and athletic until two years ago
when he began to have significant dyspnea on exertion and
fatigue. He has a long standing history of tobacco and alcohol
abuse. In [**2158-6-27**] while having a doctor's appointment, he
was found to be extremely hypertensive and was admitted to
[**Hospital3 2737**]. Testing at that time included a Cardiolite ETT
where he exercised 5 minutes 31 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, 87%
max PHR, stopping due to leg pain. EKG was non diagnostic due to
baseline ST abnormalities. He had no chest pain. Imaging did not
reveal any definite evidence of inducible ischemia. EF was noted
at 22%. Echo on [**2158-7-25**] revealed a dilated LV with an EF of 25%
with severe global hypokinesis.
Last month the patient was admitted to [**Hospital6 **] in
[**Location (un) 5503**] for a syncopal event. This was witnessed by a family
member. He apparently had lost consciousness for several
minutes. He was ruled out for an MI and told that this was most
likely due to dehydration as it was a very hot day. Per Dr. [**Name (NI) 63433**] notes, an echo suggested a regional wall motion
abnormality and persantine ETT suggested some anterior apical
infarct with some
inferoposterior ischemia. Cardiac catheterization was
recommended but the patient refused. His family has since been
able to convince him to have angiography. His daughter reports
that her father can look short of breath at
rest and with any type of walking. Previously he was quite
athletic and now he cannot even walk a of a mile. She states
that he easily becomes lightheaded when involved in light
exertion or on a hot day. She also reports that over the past
few months he has been getting chest discomfort with walking. He
does
not use SL nitroglycerin. She is unclear if he has a history of
orthopnea or PND. She reports that he does not have LE edema. He
does complain of leg
fatigue with minimal amounts of walking. She reports that he has
smoked 2 packs a day for over forty years and he has recently
cut back to a pack a day. She also states that he has been
drinking for at least forty years, currently
imbibing in several beers and several glasses of wine throughout
the day. He is also very non compliant with medications.
Past Medical History:
Cardiomyopathy, History of Syncope, ? Prior MI, Hypertension,
Hyperlipidemia
Social History:
Patient is widowed and currently lives with his mother. [**Name (NI) **] is
Portuguese speaking. He previously worked in a warehouse until
last year, stopping d/t his health. Daughter reports that he has
smoked 2 packs a day for over forty years and he has recently
cut back to a pack a day. She also states that he has been
drinking for at least forty years, currently imbibing in several
beers and several glasses of wine throughout the day. His
daughter [**Name (NI) **] helps out with his care.
Family History:
Mother with several [**Name (NI) 5290**] and a CVA in her 70's.
Physical Exam:
Vit: 140-150's/80-90, 81 regular, 18
Gen: WDWN male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
CV: regular rate and rhythm, normal s1s2, no murmur or rub
Pulm: clear bilaterally
Abd: benign, no organomegaly
Ext: warm, no edema
Skin: no lesions
Neuro: alert and oriented, mood appropriate, cranial nerves
grossly intact, FROM, 5/5 strength, no focal deficits
Pertinent Results:
[**2159-8-25**] 06:40AM BLOOD WBC-11.0 RBC-3.51* Hgb-10.8* Hct-31.0*
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.9 Plt Ct-696*
[**2159-8-26**] 06:20AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-133
K-4.4 Cl-99 HCO3-24 AnGap-14
[**2159-8-24**] 07:05AM BLOOD Mg-1.9
[**2159-8-11**] 08:44AM BLOOD Triglyc-144 HDL-43 CHOL/HD-4.2
LDLcalc-108
[**2159-8-11**] 08:44AM BLOOD TSH-3.5
Brief Hospital Course:
Mr. [**Known lastname 19688**] was admitted and underwent elective cardiac
catheterization which was signficant for severe three vessel
disease(including left main) and severely depressed left
ventricular function. Angiography demonstrated a co-dominant
system with an 80% distal left main lesion, a heavily calcified
LAD with 80% mid stenosis, an 80% lesion in the first obtuse
marginal and a proximal 60% lesion in the right coronary artery.
Ventriculogram revealed 1+ mitral regurgitatin and an LVEF of
25%. Based on his critical coronary anatomy, an IABP was placed
to augment diastolic filling. Of note, catheterization was
complicated by vasovagal episode which responded well to IV
fluids and Atropine. Cardiac surgery was subsequently consulted
and further evaluation was performed. An echocardiogram on [**8-11**] was notable for normal left ventricular cavity size. The
overall left ventricular systolic function was
moderately-to-severely depressed (ejection fraction 30%)
secondary to
severe hypokinesis of the anterior septum, anterior free wall,
and apex. There was only mild(1+) mitral regurgitation. Workup
was otherwise unremarkable and he was cleared for surgery. He
remained pain free on medical therapy.
On [**8-13**], Dr. [**Last Name (STitle) **] performed two vessel coronary artery
bypass grafting. Operative findings were notable for a heavily
calcified aorta. A cross-clamp was not utilized. The heart was
therefore on bypass beating and the Guidant CTS off-pump system
was used to obtain exposure on a beating empty heart. His
operative course was otherwise uneventful and he transferred to
the CSRU for further invasive monitoring. Within 48 hours, he
awoke neurologically intact and was extubated. He maintained
stable hemodynamics as he weaned from inotropic support. The
IABP was removed without complication. He experienced
intermittent fevers with negative workup - blood and urine
cultures remained negative. On postoperative day four, he
transferred to the SDU.
He went on to experience some confusion/agitation which
initially required Haldol. Narcotics were also withheld. His
symptoms progressed to visual hallucinations, diplopia, left
visual field cuts associated with mild left sided weakness and
facial droop. Neurology was urgently consulted and a head
MRI/MRA was obtained on [**8-20**]. Findings were suggestive of a
large subacute right occipital lobe infarct, within posterior
cerebral artery territory. No was no evidence of intracranial
bleed. Aspirin therapy was continued. Over the remainder of his
hospital stay, his neurologic/mental status gradually improved
and nearly returned to baseline. He worked daily and continued
to improve with physical and occupational therapies. At
discharge, his confusion had resolved and he had normal motor
function. Unfortunately, he continued to experience left visual
field cuts. He had no more diplopia.
Given his depressed LV function, he was maintained on an ACEI
and Coreg. He remained in a normal sinus rhythm without atrial
or ventricular dysrhythmias. He was concomitantly diuresed
toward his preoperative weight. He responded well to Lasix and
by discharge, was near his preoperative weight with oxygen
saturations of 98% on room air. His renal function remained
normal. Just prior to discharge, he was treated with a short
course of intravenous antibiotics for a superficial phlebitis.
He was eventually discharged to home on postoperative day 14. He
will be tranisitioned to PO antibiotics and follow up with Dr.
[**Last Name (STitle) **] in approximately 4 weeks.
Medications on Admission:
Metoprolol 50mg twice a day
Lipitor 20mg daily
Lisinopril 10mg daily
HCTZ 12.5mg daily
Digoxin 0.25mg daily
Asa 325mg daily
NTP (unknown dose) daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Southeastern MA
Discharge Diagnosis:
CAD - s/p CABG
Rt occipital CVA(postop)
Cardiomyopathy
s/p MI
HTN
Hyperlipidemia
Phlebitis
Discharge Condition:
Good.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 2 pounds in
one day or five in one week. Call with temperature more than
101.5, redness or drainage from incision.
No driving, no lifting more than 10 pounds until follow up with
surgeon.
Adhere to 2 gm sodium diet
2 quarts Fluid Restriction
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Local PCP 2 weeks
Cardiologist Dr. [**Last Name (STitle) 8098**] in 2 weeks
Completed by:[**2159-9-13**] | 20,024 | 199,903 | 41401,4280,4111,4240,4254,30391,5997,99702,4538,4019,3051,45829,E8790,E8498,2724,E8782,E8497 |
Admission Date: [**2110-6-13**] Discharge Date: [**2110-6-14**]
Date of Birth: [**2050-6-20**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
lady with past medical history significant for irritable
bowel syndrome, hypertension, and hypercholesterolemia, who
presents with bright red blood per rectum. The patient had a
routine screening colonoscopy on [**2110-6-12**] at 11:30 a.m. She
was found to have a polyp, which was removed. The patient
was also noted to have mild diverticulosis. Around 5:30
p.m., the patient started to pass bright red blood per rectum
approximately 100 to 400 cc every hour. She denied fever,
chills, nausea, vomiting, or abdominal pain. She went to an
outside hospital ED, but was transferred to [**Hospital1 18**] since her
doctor was Dr. [**Last Name (STitle) 1940**] who is associated with [**Hospital1 18**]. In the
ED, her vital signs were temperature 98, blood pressure
149/78, heart rate 80, respiratory rate 17, and saturating 97
percent on room air. Two large bore IVs were placed and the
patient was resuscitated with 2 liters of IV normal saline.
Her hematocrit was noted to drop from 39 to 22.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Inflammatory bowel disease.
MEDICATIONS:
1. Diovan.
2. Premarin.
3. Lipitor.
4. Hydrochlorothiazide.
ALLERGIES: CODEINE CAUSING NAUSEA.
PHYSICAL EXAMINATION: Afebrile, heart rate 80, blood
pressure 100/65, respiratory rate 15, and saturating 100
percent on room air. General: Pale, diaphoretic, alert
female. HEENT: Oropharynx clear. Sclerae anicteric, but
pale. Cardiovascular: The patient is tachy without murmurs,
rubs, or gallops. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft and nontender, normoactive bowel sounds,
positive bright red blood in bedpan. Extremities: No
clubbing, cyanosis, or edema. Pulses were 1 plus
bilaterally.
LABORATORY DATA: Chem-7 was unremarkable. CBC was
remarkable for anemia with hematocrit of 27. KUB showing no
free air.
HOSPITAL COURSE: The patient was admitted to the MICU. On
presentation to the MICU, she had a single IV. Initially her
heart rate was in the 80s and her systolic blood pressure was
in the 120s. However, she became more unstable and her heart
rate jumped to 112 to 115 and her systolic blood pressure
fell to the mid 90s. At this time a second IV was placed.
The patient was transfused with packed red blood cells
through both IVs. She remained tachycardiac and producing
large amounts of blood per rectum. The decision was made to
place a central line to allow for aggressive volume
resuscitation. During the placement of the central line, the
patient was complaining of some back pain, however, the wire
fed easily and a 3-lumen catheter was placed. On chest x-
ray, the catheter appeared to leave the subclavian vein into
an internal mammary vein. However, since the central line
both flushed and true blood, it was left in place
temporarily. However, after the transfusion of 3 units of
packed red blood cells the patient was stable, producing less
blood per rectum, non-tachycardiac, the base systolic blood
pressure in the 120s. Thus the central line was
discontinued. The patient was seen by Dr. [**Last Name (STitle) 1940**] and the GI
fellow. They took the patient to Endoscopy where they found
red blood in the transverse, left, sigmoid, and rectum.
There was no blood in the right colon. The polypectomy site
was identified opposite the valve. It had a red clot on it,
but was not bleeding. The clot was washed off. No bleeding
was noted. Then 10 cc of epinephrine was injected 1:10,000
dilution into and around the base of the polypectomy. After
this, BL-CAP electrocautery was applied for hemostasis
successfully. There was no bleeding at the conclusion of the
procedure. After this procedure, the patient's hematocrit
remained stable. She was advanced to a clear liquid diet
without difficulty. She had no additional episodes of bright
red blood per rectum. Her diet was further advanced. She
was monitored overnight and remained hemodynamically stable.
She was discharged home the following day with followup to
see Dr. [**Last Name (STitle) 1940**]. No changes to her medications were made.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS: Gastrointestinal bleed status post
polypectomy.
DISCHARGE MEDICATIONS: No changes were made to her
outpatient regimen.
FOLLOWUP PLANS: The patient was asked to follow up with Dr.
[**Last Name (STitle) 1940**] on Monday.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 39096**]
Dictated By:[**Doctor Last Name 2020**]
MEDQUIST36
D: [**2110-6-16**] 05:32:08
T: [**2110-6-16**] 06:14:05
Job#: [**Job Number 20597**]
| 20,025 | 111,968 | 99811,2765,E8788,5641,4019,2720,27541,5789 |
Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-13**]
Date of Birth: [**2122-8-20**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 74-year-old woman with
history of Alzheimer's disease and hypercholesterolemia who
has had two to three months of 25 pound weight loss, anorexia
and dysphagia. She also reports increased burping. This was
thought initially to be a side effect of Aricept, which was
started approximately six months ago, however, with
persistence of these symptoms, she reported to her primary
care physician's who initiated a malignancy work-up. She was
found to have pulmonary nodules on chest x-ray suspicious for
lung metastases, guaiac positive stools, anemia, increased
LFTs and also a bone scan positive for metastatic disease.
The primary site of cancer was unknown. She was scheduled
for a barium swallow on [**4-7**] and it is unclear whether
this was done or not. She had a negative mammogram in
[**2196-12-27**].
She was scheduled for a colonoscopy and
esophagogastroduodenoscopy as an outpatient on the morning of
admission, however, earlier that morning, she had an episode
of bright red blood, hematemesis/hemoptysis after taking her
pills. It was only approximately one ounce in quantity.
There were no clots and no sputum. She had no other
associated symptoms of nausea, vomiting, chest pain,
lightheadedness, melena, bright red blood per rectum or
abdominal pain. Her husband also reports she had transient
hematuria ten years ago. An intravenous pyelogram was done
with tomography with finding of widened bladder neck,
otherwise, normal.
The patient was sent from the Emergency Room where her vital
signs were stable to the Esophagogastroduodenoscopy Suite
where it was revealed an abnormal mucosa in the esophagus
from 30 cm to 22 cm distally with adherent clot and moderate
oozing. Colonoscopy was not performed at that time secondary
to active bleeding and she was transferred to the Medical
Intensive Care Unit for one night for observation.
PAST MEDICAL HISTORY:
1. Alzheimer's disease.
2. Weight loss, dysphagia, anorexia, pulmonary nodules on
chest x-ray guaiac positive stools, metastatic bone lesion on
bone scan, increased LFTs,
3. Hypercholesterolemia.
MEDICATIONS AT HOME: Aricept 5 mg po q.d., Lipitor 10 mg po
q.d., Prempro .625/2.5 mg q.d., Centrum multivitamin.
FAMILY HISTORY: No coronary artery disease. Father with
duodenal/stomach cancer. Mother with question of mass in
chest.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with her husband. One son, two
grandchildren. She smokes less than one pack per day times
35 years and has occasional alcohol use.
REVIEW OF SYSTEMS: No fevers, chills, nausea, vomiting,
shortness of breath or chest pain.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.1. Pulse
96. Blood pressure 113/54. Respiratory rate 14-18. O2
saturation 100% on two liters nasal cannula. In general in
no acute distress, pleasant woman. Neck: No
lymphadenopathy, no thyromegaly, no axillary lymphadenopathy.
Head, eyes, ears, nose and throat: Anicteric sclerae, dry
mucous membranes. Cardiovascular: Regular rate and rhythm,
no murmurs, rubs or gallops. Pulmonary: Clear to
auscultation bilaterally. Abdomen: Soft, nontender,
question of palpable liver edge 2 cm below diaphragm.
Extremities: No edema. Neurological: Cranial nerves
intact. Left lower extremity greater than right lower
extremity weakness, [**2-28**] on the left and [**4-30**] on the right.
LABORATORY DATA ON ADMISSION: White blood cell count 12.5,
hematocrit 26.8, platelets 361,000. Neutrophils 87%,
lymphocytes 8%, monocytes 5%, INR 1.1, PT 12.7, PTT 24.9.
Sodium 138, potassium 3.3, chloride 99, bicarbonate 26, BUN
23, creatinine .8, glucose 120.
WORK-UP PRIOR TO ADMISSION ON [**3-23**]: Sedimentation rate
68, ALT 33, AST 71, alkaline phosphatase 296, T bilirubin .8,
GGT 81, albumin 3.8, total protein 6.9, globulin 3.1, calcium
9.9, TSH 2.6, iron 3, total cholesterol 218, TIBC 280, B12
984, folate greater than 20, ferritin 245, TRF 215, HDL 65,
cholesterol to HDL ratio 3.4, SPEP abnormal band in gamma
region 2% of total protein, IgG 698, IgA 318, IGM 214, IFE
monoclonal IgM cap was seen. 24 hour urine: PH 5, protein
15, volume 380 cc, UPEP no Bence [**Doctor Last Name **] proteins, only
albumin. Urine culture on [**3-23**] negative.
CT of the head without contrast [**2196-6-26**]: Moderate atrophy
without significant abnormalities. Mammogram [**2196-12-27**]:
No evidence of malignancy. Chest PA and lateral [**2197-2-24**]:
Extensive pulmonary and right hilar metastases. Left hip
x-ray [**2197-3-28**]: Normal pelvis and left hip. Bone scan
[**2197-4-7**]: Positive for multiple foci of increased
activity, most likely secondary to metastatic disease,
particularly in the right iliac crest within parietal region
of calvaria.
Esophagogastroduodenoscopy [**2197-4-10**]: Normal stomach,
normal duodenum, esophagus with abnormal mucosa with bleeding
in esophagus from 30 cm where the TE junction is seen to 22
cm proximally, adherent clot, active bleeding and friability.
Lumen narrowed with ulceration and irregular mucosa. No
varices. Biopsy performed at lower [**12-29**] of esophagus and
middle [**12-29**] of esophagus.
IMPRESSION: This is a 74-year-old woman with metastatic
cancer of unclear etiology, although
esophagogastroduodenoscopy results reveal bleeding
ulcerations along the esophagus suggesting primary
adenocarcinoma of the esophagus.
SUMMARY OF HOSPITAL COURSE:
1. Bleeding eosphageal ulcerations: Likely eosphageal
cancer. Patient was in the Medical Intensive Care Unit for
one night and supported with intravenous fluids and
transfused two units. She remained hemodynamically stable
and hematocrit also bumped up appropriately to above 30 with
the transfusions and remained stable throughout her hospital
stay. Two large bore IVs were placed. Patient had no more
episodes of hematemesis or any other signs of active
bleeding. She was transferred to the floor after one night
in the Medical Intensive Care Unit and her diet was advanced
with good toleration. Patient was placed on a Protonix drip
in the unit and once she came to the floor was on Protonix 40
mg po b.i.d.
On the second day of admission, she was noted to have
increased coagulation factors. INR 1.5, PT 14.6, PTT 25.7.
She was started on Vitamin K subcutaneous injections times
three days and her coagulation laboratories normalized by the
time of discharge.
2. Hematology/Oncology: Patient was seen in the hospital by
Dr. [**Last Name (STitle) **] from Hematology/Oncology who had already seen
her once as an outpatient. The biopsy taken during
esophagogastroduodenoscopy was nondiagnostic as it was mainly
clot and necrotic tissue. However, a CT scan was done of her
torso showing mediastinal lymphadenopathy, right hilar
adenopathy, dilation of esophagus with air fluid level in the
distal esophagus and distal esophageal wall markedly
thickened beyond TE junction suspicious for malignancy.
Innumerable pulmonary metastatic lesions and metastatic liver
lesions, little normal liver tissue left, right adrenal mass
likely metastases, renal cyst bilaterally, no free fluid or
free air in the peritoneal cavity or pelvic cavity, no lytic
or blast lesions seen in the bone.
Of note, cavitary metastatic lesions in lungs suggestive of
squamous cell primary. Given this, result of her CT scan, as
well as what was done prior with definite metastatic disease,
the patient's husband was seen by the Home Hospice Service
and choose this as the next route management. Dr. [**Last Name (STitle) **]
and her oncologist also felt that were no aggressive
therapeutic measures to be done at this point, however, at a
later time, if she becomes more symptomatic in terms of her
swallowing or breathing, there may be room for palliative
radiation or stenting placement in her esophagus. The
patient will follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
She was discharged to Home Hospice.
3. Alzheimer's disease. Appears to be moderate. Patient's
family very supportive, making decisions for her. Aricept
was held given her esophageal ulcerations.
CONDITION OF DISCHARGE: Stable.
DISCHARGE STATUS: Home with home hospice.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po b.i.d.
2. Other medications the same except for her Aricept, which
was discontinued.
DISCHARGE DIAGNOSES:
1. Alzheimer's disease.
2. Hypercholesterolemia.
3. Metastatic cancer, possibly of eosphageal origin.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2197-4-14**] 00:01
T: [**2197-4-14**] 00:01
JOB#: [**Job Number 36353**]
| 20,026 | 150,039 | 1505,1977,1970,1985,1987,53082,28522,3310,2720 |
Admission Date: [**2176-6-27**] Discharge Date: [**2176-7-13**]
Date of Birth: [**2108-1-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Avelox
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension to 70s
Major Surgical or Invasive Procedure:
-Tunnel catheter for HD
-Blood and FFP transfusions
-Hemodialysis
History of Present Illness:
68 yo F with tracheobronchomalacia, on heparin gtt for AVR, who
was transferred here from an OSH for IP evaluation and possible
Y stent who is transferred to the MICU for hypotension. She was
initially admitted here on [**6-27**] and had a CT of her airway done
revealing tracheobronchomalacia. She was scheduled for the OR on
Monday for rigid bronch. Her bp remained stable on admission,
and was in the 130s-140s/70s-80s throughout the day on [**6-27**] and
[**6-28**]. On [**6-29**], her bp was 100/80 at 8 am (pulse 92 from 82),
92/43 at noon, and 87/54 at 4 pm (pulse 104). Per thoracic
surgery she was mentating throughout all of this. No UOP
recorded as she was incontinent, but at 8:45 pm a Foley was
placed and drained 250 cc urine. The MICU team was called at 9
pm for hypotension. [**Name8 (MD) **] RN notes her bp was 62/palp (75/p
w/doppler), pulse 120, respirations 32, and 98% on 3L. They
attempted to give a 500 cc bolus but her last peripheral IV
stopped working. She was transferred to the MICU at this time
for CVL placement and further monitoring. Of note, her INR was
subtherapeutic on admission at 1.4, and she was begun on a
heparin drip (due to AVR). Her PTT was greater than 150 since 6
pm last night, and despite adjustments in the heparin gtt it was
last measured at 147.5. Her heparin gtt was shut off at the time
of her MICU transfer.
.
Currently, she is awake but drowsy and is mentating
appropriately. She is complaining of severe abdominal and back
pain which she states has been going on since yesterday. She
also feels very cold.
.
In terms of recent history, she was admitted to [**Hospital 28448**] Center on [**6-17**] with SOB and cough. Initial CXR
was clear. They felt she had a COPD exacerbation and treated her
with steroids, bronchodilators, and azithromycin. On [**6-20**], she
became acutely SOB and CXR showed LUL infiltrate. She was begun
on zosyn and cipro for possible pseudomonal pna (as had
reportedly grown this in past). Swallow study was negative for
aspiration. On [**6-27**] (day of transfer) she was on day 7 of
cipro/zosyn. Per their notes her SOB and cough were much
improved. Her creatinine fluctuated between 1.8 and 2, and was 3
on discharge from the OSH. Her lasix and enalapril were
discontinued there, and she was begun on IVF (total 500 cc).
Renal ultrasound showed R kidney 10.2 cm w/mult cysts, left
normal, no hydro. She had a negative C diff there, blood cx
negative x2, urine cx negative. ABG 7.40/40/77 on [**6-21**].
Past Medical History:
PMH:
1. Tracheobronchomalacia, s/p prolonged intubation/trach in [**2164**]
s/p CABG
2. Recurrent pneumonias, reported hx pseudomonas in sputum
3. Bronchiectasis
4. CAD s/p CABGX5 [**2165**]
5. COPD/restrictive lung disease FEV1 680 ml (39% pred) in [**2174**]
unchanged from [**2168**], TLC 63% pred
6. PVD
7. CHF (mild per notes)
8. Bell's Palsy
9. HTN
10. Hyperlipidemia
11. s/p AVR [**2165**]
12. DM
13. CKD, felt [**1-4**] diabetes, baseline Cr 1.4
14. GERD w/hiatal hernia
15. Esophageal stricture s/p dilatation x2
[**85**]. s/p R CEA [**4-/2169**]
Social History:
She lives alone in an [**Hospital3 **] facility. She is formerly
a suitcase manufacturer. She denies any alcohol use or ever
smoking cigarettes. She denies any asbestos exposure.
Family History:
father died from MI at age 60, mother died from MI at age 70
Physical Exam:
Physical Exam:
Vitals: 96.5F HR 99 BP 94/31 RR 40 100%/4Ln.c.
Gen: conversant, alert and oriented female, apppears pale and
uncomfortable
HEENT: anicteric, mucus membranes very dry
Neck: supple
CV: tachycardic, regular
Pulm: CTA anteriorly
Abd: obese, TTP RUQ/LUQ without rebound or guarding, +bs, guaiac
negative
Ext: [**1-5**]+ pitting edema bilaterally, skin cold, pulses 1+
bilaterally
Pertinent Results:
[**2176-6-27**] 09:21PM GLUCOSE-125* UREA N-70* CREAT-2.7* SODIUM-134
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18
[**2176-6-27**] 09:21PM CALCIUM-8.9 PHOSPHATE-5.3* MAGNESIUM-2.0
[**2176-6-27**] 09:21PM WBC-13.1* RBC-3.70* HGB-11.0* HCT-30.9*
MCV-84 MCH-29.7 MCHC-35.5* RDW-13.6
[**2176-6-27**] 09:21PM PLT COUNT-263
[**2176-6-27**] 09:21PM PT-15.4* PTT-20.9* INR(PT)-1.4*
.
CT Trachea [**2176-6-28**]
IMPRESSION:
1. Severe diffuse tracheobronchomalacia.
2. Cylindrical bronchiectasis, predominantly basal, and
scattered nodular
ground-glass opacities suggest chronic and ongoing aspiration.
3. Small bilateral pleural effusion.
4. Atherosclerosis, including coronaries.
5. Moderate size hiatus hernia.
.
CT Abd/Pelvix [**2176-6-30**]
IMPRESSION:
1. Large right pelvic side wall hematoma measuring 11.7 x 9.1
cm, with
extension into the right rectus muscle. There is no evidence of
intraperitoneal extension of hemorrhage. The possibility of
active
extravasation is not optimally assessed without intravenous
contrast.
2. There are again seen scattered areas of ill-defined ground
glass opacity
and bronchiectatic changes within the lungs bilaterally, which
are not
significantly changed in comparison to most recent study from
two days prior.
.
.
Echo [**2176-7-2**]:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue
velocity imaging E/e' is elevated (>15) suggesting increased
left ventricular
filling pressure (PCWP>18mmHg). A mid-cavitary gradient is
identified,
consistent with mild flow obstruction at rest. The patient was
unable to
cooperate with the Valsalva maneuver. Right ventricular chamber
size and free
wall motion are normal. A bileaflet aortic valve prosthesis is
present. The
transaortic gradient is normal for this prosthesis. No aortic
regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is an
anterior space which most likely represents a fat pad, though a
loculated
anterior pericardial effusion cannot be excluded.
IMPRESSION: Symmetric LVH with hyperdynamic systolic function,
and no regional
wall motion abnormalities. Mild resting mid-cavitary flow
obstruction.
Normally-functioning mechanical aortic valve prosthesis.
.
LENI [**2176-7-5**]
CONCLUSION:
No evidence of DVT.
.
CXR [**2176-7-4**]:
IMPRESSION:
1. Newly inserted two right central lines with no evidence of
complications.
2. Small new right pleural effusion.
Brief Hospital Course:
68 yo woman with tracheobronchomalacia, on heparin gtt for [**Hospital 64315**]
transferred to [**Hospital1 18**] from an OSH for IP evaluation and possible
Y stent who was transferred to the MICU for hypotension,
decreased Hct in the setting of retroperitoneal bleed.
.
1. Retroperitoneal Bleed - Pt had bleed and was hypovolemic in
setting of blood loss while supratherpeutic on heparin. She
received aggressive fluid resuscitation and PRBC transfusions
while in house as needed for bleeding. Her anticoagulation was
reversed with FFP. She did not require pressors. On CT scan,
she was found to have a large right pelvic side wall hematoma
with extension into the right rectus muscle. There was no
evidence of intraperitoneal extension of hemorrhage. We
monitored her Hct closely during the acute episodes q4.
Although her Hct stabilized, when we attempted to start
anticoagulation with warfarin again at low doses, she
subsequently developed a decreasing hematocrit which required
further transfusions of FFP and Hct. While attempting slow
increase of coumadin to reach therapeutic INR for her AVR, she
began further dropping her HCT with increase of her INR to 1.8.
We reversed this INR with Vit K. We decided that she was
currently not a candidate for anticoagulation in the setting of
her acute bleed and in the setting of increasing bleeds to even
low levels of anticoagulation.
.
2. ARF on CRI - After developing hypotension, she became anuric.
The most likely explination is that she developed ATN. She has
required hemodialysis/ultrafiltration during her stay in the
hospital, and she had a tunnel catheter placed to facilitate
this in the future. She was initially on CVVH. She was
converted to hemodialysis. She did experience two transient
episodes of desaturiation of hemodialysis. The diasylate was
changed to asili. She tolerated two additional dialysis
sessions without incident.
.
3. Elevated WBC count - She was hypothermic and met criteria
for SIRS but this is all likely explained by hypovolemic shock.
She ultimately had a gram stain positive for gram positive cocci
in her sputum (culture negative to date [**7-13**]), from [**2176-7-10**]. We
subsequently treated her with Vancomycin. She began her course
on [**2176-7-10**] and was dosed by level with a goal vancomycin trough
>15. She will continue this course for 7 days total. She also
had erythema on her right lower extremity. This was thought to
be more consistent with venous stasis changes than cellulitis
and did not change when vancomycin was started.
.
4. Tracheobronchomalacia - Patient was originally transferred
for stent placement for this problem. She and her family
subsequently decided not to proceed with this procedure given
the risk/benefit ratio and the complications she has had during
her hospital stay.
.
6. CV: pump - anti-hypertensives were held given hypotension.
Volume resuscitation as above.
ischemia - no evidence of active ischemia. she had one
episode of transient right-sided chest pain. her cardiac
enzymes were negative. she was continued on statin for
secondary prevention. Aspirin was held given bleeding risk.
Antihypertensives also held.
.
7. Diabetes mellitus - She was treated with an insulin sliding
scale while in the hospital to maintain glucoses <120.
.
8. Prophylaxis - She was maintained on PPI and pneumoboots
while in the hospital. We attempted to anticoagulate her, but
stopped as described above.
.
9. Access: She had a tunnel line and PICC placed under IR while
in the hospital.
Medications on Admission:
cipro 250 mg po q12h
simvastatin 80 mg daily
insulin sliding scale
pantoprazole 40 mg daily
olanzapine 2.5 mg po qhs
prednisone 10 mg tid
ferrous sulfate 325 mg daily
buspirone 10 mg daily
ezetimibe 10 mg daily
amlodipine 5 mg daily
ipratropium nebs q6h
fluticasone-salmeterol 250/50 [**Hospital1 **]
zosyn
albuterol nebs
tylenol
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
3. Buspirone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed.
5. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
11. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for agitation/insomnia.
12. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
Dosing by level for 3 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Retroperitoneal hematoma
Discharge Condition:
-Good
Discharge Instructions:
Please call if become dizzy, weak, temp >101, chills, abdominal
pain or abnormal bruising.
Followup Instructions:
You should follow up with your PCP within one week of discharge
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2176-7-13**] | 20,028 | 159,748 | 4590,78559,570,5849,40391,2800,51882,2760,486,496,79092,25040,5191,1122,V433,41400,V4581 |
Admission Date: [**2115-6-20**] Discharge Date: [**2115-6-30**]
Date of Birth: [**2115-6-20**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 34-week, first female
twin, born to a 25-year-old, G8, P 2-0-5-2, who had received
late prenatal care and did not realize she was having twins.
The infants were born by emergency cesarean section for
concerns of an abruption and for preterm labor with breech
presentation of the second twin. The mother did not have
fever. The GBS status was unknown and rupture of membranes
were at delivery. The infant's birth weight was 1760 g and
the fluid was foul smelling. The infant was active on
delivery with spontaneous cry, was suctioned and given blow-
by oxygen in the delivery room. The Apgars were 8 and 9.
Prenatal labs on the mother were O positive, antibody screen
negative, hepatitis B negative, RPR nonreactive, and rubella
immune. The infant was admitted to the newborn ICU for
prematurity and tachypnea on initial exam.
SUMMARY OF HOSPITAL CARE:
Respiratory: The infant has remained in room
air since admission, never intubated, never placed on CPAP,
and did quite well without any requirement for oxygen.
Cardiovascular: There have been no issues. No murmur has
ever been heard on this patient. She has had stable blood
pressures throughout her hospitalization.
Fluids, electrolytes, and nutrition: The infant was
initially made n.p.o. on D10W at 80 cc/kg/day maintenance IV
fluids. Enteral ad-lib feedings were started on [**2115-6-22**].
She quickly advanced to full p.o. feeding, taking easily her
minimum by [**2115-6-24**] of 100 cc/kg/day and advanced to 150
cc/kg/day by [**2115-6-27**]. She was placed on NeoSure 22 on
[**2115-6-26**] and advanced to NeoSure 24 on [**2115-6-27**] to increase
her caloric intake. She POs well and has had no issues and
is tolerating 24 kcal formula well. The infant's discharge
weight was 1810 grams.
Hematology: The infant has had mild hyperbilirubinemia and
was placed on phototherapy on [**2115-6-23**] and the bilirubin then
decreased spontaneously. Last bilirubin was 6.1/0.3 on [**6-24**],
day 4 of life. and it has not been an issue since that time.
Neurology: The infant, on admission, was noted to be quite
jittery with strange movements of her head. The infant did
have a urine toxicology screen, as did the mother on
admission, both of which were negative. She has had
increased tone on physical exam and is somewhat jittery,
although this has improved throughout her hospitalization.
She has been placed on an Early Intervention Program because
of these concerns and because of her prematurity, and they
can follow as an outpatient. She has not had any head
ultrasounds or other screening exams.
Hearing screen was performed with augmented auditory brain
stem responses and the infant had passed. She did not fit
criteria for an ophthalmology exam for retinopathy of
prematurity.
Social: [**Hospital1 18**] SOcial Work was involved with the family. They
can be reached at [**Telephone/Fax (1) 8717**].
Infectious disease. This patient was initially ruled out for
bacterial sepsis with a blood culture and with ampicillin and
gentamicin for two days. When the blood culture returned
negative and the infant looked well, the antibiotics were
stopped after two days.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: To home.
Primary pediatrician is Dr. [**Last Name (STitle) **] at [**Location (un) 669**] Comprehensive
Health.
CARE AND RECOMMENDATIONS: The infant was sent home on
NeoSure 24 kcal per ounce. This should be continued until 6
to 9 months corrected age.
MEDICATIONS: None.
FOLLOW UP: Newborn screening has been performed, and the
infant has received hepatitis B immunization. She should
follow up with her general pediatrician on Monday, [**2115-7-1**],
and will have early intervention and a nursing visit to her
home.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Small for gestational age.
3. Hyperbilirubinemia.
4. Rule out sepsis.
DR. [**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) 57691**]
MEDQUIST36
D: [**2115-6-27**] 15:43:13
T: [**2115-6-28**] 10:01:21
Job#: [**Job Number 57692**]
| 20,029 | 140,108 | V3101,76517,7742,7793,7706,76527,76407,V290 |
Unit No: [**Numeric Identifier 61051**]
Admission Date: [**2184-2-11**]
Discharge Date: [**2184-3-1**]
Date of Birth: [**2184-2-11**]
Sex: M
Service: NBB
HISTORY: Baby [**Name (NI) **] [**Known lastname 61052**] is a 2.1 kg product of a 33 and
[**3-4**] week twin gestation, born to a 36 year-old, Gravida VII,
Para 0. Prenatal screens 0 positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B negative, GBS
unknown. Mother has history of thyroid insufficiency
secondary to Hashimoto's. She is on thyroid replacement.
Asthma, treated with inhalers. Mom has normal chromosomes,
is Parvo negative, CF non carrier, normal protein CF, and
factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**]. This was an IVF triplet pregnancy, reduced
to twins. The pregnancy was complicated by decreased fetal
growth approximately 10th percentile. The biophysical
profile was 8 out of 8 for this twin. Mother had [**Name2 (NI) **] with
worsening thrombocytopenia, prompting delivery. She was
betamethasone complete on [**1-29**]. Infant was delivered by
Cesarean section. Apgars of 7 and 8. Infant transferred back
from [**Hospital3 1810**] on day of life three. Hospital
course from day of life three on.
PHYSICAL EXAMINATION: Weight 2.1 kg, 50th percentile.
Length 47 cm, 75th percentile. Head circumference 31 cm,
50th percentile. General: Active infant, looking stated
gestational age. Normal cephalic bruise of the upper lip.
Anterior fontanel open and flat, palate intact. Red reflex
deferred. Nevus squamous on forehead. Neck supple. Lungs
with intermittent audible grunting. Mild intercostal
retractions. Cardiovascular: Regular rate and rhythm. No
murmur. Femoral pulses 2 plus bilaterally. Abdomen soft with
active bowel sounds, no masses or organomegaly. Normal
premature male. Hips stable. Clavicles intact. Good tone,
moves all extremities.
HOSPITAL COURSE: Respiratory: Has been stable in room air
throughout hospital course without any issues.
Cardiovascular: Has been stable throughout hospital course.
Fluids, electrolytes and nutrition: Birth weight 2.1 kg,
readmission to [**Hospital1 69**] 2.015 kg,
on 130 cc per kg per day on a combination of breast milk and
D-10-W. Reached full enteral feedings by day of life number
six. Is currently ad lib feedings, breast milk 24 calories,
Similac 24 calories, taking an adequate amount.
Gastrointestinal: Peak bilirubin was on day of life three.
Infant received phototherapy for a total of four days and
rebound bilirubin was within normal limits.
Infectious disease: Infant was status post 40 hour sepsis
rule out, has had no sepsis risk factors or sepsis issues
during this hospital course.
Neurology: Has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated
auditory brain stem responses and the infant passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42126**].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
24, Similac 24 calories.
MEDICATIONS: Not applicable.
CAR SEAT POSITION:
STATE NEWBORN SCREENING: Has been sent per protocol and has
been within normal limits.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2184-1-28**].
DISCHARGE DIAGNOSES:
1. Preterm twin, 33 and [**5-4**] week gestation.
2. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2184-3-1**] 00:13:35
T: [**2184-3-1**] 04:48:15
Job#: [**Job Number 61055**]
| 20,032 | 154,329 | 7742,76527,7793,76518,V502,V053 |
Unit No: [**Numeric Identifier 61051**]
Admission Date: [**2184-2-11**]
Discharge Date: [**2184-3-1**]
Date of Birth: [**2184-2-11**]
Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 61052**] is a 2.1 kg product of a 33 and
[**3-4**] week twin gestation, born to a 36 year-old, Gravida VII,
Para 0. Prenatal screens 0 positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B negative, GBS
unknown. Mother has history of thyroid insufficiency
secondary to Hashimoto's. She is on thyroid replacement.
Asthma, treated with inhalers. Mom has normal chromosomes,
is Parvo negative, CF non carrier, normal protein CF, and
factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**]. This was an IVF triplet pregnancy, reduced
to twins. The pregnancy was complicated by decreased fetal
growth approximately 10th percentile. The biophysical
profile was 8 out of 8 for this twin. Mother had [**Name2 (NI) **] with
worsening thrombocytopenia, prompting delivery. She was
betamethasone complete on [**1-29**]. Infant was delivered by
Cesarean section. Apgars of 7 and 8. Infant transferred back
from [**Hospital3 1810**] on day of life three. Hospital
course from day of life three on.
PHYSICAL EXAMINATION: Weight 2.1 kg, 50th percentile.
Length 47 cm, 75th percentile. Head circumference 31 cm,
50th percentile. General: Active infant, looking stated
gestational age. Normal cephalic bruise of the upper lip.
Anterior fontanel open and flat, palate intact. Red reflex
deferred. Nevus squamous on forehead. Neck supple. Lungs
with intermittent audible grunting. Mild intercostal
retractions. Cardiovascular: Regular rate and rhythm. No
murmur. Femoral pulses 2 plus bilaterally. Abdomen soft with
active bowel sounds, no masses or organomegaly. Normal
premature male. Hips stable. Clavicles intact. Good tone,
moves all extremities.
HOSPITAL COURSE: Respiratory: Has been stable in room air
throughout hospital course without any issues.
Cardiovascular: Has been stable throughout hospital course.
Fluids, electrolytes and nutrition: Birth weight 2.1 kg,
readmission to [**Hospital1 69**] 2.015 kg,
on 130 cc per kg per day on a combination of breast milk and
D-10-W. Reached full enteral feedings by day of life number
six. Is currently ad lib feedings, breast milk 24 calories,
Similac 24 calories, taking an adequate amount.
Gastrointestinal: Peak bilirubin was on day of life three.
Infant received phototherapy for a total of four days and
rebound bilirubin was within normal limits.
Infectious disease: Infant was status post 40 hour sepsis
rule out, has had no sepsis risk factors or sepsis issues
during this hospital course.
Neurology: Has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated
auditory brain stem responses and the infant passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42126**].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
24, Similac 24 calories.
MEDICATIONS: Not applicable.
CAR SEAT POSITION: passed
STATE NEWBORN SCREENING: Has been sent per protocol and has
been within normal limits.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2184-1-28**].
DISCHARGE DIAGNOSES:
1. Preterm twin, 33 and [**5-4**] week gestation.
2. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2184-3-1**] 00:13:35
T: [**2184-3-1**] 04:48:15
Job#: [**Job Number 61055**]
| 20,032 | 154,329 | 7742,76527,7793,76518,V502,V053 |
Unit No: [**Numeric Identifier 61051**]
Admission Date: [**2184-2-11**]
Discharge Date: [**2184-2-11**]
Date of Birth: [**2184-2-11**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 61052**] is the first
born of twins of a 33-4/7-weeks gestation pregnancy born to a
36-year-old G7, P0 woman. Prenatal screens: Blood type O
positive, antibody negative, RPR nonreactive, rubella immune,
hepatitis B surface antigen negative, group B Strep status
unknown. Prior OB history is notable for spontaneous abortion
times 6. This was an in-[**Last Name (un) 5153**] fertilization achieved
pregnancy with an estimated date of confinement of [**2184-3-27**]. The mother has medical history significant for thyroid
insufficiency secondary to Hashimoto thyroiditis. She is on
thyroid replacement treatment. She also has asthma treated
with an inhaler. There was normal chromosomes with this
pregnancy.
Mother is also parvovirus negative, cystic fibrosis
noncarrier, normal protein-C, protein-S, and factor V Leiden.
This was an in-[**Last Name (un) 5153**] fertilization triplet reduced to twins.
Pregnancy was complicated by decreased fetal growth.
Biophysical profile was [**7-5**] for this twin. The mother also
had pregnancy-induced hypertension with worsening
thrombocytopenia prompting delivery. Mother was a
betamethasone complete on [**2184-1-29**]. The infant was born
by cesarean section. Had Apgar scores of 7 at 1 minute and 8
at 5 minutes. He was admitted to the Neonatal Intensive Care
Unit for treatment of prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 2.1 kg (50th percentile), length 47 cm (75th
percentile), head circumference 31 cm (50th percentile).
General: Active infant consistent with stated gestational
age. Head, eyes, ears, nose, and throat: Normocephalic,
bruise on the upper lip, anterior fontanel open and flat,
palate intact, nevus flammeus on forehead. Neck is supple
without masses. Chest: Intermittent grunting, mild
intercostal retractions. Cardiovascular: Regular rate and
rhythm, no murmur. Femoral pulses 2+ bilaterally. Abdomen is
soft with active bowel sounds, no masses or organomegaly. GU:
Normal preterm male. Testes descending. Musculoskeletal: Hips
stable. Clavicles intact. Neurological: Good tone. Moving all
extremities.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: Respiratory: This infant required intubation and
treatment with Surfactant for his respiratory distress. His
ventilatory settings were a peak inspiratory pressure of 20
over a positive end expiratory pressure of 5, intermittent
mandatory ventilatory rate of 30, and 30% oxygen. Chest x-ray
was consistent with respiratory distress syndrome.
Cardiovascular: Blood pressure was 53/28 with a mean of 36.
Heart rate was 120s-140s with no murmurs.
Fluid, electrolytes, and nutrition: The baby was maintained
NPO and was on intravenous on D10W at 80 cc/kg/day.
Infectious disease: Due to the unknown etiology of the
respiratory distress, this baby was evaluated for sepsis. A
complete blood count was obtained. White blood cell count was
11,600, platelet count of 267,000. A blood culture was
obtained prior to starting intravenous ampicillin and
gentamicin.
Disposition: The infant was transferred to the Neonatal
Intensive Care Unit at [**Hospital3 1810**]
CONDITION AT DISCHARGE: Guarded.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] level
III Neonatal Intensive Care Unit for further treatment. The
primary pediatrician is Dr. [**Last Name (STitle) 61053**] in [**Location (un) 1887**],
[**State 350**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: NPO.
MEDICATIONS: Ampicillin 300 mg IV every 12 hours.
Gentamicin 6.5 mg IV every 24 hours.
CAR SEAT POSITION SCREENING: Recommended prior to discharge.
STATE NEWBORN SCREEN: Was obtained prior to discharge.
IMMUNIZATIONS: No immunizations administered.
DISCHARGE DIAGNOSES: Prematurity at 33-4/7 weeks gestation.
Twin #1 of twin gestation.
Respiratory distress syndrome.
Suspicion for sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2184-2-12**] 22:32:28
T: [**2184-2-13**] 04:25:05
Job#: [**Job Number 61054**]
| 20,032 | 197,596 | V3101,769,76527,76518,V290 |
Admission Date: [**2194-7-16**] Discharge Date: [**2194-7-18**]
Date of Birth: [**2139-1-31**] Sex: M
Service:
Mr. [**Known lastname 7474**] was in the hospital for 24 hours. He came from
[**Hospital3 1196**] with a history of alcoholic
hepatitis C, Child-C cirrhosis. He came into [**Location (un) **]
[**Hospital **] Hospital with peritoneal signs, where he had a
peritoneal tap. He was subsequently transferred to [**Hospital1 1444**] to GI service, where he
underwent a tap which showed a fecalith aspirate.
He had a CT scan showed which showed massive free air.
Consent was obtained. He was taken to the operating room,
where he is found to have a hostile abdomen and necrotic
portion of terminal small bowel and cecum, which were
resected.
A decision was made with conjunction of the family to make
comfort measures only.
Patient expired at 3:20 pm on [**2194-7-18**].
Dictated By:[**Last Name (NamePattern1) 99839**]
MEDQUIST36
D: [**2194-7-18**] 18:10
T: [**2194-7-22**] 11:26
JOB#: [**Job Number 99840**]
cc:[**Name8 (MD) 99841**] | 20,033 | 139,208 | 5570,56983,5672,07054,5711 |
Admission Date: [**2183-5-26**] Discharge Date: [**2183-5-30**]
Date of Birth: [**2123-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2183-5-26**] Mitral Valve Repair utilizing a 28mm [**Doctor Last Name 405**] Band
History of Present Illness:
This is a 59 year old female with recent diagnosis of mitral
regurgitation. Over the last several months, she has experienced
worsening shortness of breath and cough. Also admits to
orthopnea and dyspnea on exertion. She has no history of
myocardial infarction. Echocardiogram in [**2183-3-27**] revealed
severe mitral regurgitation with flail posterior leaflet, and
normal LV function. In preperation for cardiac surgery, she
underwent cardiac catheterization which showed normal coronary
arteries. It confirmed 4+ mitral regurgitation and normal left
ventricular function. She had moderate pulmonary hypertension
with PAP 50/19 with a mean of 30 mmHg. She was admitted for
mitral valve surgery.
Past Medical History:
Mitral regurgitation
Gastroesophogeal Reflux Disease
History of Hemoptysis
History of postive PPD - s/p treatment
Social History:
Denies tobacco and ETOH. Married, works in a grocery store.
Lives with husband.
Family History:
Father died at age 30 - unknown cause
Physical Exam:
Vitals: BP 132/86, HR 77, RR 18
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 4/6 systolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: cool, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2183-5-30**] 06:20AM BLOOD WBC-13.8* RBC-3.21* Hgb-9.6* Hct-28.5*
MCV-89 MCH-30.0 MCHC-33.8 RDW-14.5 Plt Ct-292#
[**2183-5-29**] 06:05AM BLOOD WBC-13.3* RBC-2.89* Hgb-8.6* Hct-25.4*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.3 Plt Ct-179
[**2183-5-28**] 06:35AM BLOOD WBC-16.7* RBC-3.02* Hgb-9.0* Hct-26.1*
MCV-87 MCH-29.7 MCHC-34.3 RDW-14.5 Plt Ct-148*
[**2183-5-26**] 11:57PM BLOOD WBC-20.9*# RBC-3.55* Hgb-10.7* Hct-31.0*
MCV-87 MCH-30.1 MCHC-34.5 RDW-14.5 Plt Ct-179
[**2183-5-26**] 03:06PM BLOOD WBC-13.9*# RBC-3.60* Hgb-10.8*# Hct-31.3*
MCV-87 MCH-30.0 MCHC-34.5 RDW-14.1 Plt Ct-182
[**2183-5-30**] 06:20AM BLOOD Glucose-102 UreaN-11 Creat-0.8 Na-137
K-4.6 Cl-98 HCO3-28 AnGap-16
[**2183-5-29**] 06:05AM BLOOD Glucose-157* UreaN-14 Creat-0.7 Na-134
K-3.3 Cl-97 HCO3-31 AnGap-9
[**2183-5-28**] 06:35AM BLOOD Glucose-124* UreaN-16 Creat-0.6 Na-137
K-3.8 Cl-97 HCO3-35* AnGap-9
[**2183-5-26**] 11:57PM BLOOD Glucose-119* UreaN-14 Creat-0.6 Na-140
K-4.2 Cl-108 HCO3-26 AnGap-10
[**2183-5-30**] 06:20AM BLOOD Mg-3.1*
[**2183-5-28**] 06:35AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3
[**2183-5-29**]: The central venous line was removed in the meantime
interval. The heart size is normal. The bibasilar atelectasis
are again demonstrated, the worse on the right with no
significant change on the left. The bilateral pleural effusion
is small. There is no pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname 13260**] was admitted and underwent mitral valve repair by
Dr. [**Last Name (STitle) 1290**]. For surgical details, please see seperate
dictated operative note. Following the operation, she was
brought to the CSRU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated. Her CSRU
course was uneventful and she transferred to the SDU on
postoperative day one. Chest tubes and wires were removed
without complication. She tolerated low dose beta blockade and
continued to improve with diuresis. Given persistent systolic
blood pressures in the 90 - 100mmHg range, her preoperative ACE
inhibitor was not resumed. Several self limiting bursts of
paroxysmal were noted but she remained mostly in a normal sinus
rhythm. She continued to make steady progress and was cleared
for discharge to home on postoperative day four. At discharge,
her oxygen saturations were 96% on room air and her chest x-rays
showed only small bilateral pleural effusions. Her sternum was
stable and all surgical incisions were clean, dry and intact.
Medications on Admission:
Omeprazole 20 qd, Lisinopril 5 qd, Hydroxyzine 25 qd, Singulair
10 qd, Albuterol MDI, Bromfenex
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-2**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Mitral regurgitation - s/p MV Repair
Postop Anemia
GERD
History of positive PPD
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-1**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-1**] weeks, call for appt
Completed by:[**2183-5-30**] | 20,034 | 130,185 | 4240,42731,4111,53081,4169,2768 |
Admission Date: [**2187-11-13**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2120-10-20**] Sex: F
Service: RADIOLOGY
Allergies:
Sulfa (Sulfonamides) / Amoxicillin / Percocet
Attending:[**First Name3 (LF) 25590**]
Chief Complaint:
renal artery angioplasty complicated by thrombus
Major Surgical or Invasive Procedure:
angioplasty [**2187-11-13**] complicated by renal artery thrombosis,
status post 24 hour ICU stay for thrombolysis with tPA and
heparin.
angioplasty re-attempt [**2187-11-14**], no intervention (procedure
aborted secondary to suboptimal approach)
History of Present Illness:
Pt is a 67 yo female with DMII, HTN, renal artery stenosis, who
is s/p angioplasty yesterday with resultant thombus in renal
artery noted on angiogram, s/p tPA and heparin in MICU, observed
overnight with Hct stable, VSS. She went back to IR again today
for possible restenting, however, the approach was felt to be
not adequate for stenting, procedure aborted. Plan by IR was to
have pt watched overnight, discharged in AM, to follow up at a
later date for re-stenting.
.
As far as her history of HTN and RAS, the pt reports she has
always had elevated blood pressure. It was first noted when she
was pregnant and over the years since her BP has consistently
been elevated, up to 220/110 [**First Name8 (NamePattern2) **] [**Last Name (un) **] records. Until 10 years
ago, BPs were in the 180s-190s/90s on a hefty medication regimen
and more medications were subsequently added (not noted which
[**First Name8 (NamePattern2) **] [**Last Name (un) **] records). BPs diastolic improved, but systolics
remained elevated 160s-170s.
.
In [**2184**], pt underwent angioplasty without stenting of her right
kidney as she was found to have renal artery stenosis, thought
[**1-3**] FMD. BP improved to the 120s systolic, but this lasted only
1 month. Later, an angiogram in [**3-/2185**] showed no large vessel
stenosis in renal aa. but right kidney was 9.1 cm and left one
was 11.7 cm. She had an abdominal CT scan for eval of abd pain
in [**4-/2186**] showing an atrophic right kidney (unclear the size).
Repeat MRA at the end of [**Month (only) 359**] demonstrated beading and
narrowing of right renal artery with extension in to the
branches. Her serum creatinine has been in the range of
0.7-0.9. She has had no albuminuria on [**Last Name (un) **].
.
Yesterday, around noon, a thrombus was noted on angiogram.
Simultaneously, pt also had a vasovagal episode, was put in
trendelenberg, given IVF, and give one mg of atropine. She was
given [**2181**] units of intra-arterial heparin, and 11 mg of tPA in
divided doses.
.
She was completely stable overnight, with hcts 28 to 30 the last
24 hours. Her VSS. She is being called out to the medical
floor in stable condition. Her ROS is negative for:
CP/SOB/palpitations. No nausea/vomiting/abd pain/constipation.
No numbness or tingling in extremities or weakness. Has been in
lying position since IR procedure, sheath removed at 1pm. Pt
able to sit up to 30 degrees at 6pm. C/o intermittent low back
pain from lying down for 'so many hours.' She is also c/o
hunger, wants to eat.
Past Medical History:
Diabetes mellitus
Hypertension
s/p H pylori eradication (had allergy to amoxicillin then);
repeat endoscopy cx showed gone
s/p ovarian cyst removal at age 16
s/p hysterectomy at 30
s/p CCY in [**2177**]; ovarian pathology seen and s/p oophorectomy
s/p fixation of hernia after laporotomy
s/p melanoma in situ removed from left shoulder-two months ago
Bilateral cataracts
Social History:
Married, four children. Lives in [**Location **], MA. Never smoked.
No alcohol. No IVDA.
Family History:
Mother- DM, HTN, CHF, died in her 80s. Father-died in 60s with
MI, DM. Brother died at age 39, MI and DM. Both paternal and
maternal grandmothers had [**Name2 (NI) **].
Physical Exam:
VS: Tm: 98.6 Tc: 98.6 BP: 138/43 RR: 16 O2sat: 95-99% RA. I/O
[**Telephone/Fax (1) 43382**] for net negative 779.
Gen: Well appearing CF in NAD. WNWD. AOX3, [**Location (un) 1131**] a book.
Pleasant and cooperative.
HEENT: PERRL, EOMI. No scleral icterus. MMM, OP clear.
Neck: no lymphadenopathy, no JVP appreciated.
CV: RRR S1 and S2 audible, no murmurs, rubs or gallops
Lungs: CTAB anteriorly
Abd: Soft, NT ND, obese, positive bowel sounds, no masses. No
organomegaly. Midline lower scar present and RUQ scar present.
Back: could not examine as patient must lie flat
Ext: WWP, DP/radial/PT 2+ bilaterally, no edema, right groin
with catheter removed, bandaid in place, minimal bleeding. No
palpable hematoma. No bruits.
Pertinent Results:
[**2187-11-13**] 07:42AM WBC-5.2 RBC-3.96* Hgb-12.8 Hct-34.4* MCV-87
MCH-32.3* MCHC-37.1* RDW-13.8 Plt Ct-247
[**2187-11-13**] 03:09PM WBC-9.1# RBC-UNABLE TO Hgb-11.7* Hct-34*
MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt
Ct-240
[**2187-11-13**] 05:39PM Hct-31.7*
[**2187-11-13**] 08:00PM Hct-30.9*
[**2187-11-14**] 05:57AM Hct-28.7*
[**2187-11-14**] 11:04AM WBC-10.1 RBC-3.39* Hgb-11.0* Hct-28.8* MCV-85
MCH-32.3* MCHC-38.0* RDW-13.7 Plt Ct-235
[**2187-11-14**] 05:47PM WBC-9.7 RBC-3.46* Hgb-11.3* Hct-30.3* MCV-88
MCH-32.6* MCHC-37.2* RDW-13.8 Plt Ct-264
[**2187-11-15**] 05:30AM WBC-9.8 RBC-3.22* Hgb-10.6* Hct-28.4* MCV-88
MCH-32.7* MCHC-37.2* RDW-13.5 Plt Ct-233
[**2187-11-13**] Glucose-191* UreaN-14 Creat-0.7 Na-142 K-3.8 Cl-108
HCO3-25 AnGap-13
[**2187-11-15**] Glucose-125* UreaN-12 Creat-0.9 Na-140 K-4.4 Cl-106
HCO3-25 AnGap-13
.
Radiology:
MRA kidney with and without contrast [**2187-9-27**]-
1. Beaded appearance of the right main renal artery extending
into two main branch vessels, suggestive of fibromuscular
dysplasia. Greater than 50% stenosis is noted at the main branch
point, which is approximately 2.5 cm from the aorta.
2. Patent left main and left lower pole accessory renal
arteries.
3. Marked parenchymal tissue loss of the right lower pole,
likely from prior ischemic insult.
4. 11-mm cystic lesion in the pancreatic head. Differential
includes
pseudocyst or possible intraductal papillary mucinous tumor
(IPMT). A followup study in six months is recommended to ensure
stability.
5. Narrowed celiac ostium is likely from expiratory compression
and is of little concern in the absence of related symptoms;
please correlate clinically.
.
Abd CT: right kidney with 2 x 2 cm lesion (Area of the right
kidney with increased contrast accumulation and irregular
cortex, which may represent an intraparenchymal hematoma or
reperfusion injury. No other hematoma).
.
[**2187-11-14**] RENAL ANGIOGRAM REPORT
IMPRESSION: Follow up angiography after overnight thrombolysis
demonstrated good renal artery perfusion with no evidence of
residual thrombus. There is beading of the distal main renal
artery and its proximal branch vessels consistent with
fibromuscular dysplasia as was demonstrated on the prior
angiogram from yesterday.
The patient should return to their antihypertensive regimen as
was being taken prior to the procedure.
Brief Hospital Course:
Impression/Plan: Pt is a 67 yo female with DM, HTN, renal artery
stenosis, who is s/p renal artery angioplasty complicated by
right renal artery thrombus, also s/p re-attempt today at
stenting, aborted procedure [**1-3**] suboptimal approach. Plan by IR
is to discharge and take back for follow up appt for another
attempt at stenting after the [**Holiday **] holidays (per pt
preference).
.
1. Renal artery thrombus- The patient was taken to the ICU for
tPA and heparin thrombolysis of the renal artery thrombus that
complicated her initial angioplasty on [**2187-11-13**]. The pt
tolerated the heparin and tPA without complications. The
following day, she was taken back to Interventional Radiology
for a re-look with possible restenting/angiogram, and it was
noted the thrombus was resolved, however the approach was
technically suboptimal (see report), and the procedure was
aborted. The plan is to have the pt return as an outpatient at
her convenience to have the procedure attempted again. She was
given the phone numbers for which to schedule an appt with IR.
She is currently with normal renal function, no CKD, with a
baseline creat of 0.7. Her right groin site was without
hematoma, bleeding or bruit. The sheath was removed without
complications.
.
2. Low Back Pain- Her back pain was believed to be secondary to
lying flat for several hours while her procedures was being
done. Her pain was musculoskeletal in nature, improved with
positional changes. Abdominal CT ruled out retroperitoneal
bleed. H/o apendectomy and cholecystectomy in the past. Pain
relieved with tylenol, and resolved by discharge.
.
3. Diabetes mellitus: She was restarted on her outpt regimen of
humalog 75/25 with 8 units at breakfast and 18 units at
dinnertime. Her blood sugars were stable and she was tolerating
po well.
.
4. HTN- well controlled. Etiology: secondary to renal artery
stenosis [**1-3**] FMD.
We continued her atenolol 100mg po qd, and restarted her
valsartan 320mg po qAM and 160mg po qPM, and her HCTZ 25mg po qd
after her procedure. Essentially, she is on the same
medications for blood pressure as she was on prior to procedure.
Her first procedure was complicated by a thrombus, so no
stenting. Her second procedure was a suboptimal approach,
therefore aborted.
.
5. Acute blood loss Anemia: The patient's Hct was stable the
last 48 hours, ranging from 28 to 30. Most likely secondary to
procedural blood loss. Her CT Abd was neg for RP bleed. Her
vital signs have been completely stable. She has no symptoms
and is ambulating well without complaints.
.
6. pancreatic cyst: The pt was noted on imaging to have an 11mm
pancreatic cyst, an incidental finding. Repeat imaging was
recommended for 6 months from now. The patient was given a
report of her imaging, and a copy of the report was given to her
to bring to her PCP's office in 7 days (an appointment was
scheduled for her). She was explained that it is important for
her to follow up and have repeat imaging, as the lesion could
possibly be benign, although a malignant lesion is a possibility
as well. Her PCP's office was called and notified. She has an
appointment in 1 week.
.
7. Prophylaxis: She was placed on pneumoboots and her home PPI.
ASA was held in the setting of tPA, but then restarted.
.
8. Code Status: full code
Medications on Admission:
Atenolol 100 mg qday
Humalog 75/25 [**Hospital1 **] up to 40 units
Diovan 320 mg qday
Diovan 160 mg qpm
Lipitor 20 mg qday
Promega 2 tid
Protonix 40 mg qday
MVI
Flonase 50 mcg 2 sprays qday
HCTZ 25 mg qday
ASA 81 mg- held 4 days prior to procedure
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
8. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qAM at breakfast: Inject 10 units
subcutaneously qAM. .
Disp:*qs 1 vial* Refills:*2*
9. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty (20)
units Subcutaneous qHS at dinnertime: Inject 20 units humalog
subcutaneously at dinnertime. .
Disp:*qs 1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Renal artery stenosis secondary to fibromuscular dysplasia
status post angioplasty complicated by thrombus status post
alteplase
2. Acute blood loss anemia
3. Hypertension
4. Diabetes mellitus
5. Low back pain
Discharge Condition:
Stable
Discharge Instructions:
You need to have a follow up abdominal CT since the one you had
here incidentally revealed an 11-mm cystic lesion in the
pancreatic head. You should see your PCP regarding this, who
can arrange for an outpatient Abd CT.
If you experience any chest pain, shortness of breath, numbness,
weakness in your right leg, bleeding from right groin site,
please report to the emergency room immediately.
Please take all of your medications.
Please follow up with your Primary Care Physician (see info
below).
Followup Instructions:
1. You have an appointment with Dr. [**First Name (STitle) **] (Dr.[**Name (NI) 43383**]
associate at the same office). Your appt is for 11:00 am on
Monday, [**11-19**]. Her office number is: [**Telephone/Fax (1) 31979**].
2. You should bring a copy of the CAT scan report to your
doctor so that she can schedule a follow up Abd CT to evaluate
the incidental finding of pancreatic mass seen on CT.
Completed by:[**2187-11-17**] | 20,035 | 168,760 | 4401,99772,2851,59381,4473,25050,36201,V5867,2724,7802,42789,V1082,45829,V643 |
Admission Date: [**2124-7-20**] Discharge Date: [**2124-7-28**]
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 79 year old female
with a history of coronary artery disease, status post
myocardial infarction in [**2121**] who presented to an outside
hospital [**7-17**] with complaints of warmth and malaise. She
had been in her usual state of health when these symptoms
occurred which were reminiscent of her prior myocardial
infarction. She also had palpitations and intermittent
shortness of breath. Electrocardiogram then showed ST
depressions in leads 1, V3 through V6 and she was thought to
be in heart failure. CKs were cycled and found to be
negative and she was diuresed but continued to have oxygen
requirements of 4 liters by nasal cannula. She was
transferred to [**Hospital6 256**] for
cardiac catheterization with a diagnosis of unstable angina
on a Heparin drip. Her transthoracic echocardiogram done at
the outside hospital showed an ejection fraction of about 55%
with questionable wall motion abnormalities.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2121**], no catheterization was done.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Peripheral vascular disease.
6. Peptic ulcer disease, status post gastrointestinal bleed
requiring transfusion.
7. Status post bladder suspension. The patient has no known
drug allergies.
MEDICATIONS ON ADMISSION:
1. Heparin drip
2. Nitroglycerin drip
3. Lopressor 25 b.i.d.
4. Norvasc 10 mg q.d.
5. Pravachol 10 mg q.d.
6. Zantac
7. Univasc 7.5 mg q.d.
8. NPH 15 units q AM, 10 units q PM, 5 units of regular q.
PM
FAMILY HISTORY: Mother died at 60 of myocardial infarction,
father with diabetes mellitus.
SOCIAL HISTORY: She stopped tobacco use in [**2114**], 25 pack
year history, occasional alcohol.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs of temperature 97, heartrate 62, blood
pressure 142/64, respiratory rate 22, saturation 94% on 4
liters nasal cannula. General: An elderly female lying
. Head, eyes, ears, nose and throat examination:
Anicteric, no ocular lesion. Neck with jugulovenous
distension about 6 cm, carotids 2+ bilaterally.
Cardiovascular, regular rate and rhythm, II/VI systolic
murmur, no S3 or S4. Lungs, crackles bilaterally. Abdomen
is soft, nontender, nondistended with positive bowel sounds.
Extremities, 2+ dorsalis pedis pulse bilaterally, 1+ edema of
the lower extremities to mid calf. Neurological: Cranial
nerves II through XII intact, alert and oriented times three,
nonfocal.
LABORATORY DATA: White blood count 9.8, hematocrit 31.6,
chemistries reveal sodium 139, potassium 3.9, chloride 103,
carbon dioxide 22, BUN 20, creatinine 1.1, glucose 126. CKs
were 48, troponin 2.1, MB negative. Studies revealed
electrocardiogram results as listed above. Cardiac
catheterization revealed three vessel coronary artery
disease, presumptive left main coronary artery disease,
normal ventricular function, elevated bilateral filling
pressures, severe pulmonary hypertension, severe systemic
systolic hypertension.
HOSPITAL COURSE: The patient was admitted [**2124-7-20**] with
a diagnosis of unstable angina and congestive heart failure
to the Medicine Cardiology Service where she was treated with
Aspirin, beta blockers, ACE inhibitors and Heparin drip. She
was also diuresed with Lasix pending cardiac catheterization.
Cardiac catheterization was performed with results as listed
above. The patient tolerated the procedure well. Based on
these results, it was felt that coronary artery bypass
grafting would be necessary. She was further stabilized and
diuresed with Lasix and continued on Nitroglycerin drip and
Heparin. She was taken to the Operating Room on [**2124-7-24**] where she underwent three vessel coronary artery bypass
graft with saphenous vein grafts to obtuse marginal 1,
posterior left ventricular and left anterior descending
respectively under general endotracheal anesthesia. There
were no intraoperative complications and the patient was
transferred to the Cardiac Recovery Room, intubated, being
atrioventricularly based at 90 per minute. She was extubated
on postoperative day #1 and she was weaned. She was started
on Lopressor, Aspirin and Lasix and transferred to the
regular floor that evening. That evening the patient was
complaining of some increased belching and symptoms that were
similar to her previous myocardial infarction.
Electrocardiogram was obtained which showed no changes. She
was given 1 mg of Morphine. On postoperative day #2 the
patient exhibited some confusion which cleared over the
course of the day. Her narcotics were held. On
postoperative day #3 she went into atrial fibrillation with
rates to 100s. She was given 2 mg of Magnesium Sulfate and 5
mg of Lopressor intravenously. Rate was controlled to the
70s, she was intravenously loaded with Amiodarone after which
she converted to normal sinus rhythm and then was continued
on oral Amiodarone. At this time the patient was in normal
sinus rhythm on p.o. Amiodarone and Lopressor. She is
ambulating with assistance, tolerating a regular diet and is
deemed stable for discharge to a rehabilitation facility for
further physical therapy and cardiopulmonary care.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft times three
2. Coronary artery disease, status post myocardial
infarction in [**2121**]
3. Hypertension
4. Hypercholesterolemia
5. Insulin dependent diabetes mellitus
6. Peripheral vascular disease
7. Peptic ulcer disease status post gastrointestinal bleed
8. Status post bladder suspension
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq p.o. q.d. times one week
2. Lopressor 25 mg p.o. q. 12 hours
3. Colace 100 mg p.o. b.i.d.
4. Aspirin 81 mg q.d.
5. Lasix 20 mg q. 12 hours times one week
6. Protonix 40 mg q.d.
7. Reglan 10 mg q. 8 hours
8. Amiodarone 400 mg t.i.d. times 7 days beginning [**7-28**]
and then Amiodarone 400 mg p.o. b.i.d. times 7 days and then
Amiodarone 400 mg p.o. q.d. times 7 days
9. Milk of magnesia 30 cc p.o. q.h.s. prn
10. Dulcolax suppository one p.r. q.d. prn
11. Insulin NPH 5 units q AM, 10 units q. PM
12. Insulin regular 5 units q. PM
13. Insulin sliding scale
14. Tylenol #3 one to two p.o. q. 4 to 6 hours prn
15. Zantac 150 mg p.o. b.i.d.
FO[**Last Name (STitle) 996**]P: The patient is to follow up with her primary care
physician in one to two weeks and to follow up with Dr. [**Last Name (Prefixes) 411**] in clinic in three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2124-7-28**] 08:17
T: [**2124-7-28**] 09:44
JOB#: [**Job Number 28041**]
| 20,036 | 107,366 | 41401,4111,9971,42731,4280,5990,25000,2720,4019 |
Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**]
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
bilateral claudication and rest pain
Major Surgical or Invasive Procedure:
[**2130-4-12**]: B femoral patch endarterectomy, B iliac stents (7
stents)
History of Present Illness:
This elderly lady well known to [**Month/Day/Year 1106**]/Dr. [**Last Name (STitle) **] and has
developed severe disabling claudication progressively worsening
to the point now where she will only walk a few steps without
pain and probably a mild ischemic
rest pain as well. She underwent an MRA because of renal
insufficiency which showed extensive iliac disease bilaterally.
There were high-grade stenoses at the origin of both common
iliac arteries and diffuse disease throughout
both external iliac arteries involving the common femoral
arteries as well with occlusion of her superficial femoral
arteries.
Past Medical History:
1. Coronary artery disease:
- s/p CABG [**2124**] (SVG to OM, SVG to PLV, SVG to LAD)
- Cardiac cath on [**12-13**] showed patent grafts
2. Peripheral [**Month/Year (2) 1106**] disease
3. Diabetes mellitus, type II
4. Hypertension
5. Chronic renal insufficiency (baseline creatinine 1.6-1.9)
6. s/p Right CEA
7. Macular degeneration
8. h/o GI bleed
9. s/p bladder suspension
Social History:
Lives alone. husband died 2 months ago. daughter lives nearby.
activity limited by severe PVD.
Tob: smoked for 30yrs; quit 15yrs ago
EtOH: none
Illicits: none
Family History:
NC
Physical Exam:
VSS: 99.1, 130/80, 86 94%RA
GEN: NAD
CARD: RR, [**2-7**] STEM
Lungs: [**Month/Day (4) **]
EXT: no edema, incisions c/d/i steri-strip
RT DP palp, PT dopp, LT DP/PT dopp
Pertinent Results:
[**2130-4-17**] 06:20AM BLOOD WBC-6.4 RBC-3.23* Hgb-9.5* Hct-27.8*
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.0 Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Glucose-106* UreaN-39* Creat-1.6* Na-138
K-4.3 Cl-103 HCO3-30 AnGap-9
[**2130-4-17**] 06:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.6
Brief Hospital Course:
Underwent uneventful bilateral common femoral endarterectomies
and distal external iliac endarterectomies with Dacron patch
angioplasties and balloon angioplasty and stenting of both
common and external iliac arteries. Extubated in OR and
transferred to PACU. B/L DP/PT dopplerable. pain controlled. UO
at 22 cc/hr. BP 125/43, off nitro gtt.
POD1- Hypotension overnight BP 86/42 CVP 3-4. Fluid bolus given
with improvement in BP to 114/48. Second event of hypotension to
SBP 50 HCT 28.4. Received 2 units PRBCs. Non contrast CT
negative for retroperitoneal bleed. Hypertensive meds held.
Dopamine gtt started, 5% albumin given for support. Swan
catheter placed. Denies chest pain, abdominal pain. ECG WNL,
cardiac enzymes cycled. Cardiology consult obtained.
POD2-Intermittent hypotensive events, BP 69-110/32-47. Off
Dopamine. Troponins elevated, likely demand ischemia per
cardiology.
POD3-No overnight events. VSS On heparin gtt. RT DP palp, B/L
DP/PT dop
Cardiology following patient with acute MI:Troponin 0.23, peak
CK 154 with pos MB. Exam negative for CHF.
POD4- No overnight events. OOB to chair. diet advanced to
regular. PA cath discontinued.
POD5- VSS. No overnight events. Cr 1.6. Physical therapy
consulted. transferred from VICU to [**Wardname **] floor bed.
POD6- VSS. No overnight events. Physical therapy cleared for
discharge home with PT/home safety eval. Patient will follow up
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week.
Medications on Admission:
ASA 81', Imdur 30', lisinopril 20", zestoril', metoprolol 50",
MVI' zocor 40, lantus 8hs with Humalog sliding scale
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lantus 100 unit/mL Solution Sig: 8 units at bedtime
Subcutaneous at bedtime: Follow normal Humalog sliding scale
with meals.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
B/L claudication s/p B femoral patch endarterectomy, B iliac
stents (7 stents)
Elevated Troponin-demand ischemia
PMH: CAD, PVD, IDDM, CRI, HTN, macular degeneration, h/o GI
bleed
PSH: CABG '[**24**] x3, cardiac cath [**12-7**] shows patent grafts, R CEA
'[**27**], bladder suspension
Discharge Condition:
Good. VSS
Cr 1.6
Discharge Instructions:
Division of [**Year (2 digits) **] and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr.[**Initials (NamePattern4) 5695**] [**Last Name (NamePattern4) 28043**] at [**Telephone/Fax (1) 3121**] to schedule office
visit to be seen next week.
Call Dr. [**Last Name (STitle) **] (Cardiology) at ([**Telephone/Fax (1) 10085**] to schedule
office visit to be seen next week.
Completed by:[**2130-4-18**] | 20,036 | 108,465 | 44022,41091,3968,5859,4401,4471,40390,4168,45829,43310,25000,41400,V5867,V4581 |
Admission Date: [**2119-5-20**] Discharge Date: [**2119-5-31**]
Date of Birth: [**2076-5-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
motor vehicle crash: car vs tree
Major Surgical or Invasive Procedure:
interventional radiology embolization: arteriogram via celiac
showed right posterior segmental branch with active
extravasation- embolized
History of Present Illness:
43 yo female s/p MVC vs tree. She was the restrained driver,
single occupant with no LOC, complaining of left humeral pain
and diffuse abdominal pain most severe in the right upper
quadrant.
Past Medical History:
s/p cesarean section and appendectomy
Social History:
Married, lives with husband
Family History:
Noncontributory
Physical Exam:
In the ER
BP 130's HR 80 RR 20 Sat 100%
Gen: complaining of abominal and arm pain
HEENT: laceration on dorsum of tongue, PERRL, EOMI, TM clear
bilaterally, c-spine cleared by CT and clinically
CV: RRR NTTP
Lungs: CTA B
Abd: diffusely tender to palpation
Ext: left humeral deformity, 2+ radial pulse, nl sensation of
hand and arm
Neuro: alert and oriented
Ext: left arm deformity with good pulses and cap refill of hand,
sensation intact
Pertinent Results:
CT Abd/ pelvis: complex liver laceration involving all 4
segments of the right lobe of the liver with perihepatic
hematoma and ACTIVE EXTRAVASATION of contrast. High density
fluid in pelvis consistent with hemoperitoneum.
left Humerus xray: Minimally comminuted mid shaft humerus
fracture
CXR: neg
Pelvis: neg
Head CT: neg
C spine CT: neg
Wrist: neg
Elbow: neg
[**5-20**] arteriogram via celiac shows right posterior segmental
branch with active extrav. --> embo x3 with coils, cessation of
flow.
[**2119-5-20**] 07:20AM WBC-17.2* RBC-3.60* HGB-11.7* HCT-34.1*
MCV-95 MCH-32.4* MCHC-34.2 RDW-12.4
[**2119-5-20**] 09:51AM HCT-26.2*
[**2119-5-20**] 01:39PM HCT-33.4*#
Brief Hospital Course:
Patient was evaluated in the ER by CT scan and found to have a
grade IV liver laceration with active bleeding. She was
transferred to the T-SICU and then taken to IR for embolization.
Her hematocrit was found to have significantly dropped
associated with hypotension to the 80's so she was tranfused 2
units of PRBC's. After the transfusion and embolization her
hematocrit stabilized and she was transferred to the floor. Her
pain was initially controlled with pca dilaudid and switched to
po pain medication once she was tolerating po's. Her pain was
difficult to control and the acute pain service was consulted
for input. In the end, she was discharged home with MS contin [**Hospital1 **] 15mg and dilaudid for breathrough pain only.
Her left humeral fracture was evaluated by ortho on admission
and thought to be stable and non-operativve. It was placed in a
splint. Throughout her hospitalization repeat images were
obtained and reviewed by orthopedics. They continued to feel
she was non-operative and should be kept in the splint.
She was noted to have continued abdominal discomfort with some
distention and lack of bowel movements after the embolization.
This was relieved with laxatives and improved over time.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for breakthrough pain only: only take this
medication as needed every 4 hours. .
Disp:*60 Tablet(s)* Refills:*0*
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Grade IV liver laceration s/p embolization
Left humeral fracture
Discharge Condition:
stable
Discharge Instructions:
You are being discharged home today after your motor vehicle
crash. You had a laceration in your liver that was treated by
interventional radiography embolization.
You should call your PCP or return to the ER if you should
develop any worsening abdominal pain, lightheadedness, nausea,
vomiting, fever, chills, or any other concerns.
You should take your pain medication and stool softener as
prescribed. You should not drive while taking narcotics.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in his clinic in 2 weeks by calling
[**Telephone/Fax (1) 6439**].
Follow up with orthopedics in 2 weeks by calling [**Telephone/Fax (1) 1228**].
| 20,037 | 122,029 | 86803,86405,E8160,80701,81221 |
Admission Date: [**2165-2-27**] Discharge Date: [**2165-3-4**]
Date of Birth: [**2124-11-3**] Sex: F
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 40 year old female, who has
no symptoms at this time, presented with right sided
weakness. A neurologic workup revealed the presence of 2
strokes. Cardiology workup revealed a patent foramen ovale
and the patient was referred to Dr. [**Last Name (Prefixes) **] for patent
foramen ovale closure. The patient did not have cardiac
catheterization. A transesophageal echocardiography showed a
patent foramen ovale with left to right flow.
PAST MEDICAL HISTORY: Patent foramen ovale.
Depression.
Cerebrovascular accident.
PAST SURGICAL HISTORY: Cesarean section x2.
MEDICATIONS ON ADMISSION: Medications at preoperative workup
were as follows:
1. Celexa 20 mg p.o. once daily.
2. Coumadin 5 mg p.o. 4 times a week and 7.5 mg p.o. 3 times
a week.
ALLERGIES: She is allergic to Penicillin which caused hives.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lived with her husband and had no
smoking or alcohol history and no use of recreational drugs.
LABORATORY DATA: Preoperative laboratory work as follows:
White count 7.2, hematocrit 39.0, platelet count 284,000. PT
16.8, PTT 37.2 with an INR of 1.8. This was all approximately
a week and one half preoperatively when the patient was still
on Coumadin. Her urinalysis showed some hematuria with a
small amount of bacteria. Sodium 138, potassium 3.6, chloride
101, bicarbonate 30, BUN 9, creatinine 0.6, with a blood
sugar of 76, ALT 41, AST 43, alkaline phosphatase 75, total
bilirubin 0.4, total protein 7.8, albumin 4.4, globulin 3.4.
HBA1C 5.4%. Chest x-ray showed no acute cardiopulmonary
process. EKG showed sinus rhythm at 67 with nonspecific ST-T
wave flattening.
PHYSICAL EXAMINATION: On examination, she had a heart rate
of 66 and sinus rhythm with a blood pressure of 120/61,
height 5 feet five inches tall, weight 105 pounds. She was in
no apparent distress. She had no obvious skin lesions. Her
extraocular movements were intact. The pupils are equal,
round and reactive to light and accommodation. Her neck was
supple. Her lungs were clear bilaterally without any rhonchi
or rales. The heart was regular rate and rhythm, with S1 and
S2 tones and no murmurs, rubs or gallops. Her abdomen was
soft, nontender, nondistended with positive bowel sounds. Her
extremities are warm and dry with no cyanosis, clubbing or
edema. She had no obvious varicosities. She was alert and
oriented and grossly neurologically intact cranial nerves II
through XII. She had 2+ bilateral femoral, DP, PT and radial
pulses and no carotid bruits.
HO[**Last Name (STitle) **] COURSE: The patient was admitted to the hospital on
[**2165-2-27**], after stopping her Coumadin at home. On
[**2165-2-27**], she underwent minimally invasive atrial septal
defect repair through a mini right thoracotomy by Dr. [**Last Name (Prefixes) 411**] and was transferred to the Cardiothoracic ICU in stable
condition on a Propofol drip. She had a small right [**Doctor Last Name 406**]
drain for thoracotomy drainage. She was given Morphine and
Toradol for good pain control. She was extubated overnight
and remained on a Neo-Synephrine drip at 1 mcg/kg/minute. She
had a good blood pressure of 88/53 and sinus rhythm at 75 and
temperature maximum of 99.9 postoperatively. White count rose
to 13.0, hematocrit 25.2, and platelet count 303,000.
Potassium 4.0, BUN 10, creatinine 0.6. She had coarse breath
sounds which were decreased on the right. Her Foley and her
chest tubes remained in place. Diet was advanced. She had
been extubated and her [**Doctor Last Name 406**] drain was placed to water seal
and she remained on Neo-Synephrine drip overnight. This was
weaned the following morning down to 0.25. Her hematocrit
dropped slightly to 20.2, white count remained at 9.6. She
finished her perioperative Vancomycin. Her creatinine was
stable at 0.5. Her chest tube was discontinued. Repeat chest
x-ray was done. She was hemodynamically stable in sinus
rhythm with a pressure of 110/58 and was transferred out to
the floor. Lasix diuresis was begun. On the floor, the
patient was evaluated by physical therapy to begin ambulation
and activity tolerance and was seen by case management also
for evaluation. Her Foley was removed that afternoon. On
postoperative day #3, she did complain of some sharp right
inner thigh pain with some activity. She was alert and
oriented, began her aspirin, vitamins, iron and was restarted
on her Celexa as well as Zantac. She was given Vitamin B6 for
neurologic pain. Her aspirin was increased to 325 mg p.o.
once daily. She was hemodynamically stable. Her weight was
88.2 kilograms. She was saturating 96% in room air. Her white
count dropped to 8.0, her hematocrit rose to 25.4 and her
creatinine remained stable at 0.7. She continued to work with
physical therapy. She did have some incisional pain under her
right breast, the site of her mini thoracotomy. This was
treated with p.o. Percocet. She had decreased breath sounds
at the bases. She was tolerating her p.o. well and was
medicated for pain control. On postoperative day #4, her
right inner thigh tingling decreased. She put out almost 6
liters of urine. Her heart was regular rate and rhythm. Her
lungs were clear bilaterally. Her abdomen was soft,
nontender. She was doing very well. The patient complained of
a visual field deficit from the right eye since surgery
without prior history. On examination, appeared to be
nontoxic. Her visual fields were intact. Her extraocular
movements were intact. Cranial nerves II through XII were
intact, and she had no neurologic deficit. Question was
whether the patient had an embolic stroke at that time. A CT
of the head was ordered. Neurology consultation was ordered
and plans were for discharge were placed on hold, given the
patient's complaint of right eye blurriness. An ophthalmology
consultation was obtained. The diagnosis was a small right
macular area hemorrhage. Per initial consultation
ophthalmology, it was recommended that the patient have a
follow-up at her ophthalmologist in [**Location (un) 3307**] or at the [**Hospital3 **] Eye Clinic in [**Hospital Ward Name 23**], fifth floor. Telephone number
was given to the patient, [**Telephone/Fax (1) 10153**], to make an
appointment on Monday after discharge. On postoperative day
#5, neurology saw the patient on [**2165-3-3**], after
ophthalmology consultation. At the time, this was also noted
about the sensory changes of her right thigh in the
distribution of the femoral nerve and lateral femoral
cutaneous nerve. Neurology recommended a state CT of the
pelvis with stat coagulation studies to assess for
retroperitoneal bleed as well as MRA of the brain with a
stroke protocol to evaluate for any infarctions, either water
shed or embolic, given her various neurologic complaints.
This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], neurology attendings. Ophthalmology consultation
was performed as previously noted. On postoperative day #5,
the patient was then in sinus rhythm at 72, was stable
hemodynamically, had trace peripheral edema. Her thoracotomy
incision was clean, dry and intact. Her pacing wires had been
removed. Her central venous line was out. MRI was performed,
awaiting final result. The MR scan was negative per Dr.
[**Last Name (STitle) **], and the patient was neurologically cleared. The
patient was also evaluated to go home with VNA services by
case management. The patient was instructed to follow-up with
ophthalmologist and was discharged home with VNA services on
[**2165-3-4**].
DISCHARGE DIAGNOSES: Status post minimally invasive atrial
septal defect repair.
Status post cerebrovascular accident.
Right macular hemorrhage.
Depression.
Status post cesarean section x2.
DISCHARGE INSTRUCTIONS:
1. To follow-up with Dr. [**First Name (STitle) **], her primary care physician
in approximately 2-3 weeks postdischarge with specific
instructions to follow-up with Dr. [**First Name (STitle) **] on the right
kidney mass and left pelvic cyst that were both found on
CT scan in the hospital.
2. The patient was also instructed to follow-up at the
ophthalmology clinic here at [**Hospital1 10154**], [**Telephone/Fax (1) 10153**], or to see her own ophthalmologist
in [**Location (un) 3307**] as discussed for follow-up of her right
retinal hemorrhage.
3. The patient was also instructed to follow-up with Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately 4 weeks for her
postoperative surgical visit in the office.
MEDICATIONS ON DISCHARGE:
1. Celexa 20 mg p.o. once daily.
2. Ferrous Sulfate 325 mg p.o. once daily.
3. Vitamin C 500 mg p.o. twice daily.
4. Pyridoxine Hydrochloride 50 mg p.o. once daily.
5. Enteric-coated aspirin 325 mg p.o. once daily.
6. Percocet 5/325 one tablet p.o. p.r.n. q.4hours for pain.
7. Ibuprofen 400 mg p.o. q.6hours p.r.n. for pain.
DISCHARGE STATUS: The patient was discharged to home in
stable condition with VNA services on [**2165-3-4**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2165-4-16**] 16:12:56
T: [**2165-4-16**] 19:43:38
Job#: [**Job Number 10155**]
| 20,038 | 126,882 | 7455,36281,7820,7935,V1259,V5861,2859,45829,42731 |
Admission Date: [**2102-5-4**] Discharge Date: [**2102-5-14**]
Date of Birth: [**2034-6-10**] Sex: M
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 67 year old male who
was referred to [**Hospital1 69**] from a
Stress Test Laboratory following elicitation of symptoms of
hypotension and diffuse ST depressions upon exercise. The
patient was reportedly referred to for stress testing by his
primary care provider due to complaints of chest pain after
exercising for approximately ten minutes. At baseline, the
patient walks four miles daily.
Approximately one month ago, the patient experienced the
sudden onset of chest pain across his chest, after
approximately [**2-14**] of a mile of walking. The patient had
similar symptoms the following day. The patient subsequently
discontinued his walking regimen, and [**Doctor First Name **] to a regularly
scheduled appointment with his primary care physician for
which he was subsequently referred for a stress test.
On stress testing, the patient was noted to experience
hypotension from systolic 140 to systolic 108, and diffuse ST
depressions after approximately four minutes of exercise
testing. The patient was reportedly asymptomatic during this
time, but was subsequently referred to [**Hospital1 190**] for further evaluation and management.
PAST MEDICAL HISTORY:
1. History of bleeding ulcers.
2. Question of hypercholesterolemia.
3. Gastroesophageal reflux disease status post
fundoplication.
4. History of idiopathic transaminitis.
MEDICATIONS AT HOME: Zantac.
ALLERGIES: Morphine, which causes disorientation.
Tensilon which elicits hives.
SOCIAL HISTORY: The patient is divorced. The
patient is retired and is a part time safety
officer. The patient has no history of tobacco use. The
patient has a significant history of alcohol abuse in the
distant past but has been abstinent for approximately 20
years.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2102-5-4**] for further work-up of his cardiac
symptoms . Admission EKG demonstrated left axis deviation
with 1/[**Street Address(2) 2915**] depression in V3 to V5; on exercise
per the patient's stress test, the patient's EKG demonstrated
diffuse [**Street Address(2) 31707**] depressions in V2 to V6 and ST
elevations in V3.
Cardiac catheterization conducted on [**2102-5-5**],
demonstrated a three vessel coronary artery disease with a
focal 80% stenosis in the mid-proximal segment of the left
anterior descending, a focal 90% stenosis in the mid major
obtuse marginal branch of the left circumflex, and 100%
occlusion of the right coronary artery in its mid segment.
The patient's calculated ejection fraction was noted to be
45%. At this point, Cardiac Surgery was consulted and,
following a discussion of the relative pros and consultation
of surgery, the patient consented to undergo a coronary
artery bypass graft procedure to take place on [**2102-5-10**].
In the interval, the patient was stabilized by the Medicine
Team in preparation for surgery. On [**2102-5-10**], the
patient underwent a quadruple coronary artery bypass graft
procedure. Anastomoses included from the left internal
mammary artery to the left anterior descending, saphenous
vein graft to the diagonal, saphenous vein graft to the
obtuse marginal, and saphenous vein graft to the diagonal.
The patient's pericardium was left open. Lines placed
included arterial, Swan-Ganz and central venous pressure
catheters; both ventricular and atrial wires were placed;
mediastinal, left and right pleural tubes were placed.
The patient was subsequently transferred to the Cardiac
Surgery Recovery Unit, intubated, for further evaluation and
management. On transfer, the patient's main arterial
pressure was 80; his central venous pressure was 14; his PAD
was 17 and his [**Doctor First Name 1052**] was 26. The patient's heart rate on
transfer was noted to be normal sinus rhythm at 84 beats per
minute.
On transfer, active drips included Phenylephrine and
Propofol. Shortly following arrival in the CSRU, the patient
was weaned and extubated without complication. The patient
was subsequently advanced to oral intake without
complication. On postoperative day number one, the patient's
lines and chest tubes were removed without complication. The
patient was subsequently cleared for transfer to the regular
patient floor. The patient was subsequently admitted to the
Cardiac Thoracic Service under the direction of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
On the floor, the patient progressed well clinically through
to the time of his discharge. The patient's Foley catheter
was removed and he was subsequently noted to be independently
productive of urine for the duration of his stay. Adequate
pain control was provided via oral pain medications for the
duration of his stay.
Physical Therapy was consulted and the patient was
subsequently cleared for discharge directly to home following
resolution of his acute medical issues.
The patient's pacer wires were removed without complication
and on postoperative day number four, [**2102-5-14**], the
patient was cleared for discharge to home with instructions
for follow-up.
DISCHARGE STATUS: The patient is to be discharged to home
with instructions for follow-up.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg p.o. q. day.
2. Atenolol 26 mg p.o. q. day.
3. Atorvastatin 10 mg p.o. q. day.
4. Lasix 20 mg p.o. twice a day times ten days.
5. Potassium chloride 20 mEq p.o. [**Hospital1 **] times ten days.
6. Colace 100 mg p.o. twice a day.
7. Percocet one to two tablets p.o. q. four to six hours
p.r.n. for pain.
8. Lopressor 12.5 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. The patient is to maintain his incision clean and dry at
all times.
2. The patient may shower but should pat-dry incisions
afterwards; no bathing or swimming until further notice.
3. The patient has been instructed to resume a cardiac diet.
4. The patient has been advised to limit physical exercise;
no heavy exertion.
5. No driving while taking prescription pain medications.
6. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**] in one
to two weeks; the patient is to call [**Telephone/Fax (1) 19968**], to
schedule an appointment.
7. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four
weeks; the patient is to call [**Telephone/Fax (1) 170**], to schedule an
appointment.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By: [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) 31708**], M.D.
MEDQUIST36
D: [**2102-5-13**] 16:20
T: [**2102-5-13**] 17:02
JOB#: [**Job Number 31709**]
| 20,039 | 185,427 | 41401,4111,2720,53081,V173 |
Admission Date: [**2128-11-29**] Discharge Date: [**2128-12-8**]
Date of Birth: [**2079-12-7**] Sex: F
Service: Surgery, Purple Team
HISTORY OF PRESENT ILLNESS: This is a 49-year-old woman who
was referred to Dr. [**Last Name (STitle) **] for diverticular disease for a
sigmoid colectomy.
The patient's last attack of diverticulitis was on
[**11-14**] of this past year.
PAST MEDICAL HISTORY:
1. Mild spina bifida without neurologic deficits.
2. History of bladder cancer, status post chemotherapy and
radiation therapy. Follow-up cystoscopies demonstrated no
evidence of recurrence.
3. The patient is postmenopausal.
PAST SURGICAL HISTORY:
1. The patient had a colonoscopy.
2. Resection of bladder tumor in [**2107**] for bladder cancer.
MEDICATIONS ON ADMISSION: The patient was on hormone
replacement therapy which is Estratab one-half strength,
Prometrium 100 mg p.o. q.h.s.
ALLERGIES: SULFA causes hives as well as multiple
environmental allergies.
SOCIAL HISTORY: The patient admits to one alcoholic drink
per day and denies any use or abuse of tobacco products.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were pulse
of 83, blood pressure 129/79. General impression revealed a
well-appearing, well-dressed woman in no apparent distress.
Head, ears, nose, eyes and throat revealed the patient had
scleral icterus. No lymphadenopathy, and no thyromegaly.
Lungs were clear to auscultation bilaterally. Cardiovascular
had a regular rate and rhythm. No murmurs. The abdomen was
soft, nontender, and nondistended, and without bruits.
Extremities had edema, and there were palpable dorsalis pedis
pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2128-11-29**]. She went to
the operating room and had a sigmoid colectomy with a #29 EEA
anastomosis. The patient tolerated the procedure well and an
air and water-tight anastomosis was obtained. Please see
previously dictated Operative Notes for more details.
The patient was extubated in the operating room and was
transferred from the operating room to the Postanesthesia
Care Unit. In the Postanesthesia Care Unit, the patient was
very somnolent and in fact had periods of apnea during sleep.
She received 10 mg of morphine sulfate in the operating room
and 12 mg of morphine sulfate in the Postanesthesia Care
Unit. Because of her somnolence and apneic episodes, the
patient was transferred to the Intensive Care Unit for closer
monitoring. Pain medications were switched from morphine to
Toradol. The patient did not require intubation while in the
Intensive Care Unit. The patient was transferred from the
Intensive Care Unit to the patient care floor on
postoperative day one.
While on the patient care floor she was n.p.o. while awaiting
bowel function. Her pain was controlled with Toradol and
Dilaudid patient-controlled analgesia at a minimum setting.
Her Foley was discontinued on the first day on the patient
care floor.
The patient's course after this point was uncomplicated. Her
electrolytes were periodically checked, and she was given
maintenance intravenous fluids while she was n.p.o. On
postoperative day seven despite she did not have flatus, the
patient was started on sips of clears. The patient tolerated
sips without any problems and denied any nausea or vomiting.
On postoperative day eight the patient had flatus. Her diet
was advanced as tolerated, and she tolerated a regular diet
without problems. She was switched over to p.o. pain
medication which controlled her pain adequately. At this
point she was comfortable and ready to be discharged to home.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE: The patient was discharged to
home on her previous medications which included Estratab and
Prometrium. In addition, the patient had Dilaudid 1 mg one
to two tablets p.o. q.4h. p.r.n. for pain and Colace 100 mg
p.o. b.i.d. while on Dilaudid.
DISCHARGE FOLLOWUP: The patient was to see Dr. [**Last Name (STitle) **] in
her office. The patient should call for follow-up
appointment.
DISCHARGE DIAGNOSES:
1. Diverticulosis.
2. Status post sigmoid colectomy and primary anastomosis.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2128-12-7**] 12:37
T: [**2128-12-12**] 13:37
JOB#: [**Job Number 35983**]
| 20,040 | 138,188 | 56211,78603,V1051 |
Admission Date: [**2201-2-6**] Discharge Date: [**2201-2-10**]
Date of Birth: [**2141-12-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old man
with a history of known coronary artery disease of worsening
symptomatology who was referred for cardiac catheterization.
Cardiac catheterization revealed severe three-vessel disease
and mildly depressed ejection fraction. The patient
complained of shortness of breath after climbing two or more
flights of stairs or walking two blocks at a brisk pace. His
wife also reported that he also occasionally has chest
discomfort but was not sure when this occurs.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Coronary artery disease.
PAST SURGICAL HISTORY: None.
ALLERGIES: SULFA.
MEDICATIONS: Cardizem 240 mg p.o. q.d., Lescol 80 mg p.o.
q.d., Aspirin 325 mg p.o. q.d., Multivitamin 1 p.o. q.d.
LABORATORY DATA: White count 8, hematocrit 43, platelet
count 177; CHEM7 139, 4.7, 105, 25, 17, 1.0, 95.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2201-2-6**], and underwent three-vessel coronary artery
bypass graft. The patient had LIMA to the left anterior
descending, saphenous vein graft to diagonal, and saphenous
vein graft to PL. The patient did well postoperatively and
was brought to the CSRU.
On postoperative day #1, the patient was transferred to the
floor. On postoperative day #2, the patient's chest tube and
wires were removed. The patient's Foley catheter was also
removed at that time. The patient was seen by Physical
Therapy on postoperative day #2 who felt that he was at least
level III ambulation at that time. The patient continued to
do well, and on postoperative day #3, the patient was seen by
Physical Therapy again. At this time he was felt to be at
approximately level IV and would most likely be ready for
discharge on postoperative day #4. The patient was
discharged to home on postoperative day #4 in good condition.
DISCHARGE MEDICATIONS: Percocet 5/325 [**11-26**] p.o. q.4-6 hour
p.r.n., Ibuprofen 400 mg p.o. q.6 hours p.r.n., Aspirin 325
mg p.o. q.d., Colace 100 mg p.o. b.i.d., KCl 20 mEq p.o.
b.i.d. x 7 days, Lasix 20 mg p.o. b.i.d. x 7 days, Metoprolol
12.5 mg p.o. b.i.d., Lescol 80 mg p.o. q.d.
DISCHARGE DIAGNOSIS: The patient coronary artery bypass
grafting times three.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2201-2-9**] 09:59
T: [**2201-2-9**] 10:00
JOB#: [**Job Number 25608**]
| 20,041 | 194,506 | 41401,4019,2720 |
Admission Date: [**2120-4-25**] Discharge Date: [**2120-5-1**]
Date of Birth: [**2064-3-25**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
56 yo man with hx angioplasty in [**2116**] for cad, hx afib prior to
that (none documented since, on no anticoag), p/w fall to L at
work and sudden onset L sided weakness (face, arm and leg) at
4:30PM; CODE STROKE activated. Pt had been in USOH prior to
event, and fall was witnessed by colleagues - pt collapsed to L
against a filing cabinet, noted by colleagues to be weak on the
L
with facial droop on L as well. EMS got call at 5PM and pt
arrived in ER at 5:30PM. VS in field included BG 91, BP 116/68,
HR 60. Neurology at bedside upon pt arrival. NIHSS score 6 for
facial droop (2), motor/arm (1), mild dysarthria (1), and
extinction to DSS (2). Pt himself initially denied L sided
weakness and denied that anything was wrong either with strength
of limbs or with speech. He had been noted by EMS to at times
be
unable to move his L arm, and at other times able to touch his
nose with L hand. C/o no other sx except mild L temple
headache.
No visual or hearing changes, problems swallowing, hearing
problems, or other sx except as above. Stat head CT showed
hyperdense L MCA, and CTA showed clot at M1. TPA given at
6:30PM
(bolus) and infusion to be run for 1hr after.
Past Medical History:
PMH:
CAD s/p angio in [**2116**]
Hx afib prior to angio/stent placement, not documented since
Hx L diaphragm paralysis after neck surgery
No hx htn, high chol, dm to pt's knowledge (though on lipitor)
Social History:
Social History:
Lives with wife, has kids; no tob, few drinks etoh/nt, no drugs;
works in office
Family History:
Family History:
No strokes or heart attacks in family. Father with DM.
Physical Exam:
Admission Examination:
afebrile 116/68 HR 56 99%RA 16 wt 200 lbs
General appearance: white male, NAD
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Rectal: nl, guaiac neg stool
Mental Status: The patient is alert and attentive, could provide
accurate history. Language is intact with no errors, normal
[**Location (un) 1131**] and comprehension, repetition, naming. There is however
anosagnosia, with pt repeatedly saying L side working fine; no
hand agnosia.
Cranial Nerves: The visual fields are full to confrontation, but
there is extinction to DSS on L, and he has a R gaze preference,
though no gaze palsy. The optic discs are normal in appearance.
Eye movements are normal, with no nystagmus. Pupils react
equally to light 3.5->2 bilat, both directly and consensually.
Sensation on the face is intact to light touch, pin prick per
pt,
with no ext to DSS. Facial movements are notable for L droop.
Hearing is intact to finger rub. The palate elevates in the
midline. The tongue protrudes in the midline and is of normal
appearance. Mild dysarthria for labial sounds.
Motor System: There is 5-/5 strength at the left deltoid and
tricep, 4+/5 at finger extensors on L, 5-/5 L hamstring,
elsewhere mms are full stength. There is no tremor, or abnormal
movements. There is L drift and vacillation.
Reflexes: The tendon reflexes are mildly depressed on L [**Hospital1 **]/[**Last Name (un) **]
compared to R. Knees and ankles equal. The L toe is up, R is
down.
Sensory: Sensation is intact to LT, position, but he has
intermittent extinction to DSS on the left to tactile and visual
stim, neglects L side.
Coordination: L F->N Ataxia is not out of proportion to weakness
or neglect, improves with looking at hand on L; no ataxia
elsewhere. The R finger/nose test normal.
Gait: deferred for now
Pertinent Results:
CT head [**2120-4-25**]:
IMPRESSION:
Relatively "hyperdense" proximal right MCA, raising the
possibility of acute embolic or thrombotic occulsion of this
vessel, with no definite evidence of acute major vascular
territorial infarct on this non- contrast head CT. Please refer
to concurrent CTA, including post-processed CT perfusion study
for more complete assessment of this finding.2. No acute
hemorrhage.
CTA head and neck [**2120-4-25**]:
IMPRESSION: Findings consistent ischemia within the right middle
cerebral artery territory, due to embolic occlusive fragment
seen near the origin of the right middle cerebral artery on CT
angiography.
CT head [**2120-4-26**]: New hypodense region within the right basal
ganglia with associated slight edema and mass effect on the
ventricular system suggests acute stroke; however, no
complication including no intracranial hemorrhage is detected
CTA chest [**2120-4-30**]: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multifocal, patchy air space disease. Findings nonspecific
but differential diagnosis includes infectious or inflammatory
process, including cryptogenic organizing pneumonia. While this
is an atypical distribution for aspiration, given the patient's
clinical history, this would also be a consideration.
TEE [**2120-5-1**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild to
moderate ([**12-26**]+) mitral regurgitation is seen. There is no
pericardial effusion. No aortic atheroma.
IMPRESSION: No cardiac source of embolism seen.
Brief Hospital Course:
Patient presented to ED with exam of NIHSS of 6 as per above.
He has a hyperdense right MCA sign confirmed by cut off on CTA
and
decreased CBF on perfusion. Mechanism of stroke is likely
cardioembolic from
atrial fibrillation. Patient received IV tPA after risk of 6.4%
risk of ICH discussed with family and patient . No complications
after bolus and infusion and patient monitored in ICU 24 hours
with no complications. He was transferred to Neurology floor
where he was noted to have a normal neurological exam with only
some very mild left pronator drift. The patient was on telemetry
and no arrhythmias noted. He had an echocardiogram which was
poor quality so had a transesophageal echocardiogram which
showed no cardiac embolic source for stroke. Patinet complained
of shortness of breath during his hospital stay that persisted
for two days. He had nml cardiac enzymes, nml EKG and chest
ct-with perfusion which showed some lung space disease and small
pleural effusions. His shortness of breath improved with
ambulation and incentive spirometry. Patient worked with Pt/OT
who felt he did not need any inpatient or home PT/OT service.
Medications on Admission:
Meds:
Digoxin 250mcg
ASA 81 mg
Nadolol unknown dose
Lipitor 10 mg
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
4. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please do NOT take medication till your PCP checks INR blood
level and tells you to continue the medication.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
stroke
Discharge Condition:
stable
Discharge Instructions:
Take medications as instructed
Followup Instructions:
DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] Neurology [**Hospital 4038**] Clinic
Phone:[**Telephone/Fax (1) 44**] [**2120-5-29**] 4:30 pm [**Hospital 18**] [**Hospital 878**] Clinic
[**Hospital Ward Name 23**] bldng [**Location (un) **]. YOU MUST CALL TO CONFIRM THIS
APPOINTMENT
| 20,042 | 119,892 | 43491,5180,34280,42731,412,41401,V4582 |
Admission Date: [**2182-7-10**] Discharge Date: [**2182-7-30**]
Date of Birth: [**2114-1-4**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 68-year old female
with a history of myelodysplastic syndrome transformed into
acute myelogenous leukemia (type M6A) diagnosed one month ago
who was initially admitted for treatment with low-dose Ara-C
and Hydroxyurea. Her disease was initially diagnosed
secondary to pancytopenia with circulating blast forms and a
bone marrow in [**2182-5-9**]. She was initially treated with
Procrit and weekly transfusions with packed red blood cells
and Danazol from which she developed an allergic reaction.
Over the last week prior to admission, she developed
increased fatigue. Repeat bone marrow showed 7 percent to 10
percent myeloblasts.
PAST MEDICAL HISTORY: As above, history of myelodysplastic
syndrome transformed into acute myelogenous leukemia. No
prior surgeries or prior hospitalizations.
MEDICATIONS ON ADMISSION: Procrit 40,000 units every week
and Tylenol as needed.
ALLERGIES: DANAZOL (causes facial swelling and periorbital
edema).
SOCIAL HISTORY: A 70-pack-year smoking history; currently
smokes half a pack per day. Three drinks of alcohol per
night. She is a retired office manager.
FAMILY HISTORY: Sister deceased from a central nervous
system aneurysm. Brother deceased from coronary artery
disease. She has one daughter and one son.
SUMMARY OF HOSPITAL COURSE:
1. HEMATOLOGY/ONCOLOGY ISSUES: The patient was initially
admitted on to the Bone Marrow Transplant Service. She
was treated with 13 days of low-dose Ara-C as well as
Hydroxyurea. She was treated initially with a one time
dose of GM-CSF which was then discontinued secondary to
fevers. the patient did not show any signs of tumor lysis
by laboratories. Currently waiting for counts to recover.
1. FEBRILE NEUTROPENIA ISSUES: The patient had fevers up to
103 as well as neutropenia. She was originally started on
cefepime, fluconazole, and vancomycin. The cefepime was
discontinued and switched to aztreonam because of a
diffuse rash. AmBisome was eventually started for
continued fevers, but then discontinued secondary to acute
renal failure and switched to voriconazole.
Vancomycin levels have been very elevated and was being dosed
by levels. The blood cultures have remained negative to
date. A chest x-ray did not show any infiltrates. Urine
cultures from [**7-28**] grew 10:100,000 enterococcus with
sensitivities pending. The patient was empirically started
on linezolid, and the vancomycin was discontinued.
1. GASTROINTESTINAL BLEED ISSUES: In the setting of
thrombocytopenia, the patient developed melanotic stools
on the Bone Marrow Transplant floor. She remained
hemodynamically stable and was transferred the [**Hospital Ward Name 332**]
Intensive Care Unit for better monitoring. Her platelets
were kept above 50 and her hematocrit above 25. She
continued to have a slow gastrointestinal bleed.
Gastroenterology was consulted and is following, holding
off on colonoscope at this time. She given vitamin K, as
well as amicrobic acid, and Protonix twice per day. She
requires HLA typed and matched platelets secondary to
antibodies.
1. HYPOTENSION ISSUES: The patient developed hypotension
with mean arterial pressures in the 40s; asymptomatic.
She was given multiple boluses of intravenous fluids
without significant improvement in her pressures. The
differential diagnoses included sepsis, gastrointestinal
bleed, excessive losses from fever and rash as well as
capillary leak syndrome. She was started on low-dose
dopamine for renal perfusion.
1. ACUTE RENAL FAILURE ISSUES: The patient developed acute
renal failure with a creatinine of up to 3.2. The Renal
Service was consulted. Urine sediment showed muddy brown
casts. The likely insult was hypotension in the setting
of a gastrointestinal bleed. The patient continues to
oliguric with improvement in the urine output with a low-
dose dopamine drip. Urine also showed eosinophils -
possible acute interstitial nephritis from multiple drugs.
The patient was started on a trial of prednisone. The
patient was also started on Bicitra 30 twice per day.
1. PULMONARY ISSUES: The patient was continued on albuterol
and Atrovent nebulizers for chronic obstructive pulmonary
disease seen on computerized axial tomography with a
longstanding history of smoking.
1. RASH ISSUES: The patient developed a diffuse erythematous
blanching rash which was likely secondary to drug effect -
cefepime versus vancomycin. The Dermatology Service was
consulted, and a biopsy was consistent with
hypersensitivity reaction. The patient was started
clobetasol and bacitracin topically as well as Sarna
lotion for pruritus.
1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
continued on a full liquid diet. Electrolytes were
repleted once per day. She was maintained on maintenance
fluids.
1. PROPHYLAXIS ISSUES: Proton pump inhibitor and bowel
regimen.
1. ACCESS ISSUES: Hickman catheter and peripheral lines.
1. CONTACT ISSUES: Son and daughter.
1. CODE STATUS ISSUES: Do not resuscitate/do not intubate.
The rest of the hospital course will be dictated by the next
Intensive Care Unit intern.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 35922**]
MEDQUIST36
D: [**2182-7-30**] 11:43:31
T: [**2182-7-30**] 12:29:50
Job#: [**Job Number 56334**]
| 20,043 | 121,043 | V581,V581,20500,20500,2880,2880,5849,5849,5990,5990,5781,5781,496,496,4280,4280,42830,42830 |
Admission Date: [**2103-1-15**] Discharge Date: [**2103-1-23**]
Date of Birth: [**2033-3-1**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfonamides / Novocain
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
CC-unresponsive episode
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 yo female with hx of Parkinsons s/p DBS, and dementia who
presents with episode of unresponsiveness. Per the patients son
[**Name (NI) 892**] she has had a steady clinical decline since last fall. She
initially failed placement in [**Hospital3 **] and moved in with
her daughter. The daughter was unable to care for her and she
was again moved to a higher acuity [**Hospital3 **] arrangement
at [**Location (un) 583**] Gardens [**2101-12-22**]. They also had difficulty managing
the patient as she had frequent freezing episodes, parkinson's
exacerbations and fall. She fell and had head trauma on [**1-5**] and
was brought to the [**Hospital 620**] [**Hospital 4068**] hospital where head CT was
negative, but there was no occult infection or other clear cause
of her decline so she was transferred to [**Hospital 11851**] rehab. Over
the past week she was becoming increasingly disoriented and more
somnolent when seen by her family to the point that she didn't
know her own name or recognize her family. This am while at PT
she suddenly froze for 5 min in her wheelchair and then became
unresponsive. No tonic clonic activity noted, no fecal or
urinary incontinence,no tongue biting. Of note the only recent
alteration of her medications included discontinuation of
Mirapex 2 months ago and started Detrol 3 weeks ago. Pt
initially brought to [**Hospital3 **] for altered mental. Head
CT revealed no acute process but she was transferred to [**Hospital1 18**]
for further workup. In the ED she was febrile to 101.2 and was
only mildly responsive to sternal rub. UA was negative, CXR was
clear, LP was normal. Neurology saw the patient in the
emergency room and felt that this was due to occult infection
and hypernatremia, but they plan to continue to follow the
patient on the floor.
Past Medical History:
1. Parkinson's disease-dx [**2080**] s/p DBS placement [**2097**], never had
tremor only negative symptoms with severe freezing episodes
2. dementia -likely [**Last Name (un) 309**] Body
3. HTN
4. Osteoporosis
5. Hyperlipidemia
6. Panic attacks
Social History:
Has been living at rehab as above. Worked in the media dept for
the city. Remote minimal smoking hx and no EtoH.
Family History:
No fam hx of CVA, DMII, or dementia
Physical Exam:
T 98.6 HR 89 BP 99/58 RR 12 O2Sat 99% 2l
Gen-NAD, not responding to command, wincing to sternal rub
HEENT-PERRL, no elev JVP, head contorted to the right, MM very
dry
Hrt-RRR nS1S2, [**2-17**] sm at RUSB, [**2-17**] SM at apex, [**1-20**] diastolic
murmur at LLSB
Lungs-CTA bilat, poor inspiratory effort
Abd-soft, NT, ND, no HSM, NABS
Extrem-2+ rad and dp pulses, no LE edema
Neuro-withdrawing from painful stimuli, 2+ dtr at knees and
biceps bilat, toes downgoing bilat, diffuse rigidity
Skin-No rashes or lesions
Pertinent Results:
CSF
Protein 23 Glucose 79 LD(LDH): 10
CSF WBC 0 RBC 0
Poly 0 Lymph 75 Mono 25 EOs
.
Lactate:1.2
Ammonia: 17
Chem 7
150 113 36 115 AGap=15
3.8 26 0.9
.
WBC 13.4 Hgb 12.8 Plt 272 Hgb 36.7
N:83.3 L:12.1 M:4.2 E:0.3 Bas:0.1
PT: 13.7 PTT: 25.1 INR: 1.2
.
Color Yellow Appear Clear SpecGr 1.024 pH 5.0 Urobil Neg Bili
Neg
Leuk Neg Bld Lg Nitr Neg Prot Tr Glu Neg Ket Tr RBC 0-2 WBC
0-2 Bact Many Yeast None Epi 0-2
.
ECG-pnd
.
CXR-no acute process-
.
OSH head CT-no acute process
.
Brief Hospital Course:
The patient was admitted to the neurology service after being
stabilized on the medical service. Her sinemet was restarted,
with improvement in her initial presentation, which was
consistent with an akinetic state. She regained movement in her
limbs, although still severely limited by her underlying
parkinson's disease, with R>L rigidity and her course throughout
each day interrupted by dyskinesias.
She was evaluated by a neuro-behavior specialist who knows her,
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who felt that she was near her baseline and would not
benefit from any medication changes.
She was followed closely throughout her stay by movement
disorders specialists, who will see her as an outpatient. Chief
among our concerns, as well as her son's, is that [**Known firstname **] find a
facility that can meet her medical needs, most importantly her
frequent medication dosing requirements. She occasionally
refuses her medications but accepts them readily in ice cream or
[**Last Name (un) 16320**]. She should be treated through dyskinesias and any dose
changes will be addressed as an outpatient. Dyskinesias - as
opposed to akinesia - must be dealt with over the long-term and
not during an inpatient stay. It will require close follow-up
with movement disorders. Any questions regarding her management
should go to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1942**], or his NP, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 16321**].
She is discharged to rehab, with the plan on transferring to a
facility of the family's choosing in the coming week.
Medications on Admission:
Sinemet 25/100 q2h 6am-6pm
Sinemet 50/200 8pm
Mirapex 0.25 mg [**12-19**] tab TID
Evista 60 mg qday
Lipitor 10 mg q day
Detrol LA 2 mg q day
Ativan 0.5 mg po bid
Sertraline 150 mg q day
Tylenol
Norvasc 5mg qd
Metoprolol 25 mg [**Hospital1 **]
Discharge Medications:
1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO Q8PM ().
Disp:*240 Tablet(s)* Refills:*2*
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO X1 (ONE TIME) as
needed for insomnia.
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q2H (every 2 hours): daily from 6am to 6pm.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 16322**]
Discharge Diagnosis:
Parkinson disease
Dementia
Discharge Condition:
Improved
Discharge Instructions:
Please continue to take all medications as prescribed.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1942**]
Date/Time:[**2103-1-29**] 3:00
Completed by:[**2103-1-23**] | 20,047 | 121,842 | 3320,2760,27652,73300,4019,33182,29410,2724 |
Admission Date: [**2149-2-12**] Discharge Date: [**2149-2-18**]
Date of Birth: [**2093-3-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic with +ETT and 3VD on Cath
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG-PDA, Ramus) [**2149-2-13**]
History of Present Illness:
Mr. [**Known lastname 64814**] is a pleasant 55 y/o male who has multpile cardiac
risk factors who was asymptomatic and underwent a stress. ETT
was positive and then referred for cardiac cath. Cath revealed
severe 3 vessel disease. He has then been referred for surgical
revascularization.
Past Medical History:
Hypertension
Hypercholesterolemia
Diabetes Mellitus
s/p R. Arm Surgery after MVA [**2141**]
Social History:
Denies Tobacco. Rare ETOH
Family History:
+CAD FH
Physical Exam:
General: WDWN male in NAD
HEENT: NC/AT, PERRL, EOMI
Neck: Supple, FROM, -Lymphadenopathy, Carotids 2+ without Bruits
Lungs: CTAB -w/r/r
CV: RRR, +S1S2 -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: -C/C/E, 2+ Pulses throughout
Neuro: Non-focal
Pertinent Results:
CXR [**2-15**]: No PTX, and no significant interval change versus
prior following removal of tubes.
Echo [**2-13**]: PRE-BYPASS: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits).
Cath [**2-12**]: 1. Three vessel coronary artery disease. 2. Normal
ventricular function on limited study 3. Elevation of LVEDP
consistent with diastolic dysfunction.
Carotid U/S [**2-12**]: Minimal plaque with bilateral less than 40%
carotid stenosis.
[**2149-2-18**] 05:40AM BLOOD WBC-5.0 RBC-3.05* Hgb-8.7* Hct-25.0*
MCV-82 MCH-28.6 MCHC-35.0 RDW-14.1 Plt Ct-176#
[**2149-2-15**] 02:46AM BLOOD PT-13.4* PTT-29.7 INR(PT)-1.2*
[**2149-2-16**] 05:45AM BLOOD Glucose-135* UreaN-16 Creat-1.1 Na-136
K-4.0 Cl-101 HCO3-28 AnGap-11
[**2149-2-18**] 05:40AM BLOOD UreaN-18 Creat-1.0 K-4.1
[**2149-2-18**] 05:40AM BLOOD Mg-1.7
[**2149-2-12**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, following the cardiac cath Mr.
[**Known lastname 64814**] was consulted by cardiac surgery. Following routine
pre-op work-up, he consented for surgery and was taken to the
operating room on [**2149-2-13**]. He underwent a coronary artery bypass
graft x 3. Please see op note for surgical details. Mr.
[**Known lastname 64814**] was then transferred to the CSRU in stable conition.
Later on op day sedation was weaned and he awoke neurologically
intact. He was then extubated, but had to be reintubated
secondary to respiratory distress with partial airway
obstruction. Then on post-op day one he was again weaned from
sedation and mechanical ventilation and extubated.
Neo-Synephrine was weaned by post op day two and B-blockers and
Diuretics were started. He was gently diuresed during his
hospital stay towards his preoperative weight. Chest tubes were
removed on post-op day two and he was transferred to the cardiac
surgery step-down unit. Physical therapy followed Mr. [**Known lastname 64814**]
during his entire post-op course for mobilty and conditioning.
On post-op day three his epicardial pacing wires and Foley
catheter were removed. He appeared to be doing well with no
post-op complications and was discharged home with VNA services
and appropriate follow-up appointments on post-op day five.
Medications on Admission:
Glucophage 1500 [**Hospital1 **]/500 at lunch, Glucotrol 20mg qd, Avandia 8mg
qd, HCTZ 40mg qd, Atenolol 50mg qd, Lipitor 20mg qd, Humalog,
Lantus 10units qhs, Prinivil 40mg [**Last Name (LF) **], [**First Name3 (LF) **] 325mg qd, Fish Oil
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Also take 500 mg at lunch.
Disp:*150 Tablet(s)* Refills:*0*
9. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: Two (2)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
Disp:*60 Tab, Sust Release Osmotic Push(s)* Refills:*0*
11. Prinivil 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*3 bottles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA [**State 2748**] SE
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
You should shower daily, let water flow over wounds, pat dry
with a towel. Do not take bath. Do not apply lotions, creams,
ointments or powders to incisions.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 933**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks.
Completed by:[**2149-2-18**] | 20,049 | 129,221 | 41401,4111,25001,4019,2720 |
Admission Date: [**2102-4-18**] Discharge Date: [**2102-6-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
[**2102-4-18**] Whipple Procedure
[**2102-4-21**] Exploratory-lapaorotomy with control of
pancreaticojejunostomy bleeding, revision of
hepaticojejunostomy, gastrostomy-jejunostomy tube placement,
8-french silastic biliary stent placement
[**2102-5-1**] Tracheostomy
[**2102-4-21**] EGD
[**2102-5-18**] EGD
[**2102-5-21**] Colonoscopy
[**2102-5-10**] IR drainage of abscess
History of Present Illness:
This patient is an 82 year old gentleman who presents with a
history of chronic-non-obstructing jaundice. His symptoms
started a month ago with jaundice and weight loss and he was
found to have an ampullary adenoma on endoscopy but it was too
big for resection. He also had a 1.5 cm distal common bile duct
obstruction with atypical cells on cytology brushings. On review
of systems he reports jaundice, weight loss of 15 pounds in 3
months. He has had no itching, abdominal or back pain,
flushing, ascites, steatorrhea, fever, or chills.
Past Medical History:
Chronic Atrial Fibrillation
Hypertension
Hypothyroidism
Perforated Appendicitis s/p appendectomy 40 years ago
complicated by peritonitis
History of duodenal ulcers
Social History:
The patient is a retired postal worker who now works on his
family farm. He does not smoke tobacco or drink alcohol.
Family History:
non-contributory.
Physical Exam:
On admission:
Gen: elderly male, strong-appearing, no acute distress, appears
stated age, jaundiced
HEENT: mild icterus, EOMI, moist mucous membranes
Neck: no cervical lymphadenopathy, trachea midline
CV: irregular irregular rhythm and rate, no murmurs
Pulm: chest clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds, no masses
Extr: no edema, warm and well-perfused
Pertinent Results:
SEROLOGIES:
[**2102-4-18**] 05:19PM BLOOD WBC-19.9*# RBC-3.87* Hgb-12.5* Hct-36.7*
MCV-95 MCH-32.4* MCHC-34.2 RDW-13.5 Plt Ct-259
[**2102-4-18**] 05:19PM GLUCOSE-112* UREA N-12 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-10
[**2102-4-18**] 05:19PM PT-14.1* INR(PT)-1.3
[**2102-4-22**] 09:53PM BLOOD HEPARIN DEPENDENT ANTIBODIES: negative
MICROBIOLOGY
[**2102-4-22**] Urine Cx: Negative
[**2102-4-22**] Blood Cx: Negative
[**2102-4-24**] VRE Swab: negative
[**2102-4-24**] MRSA screen: Negative
[**2101-4-29**] C. Diff: Negative
[**2102-4-30**] C. Diff: Negative
[**2102-5-1**] MRSA screen: MRSA +
[**2102-5-4**] Peritoneal Fluid culture: MRSA, VRE
[**2102-5-4**] Wound culture: MRSA
[**2102-5-6**] Sputum culture: negative
[**2102-5-13**] Blood Culture: negative
[**2102-5-13**] Urine Cx: negative
[**2102-5-14**] Pigtail catheter fluid: VRE
[**2102-5-19**] C. Diff: negative
[**2102-5-21**] C Diff B Screen: Negative
[**2102-5-20**] Urine Cx: negative
[**2102-5-24**] Urine Cx: Pseudomonas (pan-sensitive)
[**2102-5-24**] Blood Cx: Klebsiella Pneumonia (sensitive to Levoquin)
[**2102-5-28**] Urine Cx: negative
RADIOLOGY:
[**2102-4-21**] CXR: bilateral effusions
[**2102-4-28**] Abd CT: Bilateral pleural effusions. Right and left
lower lobe opacities, which may represent atelectasis or
consolidations. 2. Scattered ill-defined hypodense liver
lesions, which appear concerning for cholangitis with
microabscesses. Given the patient's history of malignancy,
follow up is recommended. 3. Moderate intraperitoneal free fluid
without evidence of a drainable abscess.
[**2102-5-8**] ABdominal CT Scan: (1) New 15 x 8cm fluid collection at
the inferior aspect of the afferent loop, consistent with
anastomotic breakdown. Findings conveyed verbally by Dr.
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] to covering surgical team. 2) Stable small
bilateral pleural effusions. 3) Unchanged appearance of
hypoattenuating region within segment 3 of the liver. The
differential for this area includes detractor injury versus
cholangitis with abscess. 4) Multiple other small
hypoattenuating lesions throughout the liver, likely consistent
with simple cysts versus hemangiomas. 5) Multiple drains at the
surgical site. 6) Bilateral simple renal cysts, many of which
are too small to characterize. 7) Stable appearance of multiple
simple-appearing cysts at the residual tail of the pancreas.
[**2102-5-17**] Video Swallow Eval: No evidence of penetration or
aspiration. Mild residual within the vallecula and piriform
sinuses, which was cleared after several attempts. Please see
speech pathologist report for a more complete account
[**2102-5-18**] Abdomninal CT Scan : 1. Stable bilateral pleural
effusions and bibasilar atelectasis. 2. Resolution of
subhepatic organized fluid collection. 3. Stable small amount
of ascites without evidence of any new drainable organized
fluid collection.
[**2102-5-24**] CXR: Bilateral Pleural Effusions
PATHOLOGY:
[**2102-4-18**] Operative Specimens:
I. Gallbladder, cholecystectomy (A): 1. Chronic cholecystitis.
2. Cholelithiasis, mixed-type.
II. Pancreaticoduodenectomy, Whipple procedure (B-Z): 1.
Adenocarcinoma of the ampulla, arising in an adenoma. See
synoptic report. 2. Pancreas: a. Small intraductal papillary
mucinous tumor, 0.9 cm, with low-grade dysplasia (slide O). b.
Tiny foci of low-grade pancreatic intraepithelial neoplasia. c.
Dilation of pancreatic duct and focal chronic inactive
pancreatitis. d. Mild hyalinization of pancreatic islets. e.
No tumor in the pancreas.
3. Chronic active inflammation of common bile duct with
dilation, and of cholecystic duct.
4. Segment of duodenum, within normal limits.
CARDIOLOGY:
[**2102-4-21**] Echocardiogram: 1. The left atrium is moderately
dilated. The right atrium is moderately dilated. 2. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis. Overall left ventricular systolic
function is mildly depressed. 3. The right ventricular cavity
is dilated. Right ventricular systolic function appears
depressed. 4. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) aortic regurgitation is seen. 5. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. 6. There is a trivial/physiologic
pericardial effusion.
GI:
[**2102-4-21**] EGD: 1- There was thick sputum and debris in the
retropharynx and piriform sinuses that was suctioned. 2- NG tube
in the esophagus and associated ulcerations 3- Blood in the
stomach. 4- Gastrojejunostomy. 5- Anastomotic ulceration
(injection).
[**2102-5-18**] EGD: 1- No blood in the visualized portions of the upper
GI tract 2- Erythema in the stomach compatible with gastritis 3-
Nonbleeding ulcer in the stomach body (beneath the balloon of
the PEG) 4- PEG tube in the stomach body 5- The endoscope was
passed to the hub in the left limb and approximately 20-30 cm in
the right limb. There was no blood in either limb. 6- Bilious
fluids in stomach 7- Nonbleeding erosion in the one of the
jejunal limbs (left side ? efferent) 8- Gastric erosion (mild)
at the anastomosis site
[**2102-5-19**] Colonoscopy: 1- There was no blood seen in the colon or
ileum. 2- Polyp in the sigmoid and transverse colon 3- There was
an area in the colon at 35cm where the mucosa was edematous and
the lumen somewhat collapsed. There appeared to be multiple
diverticulum in that area but the mucosa appeared ok. This could
be an area that was transiently ischemic or inflammed with
diverticular disease 4- Diverticulosis of the descending colon
Brief Hospital Course:
This is an 82 year old gentleman who presented for a Whipple
resection for an obstructing ampullary mass. His post-operative
course was extensive and complicated by significant
post-operative bleeding requiring emergent laparotomy,
ventillatory dependence requiring tracheostomy, tube-feeding
requirements, and urinary tract infections with bacteremia. A
brief summary of his hospital course is as follows:
.
The patient was admitted for elective Whipple resection on
[**2102-4-18**]. This went without any intraoperative complications
(please see the operative report of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for full
details). He progressed well in the initial post-operative
period but on post-operative day 3 he was noted to have
tachycardia with decreased urine output and a drop in
hematocrit with bloody NGT output. He was transfused with blood
and transferred to the ICU for close monitoring. Emergent
endoscopy was performed revealed blood in the stomach and
ulceration in the anastamosis. The patient subsequently became
tachypnic with a decrease in arterial oxygen and was intubated.
His transfusion requirements continued to increase and his
abdomen became more distended and he was taken to the OR on
[**2102-4-21**] for abdominal washout and control of bleeding from his
anastamosis (please see the operative note of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]
for full details). A Swan-ganz catheter was placed for
cardiovascular assessment and management. He was transferred
back to the ICU post-operatively.
The patient remained stable in his initial post-operative period
with good cardiovascular dynamics and stable hematocrits. On
post-op day 2 (from his abdominal washout) he was off pressors
and trophic tube feeds were started via his J-tube. His
platelets gradually dropped and an HIT panel was sent which was
negative; this was assessed as being secondary to consumption
coagulopathy. His Swan Ganz catheter was remoed on post-op day 3
and he was extubated. His tube-feeds were advanced to goal by
post-op day 4. He was re-intubated on post-op day 4 when he had
copious secretions not improved with nebulizer treatments, and
was kept on CPAP with pressure support. His Atrial fibrillation
was rate-controlled with Diltiazem and aggressive diuresis was
performed for post-operative fluid re-spacing. A percutaneous
tracheostomy was performed on [**2102-5-1**] for continued ventilatory
dependence. He was weaned off his vent on [**2102-5-3**] and tolerated
trach mas breathing. He had partial dehiscence around his
abdominal wounds which required initiation of wet to dry
dressing changes.
On [**2102-5-8**] the patient had an abdominal CT scan which revealed a
small fluid collection near the anastamosis. This was drained by
interventional radiology on [**2102-5-10**] and a pigtail catheter was
left in place; cultures from this fluid collection were
negative. The patient failed a bedside speech and swallow
evaluation on [**2102-5-11**] and was continued on tube feeding. On
[**2102-5-14**] his J-G tube was noted to be broken at the external
infusion port and the tube was removed and changed to a Foley
catheter for tube feeding. His trach was downsized to a #7
portex with a Passe-Muir valve on [**2102-5-16**] and a video swallow
evaluation on [**2102-5-17**] was passed, with a regular diet started in
addition to tube feeding.
On [**2102-5-18**] the patient was stable in appearance but was
transferred to the ICU with a significant elevation in his WBC
count and guaic positive stools with a drop in his hematocrit.
He was transfused blood and serial hematocrits subsequently
remained stable. Colonoscopy and EGD evaluation revealed no
obvious bleeding source. Pan-cultures revealed no obvious source
for the patient's WBC count but he was started on empiric
treatment for presumed C-Diff colitis. His white count gradually
declined and he was transferred back to the floor after several
days. His tube feeds were restarted on [**2102-5-21**] and he was
advanced to a regular diet with cycled tube feeds on [**2102-5-23**].
He did, however, have a fever to 102 on [**2102-5-24**] and work-up this
time revealed Pseudomonas in his urine and Klebsiella in his
blood. Infectious Disease consulation was obtained and he was
started on Levoquin for treatment and follow-up urine cultures
were negative and he remained afebrile. His remaining JP drain
was removed on [**2102-5-25**]. His Foley catheter was removed on
[**2102-5-26**] and he was able to void without it.
Towards the end of [**Month (only) 116**], social services and case management were
asked to assist with rehab placement. Plans were made to
transfer him to rehab. On [**6-2**], his trach was decanulated. He
tolerated this well and was breathing well, as well as clearing
secretions well. Physical therapy worked with the patient to
assist with ambulation. Anti-coagulation for his chronic atrial
fibrillation was not started given the chronicity and his recent
severe episodes of post-op bleeding. He has planned follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] in 2 weeks. All questions were answered to
his satisfaction upon discharge. On [**6-5**] in the morning the
patient was discharged home with physical therapy services in
addition to visiting nursing services to manage his ongoing tube
feeds. Toward the end of the [**Hospital 228**] hospital stay he was able
to take in roughly 1900 cal, tube feeds will be used to
supplement his nutition.
Medications on Admission:
Pepcid
Synthroid 50 mcg oral daily
Triamterene
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) ml
Injection ASDIR (AS DIRECTED): BS 121-160: 4 units, 161-200: 8
units, 201-240: 12 units, 241-280: 16 units, 281-320: 20 units.
2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Lansoprazole 30 mg Tablet,Lingual Delayed Release Sig: One
(1) Tablet,Lingual Delayed Release PO DAILY (Daily).
Disp:*30 Tablet,Lingual Delayed Release(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
[**Hospital 40198**] Healthcare Center - Nursing and Rehab
Discharge Diagnosis:
Primary: Periampullary mass in pancreas
Secondary: Atrial Fibrillation, post-operative bleeding, Post-op
ventilatory dependence, urinary tract infection, Klebsiella
bacteremia, Difficulty swallowing, Hypertension, hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed. You should continue your
regular diet with twice/day tube feeding supplements as
indicated. You should return to the ER or call the office with
any worsening abdominal pain, bloody stools, fever > 101.5,
nausea or inability to tolerate a regular diet, respiratory
distress, drainage from your wound, or concerning laboratory
values.
Followup Instructions:
You should follow-up in the office of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] in [**1-1**]
weeks (call [**Telephone/Fax (1) 2835**] for an appointment)
| 20,050 | 183,844 | 1562,99811,5185,9974,99832,42731,5672,7907,57410,2869,56089,5990,0417,0413,4019,2449 |
Admission Date: [**2184-5-14**] Discharge Date: [**2184-5-22**]
Date of Birth: [**2184-5-13**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname 1169**] [**Known lastname 61521**] was born at 33
6/7 weeks gestation to a 35 year old gravida 2, para 0, now 1
woman. The mother's prenatal screens were blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis surface antigen negative and Group B Strep unknown.
He was delivered by cesarean section for worsening
oligohydramnios in breech positioning.
This mother's previous medical history is remarkable for
lupus, partial thyroidectomy secondary to benign tumor, VP
shunt secondary to pseudotumor cerebri. Mother was not on any
medications during the pregnancy. Mother was followed by the
maternal fetal medicine service and her primary obstetrician.
A fetal echocardiogram and level 2 ultrasound secondary to
the maternal lupus were normal. The pregnancy was complicated
with oligohydramnios since [**06**] weeks gestation. The mother
received a complete course of betamethasone at that time. She
had been home on bedrest. The interval ultrasound had stable
amniotic fluid levels and good growth. Her biophysical
profiles remained [**8-23**]. Over the week prior to delivery the
mother had diarrhea and the amniotic fluid index was
decreased to 4 from the previous [**7-24**]. So, in light of this
change in amniotic fluid volume the mother was delivered by
cesarean section. The infant emerged with Apgar's of 9 at one
minute and 9 at five minutes.
He developed respiratory distress soon after delivery and was
transferred to the special care nursery at [**Hospital3 38285**]. The infant's birth weight was 2640 gm, the birth
length 46.5 cm and the birth head circumference 35 cm. The
infant required intubation and surfactant administration,
additionally required fluid resuscitation and pressor support
at [**Hospital3 **] and so was transferred to [**Hospital6 1760**] by the [**Hospital3 1810**]
Transport Team. He was transferred to [**Hospital6 649**] due to lack of available beds at [**Hospital3 18242**].
NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS:
Respiratory - He received 2 doses of Surfactant. He
weaned to a CPAP pharyngeal positive airway pressure on day
of life #5, and then weaned to nasal cannula on day of life
#7 where he remained at a flow of 13 cc of 100% oxygen. On
exam his respirations are comfortable, 40-60 breaths per
minute. Lung sounds are clear and equal.
Cardiovascular - He required pressor support with Dopamine to
a maximum of 20 mcg/kg/min, with weaning by day of life #3.
He has remained normotensive since that time. He has an
intermittent Grade 1/6 systolic ejection murmur at the left
sternal border. He has had no further cardiology workup.
Fluids, electrolytes and nutrition - His weight at discharge
is 2,600 grams. Enteral feeds were begun on day of life #5
and advanced without difficulty to full volume feedings on
day of life #9 the night before transfer to [**Hospital1 2436**]. He is
getting formula 20 cal/oz Similac Special Care, total fluids
of 120 ml/kg/day orally or by gavage. His last set of
electrolytes on [**2184-5-19**] were a sodium 133, potassium 5.5,
chloride 112, bicarbonate 18, and triglycerides 47.
Gastrointestinal - He was treated with phototherapy for
hyperbilirubinemia of prematurity on day of life #4 until day
of life #7. His peak bilirubin occurred on day of life #4 and
was total of 12.0, direct 0.3. His last bilirubin on [**2184-5-21**], was total of 5.2, direct 0.3.
Hematology - He has not received any blood product
transfusions during his NICU stay. His last hematocrit [**2184-5-15**] was 41.4. His platelets on [**2184-5-16**], were 186,000.
Infectious disease - He was started on ampicillin and
gentamicin at the time of admission to [**Hospital3 **]
Special Care Nursery. He will complete a 10-day course of
antibiotics for presumed sepsis. The date of transfer, [**2184-5-24**], is day #9 of 10 of antibiotic. His gentamicin levels on
[**5-16**] were trough 1.2 and peak 6.2. His blood culture
remained negative. His spinal tap on day of life #4 had a
white blood cell count of 8, a red blood cell count of 2,
total protein of 89 and glucose of 36. No blood glucose was
done concomitantly with that spinal tap, however, his blood
glucoses during that day were in the 60s. His CSF culture
remains negative.
Neurology - Audiology screening has not yet been performed
and is recommended prior to discharge.
Psychosocial - Parents have been involved in the infant's
care throughout his NICU stay. The infant is discharged in
good condition. He is transferred to [**Hospital3 **]
Special Care Nursery for continuing care.
The name of the primary pediatric care provider has not yet
been identified.
RECOMMENDATIONS AFTER DISCHARGE:
Feeding - Special care 20 cal/oz formula, currently at 120
ml/kg/day, advancing as tolerated to a recommended goal of
150 cc/k/day.
Medications - The infant has a heparin lock being flushed
every 6 hours and as needed with heparin 10 units/ml, 1 ml
IV. Ampicillin 400 mg IV every 12 hours, gentamicin 8 mg IV
every 24 hours, Desitin ointment topically to his diaper area
as needed.
Screening tests - He has not yet had a carseat position
screening test. His state newborn screen was sent on [**2184-5-16**].
Immunizations - He has not received any immunizations.
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 6/7 weeks gestation.
2. Resolving respiratory distress syndrome.
3. Resolving presumed sepsis.
4. Status post hypotension.
5. Status post hyperbilirubinemia of prematurity.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2184-5-22**] 00:28:31
T: [**2184-5-22**] 06:57:40
Job#: [**Job Number 61522**]
| 20,051 | 170,846 | 769,77181,7742,76519,76527 |
Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-9**]
Date of Birth: [**2098-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2137-7-2**] - Minimally invasive MVR (St. [**Male First Name (un) 923**] mechanical valve)
History of Present Illness:
This is a 39-year-old female with a history of [**Male First Name (un) 15196**] heart
disease, who presented in pulmonary edema after her pregnancy.
She was found to have
moderate to severe mitral regurgitation. It was recommended that
she have a mitral valve replacement, and after the risks and
benefits were explained to her, she agreed to proceed.
Past Medical History:
[**Male First Name (un) **] [**Male First Name (un) **]
CHF
MR
HTN
Social History:
Homemaker. Smoked [**1-7**] ppd quitting in [**5-11**]. Drinks 6 beers per
weekend.
Family History:
Father with [**Date Range 15196**] heart disease
Physical Exam:
Pulse 82 133/70 64" 134 lbs
GEN: WDWN female in NAD
Skin: Few mottled areas of LE's
HEENT: Unremarkable
NECK: Unremarkable
LUNGS: Clear
HEART: RRR, holosystolic murmur
ABD: Benign
EXT: Warm, well perfused, no edema
NEURO: Alert, nonfocal
Pertinent Results:
[**2137-7-7**] 04:20AM BLOOD Hct-24.1*
[**2137-7-6**] 09:50AM BLOOD WBC-8.4 RBC-2.75* Hgb-8.5* Hct-23.9*#
MCV-87 MCH-30.9 MCHC-35.5* RDW-13.9 Plt Ct-220
[**2137-7-9**] 05:55AM BLOOD PT-22.3* INR(PT)-2.2*
[**2137-7-7**] 04:20AM BLOOD K-5.1
[**2137-7-5**] CXR
Small bilateral pleural effusions have accumulated since [**7-3**]
following removal of the right apical pleural tube. There is no
detectable pneumothorax. Bibasilar atelectasis has worsened and
increased in caliber of the cardiac silhouette, still normal in
volume, may reflect increasing intravascular volume.
[**2137-7-2**] ECHO
Prebypass:
1. The left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal. There is mild
regional left ventricular systolic dysfunction. Overall left
ventricular systolic function is mildly depressed.
3. Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
5.The mitral valve leaflets are moderately thickened. The mitral
valve shows characteristic [**Month/Day/Year 15196**] deformity. There is mild
mitral stenosis. Moderate to severe (3+) mitral regurgitation is
seen. The mitral regurgitation vena contracta is >=0.7cm.
6.The tricuspid valve leaflets are mildly thickened.
7. There is no pericardial effusion.
Post Bypass:
There is a well-seated mechanical valve in the mitral position.
Trivial/normal washing jets seen. Preserved LV systolic fxn., on
inotropic
support. (epinephrine) Nl RV systolic fxn, preserved aortic
contours
Brief Hospital Course:
Mrs. [**Known lastname 62538**] was admitted to the [**Hospital1 18**] on [**2137-7-2**] for elective
surgical management of her mitral valve disease. She was taken
to the operating room where she underwent a minimally invasive
mitral valve replacement utilizing a 25mm St. [**Male First Name (un) 923**] mechanical
heart valve. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. By postoperative
day one, Mrs. [**Known lastname 62538**] had awoke neurologically intake and was
extubated. She was transfused for postoperative anemia.
Anticoagulation was started for her mechanical valve. Her drains
and wires were removed per protocol. later on postoperative day
one, Mrs. [**Known lastname 62538**] was transferred to the step down unit for
further recovery. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
NSAIDs were given for her minimally invasive approach. Slowly
her INR came within therapeutic range and she was discharged
home on postoperative day seven. She will follow-up with Dr. [**Last Name (Prefixes) **], her primary care physician and her cardiologist as an
outpatient. Her coumadin will be dosed for a target INR of
3.0-3.5 (mechanical mitral valve). Her primary care physician
will monitor her blood work for coumadin dosing.
Medications on Admission:
Bisoprolol 2.5mg QD
Lisinopril 10mg QD
Lasix 20mg QD
OCP
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
No services
Discharge Diagnosis:
MR
[**First Name (Titles) **] [**Last Name (Titles) **]
HTN
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams lotions or powders to any incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] in 4 weeks
with Dr. [**Last Name (STitle) 6254**] in [**2-8**] weeks
with Dr. [**Last Name (STitle) 62539**] in [**2-8**] weeks
Completed by:[**2137-7-11**] | 20,052 | 120,473 | 3941,39891,4019,2859,V5861,42789 |
Admission Date: [**2120-5-24**] Discharge Date: [**2120-5-27**]
Date of Birth: [**2078-7-1**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Briefly, this is a 41-year-old
male, with a long history of fibrosing mediastinitis, who has
had multiple episodes of head discomfort and shortness of
breath after leaning over. He had been worked-up extensively
and was found to have thrombosed his right subclavian, right
IJ and had developed multiple collaterals. Venography by Dr.
[**First Name (STitle) **] showed that his left innominate vein was still patent,
and it was decided that he would need a bypass of this area
to his heart to return blood flow.
PAST MEDICAL HISTORY: Depression, high cholesterol,
hypertension, SVC syndrome, gastroesophageal reflux disease,
a paralyzed right hemidiaphragm secondary to a thoracotomy,
and the fibrosing mediastinitis. He is status post
mediastinoscopy, right pleuracotomy, and multiple oral
surgeries.
ALLERGIES: He has no known drug allergies.
MEDICATIONS:
1. Coumadin which he stopped prior to surgery.
2. Lovenox subcutaneous.
3. Robaxisal 40 mg p.o. once daily.
4. Zoloft 100 mg p.o. once daily.
5. Lipitor 10 mg p.o. once daily.
PHYSICAL EXAM: He is afebrile with stable vitals. His lungs
are clear. Heart was regular. When he leaned over he was
noted to have increased venous congestion of his head, and
also got short of breath.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2120-5-24**], where a left innominate vein to right
atrial bypass graft was done using an 8 mm [**Doctor Last Name 4726**]-Tex graft
through a median sternotomy incision. Please see the
operative report for further details. The patient was
transferred to the CSRU postoperatively, and he did well. He
was weaned and extubated. His chest tubes were removed. The
patient was transferred to the floor which he tolerated, and
then he was started on a p.o. diet. His pain was well-
controlled, and his Foley was also removed. The patient
continued to do well, and he was started on Lovenox and
Coumadin again. Goal INR of around 3.0. He continued to
ambulate and improve, and his pain was well-controlled, and
on postoperative day #3 it was decided that the patient would
be safe for discharge, and the patient was discharged home.
PT was consulted prior to discharge to evaluate for any
functional losses, and it was noted that the patient had
none, and it would be safe for the patient to be discharged
home. The patient was discharged on [**2120-5-27**] in stable
condition on Lovenox and Coumadin, as well as 8 mg of
Coumadin, as well as Lovenox as a bridge for therapeutic INR,
as well as all of his home medications. The patient was
discharged in stable condition.
DISCHARGE DIAGNOSES:
1. Fibrosing mediastinitis, status post left innominate vein
to right atrial bypass graft.
2. Superior vena cava syndrome.
3. Hypertension.
4. High cholesterol.
5. Gastroesophageal reflux disease.
6. Status post mediastinoscopy.
7. Status post right thoracotomy.
8. Status post oral surgery.
9. Status post left eye surgery
[**25**]. Status post vasectomy.
11. Paralyzed right hemidiaphragm.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2120-5-27**] 13:23:19
T: [**2120-5-27**] 13:44:32
Job#: [**Job Number 56950**]
| 20,053 | 156,025 | 4592,5192,4019,2720,53081,311 |
Admission Date: [**2173-6-23**] Discharge Date: [**2173-6-30**]
Date of Birth: [**2095-7-27**] Sex: M
Service: OMED
Allergies:
Niacin
Attending:[**Doctor First Name 18856**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 77M with h/o metastatic RCC with mets to lung, thyroid,
COPD, diastoic CHF, sleep apnea, restrictive lung disease,
remote MI, presents with acute onset resp failure; intubated in
ED, became hypotensive following sedation requiring 6L NS
boluses and levophed. WBC 21 with 9%bands. CT angio-> L
infrahilar mass compressing L main bronchus and L pulm art but
stable, interval increase in parenchymal nodes and masses,
increased b/l pleural effusions, stable RLL ground glass
opacity, no PE.
[**Hospital Unit Name 153**] course: treated with steriods, nebs, Zosyn->Levoflox.
Weaned off pressors and extubated [**6-25**]; presumed mucus plugging
v COPD flare v RLL infiltrate (bronchitis). On arrival on floor
(5S on [**6-26**]), experienced some tachycardia due to frequent PAC's
and non-sustained A-tach, and was given IV Dilt, 10 mg and 30
po, with successful rate control response.
Past Medical History:
PMH: metastatic RCC, COPD, OSA, h/o prostate CA, CAD s/p MI,
hyperlipidemia, Afib, 4+MR
Social History:
Lives at home with wife; works as a heavy equipment operator.
Family History:
Leukemia, brain cancer
Physical Exam:
PE:
T 97; BP 151/58; P 111; R 16; Sat 99% on 4 lpm
I/O +6155 LOS good UOP
Gen - NAD
Heent - PERRLA, EOMI, O/P clear
Neck - 8-9 cm JVD
Lungs - LLL crackles, no wheezes
CV - Tachy, [**Last Name (un) **] [**Last Name (un) **]
Abd - Soft, NT, + BS, mod. distension
Ext - 2+ edema t/o
Neuro - A + O, moves all extremities
Pertinent Labs -
Cr 1.8, up from 1.4 on admission; blood and urine cx. neg.
Pertinent Results:
[**2173-6-23**] 06:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+
[**2173-6-23**] 06:15PM NEUTS-60 BANDS-9* LYMPHS-25 MONOS-2 EOS-1
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2173-6-23**] 06:15PM WBC-21.1* RBC-5.09 HGB-13.8* HCT-47.1 MCV-92
MCH-27.1 MCHC-29.3* RDW-14.5
[**2173-6-23**] 06:15PM TOT PROT-6.9 ALBUMIN-3.3* GLOBULIN-3.6
CALCIUM-7.2* PHOSPHATE-5.5*# MAGNESIUM-0.9*
[**2173-6-23**] 06:15PM CK-MB-15* MB INDX-4.3 cTropnT-0.01
[**2173-6-23**] 06:15PM ALT(SGPT)-53* AST(SGOT)-50* CK(CPK)-348* ALK
PHOS-143* AMYLASE-57 TOT BILI-0.4
[**2173-6-23**] 06:15PM GLUCOSE-166* UREA N-20 CREAT-1.5* SODIUM-142
POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2173-6-23**] 06:25PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
[**2173-6-23**] 06:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2173-6-23**] 06:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2173-6-23**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-6-23**] 07:00PM ALBUMIN-3.1* CALCIUM-6.8* PHOSPHATE-6.6*
MAGNESIUM-0.8*
[**2173-6-23**] 07:00PM CK-MB-15* MB INDX-4.2 cTropnT-0.03*
[**2173-6-23**] 07:00PM ALT(SGPT)-50* AST(SGOT)-50* CK(CPK)-357* ALK
PHOS-136* AMYLASE-62 TOT BILI-0.4
[**2173-6-23**] 07:00PM GLUCOSE-175* UREA N-20 CREAT-1.6* SODIUM-144
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-26 ANION GAP-17
[**2173-6-23**] 08:56PM HGB-11.0* calcHCT-33
[**2173-6-23**] 08:56PM LACTATE-1.0 K+-5.3
[**2173-6-23**] 08:56PM TYPE-ART PO2-378* PCO2-52* PH-7.21* TOTAL
CO2-22 BASE XS--7
[**2173-6-23**] 10:03PM PT-14.3* PTT-24.4 INR(PT)-1.4
[**2173-6-23**] 10:28PM TYPE-ART PO2-229* PCO2-41 PH-7.28* TOTAL
CO2-20* BASE XS--6
Brief Hospital Course:
Mr. [**Known lastname 32090**] was transfered to the OMED service from the [**Hospital Unit Name 153**]
after a one day stay which had required intubation. Initially,
he required 4 LPM O2 via nasal cannula, and on arrival on the
floor, he experienced and episode of irregularly irregular
tachycardia, with rates b/t 100 and 150. An EKG was ordered, an
interpreted as MFAT vs. ATACH with occasional PVC's. Mr.
[**Known lastname 32090**] remained stable throughout this episode, and was
asymptomatic. He was given 10 mg of Diltiazem, IVP, with
immediate rate control to the 70's. He was followed with 30 of
Dilt PO, and then put on a regular schedule of 90 mg Dilt tid.
He was monitored on telemetry while on the floor. He was
diuresed with Lasix IV 20 mg 1-2 doses/day, with occasional need
for K, Ca, and Mg repletion. His SOB continued to improve
through this interval, with lessening O2 requirements, finally
needing only 2 lpm via NC. On [**6-29**], after walking to the
bathroom without assistance, he was noted to have another
episode of atach with RVR with rates of approx 100-150. He was
again asymptomatic and stable during this episode. No Afib was
noted. He was managed at this time with rest and an additional
po dose of Dilt, 30mg. Later in the day of the 29th, his rhythm
was stable, and he completed a video swallow study. The
recommendations of the SLP were for no gulping, and sitting bolt
upright for any po. He was d/c'd on the following day with F/U
in heme/onc clinic, home O2, and home PT. His Dilt was
prescribed in ER form, at one 240 mg capsule qd.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed
for as instructed doses: Take five tablets once a day for three
days, then 4 tablets once a day for three days, then 3 tablets
once a day for three days, then 2 tablets once a day for three
days, then one tablet once a day for three days.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed
for as instructed doses: Take five tablets once a day for three
days, then 4 tablets once a day for three days, then 3 tablets
once a day for three days, then 2 tablets once a day for three
days, then one tablet once a day for three days.
Disp:*45 Tablet(s)* Refills:*0*
7. Diltiazem ER 240 mg Capsule,Degradable Cnt Release Sig: One
(1) Capsule,Degradable Cnt Release PO once a day.
Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Bronchitic pneumonia/COPD flare.
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Followup Instructions:
Heme/onc clinic. Please call Dr.[**Name (NI) 47540**] office to schedule
[**Name6 (MD) 6337**] [**Name8 (MD) **] MD [**MD Number(1) 6342**]
| 20,057 | 189,742 | 51881,49121,1970,42832,4280,19889,V1052,4169,4019 |
Admission Date: [**2133-3-17**] Discharge Date: [**2133-3-19**]
Date of Birth: [**2133-3-17**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby Girl [**Name2 (NI) 40351**] is a term
female infant, born by cesarean section for maternal
indications, who is ready to transfer to the newborn nursery.
The infant was born to a 29 year old, primigravida woman.
Her prenatal screens were blood type 0 positive, antibody
negative, Rubella immune; RPR nonreactive; hepatitis B surface
antigen negative and group B strep unknown. This pregnancy
was uncomplicated until [**2133-3-13**], four days prior to delivery
when the mother noted malaise and shortness of breath. The
symptoms persisted and on [**2133-3-15**], she developed productive
cough and fever. On [**3-16**], she was started on Zithromax,
Claritin and Albuterol as an outpatient. On the day of
delivery, she presented to the [**Hospital1 2436**] Emergency Room with
increasing shortness of breath, dyspnea, tachycardia and
hypotension, with an oxygen saturation in room air of 77%. A
chest x-ray showed bilateral pleural effusions and an echo
showed cardiomyopathy. Her ejection fraction was only 30%.
She was started on Digoxin, Labetalol and Lasix and
transferred to [**Hospital1 69**].
Mother's previous medical history is significant for a
history of kidney stones. The maternal family history is
significant for a brother with a brain tumor.
At [**Hospital1 69**], the mother was
diagnosed with severe pre-eclampsia. She was started on
magnesium sulfate and the decision was made to deliver by
cesarean section. Rupture of membranes occurred at delivery.
There was thick meconium stained amniotic fluid. The
maternal fever for the four preceding days is as described
above.
The infant required just routine suctioning and blow-by
oxygen and then was admitted to the Newborn Intensive Care
Unit for persistent oxygen requirement.
The birth weight was 4,295 grams. The birth length was 20
inches and the head circumference was 35 cms. The admission
physical examination revealed a well appearing, non
dysmorphic term female. Anterior fontanel was soft, open and
flat. Red reflexes were present bilaterally. Palate was
intact. Breath sounds were fairly clear with slightly
diminished air entry. Symmetric. Mild intercostal
retractions. No grunting or flaring. Regular rate and
rhythm and heart without murmur. 2+ peripheral pulses
including femorals. Abdomen benign without
hepatosplenomegaly, masses. Normal female external
genitalia. Normal back and extremities with stable hips. Mild
erythema toxicum rash. Appropriate tone and responsitivity.
HOSPITAL COURSE: Neonatal Intensive Care Unit course by
systems:
Respiratory: At the time of admission, her respirtory rate was
in the mid 70's with an oxygen saturation of 87% on room air
and 98% in blow by oxygen. She required small amount of
oxygen. She weaned to room air by 09:00 on [**2133-3-18**]. Her
respirations are comfortable. Lung sounds are clear and
equal.
Cardiovascular: Remained normotensive throughout her
Neonatal Intensive Care Unit stay. There are no issues.
Fluids, electrolytes and nutrition: She has been eating
Enfamil 20 calories per ounce on an ad lib schedule, taking
30 to 70 cc on a q. three to four hour schedule. She has
remained euglycemic throughout her Neonatal Intensive Care
Unit stay. Her capillary blood glucose levels have been in
the 60's. Her weight at the time of transfer is 4,285 grams.
Gastrointestinal: There are no issues.
Hematology: The patient's hematocrit at the time of
admission was 51. The infant has received no blood products
during her Neonatal Intensive Care Unit stay.
Infectious disease: The infant was started on Ampicillin and
Gentamycin at the time of admission for sepsis suspicion. She
continues on those antibiotics at the time of transfer. The
plan is to discontinue them at 48 hours if blood cultures
remain negative. Her white blood count at the time of
admission was 16,000 with a differential of 49 polys and 1
band and 25 nucleated red blood cells. Her platelet count
was 267,000 and her blood culture remains negative to date.
Neurology: There are no issues.
Sensory: Audiology: Hearing screening has not yet been done
but is recommended prior to discharge.
Psychosocial: The mother was transferred back to the [**Hospital Ward Name 8559**] of [**Hospital1 69**] on [**2133-3-18**] and
has been up to the Neonatal Intensive Care Unit to see the
infant. The infant is being transferred in good condition to
the newborn nursery.
A primary pediatric care provider has not yet been identified
by the family.
CARE AND RECOMMENDATIONS:
Feeding Enfamil 20 calories per ounce on the ad lib schedule.
MEDICATIONS:
Ampicillin 500 mg intravenous q. 12 hours.
Gentamycin 17 mg intravenous q. 24 hours.
Normal saline flush 1 cc intravenous every six hours prn to
keep her peripheral intravenous patent.
State newborn screen has not yet been set.
The infant has received no immunizations prior to transfer.
She will need hepatitis B vaccine.
DISCHARGE DIAGNOSES:
Term female newborn.
Large for gestational age.
Sepsis being ruled out.
Status post respiratory distress due to retained fetal lung
fluid.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Last Name (NamePattern1) 36864**]
MEDQUIST36
D: [**2133-3-17**] 02:55
T: [**2133-3-19**] 04:45
JOB#: [**Job Number **]
| 20,058 | 186,769 | V3001,7706,7661,V053,V290 |
Admission Date: [**2135-5-11**] Service: neonatal Sex: Male
Date of Birth: [**2135-5-11**] Didcharge Date: [**2135-5-28**]
GA: 34wk Discharge day of life:17 and PMA: 36 3/7wk
BW:1650 gm Discharge wt: 1900 gm
HISTORY: This is a 17-day-old baby boy who was born at 34
weeks gestation to a 33-year-old primigravida woman via C-
section due to preeclampsia, IUGR with absent diastolic flow.
The mother received betamethasone prior to delivery. Normal
prenatal screen (B+, antibody negative, RPR NR, RI, GBS unknown,
hepatitis B surface antigen negative. At delivery, the baby
emerged vigorous. Apgar's were 8 and 9. He was brought to the
NICU.
HOSPITAL COURSE: Birth weight was 1.650 kilograms, birth
length was 42 cm, head circumference 30.5.
Respiratory: Respiratory distress syndrome. At birth, baby
was grunting and flaring requiring nasal cannula for 6 days
of life. Never required mechanical ventilation and was on
room air for the rest of his hospitalization. He had no
problems with apnea of prematurity.
Cardiovascular: The baby was cardiovascularly stable, had
normal blood pressures throughout his hospitalization. He has
a murmur consistent with peripheral pulmonary stenosis which
is heard intermittently.
Fluids, electrolytes, nutrition: The baby was on IV fluids
until day of life 2 at which time he began to take milk via
NG tube. He has had good weight gain and will be discharged
feeding breast milk made to 24 calorie/oz with addition of
Similac powder and breast feeding. Medications at discharge: iron
and multivitamin
GI: Hyperbilirubinemia. Max Total Bili= 8.5/0.3.
Rx phototherapy for 7 days and discontinued on [**2135-5-17**].
Hematology: The CBC at birth: white count 7.1k, hematocrit
45%, platelets 161,000, normal differential. Blood culture was
no growth. No indication for further CBCs.
Infectious disease: Patient had one evaluation for possible
sepsis immediately after birth. Evaluation was negative. He did
not receive antibiotic treatment.
Neurology: Stable neurological exam, no indication for cranial
ultrasound.
Hearing test ([**2135-5-26**]) passed bilaterlly.
Ophthalmology: The patient has a positive red reflex bilaterally.
A formal eye exam was not indicated.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone number [**Telephone/Fax (1) 72821**].
FEEDINGS AT DISCHARGE: Breast milk, 24 calorie with Similac
powder.
MEDICATIONS: Iron and multivitamins.
CAR SEAT SCREENING: passed.
STATE NEWBORN SCREEN: Normal on [**2135-5-14**].
VACCINATIONS: Hepatitis B vaccine received on [**2135-5-27**].
IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxi should
be considered from [**Month (only) **] through [**Month (only) 958**] for infant's who
meet any of the following 4 criteria.
1. Born at less than 32 weeks.
2. Born between 32-35 weeks with 2 of the following: Daycare
during RC season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings.
3. Chronic lung disease.
4. Hemodynamically significant congestive heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of life, immunization against
influenza is recommended for household contacts and out of
home caregivers. The infant has not receive Rotavirus
vaccine. The American Academy of Pediatrics recommends
initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically stable and
at least 6 weeks old but few than 12 weeks of age.
FOLLOW UP APPOINTMENTS SCHEDULED:
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Sepsis ruled out.
3. PPS murmur.
4. Respiratory distress syndrome, resolved.
5. Hyperbilirubinemia treated with phototherapy.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 63980**]
MEDQUIST36
D: [**2135-5-27**] 18:22:27
T: [**2135-5-28**] 07:17:34
Job#: [**Job Number 72822**]
| 20,059 | 119,489 | V3001,769,7473,7742,76496,76527,V053,V290,V502,7706 |
Admission Date: [**2147-2-7**] Discharge Date:
Date of Birth: [**2076-4-27**] Sex: M
Service:
The patient is a 70-year-old man with Type 2 diabetes
mellitus who presented with new onset chest pain, non-Q wave
inferior myocardial infarction with ST elevations. He was on
Nitroglycerin and Heparin, no history of transient ischemic
attack, no hypertension, hemodynamically stable.
His clinical exam showed lungs were clear, no jugular venous
distention. Heart was regular rate and rhythm. Abdomen was
scaphoid. His EF was 60% and catheterization showed 100%
occlusion of the RSV and 70% of the left main. The patient
went to the operating room on [**2147-2-8**].
The patient's past medical history is significant for no
coronary artery disease, no hypertension, only diabetes
mellitus for 10 years.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lopressor.
SOCIAL HISTORY: Tobacco: Smoking for a total of 50 pack
years, no intravenous drug use.
The patient was Spanish Speaking, communication was
questionable at best. Please see the operative note for the
[**2147-2-8**] operative note in detail.
Postoperatively the patient was transferred to the
Cardiothoracic Intensive Care Unit where he was progressing
well. He was transferred to the floor on the next day after
extubation on [**2147-2-8**], the day of the operation. He remained
in the Intensive Care Unit [**2-9**] and was then transferred to
the floor on the evening of [**2-9**]. The patient's heart rate
was somewhat elevated on this day, he was given Lopressor to
no effect and during the course of his stay Lopressor was
increased to 35 mg p.o. b.i.d. which brought his heart rate
down. He showed some evidence of trigeminy, his electrolytes
were corrected and he was hemodynamically stable.
Discharged on Keflex 500 mg q.i.d. for suspected sternal
drainage which eventually towards the end of his admission
turned out to be inconsequential by physical examination and
CBC white count. Drainage was noted to be more serous then
infected or erythema or cellulitis noted.
On [**2-10**] his chest tube was discontinued and post chest x-ray
showed no pneumothorax. His wires were discontinued on
[**2147-2-12**] without any event.
Postoperatively the patient was doing well and he was
hemodynamically stable. Lytes were replaced as needed during
his hospital stay. [**Female First Name (un) 3408**] was called in on [**2-12**] because the
patient's blood sugars were initially on the outside, there
was questionable control of his blood sugars. Glucophage was
increased from his home dose of q day 500 mg to b.i.d. 500 mg
and upon discharge on [**2-13**] [**Female First Name (un) 3408**] was contact[**Name (NI) **] to help him
with insulin sliding scale and help managing his sugars which
was started post [**Female First Name (un) 3408**] seeing him and giving him
instructions and follow-up, he was deemed save for discharge.
The patient was discharged home on [**2147-2-13**]. On physical
examination his lungs were clear, he had no jugular venous
distention, no pleural rub and his heart was regular rate and
rhythm. His sternum had no discharge and no erythema. His
leg harvest site showed no signs of infection. His discharge
medications included Keflex 500 mg p.o. b.i.d. times seven
days, insulin sliding scale, Lasix 20 mg b.i.d. times one
week, KCL 20 mEq b.i.d. while on the Lasix, Glucophage 500 mg
b.i.d., Glucotrol 10 mg p.o. q day, Lopressor 75 mg p.o.
b.i.d., Percocet one to two tabs p.r.n. for pain. The
patient is to take Colace as instructed.
Rehabilitation upon discharge concurred with our assessment
that the patient was physically fit for discharge and safe to
go home.
The patient is to follow-up with Dr. [**Last Name (STitle) **].
[**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2147-2-13**] 18:03
T: [**2147-2-13**] 18:47
JOB#: [**Job Number 39079**]
| 20,060 | 138,527 | 41071,41401,25000,3051 |
Admission Date: [**2156-10-18**] Discharge Date: [**2156-10-26**]
Date of Birth: [**2076-4-27**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
nausea, vomiting, dysequilibrium
Major Surgical or Invasive Procedure:
[**10-20**] Right Craniotomy for Tumor resection
History of Present Illness:
This is an 80 year old right handed man with a 3week hisotry of
n/v/HA/gait anomalies. This worsened in the 24 hours prior to
presentation. He was taken to [**Hospital3 3383**] hospital where a CT
showed a right cerebellar mass. He was transfered to [**Hospital1 **] for
further evaulation.
Past Medical History:
DM, HTN, bypass surgery [**55**] years ago, appendectomy, cataract
surgery
Social History:
Tob: 1ppd for his "entire life", recently down to 2
cigarettes a day. EtOH 1 glass of wine with dinner
Family History:
NC
Physical Exam:
On Admission:
O: T: 98.1 BP: 148/78 HR: 71 R: 18 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-10**], IOLs OU EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Language: Speech slow with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Normal bilaterally
Toes downgoing bilaterally
Coordination: dysmetria, mild dysdiadochokinesis, normal heel to
shin
Handedness: Right
Physical Exam upon discharge:
awake, alert. oriented to self/hospital
PERRL, EOMI
face symmetric, tongue midline
MAE's with good strengths
following all commands
incision- C/D/I
Pertinent Results:
[**2156-10-18**] MRI head with and without contrast: There is
confirmation of an ovoid, irregularly rim-enhancing mass
measuring 23 x 32 mm within the right cerebellar hemisphere.
There is extensive surrounding edema, including compression of
the fourth ventricle. No other areas of pathological enhancement
are identified. The lesion exhibits very
low diffusion, which would argue against an inflammatory process
such as an abscess. The motion degraded FLAIR images suggest a
very minor degree of T2 hyperintensity within the white matter
of both cerebral hemispheres, becoming confluent in the
periatrial regions bilaterally. Given the patient's age, chronic
small vessel infarction would appear the most likely diagnosis.
[**2156-10-18**] CTA head: No definite hypervascularity is seen in
relationship to the cerebellar mass.
[**2156-10-18**] CT chest/abd pelvis:
IMPRESSION:
1. No primary tumor identified to account for metastasis.
2. There is interstitial lung disease with a basilar
predominance and
subpleural cysts consistent with interstitiell lung disease.
Centrilobular emphysema is present. A nodule within the lingula
measures 7 mm and is non- specific. Follow- up in 3 months is
recommended, alternatively this could be compared to prior
studies to ensure stability
3. A 3-mm nodule within the left lobe of the thyroid is noted
4. Diverticulosis without evidence of diverticulitis.
CT HEAD W/O CONTRAST [**2156-10-21**]
Status post resection of right cerebellar mass, with expected
postoperative changes, and no evidence of large
hematoma,increased mass
effect, or larger vascular territorial infarction
[**2156-10-22**]: MRI brain with and without contrast:
minimal amount of blood product within the postoperative bed. No
overt evidence of residual mass.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the neurosurgery service for work up
of a right cerebellar lesion. He was started on antiemetics and
steroids which improved his symptoms of nausea and vomiting.
MRI was obtained to better evaluate the lesion. CT Torso was
performed for metastatic workup but was negative for obvious
signs of primary disease.
After discussion with the patient and the patient's son and
Healthcare proxy, [**Name (NI) **], the decision was made to proceed with
resection of the mass. A pre-op work up was done. He required
>400 units of Insulin twice during the day of [**10-20**] and his RISS
was adjusted. He was made NPO at midnight in anticipation of
surgery. MRI wand study was ordered for surgical planning.
On [**10-21**] the patient underwent a right suboccipital craniotomy
for resection of right cerebellar tumor. Post operatively
patient remained stable on examination. Post op head CT showed
post surgical changes, no acute hemorrhage, mass effect or acute
infarct. On [**10-22**], he was transferred to the floor and his diet
advanced. MRI Brain demonstrated no acute infarct.
He was seen and evaluated by physical therapy and occupational
therapy who fet that he would benefit from acute rehab.
On [**10-24**] and [**10-25**] the patient's Serum Na dropped to 130 and BUN
bumped, trending up to 36. The hyponatremia responded to NS
fluid boluses and Serum Na improved to 133. Labs were followed
closely.
On [**10-26**] Na and K were WNL. BUN was improving. He was
neurologically stable and cleared for discharge.
Medications on Admission:
unknown
Discharge Medications:
1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for Pain/fever.
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Cerebellar mass
Intersitial Lung Disease
Emphysema
Thyroid nodule
Diverticulosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair 3 days after your surgery. Your wound
closure uses dissolvable sutures and the suture material will
fall out on its own - do not pull the sutures or scrub the
incision. Do not leave wet bandages or wet towels on the
incision.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Continue to take your Keppra (Levetiracetam) as prescribed.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2156-11-8**]
at 10:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions. **** You must
call registration before [**11-5**] at noon in order to be seen in
clinic to update your insurance information and referral. The
phone number for registration is [**Telephone/Fax (1) 10676**]. You should call
them as soon as possible, do not wait until [**11-5**]. ****
There were several abnormal findings on the CT scan we did of
your chest. You must see your PCP within the month to discuss
the findings of emphysema, thyroid nodule and diverticulosis.
You need to have the CT chest repeated in 3 months. You should
get a copy all your medical records to bring to your PCP.
Completed by:[**2156-10-26**] | 20,060 | 141,899 | 1983,3484,2761,515,4928,25000,V4581,1991,4019,41400,56210,3051,2410 |
Admission Date: [**2167-6-2**] Discharge Date: [**2167-6-5**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female with history of COPD, IPF, pulmonary hypertension
(60-67) on 5 L by NC home O2 who presented to her PCP on the day
of admission with a 1 week h/o increased dyspnea on exertion,
generalized fatigue. She went to her PCP and CXR ordered;
showed RLL pneumonia and PCP told pt to go to ED. In ED sats in
low 90's on 5 L but had desats into the 80's, pO2 of 49 on ABG.
.
She admits to having a nonproductive, chronic cough with no
recent change. She also has had intermittent left upper back
and chest wall pain at the site of old rib fractures. No
fevers, dizziness, abdominal pain, N/V, diarrhea, dysuria,
edema.
Past Medical History:
COPD
Idiopathic pulmonary fibrosis
Pulmonary hypertension
CAD s/p MI and stent to LCx
Hypertension
Osteoporosis
Renal Artery Stenosis s/p stent to R renal artery
CHF
Hyperlipidemia
GERD
Fe deficiency Anemia
s/p lap chole
hx MRSA pna
mesenteric ischemia
s/p L shoulder hemiarthroplasty
h/o fall with rib fractures
patent foramen ovale
Social History:
currently living in a [**Hospital3 **] facility. +tobacco in
past and quit 20 years ago; no drugs; occasional ETOH; retired
homemaker. Widowed.
Family History:
twin sister with IPF.
Physical Exam:
VS- 98.2 82 152/55 20 92% Bipap 5/0
Gen - AOX3, speaking full sentences, comfortable
HEENT - PERLA, cataracts bilaterally, anicteric
Heart - RRR, 3/6 M TR
Lungs - Dry hoarse crackles bilaterally, no wheezes
Abdomen - Soft, NT, ND + BS
Ext - No C/C/E, +2 d. pedis RLE, +1 d. pedis LLE
Skin - Multiple ecchymoses, easy bruising
Neuro - Grossly intact
Pertinent Results:
[**2167-6-2**] WBC-10.0 HGB-10.8* HCT-33.0* MCV-70* RDW-16.7* PLT-119
[**2167-6-2**] NEUTS-84.2* LYMPHS-9.7* MONOS-1.9* EOS-3.9 BASOS-0.2
[**2167-6-2**] GLUCOSE-135* UREA N-36* CREAT-1.8* SODIUM-137
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
Cardiac enzymes: negative
.
[**2167-6-2**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2167-6-2**] URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0
.
ECG: sinus, 90 bpm, normal axis, <[**Known lastname 4793**] depressions V5-V6.
Qwave II, aVF.
.
CXR ([**6-2**]): right lower lobe pneumonia, old emphysematous
changes
.
rib XR ([**6-2**]): At the site of the patient's maximal tenderness,
there are multiple deformities of the ribs that correlate with
rib fractures seen on the prior chest CT of [**2167-2-5**].
Brief Hospital Course:
Assessment and Plan:
Ms. [**Known lastname **]. [**Known lastname **] is a 77 yo female with severe baseline lung
disease (COPD and IPF) requiring home O2, presenting with
respiratory distress and pneumonia.
.
# COPD/IPF exacerbation: She has a history of COPD, IPF,
pulmonary hypertension, PFO. She has baseline DOE on 5L oxygen
at home ([**Hospital3 **]). Because of hypoxemia to 80%, she was
admitted to MICU. She was placed on bipap and was never
intubated. She eventually required CPAP only at night with 5-7
L by NC during the day. She received steroids (IV to PO) and
nebulizer treatments. The patient stated her wishes to be
DNR/DNI. She will be discharged on a prednisone taper. A bipap
machine for home was also arranged for the patient where she
will use at setting of [**4-10**]. Nasal saline also helped the
patient with dryness and bleeding from her nose due to oxygen
flow. She will continue her regular medications and inhalers at
home. She was also prescribed low dose fentanyl lozenges for
use as outpatient when preparing for exertion to decrease pain
and exertion. She will followup with Dr. [**Last Name (STitle) 217**]
regarding the effectiveness of these.
.
# Community acquired pneumonia: She was initially placed on
vancomycin and levofloxacin. Only levofloxacin was continued
for a total course of 10 days. This was renally dosed (750 mg
every other day).
.
# Acute on chronic renal failure: Creatinine 1.8 on admission;
this decreased to baseline of 1.3 by discharge. Acute component
was most likely prerenal/dehydration. Medications were renally
dosed.
.
# Blood cultures: 1/4 bottles positive for GPCs in clusters
which were later identified as coag negative staph. Due to only
having 1/4 bottles and that it was SCN, it was treated as a
contaminant, and vancomycin was discontinued.
.
# Hypertension: She remained on Coreg, diltiazem, imdur. Lasix
initally held with ARF but then restarted.
.
# Back and chest wall pain: reproducible at site of previous rib
fractures. It seemed unlikely to be cardiac in origin and
enzymes were negative; ECG did not show ischemic changes. A
lidoderm patch was used in house and will be prescribed for the
patient as an outpatient, as it provided significant relief.
.
# CAD: ASA, Imdur, Vytorin, Coreg were continued. Acute MI was
ruled out.
Medications on Admission:
Alprazolam 0.25 mg
ASA 81 mg
Boniva 150 mg PO Qmonth
Coreg 3.125 mg PO BID
Diltiazem ER 180 mg PO QD
Colace
Lasix 40 mg PO Sun/Tues/Thurs/Sat
Imdur 60 mg PO QD
MVI
Nexium 40 mg PO QD
Zoloft 150 mg PO QD
Trazadone 50 mg PO QD
Vitamin D 50,000 units
Vytorin 10/40 mg PO QD
Discharge Medications:
1. Sleep oximetry
Overnight continuous O2 saturation monitoring for one night
2. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once
a day for 10 days: Sat [**6-6**]: take 4 pills. Sun [**6-7**] through
Tues [**6-9**]: take 3 pills daily. Wed [**6-10**] through Fri [**6-12**]:
take 2 pills daily. Sat [**6-13**] through Mon [**6-15**]: take one pill
daily.
Disp:*22 Tablet(s)* Refills:*0*
3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO every other day
for 3 doses: Take first pill Sat, [**6-6**]; then take one pill
every other day.
Disp:*3 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
10. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Bipap
Diagnosis: COPD
Settings [**4-10**]
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY PRN () as needed
for back pain: Place on painful area for 12 hours out of every
day as needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
15. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal
Q3H (every 3 hours) as needed for nasal dryness.
Disp:*1 bottle* Refills:*1*
19. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
20. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-9**] Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
21. Fentanyl Citrate 200 mcg Lozenge on a Handle Sig: One (1)
Buccal three times a day as needed for pain or in preparation
for exercise.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Pneumonia
Chronic obstructive pulmonary disease
Idiopathic Pulmonary Fibrosis
Hypoxemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for difficulty brathing and pneumonia. We
treated you with oxygen and antibiotics.
.
Use oxygen at home, 5-6 liters per minute during rest and during
exercise. You can use your humidifier as needed.
.
At nighttime you will be using your new bipap machine. This is
only for use during sleep. You will be instructed on how to
operate this machine.
.
You may resume your regular activity at your [**Hospital3 **]
facility, including walking to meals.
.
Please return to the hospital if you are having trouble
breathing or chest pain, or any new symptoms that you are
concerned about.
.
Please take all of your medications and keep all of your
appointments with your doctors.
Followup Instructions:
Please see you PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 7 to 10 days. Please
call ([**Telephone/Fax (1) 33678**] to make an appointment.
.
Other upcoming appointments:
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2167-7-21**] 1:00
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2167-11-10**] 10:30
.
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2167-11-10**] 10:30
.
You also have an appointment with Dr. [**Last Name (STitle) 217**] on [**2167-11-10**]
following your PFTs. Please call ([**Telephone/Fax (1) 96590**] if you would
like to see him sooner.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
| 20,061 | 109,006 | 486,49121,5849,27651,79902,515,4280,42832,4168,7455,53081,41401,V4582,412,4019,73300,4401,2724 |
Admission Date: [**2167-12-21**] Discharge Date: [**2167-12-23**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
# Left hip fracture s/p fall
# Hypoxia
Major Surgical or Invasive Procedure:
# Arterial line placement
# Right internal jugular central venous line placement
# Endotracheal intubation
History of Present Illness:
78F h/o COPD, presumed idiopathic pulmonary fibrosis on home O2,
CAD s/p MI, CHF and Afib, presented with L hip fracture s/p fall
[**1-9**] lightheadedness after transitioning from sitting to standing
while doing laundry on the day of admission. Pt reported no LOC
or seizure activity, and had fallen to the floor without
striking furniture or head, remaining down approximately 30-40
minutes until a nursing assistant found her. Pt was unable to
walk and needed to be lifted to bed, then was brought by EMS to
[**Hospital1 18**]. Pt stated that she also had noticed increased DOE and
SOB x 1 week with yellow sputum, occasionally blood-streaked
with recent epistaxis [**1-9**] nasal drying due to home O2 NC. Pt
denied fever, chills, diarrhea, decreased PO intake, or N/V; she
did report constipation at baseline. Pt had her flu vaccine
this year and confirmed annual pneumonia vaccinations for the
last 3 years.
.
In the [**Name (NI) **], pt was hypoxic to the mid 80s with venti mask 50%, 12
L; she was placed on 100% NRB with O2 sats rising to 100% (at
baseline, pt is 90% on 5L O2 NC). Pt was also noted to have STD
in lateral leads, notably different from baseline. Pt reported
a sensation of midsternum "heartburn" which quickly resolved,
and stated that her pain during her past MI felt more like
pressure and was different than this sensation. Pt received 2L
NS, fentanyl & morphine for pain, as well as aspirin. Ortho was
consulted about her L hip fracture as seen on x-ray and
recommended ORIF as soon as medically stable. Pt was therefore
admitted for further work-up of hypoxic respiratory distress,
EKG changes, and consideration for surgical repair of her L hip
fracture.
Past Medical History:
# Cardiovascular
--Diastolic heart failure: EF 60%
--Atrial fibrillation
--MR
[**Name13 (STitle) 109519**]
--CAD: h/o LCx stenosis on prior cardiac cath
--PFO
--HTN
--Hyperlipidemia
--Mesenteric ischemia
--Renal artery stenosis s/p R renal artery stent
--PVD
--Pulmonary hypertension
--CVA
.
# Pulmonary
--Home oxygen 5L
--COPD
--Presumed idiopathic pulmonary fibrosis
stable RML lung nodule and anterior mediastinal soft tissue
density
.
# Musculoskeletal
--Osteoporosis
--h/o fall with rib fractures
.
# Gastrointestinal
--GERD
.
# Hematological
--Fe deficiency anemia
Social History:
# Personal: Widowed. Lives in [**Hospital3 **] facility.
# Tobacco: 35 pack years of smoking, quit ~[**2146**].
# Alcohol: Occasional.
# Recreational drugs: None.
Family History:
# Mother: Rheumatic heart disease
# Siblings: Twin sister died, 78.
# Children: Two sons with MI, age 40s.
Physical Exam:
VS: Temp 96.8, BP 116/41, HR 70/NSR, RR 18/O2sat 96%
GEN: Pleasant, NAD; speaking in full sentences with face mask,
with decreased O2 sats with prolonged narration.
HEENT: PERRL, EOMI, anicteric, MM mildly dry
NECK: ?JVP = 10cm
RESP: CTAB anteriorly, faint crackles as bases posteriorly
CV: RR, S1 and S2 WNL, holosystolic murmur througout the
precordium, loudest at apex
ABD: Soft, ND, NT, BS+, no masses or hepatosplenomegaly
EXT: No c/c/e, warm, good pulses
SKIN: No rashes/no jaundice; 3cm skin tear on L distal shin
NEURO: AAOx3. No sensory deficits to light touch.
Pertinent Results:
Admission labs:
.
[**2167-12-21**] 06:24PM WBC-10.6# RBC-3.88* HGB-8.7* HCT-28.9*
MCV-75* MCH-22.4* MCHC-30.1* RDW-16.7*
[**2167-12-21**] 06:24PM NEUTS-85.4* LYMPHS-8.8* MONOS-2.3 EOS-3.2
BASOS-0.3
[**2167-12-21**] 06:24PM CK(CPK)-67
[**2167-12-21**] 06:24PM cTropnT-0.02*
[**2167-12-21**] 06:24PM GLUCOSE-127* UREA N-45* CREAT-1.6* SODIUM-139
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
.
Imaging:
.
PELVIS (AP ONLY) [**2167-12-21**] 7:55 PM
Extensively comminuted intertrochanteric fracture of the left
proximal femur, with marked varus angulation, as described.
.
CHEST (PORTABLE AP) [**2167-12-21**] 6:54 PM
Probable mild pulmonary vascular congestion, superimposed on
chronic, diffuse interstitial process which (according to
previous reports) represents known idiopathic pulmonary
fibrosis. There is no definite new airspace process.
.
TEE (Complete) Done [**2167-12-22**] at 2:49:50 PM
Emergency TEE performed in the operating room after cardiac
arrest. The right atrium is dilated. A patent foramen ovale with
flow across it is seen by color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). The right ventricular cavity is dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. There are simple atheroma in the
aortic arch. There are focal calcifications in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. No thrombus/embolus is seen in the
pulmonary artery.
Brief Hospital Course:
78F h/o COPD, idiopathic pulmonary fibrosis, CAD s/p MI,
admitted to MICU with hypoxia and L intertrochanteric femur
fracture.
.
# PEA arrest: Pt was noted to enter into PEA arrest while
undergoing induction in the OR for ORIF. Pt was intubated and
received 20min CPR, after which she was placed on epinephrine
and norepinephrine gtt; per verbal report to this author, pt had
also received NS fluid resuscitation. Emergency TTE performed
in the OR demonstrated severe global free wall hypokinesis at
the dilated right ventricular cavity. Pt was returned to the
MICU, during which time she was ultimately placed on four
pressors (norepinephrine, phenylephrine, dobutamine, and
vasopressin), as well as NS boluses for hemodynamic support, and
increased FiO2 for respiratory support. Given her poor
prognosis, family members decided to withdraw care; pt expired
within minutes of withdrawing pressor and ventilatory support.
.
# L femur fracture: Orthopedics was consulted in the ED and
recommended ORIF after pt was deemed medically stable. Given h/o
pulmonary disease and cardiac disease, MICU team discussed with
the patient about risks associated with surgical repair,
specifically perioperative MI and difficult post-op extubation.
Pt stated her understanding of this risk, but that her quality
of life would be very diminished if she did not undergo surgical
repair. During a family meeting on [**12-22**] AM, all family members
present concurred that surgical repair was desired, and stated
their understanding of pt's high perioperative risk. Pt
reversed her DNR/DNI status in order to undergo surgery, and in
prepartion for surgery, received 2units PRBC given her low
hematocrit. During induction, pt entered into pulseless
electrical activity while on the OR table and underwent 20min of
CPR. Surgery was aborted and pt was returned to the MICU.
.
# CAD s/p MI: Lateral [**Known lastname **] depressions on admission EKG resolved
on repeat EKGs with troponin T elevated to 0.10, possibly
indicating some cardiac demand. Pt reported "heartburn" but no
chest pressure. Prior cardiac catheterizations demonstrated LCx
involvement, and given this constellation of data, pt was
considered a high peri-operative risk for MI. During induction,
pt did enter into PEA arrest.
.
# Hypoxia: Pt was noted to have increased O2 requirement from
baseline of 90% on 5L O2 NC, with DDx including PE (thrombotic
vs fat in the setting of fracture), COPD flare, worsening
idiopathic pulmonary fibrosis, infection, or worsening heart
failure with associated pulmonary congestion. Pt improved
rapidly overnight, indicating possible reversible cardiac
etiology as also evidenced on EKG changes. Based on the
considerations for her quality of life, pt's chronic pulmonary
pathologies were not considered obstacles to ORIF per
communication with her pulmonologist Dr. [**Last Name (STitle) 217**].
.
# Code status: Pt was initially DNR/DNI, but after deciding to
proceed with hip fracture repair, reversed her status to full
code. After coding during induction for surgery, pt was
intubated and received CPR. Pt's status was changed back to
DNR, and she was later made CMO after her family decided to
withdraw care based on her poor prognosis. Pt expired minutes
after pressors and ventilatory support were withdrawn.
Discharge Disposition:
Expired
Discharge Diagnosis:
Left hip fracture
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2167-12-23**] | 20,061 | 127,362 | 82021,5849,7455,42832,4275,496,515,4019,4401,4168,V1254,73300,41401,42731,4280,412,53081,E8859 |
Admission Date: [**2164-11-23**] Discharge Date: [**2164-12-10**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 yo female with multiple medical problems including CAD,
hypertension, osteoporosis, CHF who presents with 2-3 days of
woresning back pain to the point that it has become very
difficult for her to walk and ambulate. She denies any numbness,
tingling sensation, or other associate symptoms like fever,
chills. Just complaining of pain and diffculty ambulating
secondary to pain. No dysuria, urinary or bowel incontinence.
Was seen by Dr. [**Last Name (STitle) 18068**] who gave her Percocet and she was
taking [**12-11**] tablet every night and pain did not improve. Came in
to the ED for further evaluation. Had imaging in the ED that did
not show any evidence of acute fracture or any misalignment.
Being admitted for pain control and possible rehab placement.
Past Medical History:
1. CAD s/p MI and stent to LCx
2. Hypertension
3. Osteoporosis
4. Renal Artery Stenosis s/p stent to R renal artery
5. CHF
6. Hyperlipidemia
7. GERD
8. Fe deficiency Anemia
9. COPD
10. s/p lap chole
11. s/p L shoulder hemiarhtroplasty
Social History:
Lives at home with good social support; denies any EtOH, tobacco
use or an IV drug or recreational drug use
Family History:
Non contributory
Physical Exam:
VS: T 97.6, pulse 71, BP 109/72, RR 92% room air
Gen: moderately discomfort secondary to pain
HEENT: PERRLA, EOMI, OP clear
Neck: supple, no JVD
Heart: S1, S2, RRR, no murmurs, rubs, gallops
Abd: soft, ND, NT, no HSM
Extrem: paraspinal tenderness, no rashes
Neuro: AAO x 3, good sensation and [**4-11**] motor strength, decrease
range of motion mainly secondary to pain
Pertinent Results:
[**2164-11-23**] 03:00PM PT-13.5 PTT-38.0* INR(PT)-1.1
[**2164-11-23**] 03:00PM WBC-8.1 RBC-5.25# HGB-11.6*# HCT-37.0#
MCV-71* MCH-22.0* MCHC-31.3 RDW-16.9*
[**2164-11-23**] 03:00PM GLUCOSE-119* UREA N-40* CREAT-1.7* SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2164-11-23**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2164-11-23**] 03:00PM URINE RBC-0-2 WBC-[**10-27**]* BACTERIA-RARE
YEAST-NONE EPI-[**5-17**] RENAL EPI-0-2
Brief Hospital Course:
75 yo female with multiple medical problems who presents with
back pain and difficulty ambulating but no evidence of any
fractures. Hospital course was complicated be hypotension and
hypoxia leading to mesenteric ischemic colitis and MRSA
pneumonia.
1. MRSA Pneumonia - patient was diagnosed with MRSA pneumonia
and so was started on Vancomycin 1000mg IV daily. She had a PICC
line placed, and will need an additional 2 weeks of total
antibiotics. In addition, given her history of COPD, she will
need aggressive pulmonary toilet / chest physical therapy as she
is at an increased risk of mucous plugging if she does not clear
well.
2. Mesenteric Ischemia - this was diagnosed on CT abdomen. This
was likely secondary to her being hypotensive for a long period
of time but throughout the hospital course, her diet was
advanced and she tolerated it well. Her abdominal exam was
benign.
3. Hypertension - her BP has been labile for most of the
hospital course, but we finally were able to reach a regimen
that was well tolerated by her. Given her history of renal
artery stents, our goal is to keep her SBP around 140s and so
she is currently on Diltiazem, and Isosorbide Dintrate.
4. CAD - she should continue her Aspirin, Plavix, and
Simvastatin
5. Back Pain - likey secondary to her osteoporosis with possible
compression fractures; she had plain films of her lumbar and
thoracic areas that showed no evidence of fractures or
misalignment. However, given her extent of pain, there was
concern for compression fracture but an MRI could not be obtain
due to her recent shoulder surgery and her history of renal
artery stents. At that time, it was decided to obtain a CT of
her lumbar and thoracic area that also did nto show any
fractures - only some foramenal narrowing. Her pain was
initially controlled with Ultram, Oxycodone, and Valium but she
had an episode of becoming hypotensive and so her pain
medications were switched around to Tylenol around the clock,
with Calcitonin nasal spray.
6. Renal - she is s/p stent to the R renal artery from stenosis;
she was seen by the Renal team who agreed with our current
medication plans. Her baseline Creat is between 1.4 and 1.7 and
she is well below her baseline at this the time of discharge.
Medications on Admission:
1. Imdur 120mg po daily
2. Aspirin 325 mg po daily
3. Zocor 80mg po daily
4. Toprol XL 100mg po daily
5. Plavix 75mg po daily
6. Fosamax 70mg po q week
7. Zetia 10mg po daily
8. Norvasc 10mg po daily
9. Trazadone 50mg po qhs
10. Atrovent 2 puffs qid
11. Uniretic 15-25mg po daily
12. Percocet [**12-11**] tablet prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QMON
(every Monday).
7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg
Intravenous Q24H (every 24 hours) for 14 days.
18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
treatment Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
21. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inhaler Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. MRSA Pneumonia
2. Back Pain
3. Hypertension
4. Renal Artery Stenosis s/p renal artery stents
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**12-9**] weeks.
Please take your blood pressure medications with caution as we
would like your blood pressure around 140 systolic. Please hold
medications if SBP less than 140.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2164-12-18**] 2:00
| 20,061 | 151,077 | 73313,48241,5570,42832,51882,5990,585,496,4280,7197,73300,45829,V090,4019 |
Admission Date: [**2142-7-20**] Discharge Date: [**2142-7-28**]
Date of Birth: [**2080-6-12**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Initially presented to [**Hospital Unit Name 196**] for atrial flutter ablation.
Transferred to ICU for hypotension.
Major Surgical or Invasive Procedure:
EP mapping
History of Present Illness:
61 yo male with CAD s/p inferior and anteroseptal MI '[**30**] s/p 3V
CABG (LIMA to LAD, SVG to OM, SVG to DM) and AVR (bovine) in
[**2-24**], CHF (EF40%, mod pulm htn, apical aneurysm), HTN, AF dx'd
[**6-6**] and failed CV on sotalol and amio, s/p DDD PM [**6-14**] for
post-CV bradycardia.
Presented to [**Hospital **] hospital with hypotension and atrial
fibrillation -> Aflutter. Amio started [**7-9**] and dig there and CV
[**2142-7-10**]. Converted to Aflutter [**7-14**]. [**7-18**] had VT/VF in setting
of K 6.6 and transferred to [**Hospital1 18**].
[**Hospital1 18**] Course: TEE/CV [**7-19**], pacer DDDR 70 with mode-switch, dig
stopped. Got 3 doses Coumadin (last [**7-22**]), and INR up to 5.1
[**7-25**], wbc climbing with lymphopenia. Waiting for INR to come down
(received 3 doses coumadin after amio started and INR went to
21) before flutter ablation. Over the past several days, BP
noted to be trending down. [**7-27**] hypotensive d/t ??infxn.
Transferred to MICU service for mgt of hypotension.
Past Medical History:
1. CAD
-Coronary artery disease status post inferior and
anteroseptal MI in [**2130**]
-status post three vessel CABG(LIMA to LAD, SVG to OM, SVG to
DM) and AVR (bovine) in [**2141-2-21**].
-ETT MIBI [**4-26**] on 8 min mod-[**Doctor First Name **] (7METS)57% PMHR-severe fixed
defect dital inf wall and septum
2. CHF
3. Hypertension.
4. Hypercholesterolemia.
5. Hypothyroidism.
6. Melanoma on left shoulder in [**2140-10-23**].
7. Erectile dysfunction.
8. History of erythema nodosum.
9. Community acquired pneumonia in [**2140-6-23**].
10.light chain multiple myeloma.
12. Multifactorial renal failure.
13. DM
14. Light chain nephropathy/proteinuria.
15. Restless leg syndrome.
16. Hypercholesterolemia.
17. Hypocalcemia.
Social History:
The patient is divorced and lives alone in
[**Location (un) 6691**], [**State 350**] in the Berkshires. He has two
children. He was working in produce at a market but had to
stop a week prior to admission because of shortness of breath
and edema. He smoked one cigar per day for 30 years. He
denies alcohol use.
Family History:
The patient's father had coronary artery
disease and was an alcoholic. The patient's mother had
diabetes mellitus and coronary artery disease. The patient's
sister has coronary artery disease and atrial fibrillation.
Physical Exam:
T96.7 BP110/72 P76 97%RA
Gen-very pleasant
HEENT-anicteric, no conjunctival pallor, no nasal findings, no
oral findings, neck supple, no LAD, infroorbital ecchymoses on
right eye, laceration on left forehead.
CVS-nl S1/S2, no S3/S4, 2/6 SEm at USB, no pedal edema, DP 1+
bilaterally, JVP 7cm.
resp-CTAB, no wheezes, no crackles
GI-nl BS, no tenderness
neuro-A+O X 3, move all 4 limbs
Pertinent Results:
[**2142-7-20**] 03:40AM GLUCOSE-120* UREA N-43* CREAT-4.8* SODIUM-140
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
[**2142-7-20**] 03:40AM CALCIUM-8.5 PHOSPHATE-6.3*# MAGNESIUM-1.8
[**2142-7-20**] 03:40AM DIGOXIN-1.2
[**2142-7-20**] 03:40AM WBC-16.9*# RBC-4.28*# HGB-13.5*# HCT-41.1#
MCV-96 MCH-31.5 MCHC-32.8 RDW-16.4*
[**2142-7-20**] 03:40AM PLT COUNT-169#
[**2142-7-20**] 03:40AM PT-12.7 PTT-26.4 INR(PT)-1.0
[**2142-7-21**] 06:35AM BLOOD WBC-10.6 RBC-4.15* Hgb-13.2* Hct-40.4
MCV-97 MCH-31.9 MCHC-32.7 RDW-16.2* Plt Ct-166
[**2142-7-22**] 08:20AM BLOOD WBC-10.5 RBC-4.23* Hgb-13.6* Hct-40.4
MCV-96 MCH-32.1* MCHC-33.7 RDW-16.1* Plt Ct-162
[**2142-7-23**] 06:10AM BLOOD WBC-12.1* RBC-4.31* Hgb-13.8* Hct-41.0
MCV-95 MCH-32.0 MCHC-33.7 RDW-16.2* Plt Ct-170
[**2142-7-24**] 04:00AM BLOOD WBC-16.7* RBC-4.50* Hgb-14.2 Hct-42.1
MCV-94 MCH-31.6 MCHC-33.9 RDW-16.2* Plt Ct-190
[**2142-7-24**] 09:21AM BLOOD WBC-17.0* RBC-4.49* Hgb-14.2 Hct-42.6
MCV-95 MCH-31.6 MCHC-33.3 RDW-16.3* Plt Ct-191
[**2142-7-25**] 06:20AM BLOOD WBC-12.7* RBC-4.24* Hgb-13.4* Hct-41.0
MCV-97 MCH-31.5 MCHC-32.6 RDW-15.9* Plt Ct-169
[**2142-7-26**] 06:35AM BLOOD WBC-16.7* RBC-4.35* Hgb-13.6* Hct-41.4
MCV-95 MCH-31.3 MCHC-32.8 RDW-16.1* Plt Ct-180
[**2142-7-26**] 08:20AM BLOOD WBC-15.0* RBC-4.09* Hgb-13.3* Hct-39.0*
MCV-95 MCH-32.4* MCHC-34.0 RDW-16.1* Plt Ct-173
[**2142-7-27**] 07:25AM BLOOD WBC-11.5* RBC-3.07* Hgb-9.7*# Hct-29.6*
MCV-97 MCH-31.6 MCHC-32.8 RDW-16.1* Plt Ct-145*
[**2142-7-27**] 11:06AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.8* Hct-28.2*
MCV-98 MCH-30.6 MCHC-31.3 RDW-16.0* Plt Ct-155
[**2142-7-27**] 02:15PM BLOOD WBC-16.4*# RBC-3.47* Hgb-10.8* Hct-33.5*
MCV-96 MCH-31.1 MCHC-32.3 RDW-15.8* Plt Ct-189
[**2142-7-28**] 12:14AM BLOOD WBC-16.4* RBC-2.85* Hgb-9.1* Hct-26.8*
MCV-94 MCH-32.0 MCHC-34.0 RDW-15.9* Plt Ct-193
[**2142-7-24**] 04:00AM BLOOD Neuts-95.0* Bands-0 Lymphs-1.9* Monos-3.0
Eos-0.1 Baso-0
[**2142-7-27**] 11:06AM BLOOD PT-17.1* PTT-37.2* INR(PT)-1.8
[**2142-7-25**] 02:45PM BLOOD PT-29.1* PTT-43.1* INR(PT)-5.3
[**2142-7-24**] 09:40AM BLOOD PT-37.5* INR(PT)-8.9
[**2142-7-25**] 02:45PM BLOOD Fibrino-329 D-Dimer-995*
[**2142-7-20**] 03:40AM BLOOD Glucose-120* UreaN-43* Creat-4.8* Na-140
K-4.9 Cl-104 HCO3-23 AnGap-18
[**2142-7-21**] 06:35AM BLOOD Glucose-99 UreaN-61* Creat-5.9*# Na-138
K-5.3* Cl-102 HCO3-21* AnGap-20
[**2142-7-22**] 08:20AM BLOOD Glucose-119* UreaN-49* Creat-5.2* Na-138
K-5.0 Cl-101 HCO3-26 AnGap-16
[**2142-7-23**] 06:10AM BLOOD Glucose-152* UreaN-62* Creat-6.3*# Na-136
K-5.3* Cl-99 HCO3-22 AnGap-20
[**2142-7-24**] 04:00AM BLOOD UreaN-79* Creat-7.1* Na-137 K-5.6* Cl-98
HCO3-19* AnGap-26*
[**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137
K-6.1* Cl-98 HCO3-19* AnGap-26*
[**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137
K-6.1* Cl-98 HCO3-19* AnGap-26*
[**2142-7-25**] 06:20AM BLOOD Glucose-107* UreaN-62* Creat-5.8*# Na-139
K-5.6* Cl-101 HCO3-23 AnGap-21*
[**2142-7-26**] 06:35AM BLOOD Glucose-105 UreaN-86* Creat-6.9*# Na-138
K-6.0* Cl-98 HCO3-24 AnGap-22*
[**2142-7-26**] 08:20AM BLOOD Glucose-102 UreaN-85* Creat-7.1* Na-137
K-6.1* Cl-97 HCO3-25 AnGap-21*
[**2142-7-27**] 07:25AM BLOOD Glucose-111* UreaN-90* Creat-4.9*# Na-138
K-5.7* Cl-102 HCO3-23 AnGap-19
[**2142-7-27**] 11:06AM BLOOD Glucose-171* UreaN-66* Creat-3.2*# Na-141
K-3.7 Cl-114* HCO3-19* AnGap-12
[**2142-7-27**] 07:55PM BLOOD Creat-5.3*# K-6.2*
[**2142-7-28**] 12:14AM BLOOD Glucose-207* UreaN-116* Creat-5.5* Na-137
K-6.4* Cl-100 HCO3-23 AnGap-20
[**2142-7-24**] 09:21AM BLOOD ALT-16 AST-28 AlkPhos-99 TotBili-0.2
[**2142-7-27**] 11:06AM BLOOD LD(LDH)-243 CK(CPK)-43
[**2142-7-27**] 05:33PM BLOOD CK(CPK)-72
[**2142-7-27**] 09:32PM BLOOD CK(CPK)-66
[**2142-7-27**] 11:02PM BLOOD LD(LDH)-402* TotBili-0.2
[**2142-7-28**] 12:14AM BLOOD ALT-20 AST-26
[**2142-7-27**] 11:06AM BLOOD CK-MB-NotDone cTropnT-0.49*
[**2142-7-27**] 05:33PM BLOOD CK-MB-NotDone cTropnT-0.81*
[**2142-7-27**] 09:32PM BLOOD CK-MB-NotDone cTropnT-0.87*
[**2142-7-20**] 03:40AM BLOOD Calcium-8.5 Phos-6.3*# Mg-1.8
[**2142-7-21**] 06:35AM BLOOD Mg-2.1
[**2142-7-22**] 08:20AM BLOOD Mg-1.9
[**2142-7-23**] 06:10AM BLOOD Mg-2.6
[**2142-7-24**] 04:00AM BLOOD Mg-2.7*
[**2142-7-24**] 09:21AM BLOOD Albumin-3.0* Calcium-10.3* Phos-7.9*#
Mg-3.3*
[**2142-7-25**] 06:20AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.4
[**2142-7-26**] 06:35AM BLOOD Calcium-9.4 Phos-7.2*# Mg-2.9*
[**2142-7-26**] 08:20AM BLOOD Phos-7.2* Mg-2.7*
[**2142-7-27**] 07:25AM BLOOD Calcium-8.2* Phos-5.1*# Mg-2.2
[**2142-7-27**] 11:06AM BLOOD Calcium-4.8* Phos-3.1# Mg-1.5*
[**2142-7-27**] 02:15PM BLOOD Calcium-8.6
[**2142-7-28**] 12:14AM BLOOD Calcium-8.2* Phos-6.5*# Mg-3.1*
[**2142-7-27**] 11:02PM BLOOD Hapto-241*
[**2142-7-27**] 05:33PM BLOOD TSH-6.4*
[**2142-7-27**] 05:33PM BLOOD T3-26* Free T4-0.6*
[**2142-7-24**] 04:00AM BLOOD PTH-43
[**2142-7-27**] 11:02PM BLOOD Cortsol-29.3*
[**2142-7-27**] 09:32PM BLOOD Cortsol-25.5*
[**2142-7-27**] 07:55PM BLOOD Cortsol-22.9*
[**2142-7-20**] 03:40AM BLOOD Digoxin-1.2
[**2142-7-28**] 12:29AM BLOOD Type-ART pO2-175* pCO2-39 pH-7.38
calHCO3-24 Base XS--1 Intubat-NOT INTUBA
[**2142-7-27**] 08:04PM BLOOD Type-ART pO2-125* pCO2-45 pH-7.34*
calHCO3-25 Base XS--1 Intubat-NOT INTUBA
[**2142-7-27**] 06:16PM BLOOD Type-[**Last Name (un) **] pH-7.31*
[**2142-7-27**] 11:10AM BLOOD Lactate-2.1*
[**2142-7-27**] 06:16PM BLOOD Lactate-1.8
[**2142-7-27**] 08:04PM BLOOD Lactate-1.3
[**2142-7-28**] 12:29AM BLOOD Glucose-208* Lactate-1.4 K-6.0*
[**2142-7-27**] 06:16PM BLOOD freeCa-1.14
[**2142-7-27**] 08:04PM BLOOD freeCa-1.12
[**2142-7-28**] 12:29AM BLOOD freeCa-1.07*
[**7-27**] on transfer to the ICU:
EKG: Atrial paced rhythm
Right bundle branch block
Inferior infarct, age indeterminate
Anterior myocardial infarct, age indeterminate
Diffuse ST-T wave abnormalities - cannot exclude in part
ischemia
CXR: Worsening left retrocardiac opacity with adjacent moderate
sized pleural effusion. Pneumonia cannot be excluded.
CT abd/pelvis: 1. No evidence of retroperitoneal hematoma.
2. Standing in the subcutaneous tissues and small amount of free
fluid noted in the presacral space consistent with edema.
3. Moderate-sized bilateral pleural effusion with associated
atelectasis.
Brief Hospital Course:
61 yo M with MM, ESRD, CAD s/p V-tach arrest, CHF,
a-fib/flutter, awaiting INR to trend down for elective ablation,
when he subsequently became increasingly hypotensive and
confused/disoriented, so he was transferred to the ICU for
further management of ?sepsis vs.adrenal insufficiency. He was
under the care of the ICU team for only several hours before he
went into v-fib arrest, coded and was not able to be
resuscitated.
1)Hypotension: Likely sepsis vs adrenal insufficiency.
BCXs/fungal cx were sent in light of the recent steroid use.
Vanc and cefepime (for gram neg coverage) were started
empirically. As line infection was of high likelihood, the plan
was to d/c HD line when possible. He was started on IV stress
dose steroids Q8hrs empirically and cortisol stim test was sent.
Pressors were initiated with neo and levophed to maintain
MAP>60, and IVF boluses were given as needed. He was transfused
to HCT >30 and H/H chakcs proceeded Q6hours. CT was negative for
retroperitoneal bleed.
2) Renal: He was HD dependent and had been dialyzed the day
prior to transfer to the ICU.
3) Cor: He was on ASA and a statin, BP meds were held given
hypotension. On transfer to the ICU, EKG showed possible new
ischemia and cardiac markers trended upwards. However, in the
setting of his renal insuffuciency, level of elevation was not
clear. His potassium level was slowly creeping up. Kayexalate
was given and K followed. Prior to his subsequent K level at 6.4
and the third set of markers coming back, Mr.N went into v-fib
arrest. Code was called and CPR initiated. Despite 30 minutes
resus efforts, Mr.N was not able to be revived, code was stopped
and he was pronounced. His family was notified and they declined
autopsy.
[4) Thyroid: There was a question as to whether this was the
source of afib/flutter; however, TFT were normal. He was kept on
synthroid.
5) A-flutter: He was to undergo elective ablation after
stabilization of BP.
6) Heme: H/O multiple myeloma. Cont thalidomide, monitor HCT.
7) FEN: NPO
8) Code: FULL]
Medications on Admission:
1. Toprol-XL 50 mg po qd.
2. Trazodone 100 mg po qd.
3. Isosorbide mononitrate 30 mg ER qd.
4. Sinemet 10/100 mg qhs, prn, restless leg syndrome.
5. Lipitor 20 mg qd.
6. Synthroid 175 mcg qd.
7. Wellbutrin 100 mg [**Hospital1 **].
8. Aspirin 81 mg qd.
9. Glargine 20 units qhs.
10. Humalog sliding scale.
11. Calcium carbonate 500 mg tid.
12. Pamidronate 30 mg times one.
13. Zantac 300 mg qhs.
14. amiodarone 200mg [**Hospital1 **]
15. digoxin 0.125 QD
16. prednisone 50 on taper
17. clonasepam 2mg QHS
17. Thalidomide 400 [**Hospital1 **]
18. calcium acetate 1334
Discharge Medications:
None
Discharge Disposition:
Home with Service
Discharge Diagnosis:
1. Deceased
2. hyperkalemia
3. Atrial flutter
4. coronary artery disease post MI and CABG
5. CHF
6. Hypotension.
7. Hypothyroidism.
8.light chain multiple myeloma.
9.renal failure requiring hemodialysis
10. DM
Discharge Condition:
Deceased
Discharge Instructions:
None--deceased
Followup Instructions:
None-deceased
| 20,062 | 157,698 | 4589,40391,4275,20300,4280,2767,42731,V433,V4581 |
Admission Date: [**2141-3-13**] Discharge Date: [**2141-3-24**]
Date of Birth: [**2080-6-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 60 year old white male has
a known murmur since childhood. He is status post inferior
myocardial infarction and anteroseptal myocardial infarction
in [**2130**] and status post angioplasty at that time. Since
[**2140-9-23**] he has had increased dyspnea on exertion and
an echocardiogram in [**2140-12-24**], revealed an aortic
stenosis with an 80 mm gradient and ejection fraction of 40%
with apical akinesis. He had a cardiac catheterization in
[**2140-12-24**] which revealed an ejection fraction of 40%, 1+
mitral regurgitation with moderate MAC, left anterior
descending is 90% mid 90% lesion, diagonal 1 70% lesion and
the right coronary artery had a mid occlusion. He is now
admitted for aortic valve replacement and coronary artery
bypass graft.
PAST MEDICAL HISTORY: Significant for history of skin cancer
of the left shoulder, history of hypothyroidism, history of
hypercholesterolemia and history of hypertension and history
of coronary artery disease, status post angioplasty in [**2130**],
status post inferior myocardial infarction and anteroseptal
myocardial infarction in [**2130**].
MEDICATIONS ON ADMISSION: Prozac 20 mg p.o. q. day;
Synthroid .125 mEq; Pravachol 80 mg p.o. q. day; Toprol XL
100 mg p.o. q. day; Altace 5 mg p.o. q. day; Aspirin 325 mg
p.o. q. day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He smokes cigars occasionally and drinks
alcohol occasionally.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: He is a well developed, well nourished
male in no apparent distress. Vital signs are stable,
afebrile. Head, eyes, ears, nose and throat examination,
normocephalic, atraumatic, extraocular movements intact.
Oropharynx was benign. Neck supple, full range of motion, no
lymphadenopathy or thyromegaly. Carotids 2+ and equal
bilaterally without bruits. Lungs, clear to auscultation and
percussion. Cardiovascular examination, regular rate and
rhythm, III/VI blowing murmur. Abdomen was soft, nontender,
with positive bowel sounds, no masses or hepatosplenomegaly.
Extremities were without cyanosis, clubbing or edema.
Neurological examination was nonfocal. Pulses were 2+ and
equal bilaterally throughout.
HOSPITAL COURSE: He was admitted to the unit for heart
failure workup. He was in stable condition on the unit and
on [**2141-3-15**] he underwent aortic valve replacement, 24
mm [**Last Name (un) 3843**]-[**Doctor Last Name **], and coronary artery bypass graft times
three with left internal mammary artery to the left anterior
descending, reverse saphenous vein graft to obtuse marginal 1
and diagonal. Crossclamp time was 93 minutes, total bypass
time 131 minutes. He was transferred to the Cardiothoracic
Surgery Recovery Unit in stable condition. He was extubated.
He was started on an ACE inhibitor. Chest tubes were
discontinued on postoperative day #2. He was transferred to
the floor on postoperative day #2. He continued to have a
stable postoperative course. He went into rapid atrial
fibrillation and had to be anticoagulated and converted back
to sinus rhythm. Electrophysiology was following him and
wanted him to be seen in follow up on [**4-18**] at 2 PM, Tuesday
with Dr. [**Last Name (STitle) **]. He was on Amiodarone and he had an
increased TSH to 46 with a decrease T3 and free T4, so he was
discontinued from the Amiodarone and his Levoxyl was
increased to .150 mg. He needs his pulmonary function tests
checked in two to three weeks. So, he was discharged to home
on postoperative day #9 in stable condition.
His laboratory data on discharge revealed hematocrit 33.1,
white count 8,700, platelets 164. Sodium 135, potassium 4.2,
chloride 98, carbon dioxide 27, BUN 16, creatinine 0.6 and
blood sugar 104.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. b.i.d.
2. Percocet 1 to 2 p.o. q. 4-6 hours prn pain
3. Ecotrin 81 mg p.o. q. day
4. Coumadin 5 mg p.o. q.h.s.
5. Prozac 20 mg p.o. q. day
6. Levoxyl 150 mcg p.o. q. day
7. Atenolol 25 mg p.o. q. day
8. Altace 5 mg p.o. q. day
9. Lipitor 10 mg p.o. q. day
FO[**Last Name (STitle) 996**]P: He will be followed by Dr. [**Last Name (STitle) 46214**] in one to two
weeks and Dr. [**Last Name (Prefixes) **] in four weeks and Dr. [**Last Name (STitle) **] on
[**4-18**]. Also the visiting nurses will check his coagulation
screens on Monday, Wednesday and Friday and call them to Dr.
[**Last Name (STitle) 46214**] and he is aware of that.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2141-3-24**] 16:04
T: [**2141-3-24**] 17:02
JOB#: [**Job Number 46215**]
| 20,062 | 159,643 | 4241,4280,2767,2765,9971,42732,41401,412,V4582 |
Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-26**]
Date of Birth: [**2067-5-16**] Sex: M
Service: SURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
high speed MVC, unrestrained driver-drove off a median
Major Surgical or Invasive Procedure:
[**2143-3-3**]: Thoracic stent graft repair of thoracic aorta; femoral
to axillary bypass graft with ringed PTFE; bilateral pelvic
angiography and thoracic angiography.
[**2143-3-7**]: Status post PEG (percutaneous endoscopic gastrostomy
tube) placement and open tracheostomy.
[**2143-3-21**]: Halo placement
RSC CVL
ETT
History of Present Illness:
75 M (General Surgeon) w/ CAD sp CABG X 4 sp high speed MVC,
unrestrained driver-drove off a median. Transferred vis
[**Location (un) **] HD stable w/ GCS 15.
Injuries: aortic dissection (take off of L SC), C2 burst fx, C7
TP/SP fx, T4/5 vertebral body burst fractures w/ increased
kyphotic angulation, T3 inf endplate fx, w/ compression
deformities at T4/T5, Mild retropulsion of T4/T5, multiple high,
B rib fx, sm SDH, nasal sinus fx, lg post scalp lac.
Past Medical History:
1. CAD sp CABG X 4 [**2124**]
2. ? h/o spinal shock syndrome (denies h/o spinal fx)
Social History:
General surgeon
quit tobacco in [**2104**]
no ETOH
has 1 son and 7 daughters
Family History:
NC
Physical Exam:
98.8 82 115/82
NAD, A&O x 3, GCS 15
PERRLA
7cm R posterior scalp laceration
R orbit edema/ecchymosis
RRR
CTA B
+ BS, NT, ND
rectal tone wnl, guiac negative
moves all extremities.
5/5 strength
+2 PT, DP B
TLS no stepoffs/ deformities
Pertinent Results:
[**2143-3-3**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-3-3**] 06:00AM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2143-3-3**] 06:00AM FIBRINOGE-274
[**2143-3-3**] 06:00AM PT-13.0 PTT-23.2 INR(PT)-1.1
[**2143-3-3**] 06:00AM PLT COUNT-152
[**2143-3-3**] 06:00AM WBC-12.5* RBC-3.86* HGB-10.7* HCT-30.9*
MCV-80* MCH-27.8 MCHC-34.7 RDW-14.4
[**2143-3-3**] 06:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2143-3-3**] 06:00AM URINE HOURS-RANDOM
[**2143-3-3**] 06:00AM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-3-3**] 06:00AM AMYLASE-56
[**2143-3-3**] 06:00AM UREA N-25* CREAT-1.2
[**2143-3-3**] 06:19AM freeCa-1.11*
[**2143-3-3**] 06:19AM HGB-11.4* calcHCT-34 O2 SAT-57 CARBOXYHB-1
MET HGB-0.4
[**2143-3-3**] 06:19AM GLUCOSE-155* LACTATE-2.2* NA+-140 K+-3.8
CL--106 TCO2-26
[**2143-3-3**] 06:19AM PH-7.29* COMMENTS-TRAUMA GRE
[**2143-3-3**] 09:36AM freeCa-1.11*
[**2143-3-3**] 09:36AM HGB-7.2* calcHCT-22
[**2143-3-3**] 09:36AM GLUCOSE-147* NA+-136 K+-3.9
[**2143-3-3**] 09:36AM GLUCOSE-147* NA+-136 K+-3.9
[**2143-3-3**] 09:36AM TYPE-ART PO2-345* PCO2-42 PH-7.35 TOTAL
CO2-24 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
RADIOLOGY Final Report
C-SPINE (PORTABLE) IN O.R. [**2143-3-21**] 9:21 PM
C-SPINE (PORTABLE) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOG
Reason: INTRA OP CK HALO PLACEMENT
INDICATION: Intraoperative check of halo placement.
Single intraoperative fluoroscopic spot view of the lateral
C-spine was obtained without radiologist present. Limited view
of C1 through C5 is seen without overlying instrumentation. For
complete details, please see the surgical note.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: FRI [**2143-3-22**] 8:12 PM
Cardiology Report ECG Study Date of [**2143-3-10**] 7:46:24 PM
Sinus rhythm. Occasional ventricular premature beats. Left
atrial abnormality.
Incomplete right bundle-branch block. Probable old anterior wall
myocardial
infarction. Diffuse non-specific ST-T wave changes. Compared to
the previous
tracing of [**2143-3-8**] ventricular premature beats are new.
Otherwise, no
significant diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 160 110 396/441.57 67 79 68
RADIOLOGY Final Report
UNILAT LOWER EXT VEINS LEFT PORT [**2143-3-12**] 6:01 PM
UNILAT LOWER EXT VEINS LEFT PO
Reason: SWELLING LEFT LEG
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with Left ax fem bypass, now with increased LLE
swelling
REASON FOR THIS EXAMINATION:
R/O left lower extremity DVT - portable please
HISTORY: 75-year-old man with left ax-fem bypass, now with
increased left lower extremity swelling.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left common
femoral, superficial femoral, and popliteal veins were
performed. Normal flow, augmentation, compressibility, and
waveforms are demonstrated. Intraluminal thrombus is not
identified.
IMPRESSION: No evidence of DVT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: WED [**2143-3-13**] 8:51 AM
Cardiology Report ECHO Study Date of [**2143-3-11**]
PATIENT/TEST INFORMATION:
Indication: H/O cardiac surgerywith distant CABG . Left
ventricular function.
Height: (in) 67
Weight (lb): 190
BSA (m2): 1.98 m2
BP (mm Hg): 113/45
HR (bpm): 88
Status: Inpatient
Date/Time: [**2143-3-11**] at 13:42
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 224 msec
TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Moderately
depressed LVEF. No resting LVOT gradient. Cannot exclude LV
mass/thrombus.
AORTA: Mildly dilated aortic root. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with
normal cavity size. Overall left ventricular systolic function
is moderately
depressed with septal and apical akinesis. The lateral wall
moves best. A left
ventricular mass/thrombus cannot be excluded. The aortic root is
mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic
pressure is normal. There is no pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2143-3-11**] 16:49.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **]
([**Numeric Identifier 65363**])
RADIOLOGY Final Report
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2143-3-6**] 9:17 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: facial bone fx
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with major trauma s/p MVC, multiple facial
ecchymoses and known nasal fx
REASON FOR THIS EXAMINATION:
facial bone fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: MVC. Multiple facial ecchymoses. [**Hospital **] facial
fractures.
TECHNIQUE: Contiguous axial images of the facial bones were
obtained with coronally reformatted images.
FINDINGS: The patient is intubated, with an OG tube present.
Findings relating to comminuted C2 cervical spine fracture have
been previously described. Aside from the previously described
comminuted and mildly displaced nasal bone fracture, no other
facial fractures are identified.
Fluid levels, with some component of mild mucosal thickening,
are seen within the frontal, maxillary, and sphenoid sinuses,
with near confluent opacification of the ethmoid air cells as
well. The mastoid air cells are aerated.
The orbits appear intact, including the lamina papyracea as well
as the orbital floors. There is a moderate left-sided nasal
septal spur.
Note is also made of diffuse soft tissue thickening of the face
and neck, probably a combination of hemorrhage and edema.
A 1 cm area of increased density in the frontal subcutaneous
soft tissues probably represents a hematoma.
IMPRESSION:
1. Nasal fracture. No other facial fractures identified.
2. Fluid levels are seen within the frontal, maxillary,
sphenoid, and ethmoid sinuses, either post-traumatic or relating
to intubation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2143-3-7**] 12:47 PM
RADIOLOGY Final Report
MRA BRAIN W/O CONTRAST [**2143-3-5**] 8:25 AM
MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST
Reason: possible intraspinal hematoma, carotid dissection
[**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p MVC with multiple spine fractures, thoracic
aortic stenting.
REASON FOR THIS EXAMINATION:
possible intraspinal hematoma, carotid dissection
MRI OF THE BRAIN AND MRA OF THE CIRCLE OF [**Location (un) **] AND UPPER
CERVICAL VASCULATURE
INDICATION: Trauma with cervical spine fracture and aortic
dissection.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain
was performed. Diffusion-weighted images are included.
3D Time-of-Flight MR angiography of the circle of [**Location (un) 431**] was
performed. Multiplanar reformatted images and source image data
are reviewed.
2D Time-of-Flight MR angiography of the superior cervical
vasculature was also obtained.
Comparison is made with the CT scan of the brain from [**3-4**], [**2143**] and with CT angiographic images from [**2143-3-3**].
FINDINGS:
On diffusion-weighted images, two foci of increased signal
intensity are observed within the inferior left occipital lobe,
and also two within the cerebellum, one in each hemisphere.
These are suspicious for areas of acute infarction, or shear
injury. There is no susceptibility artifact identified in these
locations. Tiny foci of T2 signal hyperintensity are visualized
where the diffusion signal abnormalities are observed. On FLAIR
images, there are additional small foci of increased signal
intensity in the subcortical and periventricular white matter of
the cerebral hemispheres. These may reflect chronic areas of
microvascular infarction.
There is evidence of a small amount of intraventricular blood,
as noted on the CT scan. Subarachnoid blood is not well seen on
MR imaging, though there is a small amount visible as increased
signal within a few of the posterior cerebral sulci on the FLAIR
images.
The ventricles are not dilated. No subdural hematomas are
visualized.
MR angiography of the circle of [**Location (un) 431**] demonstrates flow within
both intracranial vertebral arteries, within the basilar artery,
and within the proximal portions of the posterior cerebral
arteries. The internal carotid arteries, anterior and middle
cerebral arteries, and posterior communicating arteries, also
demonstrate flow signal. Some flow signal is also observed
within the posterior inferior cerebellar arteries. The CTA of
[**3-3**] demonstrated atherosclerotic narrowing of the left
carotid siphon, but this is difficult to appreciate on the MRA.
MRA of the upper cervical vasculature is somewhat limited by
motion artifact. In particular, signal within the vertebral
arteries at the craniocervical junction is blurred. However,
there does appear to be continuous signal throughout the
superior cervical right vertebral artery and into the
intracranial portion of this vessel. On the left, there is a
segment of the vertebral artery, at the level of C1, where no
flow is seen. This vessel was better visualized on the CT
angiographic portion of the examination of [**2143-3-3**].
IMPRESSION:
1. MRI of the brain demonstrates a few small foci of diffusion
signal abnormality in the cerebellum and inferior left occipital
lobe, which are suspicious for infarctions or areas of axonal
shear injury. Otherwise, the brain is stable in appearance,
compared to the [**2143-3-4**] CT.
2. MRA of the circle of [**Location (un) 431**] demonstrates flow in the anterior
and posterior circulations.
3. MR angiography of the upper cervical vasculature shows poor
signal in the distal segment of the left vertebral artery, at
the skull base. This segment of the left vertebral artery was
better visualized on the CT of [**2143-3-3**]. Poor
visualization of signal in this location on the MRA may be due
to technical factors. Small sites of non-occlusive arterial
injury may not be apparent on this exam. Otherwise, the superior
segments of the cervical internal carotid arteries and vertebral
arteries, and their proximal intracranial components,
demonstrate flow signal.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: [**First Name8 (NamePattern2) **] [**2143-3-5**] 2:16 PM
RADIOLOGY Final Report
MR CERVICAL SPINE [**2143-3-5**] 8:25 AM
MR CERVICAL SPINE; MR THORACIC SPINE
Reason: Eval C2 burst fx
[**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p MVC with multiple spine fractures, thoracic
aortic stenting.
REASON FOR THIS EXAMINATION:
Eval C2 burst fx
INDICATION: Status post MVC, multiple spine fractures and
thoracic aortic stenting. [**Hospital **] C2 burst fracture.
TECHNIQUE: Multiplanar T1 and T2 weighted scans of the cervical
and thoracic spine were obtained. Correlation is made to CT of
the cervical spine performed [**2143-3-3**].
PLEASE NOTE: This examination was performed and originally
dictated [**2143-3-5**]. However, the dictation has been lost, and it
has been presented to us for reinterpretation, and is being
dictated on [**2143-3-6**].
FINDINGS:
MR OF THE CERVICAL SPINE: The actual fracture lines in C2 seen
on the prior CT are not clearly visualized on this examination.
Evaluation of the vertebral bodies demonstrate elevated STIR
signal within the C2 vertebral body, representing edema
associated with the fractures in that bone. In addition, the
fracture line of the C7 spinal process is seen, with mild
distraction at the fracture site. Diffuse high signal is seen on
the STIR images in the tissues posterior to the C2- C6 levels,
as well as at the paraspinal muscles at and below the C6 level.
No evidence of focal distortion at the cervical extent of the
spinal cord is noted.
MRA OF THE VERTEBRAL ARTERIES: Limited 3D imaging of the C1/2
region was performed.
No gross abnormalities are seen along the course of the
vertebral arteries. There is arterial flow seen through the
region of the foramen transversarium fractures.
MRI THORACIC SPINE: Increased T2 and STIR signal is seen within
the T3, T4, and T5 vertebral bodies, with compression
deformities of the T4 and T5 vertebral bodies. Although on the
prior CT, no definite retropulsion was seen, there appears to be
a small mid- vertebral focus of retropulsion of less than 5 mm
arising from both the T4 and T5 vertebral bodies posteriorly.
Examination of the spinal cord demonstrates focal widening of
the spinal cord diameter in the AP direction at the T4 and T5
levels, and corresponding narrowing in the transverse dimension.
To the right of the spinal cord, there is a 9-mm region which
demonstrates decreased STIR signal, and appears to have elevated
T2-weighted signal (series 14, image 324, series 18, image 394).
This may represent an epidural hematoma, as it appears that the
thecal sac is compressed from the lateral direction, resulting
in the elongation in the AP dimension. We cannot definitively
determine whether or not there is any spinal cord edema at this
level, although the physical distortion of the cord itself is
evident. Note is also made of increased prevertebral soft tissue
signal and thickness at this level, also likely resulting from
hematoma. The left side of the superior T6 vertebral body also
demonstrates elevated STIR signal, probably representing focal
contusion.
Note is also made of bilateral pleural effusions. Elevated
paravertebral STIR signal is seen, extending from the lower
cervical to the upper thoracic (approximately T8) levels,
representing soft tissue injury. The remainder of the lower
thoracic and visualized upper lumbar spine appear otherwise
unremarkable.
IMPRESSION:
1. C2 vertebral body and C7 spinous process fractures with bone
marrow edema.
2. Diffuse soft tissue edema/inflammation in the region of the
interspinous ligaments.
3. No evidence of spinal cord abnormalities in the cervical
region.
4. Patent appearance of the vertebral arteries with appropriate
vascular flow at the C1/2 region.
5. Marrow edema involving the T3-T6 vertebral body levels, with
compression deformities at T4 and T5.
6. Mild retropulsion of T4 and T5 vertebral bodies, not clearly
deforming the spinal cord. However, there appears to be mass
effect upon the thecal sac at this site, probably from a right
epidural hematoma, causing slight elongation of the spinal cord
in the AP dimension. We cannot assess on this examination for
cord edema.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] on [**2143-3-6**], 3 o'clock
p.m. The orthopedic spine service is also following this
patient, and have reviewed the images from this examination.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: WED [**2143-3-6**] 8:21 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2143-3-4**] 11:11 AM
CT HEAD W/O CONTRAST
Reason: eval sdh
[**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p mva w/sdh
REASON FOR THIS EXAMINATION:
eval sdh
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post MVA, subdural hemorrhage. [**Hospital **]
interval change.
TECHNIQUE: Non-contrast CT of the head was performed in
comparison with examination performed [**2143-3-3**].
FINDINGS: The tiny foci of increased attenuation seen on the
prior examinations in the frontal and parietal sulci are
slightly more diffuse on this examination, without evidence of
new hemorrhage. A trace amount of dependent blood is seen within
both atria of the lateral ventricles, likely post-traumatic. The
extra-axial spaces are preserved. The [**Doctor Last Name 352**] white matter
differentiation remains preserved as well. There is no
appreciable mass effect.
Note is again made of the large subgaleal soft tissue hematomas,
which in conjunction with diffuse edema appears significantly
worse than on the prior study. In addition, there is an
increased amount of fluid within the sphenoid sinuses as well as
in the nasopharynx and minimally within the ethmoid air cells.
The mastoid air cells remain aerated. There appears to be a
nasal bone fracture. In addition, there is a moderate amount of
radiopaque debris on the skin surface at the right vertex, in
the regions of skin irregularity probably representing
laceration.
IMPRESSION: 1) Tiny foci of subarachnoid blood are unchanged. No
mass effect or hydrocephalus. 2) High attenuation fluid within
the sphenoid sinus as well as in the nasopharynx, consistent
with blood and secretions. 3) Nasal bone fracture. 4) Enlarging
frontal/parietal subgaleal hematomas.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: MON [**2143-3-4**] 9:05 PM
RADIOLOGY Final Report (Revised)
CT C-SPINE W/O CONTRAST [**2143-3-3**] 6:57 AM
CT C-SPINE W/O CONTRAST
Reason: MVC, ? FX
[**Hospital 93**] MEDICAL CONDITION:
75 year old man sp MVC, ? SDH, C2c7 fx
REASON FOR THIS EXAMINATION:
eval fx
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 75-year-old man status post MVC.
TECHNIQUE: Multidetector axial images of the cervical spine were
obtained without contrast. Coronal and sagittal reformatted
images were obtained.
FINDINGS: There coronally oriented fractures of the C2 body with
widening of the fragments. The posterior longitudinal ligament
appears intact at this level and there is no impingement on the
thecal sac. In addition there are multiple fractures of C7
involving the spinous process and both transverse processes. The
ring appears to remain intact. There are also bilateral first
and second rib fractures. Opacities at the lung apices may
represent contusions. Overall the alignment of the cervical
vertebral bodies remains intact. There is mild prevertebral soft
tissue swelling and significant posterior soft tissue swelling.
In addition there are degenerative changes of the cervical spine
most prominent at C5-6 with posterior disc bulge and osteophyte
formation. There may be mild canal stenosis at this level. CT is
limited in its ability to [**Hospital 4656**] intrathecal detail however
the remainder of the visualized outline of the thecal sac is
unremarkable.
IMPRESSION:
1. C2 burst fracture.
2. Multiple C7 fractures however the pedicles and lamina remain
intact.
3. Bilateral first and second rib fractures.
4. No traumatic cord compression identified on this scan.
NOTE ADDED AT ATTENDING REVIEW: The C2 fractures extend to
invovle the transverse foramina bilaterally. This raises a
concern of vertebral artery injury. There is also a fracture of
the right lamina, just to the right of midline.
I do not believe there is CT evidence that reassures me about
the posterior longitudinal ligament. In fact, the fracture of
the C7 spinous process suggests a tear of the interspinous
ligaments, which would also indicate compromised integrity.
Further, there is prevertebral soft tissue space widening,
worrisome for an anterior longitudinal ligament tear.
There is high density in the spinal canal that may represent
thin subdural or epidural hematoma.
There are two small fragments adjacent to the anterior inferior
endplate of C2, which may represent avulsion fractures, and may
be acute or chronic.
There is fusion, apparently congenital, of the facets
bilaterally at C7- T1.
These additional findings indicate the need for a cervical spine
MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] the ligaments and possible intraspinal hematoma.
There is also concern for injury to the vertebral arteries, and
this may be evaluated with MR, including axial fat saturated T1
weighted images on the [**Company 14672**] instrument, and an MRA.
The CTA examination is not a substitute for the MR.
These findings were discussed with Dr. [**Last Name (STitle) **] at 11:15 am on
[**2143-3-4**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
DR. [**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: MON [**2143-3-4**] 11:46 AM
RADIOLOGY Final Report
CTA NECK W&W/OC & RECONS [**2143-3-3**] 7:10 AM
CTA NECK W&W/OC & RECONS; CTA CHEST W&W/O C &RECONS
Reason: MCV, C2, C7, RIB FX. ? CAROTID/AORTIC INJURIES
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with
REASON FOR THIS EXAMINATION:
[**Hospital **] carotid injury
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 75-year-old man status post high-speed motor vehicle
accident.
TECHNIQUE: Multidetector axial images of the neck, chest,
abdomen and pelvis were obtained using a CTA protocol with 100
cc Optiray. Multiplanar reformatted images were obtained.
CT NECK WITH IV CONTRAST: As described on the preceding C-spine
CT, there is a burst fracture of C2 as well as multiple C7
fractures. The carotid and vertebral arteries are patent. As the
right vertebral artery passes the C2 fracture, there may be a
small raised intimal flap. This is nonocclusive. Fluid is
observed in the sphenoid sinuses. A nasal bone fracture is also
observed which is slightly deviated to the right. Overlying soft
tissue swelling is also noted. Multiple lymph nodes are observed
but do not meet CT criteria for pathologic enlargement.
CT CHEST WITH IV CONTRAST: At the level of the ligamentum
arteriosum, there is a defect in the aortic wall with apparent
pseudoaneurysm. An associated periaortic hematoma is observed.
The patient is status post CABG. A penetrating ulcer is also
observed in the ascending aorta. There is moderate cardiomegaly.
No axillary, mediastinal, or hilar lymphadenopathy is
identified. There are diffusely increased interstitial markings
as well as bibasilar atelectasis. Opacity at the lung apices may
represent small contusions. There are bilateral first and second
rib fractures. In addition there are compression burst fractures
of T4 and T5. Inferior endplate changes of T3 are also noted.
There is increased kyphotic angulation of the thoracic spine at
these levels.
CT ABDOMEN WITH IV CONTRAST: Just inferior to the takeoff of the
inferior mesenteric artery, there is a short segment of aortic
dissection which is non- flow limiting. A similar short segment
of non-flow-limiting dissection is observed at the proximal left
common iliac artery. The external iliac and common femoral
arteries are patent bilaterally.
The liver, gallbladder, pancreas, adrenal glands, and kidneys
are unremarkable. Small focus of hypodensity in the spleen may
represent a cyst. There is a small hiatal hernia. The stomach
and bowel loops are otherwise unremarkable. There is no free air
or free fluid. No mesenteric or retroperitoneal lymphadenopathy
is identified.
CT PELVIS: Foley catheter and air are observed in the bladder.
The bladder wall appears mildly thickened. Calcifications are
observed in the enlarged prostate gland. The sigmoid colon and
rectum are unremarkable. There is no free fluid and no pelvic or
inguinal lymphadenopathy. Bone islands are observed in the left
superior acetabulum and sacrum.
IMPRESSION:
1. Acute traumatic aortic injury at the level of the ligamentum
arteriosum with associated mediastinal hematoma. The site of
injury is approximately 2 cm from the origin of the left
subclavian artery.
2. Short segment non-flow-limiting dissections of the infrarenal
aorta and left common iliac artery. Possible raised intimal flap
in the right vertebral artery at the C2 level.
3. Redemonstration of C2, C7, and bilateral first and second rib
fractures. Additional findings of T4 and 5 vertebral body burst
fractures with increased kyphotic angulation of the thoracic
spine at this level. There may be a T3 inferior endplate
fracture as well.
4. Redemonstration of fluid within the sphenoid sinuses and
large right frontal and parietal subgaleal hematomas.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 1:55 PM
RADIOLOGY Final Report
CTA ABD W&W/O C & RECONS [**2143-3-3**] 7:10 AM
CTA NECK W&W/OC & RECONS; CTA CHEST W&W/O C &RECONS
Reason: MCV, C2, C7, RIB FX. ? CAROTID/AORTIC INJURIES
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with
REASON FOR THIS EXAMINATION:
[**Hospital **] carotid injury
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 75-year-old man status post high-speed motor vehicle
accident.
TECHNIQUE: Multidetector axial images of the neck, chest,
abdomen and pelvis were obtained using a CTA protocol with 100
cc Optiray. Multiplanar reformatted images were obtained.
CT NECK WITH IV CONTRAST: As described on the preceding C-spine
CT, there is a burst fracture of C2 as well as multiple C7
fractures. The carotid and vertebral arteries are patent. As the
right vertebral artery passes the C2 fracture, there may be a
small raised intimal flap. This is nonocclusive. Fluid is
observed in the sphenoid sinuses. A nasal bone fracture is also
observed which is slightly deviated to the right. Overlying soft
tissue swelling is also noted. Multiple lymph nodes are observed
but do not meet CT criteria for pathologic enlargement.
CT CHEST WITH IV CONTRAST: At the level of the ligamentum
arteriosum, there is a defect in the aortic wall with apparent
pseudoaneurysm. An associated periaortic hematoma is observed.
The patient is status post CABG. A penetrating ulcer is also
observed in the ascending aorta. There is moderate cardiomegaly.
No axillary, mediastinal, or hilar lymphadenopathy is
identified. There are diffusely increased interstitial markings
as well as bibasilar atelectasis. Opacity at the lung apices may
represent small contusions. There are bilateral first and second
rib fractures. In addition there are compression burst fractures
of T4 and T5. Inferior endplate changes of T3 are also noted.
There is increased kyphotic angulation of the thoracic spine at
these levels.
CT ABDOMEN WITH IV CONTRAST: Just inferior to the takeoff of the
inferior mesenteric artery, there is a short segment of aortic
dissection which is non- flow limiting. A similar short segment
of non-flow-limiting dissection is observed at the proximal left
common iliac artery. The external iliac and common femoral
arteries are patent bilaterally.
The liver, gallbladder, pancreas, adrenal glands, and kidneys
are unremarkable. Small focus of hypodensity in the spleen may
represent a cyst. There is a small hiatal hernia. The stomach
and bowel loops are otherwise unremarkable. There is no free air
or free fluid. No mesenteric or retroperitoneal lymphadenopathy
is identified.
CT PELVIS: Foley catheter and air are observed in the bladder.
The bladder wall appears mildly thickened. Calcifications are
observed in the enlarged prostate gland. The sigmoid colon and
rectum are unremarkable. There is no free fluid and no pelvic or
inguinal lymphadenopathy. Bone islands are observed in the left
superior acetabulum and sacrum.
IMPRESSION:
1. Acute traumatic aortic injury at the level of the ligamentum
arteriosum with associated mediastinal hematoma. The site of
injury is approximately 2 cm from the origin of the left
subclavian artery.
2. Short segment non-flow-limiting dissections of the infrarenal
aorta and left common iliac artery. Possible raised intimal flap
in the right vertebral artery at the C2 level.
3. Redemonstration of C2, C7, and bilateral first and second rib
fractures. Additional findings of T4 and 5 vertebral body burst
fractures with increased kyphotic angulation of the thoracic
spine at this level. There may be a T3 inferior endplate
fracture as well.
4. Redemonstration of fluid within the sphenoid sinuses and
large right frontal and parietal subgaleal hematomas.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 1:55 PM
RADIOLOGY Final Report
-76 BY SAME PHYSICIAN [**2143-3-3**] 5:28 PM
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
Reason: please assess for bleeding, mediastinal widening
[**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p repair of dissected aorta
REASON FOR THIS EXAMINATION:
please assess for bleeding, mediastinal widening
HISTORY: Aortic dissection.
A single portable chest radiograph demonstrates interval
placement of an aortic endograft at the level of the aortic knob
and descending aorta, new when compared to the radiographs
obtained earlier the same day. There is a right subclavian
Swan-Ganz catheter with its tip in the left main pulmonary
artery. There is an endotracheal tube with its tip at the level
of the clavicular heads. Surgical skin staples are new and
project over the superior left hemithorax. Sternotomy wires and
surgical clips overlying the cardiomediastinal silhouette remain
unchanged. There is no right-sided effusion. There is a moderate
left-sided pleural effusion.
Of note, lucency about the distal aspect of the endotracheal
tube may represent overinflation of the cuff balloon.
IMPRESSION:
Interval placement of aortic endograft.
Support lines as described. The endotracheal cuff balloon may be
overinflated and clinical correlation is requested.
Interval development of left-sided pleural effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 10:36 PM
Brief Hospital Course:
Pt was taken to the trauma bay by EMS. Pt was evaluated in the
ED and admitted to the trauma service.
Neurologically: 1. meds: tylenol, motrin, roxicet, olanzypine,
ativan. 2. C2 burst fracture. 3. Multiple C7 fractures however
the pedicles and lamina remain intact.
4. Bilateral first and second rib fractures. 5. T4 and T5
thoracic burst fractures with increased kyphotic angulation of
the thoracic spine at this level. 6. Pt now has a halo on placed
by Dr. [**Last Name (STitle) 363**] on [**2143-3-21**]. Pt can ambulate.
Respiratory: 1. Open Tracheostomy 2. meds: albuterol,
ipratropium bromide, tessalon pearls.
CV: 1. Thoracic stent graft repair of thoracic aorta; femoral to
axillary bypass graft with ringed PTFE; bilateral pelvic
angiography and thoracic angiography. 2. Meds: lopressor,
[**Last Name (LF) 17339**], [**First Name3 (LF) **], lisinopril. 3. Pt had cardiac contusion vs MI with
enzyme leak while in ICU, echo done [**3-11**] shows EF 30-35%
GI: 1. Status post PEG (percutaneous endoscopic gastrostomy
tube) placement 2. meds: colace, dulcolax, milk of magnesia.
FEN: 1. Cardiac healthy diet. 2. Tubefeeding: Start After
midnight; Promote w/ fiber Full strength; Starting rate: 85
ml/hr; Do not advance rate Goal rate: 85 ml/hr Cycle?: Yes,
starting now Cycle start: 1900 Cycle end: 0700 Residual Check:
q4h Hold feeding for residual >= : 150 ml Flush w/ 100 ml water
q8h Other instructions: Please hold TF for today until 7 pm. You
can start them at 7 pm on [**3-24**] and stop at 7 a.m. on [**3-25**].
Please check a calorie count during the day 3. Calorie count
(for dates: [**3-26**], [**3-27**], [**3-28**]).
Endocrine: placed on sliding scale insulin. Blood sugars in
120s.
Activity: ambulate. Halo to remain on at all times.
Medications on Admission:
Tenormin
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Artificial Tear Ointment 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1) Appl
Ophthalmic PRN (as needed).
3. Enoxaparin 40 mg/0.4 mL Syringe [**Month/Year (2) **]: One (1) Subcutaneous
DAILY (Daily).
4. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2)
Puff Inhalation QID (4 times a day).
8. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
9. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection ASDIR (AS DIRECTED).
10. Docusate Sodium 150 mg/15 mL Liquid [**Month/Year (2) **]: One Hundred (100)
mg PO BID (2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Year (2) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
12. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
13. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for agitation.
14. Nystatin 100,000 unit/mL Suspension [**Month/Year (2) **]: Five (5) ML PO QID
(4 times a day) as needed.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Olanzapine 7.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
17. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
18. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
19. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
20. Benzonatate 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3
times a day) as needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MVC
1. Partial transection of thoracic aorta.
2. C2 burst fracture.
3. Multiple C7 fractures however the pedicles and lamina remain
intact.
4. Bilateral first and second rib fractures.
5. Respiratory failure status post trauma, nutritional needs.
6. Nasal bone fracture
7. T4 and T5 thoracic burst fractures with increased kyphotic
angulation of the thoracic spine at this level.
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) 363**] in 2 weeks. You will also have
xrays of your C-spine and T-spine that day.
Please follow-up with the trauma clinic in 2 weeks.
Please follow-up in vascular clininc in 1 month with Dr.
[**Last Name (STitle) **].
Followup Instructions:
Please call [**Telephone/Fax (1) 3573**] to schedule an appointment with Dr.
[**Last Name (STitle) 363**]. Please see him in 2 weeks.
Please call [**Telephone/Fax (1) 6439**] to schedule an appointment with the
trauma clinic. Please be seen in the office in 2 weeks.
Please call [**Telephone/Fax (1) 1237**] to schedule an appointment with Dr.
[**Last Name (STitle) **]. Please see him in 4 weeks.
Completed by:[**2143-3-26**] | 20,063 | 165,620 | 9010,80502,8052,5185,8602,85222,41071,E8160,80507,80704,486,2851,4280,5601,8730,8020,V4581 |
Admission Date: [**2117-6-2**] Discharge Date: [**2117-6-8**]
Date of Birth: [**2068-6-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 48 yr old male with hx of type A aortic dissection s/p
re-do repair in [**12/2116**], AVR who present with worsening SSCP x 5
days. Pt states that the pain is on-and-off, described as
"ripping" from his chest radiating into his back, assoc with
mild SOB, no n/v. Pain is not exertional and resolves on its
own. Pt presented to [**Location (un) 620**] where a CT was performed and showed
"new leakage and a large hematoma" so he was transferred to
[**Hospital1 18**]. Here, a CTA was performed and showed a type A dissection
with no leakage but a fluid collection around the ascending
aorta, likely [**12-30**] post-op changes. CT surgery evaluated the
patient and disagreed with radiology stating that he could not
have a type A dissection given that his ascending aorta has been
replaced. They diagnosed him with a chronic type B with a
residual hematoma. He was admitted to the MICU for rule out MI,
BP control and close observation. Pt is currently pain free.
.
Pt initially presented in [**2111**] with chest pain radiating to his
neck and a CT scan revealed a type I aortic dissection. At that
time, he had a tube graft replacement of the ascending aorta.
That hospital course was complicated by a left MCA CVA. In
[**12/2116**], pt again presented to the hospital with chest pain
radiating to his neck and CT scan showed Type 1 aortic
dissecting aneurysm involving thoracic and abdominal aorta,
extending to the proximal aspect of left iliac artery. He was
brought to the operating room where he underwent a Redo
Ascending Aortic replacement (and Bentall procedure) w/ a #28
Gel weave graft along with an AVR w/ a #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**].
Past Medical History:
PMH:
1. Type A Aortic dissection dx in [**2111**]
- [**2111**]: s/p repair with tube graft(thoracic/abd)
- [**12/2116**]: redo ascending aortic replacement with AVR
2. CVA of left MCA, residual right-sided hemiparesis, dysarthria
3. Hypertension
4. Hypercholesterolemia
5. GERD
6. Anemia
Social History:
Social Hx: Lives in [**Location 620**] with family. Currently not working.
Quit
smoking 5 yrs ago after 15 yr pk hx. no etoh
Family History:
Non-contributory
Physical Exam:
Exam: temp, BP 182/120-->99/65 on Nipride gtt, HR 75, R 14, O2
97% 2L
Gen: NAD, resting comfortably
HEENT: PERRL, EOMI, MMM
Neck: no JVD appreciated
CV: RRR, 3/6 systolic murmur heard best at RUSB, loud S2 click
Chest: clear
Abd: +BS, soft, NT
Ext: warm, no edema, 2+ DP
Neuro: CN 2-12 intact; left facial droop; +dysarthria; [**12-2**]
strength in RUE/RLE; [**4-1**] in LUE/LLE
PE on acceptance to floor:
Vitals: T97.0 / 56 / 18 / 120/62 / No O2 sat taken
Gen: A&Ox3, aphasic
HEENT: No JVD, no LAD, R facial drop, R face decreased
sensation, no erythema/edema/exudates in throat
Lungs: CTA B
Heart: 3/6 systolic murmur radiating to the carotids and USBs,
loud S1/S2, no r/g
Abdomen: Soft, mild RUQ tenderness, +BS, ND
Extr: R distal UE 0/5 motor (R hand paralysis), R leg [**4-1**] motor
(but much weaker than L leg), no c/c/e
Neuro: Aphasia, neuro findings noted above
Pertinent Results:
[**2117-6-1**] 07:00PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2117-6-1**] 07:00PM CK-MB-3 cTropnT-<0.01
[**2117-6-1**] 07:00PM CALCIUM-9.2 MAGNESIUM-2.0
[**2117-6-1**] 07:00PM WBC-5.6# RBC-5.03# HGB-10.9*# HCT-36.7*#
MCV-73*# MCH-21.7*# MCHC-29.7* RDW-15.0
[**2117-6-1**] 07:00PM NEUTS-51.9 LYMPHS-41.8 MONOS-4.9 EOS-0.9
BASOS-0.5
[**2117-6-1**] 07:00PM HYPOCHROM-3+ MICROCYT-3+
[**2117-6-1**] 07:00PM PLT COUNT-246#
EKG: NSR at 67, LAD (new); LVH by voltage; no ST-T wave changes
.
CT of abd at [**Location (un) 620**], [**2118-6-1**]:
OLD DISSECTION OF UNCHANGED APPEARANCE EXTENDING WELL INTO THE
LUMBAR AORTA. ALSO EVIDENCE OF INTERVAL AORTIC VALVE REPAIR AND
CHANGES COMPATIBLE WITH A NEW LEAKAGE AROUND THE AORTIC ROOT
WHERE THERE IS A LARGE HEMATOMA EXTENDING CRANIALLY ENDING JUST
PRIOR TO THE TAKE OFF OF THE CRANIAL VESSELS. NO INVOLVEMENT OF
THE PERICARDIUM.
.
CTA at [**Hospital1 18**]:
1. Extensive type 1 aortic dissection extending superiorly into
the
brachiocephalic and left common carotid artery, and extending
inferiorly into the left iliac artery. All major aortic vascular
branches, with the exception of the left renal artery
originating off the true lumen. There is no evidence of major
organ infarction.
2. Small low-attenuation fluid collection around the ascending
aorta, at the area of the prior aneurysm graft repair. This is
likely postoperative in nature. There is no evidence to suggest
leak.
3. Small hiatal hernia.
4. Small low-attenuation lesion in the left lobe of the liver
likely
representing a small cyst versus hemangioma, but not
definitively
characterized on this study.
5. Bibasilar atelectasis.
.
Echo, [**3-2**]: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. A bileaflet aortic valve prosthesis is
present. The aortic prosthesis is well functioning. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
1. Chest Pain: Given the patient's initial presentation with
chest pain, the immediate concern was leakage or worsening
dissection. However, given the CTA performed at [**Hospital1 18**], it was
found that the changes that were initially so concerning at the
OSH were in fact more consistent with post-surgical changes than
with new dissection. There were no signs of leakage on the CTA.
CT surgery was consulted, and were in full agreement that there
did not appear to be any worsening of the patient's prior
surgical site, and that the patient's dissection was stable.
Cardiac enzymes were obtained that ruled the patient out for new
MI. EKG remained stable and convergent with previous EKGs on
file.
.
2. Chronic Type I Aortic Dissection: As noted above, the
initial workup revealed that the cause of the patient's chest
pain was not compatible with new aortic dissection or furthering
of the patient's previous dissection. It was immediately
obvious that the patient's BP was not being adequately
controlled, and so on arrival the patient was transferred to the
MICU for observation and management of hypertension. A Nipride
drip was started, then transitioned to captopril and metoprolol,
with a goal BP of 100-120 systolic. The patient had HR in the
50s for the majority of his hospitalization, but was reasonably
active with no subjective side effects of his bradycardia.
Because of initial concern at the OSH, the patient's warfarin
was held, and on arrival to [**Hospital1 18**], once it was clear that this
was not an evolution of his dissection, a heparin gtt was begun,
with eventual bridging to resumption of warfarin therapy. The
patient was eventually titrated to an adequate INR, with a goal
of 2.5-3.
.
3. Hypertension: As noted above, the patient was noted to be
hypertensive on arrival, and so he was initially given nipride
gtt, then onto metoprolol and captopril. This achieved the
target SBP with no adverse side effects other than an
asymptomatic bradycardia. He was instructed to continue this
regimen as an outpatient.
.
4. Hypercholesterolemia: The patient was continued on his
outpatient doses of pravachol and gemfibrozil. A FLP was
checked during his hospitalization that was found to be
satisfactory.
Medications on Admission:
coumadin 2mg qhs
protonix 40mg qd
pravachol 20mg qd
gemfibrozil 600mg [**Hospital1 **]
percocet
metoprolol 50mg [**Hospital1 **]
Discharge Medications:
1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
6. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSAT
(every Saturday).
7. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSUN
(every Sunday).
8. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTUES (every
Tuesday).
9. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTHUR (every
Thursday).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Type I aortic dissection
Aortic Valve Repair, St. [**Male First Name (un) 923**] Mechanical valve. INR goal 2.5-3
Hypertension, SBP goal of 100-120 SBP
Hypercholesterolemia
Discharge Condition:
Stable, ambulating well without assist.
Discharge Instructions:
If you experience chest pain, shortness of breath, fevers,
chills, nausea, vomiting, or any other concerning symptoms,
contact your physician or return to the emergency room.
Followup Instructions:
Please report for an INR check on THURSDAY of this week at your
regular location. Then, call your primary care physician for an
appointment on FRIDAY of this week. An INR was drawn before you
left on Tuesday and should be available to your primary doctor
during your appointment on friday.
Also, in the next week, please call Dr. [**Last Name (STitle) 31068**] (your
cardiologist) for an outpatient appointment. Please make this
appointment for sometime in the next 1-2 weeks.
Completed by:[**2117-6-15**] | 20,064 | 144,372 | 44103,99812,E8788,42789,43820,V433,53081,V5861,2720,4019 |
Admission Date: [**2117-1-8**] Discharge Date: [**2117-1-22**]
Date of Birth: [**2068-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Bental/Asc Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
History of Present Illness:
48 y/o male who presented in [**10-1**] with acute onset of chest
pain radiating to back of neck with N&V. CT scan showed Type 1
aortic dissecting aneurysm involving thoracic and abd. aortas,
exteding to prox. aspect of left iliac artery. Previous hx is
relevant for thoracic/abd aorta replacement in 03. He presented
on [**12-16**] with DOE since [**10-1**] and back pain. The cardiac cath
showed an aneurysmal dilatation of the proximal third of the
aorta, below the previous graft, along with significant root
dilatation and aortic regurgitation. The pt. was then scheduled
for an aortic valve and root replacement.
Past Medical History:
Type A Aortic dissection [**2111**] & repair w/tube
graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04
CVA w/ residual rt sided hemiparesis
HTN
^chol
GERD
anemia
Social History:
Lives in [**Location 620**] with family. Currently not working. Quit
smoking 5 yrs ago after 15 yr pk hx. Pt. denies ETOH drinking.
Family History:
Non-contributory
Physical Exam:
VS: Ht.: 6'2" Wt.: 216 BP: 108/85 HR: 58
General: Sitting in bed in NAD
Resp: CTAB
CV: RRR, S1S2 with 3/6 SEM and radiation to carotids
GI: Soft, flat, NT/ND +BS
Neuro: A&O x 3, appropriate with R hemiparesis
Ext: warm, well-perfuses, - edema, - varicosities
Pulses: 1+ throughout
Brief Hospital Course:
Pt. was scheduled to be a same day admit following his surgery
but was found to have an elevated INR and had to be admitted and
delayed until a lower INR. On [**2117-1-10**] pt. was given one dose of
Vitamin K and scheduled for the OR the next day. On [**2117-1-11**] pt.
had a stable INR and was brought to the operating room where he
underwent a Redo Ascending Ao replacement (and Bentall
procedure) w/ a #28 Gel weave graft. Along with an AVR w/ a #23
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]. Please see surgical note for full details. Pt.
tolerated the procedure well. Total CPB time was 210 minutes
with a XCT of 142 minutes. Pt. was brought to the CSRU in stable
condition with a MAP 80, CVP 12, PAD 15, [**Doctor First Name 1052**] 22, and a HR of 80
NSR. He was being titrated on Nitro, Epi, and propofol when
transferred.
On Post-Op day #1, propofol was weaned. NMB reversed and pt. was
weaned off ventilation. After extubation, pt was awake, alert
and oriented and had no new deficits(r-sided hemiparesis
pre-op). Pt. was now on Nipride and that was planned to be
weaned.
POD #2 pt. had no new events but was still being titrated on
Nipride. Anticoagulation started today.
POD #3, pt. was transfused 1 unit of PRBC due to low HCT (25).
Still in CSRU secondary to not being able to titrate off
Nipride. Chest tubes were removed and Foley replaced.
POD #4, HCT increased to 29.1. Pt. had increased DOE though the
day with a transient drop in SBP after Lopressor (80's). Neo was
started. An echo was performed which showed a small pericardial
effusion. CXR showed L. pleural effusion. Suture over CT site
due to bleeding.
POD #5 Neo was weaned.
POD # 6 pt. had PO2 in 90's and was receiving O2 via open face
tent.
POD #7, repeat CXR performed yesterday revealed increased L
pleural effusion. A pigtail catheter was placed over guidewire
into left chest which immediately drained 550 cc. Weaned mask to
nasal cannula since oxygenation improved.
POD #8, CT d/c'd. Later that night pt. was oozing from l. chest
tube sight with resolution after stitch placement. Pt. was
transferred to telemetry floor.
POD #9 & 10: Hemodynamically stable. Pt. is now awaiting INR to
increase and still needs an increase and strength and activity
before being discharged home. Cont. to receive Coumadin.
POD #11, pt doing well and was d/c'd home with VNA services and
INR will be checked on [**1-23**] and [**1-25**] with results sent to Dr.
[**Last Name (STitle) 30197**].
D/C PE:
VS: 99.5 75 SR 120/60 22
Neuro: alert, oriented with r-side hemiparesis
Pulm: CTAB
Cardiac: RRR
Sternum: + Bledding from pacer site, -Erythema
Abd: soft, NT/ND +BS
Ext: warm, -c/c/e
Medications on Admission:
1. Lopressor 25mg [**Hospital1 **]
2. Diovan 160mg [**Hospital1 **]
3. Enalapril 20mg qd
4. HCTZ 25mg qd
5. Nifedical 30mg [**Hospital1 **]
6. Protonix 40mg qd
7. Pravachol 20mg qd
8. Tizanidine 4mg qd
9. Gemfibrizol 600mg [**Hospital1 **]
10. FeSO4 325mg qd
Discharge Medications:
1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once
a day: goal INR 2.5-3
pt to take 5 mg Sat and Sun then inr check and as directed.
Disp:*100 Tablet(s)* Refills:*0*
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: pt may resume
after d/c.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P Redo Asc. & Bentall Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **]
[**Male First Name (un) 923**]
Type A Aortic dissection [**2111**] s/p repair w/tube
graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04
CVA (stroke) w/ residual rt sided hemiparesis
Hypertension
Hypercholesterolemia
GERD/Acid reflux
Anemia
Discharge Condition:
good
Discharge Instructions:
KEEP WOUNDS CLEAN AND DRY. OK TO SHOWER, NO BATHING OR SWIMMING.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
[**Last Name (NamePattern4) 2138**]p Instructions:
wound clinic in 1 week
Dr [**Last Name (STitle) 30197**] in [**12-31**] weeks and for INR checks as directed
Dr [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2117-3-15**] | 20,064 | 180,633 | 4241,44101,99671,E8781,2809,4019,79092 |
Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-20**]
Date of Birth: [**2179-4-14**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname **] was born at 37 6/7 weeks
gestation by spontaneous vaginal delivery after an induction
for intrauterine growth restriction and a non-reassuring
fetal heart rate pattern. She was born to a 23-year-old
gravida IV, para I now II woman, whose prenatal screens are
blood type A positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, group B
strep unknown. Rupture of membranes occurred four and a half
hours prior to delivery, with clear fluid. There was no
intrapartum fever or sepsis risk factors. The second stage
of labor lasted only six minutes. The infant emerged
vigorous. Apgars were 8 at one minute and 9 at five minutes.
She went to the Newborn Nursery, where she was noted to be
grunting at the time of admission and, at five hours of age,
she was transferred to the Newborn Intensive Care Unit for
persistent respiratory distress. Her birth weight was 3100
grams (75th percentile for gestational age), her birth length
was 49.5 cm (75th percentile), and her head circumference 35
cm (90th percentile).
PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic,
term-appearing infant. Anterior fontanel open and flat,
sutures approximated. A small unilateral cleft lip, palate
intact. Mild grunting, however, intermittently quiet.
Breath sounds equal with quiet. No flaring, some head
bobbing. Pink and well perfused. Normal S1, S2 heart
sounds, no murmur. Femoral and brachial pulses +2 and equal.
Abdomen soft. Clavicles intact. Normal spine examination,
normal extremity examination. Term female external
genitalia, and tone slightly decreased generally.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant required nasal cannula oxygen
until day of life three, when she weaned to room air, and has
remained there since that time. Her chest x-ray was
consistent with retained fetal lung fluid. On examination,
her respirations are comfortable, and her lung sounds are
clear and equal.
2. Cardiovascular: She has remained normotensive throughout
her Newborn Intensive Care Unit stay. She has normal S1, S2
heart sounds, no murmur. She is pink and well perfused.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun at the time of delivery. She is breast feeding. She
did have some trouble with latching on, and is currently
bottle feeding, and she has tried a variety of nipples, but
is now taking adequate volume with a well-coordinated suck
and swallow. She has been taking breastmilk ad lib volumes by
bottle - up to 75-80cc. Mother plans on trying to
breastfeeding again at home.
Her weight at the time of discharge is 2960 grams.
She was evaluated by Plastic Surgery nurse, [**First Name8 (NamePattern2) 40699**] [**Last Name (NamePattern1) **]
from [**Hospital3 1810**] Plastic Surgery team. The plan is
for her to be seen at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40701**] at one
month of age, and surgery for repair of the cleft lip at
approximately three months of age.
4. Gastrointestinal: She has been treated with phototherapy
for physiologic hyperbilirubinemia. Her peak bilirubin on
[**2179-4-17**] was total 16.0, direct 0.3. Her bilirubin on the day
of discharge was
5. Hematology: Her hematocrit at the time of admission was
54, platelets 389,000. She has received no blood products
during this Newborn Intensive Care Unit stay.
6. Infectious Disease: Ampicillin and gentamicin were begun
at the time of admission for sepsis risk factors. The
antibiotics were discontinued after 48 hours when the blood
cultures remained negative and the infant was clinically
well.
The patient was found to be positive for vancomycin resistant
enterococcus on surveillance cultures done in the NICU 2 days
ago. The parents were informed of these results and informed
of the implications of this including the very low risk of any
clinical infection in their baby but the need to inform other
healthcare providers regarding the colonization status. It is
anticipated that this organism will most likely be cleared
from the GI tract over the next several months.
7. Sensory: Hearing screen was performed with automated
auditory brain stem responses, and the infant passed in both
ears.
8. Psychosocial: Mother has been very involved in the
infant's care throughout the Newborn Intensive Care Unit
stay.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The infant is being discharged home with
her parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of [**Hospital 2312**] Pediatrics, address [**Apartment Address(1) 41118**], [**Location (un) 538**], [**Numeric Identifier 41119**],
telephone number [**Telephone/Fax (1) 37109**].
CARE RECOMMENDATIONS:
1. Feedings: On an ad lib schedule, breast feeding or
Enfamil 20 calories/ounce.
2. Medications: The infant is discharged on no medications.
3. A state newborn screen was sent on [**2179-4-19**].
4. Immunizations received: The infant has received
hepatitis B vaccine on [**2179-4-19**].
5. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
6. Follow-up appointments:
a. Follow up with primary pediatric care provider within one
week of discharge.
b. Follow up with the Plastic Surgery team at [**Hospital1 **],
telephone number [**Telephone/Fax (1) 41120**], at one month of age.
DISCHARGE DIAGNOSIS:
1. Term female newborn
2. Status post transient tachypnea of the newborn due to
retained fetal lung fluid
3. Sepsis ruled out
4. Minor left cleft lip
5. Hyperbilirubinemia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2179-4-20**] 00:42
T: [**2179-4-20**] 00:59
JOB#: [**Job Number 41121**]
| 20,065 | 174,966 | V3000,7706,74912,7746,V289,V053 |
Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-22**]
Date of Birth: [**2179-4-14**] Sex: F
Service: Neonatology
ADDENDUM: This is an addendum to Discharge Summary signed on
[**4-22**].
Additional information revealed the bilirubin on the day of
discharge was 12.9 with a direct component of 0.3 after
receiving double phototherapy overnight. A follow-up
bilirubin will be checked on [**4-22**] at [**Hospital1 190**] in the Neonatal Intensive Care Unit at 10 a.m.
in the morning. The parents are aware of the need for this
follow-up bilirubin off of phototherapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern4) 41252**]
MEDQUIST36
D: [**2179-4-21**] 16:10
T: [**2179-4-21**] 15:23
JOB#: [**Job Number 41253**]
| 20,065 | 174,966 | V3000,7706,74912,7746,V289,V053 |
Admission Date: [**2108-10-28**] Discharge Date: [**2108-11-5**]
Date of Birth: [**2066-7-8**] Sex: F
Service: TRANSPLANT SURGERY
CHIEF COMPLAINT: Fever, nausea and vomiting.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 28926**] is a 42 year-old
female approximately seven weeks status post cadaveric renal
transplant with a postoperative course complicated by a
ureteral leak requiring nephrostomy tube placement and V.A.C.
care to wound as well as a line associated SVC syndrome
requiring Coumadinization. The patient subsequently was
discharged to a rehabilitation center, but now returned to
[**Hospital1 69**] on [**2108-10-28**]
with several day history of fevers, nausea, vomiting. Her
fevers were as high as 101.5. She also reported decrease in
her urine output for one week. Her wound care continued
with no notable signs of infection. The patient continued to
have bowel movements without any evidence of diarrhea. She
was without any abdominal pain, chest pain, shortness of
breath or any respiratory symptoms. At presentation in the
Emergency Department her systolic blood pressure was noted to
be in the 90s requiring intravenous boluses.
PAST MEDICAL HISTORY:
1. Diabetes mellitus insulin dependent.
2. End stage renal disease.
3. Hypertension.
4. Hypothyroidism.
5. Left line associated SVC syndrome requiring
thrombolectomy and Coumadinization.
PAST SURGICAL HISTORY:
1. Status post cadaveric renal transplant on [**2108-9-8**].
2. Status post Perm-A-Cath in the right IJ.
3. Status post AV fistula times three.
4. Status post stenting of the right brachiocephalic and
SVC.
5. Status post SVC thrombectomy on [**9-17**] and [**9-18**].
ALLERGIES: Floxins and Vancomycin.
SOCIAL HISTORY: She is divorced on disability. She denies
any ethanol or tobacco use.
MEDICATIONS ON ADMISSION:
1. Bactrim SS one tab po q day.
2. CellCept 1 gram po b.i.d.
3. Neurontin 100 mg po t.i.d.
4. Lansoprazole 30 mg po q day.
5. Valcyte 350 mg po q.o.d.
6. NPH 22 b.i.d.
7. Zinc 220 mg po q.d.
8. Coumadin 4 mg po q day.
9. Dulcolax 10 mg po b.i.d.
10. Prograf 2 mg po b.i.d.
11. Levoxyl 75 micrograms po q day.
12. Celexa 20 mg po q day.
13. Lipitor 10 mg po q day.
14. Percocet one to two tabs po q 4 to 6 hours prn pain.
15. Lopressor 75 mg po b.i.d.
16. Lasix 40 mg po q day.
17. Vitamin C 500 mg b.i.d.
18. Prednisone 0.5 mg po q day.
PHYSICAL EXAMINATION: Temperature 98.9. Blood pressure
131/46. Heart rate 91. Respiratory rate 17. She was 100%
on 4 liters nasal cannula. General, she was well developed,
well nourished lady in no acute distress. Head, eyes, ears,
nose and throat normocephalic, atraumatic. Anicteric.
Oropharynx without any lesions. They were moist. Neck was
supple. Heart regular rate and rhythm. Respirations clear
to auscultation bilaterally. Abdomen soft, nontender,
nondistended. Packed right lower quadrant wound. The wound
was without any purulent drainage on removal of the V.A.C.
Extremities there was noted for some left ankle skin ulcer.
LABORATORIES ON ADMISSION: White blood cell count 3.5,
hematocrit 37.1, platelets 155, sodium 136, potassium 5.0,
chloride 107, bicarb 18, BUN 42, creatinine 3.1, glucose 83.
[**Name (NI) 2591**] PT 20.8, PTT 37, INR 2.9. Her urinalysis was notable
for moderate amounts of leukocyte esterase, negative nitrite,
21 to 50 white blood cell and moderate bacteria. Chest x-ray
was negative. Renal ultrasound was obtained, which was
negative for hydro. There was no fluid collection. There is
normal arterial wave forms and normal resistive indices.
HOSPITAL COURSE: The patient is a 42 year-old female status
post cadaveric renal transplant on [**2108-9-8**] for end
stage renal disease secondary to diabetes mellitus who had a
postoperative course complicated by a ureteral leak requiring
nephrostomy as well as a V.A.C. to the wound. During that
hospital stay had a line associated SVC syndrome requiring
thrombolectomy. She returned from rehab on [**2108-10-28**]
to [**Hospital1 69**] with fevers and
nausea and vomiting as well as decreased urine output. She
was noted to have a positive urinalysis. Urine culture was
sent. She was initially kept in the Intensive Care Unit for
close monitoring for urosepsis. She was bolused and provided
with intravenous hydration and her blood pressure responded
appropriately. Her urine output improved. She was placed
initially on Zosyn for appropriate antimicrobial coverage.
Her urine culture was followed up, which indicated
Enterobacter cloacae, which was actually resistant to Zosyn
and sensitive to Levofloxacin. At that point she was
switched over to a 14 day course of Levofloxacin. The
patient continued with complaints of nausea and voting. Her
Prograf was discontinued and the patient was switched onto
Imuran and by the time of discharge she was on a 150 mg po q
day. Additionally, since admission the patient's Coumadin
dose had been held secondary to elevated INR, but by the time
of discharge the patient was placed on a Coumadin dose of 0.5
mg po q day and to have a regular biweekly laboratory blood
work drawn including close monitoring of her coagulation.
The patient underwent a nephrostogram, which indicated a
small anastomotic leak. It was thought that it would be best
to keep the nephrostomy tube open for another four weeks and
to repeat the study at that time. Renal function, however,
was improving and was noted to make adequate amount of urine
through the nephrostomy tube. By the time of discharge on
hospital day nine the patient was tolerating a regular diet.
Her nausea and vomiting had resolved and she continued to
make excellent urine output. She was on a immunosuppressant
regimen of Prednisone 5 mg po q day, Tacrolimus 1 mg po
b.i.d. as well as Imuran 150 mg po q day.
DISCHARGE STATUS: To rehabilitation center.
DISCHARGE DIAGNOSES:
1. Urosepsis/urinary tract infection.
2. Hydration.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg po q day.
2. Bactrim SS one tab po q day.
3. Celexa 20 mg po q day.
4. Colace 100 mg po b.i.d.
5. Valcyte 450 mg po q day.
6. Synthroid 75 micrograms one tab po q day.
7. Vitamin C 500 mg po b.i.d.
8. Zinc sulfate 220 mg one tab po q day.
9. Tylenol one to two tabs po q 4 to 6 hours prn.
10. Sulfa 500 mg one tab po b.i.d.
11. Prednisone 5 mg one tab po q day.
12. Albuterol one to two puffs inhalation q 6 hours prn.
13. Robitussin 5 to 10 ml po q 6 hours prn.
14. Reglan 10 mg one tab po t.i.d.
15. Levofloxacin 250 mg one tab po q day for eight more days
for a total of 14 days treatment.
16. Famotidine 200 mg one tab po q day.
17. Imuran 150 mg po q day.
18. Tequin one tab po b.i.d.
19. Percocet one to two tabs po q 4 to 6 hours prn.
20. Zofran 2 mg intravenously q 4 to 6 hours prn nausea and
vomiting.
21. Benadryl 150 mg intravenously q 6 hours prn.
22. Coumadin 0.5 mg one tab po q day.
23. Insulin sliding scale.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on
Monday [**2108-11-12**] at the Transplant Center, telephone
number [**Telephone/Fax (1) 673**] at 2:40 p.m. She is additionally to call
the Transplant Center for follow up appointments with Dr.
[**Last Name (STitle) **] as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She is additionally to
have laboratories biweekly including CBC, chem 10, [**Last Name (NamePattern1) **],
liver function tests, amylase, lipase as well as Tacrolimus
levels in the a.m. before the a.m. dose is given. She is to
continue to have V.A.C. treatment as well as nephrostomy care
at the rehabiltiatino center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (STitle) 28927**]
MEDQUIST36
D: [**2108-11-5**] 11:28
T: [**2108-11-5**] 11:32
JOB#: [**Job Number 28928**]
| 20,066 | 147,919 | 99681,70713,99674,5990,E8780,V5861,25000,4019,2449 |
Admission Date: [**2108-9-16**] Discharge Date: [**2108-10-12**]
Date of Birth: [**2066-7-8**] Sex: F
Service:
ADMITTING DIAGNOSIS: Superior vena cava syndrome.
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant on [**2108-9-8**].
2. Superior vena caval syndrome.
3. Distal ureter necrosis.
4. Status post revision of ureter bladder anastomosis.
HISTORY OF PRESENT ILLNESS: At the time of admission the
patient is a 42 year old female with a history of diabetes
mellitus type 1, end-stage renal disease who was on
hemodialysis prior to cadaveric renal transplant done on
[**2108-9-8**]. The patient also has a history of
hypertension, hypothyroidism, and a left lower extremity deep
vein thrombosis. The patient has a history of a Perma-Cath
and three arteriovenous fistulae. The patient also was found
out to have a history of a right brachiocephalic and superior
vena caval venous stent.
The patient presented to the [**Hospital1 188**] in the Emergency Department on [**2108-9-16**], with
demonstrable edema of the bilateral upper extremities and her
head and neck. The patient was without other complaints.
The patient was highly concerning for superior vena caval
syndrome. The patient was admitted to the Surgical Service.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1.
2. History of end-stage renal disease.
3. Status post cadaveric renal transplant on [**2108-9-8**].
4. Hypertension.
5. Hypothyroidism.
6. History of left lower extremity deep vein thrombosis.
7. Status post Perma-Cath placement.
8. History of arteriovenous fistulae times three.
9. It is unclear when it was placed but patient also had a
history of a right brachiocephalic and a superior vena caval
stent.
10. The patient at the time of admission had a right IJ
Perma-Cath which was placed in the superior vena cava.
PAST SURGICAL HISTORY:
1. Right internal jugular Perma-Cath.
2. History of arteriovenous fistula times three.
3. Status post cadaveric renal transplant, as stated on
[**2108-9-8**].
HOSPITAL COURSE: The patient was admitted to the hospital
and at the time of admission, the patient was afebrile; blood
pressure was 143/53. The patient's admission laboratory
examination revealed a white blood cell count of 14.0,
hematocrit of 33, platelets of 151. Sodium 136, potassium
4.4, chloride 104, carbon dioxide of 16, BUN of 102,
creatinine of 5.1 which is down from a creatinine of 5.5 at
the time of discharge from her cadaveric renal transplant.
Glucose was well controlled at 56.
The patient underwent an ultrasound which showed dilation of
both of her internal jugular veins. The patient had an MRV
which demonstrated left IJ and bilateral brachiocephalic vein
and a superior vena caval thrombus. The patient also, on
chest x-ray, demonstrated a stent within her right
brachiocephalic and superior vena cava. It is unclear when
these were placed.
The [**Hospital 228**] hospital course included angiogram done on the
20th with thrombectomy. This did not completely remove all
of the clot. The patient was treated with repeat angiogram
on the 21st with stenting and thrombectomy of the clot from
the superior vena cava, brachiocephalic and internal jugular
with modest return of flow and removal of her Perma-Cath.
A few days later the patient was taken back down to angiogram
where the patient had recanalization of all of her central
veins in her neck with good return of flow, and the patient
had a dramatic clinical response with resolution of her upper
extremity swelling and edema. The patient was treated with
heparin and then Coumadinized.
The patient was also noted on her hospital stay to have a
large amount of fluid coming from her wound. The wound was
opened down to the level of the fascia. Creatinine in the
fluid was consistent with a urine leak. The patient was
taken down to Interventional Radiology where she had a
nephrostomy tube placed which demonstrated stricturing of the
distal ureter.
Of note, it should be stated at the time of the kidney
transplant, it was noted that the Transplant Team had
transsected a lower polar artery that was probably supplying
the bladder which was probably supplying the ureter and this
was the reason for the necrosis of the distal end of the
ureter.
Interventional Radiology had a stent placed through the
distal stricture and into the bladder. The patient was taken
to the Operating Room on the [**9-26**] for a upper
ureteral bladder anastomosis. At the time of the operation,
the previous ureteral anastomosis of the bladder was
identified. This was taken down sharply. Previously, the
necrotic and ischemic ureter was transsected. A new ureter
to bladder anastomosis was performed in good fashion.
The patient, postoperatively, did well. The large wound was
treated with a wound VAC which was changed every two to three
days. The [**Location (un) 1661**]-[**Location (un) 1662**] which was placed at the time of the
surgery decreased in output and once there was no further
evidence of leak, the [**Location (un) 1661**]-[**Location (un) 1662**] creatinine was normal.
The [**Location (un) 1661**]-[**Location (un) 1662**] was removed.
The patient was seen and evaluated by Physical Therapy. The
patient was ambulatory but could not meet reasonable goals
and therefore was felt to an adequate candidate for further
rehabilitation work at rehabilitation hospital.
The patient was tolerating a regular diet. The wound was
cleaning up nicely with a wound VAC. The patient was on
Coumadin, and the patient was placed back on therapeutic
levels of her immunosuppressants.
At the time of discharge, the patient had a repeat renal
duplex on the [**2108-10-8**]. Resistant indices at
0.7 with normal flow already in the veins. The patient's
creatinine which had risen, at the time of discharge was down
to 3.7, which is the lowest point it had been so far.
Therefore, discharge diagnosis included the following.
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant on the [**2108-9-8**].
2. Severe vena caval syndrome secondary to occlusion,
secondary to a Perma-Cath in the superior vena cava and
stent.
3. Status post angiographic thrombectomy of the central
veins of the neck.
4. Distal ureteral necrosis.
5. Status post revision of ureteral bladder anastomosis.
6. Opening of transplant wound treated with wound VAC.
DISCHARGE MEDICATIONS:
1. Coumadin 2 mg p.o. q. h.s.
2. Lanosolid 600 mg p.o. q. 12.
3. Zinc sulfate 220 mg p.o. q. day.
4. Lasix 40 mg p.o. twice a day.
5. Insulin sliding scale.
6. Metoprolol 75 mg p.o. twice a day.
7. Fancyclovir 450 mg p.o. q.o.d.
8. Pantoprazole 30 mg p.o. q. day.
9. Atorvastatin 10 mg p.o. q. day.
10. Gabapentin 100 mg p.o. three times a day.
11. Artificial tears o.u. p.r.n.
12. Synthroid 75 micrograms p.o. q. day.
13. Single strength Bactrim one tablet p.o. q. day.
14. Her immunosuppressant medications which include
Prednisone 10 mg p.o. q. day; Mycophenolate mofetil 100 mg
p.o. twice a day and Prograf 4 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. Wound therapy q. day. Dressings include a wound VAC
which should be changed every two days to the right lower
quadrant wound incision.
2. The patient's follow-up will include an appointment with
Dr. [**Last Name (STitle) 28924**] in the Transplant Office on Tuesday, the 18th.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 14369**]
MEDQUIST36
D: [**2108-10-12**] 15:45
T: [**2108-10-12**] 17:58
JOB#: [**Job Number 28925**]
| 20,066 | 150,208 | 99674,99681,5849,25001,5990,E8798,4592,E8781,E8780 |
Admission Date: [**2194-6-28**] Discharge Date: [**2194-7-16**]
Date of Birth: [**2176-9-4**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Traumatic amputation left foot
Major Surgical or Invasive Procedure:
1. Left anterior lateral thigh free fasciocutaneous flap to
the left dorsal foot.
2. Debridement of skin and muscle of the left foot.
3. Neurorrhaphy of the superior and median perforator nerves
from the anterolateral thigh to the superficial peroneal
nerve of the foot.
4. Local advancement flap closure of anterior thigh defect.
5. Local advancement flap elevation of left foot plantar
skin.
History of Present Illness:
17 yo M transferred from an outside hospital on [**2194-6-28**] after a
traumatic amputation of his left foot by a lawnmower. After
initial debridement of the wound in NH, Mr. [**Known lastname 67756**] was sent
to [**Hospital3 **] for additional deep debridement and flap coverage
of his wound.
Past Medical History:
Otherwise healthy
Social History:
Occ. ETOH.
Recently quit smoking.
Occasional marijuana prior to admission.
No IVDU.
Lives with girlfriend's parents in NH.
High school student.
Family History:
Non-contributory.
Physical Exam:
GEN: A&O, NAD, pleasant
HEENT: Visual acuity equal and intact bilat., EOMI, PERRLA
CV: RRR
PULM: CTA bilat.
ABD: soft, nt/nd
EXT: L extremity splinted, elevated. Flap wwp, cap refill <2sec,
strong doppler. Wound edges c/d/i. Graft site healing well.
Pertinent Results:
[**2194-6-28**] 07:20PM PLT SMR-VERY HIGH PLT COUNT-646*
Brief Hospital Course:
17 yo M transferred from an outside hospital on [**2194-6-28**] after a
traumatic amputation of his left foot by a lawn mower. After
initial debridement of the wound in NH, Mr. [**Known lastname 67756**] was sent
to [**Hospital3 **] for additional deep debridement and flap coverage
of his wound. He underwent debridement with orthopedics on [**6-30**]
without complication. He was returned to the OR for definitive
flap coverage on [**2194-7-2**] and transferred to the plastic surgery
service. He was noted to have a corneal abrasion
post-operatively and was treated to resolution by ophthalmology.
Mr. [**Known lastname 67756**] did well post-operatively with no evidence of flap
failure and was discharged home with services after PT/OT
evaluation and patient education on flap dangle protocol.
Medications on Admission:
None.
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
2. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-10**]
hours as needed for Pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
Disp:*20 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*80 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Name6 (MD) 67757**] [**Name8 (MD) **] RN ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67758**]) to set up
Discharge Diagnosis:
Traumatic amputation of left foot
Status post flap repair of wound.
Discharge Condition:
Stable.
Discharge Instructions:
Please resume your home medications. Call or return to the
hospital if you experience: fever > 100.8F, increasing or foul
smelling drainage from your wound, significant color or
temperature change to your flap, increasing pain any significant
change in your medical condition.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week.
| 20,067 | 140,991 | 8961,E9200,9181,E9289,3536 |
Admission Date: [**2145-4-30**] Discharge Date: [**2145-5-6**]
Service: NEUROLOGY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
confusion, aphasia, right facial droop
Major Surgical or Invasive Procedure:
CT/CTA head and neck
iv-tPA
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with a history of Afib (not on
coumadin), prior strokes ([**2131**], [**2133**]) details of which are
unknown, HTN and recent right arm fracture and osteotomy who
developed "confusion", decreased verbal output and right facial
droop this AM at her NH. She was well this AM until she went to
the bathroom at the NH just before 8:00AM. At that time, she
was
noted to have decreased verbal output (which is unusual for her)
completely non-verbal with a right facial droop. EMS was called
and she arrived in the ER at 9:50AM. She was initially evaluated
by the stroke fellow who found her to be awake, non- verbal,
following simple commands, with right facial droop and right
hemiparesis. Her initial NIHSS was 12. She had a CT Scan at
which
showed no evidence of hemorrhage or infarction. CTA showed no
large branch occlusions in the intracranil circulation. She was
given IV t-PA at 11:00 AM, 3 hours after symptom onset.
Past Medical History:
PAF not on anticoagulation
Tachy-Brady Syndrome
HTN
dyslipidemia
h/o CVA ('[**31**], '[**33**])
Urinary incontinence
Diastolic CHF (EF >60% 9/04)
Social History:
Lives alone in own Sr. apartment. Does own housework, but
decreased function lately. Has VNA home care. Never married. No
HCP.
Family History:
Non-contributory
Physical Exam:
Admission Exam: T 98.0 BP 134/71 HR 120irreg RR20 O2 Sat 90%
Gen: Resting on ED stretcher, appears somewhat agitated
Neck: supple, no carotid bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: +left basilar crackles, decreased BS at right base
aBd: +BS soft, nontender
ext: + 1 pedal edema
Neurologic examination:
Mental status: Awake and alert, unable to state name, follows
simple, one step midline and appendicular commands. Practically
non-verbal, though tries to initiate speech; occasionally able
to
say yes or no. Unable to repeat single words or name any items.
Does not appear to understand complex commands or questions.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
Visual fields appear full to threat (could not comply with
confrontation testing). Extraocular movements intact bilaterally
without nystagmus. Sensation to noxious appears intact V1-V3.
Right facial droop. Tongue deviated to right (? due to facial).
Tongue midline without fasciculations, intact movements
Motor:
Normal bulk bilaterally. Tone slightly increased in right LE. No
adventitious movements. Unable to comply with formal motor
testing, but could hold left arm and leg antigravity and right
leg antigravity for >10 seconds. Moved Right UE on the bed (at
least [**1-23**]).
Sensation: Withdraws to pinch in all 4 extremities.
Reflexes:
B T Br Pa Ach
Right 2 2 * 2 2
Left 2 2 2 2 2
Rflxs slightly more brisk on the right
Toes were downgoing bilaterally
Coordination: Unable to assess (pt doesn't appear to understand
task)
Pertinent Results:
MRA BRAIN W/O CONTRAST [**2145-5-2**] 11:12 AM
FINDINGS: Abnormal diffusion is noted in the posterior left
frontal lobe in the precentral gyrus region, consistent with
acute stroke.
Subacute/chronic infarct is noted in the right cerebellar region
as evidenced by abnormal signal on T2 and FLAIR images with
shine through artifact on diffusion-weighted images.
Patchy areas of hyperintensity are noted in the periventricular
deep white matter consistent with a small vessel disease.
A punctate area of susceptibility abnormality is noted in the
right cerebellum, may represent tiny calcification versus tiny
punctate hemorrhage.
IMPRESSION:
1) Acute infarct is noted in the left posterior frontal lobe.
2) Subacute/chronic infarct noted in the right cerebellum.
CTA HEAD W&W/O C & RECONS [**2145-4-30**] 10:30 AM
COMPARISON: [**2145-3-25**].
FINDINGS: There is no intracranial hemorrhage, shift of normally
midline structures, or hydrocephalus. The ventricles and sulci
remain enlarged, consistent with atrophy. There is low
attenuation of the periventricular white matter consistent with
chronic microvascular infarction. The [**Doctor Last Name 352**]-white matter
differentiation remains intact. There is no evidence of a new
major vascular territorial infarct. The osseous structures are
normal. There are several right maxillary sinus mucosal
retention cysts versus polyps.
IMPRESSION: No intracranial hemorrhage or change in the
appearance of the brain. Please note that an MRI with
diffusion-weighted imaging is more sensitive for detection of an
acute infarct.
[**2145-4-30**] 10:15AM GLUCOSE-119* UREA N-26* CREAT-1.0 SODIUM-140
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-33* ANION GAP-16
[**2145-4-30**] 10:15AM CK(CPK)-19*
[**2145-4-30**] 10:15AM CK-MB-2 cTropnT-<0.01
[**2145-4-30**] 10:15AM CHOLEST-222*
[**2145-4-30**] 10:15AM %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE
[**2145-4-30**] 10:15AM TRIGLYCER-138 HDL CHOL-63 CHOL/HDL-3.5
LDL(CALC)-131*
[**2145-4-30**] 10:15AM WBC-10.7 RBC-4.58 HGB-13.4 HCT-39.5 MCV-86
MCH-29.1 MCHC-33.9 RDW-14.4
[**2145-4-30**] 10:15AM PLT COUNT-219
[**2145-4-30**] 10:15AM PT-12.9 PTT-25.7 INR(PT)-1.1
Brief Hospital Course:
After IV-tPA administration Pt was observied in the Neurological
ICU x48 hours during which time there was limited improvement in
her presenting symptoms. She was transferred to the general
Inpatient Stroke Service where bedside swallowing evaluation
proved her incompetent to handle PO but unfortunately would not
allow for NG-tube placement. In addition, prior to discharge
she was evaluated by Speech Pathology. After some discussion
with the family and medical care team, the decision was made to
transfer to an extened care facility for further care.
Medications on Admission:
Lasix 60mg qd
Plavix 75 qd
Diltiazem 180mg qd
Colace 100mg [**Hospital1 **]
Toprol 100mg qd
Lisinopril 2.5mg qd
Zaroxolyn 2.5mg qd 30min prior to lasix
Discharge Medications:
Lasix 60mg qd
Plavix 75 qd
Diltiazem 180mg qd
Colace 100mg [**Hospital1 **]
Toprol 100mg qd
Lisinopril 2.5mg qd
Zaroxolyn 2.5mg qd 30min prior to lasix
Discharge Disposition:
Extended Care
Discharge Diagnosis:
left MCA infarct
pulmonary effusion
Discharge Condition:
guarded
Discharge Instructions:
Take all medications as prescribed.
Follow-up with all appoinments as directed.
Followup Instructions:
Follow-up with your primary care physician on discharge.
Completed by:[**2146-8-2**] | 20,068 | 190,986 | 43411,51881,42831,5119,42731,5070,4019,43811 |
Admission Date: [**2186-9-16**] Discharge Date: [**2186-10-6**]
Date of Birth: [**2127-6-21**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 F car vs tree with unstable T4 fx involving all 3 columns
with compression, T7 fracture, sternal fracture s/p transfer to
the ICU with intubation for worsening sats and collapse of lower
lobes on chest CT
Past Medical History:
asthma, COPD
Social History:
Smoker, no drugs, occasional EtOH
Family History:
non-contributory
Physical Exam:
upon arrival in ER:
96 85 105/64 18 95%on 3L
HEENT: R lateral canthus laceration
NEck: C-collar in place
Chest: CTAB, RRR
Abd: Sort, NT, ND
Pelvis: stable
GU: Guiac neg
Ext: [**5-4**] stregnth b/l LE's, no deformities or ecchymosis
Pertinent Results:
[**2186-9-16**] 06:40AM NEUTS-84.2* BANDS-0 LYMPHS-12.1* MONOS-2.5
EOS-0.9 BASOS-0.3
[**2186-9-16**] 06:40AM WBC-12.8* RBC-3.66* HGB-12.3 HCT-36.2 MCV-99*
MCH-33.6* MCHC-34.0 RDW-13.6
[**2186-9-16**] 06:40AM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-1.6
[**2186-9-16**] 06:40AM LIPASE-54
[**2186-9-16**] 06:40AM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-66
AMYLASE-34 TOT BILI-0.4
[**2186-9-16**] 06:40AM GLUCOSE-112* UREA N-7 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
[**2186-9-16**] 08:20PM HCT-36.7
RADIOLOGY Final Report
CT RECONSTRUCTION [**2186-9-16**] 7:15 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: high speed [**Month/Day/Year 39447**] with sternal fracture and T4 fracture.
Would
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with
REASON FOR THIS EXAMINATION:
high speed [**Hospital 39447**] with sternal fracture and T4 fracture. Would like
to evaluate chest and abdomen with IV contrast. NO PO contrast.
CONTRAINDICATIONS for IV CONTRAST: None.
CT SCAN OF THE CHEST, ABDOMEN AND PELVIS WITH CONTRAST DATED
[**2186-9-16**].
CLINICAL HISTORY: Status post high speed [**Month/Day/Year 39447**] with sternal
fracture and T4 fracture. Please evaluate chest and abdomen with
IV contrast.
TECHNIQUE: CT scan evaluation of the chest, abdomen and pelvis
was performed with IV contrast using 5 mm collimation. Images
were reformatted and evaluated in both the coronal and sagittal
planes.
COMPARISON: Comparison is made to prior CT scans of the
cervical, thoracic and lumbar spines.
FINDINGS: There is a nondisplaced fracture through the
manubrium. A small amount of retromanubrial hematoma is
identified.
As seen in the recent CT examination, there is a complex
fracture involving the T4 vertebral body. There is approximately
80% compression of this vertebral body and 25 degrees of
kyphosis at this level. Bilateral pars fractures are also
identified at T4, representing posterior column injury. Moderate
canal narrowing and angulation is noted at this level. A small
amount of paraspinal hematoma is noted.
There is also a compression fracture involving the T7 vertebral
body with approximately 30% loss of vertebral body height. The
fracture does not appear to extend to the posterior column. No
significant canal narrowing is identified at this level.
There is no evidence for mediastinal hematoma. The aorta is
normal in contour and there is no evidence for contrast
extravasation. Heart and great vessels are unremarkable.
There are small bibasilar consolidations and small bilateral
effusions. No significant lymphadenopathy is identified within
the chest.
The liver, gallbladder, pancreas, spleen and adrenal glands are
unremarkable. Both kidneys enhance symmetrically and are
otherwise unremarkable. There is no free fluid or significant
lymphadenopathy within the abdomen or pelvis. A Foley catheter
is noted within the bladder.
IMPRESSION:
1. Nondisplaced fracture through the manubrium.
2. Complex fracture involving the T4 vertebral body with
involvement of the posterior column and 25 degrees of kyphosis.
This results in moderate narrowing and angulation of the spinal
canal at this level.
3. Compression fracture involving the T7 vertebral body with
loss of approximately 30% of vertebral body height.
4. No evidence for aortic injury.
5. No evidence for free fluid in the abdomen or pelvis.
Findings were discussed with Dr. [**Last Name (STitle) 62533**] at the time of the
examination.
The study and the report were reviewed by the staff radiologist.
DR. [**Known lastname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 62534**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: SUN [**2186-9-17**] 8:35 AM
RADIOLOGY Final Report
CT T-SPINE W/O CONTRAST [**2186-9-16**] 7:18 AM
CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: evaluate known T4 fx
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman s/p MVA
REASON FOR THIS EXAMINATION:
evaluate known T4 fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 59-year-old female status post MVA with T4 acute
fracture.
COMPARISONS: No comparisons are available.
TECHNIQUE: Multiple CT axial images of the thoracic spine were
obtained without IV contrast. Coronal and sagittal reformations
were performed. Coronal and sagittal reformations of the sternum
were also performed.
FINDINGS: There is compression fracture of T4 with retropulsion
of the superior corner of the body into the spinal canal. There
are bilateral fractures at the bases of the pedicles, pars
interarticularis and transverse processes and the left lamina.
There is approximately 25% narrowing of the canal. There is 30
degrees of kyphosis.
There is also a mild compression fracture of the T7 vertebral
body. No other thoracic spine fractures were identified. The
spinal canal contents are not well evaluated.
There are small paraspinal hematomas associated with the above-
described fractures.
IMPRESSION:
1. Unstable fracture of T4 with features as discussed above.
2. Compression fracture of T7
3. Subjacent to the xiphoid process of the sternum is a small
density, probably a vein, but there could be a small hematoma.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**]
DR. [**First Name (STitle) 23303**] [**Doctor Last Name **]
Approved: MON [**2186-9-18**] 8:25 AM
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2186-9-18**] 5:14 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: HYPOXIA, EVAL FOR PE
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with h/o asthma, COPD; admitted to hosp
following [**Last Name (LF) 39447**], [**First Name3 (LF) **] spine fracture now with hypoxia and left
pulmonary artery fullness on CXR.
REASON FOR THIS EXAMINATION:
PE?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 59-year-old female with asthma admitted status post
[**First Name3 (LF) 39447**] now presenting with hypoxia, left pulmonary artery fullness
on the chest x-ray.
COMPARISON: Comparison is made to [**2186-9-16**].
TECHNIQUE: MDCT axial images of the chest were obtained without
and with IV contrast. Nonionic IV contrast was used as a rapid
bolus as necessary for this study. 100 cc of Optiray 250 were
used.
Multiplanar reconstructions were performed.
CT OF THE CHEST: There are no significant axillary lymph nodes.
There are multiple small AP window lymph nodes that do not meet
CT criteria for pathology. There is no pericardial effusion. The
heart is mildly enlarged. The aorta appears to be intact. The
pulmonary artery is slightly enlarged measuring 2 cm, which may
represent chronic pulmonary artery hypertension. Clinical
correlation is recommended. This is unchanged to [**2186-9-16**]. The pulmonary artery branches are patent. There are no
filling defects which suggest pulmonary embolism. There are mild
calcifications of the coronary arteries. The suggestion of
enlargement of the left pulmonary artery as seen in the chest
radiograph is likely due to atelectasis of left upper lobe
posteriorly and superior segment of left lower lobe. The
appearance of the pulmonary artery is unchanged compared to the
prior study.
Examination of the lung windows again demonstrate paraseptal
emphysema with multiple subpleural blebs. There is interval
worsening of the atelectasis of the posterior aspect of the
bilateral upper lobes and lower lobes. There is basically
complete atelectasis of the bilateral lower lobes. Most of the
segmental branches, however, are patent with the exception of
the superior segment of the left lower lobe where you can see an
abrupt cut off.. There are very small bilateral pleural
effusions. There are minimal atelectasis in the right middle
lobe.
Limited images of the upper abdomen do not demonstrate
significant abnormality.
BONE WINDOWS: Again noted complex unstable fracture of T4 which
is unchanged in appearance when compared to the prior study. The
degree of angulation also appears to be unchanged. As is the
narrowing of the spinal canal. Note that this fracture involves
the anterior, medial and posterior columns as described in
detail in the CT of the thoracic spine. Also the appearance of
the compression fracture of T7 is also unchanged when compared
to the prior study. No definite sternal fracture can be seen.
Multiplanar reconstructions were important to better evaluate
the bone alignment.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. The apparent enlargement of the left pulmonary artery is
secondary to the overlapping of the atelectasis of the posterior
aspect of the left upper lobe and superior segment of the left
lower lobe.
3. Interval worsening of bilateral atelectasis involving the
posterior aspect of the upper lobes and the bilateral lower
lobes. This is described above in detail.
4. Unchanged appearance of fractures of the thoracic spine.
5. The aorta is intact.
6. Mildly enlarged main [**MD Number(3) 62535**] be secondary to pulmonary
artery hypertention. It is unchanged when compared to the prior
study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: TUE [**2186-9-19**] 10:10 AM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2186-9-26**] 11:19 AM
CHEST (PORTABLE AP)
Reason: consolidation?
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with hypoxia and productive cough
REASON FOR THIS EXAMINATION:
consolidation?
INDICATION: Hypoxia, cough.
COMPARISON: Chest x-ray from [**2186-9-19**].
SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: There is
persistent left lower lobe collapse with an associated small
left pleural effusion. There is right lower lobe atelectasis
with a small right pleural effusion. There is no pneumothorax.
The cardiac and mediastinal contours are within normal limits.
Spinal stabilization device obscures the midline chest.
IMPRESSION: Persistent lower lobe atelectasis, left worse than
right with associated small bilateral pleural effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2186-9-26**] 8:51 PM
Brief Hospital Course:
60 F car vs tree transferred to [**Hospital1 18**] ER from OSH. Pt. was
immediately evaluated by the Emergency Medicine and Trauma
Surgery teams. CT scans during initial evaluation revealed an
unstable T4 fx involving all 3 columns with compression, T7
fracture, and a manubrium fracture. The pt. was kept immobilized
and put on log roll precautions, and orthopedics-spine service
was consulted. The pt. was admitted to the step down unit for
decreased O2 sats due to COPD,asthma, started on CIWA protocol,
given asthma meds and aggressive pulmonary toilet. Pt. was
subsequently intubated for decreasing O2 sats and increasing O2
demand and sent to TSICU for management. Pulmonary service was
consulted who recommended continued chest PT and steroid
administration. Ortho-spine service changed plan at this time
from operative to non-operative management of unstable T-spine
fractures considering pt's pulmonary status. Pt. to remain in
TLSO brace at all times. Pt had repeated pulm eval including a
CTA that was negative for thrombus, but showed bilateral
collapse of lower lobes with effusions. Pt.'s respiratory
status slowly improved over course with eventual uneventful
extubation and transfer to step down and then to floor with
increasing saturations and decreasing O2 demand. She was treated
with Levofloxacin for a presumed pneumonia and developed
diarrhea at the end of this 7 day course. Stool specimen x3 for
C-diff were obtained and sent; thus far 2 cultures have come
back as negative; the 3rd specimen pending at time of this
report. Imodium has been started after 2nd negative report came
back. Pt. also became delirious over length of hospital stay,
but with increased O2 status, mental status has slowly improved.
Pt. has been on regular floor for a number of days off any O2,
satting well, clear mental status, and has been receiving daily
PT. Pt. ready for d/c to rehab facility for continuation of PT
and respiratory therapy. Pt. to follow up with ortho-spine and
orthopedics after her discharge. Her home regimen of Wellbutrin,
Spiriva, Singulair, Advair and prn Albuterol MDI were restarted
prior to her discharge.
Medications on Admission:
albuterol
Spiriva
Advair
Singulair
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB/wheezing.
Disp:*1 1* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Wellbutrin 100 mg Tablet Sig: 1 [**1-1**] Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 26478**] - [**Location (un) 1157**]
Discharge Diagnosis:
s/p Motor vehicle crash
T4 compression fracture
T7 fracture
Sternal fracture
Discharge Condition:
Stable
Discharge Instructions:
Keep your brace on at all times!
Followup Instructions:
1) Please make an appointment to follow up with the ortho-spine
service in clinic in 3 weeks: [**Telephone/Fax (1) 3573**]
2) Please make an appointment to follow up with the trauma
surgery service in clinic in 3 weeks: [**Telephone/Fax (1) 6439**]
3) Follow up with your primary doctor, Dr. [**Last Name (STitle) 37133**] after your
dicharge; you will need to have an evaluation by a
Pulmonologist; this referral will need to be made by your PCP.
4) Follow up with your primary Allergists after your discharge.
Completed by:[**2186-10-6**] | 20,069 | 156,229 | 8072,8052,5185,486,49320,30500,2763,8509,E8150,3051,3079,78791,V1079 |
Admission Date: [**2137-11-26**] Discharge Date: [**2137-12-1**]
Date of Birth: [**2084-9-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25342**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Endoscopic Gastroduodenoscopy with Biopsy
Temporary Dialysis catheter placement in Right Femoral Vein
PICC line placement
History of Present Illness:
Patient is a 52yo F with HIV/HCV coinfection (not on Haart, CD4
250s, VL 4K), ESRD on HD - admitted with fever to 104.9. She did
not have any pain or cough or urinary/bowel sx.
HD stopped early today due to fevers, given vanco there. Here in
ED given levo/flagyl/vanco, also recieved gent.
Patient has tunnel cath-- recent stripping at [**Hospital1 2177**] 1 wk ago.
Patient had a recent admission for esophagitis and [**Doctor First Name 329**] [**Doctor Last Name **]
tear for which she was treated with fluc. and acyclovir (d/c'd
[**11-15**]).
In ed, cxr was neg, blood cx were taken, patient rec'd
vanc,levo,flagyl, gent x 1. Also rec'd vanc at dialysis.
Past Medical History:
HIV: Diagnosed approximately 6 years ago. Never been on
antiretroviral therapy. No history of opportunistic
infections. No other HIV associated complications.
Hepatitis C
Hepatitis B
Hypertension
End-stage renal disease: hypertensive nephrosclerosis. Gets
hemodialysis on Tuesday, Thursday, and Saturdays. Has
previously been on peritoneal dialysis but that
was changed to hemodialysis approximately 1-2 years ago,
secondary to complications of peritonitis.
Status post burn injury to lower anterior abdomen.
Sigmoid colon polyp: Status post polypectomy on
[**2136-4-30**], pathology showing adenoma with high-grade dysplasia.
No evidence of invasive carcinoma.
Social History:
Hx of tobacco, denies alcohol or IVDU. Pt says she contracted
HIV after being raped several years ago.
Family History:
No history of diabetes, coronary artery disease, kidney disease,
or liver disease. History of colon cancer in her father who
died when she was very young.
Physical Exam:
Temperature 97.7
HR 60 BP 110/66 (113-137)/(66-74) P 56-62 o2 100% RA
I/O= 90/0
GENERAL: NAD
HEENT: Oropharynx is clear without blood or petechia. No
thrush. No scleral icterus.
NECK: Supple. tunneled IJ
CARDIOVASCULAR: Normal S1, S2. Regular rate and rhythm. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft/nontender/nondistended. No rebound/guarding. No
masses. No peritoneal signs. No organomegaly. Positive bowel
sounds.
EXTREMITIES: Warm and well perfused. +2 bilateral radial and
DP pulses. Symmetric pulses.
SKIN: No rashes or other lesions noted.
NEUROLOGIC: Alert, awake, oriented x3. Motor and sensory
grossly nonfocal.
Pertinent Results:
MICRO:
[**2137-11-26**] 1:30 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2137-11-30**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2137-11-27**] AT 9:25AM.
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
PSEUDOMONAS AERUGINOSA. 2ND MORPHOLOGY. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S 2 S
CEFTAZIDIME----------- 4 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ 2 S 2 S
IMIPENEM-------------- 2 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
ANAEROBIC BOTTLE (Pending):
.
[**2137-11-26**] 2:00 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2137-11-29**]):
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES PERFORMED ON CULTURE # 221-4221M
[**2137-11-26**].
ANAEROBIC BOTTLE (Pending):
.
[**2137-12-1**] 6:45 am SEROLOGY/BLOOD
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
.
Cardiology Report ECHO Study Date of [**2137-11-30**]
PATIENT/TEST INFORMATION:
Indication: ? Endocarditis.
Height: (in) 65
Weight (lb): 122
BSA (m2): 1.60 m2
BP (mm Hg): 140/90
HR (bpm): 63
Status: Inpatient
Date/Time: [**2137-11-30**] at 11:40
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.67
Mitral Valve - E Wave Deceleration Time: 243 msec
TR Gradient (+ RA = PASP): <= 20 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.8 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter
with >50% decrease collapse during respiration (estimated RAP
5-10 mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter.
AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Calcified tips of papillary muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Echocardiographic results were reviewed by
telephone with
the houseofficer caring for the patient.
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure [**4-17**]
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Right ventricular chamber
size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened
with a 5mm non-mobile echodensity suggested on the LVOT side of
the
non-coronary leaflet c/w a possible vegetation. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets and
supporting structures are mildly thickened. There is trivial
mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Possible vegetation on the aortic valve without
evidence for
aortic regurgitation.
If clinically indicated, a TEE would be better able to define
the aortic valve
morphology.
CLINICAL IMPLICATIONS:
Based on [**2127**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a low risk (prophylaxis not recommended).
Clinical decisions regarding the need for prophylaxis should be
based on clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2137-11-30**]
14:00.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.
.
DISCHARGE LABS:
[**2137-12-1**] 06:45AM BLOOD WBC-2.5* RBC-3.52* Hgb-11.2* Hct-33.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.7 Plt Ct-219
[**2137-12-1**] 06:45AM BLOOD Neuts-45* Bands-0 Lymphs-32 Monos-18*
Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2137-12-1**] 06:45AM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-NORMAL Schisto-OCCASIONAL Burr-OCCASIONAL
[**2137-12-1**] 06:45AM BLOOD PT-12.2 PTT-32.0 INR(PT)-1.0
[**2137-12-1**] 06:45AM BLOOD Gran Ct-1020*
[**2137-12-1**] 06:45AM BLOOD Glucose-85 UreaN-27* Creat-11.7*# Na-135
K-4.0 Cl-96 HCO3-26 AnGap-17
[**2137-12-1**] 06:45AM BLOOD Albumin-3.5 Calcium-10.7* Phos-4.2 Mg-2.3
[**2137-12-1**] 06:55AM BLOOD Genta-2.5*
Brief Hospital Course:
53 y/o female with HIV, Hep B, Hep C, HTN, ESRD on HD, with
pseudomonal bacteremia, blood cultures quickly cleared, on gent
and ceftaz, with evidence of possible aortic valve vegitation on
TTE.
.
1. Pseudomonal Bacteremia: Blood cultures positive on [**2137-11-26**].
Cleared the next day. Remained clear for several more days.
Discharged on gentamycin and ceftazapime. TTE showed possible
aortic valve vegitation. She will need TEE on Tuesday [**2137-12-3**]
and course of antibiotics (to be given with HD) to be determined
by result of TEE. Likely will need at least six weeks.
.
2. ESRD: Temporary dialysis line placed Sunday by surgery.
Dialysed sunday. Line removed before discharge. Next dialysis
should be Tuesday [**2137-12-3**]. She is scheduled for a tunneled
line, to be done Tuesday [**2137-12-3**] by IR. Her nephrologist is
[**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**].
.
3. HTN: Controled on 5 mg Lisinopril. Metoprolol XL 100 mg QD
was held initially because of hypotension and restarted on
discharge.
.
4. HIV: Last CD4 248. Not on HAART. Needs follow up with [**First Name8 (NamePattern2) 1059**]
[**Last Name (NamePattern1) 1057**].
.
5. Hep B/Hep C: Stable. Needs to follow upo with [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**].
.
6. Leukopenia: Trending down. Monocytosis. Not neutropenic
(ANC>1000). Needs CBC checked to ensure trend of WBC count.
.
7. Anemia: Newly anemic this admission. She is iron deficient,
but has a high ferritin and low TIBC consistant with ACD. Needs
CBC to trend Hct.
.
8. Esophagitis on EGD: Continued on [**Hospital1 **] Pantoprazole. H. pylori
serology positive on [**2137-11-11**]. Had H. pylori serology resent and
needs to be followed up. Needs esophageal biopsy results
followed up.
Medications on Admission:
Medications at home:
Lisinopril 5mg QD
Nephrocaps
Renalgel/Sevelamer 800 mg Tablet Sig
Metoprolol XL 100 mg po qd
.
Discharged [**2137-11-15**] additionally on:
Pantoprazole 40mg [**Hospital1 **]
Carbamide Peroxide 6.5 % Drops
Acyclovir 200 mg Capsule Capsule PO Q24H
Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q48H
Discharge Medications:
1. Gentamicin in Normal Saline 60 mg/50 mL Piggyback Sig: Sixty
(60) mg Intravenous QHD (each hemodialysis) for 6 weeks.
2. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous QHD (each hemodialysis) for 6 weeks.
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
please check with gastrointestinal doctor before stopping.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pseudomonal Bacteremia secondary to Dialysis Line Infection
Aortic Valve Endocarditis
Leukopenia
Anemia
Esophagitis
Secondary Diagnosis:
End Stage Renal Disease
Hypertension
HIV
Hepatitis C
Hepatitis B
Discharge Condition:
Afebrile. O2 saturation of 100%. Dialysed Sunday [**2137-12-1**].
Ambulatory.
Discharge Instructions:
You had an infection in your blood which may have caused
bacteria to attach to your heart valve.
If you notice fever or chills, please call your doctor or come
to the emergency room for evaluation.
Please come back to [**Hospital1 18**] on Tuesday [**2137-12-3**] at 9:00AM to the
[**Hospital Unit Name **]-Fourth Floor Cardiology Department on the [**Hospital Ward Name 12837**] in order to get the ultrasound of your heart. You should
not have anything to eat or drink starting Monday night at
midnight until after the procedure on Tuesday.
You will then go to the Interventional Radiology Department on
the [**Hospital Ward Name 517**] in the Clinical Center-[**Location (un) **] to have a new
dialysis line placed. Please ask to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
You will then get dialysis here at [**Hospital1 18**] that day.
Please be sure to folow up with Dr. [**Last Name (STitle) 1057**] of the Infectious
Disease Clinic for evaluation of your HIV infection and
Hepatitis. You can call ([**Telephone/Fax (1) 1300**] to make an appointment.
This is very important.
Followup Instructions:
TEE on Tuesday [**2137-12-3**] to evaluate aortic valve for vegitation
IR to place tunneled dialysis line Tuesday [**2137-12-3**] for dialysis
H. Pylori results form EGD/Biopsy
CBC to evaluate trend of leukopenia
Needs to consider starting HAART therapy for HIV infection
Completed by:[**2137-12-2**] | 20,071 | 163,164 | 99662,03843,4210,5856,07054,07032,40391,V08,53019,28521,28850 |
Admission Date: [**2142-10-11**] Discharge Date: [**2142-10-12**]
Date of Birth: [**2084-9-7**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Abacavir
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
58 y/o anuric HD dependent female with HIV on HAART (last CD4
94), CKD stage V on HD ([**1-10**] HTN, dialyzed MWF via L CVL), RUE
AVG (ligation and subsequent excision ([**2142-9-15**]), HCV with liver
biopsy [**3-/2137**] (grade II inflammation) who p/w RUQ pain and
vomiting starting at 4 pm today after HD.
.
Of note, pt recently admitted from [**Date range (1) 100888**] on surgery service
for right arm arteriovenous graft infection. She underwent
excision right arteriovenous graft. GPC bacteremia on blood
cultures [**2142-9-13**]. Graft cultures speciated as enterobacter.
She completed vancomycin for 2 weeks at [**Year (4 digits) 2286**], and
ciprofloxacin PO daily for 2 weeks.
.
Pt reports RUQ pain, intermittent, +chills. Denies fevers. No
diarrhea, constipation, cough/cold sx. Reports vomiting,
non-bloody. No HA, visual changes. Reports she missed her BP
pills yesterday and today due to nausea/vomiting. Of note, pt
does not make urine.
.
In ED, initial VS - initial VS were: 8, 98.6, 53, 226/101, 18,
100%. EKG showing sinus brady 48, NA, Qtc 461. Lactate wnl. Alk
phos slightly above baseline. RUQ US showing stones, no
cholycystitis. CXR showing no acute process. Transplant surgery
notified, and they are aware and recommend MICU admission. CT
A/P negative for acute process. Overall, "no SBO. Distal colonic
wall thickening is more likely related to underdistension than
colitis, but clinical correlation recommended. Polycystic
kidneys. High density streaks in peritoneum unchanged since
[**2137**], could be related to a barium spill. CT head showed no
acute proces.
.
Pt started to develop worsening SOB, and there was a ? of mild
pulmonary edema. SBP was 240s at this time. Nitro gtt started at
0.2 mcg.
.
Vitals on transfer - BP 215/117, HR 72, RR 18, 100% 2L NC.
Access - 20G, HD line, R EJ.
.
On arrival to the MICU, mental status is alert.
.
Review of systems:
(+) Per HPI. (+) HA
(-) Denies fever, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
HIV on HAART
CKD stage V on HD ([**1-10**] HTN)
RUE AVG, ligated [**2142-6-15**]
Hep C: Liver biopsy [**3-/2137**] showed focal mild-to-moderate portal
chronic inflammation with focal periportal extension (grade II).
HTN
Diverticulosis
High-grade adenomatous polyp
Social History:
no current IV drug use, no current etoh or smoking
Family History:
non-contributory
Physical Exam:
Vitals: 97.6, 222/120, 72, 18, 100 RA
General: Alert, but somewhat sleepy, oriented, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1, prominent S2, grade III
holodystolic murmur heard best at LSB
Lungs: mild crackles at bases, no wheezes, rales, ronchi
Abdomen: soft, minimally tender RUQ, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Labs on Admission:
[**2142-10-11**] 12:35AM BLOOD WBC-3.5* RBC-3.99* Hgb-11.9* Hct-39.0
MCV-98 MCH-29.9 MCHC-30.5* RDW-17.3* Plt Ct-148*
[**2142-10-11**] 12:35AM BLOOD Neuts-66.3 Lymphs-26.5 Monos-4.9 Eos-1.4
Baso-0.9
[**2142-10-11**] 12:35AM BLOOD Plt Ct-148*
[**2142-10-11**] 01:41PM BLOOD WBC-3.2* Lymph-25 Abs [**Last Name (un) **]-800 CD3%-56
Abs CD3-449* CD4%-25 Abs CD4-200* CD8%-31 Abs CD8-246
CD4/CD8-0.8*
[**2142-10-11**] 12:35AM BLOOD Glucose-110* UreaN-27* Creat-5.9* Na-137
K-4.2 Cl-93* HCO3-29 AnGap-19
[**2142-10-11**] 12:35AM BLOOD ALT-18 AST-39 CK(CPK)-52 AlkPhos-490*
TotBili-0.7
[**2142-10-11**] 12:35AM BLOOD Lipase-39
[**2142-10-11**] 12:35AM BLOOD CK-MB-2 cTropnT-0.02*
[**2142-10-11**] 12:35AM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1
[**2142-10-11**] 01:41PM BLOOD PTH-2913*
[**2142-10-11**] 12:48AM BLOOD Lactate-1.8
.
Labs on Discharge:
[**2142-10-12**] 03:29AM BLOOD WBC-3.3* RBC-3.63* Hgb-10.7* Hct-34.7*
MCV-96 MCH-29.6 MCHC-30.9* RDW-17.1* Plt Ct-137*
[**2142-10-12**] 03:29AM BLOOD Neuts-56 Bands-0 Lymphs-40 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-10-12**] 03:29AM BLOOD Plt Ct-137*
[**2142-10-12**] 03:29AM BLOOD Glucose-87 UreaN-41* Creat-8.1*# Na-136
K-4.3 Cl-94* HCO3-30 AnGap-16
[**2142-10-12**] 03:29AM BLOOD ALT-20 AST-34 LD(LDH)-174 AlkPhos-415*
TotBili-1.1
[**2142-10-11**] 01:41PM BLOOD GGT-62*
[**2142-10-12**] 03:29AM BLOOD Albumin-4.2 Calcium-10.0 Phos-4.8* Mg-2.0
[**2142-10-11**] 01:41PM BLOOD PTH-2913*
.
CT head without contrast [**10-11**]:
IMPRESSION:
1. No acute intracranial process.
2. Opacification of the left mastoid air cells may be due to
inflammatory or infectious process.
.
CT abd/pelvis without contrast:
IMPRESSION:
1. No evidence of bowel obstruction, diverticulitis or renal
stones.
2. Left and sigmoid colonic wall thickening with mild stranding
along the
medial wall of the descending colon is most likely
undersitension and chronic abnormality rather than mild colitis,
though clinical correlation is needed.
3. Polycystic kidneys with some new intermediate density lesions
and some
increased in size and a septated left cystic lesion. Outpatient
MRI is
recommended in no more than 6 months to assess further.
4. Cholelithiasis without CT evidence of cholecystitis.
5. 4 mm right middle lobe nodule needs no follow- up if patient
is low risk for malignancy. 12 month f/u chest CT if patient is
high risk for a
malignancy.
.
CXR PA and lateral:
IMPRESSION: Vascular engorgement and early pulmonary edema, due
to volume
overload, and/or cardiac insufficiency.
.
Liver/gallbladder US [**2142-10-11**]:
IMPRESSION:
Cholelithiasis without evidence of cholecystitis. Polycystic
kidneys are
partially imaged and not completely evaluated, though no overtly
concerning lesion is seen in their visualized portions.
Brief Hospital Course:
58 y/o anuric HD dependent female with HIV on HAART, HCV, CKD
stage V on HD, RUE AVG ligation and subsequent excision
([**2142-9-15**]), who p/w RUQ pain, nausea, and vomiting, and is
admitted to MICU for hypertensive emergency.
.
# HTN emergency: pt presented with SBP in 230s and evidence of
vascular engorgement and early pulmonary edema with volume
overload, classifying her HTN as HTN emergency. Head CT was wnl.
No EKG evidence of strain or ischemia was seen. Etiology of
elevated BP was likely related to nausea/vomiting/missing BP
pills at home, along with pain. Baseline SBP 140-160 per review
of clinic notes. Of note, mental status was alert. She was
started on nitro gtt with goal SBP 180 but was d/ced in the PM
after normalization of her pressures. We continued home
lisinopril and home metoprolol. Pain control was achieved with
IV morphine. Patient tolerated HD performed in the ICU and was
discharged after overnight stay.
.
# RUQ pain: RUQ US showed cholelithiasis without cholecystitis.
CT A/P showed no SBO. Distal colonic wall thickening is more
likely related to underdistension than colitis. No fever or
jaundice, or evidence for cholecystitis. Elevated alk phos may
suggest infiltrative disease. Recommend repeating outpatient
LFTs and w/u with possible MRCP if alk phos remains elevated.
Consider outpt cholecystectomy for biliary colic, now resolved.
.
# CKD stage V on HD ([**1-10**] HTN): gets dialyzed on MWF. Renal team
performed UF on hospital day 1, and HD on Friday (hospital day
2). Continued sevelamer, nephrocaps. Of note, patient's PTH
returned as 2913. Pt will start IV zemplar at HD for ? secondary
vs. tertiary hyperparathyroidism.
.
# HIV: on HAART. Last CD4 94 (22%) and VL 71 copies/ml. We
continued atazanavir, raltegravir, ritonavir, lamivudine. On
discharge, CD4 count pending. Pt may require bactrim ppx
depending on CD4 count. Pt was set up with ID appt on discharge.
.
# HCV: liver biopsy [**3-/2137**] showed focal mild-to-moderate portal
chronic inflammation with focal periportal extension (grade II).
.
# Hx of right arm arteriovenous graft infection/excision right
arteriovenous graft: GPC bacteremia on blood cultures [**2142-9-13**].
Graft cultures speciated as enterobacter. She completed
vancomycin for 2 weeks at [**Year (4 digits) 2286**], and ciprofloxacin PO daily
for 2 weeks. No signs of infection locally or systemically. Bcx
pending on d/c.
.
# 4 mm right middle lobe nodule: per radiology, needs no
follow-up if patient is low risk for malignancy. 12 month f/u
chest CT if patient is high risk for a malignancy.
Communicated above with oupt PCP.
.
# Transitional issues:
- follow up CD4 count, and start bactrim prophylaxis depending
on result.
- Started IV zemplar at HD (Dr [**Last Name (STitle) 7473**] [**Name (STitle) 82414**]) given high PTH
values (2913).
- 4 mm RML nodule, which requires repeat evaluation and possible
CT if high risk for malignancy
- ID appt re: HIV care as outpt
Medications on Admission:
1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: 25 mg PO DAILY (Daily).
7. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1)
PO DAILY (Daily).
11. heparin (porcine) 1,000 unit/mL Solution [**Name (STitle) **]: One (1)
Injection PRN (as needed) as needed for line flush.
12. aspirin 81 mg Tablet, Chewable [**Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
13. acetaminophen 325 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
15. metoprolol succinate 100 mg Tablet Extended Release 24 hr
[**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. oxycodone 5 mg Tablet [**Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: Twenty Five (25) mg PO
DAILY (Daily).
7. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1)
packet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
[**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
14. oxycodone 5 mg Capsule [**Name (STitle) **]: [**12-10**] Capsules PO every four (4)
hours as needed for pain.
15. zemplar qhd
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- hypertensive emergency
.
SECONDARY:
- end stage renal disease, on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you in the hospital. You were
admitted to the intensive care unit due to very high blood
pressures, likely a result of nausea/vomiting, inability to take
your home pills, and a shortened [**Known lastname 2286**] session the day
before.
.
While you were here, we controlled your blood pressure with IV
medications. Your blood pressure responded nicely. You are being
discharged on your home blood pressure regimen of metoprolol and
lisinopril.
.
While you were here, we also checked some blood tests related to
your kidneys. Your PTH levels were high and the kidney team will
add a new IV medication called zemplar with your [**Known lastname 2286**].
.
MEDICATION CHANGES
- addition of IV zemplar with [**Known lastname 2286**]
.
No other changes were made to your medications. Please follow-up
with your outpatient appointments below. Please seek medical
attention for any concerns.
Followup Instructions:
Appointments:
1) Department: [**Hospital3 249**]
When: THURSDAY [**2142-10-18**] at 3:50 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD
[**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] linical Ctr [**Location (un) 895**] Campus:
EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
2) Department: INFECTIOUS DISEASE
When: TUESDAY [**2142-10-30**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2142-10-12**] | 20,071 | 175,239 | 40391,5856,042,V4511,07054,78701,57420,56210,51889,V1272 |
Admission Date: [**2142-11-25**] Discharge Date: [**2142-11-26**]
Date of Birth: [**2084-9-7**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Abacavir
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 58 year-old woman with HCV, HIV CD4 200, ESRD on
HD last HD [**11-23**] and 9 prior admissions this year for abdominal
pain and HD access issues last discharge [**10-18**] presenting with
epigastric pain. She reports epigastric pain that began this
morning and is associated with nausea and non-bloody non-bilious
vomiting. She also reports mild dyspnea and orthopnea with
nonproductive cough. She denies any chest pain or pressure.
In the ED, initial VS were 100.1 76 221/110 16 97%RA. Labs in
the ED were notable for TropT 0.01, K 7, Cr 9.4, BUN 69, WBC 4.6
and BNP 30K. She received 2mg of zofran and 10mg of morphine IV
for nausea and abdominal pain in the ED. She also received 2g
calcium gluconate IV, 1 amp D50 and 10units of insulin and
admitted to the MICU for emergent treatment of her hyperkalemia.
Vitals on transfer were 99.6 76 189/96 99% on RA.
On arrival to the MICU, patient appears comforatable and is
without additional complaints.
Past Medical History:
- HIV/AIDS on HAART CD4 200 [**10-11**]
- CKD stage V on HD ([**1-10**] HTN)
- RUE AVG, ligated [**2142-6-15**]
- Hep C: Liver biopsy [**3-/2137**] showed focal mild-to-moderate
portal
- chronic inflammation with focal periportal extension (grade
II)
- HTN
- Diverticulosis
- High-grade adenomatous polyp
Social History:
No current IV drug use, No current etoh or Smoking
Family History:
non-contributory
Physical Exam:
VS: T: 97, P: 87, BP: 142/74, RR: 15, O2 sat 100% on RA
General: Alert, oriented, no acute distress
HEENT: Swollen face, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to 12cm H2O, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to ausculation bialreally, no wheezes, rales or
ronchi
Abdomen: Obese, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally.
Discharge:
VS: T: 97, P: 60, BP: 135/71, 95% on RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to ausculation bialreally, no wheezes, rales or
ronchi
Abdomen: Obese, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally.
Pertinent Results:
Hematology:
[**2142-11-26**] 06:08AM BLOOD WBC-3.5* RBC-3.79* Hgb-11.4* Hct-35.4*
MCV-93 MCH-30.1 MCHC-32.3 RDW-17.8* Plt Ct-124*
[**2142-11-25**] 07:49PM BLOOD WBC-4.6# RBC-4.16* Hgb-12.0 Hct-39.4
MCV-95 MCH-28.8 MCHC-30.4* RDW-18.2* Plt Ct-160
[**2142-11-25**] 07:49PM BLOOD Neuts-70.8* Lymphs-25.1 Monos-3.2 Eos-0.5
Baso-0.5
[**2142-11-26**] 06:08AM BLOOD PT-11.2 PTT-34.8 INR(PT)-1.0
[**2142-11-25**] 07:49PM BLOOD PT-10.8 PTT-35.1 INR(PT)-1.0
Chemistries:
[**2142-11-26**] 06:08AM BLOOD Glucose-95 UreaN-40* Creat-6.6*# Na-134
K-4.9 Cl-93* HCO3-33* AnGap-13
[**2142-11-25**] 07:49PM BLOOD Glucose-95 UreaN-69* Creat-9.4*# Na-138
K-7.0* Cl-94* HCO3-28 AnGap-23*
[**2142-11-26**] 06:08AM BLOOD ALT-19 AST-27 CK(CPK)-40 TotBili-0.9
[**2142-11-25**] 07:49PM BLOOD ALT-20 AST-29 CK(CPK)-55 AlkPhos-604*
TotBili-1.2
[**2142-11-26**] 06:08AM BLOOD Albumin-4.3 Calcium-10.4* Phos-4.4 Mg-2.2
[**2142-11-25**] 07:49PM BLOOD Calcium-10.3 Phos-4.1 Mg-2.4
[**2142-11-26**] 01:43AM BLOOD Lactate-1.2
[**2142-11-25**] 08:10PM BLOOD Lactate-2.6* K-6.5*
[**2142-11-25**] CXR
IMPRESSION: No evidence of congestive heart failure.
Brief Hospital Course:
58 year-old woman with poorly controlled HTN, HIV(last CD4 200
on [**10-11**]), ESRD on HD presents with acute onset of abodminal pain
and is found to have hyperkalemia.
.
#. Hyperkalemia: Patient was found to be hyperkalemic to 7.0 in
the ED and was treated with calcium gluconate, D50 and insulin
with follow-up value of 6.5. Patient has a recent baseline
potassium 4.3-5 thus this represents an acute increase in her
potassium level. She denies missing any HD sessions. Her
hyperkalemia may have been related to dietary indiscretion. She
underwent emergent hemodialysis and her hyperkalemia corrected.
# Abdominal pain: Patient presents after acute onset of nausea,
vomiting and abdominal pain. There was no sign if infectious
etiology- no leukocytosis, no fever. Her nausea was liked
related to her uremia and all her symptoms improved with HD. She
was able to tolerate a diet at the time of discharge.
# ESRD: CKD Stage V due to HTN. On HD MWF. Patient last received
[**Month/Day (4) 2286**] on 2 days prior to admission. She underwent emergent HD
on admission and then had her regularly scheduled [**Month/Day (4) 2286**] in
the morning. She was continued on Sevelemer and Nephrocaps.
# HIV/AIDS: On HARRT, last CD4 200 on [**2142-10-11**]. Continued on
atazanavir, raltegravir, ritonavir, lamivudine.
# HTN: Patient has poorly contolled HTN with prior admissions
for hypertensive emergency, she presented hypertensive again
today to the ED. Vitals on admission were slightly improved
after her nausea and pain were contolled. She was continued on
her home lisinopril, metoprolol and amlodipine.
# Shoulder arthritis: Extensive workup as outpatient for
shoulder pain, thought to be musculoskeletal. Patient was
continued on PO oxycodone as needed for control of symptoms.
#CODE: Full Code (confirmed with patient)
Medications on Admission:
- Sevelamer carbonate 800 mg TID QAC
- B complex-vitamin C-folic acid 1 mg daily
- atazanavir 300 mg daily
- raltegravir 400 mg [**Hospital1 **]
- ritonavir 100 mg daily
- lamivudine 10 mg/mL daily
- senna 8.6 mg [**Hospital1 **]:PRN
- docusate sodium 100 mg [**Hospital1 **]
- lactulose 10 gram/15 mL daily
- polyethylene glycol 3350 17 gram/dose daily
- aspirin 81 mg daily
- lisinopril 40 mg daily
- metoprolol succinate 100 mg daily
- oxycodone 5 mg Q4H
- amlodipine 2.5 mg daily
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
3. atazanavir 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
4. raltegravir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
5. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
6. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
8. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO DAILY
(Daily).
9. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. lamivudine Oral
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
[**Hospital1 **]: One (1) Tablet Extended Release 24 hr PO once a day.
14. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyperkalemia, ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital with abdominal pain. We found
that your potassium was very high and you were admitted to the
intensive care unit for [**Known lastname 2286**]. Your potassium improved after
[**Known lastname 2286**]. Your abdominal pain also improved and you were
discharged home.
No changes were made to your medications.
Followup Instructions:
Please call your primary care doctor at [**Telephone/Fax (1) 250**] to
follow-up in [**12-10**] weeks.
Please keep the following appointments:
Department: [**Hospital3 249**]
When: TUESDAY [**2143-1-15**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OBSTETRICS AND GYNECOLOGY
When: THURSDAY [**2143-2-14**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71322**], MD [**Telephone/Fax (1) 2664**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2143-4-2**] at 10:15 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| 20,071 | 186,517 | 2767,5856,042,40391,27669,V4511,07054,28521,78900,71691 |
Admission Date: [**2187-9-4**] Discharge Date: [**2187-9-15**]
Service: CCU
ADMISSION DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
female with CRF, DM, HTN, remote tobacco use who was in her
usual state of health until [**9-3**] when she presented to an
outside hospital with non-ST elevation MI with peak CK equal
to 1500. The patient was treated medically with Lovenox,
Integrilin, aspirin, dopamine, nitropaste. On [**9-4**] recurrent
angina and transferred to [**Hospital1 18**] for cardiac catheterization
showing three vessel disease with elevated left and right
sided filling pressures. IVC was placed. Dobutamine and
nitroglycerin drips and 40 of IV Lasix given. The patient
was transferred to the CCU in stable condition.
PAST MEDICAL HISTORY: Coronary artery disease status post
cath. Diabetes. Hypertension. A-fib. Remote history of
small CVA.
ALLERGIES: No known drug allergies.
MEDICATIONS: Fluoxetine, guaifenesin, nifedipine, glyburide,
lovastatin, Toprol XL, lisinopril, Protonix, isosorbide
dinitrate, metformin, KCl, hydrochlorothiazide.
PHYSICAL EXAMINATION: Afebrile, blood pressure 110/69, heart
rate 91, respiratory rate 18, O2 96 percent on 2 liters nasal
cannula. In general, elderly female in no apparent distress.
HEENT dry mucous membranes. Chest clear to auscultation
bilaterally. CV irregular, no rubs or gallops, IABP sounds.
Abdomen soft, nondistended, nontender, good bowel sounds.
Extremities full pulses.
LABORATORY DATA:
CK 626, CKMB 24, troponin T 6.4.
HOSPITAL COURSE:
1. Cardiovascular. The patient is status post non-ST
elevation MI with three vessel disease and needs CABG in the
future. The patient was cathed on admission and showed three
vessel disease with elevated left and right filling
pressures. The patient was taken off IABP and pressors
slowly as tolerated and medications were optimized throughout
hospitalization for better control of blood pressure and
cardiac risk factors. Please see updated list of
medications. CT surgery was also consulted for surgery for
CABG and because of complicating mental status changes and
rising creatinine, recommended outpatient rehab, then follow
up with CT surgery for elective CABG.
2. Diabetes type 2. Well controlled throughout her
hospitalization.
3. Psych. The patient had ICU psychosis, but when all her
antianxiety, antipsychosis medications were held, she
remained awake, alert and oriented times three for 48 hours
before discharge. Vital signs were stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Anterior myocardial infarction.
2. Subendocardial hypertension.
3. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Tylenol 325 one to two tablets q.4 to 6h.
2. Multivitamin one tablet q.day.
3. Atorvastatin 40 mg p.o. q.day.
4. Fluoxetine 20 mg p.o. q.day.
5. Folic acid 1 mg p.o. q.day.
6. Cyanocobalamin 25 mcg p.o. q.day.
7. Thiamine 100 mg p.o. q.day.
8. Docusate one tab p.o. b.i.d.
9. Albuterol ipratropium one two puffs p.r.n.
10. Albuterol one inhalation p.r.n.
11. Ipratropium one inhalation q.6h. p.r.n.
12. Aspirin 325 a day.
13. Pantoprazole 40 q.day.
14. Diltiazem 60 p.o. q.i.d.
15. Levofloxacin 250 p.o. q.o.d.
16. Warfarin 5 mg p.o. q.h.s.
17. Lisinopril 5 mg p.o. q.day.
18. Glyburide 5 mg p.o. q.day.
19. Regular insulin sliding scale.
20. Toprol XL 25 mg p.o. q.day.
FOLLOWUP: Follow up with Dr. [**Last Name (STitle) 70**], cardiothoracic
surgery, on [**10-3**]. The patient is also to follow up
with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50479**], in one to two weeks. Appointments
are made on discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2187-9-15**] 13:41
T: [**2187-9-15**] 14:09
JOB#: [**Job Number 50480**]
| 20,072 | 185,009 | 41071,42731,4271,5849,40391,78551,5990,00845,41401 |
Admission Date: [**2187-9-4**] Discharge Date: [**2187-9-18**]
Service: CCU-MEDICINE
ADMITTING DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
female with chronic renal failure, diabetes mellitus,
hypertension, remote tobacco use, who was in her usual state
of health until [**2187-9-3**], where she presented to an outside
hospital with non ST elevation myocardial infarction with
peaked CK of 1500. The patient was treated medically with
Lovenox, Integrilin, Aspirin, Dopamine, Nitroglycerin, and
Aspirin. On [**2187-9-3**], she had recurrent angina and was
transferred to [**Hospital1 69**] for
cardiac catheterization which showed three vessel disease
with elevated left and right filling pressures. An IAVP was
placed and Dobutamine and Nitroglycerin drips were started
and intravenous Lasix was given. The patient was then
transferred to the CCU in stable condition.
PAST MEDICAL HISTORY:
1. Coronary artery disease with catheterization.
2. Diabetes mellitus.
3. Hypertension.
4. Atrial fibrillation.
5. Remote small cerebrovascular accident
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Fluoxetine.
2. Guaifenesin.
3. Nifedipine.
4. Glyburide.
5. Toprol XL.
6. Lovastatin.
7. Lisinopril.
8. Protonix.
9. Isosorbide Dinitrate.
10. Metformin.
11. Potassium Chloride.
12. Hydrochlorothiazide.
PHYSICAL EXAMINATION: On admission, the patient was
afebrile, blood pressure 110/69, heart rate 91, respiratory
rate 18, oxygen saturation 96% on two liters nasal cannula.
In general, the patient is an elderly female in no apparent
distress. Head, eyes, ears, nose and throat - Dry mucous
membranes. Chest is clear to auscultation bilaterally.
Cardiovascular is irregularly irregular, no rubs or gallops.
IAVP sounds. The abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities - palpable pulses.
LABORATORY DATA: On admission, CK was 626, CK MB 24.0,
troponin T 6.4. Otherwise Chem7 and complete blood count
were stable.
HOSPITAL COURSE:
1. Cardiovascular - The patient assessed non ST elevation
myocardial infarction with three vessel disease and need for
coronary artery bypass graft in the future. The patient's
catheterization on admission showed three vessel disease with
elevated left and right filling pressures. In the CCU, the
patient was taken off IAVP and pressors were slowly weaned as
tolerated and medications were optimized throughout
hospitalization for better blood pressure control and control
of her cardiac risk factors. Please see updated list of
discharge medications. Cardiothoracic Surgery was also
consulted for surgery for coronary artery bypass graft and
because of complicating mental status changes and rising
creatinine, it was recommended to follow-up with
Cardiothoracic Surgery as an outpatient for an elective
coronary artery bypass graft.
The patient also has a history of atrial fibrillation and was
placed on a Diltiazem drip while being NPO. Once able to
take p.o., the patient's rate was well controlled with p.o.
Diltiazem which was titrated to keep her heart rate less than
100, and the patient was kept on a Heparin drip and converted
to p.o. Warfarin with goal INR of 2.0 to 3.0. The patient
will need frequent INR checks at rehabilitation to titrate
Coumadin dose.
The patient also had a few episodes of nonsustained
ventricular tachycardia during this hospitalization and her
Toprol XL was titrated upwards for this.
2. Diabetes mellitus type 2 - The patient was well
controlled throughout hospitalization with a regular insulin
sliding scale and p.o. Glyburide.
3. Psychiatry - The patient had Intensive Care Unit
psychosis for a short period of time while on Haldol and
Ativan. Once all her antianxiety medications were held, her
mental status began to clear and the patient remained awake,
alert and oriented times three times 48 hours before
discharge. Psychiatry was also consulted and agreed with her
mental status being back to baseline 48 hours before
discharge.
4. Infectious disease - The patient had increasing white
blood cell count during hospitalization and was found to be
Clostridium difficile positive. The patient also had a chest
CT for concern of a lung process but was found to have
congestive heart failure, mediastinal lymphadenopathy which
needs to be followed up with a chest CT in three months, and
an indeterminate adrenal mass will need to be followed up
with a magnetic resonance scan in three months. The patient
was also started on Flagyl for a ten day course for
Clostridium difficile.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction, subendocardial, initial
episode.
2. Hypertension, benign and essential.
3. Coronary artery disease, native.
MEDICATIONS ON DISCHARGE:
1. Tylenol one to two tablets p.o. q4-6hours p.r.n.
2. Multivitamin one tablet p.o. once daily.
3. Atorvastatin 40 mg p.o. once daily.
4. Fluoxetine 20 mg p.o. once daily.
5. Folic Acid 1 mg p.o. once daily.
6. Cyanocobalamin 50 mcg p.o. once daily.
7. Thiamine HCl 100 mg p.o. once daily.
8. Regular insulin sliding scale.
9. Docusate 100 mg p.o. twice a day.
10. Albuterol Ipratropium one to two puffs inhaled q4hours
p.r.n.
11. Albuterol nebulizer one nebulizer inhaled q4hours p.r.n.
12. Ipratropium Bromide one nebulizer inhaled q6hours p.r.n.
13. Aspirin 325 mg once daily.
14. Lisinopril 5 mg p.o. once daily.
15. Glyburide 5 mg p.o. twice a day.
16. Diltiazem 60 mg p.o. four times a day.
17. Metoprolol XL 100 mg p.o. once daily.
18. Warfarin 2 mg p.o. q.h.s.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 70**],
cardiothoracic surgery, [**2187-10-3**], at 1:30 p.m. The patient
is to follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50481**] in
one to two weeks.
The patient will also need a follow-up chest CT in three
months with a follow-up magnetic resonance scan in three
months for adrenal mass.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern4) 50356**]
MEDQUIST36
D: [**2187-9-19**] 17:01
T: [**2187-9-19**] 18:48
JOB#: [**Job Number 50482**]
| 20,072 | 185,009 | 41071,42731,4271,5849,40391,78551,5990,00845,41401 |
Admission Date: [**2143-2-15**] Discharge Date: [**2143-2-18**]
Service:
PRINCIPLE DIAGNOSIS AT DISCHARGE:
Right caudate thalamic hemorrhage secondary to hypertension.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 46608**] is a 60-year-old man
with past medical history of hypertension and coronary artery
disease. Has been having fevers over the last three days.
On the night prior to admission he began to complain that
"something is happening to me." According to his wife at
baseline he ambulates with a walker because of "back
problems." [**Name2 (NI) **] has had a fever since [**2143-2-12**] with a dry cough
but no other localizing symptoms and he was being empirically
treated with antibiotics by his primary care physician. [**Name10 (NameIs) **]
night prior to admission he got up to urinate and was unable
to take off his pants or later to put them back on. He also
developed a left sided throbbing headache at that time.
However, he went back to sleep in the morning. He had the
sense that something was wrong and his wife brought him to
[**Name (NI) 16843**] Hospital where a Head CT was obtained that showed
a right caudate hemorrhage without extension into the
ventricles. He was then transferred to [**Hospital1 190**] for further evaluation and treatment.
REVIEW OF SYSTEMS: He has had fevers without change in
urination. He has had decreased hearing and he wears a
hearing aid in the right ear. he complains of chronic left
hip pain and back pain. The patient denied any problems with
sore throat, nausea, vomiting, visual changes, difficulty
swallowing, chest pain, palpitations, short of breath,
abdominal pain or change in bowel and bladder habits.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Left hip replacement [**2141**].
3. Coronary artery disease. Status post three vessel
Coronary artery bypass graft in [**2130**]. Angioplasty in
[**2131**].
4. Hypercholesterolemia.
5. Gout.
6. Prostate cancer [**2128**].
7. Colon surgery for gastrointestinal bleed/diverticulosis
in [**2138**].
8. Cholecystectomy in [**2138**].
9. Bladder sphincter surgery in [**2135**].
10. Ear surgery times three.
11. Hernia repair times three.
12. Bilateral cataract surgery.
ALLERGIES: Sulfa gives him a rash. Penicillin gives a rash.
Demerol and Ambien with unknown reaction.
MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. KCL 10 mg p.o. twice a day.
3. Hydralazine 15 mg p.o. three times a day.
4. Flomax 64 mg p.o. q day.
5. Aciphex 20 mg p.o. q day.
6. Zocor 40 mg p.o. q day.
7. Allopurinol 100 mg p.o. q day.
8. Norvasc 5 mg q day.
9. Lasix 20 mg p.o. q day.
10. Iron 325 mg p.o. q day.
11. Hydrocodone twice a day p.r.n.
SOCIAL HISTORY: Originally from [**State 9512**], worked as an Air
Force plane mechanic. Married with children. Positive
smoking history
PHYSICAL EXAMINATION: At presentation his temperature was
97.1, blood pressure is 177/76, heart rate was 87.
Respiratory rate was 24. He was sating 100% on two liters.
In general the patient appeared his stated age lying in bed
in no acute distress. His head was normocephalic and
atraumatic. Eyes: Nonicteric. Oropharynx was clear without
lesions. Mucous membranes were moist. Neck was supple with
no jugular venous distention or bruits. Lungs were clear to
auscultation bilaterally. Cardiac exam revealed a normal S1
and S2. 2/6 systolic ejection murmur heard best at the upper
sternal border. Abdomen was soft, nontender, nondistended
with normal bowel sounds. Extremities were warm with no
clubbing or cyanosis. He had mild pitting edema at the
ankles. Neurologic: He was awake, alert, cooperative,
appeared grossly oriented. He was able to provide some
detail of recent and remote events. Serial 3's were intact.
His object naming was intact. Registration intact with four
attempts. Recall [**3-5**] items in three minutes. He followed
simple commands. Speech: Normal voice quality and
articulation. Comprehension is coherent. He was fluent
without paresthesias. He was able to say no if's, and's and
but's intact.
Cranial nerve exam: The patient with left lower facial droop
without trismus. His extraocular movements intact without
nystagmus. His visual fields intact with confrontation. His
funduscopic exam revealed normal vasculature with sharp optic
discs. Pupils were reactive to light directly and
consensually, 3 mm to 2 mm, palate was symmetric and tongue
was midline. Hearing was decreased to finger rub
bilaterally. His neck and shoulder shrug however, were
normal. On motor examination his legs were adducted at rest
with increased tone. There is no upper extremity cogwheeling
rigidity. There is no pronator drift. His interphalangeal
testing was limited by pain. Strength exam was symmetric
with 5- strength in the deltoids, 5 in the biceps, 5 in the
wrist flexors and extensors, 5 in the finger flexors, 5- in
the finger extensors. 4 on the hip flexors, 5 in the knee
flexors, 4+ in the knee extensors, 5- in the ankle flexors,
4+ in the ankle extensors, 5 in the toe reflexes, 4+ in the
toe extensors. Reflexes were 2+ and symmetric in the biceps,
triceps and brachioradialis. Lower extremity they were 4+ in
the patella on the left and 3+ on the right. Achilles jerks
were absent and toes were upgoing bilaterally. There is no
ankle clonus. Sensory: Pinprick is decreased on the left
face, arm and leg. Vibration is decreased in the toes.
Proprioception intact in the fingers. Coordination
finger-to-nose intact with mild action tremor. Heel-to-shin
was intact. Rapid alternating movements intact. Toe tap was
intact. Gait was very unsteady with retropulsion, normal
base but short step and stride.
HOSPITAL COURSE: Mr. [**Known lastname 46608**] was admitted to the
neurological Intensive Care Unit for further evaluation and
treatment of his right caudate hemorrhage. An magnetic
resonance scan of his head was done with Gadalidium to look
for additional reasons for sensory changes such as an
ischemic stroke and none were found. There was no evidence
of enhancement underneath the hemorrhage to suggest a lesion
which later bled. Systolic blood pressure was maintained
between 120 to 140 and his aspirin was held and will continue
to be so for the next 10 days. The following day Mr.
[**Known lastname 46608**] was transferred to the floor. However, on the 16th
he was found to be much less responsive and to have fevers
and the source of his fevers were eventually found however,
over the next day Mr. [**Known lastname 46608**] was no longer febrile and was
back to his baseline.
On the 17th Mr. [**Known lastname 46608**] was observed to ambulate well with
his walker avoiding obstacles and was able to transfer in and
out of his bed with minimal assistance.
DISCHARGE INSTRUCTIONS: Mr. [**Known lastname 46608**] was discharged to home
on [**2143-2-18**].
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q day.
2. Amlodipine 5 mg p.o. q day.
3. Allopurinol 100 mg p.o. q day.
4. Zocor 40 mg p.o. q day.
5. Hydralazine 50 mg p.o. three times a day.
6. KCL 10 mEq p.o. twice a day.
7. Slow-Mag 64 mg p.o. q day.
8. Aciphex 20 mg p.o. q day.
9. Iron 325 mg p.o. q day.
10. Hydrocodone one tab twice a day p.r.n.
He is to hold his aspirin for one further week and then may
resume all pre-admission medications.
DIET: Low sodium, low cholesterol.
He has been asked to return for follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) **] on [**2143-3-12**], [**Telephone/Fax (1) 46609**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**MD Number(1) 2107**]
Dictated By:[**Last Name (NamePattern1) 660**]
MEDQUIST36
D: [**2143-2-18**] 20:29
T: [**2143-2-18**] 20:09
JOB#: [**Job Number **]
| 20,073 | 109,841 | 431,2720,4019,V1046,2749 |
Admission Date: [**2101-12-1**] Discharge Date: [**2101-12-5**]
Date of Birth: [**2055-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Alcohol intoxication, Suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 M with PMHx significant for nephrectomy, and prior admissions
for alcohol intoxication, who presents with suicidal ideation.
Patient has prior history of ED visits with both of these
presentations. Patient reports that he has been on a drinking
binge (vodka & listerine) for the past 2 months, with his last
drink 2 days prior to admission. Patient denies ever having
EtOH withdrawal seizures and just reports having "shakes".
Since stopping alcohol on day prior to admission, he has been
feeling anxiety, depression, nausea with nonbloody bilious
emesis, headache, chills, & tremors. he also reports
lightheadedess and dizziness. He denies any methanol or
ethylene glycol ingestions, fevers, abdominal pain, diarrhea.
He does reports that his last meal was 3 days prior to
admission, and he has consumed essentially nothing but alcohol
since. Patient reports that he's been feeling suicidal for the
past couple days after stopping alcohol. he reports that he has
significant financial, occupational and familial stressors. He
called 911 this am and was brought to the ED. .
.
.
ROS:
Positive: chest rash
Negative: change in vision, oral ulcerations, neck stiffness,
chest pain, abdominal pain, diarrhea, constipation
In the ED, vitals signs were T:96.7, HR:130, BP: 72/44. The
patient was also found to have a significant ETOH intoxication,
as well as an AG acidosis (anion gap 35)and ARF. Tox screen was
positive for only EtOH and LFTs were mildly elevated. he was
given Ativan, 2L fluids, phenergan for nausea, one dose of
ceftriaxone and sent to the floor.
Past Medical History:
1. Alcohol abuse.
2. Right nephrectomy for a mass in his kidney.
3. HTN
4. Dyslipidemia
Social History:
Patient reports that he drinks 1 quart of vodka or listerine per
day. Has been doing this lately for 2 months. Long-standing
drinking history. Patient has had prior visits to [**Hospital1 18**] ED for
suicide attempt and EtOH intoxication. Patient reports smoking
1 pack per week, denies any other illicit drugs.
Family History:
No family history of cancer, no bleeding diathesis
Father - deceased - MI age 70
Mother - recent CVA
Physical Exam:
Physical Exam:
Vitals - T: 100.3 BP: 100/62 HR: 123 RR: 12 02 sat:96RA
Gen: NAD, anxious, cooperative
SKIN: redness to face and upper chest, no excoriations or
lesions
HEENT: AT/NC, bilateral scleral injection without exudate, pink
conjunctiva, PERRL, EOMI, dry MM, poor dentition, no evidence of
oral ulceration
Neck: no masses, no LAD, no JVD, no carotid bruit
CV: tachycardic, S1/S2, flow murmur @ RUSB, nondisplaced PMI
Chest: cta b/l, no crackles or wheezes.
Abd: soft, nd, +bs, no organomegaly, no rebound, no guarding
Extr: no cyanosis, no clubbing; no edema, 2+ pulses b/l.
Neuro: awake, alert, a&ox3, cn ii-xii intact; strength 4/5
bilaterally
Pertinent Results:
[**2101-12-1**] 02:01PM WBC-6.5 RBC-4.65 HGB-15.9 HCT-46.0 MCV-99*#
MCH-34.2* MCHC-34.6 RDW-16.0*
[**2101-12-1**] 02:01PM NEUTS-74.4* LYMPHS-14.3* MONOS-10.9 EOS-0.1
BASOS-0.3
[**2101-12-1**] 02:01PM ASA-NEG ETHANOL-296* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-12-1**] 02:01PM CALCIUM-7.8* PHOSPHATE-7.5*# MAGNESIUM-2.1
[**2101-12-1**] 02:01PM CK-MB-21* MB INDX-3.1 cTropnT-<0.01
[**2101-12-1**] 02:01PM LIPASE-71*
[**2101-12-1**] 02:01PM ALT(SGPT)-99* AST(SGOT)-156* CK(CPK)-688* ALK
PHOS-122* AMYLASE-92 TOT BILI-0.4
[**2101-12-1**] 02:01PM GLUCOSE-118* UREA N-37* CREAT-2.1* SODIUM-141
POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-15* ANION GAP-40*
.
[**2101-12-1**]
CXR: IMPRESSION: No acute pulmonary process.
.
CT HEAD: IMPRESSION: No intracranial hemorrhage or fracture.
No mass effect.
Brief Hospital Course:
Patient is a 46 M with suicidal ideation, EtOH withdrawal,
hypotension, elevated lactate, ARF, metabolic acidosis, &
tachycardia.
.
# EtOH Withdrawal: Patient ceased drinking approximately 24
hours prior to admission. Load with Valium 10mg until
confortable, then Q1hprn per CIWA > 10. the patient initially
required high doses. MVI/Thiamine/Folate were also given.
.
# Hypotension: due to volume depletion in the context of poor po
intake, responded well to fluids.
.
# Tachycardia - Likely due to a combination of etoh withdrawal
hypovolemia. Patient's HR has decreased with fluid challenge.
Fluid hydration.
.
# Fevers - Likely in the setting of alcohol withdrawal.
Cultures negative.
.
# ARF- Cr on admission to 2.0. Baseline is 0.8. Likely
pre-renal renal failure, responded well to fluids. No evidence
of secondary ingestions. Renal was consulted to help with
management.
.
# Metabolic Acidosis: Patient with metabolic acidosis. Likely
due to alcoholic and starvation ketoacidosis as well as renal
failure. Lactate minimally elevated. No evidence of seconday
ingestion. Resolved with IVF hydration.
.
# Suicide attempt- patient currently with 1:1 sitter. Consulted
Psychiatry. Recommended inpatient psychiatry admission.
.
FULL CODE
Medications on Admission:
Paxil
Lipitor 20
Norvasc 20
"Something to stop Alcohol cravings"
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
EtOH withdrawal
Suicide Attempt
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience shortness of
breath, chest pain, fevers/chills.
.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 3 weeks
of discharge. On this admission, it was noted that you have a
small amount of red blood cells in your urine. This will need to
be followed up with your primary care physician upon discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
| 20,075 | 116,887 | 29181,5849,2762,30391,4019,V1052,V600 |
Admission Date: [**2105-9-26**] Discharge Date: [**2105-9-29**]
Date of Birth: [**2055-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 50 y/o male with PMHx EtOH abuse with withdrawal
symptoms and DTs, depression, HTN who presents to the ED with
suicidal ideations after an episode of binge drinking, called
EMS on self with SI. Did not actually harm himself. Was
recently admitted to dual diagnosis center for ~1 week starting
on [**9-16**], after discharge began drinking 1 pint of vodka nightly
and reports he drank [**1-3**] gallon of vodka today.
.
In the ED, initial vs were: Temp:99.3 HR:124 BP:135/88 Resp:16
Sat:95
Patient received thiamine, folate, multivitamin, 2L fluid and
was started on CIWA scale with valium and received a total of
80mg PO with 2mg Ativan due to withdrawal symptoms - agitation,
tachycardia, and tremulousness that resolved with treatment.
Psych was consulted and did not feel that a section 12 was
necessary at this time.
.
Of note, patient does admit to an admission at [**Hospital1 2025**] where he
experienced seizures and self reports a diagnosis of delirium
tremens.
.
On the floor, the patient feels shaky, anxious and tremulous.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
(from OMR, confirmed with patient)
PAST MEDICAL HISTORY:
- PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49342**] at [**Hospital **] Medical Associates in [**Location (un) 5110**], MA
- s/p R nephectomy in [**2096**] [**2-3**] renal mass, HTN, dyslipidemia
PAST PSYCHIATRIC HISTORY: (from OMR, confirmed with patient)
- Unclear psychiatric diagnosis separate from his alcoholism.
Historical diagnosis of MDD, anxiety, bipolar disorder.
- Multiple past dual diagnosis hospitalizations, two at [**Hospital1 1680**]
JP
in the past month.
- Medication trials include prozac, seroquel and benzos.
- Pt reports one prior SA/SBI by stabbing himself once in [**2099**]
in
the RLQ, sought medical treatment at [**Hospital1 2025**]. Patient has scar on
RLQ, but appears to be surgical incision, possibly from
nephrectomy.
Social History:
- Tobacco: 1 pack/week
- Alcohol: 1 qt of vodka daily, reportedly [**1-3**] gallon today;
multiple in/outpatient detoxes; self-reported h/o withdrawal
seizure at [**Hospital1 2025**] ([**2100**]), self-reported DT's (tremors and VHs, no
ICU stays), and blackouts. Longest period of sobriety for three
months ending a couple months ago (similar to past evaluations,
patient vague about time frame.)
- Illicits: denies IVDU, remote h/o benzo and cocaine abuse
Family History:
Father died of MI at age 70.
Physical Exam:
Vitals: T: 98.0 BP: 142/794 P:70 R: 16 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, 2x2 erythematous scaly patch on right thigh since last
hospitalization
Skin: Diffuse erythematous macules on back and chest, some
excoriated, blanching. Erythematous face.
Neuro: AAOx3, 5/5 strength all extremities, +tremor, no
nystagmus
Pertinent Results:
Labs on Admission:
[**2105-9-26**] 02:55PM BLOOD WBC-7.8 RBC-4.60 Hgb-14.8 Hct-42.5 MCV-92
MCH-32.3* MCHC-35.0 RDW-14.4 Plt Ct-313
[**2105-9-26**] 02:55PM BLOOD Neuts-59.3 Lymphs-31.9 Monos-5.6 Eos-1.2
Baso-2.0
[**2105-9-26**] 02:55PM BLOOD Glucose-147* UreaN-15 Creat-1.1 Na-144
K-3.8 Cl-102 HCO3-23 AnGap-23*
[**2105-9-26**] 02:55PM BLOOD ALT-52* AST-60* LD(LDH)-197 AlkPhos-105
TotBili-0.5
[**2105-9-26**] 02:55PM BLOOD Albumin-4.3 Calcium-9.2 Phos-1.3*# Mg-1.9
[**2105-9-26**] 02:55PM BLOOD ASA-NEG Ethanol-277* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
Labs on Discharge:
[**2105-9-29**] 08:50AM BLOOD WBC-4.9 RBC-4.34* Hgb-13.6* Hct-40.7
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.0 Plt Ct-209
[**2105-9-29**] 08:50AM BLOOD Glucose-94 UreaN-9 Creat-1.0 Na-140 K-4.5
Cl-104 HCO3-28 AnGap-13
[**2105-9-29**] 08:50AM BLOOD UricAcd-4.8
Brief Hospital Course:
In the MICU [**Date range (3) 49343**]:
50 y/o male with known history of EtOH withdrawal and DTs who
presents after SI while intoxicated, now with EtOH withdrawal
symptoms. In the [**Name (NI) **], Pt received diazepam 80mg PO with lorazepam
2mg and a banana bag and another 20mg of diazepam with 1mg
lorazepam overnight in the CCU. He felt better the following
morning and was transferred to the medical floor. Psych did not
recommend section 12. Pt also had an anion gap acidosis - (Gap
of 19 on admission) that had closed by morning.
.
Called out to the medical floor, [**9-27**] - [**9-29**]:
.
# ETOH withdrawal, dependence - On folate, thiamine, CIWA.
Continued to receive Valium through day 2 on medical floor for
CIWA > 10. When patient's symptoms of withdrawal had resolved,
he was discharged home with instructions for close follow-up.
.
# gout - Patient developed pain in right toe on the medical
floor. Presentation consistent with acute gout. Started on
naproxen and colchicine with significant improvement.
.
# depression with suicidality - Suicidal ideation resolved by
the time of discharge. Patient was seen by psych who recommended
dual diagnosis, however the patient refused.
.
# hepatitis, NOS - Mild elevation in ALT, AST. Most likely fatty
liver vs. alcohol induced.
.
# follow-up: Consider HIV testing and would vaccinate for HAV
and HBV.
Medications on Admission:
Zoloft
Trazodone
Norvasc
"Cholesterol medication"
Discharge Medications:
1. Outpatient Meds
Patient does not know doses of home medications. Please continue
taking trazodone and amlodipine as you have been directed.
2. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) for 5 days: Please take for five days following discarge.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with alcohol intoxication and
withdrawal. You were given medication for your symptoms of
withdrawal. By the time of discharge, your symptoms had
resolved. Please do not drink alcohol.
.
You were also treated for pain that you experienced in your toe.
We believe this was related to a condition called gout. Please
take the Naprosyn (naproxen) 500 mg every twelve hours for the
next five days for this pain in your toe.
Followup Instructions:
Please follow-up at the following time/place:
.
Department: [**Hospital3 249**]
When: FRIDAY [**2105-10-16**] at 2:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
******PLEASE NOTE: YOU HAVE A MANAGED CARE INSURANCE PLAN AND
YOU MUST CALL YOUR INSURANCE TO TELL THEM WHO YOUR PRIMARY CARE
DOCTOR IS. DR [**Last Name (STitle) **] WORKS CLOSELY WITH DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
PLEASE LIST DR [**First Name (STitle) **] AS YOUR PCP WITH YOUR INS. QUESTIONS
PLEASE CALL NUMBER ABOVE.
| 20,075 | 175,728 | 29181,V6284,30301,311,4019,2749,5733,7821 |
Admission Date: [**2101-8-18**] Discharge Date: [**2101-8-24**]
Date of Birth: [**2030-12-10**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
gentleman has had symptoms of shortness of breath and fatigue
for approximately one year prior to admission. He underwent
a cardiac echocardiogram on [**2101-5-5**] revealing a
moderately enlarged left atrium with a torn chordae of the
anterior mitral valve leaflet. There was also [**4-7**]+ mitral
regurgitation, mild to moderate pulmonary hypertension. The
patient was admitted to the [**Hospital1 188**] on [**2101-8-18**] for a cardiac catheterization. This
revealed normal left ventricular ejection fraction of 65
percent as well as normal coronary arteries. It also showed
moderate pulmonary hypertension with pulmonary artery
pressures of 45/16 and the patient was referred for mitral
valve repair versus replacement with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Mitral regurgitation.
3. Esophageal donut placed approximately 15 years ago.
4. Rectal fissure repair.
5. Back surgery in [**2056**].
ALLERGIES: The patient states allergies to Klonopin and all
antidepressant medications which resulted in nausea and
fatigue.
PREOPERATIVE MEDICATIONS:
1. Lasix 20 mg p.o. q.d.
2. Potassium 10 mEq p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
LABORATORY DATA: The laboratory values preoperatively were
unremarkable.
PHYSICAL EXAMINATION: The patient's physical examination was
unremarkable.
SOCIAL HISTORY: The patient denied alcohol intake and was a
cigar smoker for 20 years but quit three months prior to
admission.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2101-8-19**] with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he
underwent a mitral valve repair with a #28 CE anuloplasty
band. Postoperatively, the patient was on a nitroglycerin
drip and transported to the Cardiac Surgery Recovery Unit in
good condition. The patient was successfully weaned from
mechanical ventilation and extubated the night of surgery.
He was in normal sinus rhythm with stable hemodynamic
parameters.
On postoperative day number one, beta blockers were
initiated. His Swan-Ganz catheter was removed.
On postoperative day number two, diuresis was initiated. The
patient remained hemodynamically stable and was ready to be
transferred to the telemetry floor. The patient, on
postoperative day number three, had a number of hours of
atrial fibrillation, was treated with increasing beta
blockers as well as Amiodarone and before the following
morning had converted to sinus rhythm with no further
episodes of atrial fibrillation.
Today, postoperative day number five, he remains
hemodynamically stable and ready to be discharged home.
Condition today: Neurologically, he was grossly intact with
no apparent deficits. The pulmonary examination revealed
that his lungs were clear to auscultation bilaterally.
Coronary examination revealed a regular rate and rhythm.
Sternal incision was clean with Steri-Strips clean, dry, and
intact. His abdomen was benign. His extremities were warm
without edema.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. b.i.d. for one week and then 200 mg
p.o. q.d. for three weeks or until discontinued by Dr.
[**Last Name (STitle) **].
2. Lopressor 25 mg p.o. b.i.d.
3. Aspirin 325 mg p.o. q.d.
4. Zantac 150 mg p.o. b.i.d.
5. Colace 100 mg p.o. b.i.d.
6. Dilaudid 2 mg p.o. q. 4-6 hours p.r.n. pain.
7. Lasix 20 mg p.o. b.i.d. times seven days.
8. Potassium chloride 20 mEq p.o. b.i.d. times seven days.
DISCHARGE DIAGNOSIS: Mitral regurgitation, status post
mitral valve repair.
CONDITION ON DISCHARGE: Good.
FOLLOW UP: The patient is to follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **] in one to two weeks, his cardiologist. He is also to
follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**], in
one to two weeks. He is to follow-up with his cardiac
surgeon, Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], in three to four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2101-8-24**] 16:59:55
T: [**2101-8-24**] 17:46:57
Job#: [**Job Number 58312**]
| 20,077 | 169,009 | 4240,9971,42731,4295,2720,4169,E8789 |
Admission Date: [**2167-8-23**] Discharge Date: [**2167-9-10**]
Service: SURGERY
Allergies:
Pronestyl / Clindamycin / Coumadin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
"I need a colonoscopy"
Major Surgical or Invasive Procedure:
[**8-24**] Colonoscopy
[**8-25**] EGD with push enteroscopy
[**8-25**] Exploratory laparotomy with right hemicolectomy
History of Present Illness:
[**Age over 90 **] yo female with a h/o CHF and anemia, who presents for bowel
prep for a colonoscopy tomorrow AM. She reportedly has guaiac
positive stools, but colonoscopy has not been completed [**1-29**] pt
vomiting contrast material. She notes that she can eat solids
and liquids, but the rate at which she can swallow is her
limiting factor. Unclear what her baseline Hct is, but she has
recently been hospitalized for CHF/PNA/"severe" anemia in
[**Month (only) 404**] and again [**2167-1-28**] at [**Hospital3 **] Hospital. She
states that she does get "dizzy" with standing abruptly, and has
fallen multiple times, but mostly [**1-29**] decreased vision as
opposed to orthostasis. She has had DOE for years, stable, able
to walk half a mile or 1 flight of stairs before getting short
of breath. No chest pain or pedal edema. On ROS, no
constipation/diarrhea/melena/BRBPR/fever/chills/night
sweats/PND/orthopnea/incontinence or other urinary symptoms.
Past Medical History:
Pacemake placed >25 years ago
L Carotid stent placed 5-10 years ago
Open heart surgery in 50s for VSD
Has "lazy valve" per report
Gout in [**2167**] resolved with ibuprofen
Social History:
Pt lives with her daughter in [**Name (NI) **] in [**Hospital3 **] on the
weekends, and in [**Last Name (un) **] on the weekends at home. Has 2 cats and
1 dog. Drinks 1.5 cups of whiskey+soda daily, no smoking/IVDU
Family History:
No family h/o CA, DM, heart disease
Physical Exam:
T 98.5 BP 170/70 P 72 RR 20 93% O2 Sats RA
Gen: Pleasant woman in NAD, appears younger than stated age
HEENT: Clear OP, MMM, L surgical pupil, R pupil reactive at 1
cm, vision impaired bilaterally; can detect light and large
objects.
NECK: Supple, No LAD, JVP at 8-10 cm, No bruits
CV: RR, NL rate. NL S1, S2. Early diastolic murmur loudest over
apex
LUNGS: bibasilar fine crackles
ABD: Soft, NT, mild epigastric tenderness to deep palpation. NL
BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2167-8-23**] 03:45PM WBC-10.5 RBC-3.96* HGB-11.2* HCT-34.1* MCV-86
MCH-28.2 MCHC-32.7 RDW-15.4
[**2167-8-23**] 03:45PM PLT COUNT-310
[**2167-8-23**] 03:45PM PT-12.6 PTT-26.6 INR(PT)-1.1
[**2167-8-23**] 05:10PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.8
MAGNESIUM-1.8
[**2167-8-23**] 05:10PM LIPASE-29
[**2167-8-23**] 05:10PM ALT(SGPT)-35 AST(SGOT)-48* ALK PHOS-91
AMYLASE-77 TOT BILI-0.5
[**2167-8-23**] 05:10PM GLUCOSE-546* UREA N-23* CREAT-0.8 SODIUM-134
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12
[**2167-8-23**] 05:10PM BLOOD Lipase-29
[**2167-8-23**] 05:10PM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.8 Mg-1.8
Pre-operative Labs:
[**2167-8-25**] 10:37PM BLOOD WBC-12.7* RBC-3.60* Hgb-10.3* Hct-31.1*
MCV-87 MCH-28.6 MCHC-33.1 RDW-15.4 Plt Ct-301
[**2167-8-25**] 03:50PM BLOOD Neuts-85* Bands-5 Lymphs-7* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2167-8-25**] 10:37PM BLOOD PT-13.3* PTT-26.8 INR(PT)-1.2*
[**2167-8-25**] 10:37PM BLOOD Glucose-91 UreaN-30* Creat-1.4* Na-142
K-3.6 Cl-101 HCO3-25 AnGap-20
[**2167-8-25**] 10:37PM BLOOD CK(CPK)-59
[**2167-8-25**] 10:37PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2167-8-25**] 10:37PM BLOOD Calcium-8.3* Phos-4.8*# Mg-1.5*
Discharge Labs:
[**2167-9-8**] 03:15AM BLOOD WBC-14.5* RBC-2.69* Hgb-8.0* Hct-23.6*
MCV-87 MCH-29.6 MCHC-33.9 RDW-17.3* Plt Ct-444*
[**2167-9-8**] 03:15AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.1
[**2167-9-8**] 03:15AM BLOOD Plt Ct-444*
[**2167-9-8**] 03:15AM BLOOD Glucose-57* UreaN-27* Creat-1.0 Na-142
K-3.6 Cl-105 HCO3-28 AnGap-13
[**2167-9-8**] 03:15AM BLOOD Phos-3.1 Mg-1.7
[**2167-9-8**] 03:26AM BLOOD Type-[**Last Name (un) **] pH-7.36 Comment-GREEN TOP
[**2167-9-8**] 03:26AM BLOOD freeCa-1.11*
Microbiology:
[**2167-8-25**] 5:50 pm SWAB Site: PERITONEAL REC'D AT 11:30
PM.
GRAM STAIN (Final [**2167-8-27**]):
[**2167-8-26**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1052**] [**Last Name (NamePattern1) 5259**] AT 4:00 AM.
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S).
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
[**2167-8-31**] 9:52 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2167-9-3**]**
MRSA SCREEN (Final [**2167-9-3**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin sensitivity performed by agar screen.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- R
[**2167-8-31**] 9:49 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2167-9-3**]**
GRAM STAIN (Final [**2167-8-31**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2167-9-3**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
[**2167-9-7**] 3:49 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
[**2167-9-7**] 3:49 pm SWAB Site: RECTAL
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary): No VRE
isolated.
CT CHEST W/CONTRAST [**2167-8-25**] 4:33 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: please evaluate for perforation
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with severe abdominal pain s/p colonoscopy.
REASON FOR THIS EXAMINATION:
please evaluate for perforation
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT abdomen.
INDICATION: Severe abdominal pain post-EGD.
FINDINGS: A CT of chest and abdomen was performed with axial
images taken from the lung apices to the symphysis pubis. IV
contrast only was administered.
On the CT of thorax there is some soft tissue in the apices
bilaterally which may represent apical scarring.
This patient has a pacemaker with two leads in situ.
The pulmonary arteries are very large and the left atrium is
also prominent. The appearances may be consistent with pulmonary
hypertension.
The patient has cardiomegaly.
On the lung windows there is emphysematous change in the lungs
and some scattered scarring.
Anterior to the distal esophagus there is some free air.
Below the diaphragm air is seen to extend along the posterior
part of the caudate lobe and along the falciform ligament. Free
air is also seen anterior to the left lobe of the liver. More
inferiorly free air is seen posterior to the tip of the right
lobe of the liver.
There is intrahepatic bile duct dilatation. The common bile duct
measures 1 cm. The appearances may be consistent with the
patient's age.
The spleen is normal.
The adrenals and kidneys are unremarkable.
The bowel where visualized is normal.
CT PELVIS: Some free fluid is seen in the pelvis and extending
to the right side of the rectum. Several diverticula are seen in
the sigmoid colon.
BONY WINDOWS: Degenerative changes noted throughout the spine.
There is a high-density medium in the spinal canal which may
represent previous Thorotrast examination.
IMPRESSION:
Status post perforation from recent examination most likely
secondary to EGD. Free air seen extending into the mediastinum
from the inferior esophagus and extending down into the abdomen
around the liver and into the falciform ligament.
Bilateral pleural effusions and atelectasis. Biapical scarring
and emphysema. Cardiomegaly and enlarged pulmonary arteries
which may be secondary to pulmonary hypertension.
Diverticula in the sigmoid colon. Free fluid in the pelvis.
Degenerative change in the spine.
Intra- and extra-hepatic bile duct dilatation.
Possible Thorotrast exposure in the spinal canal.
Cardiology Report ECHO Study Date of [**2167-8-27**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Valvular heart disease.
Height: (in) 62
Weight (lb): 104
BSA (m2): 1.45 m2
BP (mm Hg): 108/35
HR (bpm): 60
Status: Inpatient
Date/Time: [**2167-8-27**] at 09:19
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.1 cm
Left Ventricle - Fractional Shortening: 0.51 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec)
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - E Wave: 1.6 m/sec
Mitral Valve - E Wave Deceleration Time: 566 msec
TR Gradient (+ RA = PASP): *50 to 60 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: *1.2 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall
hypokinesis.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused
commissures and tethering of leaflet motion. Moderate thickening
of mitral
valve chordae. Moderate MS. Mild to moderate ([**12-29**]+) MR.
TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic
hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
3. The right ventricular cavity is moderately dilated. There is
severe global
right ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. Mild (1+) aortic regurgitation is seen.
5. The mitral valve leaflets are severely thickened/deformed.
The mitral valve
shows characteristic rheumatic deformity. There is moderate
thickening of the
mitral valve chordae. There is moderate mitral stenosis. Mild to
moderate
([**12-29**]+) mitral regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
OPERATIVE REPORT
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 66760**]
Service: Date: [**2167-8-25**]
Surgeon: [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD 2205
PREOPERATIVE DIAGNOSIS: Perforated viscus.
POSTOPERATIVE DIAGNOSIS: Perforation of the right colon.
SURGICAL PROCEDURE: Laparotomy, right colectomy and
abdominal washout.
ASSISTANT: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD (RES)
ANESTHESIA: General.
INDICATIONS: This elderly woman has undergone 2 endoscopic
procedures with therapy in 2 days. These have included a
colonoscopy with BICAP of angiodysplastic lesions in the
cecum, as well as removal of a sigmoid polyp. On the
following day, she had a push enteroscopy with BICAP of
several lesions in her stomach. She originally did well, but
then developed the sudden onset of abdominal pain and had
free air under the diaphragm, confirmed both by upright chest
x-ray and CT scan. She is complaining of abdominal pain with
tenderness and has been given the option of surgical
treatment. At [**Age over 90 **] years old, she does wish to undergo surgery,
as there is a reasonable chance of fixing the problem.
PREPARATION: In operating room, the patient was given a
general endotracheal anesthetic. Intravenous antibiotics were
given, 2 grams of heparin and boots. The abdomen was prepared
with Betadine solution and draped in the usual fashion.
INCISION: A midline incision was made incorporating a
portion of the old lower midline incision with another upward
extension part way up between the umbilicus and the xiphoid.
The abdomen then opened and explored.
FINDINGS: There was a pneumoperitoneum. There were some
adhesions from her old surgery in the midline. There were
also adhesions from her cholecystectomy to the liver. There
was purulent fluid in the abdomen, a small but modest amount.
There was a small amount of free stool spillage from a tiny
perforation of the right colon. There was another perforation
which was even smaller, a centimeter or two away, in the
right colon. There were no other perforations that we could
see.
PROCEDURE IN DETAIL: The abdomen was opened. The adhesions
were lysed. We were able to suck out purulent fluid and find
the perforation in the cecum, which was closed over with silk
suture. The abdomen was then irrigated copiously after
control of the spill was accomplished. We also ran the bowel
and found several small diverticula of the small bowel which
were totally intact. There was no injury to the small bowel.
There did not appear to be any problem with the stomach. The
sigmoid colon also appeared to be normal, although there were
some adhesions down to the pelvis.
It was my feeling that the best therapy here would be a right
colectomy, in that the patient had a diseased right colon to
begin with, and the cause of the bleeding most likely. It
also appeared to be relatively thin walled and I was worried
that if I had oversewn the 2 areas where there were
perforations present now, that some of the other treated
areas, of which there were approximately 10, might become
problem[**Name (NI) 115**] in the next several days. Therefore, we mobilized
the right colon at the white line of Toldt. The hepatic
flexure was taken down. The omentum was taken off the
transverse colon. We selected our resection margin, taking
only approximately 3 or 4 inches of terminal ileum. We then
extended our resection down well around to the mid transverse
colon, in order to ensure that we had gotten all of the areas
of vascular malformation seen in the descending and ascending
colon. Bowel was cleaned off and [**Female First Name (un) 3224**] stapler was applied
across both the ileum and the colon. Mesentery was then taken
between clamp with 2-0 silk ties. The specimen was sent off
the field. Due to the lateness of the hour, it was not open.
We then oversewed the staple line with interrupted sutures of
3-0 silk. A side-to-side anastomosis was then created using
interrupted 3-0 silk in a single layer. The posterior row was
placed of sutures of 3-0 silk and then tied down. The colon
and ileum were then opened and the anterior row was placed.
The neck of the anastomosis was quite wide and spacious.
There was no evidence of leak. It was noted that gas and
liquid stool would pass without problem. The mesentery was
then closed with the 3-0 silk. The areas were inspected and
were dry.
CLOSURE: The fascia was closed with a running suture of #1
PDS. The skin was closed with a stapling device. Dry sterile
dressings were applied. The patient was then extubated and
sent to the recovery area in satisfactory condition, having
tolerated the procedure well.
DRAINS: None.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
Brief Hospital Course:
Ms. [**Known lastname 4427**] had been admitted to [**Hospital1 18**] on [**8-23**] under the medical
service for a colonoscopy secondary to her inability to tolerate
the oral contrast and a history of congestive heart failure and
anemia, along with her age of [**Age over 90 **] years. The colonoscopy
demonstrated multiple diverticula and angioectasias which were
cauterized. It was recommended that she undergo an enteroscopy
and be placed on iron replacement therapy. The small bowel
enteroscopy was performed on [**8-25**] which showed gastric
angioectasias that were cauterized and duodenal diverticula.
She developed acute abdominal pain with peritoneal signs after
her small bowel enteroscopy. An abdominal x-ray showed free air
under the diaphragm. An abdominal and pelvic CT scan was done
which showed free intraperitoneal air and perforation. The
surgical service was consulted and she was taken to the
operating room under the care of Dr. [**Last Name (STitle) **] for an
exploratory laparotomy and right hemicolectomy on [**8-25**]. She was
started on intravenous Zosyn and Flagyl pre-operatively and gram
negative rods were found on a peritoneal swab intra-operatively
and continued for a total of fourteen days. Ampicillin was added
on POD 4 after a nasal swab confirmed Staph Aureus Coag + and
was completed after four days of treatment and a repeat culture
showing no growth.
Post-operatively she developed low urine output and hypotension
and was admitted to the surgical intensive care unit. Her
creatinine was found to be elevated at 1.7 which was thought to
be related to the CT scan contrast. On POD 2 a Levophed drip was
started to maintain her systolic blood pressure greater than 110
and a renal consultation was initiated. The renal service
recommended more intravenous resuscitation and then challenging
with Lasix. An echocardiogram was also done in the setting of
her history of congestive heart failure, her central venous
pressures of 16 and low urine output. This showed her systolic
function to be >55% along with mild pulmonary hypertension,
tricuspid, and mitral regurgitation. On POD 3 her respiratory
status deteriorated and she was not tolerating continous
positive airway pressure via a face mask. An arterial blood gas
demonstrated respiratory and metabolic acidosis. A chest x-ray
confirmed pulmonary edema. She had persistent anuria after
Lasix, Bumex, and intravenous fluids. Hemodialysis was also
started on POD 3 by the renal service after her persistent
anuria and a creatinine of 3.7. After discussion with her
family, the patient's advanced orders of not intubating were
rescinded but the order of no resuscitation with chest
compressions was maintained, she was intubated and mechanically
ventilated on POD 3.
A Dobbhoff feeding tube was placed on POD 5 and tube feeds were
started. On POD 6 the dialysis was stopped secondary to an
increase in urine output but was resumed on POD 7 after her
weight was noted to have increased, she was anuric, and
pulmonary failure was noted on chest x-ray. The Levophed drip
continued along with mechanical ventilation. On POD 6 and 7 she
was transfused a total of two units of packed red blood cells
for a hematocrit of 24 and 21 with no active signs of bleeding,
with a good response in her hematocrit. On POD 9 the Levophed
was discontinued and hemodialysis was stopped secondary to
improvement in her renal function; her serum creatinine was 0.7,
and her urine output was satisfactory. On POD 10 she was
successfully extubated.
POD 12 a diet was resumed, she remained afebrile, and her
central venous catheter was removed secondary to an increased
white blood cell count of 15.5k; the tip was cultured with no
growth found. Diuresis continued with daily Lasix with a good
response in her urine output. On HD 13 her Dobbhoff was removed
and she was tolerating a regular diet. At the time of discharge
she was afebrile, oxygenating well on 3 liters nasal cannula,
tolerating a regular diet with +bowel movements and +flatus. She
had completed her antibiotic course and her white blood cell
count was stable at 12.9k. On HD18, she had an episode of
hypoglycemia (40 mg/dl). Her insulin was held, she was given
glucose, and she recovered without incident. The Lasix was
continued daily with the dose decreased from 40mg to 20mg, her
BUN was 29 with a creatinine of 0.9. She was hemodynamically
stable at the time of discharge with a hematocrit of 25.2. She
was transferred to [**Hospital1 599**] of [**Hospital 23638**] rehabilitation facility for
further strength and mobility training.
Medications on Admission:
Lorazepam 0.5 mg PO HS:PRN anxiety
Multivitamins 1 CAP PO DAILY
Atorvastatin 10 mg PO HS
Digoxin 0.125 mg PO DAILY
Furosemide 40 mg PO DAILY
Trandolapril 8 mg PO DAILY
Occuvite
Nexium 40
Plavix 75 (held)
Calcium qd
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Other Sig: Zero (0) every six (6) hours: Fingersticks to
be done every 6 hours with Regular Insulin Sliding Scale.
9. Lasix 20mg Tablet Sig: One (1) Tablet PO once a day.
10. Acetaminophen 500 mg/5 mL Liquid Sig: One (1) PO every six
(6) hours as needed for pain: Dose should equal 650mg or 6.5ml.
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Lorazepam 0.5 mg PO QHS for insomnia
Discharge Disposition:
Extended Care
Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]
Discharge Diagnosis:
Anemia
Perforated bowel
Discharge Condition:
Good
Discharge Instructions:
Notify your MD or return to the emergency department if you
experience:
*Increased or persistent pain
*Fever > 101.5
*Nausea or vomiting
*Inability to pass gas or stool
*If incision appears red, is warm, or if there is drainage
*Any other symptoms concerning to you
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, call ([**Telephone/Fax (1) 8818**] for an appointment
| 20,079 | 180,684 | 56985,4928,39891,3963,3970,9982,2762,5849,2851,42731,53782,2113,V4501,E8788 |
Admission Date: [**2130-9-28**] Discharge Date: [**2130-10-6**]
Date of Birth: [**2130-9-28**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 62319**] is the [**2080**] gram product of a 34-
[**4-17**] week gestation born to a 35 year old G2 P0 now 1 mother.
Prenatal screens were O positive, antibody negative,
hepatitis surface antigen negative, RPR nonreactive, rubella
immune, GBS unknown. Maternal history of uterine fibroids and
recurrent abdominal pain during this pregnancy. Previous
evaluations consistent with left fibroid pain and left
ovarian cyst. Mother presented at [**Hospital1 190**] on [**9-26**] with right abdominal pain.
Admitted to antepartum floor. On ultrasound on the day of
delivery, had features consistent with right ovarian torsion.
Mother's maximum temperature was 100.4. The decision was made
to deliver the infant by cesarean section. Of note, recent
fetal scan was suggestive of horseshoe kidney. No other
anomalies identified.
Maternal medications included Dilaudid and non steroidal anti-
inflammatories.
SOCIAL HISTORY: The father is involved and is a physician at
[**Hospital6 33**].
The infant emerged with good tone and grimace. Routine bulb
suctioning. Dried, stimulated, and responded well, with
spontaneous cry and improved color. Apgars were 8 and 9.
PHYSICAL EXAMINATION ON ADMISSION: Weight [**2080**] grams (25th
percentile), length 43.25 cm (25th percentile), head
circumference 32.25 cm (50th percentile). Pink, comfortable,
eyes open, looking around. Non dysmorphic. Palate intact. Red
reflex x 2. Ears normal set without anomalies. Neck supple
with no masses. Clavicles intact. Lungs clear to apex, fair
to good aeration. Positive subcostal retractions, but no
flaring or grunting. Cardiovascular - Regular rate and
rhythm. No murmur. 2+ femoral pulses. Abdomen soft. Positive
bowel sounds. No hepatosplenomegaly. Three vessel cord.
Genitourinary - Normal preterm female. Patent anus. Stable
hips. No sacral anomalies. Extremities pink, well perfused,
except for mild acrocyanosis. Good grasp, plantar reflex,
symmetric Moro.
HOSPITAL COURSE:
1. RESPIRATORY. [**Doctor First Name 21212**] has been stable in room air throughout
hospital course.
2. CARDIOVASCULAR. Has had no issues.
3. FLUID AND ELECTROLYTES. Birth weight was [**2080**] grams.
Discharge weight is 1890 gms. She was initially started on 60
cc/kg/day of D10W. Enteral feedings were started at 24
hours of age. Infant is currently ad lib feeding breast
milk or Enfamil 24 calorie, taking in good amounts.
4. GASTROINTESTINAL. Peak bilirubin was on day of life 3 of
11.2/0.3. She received phototherapy, and the issue has
resolved.
5. HEMATOLOGY. Hematocrit on admission is 54. She has not
required any blood transfusions.
6. INFECTIOUS DISEASE. A CBC and blood culture were obtained
on admission. CBC was benign, and blood culture remained
negative at 48 hours, at which time ampicillin and
gentamicin were discontinued.
7. NEUROLOGIC has been appropriate for gestational age.
8. SENSORY. Audiology - Hearing screen was performed with
automated auditory brainstem responses. Infant passed
bilerally.
9. GENITOURINARY. A renal ultrasound was done on [**10-2**],
revealing a horseshoe kidney. There was no hydronephrosis
evident.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home. VNA arranged for [**10-7**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Telephone/Fax (1) 51822**].
Appointment scheduled for [**10-9**].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
24 calorie, Enfamil 24 calorie, or ad lib breast feeding.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Was performed, and the infant
passed.
STATE NEWBORN SCREENING: Screens have been sent per
protocol, and have been within normal limits.
The infant received hepatitis B vaccine on [**10-5**].
DISCHARGE DIAGNOSES:
1. Premature infant born at 34-3/7 weeks.
2. Rule out sepsis, with antibiotics.
3. Horseshoe kidney.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2130-10-5**] 20:50:49
T: [**2130-10-5**] 23:19:22
Job#: [**Job Number 62320**]
| 20,080 | 125,299 | V3001,7533,7742,7608,76527,76517,V290,V053 |
Unit No: [**Numeric Identifier 57244**]
Admission Date: [**2132-12-8**]
Discharge Date: [**2133-3-13**]
Date of Birth: [**2132-10-16**]
Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is a 696 gram
product of a 24 and [**1-19**] week twin gestation with estimated
date of confinement of [**2133-2-3**], born to a 28-year-
old gravida 3, para 0, mom with prenatal screens - blood type
O positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, group beta
strep status unknown. This pregnancy was complicated by
prenatal neural tube defect in the sibling of this infant.
This infant subsequently died on [**10-31**], secondary to
complications from the neural tube defect. Pregnancy
otherwise uncomplicated until mom went into unstoppable
preterm labor. She had spontaneous rupture of membranes and
was treated with antibiotics prior to delivery. This infant
was delivered by cesarean section because of transverse lie.
She had Apgar scores of 6 at 1 minute, and 7 at 5 minutes of
age. She was dried and received bulb suctioning and was
intubated in the delivery room. She was always active and
vigorous. She was transported to the newborn intensive care
unit for management of prematurity.
PHYSICAL EXAMINATION: Weight 696 grams (25th to 50th
percentile), head circumference 23 cm (10th percentile),
length 32.5 cm (10th to 25th percentile).
VITAL SIGNS: Temperature 92.9 rectally, heart rate 148,
respiratory rate 64, blood pressure 34/16 with a mean
arterial pressure of 22, blood glucose 77.
HEENT: Anterior fontanel open and flat. Lips, gums and
palate intact. Skin bruising noted on arms and legs and head.
Neck supple.
LUNGS: Intercostal retractions and coarse breath sounds
noted.
HEART: Regular rate and rhythm. No murmurs. 2+ femoral pulses
bilaterally.
ABDOMEN: Soft. No active bowel sounds.
EXTREMITIES: Capillary refill brisk.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 57245**]
was admitted to the newborn intensive care unit and placed on
conventional mandatory ventilation shortly after admission.
She received 3 doses of surfactant. She was switched to hi-fi
ventilation on day of life 1 for worsening ventilation and
oxygenation. She received several doses of bicarb in the
first week of life for a persistent metabolic acidosis. She
remained on hi-fi oscillatory ventilation until day of life
25 when she was switched back to conventional mandatory
ventilation. She was started on Combivent on day of life 21
and Flovent on day of life 25. Flovent was weaned off by day
of life 43. Caffeine citrate was started on day of life 34
for apnea of prematurity. This was subsequently discontinued
on day of life 88. Diuril was started on day of life 36 for
chronic lung disease and Aldactone was started on day of life
75 also for chronic lung disease. She was extubated to
continuous positive airway pressure on day of life 82. She
required reintubation on day of life 111 secondary to
complications from eye drops and eye examination. She was
placed back on CPAP on day of life 117. She transitioned to
vapotherm (high flow humidified oxygen) on day of life 25,
and then finally to nasal cannula oxygen 200 cc, 100% by day
of life 141 ([**3-6**]). She remains on Diuril and Aldactone.
She also has been receiving Lasix twice a week.
Gas on day of discharge is: 7.35/61
Of note, infant had elevated pancreatic enzymes noted on newborn
screen that decreased with sample post blood transfusion. The
newborn screen was negative for CF mutations BUT given that there
are other potential mutations and pancreatic enzymes were very
elevated, newborn screening program recommended obtaining a sweat
test at~2 months of age.
CARDIOVASCULAR: [**Known lastname 57245**] received multiple fluid boluses and
was started on dopamine for hypotension on the date of
delivery. Dopamine was weaned off on day of life 2. She was
treated with 2 courses of indomethacin for patent ductus
arteriosus. The second course of indomethacin ended on day of
life 5. A follow up echo on [**10-22**] showed a persistent
patent ductus arteriosus. She was transferred to [**Hospital3 **] at 7 days of age for patent ductus arteriosus
ligation. Dopamine was restarted on day of life 6 for
continued hypotension. She remained on dopamine through day
of life 15 with maximum dose reaching 25 mcg per kg per
minute. Dopamine requirement likely related to presumed
sepsis going on at this time although she did receive 2 doses
of hydrocortisone, the first on [**10-27**] and the second on
[**12-3**], for presumed adrenal insufficiency which
subsequently helped her to wean off of the dopamine. She
continues to have a soft murmur. Last echo on [**10-30**]
showed good bilateral ventricular function. She will receive
a baseline echocardiogram prior to her discharge.
FLUIDS, ELECTROLYTES AND NUTRITION/ GASTROINTESTINAL: Upon
admission to the newborn intensive care unit, umbilical
arterial catheter and umbilical venous catheters were placed.
Intravenous fluids of D5W were started at 100 cc per kg per
day. Her maximum fluid volume reached 180 cc per kg per day
by day of life 5. [**Known lastname 57245**] had an acute episode on [**10-27**]
with hypotension and abdominal distention. Although there
were no corresponding radiographic signs this was presumed to
be necrotizing enterocolitis. She was started on antibiotics
at that time and watched clinically for progressing signs of
acute peritonitis. After this episode on [**10-27**], the
patient had progressive worsening of abdominal distention.
A contrast enema was performed on [**11-26**] which was
within normal limits revealing no structural defects and no
overt colonic obstruction. Upper gastrointestinal was
performed on [**12-1**] which showed delayed contrast into
the jejunal junction. Trophic feeds of breast milk at 20
calories per ounce were started on [**11-17**] and held on
[**11-20**] secondary to repeated biliary aspirates and
worsening abdominal distention. This prompted the above two
studies, the contrast enema and upper gastrointestinal.
[**Known lastname 57245**] has also had issues with indirect hyperbilirubinemia.
On [**11-5**], the bilirubin was total 4.2 with an indirect
of 2.3. On [**12-1**], her bilirubin was 4.8 with an
indirect of 3.3. This indirect hyperbilirubinemia was likely
due to a total parenteral nutrition cholestasis. The trace
elements were removed from her parenteral nutrition. In
addition carnitine was added to her daily parenteral
nutrition. Liver function tests were normal on [**11-7**].
On [**11-25**] they were mildly elevated with the following
values: ALT of 158, AST of 242, and alkaline phosphatase of
533. [**Known lastname 57245**] had a right middle quadrant, right lower quadrant
abdominal mass discovered on ultrasound on [**2132-11-5**].
This abdominal mass was of unknown etiology despite repeated
serial abdominal ultrasounds on [**11-12**], [**11-24**] and
[**12-1**]. In addition the patient received a noncontrast
abdominal CT on [**11-7**]. This abdominal mass has been
confirmed to be extraluminal, and not within the parenchyma
of the liver. Abdominal ultrasound on [**11-24**], revealed
evolving calcifications within this mass as well. Contrast
enema on [**11-26**] revealed that this mass is not likely to
be causing any colonic obstruction. In addition upper
gastrointestinal series on [**12-1**] revealed that this
mass is not likely to be causing any small bowel obstruction
as well. The patient had several meconium stools after the
barium enema on [**11-26**]. On [**12-3**], the patient was
taken for an exploratory laparotomy at [**Hospital1 57246**] hospital
to assess the abdominal mass No. 1 and No. 2 to assess the
patient's lower colonic small bowel strictures. The
exploratory laparotomy revealed multiple ileal perforations
and adhesions. The perforations were oversewn and the
procedure was tolerated well.
[**Known lastname 57245**] returned to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on
[**12-8**]. She remained NPO until do 62 at which time
trophic feeds were started. She was advanced over to full
volume feeds by day of life 76. Caloric density was increased
to maximum of 33 calories per ounce breast milk with ProMod.
Reglan was started on day of life 63. A rectal tube was
placed on day of life 62 to administer normal saline enemas
on a regular basis to promote stool passage. This was
discontinued on day of life 73. She is currently received PO,
PG feeds of NeoSure or breast milk concentrated to 28
calories per ounce. Her weight at the time of transfer is 3.9
kg. Her last electrolytes on [**3-10**] were sodium of 140,
potassium 4.3, chloride 94 and bicarb of 39. On [**3-6**],
her calcium was 10.9, alkaline phosphatase 483.
HEMATOLOGY: [**Known lastname 57245**]'s blood type is O positive, direct
antibody test negative. She has received a total of 14 packed
red blood cells transfusions and one platelet transfusion
during her newborn intensive care unit hospitalization. Her
last hematocrit on [**3-10**] was 34.7 with a reticulocyte
count of 2.2.
INFECTIOUS DISEASE: Upon admission to the newborn intensive
care unit, CBC and blood cultures were drawn and the infant
was placed on ampicillin and gentamycin. Blood culture at
this time was negative. CBC was remarkable for initial white
blood cell count of 5.3. She remained on ampicillin and
gentamycin for 7 days at which time they ampicillin and
gentamycin were discontinued. Vancomycin and gentamycin were
restarted on day of life 6 for presumed episode of
necrotizing enterocolitis. The patient was also put on
clindamycin at that time. On [**11-7**], the antibiotic
regimen was changed to vancomycin, meropenem, and
amphotericin secondary to this abdominal mass of unknown
etiology. The patient remained on this regimen for 2 weeks at
which time only meropenem was continued secondary to the
unresolving abdominal mass. On [**12-1**], vancomycin was
added to the regimen for the presence of a low grade
temperature. This was discontinued on [**12-3**] once blood
cultures showed no growth at 48 hours. The patient has had no
positive blood cultures throughout her hospital course. The
meropenem was discontinued postoperatively after the
exploratory lap.
Vancomycin and gentamycin were restarted on day of life 62
for increased abdominal distention. Blood culture was
negative at that time and vancomycin and gentamycin were
discontinued after 48 hours. Vancomycin and gentamycin were
again restarted on day of life 112 for an acute respiratory
decompensation and presumed pneumonia. Vancomycin was
discontinued and presumed pneumonia was ultimately treated
for 7 days with gentamycin, Zosyn and oxacillin. She had
thrush which was treated with nystatin from day of life 120
to 134.
NEUROLOGY: [**Known lastname 57245**] had normal head ultrasounds on [**10-17**],
[**10-20**], [**10-24**], [**10-27**], [**11-19**], and [**1-8**]. Head ultrasound on [**3-4**] showed asymmetry of the
lateral ventricles, the left being larger than the right with
increased echogenicity lateral to the left lateral ventricle.
A follow up MRI on [**3-5**] was normal. [**Known lastname 57245**] was on
Fentanyl infusions and boluses on and off for the first 2
months of age.
SENSORY:
1. Audiology: [**Known lastname 57245**] has not yet had a hearing screening.
2. Ophthalmology: [**Known lastname 57245**]'s last examination was on [**3-9**]
which showed regressing ROP, stage 2, zone 2. She is to
get a follow up ophthalmology examination in 2 weeks.
PSYCHOSOCIAL. [**Known lastname 57245**] has involved in loving parents. [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] social work is involved with
the family. The contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT THE TIME OF TRANSFER: [**Known lastname 57245**] is stable on nasal
cannula oxygen 200 cc, 100%.
DISCHARGE DISPOSITION: To [**Hospital3 1810**] via ambulance
for G-tube placement.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1787**] [**Last Name (NamePattern1) **], at
[**Hospital3 1810**]. Phone: [**Telephone/Fax (1) 38541**].
CARE RECOMMENDATIONS: [**Known lastname 57245**] has been NPO since 4 a.m.
Intravenous fluids of D10W with 2 mEq of sodium chloride and
1 mEq of potassium chloride infusing at 100 cc per kg per
day.
MEDICATIONS: On hold for now.
CAR SEAT POSITION SCREEN: Pending.
THE STATE NEWBORN SCREEN: The last State Newborn Screen was
sent on [**1-2**]. No abnormal results have been reported.
IMMUNIZATIONS RECEIVED: [**Known lastname 57245**] received Hepatitis B vaccine
on [**12-17**] and [**1-30**]. DTAP vaccine on [**12-17**], and
[**2-19**], HIB vaccine [**12-16**] and [**2-19**], IPV vaccine on
[**12-17**], and [**2-19**]. Prevenar vaccine on [**12-15**], and
[**2-19**], and Synagis vaccine on [**3-5**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria.
A. Born within 32 weeks.
B. Born between 32 and 35 weeks with two of the following:
2. daycare during the RSV season.
3. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
4. with chronic lung disease.
1. Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
Follow up appointments with infant include:
A sweat test is recommended for [**Known lastname 57245**] when age appropriate.
[**Known lastname 57245**] will be followed by pulmonology, the name is [**Name (NI) 4468**]
[**Name (NI) 37305**] at [**Hospital3 **]. [**Known lastname 57245**] will also be followed
by care group VNA ([**Hospital6 **]). Tel No. [**Telephone/Fax (1) 57247**]. Fax No [**Telephone/Fax (1) 57248**].
[**Known lastname 57245**] will be getting her G-tube supplies, formula, oxygen
and home monitor through [**Location (un) 511**] Home Therapy. Phone No.
1-[**Telephone/Fax (1) 33819**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 24 and 2/7 weeks.
2. Respiratory distress syndrome.
3. Presumed sepsis.
4. Patent ductus arteriosus status post patent ductus
arteriosus ligation.
5. Necrotizing enterocolitis.
6. Ileal perforations status post exploratory lap and
oversew.
7. Direct hyperbilirubinemia.
8. Physiologic jaundice.
9. Apnea of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2133-3-12**] 22:12:31
T: [**2133-3-13**] 00:10:46
Job#: [**Job Number 57249**]
| 20,082 | 147,507 | 7707,7742,7775,7793,78341,769,77081,36221,7766 |
Unit No: [**Numeric Identifier 57244**]
Admission Date: [**2133-3-13**]
Discharge Date: [**2133-3-19**]
Date of Birth: [**2132-10-16**]
Sex: F
Service: Neonatology
ADDENDUM: Please see previously detailed discharge summary
for hospital course by systems. This dictation covers the
period from [**3-13**] through [**2133-3-19**], postoperatively from
gastrostomy tube placement.
System number one: Respiratory.
[**Known lastname 57245**] is stable on nasal cannula oxygen, 200 cc flow, 100
percent. Her baseline respiratory rate is 40 to 60 breaths
per minute. She is being discharged on oxygen and diuretics,
Diuril and Aldactone. She will be seen in pulmonary clinic
with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] at [**Hospital3 1810**]. As noted in the
previous discharge summary Myelia had elevated pancreatic
enzymes noted on initial newborn screen that decreased with
sample post blood transfusion. The newborn screen wa negative
for CF mutations BUT given that there are other potential
mutations and pancreatic enzymes were very elevated, newborn
screen program recommended obtaining a sweat test at ~2 months
of age.
Baseline ABG obtained [**3-19**]: 7.35/61/64 on RA
System number two: Cardiovascular.
A murmur remains audible at the time of discharge. A recent
echocardiogram on [**2133-3-6**] showed a patent foramen ovale with
left to right flow and a slightly dilated right ventricle
with good function. Recent blood pressure is 80/44 with a
mean of 67. Baseline heart rate is 120 to 150 beats per
minute.
System number three: Fluids, electrolytes and nutrition.
[**Known lastname 57245**] is allowed to p.o. feed ad lib from 6 a.m. to 6 p.m.
during the day. At night, her total volume is adjusted to
deliver 130 cc/kg per day via the gastrostomy tube and pump.
Her formula is either breast milk or Similac, both fortified
to 30 calories per ounce. The formula is four scoops of
unpacked powdered formula to 185 cc of water. The breast
milk is 1.5 tsp of Similac formula powder to 70 cc of breast
milk. An additional four calories per ounce is added by 0.5
cc of corn oil. Weight on the day of discharge is 3.99 kg
with a length of 54 cm and a head circumference of 38 cm.
lytes on [**3-19**]: 134/5.1/94/34
System number four: Gastrointestinal.
[**Known lastname 57245**] had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] gastrostomy tube placed on [**2133-3-13**] for
postoperative recovery. This has been uneventful.
System number five: Sensory.
Audiology: Hearing screening was performed with automated
auditory brain stem responses. [**Known lastname 57245**] passed in both ears.
Ophthalmology: Most recent eye examination was on [**2133-3-9**],
showing regressing stage II retinopathy of prematurity.
Follow up is recommended with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital3 1810**].
System number six: Psychosocial.
The patient's name, after discharge, will be Wornum.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 56128**] [**Last Name (NamePattern1) **], [**Hospital3 1810**],
[**Hospital1 9796**], [**Location (un) 86**], [**Numeric Identifier **]. Phone number [**Telephone/Fax (1) 57250**]. Fax number [**Telephone/Fax (1) 38542**].
CARE AND RECOMMENDATIONS:
1. Feeding: Feeding to be by p.o. or by gastrostomy tube
feeding for a total of 130 cc/kg per day of breast milk or
Similac, 30 calories per ounce.
2. Medications:
Diuril 80 mg p.o. twice a day.
Aldactone 12 mg p.o. once daily.
Lasix 8 mg twice weekly on Monday and Thursday p.o..
Ferrous sulfate 25 mg/ml dilution, 0.3 ml p.o. once daily.
Prilosec 4 mg p.o. once daily.
Potassium chloride supplement, 6 meq twice a day.
Reglan 0.4 mg p.o. three times daily, one-half hour before
feeding.
1. Car seat position screening was performed. [**Known lastname 57245**] was
observed for 90 minutes in her car seat without any
episodes of oxygen desaturation or bradycardia.
2. No new additional state screens have been sent. Last was
on [**2133-1-2**], with normal results.
3. No further immunizations have been administered. Synagis
was given on [**2133-3-5**].
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 and 35 weeks with two of the following: Daycare during
RSV season , a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; or (3)
with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for house hold
contacts and out of home caregivers.
FOLLOW UP: Scheduled or recommended:
1. Dr. [**First Name8 (NamePattern2) 56128**] [**Last Name (NamePattern1) **], primary pediatrician, Friday, [**3-20**]
at 2:15 p.m.
2. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], pediatric pulmonology, phone number [**Telephone/Fax (1) 57251**]. Appointment scheduled for [**3-31**] at 11 a.m.
A sweat test is scheduled and an appointment at 12:30 with
Dr. [**Last Name (STitle) 37305**].
3. Dr. [**Last Name (STitle) **], pediatric ophthalmology, phone number [**Telephone/Fax (1) 57252**]. An appointment is needed the week of [**2133-3-23**].
4. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5715**], pediatric surgery, phone number [**Telephone/Fax (1) 57253**]. Appointment scheduled for [**4-13**] at 10:30 a.m.
5. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 1557**], pediatric feeding team, phone number [**Telephone/Fax (1) 57254**]. Appointment to be scheduled.
6. Would also recommend family contacting state registry motor
vehicles to obtain a handicapped plackard in setting of Myelia's
oxygen need.
DISCHARGE DIAGNOSES:
1. Former premature infant at 24 and 2/7 weeks gestation.
2. Chronic lung disease.
3. Patent foramen ovale.
4. Retinopathy of prematurity.
5. Status post gastrostomy tube placement.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 43886**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2133-3-19**] 04:24:33
T: [**2133-3-19**] 05:40:57
Job#: [**Job Number 57255**]
| 20,082 | 147,507 | 7707,7742,7775,7793,78341,769,77081,36221,7766 |
Admission Date: [**2132-10-16**] Discharge Date: [**2132-12-3**]
Date of Birth: [**2132-10-16**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is a 24 [**1-19**]
week gestational age twin girl born to a 28 year old gravida
III, para 0 mother with the following prenatal laboratories:
Blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, GBS unknown.
Of note was a prenatal diagnosis of twin boy number 1 with a
known neural tube defect discovered on prenatal ultrasound.
This patient, twin girl 2 had no prenatally diagnosed
congenital formations on ultrasound. The patient was born
via cesarean section secondary to unstoppable preterm labor.
The patient was delivered in transverse lie, vigorous at
birth with spontaneous respirations. Heart rate at 100.
Patient was given bag mas ventilation times one minute and
promptly intubated in the delivery room. Apgars 6 and 7 at
one and five minutes. The patient was subsequently
transferred to the Neonatal Intensive Care Unit for further
management.
PHYSICAL EXAMINATION ON PRESENTATION: Birth weight is 696
grams, length was 32.5 cm, head circumference was 23 cm.
Vital signs on admission: Heart rate 140 to 150, blood
pressure means ranging from 24 to 36, respirations on
mechanical ventilation 25 breaths per minute, temperature
98.7.
General: Preterm female on mechanical ventilation in radiant
warmer.
Head, eyes, ears, nose and throat: Anterior fontanelle open
and flat, oropharynx clear, palate intact, endotracheal tube
in place, no dysmorphic features. Eyes fused. Neck supple,
no crepitus.
Respiratory: Mechanical breath sounds equal bilaterally,
good air exchange, mild intermittent retractions.
Cardiac: Regular rate and rhythm, S1, S2 normal, II/VI
systolic ejection murmur with radiation to the left axilla,
femoral pulses 2 plus bilaterally.
Abdomen: Soft, nondistended, bowel sounds, no
hepatosplenomegaly noted, anus patent.
Extremities: Well perfused, no cyanosis or edema. Spine
intact, no dimpling. No Ortolani or Barlow sign present.
Neurologic: Spontaneous MAE, appropriate tone on
examination. Palmar and plantar reflexes intact.
PHYSICAL EXAM AT TIME OF TRANSFER: alert, active, AFOF, coarse
breath sounds, mild-moderate ic/sc retx. abdomen extremely
distended, decreased bowel sounds, ext well perfused. tone aga.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient was intubated in the delivery
room and brought down to the Neonatal Intensive Care Unit
for further management. Patient received a total of three
doses of surfactant. Patient was ventilated on
synchronous intermittent mandatory ventilation for 24
hours and then transitioned to high frequency ventilation
on day of life number 2. Patient remained on high
frequency ventilation until [**2132-11-11**] at which point she
was transitioned back to conventional ventilation. At the
time of this summary, the patient is on conventional
ventilation with current settings of 21/5, respiratory
rate of 24 and FIO2 of 28 percent oxygen.
At approximately one week of life patient showed radiographic
signs of pulmonary interstitial emphysema bilaterally and
showed persistent signs until two weeks of life at which
point this resolved. During the 2nd week of [**Month (only) 1096**], cysts
were noted in the right lower base and mean airway pressures
were minimized as low as 19/5. On the most recent films,
these cysts have resolved. For persistent pulmonary
insufficiency patient was trialed on Flovent MDI starting
[**2132-11-11**] and was continued on this medication for two
weeks at which point it was weaned off. She was also
trialed on Combivent 2 puffs q 6 starting on [**2132-11-11**]
and remains on this medicine at time of this summary.
Patient was also started on Diuril on [**2132-11-17**] and weaned
to a maximum intravenous dose. Patient has been on
caffeine since [**2132-11-20**] and remains on caffeine at time
at thissummary.
2. CARDIAC: Cardiac murmur was detected on day of life
number two consistent with a patent ductus arteriosus. On
[**2132-10-20**] a course of indomethacin was started. Patient
received two full doses of indomethacin with no resolution
signs of a patent ductus arteriosus including murmur,
widened pulse pressures and palmar pulses. Cardiac
echocardiogram on [**2132-10-20**] revealed a large unidirectional
patent ductus arteriosus with no other structural defects
of the heart. On [**2132-10-23**] patient was taken to
[**Hospital3 1810**] for ligation of the patent ductus
arteriosus. The operation was well tolerated with no
problems afterwards.
The patient had intermittent periods
of hypotension throughout her hospital course. Dopamine
was started on day of life number 2. Patient continued on
dopamine for hypotension until [**2132-10-31**] at which time it
was discontinued. The patient did receive stress doses of
hydrocortisone on [**10-27**] as well as [**12-3**] for presumed
adrenal insufficiency prior to abdominal surgery.
GASTROINTESTINAL: Patient had an acute episode on
[**2132-10-27**] with hypotension and abdominal distention.
This episode was presumed to be necrotizing enterocolitis
although there were no corresponding radiographic signs.
The patient was started on antibiotics at that time and
watched clinically for progressing signs of acute
peritonitis. After this episode on [**10-27**] the patient had
progressive worsening of abdominal distention. A contrast
enema was performed on [**2132-11-26**] which was within normal
limits revealing no structural defects and no overt
colonic obstruction. Upper gastrointestinal was performed
on [**2132-12-1**] which showed delayed contrast into the
jejunal junction.
Trophic feeds of breast milk 20 calories per ounce was
started on [**2132-11-17**] and held on [**2132-11-20**] secondary to
repeated biliary aspirates and worsening abdominal
distention. This prompted the above two studies--contrast
enema and UGI.
Patient also had a problem of indirect
hyperbilirubinemia. On [**11-5**] the bilirubin was total of
4.2, indirect 2.3. On [**12-1**] bilirubin 4.8 with indirect
of 3.3. This indirect hyperbilirubinemia was likely due
to total parenteral nutrition cholestasis. The trace
elements have been removed from her parenteral nutrition.
In addition Carnitine has been added to her daily
parenteral nutrition. Liver function tests were normal on
[**2132-11-7**]. On [**2132-11-25**] they were mildly elevated with
the following values, ALT 158, AST 242, alkaline
phosphatase 533.
Patient has had a right middle
quadrant/right lower quadrant abdominal mass discovered on
ultrasound on [**2132-11-5**]. This abdominal mass is of
unknown etiology despite repeated serial abdominal
ultrasounds on [**2132-11-12**], [**2132-11-24**] and [**2132-12-1**]. In
addition, the patient received a noncontrast abdominal CT
on [**2132-11-7**]. This abdominal mass has been confirmed to
be extraluminal, and not within the parenchyma of the
liver. Abdominal ultrasound on [**2132-11-24**] revealed
evolving calcifications within this mass as well. Contrast
enema on [**2132-11-26**] revealed that this mas is not likely
to be causing any colonic obstruction. In addition, upper
gastrointestinal series on [**2132-12-1**] revealed that this
mass is not likely to be causing any small bowel
obstruction as well. Patient has had several meconium
stools after the barium enema on [**2132-11-26**]. On
[**2132-12-3**] the patient was taken for an exploratory
laparotomy at the [**Hospital3 1810**] to assess the
abdominal mass number one, and number two to assess the
patient's lower colonic/small bowel strictures.
1. FLUID, ELECTROLYTES AND NUTRITION: The patient has been
placed on parenteral nutrition on day of life number one
and is continued on parenteral nutrition at the time of
discharge suddenly. Patient has been given interlipids
which have been stopped intermittently for increased
triglycerides.
1. HEMATOLOGY: The patient has had anemia secondary to her
prematurity and frequent phlebotomy. She has received
packed cell transfusions on [**2132-10-20**], [**2132-10-27**],
[**2132-10-30**], [**2132-11-4**], [**2132-11-12**], [**2132-11-19**]. 12/20/2204
and [**2132-12-3**]. Patient has had direct hyperbilirubinemia
for which she has received phototherapy times two courses
in her hospital course.
1. INFECTIOUS DISEASE: The patient was initially placed on
Vancomycin and Gentamycin for a seven day course at which
time this was discontinued. On [**2132-10-27**] secondary to a
presumed episode of necrotizing enterocolitis. The
patient was placed on Vancomycin, Gentamicin, Clindamycin.
On [**2132-11-7**] the antibiotic regimen was changed to
Vancomycin, meropenem, M amphotericin secondary to this
abdominal mass of unknown etiology. The patient remained
on this antibiotic regimen for two weeks at which time
only meropenem was continued secondary to the nonresolving
abdominal mass. On [**2132-12-1**] Vancomycin was added to the
regimen for the presence of a low grade temperature. This
was discontinued on [**2132-12-1**] once blood cultures were no
growth to date from [**2132-12-1**] times 48 hours. The
patient has had no positive blood cultures throughout her
hospital course. The plan was to discontinue meropenem post-
operatively if an abscess was not found.
1. NEUROLOGIC: Patient has been on a Fentanyl drip
throughout her hospital course for agitation and lability.
Head ultrasounds on [**2132-10-20**], [**2132-10-27**], [**2132-11-4**] and
[**2132-11-19**] have all been within normal limits revealing no
structural defects as well as no intraventricular
hemorrhage.
1. EYE EXAMINATIONS: On [**2132-11-11**] revealed immature retinas
zone 1. Eye examination on [**2132-12-2**] showed immature
retinas, stage 1, zone 2. Follow up recommended in two
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 56760**]
MEDQUIST36
D: [**2132-12-3**] 10:23:35
T: [**2132-12-3**] 12:18:58
Job#: [**Job Number 57243**]
| 20,082 | 165,977 | V3101,76502,769,7775,7742,7707,7793,77181,7757,76522,7470,7766,36221,4589,78933,2554 |
Admission Date: [**2132-10-16**] Discharge Date: [**2132-12-3**]
Date of Birth: [**2132-10-16**] Sex: M
Service: NB
ADDENDUM FROM [**2132-12-3**]
FEEDS: No feeds at time of discharge.
MEDICATIONS:
1. Meropenem (to be discontinued if no abscess found)
2. Fentanyl 2.5 mcg/kg/min.
3. Combivent 2 puffs MDI q 6 h.
4. Diuril 20 mg/kg/day
IMMUNIZATIONS: None administered through hospital course.
CONDITION ON DISCHARGE: Critical.
DISCHARGE DISPOSITION: To [**Hospital3 1810**] for further
management.
DISCHARGE DIAGNOSES:
1. Prematurity at 24-2/7 weeks gestational age.
2. Respiratory distress.
3. Chronic lung disease.
4. Patent ductus arteriosus, status post ligation.
5. Hypotension, resolved.
6. Necrotizing enterocolitis.
7. Abdominal distention.
8. Abdominal mass, unknown etiology.
9. Indirect hyperbilirubinemia.
10. Anemia.
11.
Presumed sepsis.
12. Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 43886**]
Dictated By:[**Last Name (NamePattern1) 57241**]
MEDQUIST36
D: [**2132-12-3**] 10:26:17
T: [**2132-12-3**] 11:50:32
Job#: [**Job Number 57242**]
| 20,082 | 165,977 | V3101,76502,769,7775,7742,7707,7793,77181,7757,76522,7470,7766,36221,4589,78933,2554 |
Admission Date: [**2197-11-7**] Discharge Date: [**2197-11-15**]
Date of Birth: [**2152-10-15**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 6483**] is a 44 year-old
female who was evaluated by the Transplant Center for a right
donor hepatectomy for her sister [**Name (NI) **] [**Name (NI) 41841**]. Ms.
[**Known lastname 6483**] is otherwise in excellent health. She presented to
[**Hospital1 69**] for a donor liver
transplant. Preoperative risks and complications were
reviewed prior.
PAST MEDICAL HISTORY: Migraines. Otherwise there is no
cardiac or pulmonary disease noted.
PAST MEDICAL HISTORY: Status post left knee arthroscopy
times two.
ALLERGIES: Percocet and Codeine, which gives the patient
gastrointestinal upset.
MEDICATIONS:
1. Zoloft 50 mg po q.d.
2. Multivitamin.
3. Trazodone prn at bedtime.
PHYSICAL EXAMINATION: Temperature 97.8. Blood pressure
107/50. Pulse 64. Respiratory rate 18. Satting 97% on room
air. Height 5'5", weight 150 pounds. General, alert and
oriented times three. Well developed, well nourished female
in no acute distress. Head, eyes, ears, nose and throat
pupils are equal, round and reactive to light.
Normocephalic, atraumatic. Extraocular movements intact.
Oropharynx was clear. Respirations lungs were clear to
auscultation bilaterally. Cardiac regular rate and rhythm.
No murmurs, rubs or gallops. Abdomen soft, nontender,
nondistended. Extremities no clubbing, cyanosis or edema.
Moving all extremities times four.
LABORATORY DATA COLLECTED PREOPERATIVELY: Normal white blood
cell count, hemoglobin, platelets, liver function tests and
albumin of 4.4. Her hepatitis A antibody was negative. Her
hepatitis B surface antigen, surface antibody and core
antibody were negative. Hepatitis C antibody was negative as
well. The patient underwent the normal preoperative imaging
and tests required for a donor hepatectomy.
HOSPITAL COURSE: Ms. [**Known lastname 6483**] is a 45 year-old female in
otherwise good health. She presented to [**Hospital1 346**] on [**2197-11-17**] for a right
donor hepatectomy for her sister [**Name (NI) **] [**Name (NI) 41841**]. The
operation went without any complications. She had an
estimated blood loss of about 1800, which was replaced with
1000 Cell [**Doctor Last Name 10105**]. Epidural was placed initially for pain
control and was placed on a short course of Unasyn
perioperatively. From the recovery room she was transferred
to the Intensive Care Unit for close monitoring. She had
some respiratory insufficiency with a combination of
respiratory metabolic acidosis. She required some fluid.
Arterial blood gases were continually checked and her
acidosis eventually resolved. However, on postoperative day
two she was markedly around 12 liters positive for overall
fluid balance. The patient went into a rapid atrial
fibrillation. She was placed on a Diltiazem drip and she
received Amiodarone as well at which time she converted to
normal sinus rhythm. Her liver function tests continually
trended downward. She maintained good urine output
throughout her postoperative course. She had a postoperative
liver duplex ultrasound, which was a normal study with
normal wave forms. A bilirubin was checked within her JP
drain, which revealed 7.5. All her cardiac enzymes were
negative times three. She was noted to have a left hand
thrombophlebitis for which she was started on Unasyn. The
patient was transferred to the floor on postoperative day
four wherein she remained in stable condition. Her diet was
advanced slowly, which was tolerated. Our goal at that point
was to continue with diuresis at around 2 liters negative per
day, which is achieved using Lasix. Her lateral JP drain was
removed on postoperative day nine. It was felt that the
patient was stable for discharge on postoperative day nine.
Her pain was well controlled. Her liver function tests had
trended downward within normal limits. She was to be
discharged with a one week course of Augmentin for a left
hand thrombophlebitis. She additionally is to follow up with
Dr. [**Last Name (STitle) **] at the Transplant Center.
CONDITION ON DISCHARGE: Home.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Status post right donor hepatic lobectomy.
2. Status post left hand thrombophlebitis.
3. Short course postoperative atrial fibrillation.
DISCHARGE MEDICATIONS:
1. Sertraline 50 mg one tab po q day.
2. Trazodone 25 mg po q.h.s. prn insomnia.
3. Augmentin 875 mg one tab po b.i.d. for seven days total.
4. Percocet one to two tabs po q 4 to 6 hours prn pain.
5. Colace 100 mg one tab po b.i.d.
FOLLOW UP PLANS: The patient is to follow up at the
Transplant Center, telephone number [**Telephone/Fax (1) 673**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Monday [**2197-11-20**] at 1:50 p.m. She
is additionally to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the
Transplant Center on [**2197-11-29**] at 10:00 a.m. She is
to be discharged with her medial JP drain in place to be
removed in clinic. At that time she is to undergo additional
laboratory work.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2197-11-15**] 03:32
T: [**2197-11-20**] 06:15
JOB#: [**Job Number 50945**]
| 20,083 | 162,595 | V596,2762,462 |
Admission Date: [**2124-12-12**] Discharge Date: [**2124-12-22**]
Date of Birth: [**2050-4-17**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Stroke (right sided weakness and dysarthria)
Major Surgical or Invasive Procedure:
PEG placement [**2124-12-21**]
History of Present Illness:
This is a 74 year-old female with a history of diabetes,
hypertension, hyperlipidemia, with known CAD by cath in [**2120**],
and diastolic dysfunction transferred from [**Hospital3 46817**] for cardiac catheterization for NSTEMI and found to
have a new stroke. Per husband, she had sustained slip and
fall(unwitnessed) [**2124-12-11**], found down by her husband and son
helped her into bed and she was unsteady on her feet. They
brought pt to [**Hospital6 8283**] where CT head was
negative but troponins were elevated, TNI 2.21. She was
heparinized overnight and transferred on the first boat to [**Hospital1 18**]
this AM. Per report at [**Hospital6 8283**], Stroke score
0, verbal w/o focal abnormalities, heparin IV, ASA, plavix for
TNI 0.02 came w/new facial droop, slow speech, lethargic,
picking at herself.
She was transferred here for further evaluation. CT head
negative here, MRI/MRA w/acute MCA stroke. Neuro consulted, said
no TPA because were unsure of chronicity. TNI here 0.09, EKG
w/STD in 1 V5-V6 TWI in III, avF. Cardiology was concerned about
NSTEMI. exam also significant for dysarthria (pt's son said
started [**12-11**]), right arm drift and diffuse weakness/asthenia.
MRI-small b/l strokes.
.
In the ED, initial vitals were Tm: 98.0 HR: 102 BP: 195-94 RR:
17 O2Sat: 96% on 4L. There, she was found to be somnolent, have
a facial droop and right pronator drift. She had a non-contrast
head CT which was negative, but the MRI showed acute MCA stroke,
L striatocapsular stroke w/ additional small R striatocapsular
stroke per Neurology. No evolution of neuro exam. For management
of her elevated blood pressures, she received 10mg IV labetalol,
hydralazine and metoprolol 5mg IV. The patient was admitted for
further evaluation and management. Unable to perform ROS as pt
aphasic.
Past Medical History:
CAD, 3 vessel disease found on cardiac cath [**2120-7-23**]; s/p cabg
Diastolic Dysfunction
Diabetes
Dyslipidemia
Hypertension
Atrophic Kidney
Hx of R retinal artery embolus [**2123-10-18**], when she had presented
with visual illusion of a purple flower, started on Plavix at
that time in addition to her full ASA 325. Work-up at the time
included negative TTE and carotid U/s. Residual decrease VA in
that eye.
MEDICATIONS:
-Metformin 750 Qday
-Glyburide [**Hospital1 **]
-ASA 325
-Plavix 75
-Candesartan 16 Qday
-Fluticasone nasal spray
-Lipitor 20
-Metorpolol 50 [**Hospital1 **]
Social History:
Retired, lives in [**Hospital3 4298**] with husband,
helps out at family's flower shop, no hx tobacco, social EtOH,
has 2 children, functionally independent at baseline, drives.
Daughter [**Name (NI) 402**] [**Telephone/Fax (1) 56188**]
Son [**Name (NI) **] and husband [**Name (NI) **] [**Telephone/Fax (1) 56189**]
Family History:
Non contributory
Physical Exam:
T 98 HR 86 BP 210/110 [**Month (only) **] to SBP 175 after 10 mg Hydral RR 16
sO2
98% on 2 L nc
GEN: looks unwell but no acute distress
HEENT: mmm
NECK: no LAD; no carotid bruits; no meningismus, limited ROM at
neck
LUNGS: Clear to auscultation bilaterally
HEART: Nitro patch, regular rate and rhythm, normal S1 and S2,
no
murmurs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Attention: DOWbw.
Language: fluent; repetition: intact; Naming intact;
Comprehension intact; moderate dysarthria and hypophonic speech,
no paraphasic errors. Prosody: normal. No Apraxia. No Neglect.
CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round
and reactive to light both directly and consensually, 3-->2 mm
bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus. No
ptosis.
V: Facial sensation intact to light touch.
VII: R facial droop
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis. RUE pronator drift with
deltoid and triceps 5-, bilat [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] more prominent on
IP/hamstrings/dorsiflexion but symmetric bilat.
REFLEXES: 1+ throughout, plantar response mute bilat
SENSORY SYSTEM: Sensation intact to light touch without
extinction to DSS.
COORDINATION: Difficulty with FNF in RUE.
GAIT: too weak to stand
Pertinent Results:
[**2124-12-12**] 10:50AM
FIBRINOGE-459*
PT-13.7* PTT-37.0* INR(PT)-1.2*
PLT COUNT-284
NEUTS-78.2* LYMPHS-15.7* MONOS-4.0 EOS-1.5 BASOS-0.6
WBC-9.7 RBC-4.58 HGB-13.6 HCT-39.2 MCV-86 MCH-29.7 MCHC-34.8
RDW-13.6
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.5*
GLUCOSE-187* UREA N-13 CREAT-0.6 SODIUM-139 POTASSIUM-3.9
CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2124-12-12**] 11:20AM URINE
MUCOUS-RARE
HYALINE-0-2
RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2
BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG
mthdone-NEG
ECG: Sinus rhythm at 101 bpm, <1mm STD in 1 V5-V6 TWI in III,
avF new compared to old dated [**2120-7-26**].
[**2124-12-12**] 10:50AM CK-MB-11* MB INDX-2.3
[**2124-12-12**] 10:50AM cTropnT-0.09*
[**2124-12-12**] 10:50AM CK(CPK)-475*
[**2124-12-12**] 08:38PM CK-MB-8 cTropnT-0.07*
CT HEAD W/O CONTRAST Study Date of [**2124-12-12**] 10:33 AM
IMPRESSION: No evidence of acute intracranial hemorrhage or
large vascular
territory ischemia. However, if acute stroke is suspected, MRI
is
recommended.
CHEST (PORTABLE AP) Study Date of [**2124-12-12**] 11:59 AM
IMPRESSION: Stable cardiomegaly with no signs of failure or
acute pneumonia. Density in the aorticopulmonary window may
represent clips from prior surgical procedure (closure of PDA).
Study Date of [**2124-12-12**] 12:43 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O
CONTRAST; MR 3D RENDERING W/POST PROCESS
1. Acute infarction of the left corona radiata and the left
posterior aspect of the putamen. Focal area of infarction in the
right parietal lobe. This distribution is indicative of a
central source of emboli-like a cardiac source.
2. Changes consistent with chronic small vessel ischemic disease
and old
lacunar infarctions.
3. Stenosis of the right M1 segment.
TTE (Complete) Done [**2124-12-13**] at 11:01:15 AM
IMPRESSION: No cardiac source of embolism identified. Preserved
global and regional biventricular systolic function. Mild aortic
regurgitation.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the report of the prior study (images unavailable
for review) of [**2120-7-23**], there is now symmetric LVH. The degrees
of mitral and aortic regurgitation are slightly less on the
current study.
TTE (Focused views) Done [**2124-12-13**] at 3:48:37 PM
IMPRESSION: Suboptimal image quality. No premature passage of
microbubbles into the left heart is seen at rest or with
maneuvers.
HIP 1 VIEW Study Date of [**2124-12-13**] 7:32 AM
Single bedside frontal radiograph of the right hip is normal. No
fracture
identified and normal appearing right hip
CT C-SPINE W/O CONTRAST Study Date of [**2124-12-13**] 9:30 AM
IMPRESSION:
1. No fracture or malalignment.
2. Multilevel spondylosis. Mild spinal canal stenosis at C5/6.
Brief Hospital Course:
This 74 yo woman was admitted with simultaneous NSTEMI (max trop
0.09) and stroke affecting her left corona radiata and posterior
putamen resulting in right face, arm, and leg weakness, and
dysphagia. The etiology was thought to be more small vessel, but
in the context of these events on anti-platelet agents, it was
felt she would ultimately benefit from anticoagulation. In the
short term, a joint decision between neurology and cardiology
was made to hold off on anticoagulation out of fear for
hemorrhagic conversion and to continue her aspirin and plavix.
Her echo showed preserved EF, no evidence of embolic source and
no PFO. Her HgbA1C was 7.2. Her blood sugars were difficult to
control in the context of having her home metformin and
glyburide held. These were re-started on discharge. Her blood
pressures were also difficult to control and after a period of 3
days during which most of her BP meds were held in an attempt to
allow her BP to autoregulate in the aftermath of her stroke, she
was restarted on her home regimen, and her lisinopril was
increased to 10 mg daily. Her lipid panel showed elevated lipids
including an LDL of 113, and so her lipitor was increased from
20 to 80 mg daily and zetia 10 mg daily was added. She failed
her S/S eval and she subsequently received meds and tube feeds
through an NG tube. She was originally scheduled for PEG
placement [**2124-12-18**], but this was postponted until [**12-21**] as she was
quite hypertensive immediately before the initially scheduled
PEG placement. In the meantime, her plavix was DC'd and she was
kept on aspirin as the only blood thinnner. After PEG placement
[**12-21**], aspirin was DC'd and coumadin was started with a lovenox
bridge. On discharge, her neurological exam was significant for
right arm and leg weakness in the 4/5 range, dysphagia, and
dysarthria with language output limited to stating name and
answering simple yes/no questions.
Medications on Admission:
-Metformin 750 Qday
-Glyburide [**Hospital1 **]
-ASA 325
-Plavix 75
-Candesartan 16 Qday
-Fluticasone nasal spray
-Lipitor 20
-Metorpolol 50 [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 160 mg/5 mL Solution Sig: [**1-19**] PO Q6H (every 6
hours) as needed for fever,ha,pain.
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Candesartan 16 mg Tablet Sig: One (1) Tablet PO Qday ().
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous twice a day.
10. Insulin Lispro 100 unit/mL Cartridge Sig: 6-16 Units
Subcutaneous three times a day: Per Insulin sliding scale. .
11. Metformin 750 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Can DC Lovenox when INR is >
2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis: stroke and NSTEMI
Secondary diagnoses:
CAD
HTN
DM
Hyperlipidemia
Discharge Condition:
Stable right arm and leg weakness in the 4/5 range, dysphagia,
and dysarthria with language output limited to stating name and
answering simple yes/no questions.
Discharge Instructions:
You have had a stroke and simultaneous type of heart attack call
an NSTEMI. You will need to continue to control your risk
factors including your blood pressure, blood sugars, and
cholesterol. Your speech has been slowly improving and you
should continue to work with speech therapy, as well as physical
therapy for your weakness. You should see a nutritionist at
rehab to help control your diabetes, especially in the context
of having to be on liquid feeds through your PEG tube. Please
return to the ER if you experience any sudden weakness, change
in sensation, vision, or language, develop any severe headaches,
vertigo, seizures, or anything else that concerns you seriously.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of Neurology [**2125-2-6**], 2pm at the
[**Hospital Ward Name 23**] Clinical Center. Call to change or cancel: [**Telephone/Fax (1) 2574**].
Please follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 29822**], especially
for having your blood INR followed
Completed by:[**2124-12-22**] | 20,084 | 121,824 | 43411,41071,V4581,25000,41401 |
Admission Date: [**2120-7-26**] Discharge Date: [**2120-8-1**]
Date of Birth: [**2050-4-17**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 70-year-old female
with no known history of coronary artery disease. She had
one previous episode of chest tightness with exertion upon a
routine physical examination with her primary care physician.
[**Name10 (NameIs) **] had electrocardiogram changes with ST depression, fatigue
and chest tightness. On Myoview she had a large zone of
distal anterior apical ischemia with preserved systolic and
diastolic function. She was referred for cardiac
catheterization. Cardiac catheterization on [**2120-7-23**]
showed an ejection fraction of 60 percent, 100 percent right
PDA, 90 percent mid LAD, 90 percent distal circumflex, 80
percent OM2, 80 percent OM3 with normal wall motion.
PAST MEDICAL HISTORY: Significant for hypertension, elevated
cholesterol, anxiety, allergic rhinitis, osteopenia,
microscopic proteinuria, status post hamstring repair in
[**2112**], status post partial hysterectomy, status post
rectocele, cystocele repair, diabetes type 2.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Lipitor 20 once a day.
2. Atacand 16 once a day.
3. Atenolol 50 once a day.
4. Glucovance 2.5/100 once a day.
5. Zyrtec 10 once a day.
6. Glyburide 5 once a day.
7. Catapres 2 every week.
8. Aspirin 325 once a day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs: Pulse
58, sinus bradycardia, blood pressure 132/56, respiratory
rate 14, room air SPO2 95 percent. General: Awake,
pleasant. Neurological: Alert and oriented times three.
Grip strength equal bilaterally. Plantar flexion equal
bilaterally. Pupils equal, round and reactive to light.
Extraocular movements intact. Cardiovascular: Regular rate
and rhythm. No murmur, rub or gallop. Respiratory: Clear
to auscultation. Gastrointestinal: Obese. Abdomen: Softly
distended, nontender. Extremities: Cool, no varicosities,
equal bilaterally. Pulses: Femoral 2 plus right and left,
popliteal 2 plus right and left. DP, PT 2 plus right and
left. Radial 2 plus right and left. Carotids: No bruit.
HOSPITAL COURSE: Mrs. [**Known lastname **] was admitted the morning of
[**2120-7-26**] to go to the Operating Room. She underwent a
coronary artery bypass graft times 3 with LIMA to the LAD,
saphenous vein graft to the PDA and saphenous vein grafts to
the OM. She was under general anesthesia and cardiopulmonary
bypass. Endoscopic vein harvest of the right thigh and open
vein harvest of the upper right calf were the saphenous vein
graft sites. She was transferred out of the Operating Room,
intubated on small amounts of Neo and Propofol, a-paced with
an underlying rhythm of 50 in sinus bradycardia. The
evening of postoperative day 1, she was extubated. On
postoperative day 2, she was transfused one unit of packed
red blood cells for a hematocrit of 24 with a low blood
pressure. Her chest tubes were also removed on postoperative
day 2. On postoperative day 3, she was transferred to the
inpatient floor, F2, and her atrial and ventricular pacing
wires were removed. She was followed throughout her hospital
course by physical therapists and she was cleared by Physical
Therapy, found to be safe for home, on [**2120-7-30**]. She
progressed well throughout her hospital course, staying in a
normal sinus rhythm with stable vital signs. She was
ambulating three times a day with strict pulmonary toilet
throughout her stay and was ambulating independently by
[**2120-7-31**].
CONDITION ON DISCHARGE: Vital signs: Temperature 99.6
degrees, pulse 94 in sinus rhythm, blood pressure 140/67.
Respiratory rate 16. Room air SPO2 94 percent. Labs on
[**2120-8-1**], white count 11.2, hematocrit 33.2, platelets 222,
potassium 4.5, BUN 14, creatinine 0.6. Weight 71 kg, down
from 72 kg preoperatively.
PHYSICAL EXAMINATION: Neurological: Awake, alert and
oriented times three, nonfocal. Respiratory: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm.
No rub or murmur. Incision: Clean, dry and intact. Sternum
stable with no click. Right leg vein harvest site clean, dry
and intact, open to air. Gastrointestinal: Abdomen soft,
nontender, nondistended with positive bowel sounds.
Extremities: 1 to 2 plus edema bilaterally.
DISCHARGE STATUS: Home with visiting nurse.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass graft.
Type 2 diabetes.
Hypertension.
DISCHARGE MEDICATIONS:
1. Colace 100 mg twice a day.
2. Zantac 150 mg twice a day.
3. Aspirin 325 mg once a day.
4. Plavix 75 mg once a day.
5. Glyburide 5 mg once a day.
6. Glucovance 5/500 once a day.
7. Lipitor 20 mg once a day.
8. Vicodin 5/500 one to two tablets p.o. q.4-6h. p.r.n.
9. Lasix 20 mg once a day for 7 days.
10. Lopressor 75 mg twice a day.
11. Atacand 8 mg once a day.
FOLLOW-UP PLAN: The patient is discharged with visiting
nurse to follow. Follow-up with Dr. [**Last Name (STitle) 19751**] in one to two
weeks, with Dr. [**Last Name (STitle) **] in one to two weeks, and Dr. [**Last Name (STitle) 70**] in
5 to 6 weeks. She will also follow-up in the Outpatient
[**Hospital 409**] Clinic in [**1-19**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 28068**]
MEDQUIST36
D: [**2120-8-1**] 10:55:42
T: [**2120-8-1**] 11:29:46
Job#: [**Job Number 56187**]
| 20,084 | 157,791 | 41401,25000,4019 |
Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-28**]
Service: MICU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman
with a history of tracheobronchiomalacia and chronic
respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital. The
patient originally had her respiratory failure following an
episode of aspiration pneumonia back in [**Month (only) 404**], at which
time she had failed attempts at stenting of her
tracheobronchiomalacia and required tracheostomy and PEG tube
placement for her chronic respiratory failure. She has been
at [**Hospital3 672**] Hospital since that time and has been
unable to wean from the ventilator. Her usual vent settings
are SIMV, respiratory rate of 8, tidal volume of 500,
pressure support of 15, PEEP of 5, FIO2 of 0.3. The patient
had been doing well and had been gradually weaned off the
ventilator until the day of admission. At that time she was
noted to be in respiratory distress. She was tachypneic and
short of breath. Two saturations decreased to 90%. She went
from CPAP back to IMV. Arterial blood gas was
7.23/70/123/30/96%. Breath sounds were noted to be distant
and chest x-ray could not be obtained for a significant
period so she was sent to [**Hospital1 188**] for further evaluation.
In the Emergency Department the patient was bagged and
suctioned. No obvious mucous plugs were removed and Lasix 60
mg IV x 1 was given. The patient's symptoms improved and she
was transferred to the medical intensive care unit for
further evaluation.
PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2.
Hypertension. 3. Tracheobronchiomalacia as above. 4.
Anemia. 5. Moderate to severe mitral regurgitation.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Ritalin 5 mg
p.o. q.d. 3. Zoloft 50 mg p.o. q.d. 4. Albuterol p.r.n. 5.
Subcutaneous heparin 5,000 mg subcutaneous b.i.d. 6. Ativan
0.25 mg p.o. q. 8 hours p.r.n. 7. Lasix 40 mg p.o. q.d. on
hold x 1 week.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital. She has some family members who
are involved in her care. She has no known history of
tobacco or drug use.
PHYSICAL EXAMINATION: Vital signs were 98.8, heart rate 82,
blood pressure 92/47, respiratory rate 18, 100% bagged. In
general she was an obese, confused woman who was in no acute
distress at the time of the medical intensive care unit
evaluation. HEENT: Left eye cataract with some ptosis.
Oropharynx was noted to have thrush, otherwise dry. Neck:
No jugular venous distension, no lymphadenopathy.
Tracheostomy in place. Cardiac: Regular rate and rhythm, no
murmurs, gallops, or rubs. Lungs: Rhonchi noted diffusely
with decreased breath sounds at the bases bilaterally,
occasional expiratory wheezes. Abdomen: Soft, nontender,
distended abdomen, positive bowel sounds. PEG in place with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp. Extremities: No cyanosis, clubbing or edema,
warm with good pulses, no calf tenderness, no palpable cord.
Neurological: The patient was able to move all extremities,
decreased hearing and unable to communicate or take p.o.
LABORATORY DATA: White blood count 18.2, hematocrit 36.4,
platelet count 425, and 87.5, no bands. Sodium 132, BUN 49,
creatinine 1.1, glucose 231. Urinalysis had large blood,
greater than 50 white blood cells, [**12-5**] red blood cells,
nitrite negative, leukocyte esterase moderate.
HOSPITAL COURSE: 1. Pulmonary: The patient was admitted
with respiratory distress of unclear etiology. She was given
Lasix initially for congestive heart failure, although this
was unlikely to be congestive heart failure. The patient was
thought to have a mucous plug given the rapid improvement of
her symptoms after suctioning. The patient had follow-up
chest x-ray which demonstrated right middle lobe pneumonia
and question of pneumonia at the left base. The patient was
initially started on ceftriaxone and azithromycin in the
Emergency Department, but was then changed to vancomycin and
Zosyn to cover a ventilator-associated pneumonia. The
patient was then put back on her [**Hospital3 672**] Hospital
ventilator settings and her white count decreased. She
continued to have low-grade temperatures which were thought
to be due to her lack of adequate antibiotics. Sputum
culture showed greater than 25 polys, less than 10 epithelial
cells with mixed flora and final culture is pending at the
time of this dictation.
2. Cardiac: The patient was treated empirically in the
Emergency Department for congestive heart failure. She
underwent transthoracic echocardiogram to evaluate her
ejection fraction given possible congestive heart failure.
This demonstrated left atrium with moderate dilatation, right
atrium with moderate dilatation, mild left ventricular
hypertrophy, minimal aortic stenosis, 1+ aortic
regurgitation, mild to moderate mitral regurgitation,
impaired ventricular relaxation. It was not clear if the
patient was in any congestive heart failure and she was not
given Lasix. This can be restarted should her symptoms
worsen.
3. Weakness: On hospital day number one the patient was
noted to have some left-sided weakness. It is unclear
exactly what her baseline is. She was able to move all four
extremities, however she had some flaccidity and
hyperreflexia in the left upper and lower extremities. She
underwent CT scan of the head which demonstrated no acute
changes but chronic microvascular changes and atherosclerosis
of the internal carotid and vertebral arteries. Given the
patient's condition and unclear age of her findings, no
additional work-up was undertaken.
4. Endocrine: The patient was maintained on fingersticks
q.i.d. and a Regular Insulin sliding scale for her diabetes
mellitus. This should be maintained at her discharge for
optimal blood sugar control during her time of infection.
5. Anemia: The patient's blood counts decreased from
admission of 36 down to 26 on hospital day number two. Some
of this was thought to be dilution as the patient did receive
some intravenous fluids during her admission. She was guaiac
negative and did not have any signs of active bleeding.
Blood count is stable at the time of her discharge. She did
not have a history of coronary artery disease so no packed
cells were given. Should her hematocrit decreased to less
than 24, blood transfusion may be of benefit to her.
6. Access: The patient had a PICC line placed for
intravenous antibiotics to complete a 14-day course of
vancomycin and Zosyn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged back to [**Hospital3 **] Hospital for continued weaning and intravenous
antibiotic therapy.
DISCHARGE DIAGNOSES:
1. Ventilator-associated pneumonia.
2. Cerebrovascular accident of unclear duration.
3. Mitral regurgitation.
4. Anemia.
5. Diabetes mellitus.
6. Urinary tract infection: Positive urinary tract infection
with Gram-negative rods and beta streptococcus.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram q. 48 hours started on [**2199-5-27**] to
receive a 14-day course.
2. Zosyn 2.25 grams IV q. 6 hours started on [**2199-5-27**] to
complete a 14-day course.
3. Sertraline 50 mg p.o. q.d.
4. Methylphenidate 5 mg p.o. b.i.d.
5. Albuterol nebulizer inhaled q. 6 hours p.r.n.
6. Atrovent 2 puffs inhaled q.i.d.
7. Heparin 5,000 mg subcutaneous b.i.d.
8. Fluticasone 110, 2 puffs inhaled b.i.d.
9. Regular Insulin sliding scale.
10. Fluconazole 100 mg p.o. q. 24 hours for thrush to
complete four additional doses.
11. Lansoprazole 30 mg via nasogastric tube q.d.
12. Ativan 0.25 mg p.o./IV t.i.d. p.r.n.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2199-5-28**] 10:50
T: [**2199-5-28**] 11:03
JOB#: [**Job Number 46668**]
| 20,086 | 103,104 | 486,51882,3968,5990,2765,43311,E8798,04119,5191 |
Admission Date: [**2201-10-19**] Discharge Date: [**2201-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
HPI: 86 year old female with tracheobronchiomalacia and chronic
respitory distress vent dependent, h/o UTI, h/o aspiration PNA,
DM type2, MR who presents from OSH after difficulty with
ventilation and found to have rapid atrial fibrillation. Patient
found at OSH to be in severe respitory distress with minimal.
EKG done which showed afib with RVR of 140-170. Patient given
solumedral 125mg and lasix 20mg at OSH for concern of CHF.
Patient transferred to ED were found to be in rapid afib,
hypotensive to SBP 60s and hypoxic with O2Sat in 80s. Patient
was cardioverted in the ED and returned to sinus rhythm,
decrease in HR and increase in BP. Patient given 4L IVF in the
ED with minimal urine output. Patient was also found to be
febrile with temp 104. Given flagyl,vanco,ceftriaxone in the ED.
On CXR in ED found that there was an overdistension of
tracheostomy cuff which was reduced in the ED.
Past Medical History:
1. Diabetes mellitus type 2.
2. Hypertension.
3. Tracheobronchiomalacia
4. Anemia.
5. Moderate to severe mitral regurgitation.
6. PAF
7. COPD
8. CVA
9. C. diff being treated at OSH with flagyl and aztreonam
Social History:
Unknown
Family History:
The patient is currently a resident at
[**Hospital3 672**] Hospital. No known tobacco or drug use
Physical Exam:
T 104.2 HR 90-107 BP 96-100/34 RR 27 O2Sat 100% on vent. CMV
Vt450x RR 26 PEEP 6 FiO2 40%
Gen: Patient attached to vent via tracheostomy. Spontaneously
moving LE B/L. Patient responds to painful stimuli.
Heent: Pupils pinpoint, unable to get movement, MMM
Lungs: Course BS ant/lat, good airway entry
Cardiac: RRR S1/S2 hol
Abd: distended, decreased BS
Ext: no edema
Neuro: repsonsive to painful stimuli
Pertinent Results:
[**2201-10-19**] 08:20PM O2 SAT-99
[**2201-10-19**] 08:20PM freeCa-1.11*
[**2201-10-19**] 08:20PM TYPE-ART PO2-194* PCO2-36 PH-7.36 TOTAL
CO2-21 BASE XS--4
[**2201-10-19**] 08:20PM LACTATE-1.4
[**2201-10-19**] 04:15PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2201-10-19**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2201-10-19**] 04:15PM URINE RBC->50 WBC-[**12-6**]* BACTERIA-MANY
YEAST-MANY EPI-[**6-26**] TRANS EPI-[**6-26**]
[**2201-10-19**] 04:15PM URINE GRANULAR-0-2 FINE GRANULAR CASTS
[**2201-10-19**] 02:58PM TYPE-ART TEMP-40.0 RATES-/24 TIDAL VOL-600
O2-98 PO2-609* PCO2-74* PH-7.11* TOTAL CO2-25 BASE XS--7
AADO2-42 REQ O2-19 -ASSIST/CON INTUBATED-INTUBATED
[**2201-10-19**] 01:57PM LACTATE-1.4
[**2201-10-19**] 01:30PM GLUCOSE-237* UREA N-78* CREAT-1.6* SODIUM-134
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12
[**2201-10-19**] 01:30PM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-50 ALK
PHOS-83 TOT BILI-0.2
[**2201-10-19**] 01:30PM cTropnT-0.08*
[**2201-10-19**] 01:30PM CK-MB-NotDone
[**2201-10-19**] 01:30PM TOT PROT-7.5 CALCIUM-7.9* PHOSPHATE-5.0*
MAGNESIUM-2.4
[**2201-10-19**] 01:30PM WBC-22.8*# RBC-2.99* HGB-9.0* HCT-29.9*
MCV-100*# MCH-30.0 MCHC-30.0*# RDW-14.3
[**2201-10-19**] 01:30PM NEUTS-90* BANDS-3 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2201-10-19**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
[**2201-10-19**] 01:30PM PLT COUNT-447*
[**2201-10-19**] 01:30PM PT-15.2* PTT-88.5* INR(PT)-1.6
.
EKG: on arrival; atrial fibrillation @ RVR of 140, nl axis, no
ST changes
.
CXR: Marked overdistention of tracheostomy tube cuff, placing
the trachea at risk for perforation and fistula formation.
Probable pleural and parenchymal scarring at the lung bases,
although it
is difficult to fully exclude a pneumonia at the left lung base.
.
CXR [**10-21**] 1. Persistent tracheostomy cuff distention. 2.
Worsening mild congestive heart failure with mild cardiomegaly
and small bilateral pleural effusions.
.
[**2201-10-20**] 12:23 am SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2201-10-20**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
NOTE: Culture data pending at time of discharge.
.
[**2201-10-20**] 12:30AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2201-10-20**] 12:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2201-10-20**] 12:30AM URINE RBC-21-50* WBC-[**12-6**]* Bacteri-MOD
Yeast-MOD Epi-[**3-21**]
.
Brief Hospital Course:
A/P: 86 y/o female with PMHx significant for
tracheobronchiomalacia and chronic respitory distress with
tracheostomy on chronic vent who presents from [**Hospital3 672**]
in severe respitory distress, afib with RVR, hypotension and
febrile.
.
1. Sepsis: PNA vs Cdiff. Pt came in with Positive Cdiff
cultures from OSH. Cultures sent from [**Hospital1 18**] were subsequently
negative. Will continue flagyl for complete course. In
addition, gram stain revealed gram neg rods, gram + cocci in
pairs and cocci and gram + rods. Speciation pending at time of
discharge.
- Will continue to keep patient on current vent setting and
titrate back to baseline as tolerated.
- Will conitnue vanco/zosyn/flagyl which could cover possible
VAP or aspiration PNA and CDIFF. Should complete full course of
antibiotics at [**Hospital3 672**]. Vanco and zosyn started [**10-20**]
and flagyl started at OSH should continue until [**10-27**].
- Continue albuterol/atrovent nebs prn
- Patient with resp acidosis, would check daily ABG to make sure
correcting on current vent settings
- [**10-15**] Cdiff positive from [**10-15**] sample drawn at OSH. Cdiff
negative at [**Hospital1 18**] [**10-20**].
.
2. Yeast infection- From urine cx. Pulled foley on [**10-21**].
Should recheck U/A at [**Hospital3 672**] on [**10-23**] for persistent
fungal UTI.
.
3. PAF - Patient currently in sinus rhythm, atrial fibrillation
could have been exacerabted by infectious cause.
- Will hold off on BBlocker at this time as BP low.
- Consider repeat cardiovesion if returns back to atrial fib.
- Pt needs to be anticoagulated with Warfarin. This was
communicated with physician at [**Hospital3 672**] on [**10-21**].
.
4. Acute Renal Failure - Patient with Cre 1.3, last Cre was 1.1
in [**2199**]. Could be ATN secondary to hypotensive episode.
Patient with minimal urine output. Would continue to monitor
BUN/Cre and K+. Trending down. Probably [**2-18**] infection.
.
5. DM RISS
.
6. Anemia: HCT improved but some guiaic + stool on last day of
admission in setting of heparin. D/C'd heparin on final night
of admission. Can reconsider anticoagulation at [**Hospital1 1099**].
.
7. Access: Femoral line
.
8. FEN: Continue IVF to maintain BP and UOP
.
9. PPx: Heparin SC, PPI, bowel regimine
.
10. Code: Full
.
11. Comm with daughter
.
12. Disp: To rehab
Medications on Admission:
1) Lopressor 12.5 [**Hospital1 **]
2) Protonix 40mg qd
3) Modafonil 200mg qd
4) Albuterol 2puff q6 prn
5) Atrovent 2puff q6 prn
6) Heparin SC 5000units [**Hospital1 **]
7) Zoloft 75mg qd
8) Aranesp 25 mcg/qweek
9) Flagyl 500mg tid
10) Aztreonam 1g IV q12
11) Ferrlecit 62.5mg x3/week
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Respiratory Distress/Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Pls administer all meds as indicated and call with any ?s. Pt
to complete course of antibiotics with vanco, flagyl and zosyn
through newly place ([**10-21**]) PICC line.
Followup Instructions:
At OSH
| 20,086 | 159,602 | 0389,51884,486,5849,42731,00845,496,4240,99592,5191,V440,1122,4019 |
Admission Date: [**2199-1-27**] Discharge Date:
Service: MICU
This is a dictation summary from admission until [**2199-2-10**]. The rest will be completed by next intern.
CHIEF COMPLAINT: Respiratory distress.
admitted with decreased responsiveness and respiratory
distress. Patient's past history of present illness is not
well known except that the patient has been noted to have
increasing dyspnea over the past month or two, most notable
with exertion. An exact number cannot be known. The patient
gets short of breath after a block or so. The family of the
patient also said that the patient had been coughing for a
unresponsiveness and very short of breath. She was not noted
to have any fevers, chills, nausea, vomiting, abdominal pain,
diarrhea or constipation, rhinorrhea or sore throat prior to
admission.
EMS was called and the patient was brought to the Emergency
Department. In the Emergency Department, she had a chest
x-ray which demonstrated right middle lobe pneumonia.
Arterial blood gas revealed 7.11/93/300. Patient was placed
on BiPAP with minimal improvement in her gas. Patient was
then intubated. A thick sputum was also suctioned from her.
She also received Solu-Medrol and nebulizers in the Emergency
Department for a question of a chronic obstructive pulmonary
disease flare.
Patient's blood pressure was systolic 120s to 140s and
briefly dropped to 50/20. Patient was started on dopamine,
however, increased to 190s. Dopamine was changed to Neo with
improvement of the patient's rate and pressure. She received
Ceftriaxone and Flagyl and 1400 cc of intravenous fluid and
sent to the Medical Intensive Care Unit for further
evaluation.
PAST MEDICAL HISTORY:
1. Diabetes. No further information available.
2. Hypertension.
3. Arthritis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Hydrochlorothiazide 25 mg po q.d.
2. Lisinopril 40 mg po q.d.
3. Tolazamide 250 mg po q.d.
4. Naprosyn 500 mg po b.i.d.
SOCIAL HISTORY: The patient drinks approximately one drink
per day, usually to help her sleep. She denies any history
of tobacco or drug use per the family. The patient lives
with her daughter and her family is very involved in her
care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 46665**].
PHYSICAL EXAMINATION: Temperature 101.8, 104. Blood
pressure 120/40. General: The patient is vented, sedated in
no acute distress. Head, eyes, ears, nose and throat:
Pinpoint pupils, but received morphine in the Emergency
Department. Normocephalic, atraumatic. No icterus. Small
hemorrhage in left conjunctivae. Neck supple. Heart:
Regular rate and rhythm, no murmurs, rubs or gallops. Lungs:
Coarse rhonchi bilaterally. Inspiratory and expiratory
wheeze with increased expiratory time. Abdomen: Soft,
nontender, nondistended with positive bowel sounds.
Extremities: Cool, no edema.
LABORATORIES: White blood cell count 22, hematocrit 47,
creatinine of 2.1. Toxicology screen negative.
Electrocardiogram: Sinus tachycardia at 132 with normal
axis, normal intervals, Qs in III and aVF. Chest x-ray with
right middle lobe pneumonia.
HOSPITAL COURSE:
1. Pulmonary: The patient was admitted with possible
aspiration pneumonia given the questionable history of
alcohol use, although, upon further questioning, his history
of alcohol was less substantial. Patient was started on
levofloxacin, Flagyl and vancomycin. She was also started on
Combivent nebulizers and Solu-Medrol for question of chronic
obstructive pulmonary disease exacerbation given the
patient's wheezing on physical examination. Patient remained
afebrile after a couple of days and the vancomycin was
discontinued. As there appeared to be no indication of
flora, the patient was be treated for 14 days with
levofloxacin and Flagyl for a probable aspiration pneumonia.
Because the patient was noted to be noted to have severe
wheezing and also had an effusion on chest x-ray, CT was
performed of the chest which showed no change in her
pneumonia. It did note small bilateral pleural effusions.
Patient was attempted several times to be weaned to pressure
support from AC ventilation, however, she did tolerate this
and she became very agitated and desynchronous with the
ventilator.
On hospital day six, the patient had a bronchoscopy to
further examine her wheezing as she had no history of chronic
obstructive pulmonary disease, smoking, and no clear reason
for her wheezing. Bronchoscopy demonstrated very severe
tracheomalacia with 80-90% distal tracheal collapse, also severe
malacia of her RMST/RBI with complete obstruction of the bassilar
segments of the right lower lobe, moderate collapse of her left
main stem bronchus. At this point, the patient's
steroids were discontinued and in house, the following day,
the patient was brought to the OR by Interventional Pulmonary for
stenting of her distal trachea and left mainstem were
performed. Patient's wheezing did not improve and she
remained difficult to wean. The plan was then to remove the
stents and to perform a tracheostomy, to wean her off her AC and
ventilatory support.
On hospital day ten, the patient's temperature spiked and
grew gram positive cocci in her sputum. The vancomycin was
restarted and awaiting final respiratory cultures.
2. Cardiovascular: The patient was initially brought to the
floor on Neo after her failure with dopamine. Patient's
blood pressure remained somewhat tenuous and the patient's
Neo was changed to a vasopressin with good improvement. She
remained on this for approximately two hospital day and then
was able to wean off her pressures altogether. She underwent
cardiac echocardiogram which demonstrated normal ejection
fraction, moderate to severe mitral regurgitation. Patient
remained off her blood pressure medications with minor
fluctuations in her blood pressure.
Patient became increasingly total volume overloaded during
her admission, up to 20 liters positive. However, her
intervascular space remained volume depleted. She was then
tried to be diuresed with Lasix, although, this tended to dry
her out. On hospital day 12, the patient received 20 of
Lasix intravenously and dropped her pressures to the 70s.
She was restarted on vasopressin which provided only some
improvement in her blood pressure.
On hospital day 14, the patient was started on dopamine with
the hope of improving her profusion to her kidneys in hope of
auto-diuresis.
3. Renal: Patient was admitted with acute renal failure
with a creatinine of 2.0. She was noted to have normal renal
function prior to admission. Patient was treated with
intravenous fluids in the Emergency Department. This slowly
resolved over several days until she came to a creatinine of
0.8 which was felt to be her baseline.
4. Infectious Disease: Patient was started on antibiotics
for her pneumonia as listed in the pulmonary section. On
hospital day 14, the patient remained to have low grade
temperature spikes. Patient will have CT of the sinuses to
rule out sinusitis. She will be changed from Levaquin to
vancomycin and ceftazidime for a presumed sinusitis until the
CT scan results have returned.
5. Nutrition: Patient was started on tube feeds upon
admission. Promote with fiber. Patient tolerated these well
through her nasogastric or OT tube. Due to patient's
inability to wean off the ventilator, the option of
percutaneous endoscopic gastrostomy was discussed with the
patient's family. The agreed that percutaneous endoscopic
gastrostomy was wanted should the patient still have some
chance of recovery. Gastrointestinal came to evaluate the
percutaneous endoscopic gastrostomy and once the patient is
off pressors, they will perform this procedure.
6. Fluid and electrolytes: The patient became increasingly
volume overloaded during the length of her stay up to 20
liters positive. The reasoning for her inability to secrete
this fluid is not clear. Should have normal renal function.
Patient does have a low abdomen which is likely contributing
to this problem. >.....<pressors with diuresis may be
wanted.
7. Prophylaxis: The patient will remain on H2 blocker due
to lack of intravenous PPI availability. Pneumoboots and
heparin subcutaneously.
8. Code status: Patient is full code. Should the patient's
prognosis worsen, this should be readjusted with the family.
9. Endocrine: Patient was maintained on an insulin drip,
taken off her oral hypoglycemic. Increase fingersticks as
well once the patient is off pressors and is doing better,
she will be returned to insulin or oral hypoglycemics.
DICTATION WILL BE CONTINUED BY INTERN TAKING OVER THIS
SERVICE.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**First Name3 (LF) 46666**]
MEDQUIST36
D: [**2199-2-10**] 01:23
T: [**2199-2-10**] 13:30
JOB#: [**Job Number 46667**]
| 20,086 | 168,211 | 5070,51884,5849,2766,7070,0389,5191,4589,25000 |
Unit No: [**Numeric Identifier 67511**]
Admission Date: [**2101-5-30**]
Discharge Date: [**2101-5-30**]
Date of Birth: [**2101-5-30**]
Sex: M
Service: NB
ADMISSION DIAGNOSES:
1. Antenatally diagnosed hypoplastic left heart syndrome.
2. Antenatally diagnosed bilateral pyelatelectasis
DISCHARGE DIAGNOSES:
1. Antenatally diagnosed hypoplastic left heart syndrome.
2. Antenatally diagnosed bilateral pyelatelectasis
HISTORY: This infant was delivered at 38-6/7 weeks to a 38-
year-old gravida 2 para 1 now 2 woman with a past obstetric
history notable for a term spontaneous vaginal delivery in
[**2097**]; this child is alive and well.
PAST MEDICAL HISTORY: Noncontributory.
PRENATAL SCREENS: Blood group A+; direct antibody test
negative; hepatitis B surface antigen negative; RPR
nonreactive; rubella immune; gonococcus negative; Chlamydia
negative; HIV negative; quadruple-AFP normal/low risk; cystic
fibrosis negative.
Last menstrual period was [**2100-9-8**], for an estimated
date of delivery of [**2101-6-7**], and an estimated
gestational age of 38-6/7 weeks at delivery today, [**2101-5-30**], at 14:30. Pregnancy was complicated by ventricular size
discrepancy noted on fetal survey with subsequent echo
showing the following: hypoplastic left heart syndrome with
probable aortic and mitral valve atresia, mild tricuspid
regurgitation, adequate pulmonary artery, good right
ventricular systolic function, large PDA, small left atrium,
moderate nonrestrictive atrial septal defect. The fetal
survey also showed bilateral pyelectasis. Parents declined
amniocentesis. Elective cesarean section was undertaken,
without prior labor, for fetal indications. Ruptpure of membranes
occurred at delivery, yielding clear amniotic fluid. There
was no fever or other clinical evidence of chorioamnionitis.
The mother received spinal anesthesia.
The infant was vigorous at delivery. He was orally and
nasally bulb suctioned and dried. Infant was mildly cyanotic
initially but attained good color over 1-2 minutes. No oxygen was
required. Apgars were 9 at 1 minute and 9 at 5
minutes. Infant was transferred uneventfully to the NICU on
room air.
PHYSICAL EXAMINATION: Term infant in no distress. Right
arm blood pressure is 79/37 [mean 52], left arm 63/28 [43],
right leg 61/27 [40], left leg 72/28 [41], SaO2 is 90% in
room air [postductal], heart rate 164, respiratory rate 40-
60. HEENT: Anterior fontanel is soft and flat. Facies
nondysmorphic. Palate intact. Neck/mouth normal. No nasal
flaring. CHEST: No retractions. Good breath sounds
bilaterally. No adventitious sounds. CVS: Well
perfused [capillary refill 3 seconds], regular rate and
rhythm; femoral pulses normal; II/VI systolic ejection murmur
at the left sternal border radiating across the chest and
into both axilla. ABD: Soft, nondistended, no
organomegaly. Bowel sounds active. Anus appears patent. A 3-
vessel umbilical cord is noted. GU: Infant has a
normal penis with bilaterally descended testes.
INTEG: Normal. MSK: Infant has a shallow
sacral dimple with an easily visualized base. There is a
normal spine, limbs, hips and clavicles. CNS: The infant is
active and responsive to mild stimulation. Tone is normal and
symmetrical. He is moving all extremities symmetrically.
Suck, root, gag are intact; facies are symmetrical;
extraocular movements are normal; pupils are equal and
reactive to light.
INVESTIGATIONS: D-stick 47.
IMPRESSION: This term infant presents with antenatally
diagnosed hypoplastic left heart syndrome, currently stable
in room air, and antenatally diagnosed bilateral
pyelatelectasis.
PLAN: The infant is to be transferred to [**Hospital3 1810**]
for definitive management.
Two peripheral IVs have been started, and prostaglandin
has been initiated at 0.01 mcg/kg per minute. We will
continue to monitor perfusion and postductal oxygen
saturation closely on the transport. We will target oxygen
saturations of 70%-85% and mean blood pressures above 40
mmHg.
The infant has no sepsis risk factors. We will
therefore defer antibiotic coverage for now but consider this
if cardiorespiratory symptoms develop.
Respiratory drive appears well maintained with the start of the
prostaglandin infusion. We will, therefore, defer intubation
unless apnea is noted.
Enteral feeds will be deferred given the likelihood of
cardiorespiratory compromise. In the interim, maintenance IV
D10W has been started with the usual attention to fluid and
metabolic issues.
The infant will require postnatal abdominal ultrasound in
followup of the antenatally diagnosed renal dilatation.
The parents have been updated through an interpreter.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 1810**]
Cardiac Intensive Care Unit.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 2427**] [[**Hospital1 1474**]].
DISCHARGE MEDICATIONS:
1. Prostaglandin 0.01 mcg/kg per minutes through peripheral
IV.
2. D10W at 80 ml/kg per minute through peripheral IV.
A state screen has been sent. The infant has not received a
hearing screen or hepatitis B immunization. Vitamin K and
ophthalmic erythromycin prophylaxis have been administrated.
Reviewed By: DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-622
Dictated By:[**Last Name (NamePattern4) 55784**]
MEDQUIST36
D: [**2101-5-30**] 16:26:19
T: [**2101-5-30**] 17:41:45
Job#: [**Job Number 67512**]
| 20,087 | 123,205 | V3001,7705,7467 |
Admission Date: [**2179-8-9**] Discharge Date: [**2179-8-17**]
Date of Birth: [**2133-5-8**] Sex: M
Service: MEDICINE
Allergies:
E-Mycin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
RLE Cellulitis/Code Sepsis
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
46 yo M with HTN, DM2, who presents to the ED with 1 day of
right lower extremity warmness. Pt and wife say that yesterday
he was feeling fatigued and "achy" all over. +Fevers (did not
take with thermometer), +chills. +Nausea. No vomiting.
+sweating. Last night he was walking and hit his right leg on
the corner of the dishwasher which called attention to his RLE.
He noticed that it was warm and slightly duskier than usual (has
normal status changes). No cough. No dysuria.
.
In the ED, VS on arrival were: T: 105.3; HR: 120; BP: 125/82,
RR: 20; O2: 94 RA. He received Vancomycin 1 g IV x 1,
ceftriaxone 1 g IV x 1, dolansterone mesylate 12.5 mg IV x 1,
Ketolorac 30 mg, Tylenol 1 g IV x 1. BP noted to be 70s systolic
and pt received 5-6 L NS. He was put on the code sepsis protocol
and a RIJ was placed.
Past Medical History:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. h/o b/l DVT 94' in setting ARDS (see below). Since then, RLE
swollen and with venous stasis changes.
4. High cholesterol.
5. Anal fissure.
6. Thalassemia.
7. h/o ARDS with Enterococcus and coag- negative Staphylococcus
in [**2168**].
Social History:
Married with four children. Financial risk analyst at Fidelity.
No smoking. Occasional EtOH. No drugs.
Family History:
Family History: M: DM, HTn; F: HTN. No CAD. No clotting
disorders in family.
Physical Exam:
VS: T: 103.4; HR: 118; BP: 108/54; RR:22; O2: 100 2L
Gen: Speaking in full sentences, in NAD
HEENT: MMM, sclera anicteric. OP clear
Neck: JVD difficult to see [**3-11**] neck girth. No LAD. RIJ in place
without erythema or bleeding.
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l with slightly diminished air flow at bases.
Abd: NABS. SOft, NT, ND
Back: No spinal, paraspinal, CVA tenderness
Ext: RLE: swollen >>L. Non pitting edema 2+. DP 2+ b/l. +venous
stasus changes mid calf down. +slight erythema/duskiness above
that to knee. +warmth in that area (marked with pen). +right
lower inguinal lymph nodes palpable and painful. No streaks or
cords
Neuro: MS [**6-11**] LE. A&O x 3
Pertinent Results:
[**2179-8-9**] 11:20AM WBC-8.4 RBC-6.06 HGB-12.3* HCT-36.4* MCV-60*
MCH-20.3* MCHC-33.8 RDW-16.1*
[**2179-8-9**] 11:20AM NEUTS-87.5* LYMPHS-8.3* MONOS-3.6 EOS-0.2
BASOS-0.3
[**2179-8-9**] 11:38AM LACTATE-3.0*
Brief Hospital Course:
#) Sepsis/RLE cellulitis: source appeared to be the cellulitis.
Surgery was consulted and felt that clincially, pt did not have
Nec Fasc or compartment syndrome. All Micro data from admission
negative. Initial CT scan or RLE (without contrast) showed:
Low-density region within the inferior aspect of the medial head
of the gastrocnemius muscle suggests pyomyositis, particularly
given the patient's clinical history. Several areas of low
density may reflect developing loculated fluid collections,
although at this time, no single loculated fluid collection is
identified that might be amenable to drainage.
Extensive and circumferential edema of the subcutaneous fat is
nonspecific, likely reflecting a combination of venous stasis
and cellulitis.
No specific evidence of osteomyelitis.
As there was evidence for ? fluid collection on initial CT scan,
a repeat CT scan the day before discharge showed diffuse
subcutaneous soft tissue edema. The differential diagnosis
includes changes related to cellulitis. However, there is no
evidence for phlegmon or abscess on this examination.
The patient was started in the ICU on broad spectrum abx
(Vanc/Unasyn-->Vanc/Zosyn) and the patient will complete a total
of 14 d of Vanc/Zosyn for treatment of the cellulitis.
#) DM2: Restarted metformin, 1000mg [**Hospital1 **] and Actos, 45mg QD. As
patient had recent CT with IV contrast, will hold Metformin for
48 hours and pt to restart as outpt.
.
#) HTN: given recent Hypotension, ICU team started short acting
BB. Pt's Blood pressure was stable on the floor; eventually
switched back to Atenolol 100 mg qhs with plans to reinstitute
Lisinopril 5 mg as outpt.
.
#) Anemia: Likely [**3-11**] aggressive fluid repletion in setting of
anemia, inflammation, and thalasemmia. Pts HCT on admission was
36.4 which dropped to a nadir of 25.9 during the
hospitalization. HCT on discharge was 27.5, pt was guiac (-).
Medications on Admission:
Metformin 1000 mg [**Hospital1 **]
Atenolol 100 mg qpm
Lisinopril 5 mg qpm
Lipitor 10 mg qhs
Actos 45 mg qday
ASA 81 mg qday
Ibuprofen 600 mg prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*12 Tablet(s)* Refills:*0*
5. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gm Recon
Solns Intravenous Q8H (every 8 hours) for 10 days: course to
finish on
[**8-27**].
Disp:*qs Recon Soln(s)* Refills:*0*
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 8H (Every 8 Hours) for 10 days: Course to finish
on [**8-27**].
Disp:*qs gm* Refills:*0*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
DO NOT take until the evening of [**8-18**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis: Right Lower Extremity Cellulitis
Secondary Diagnoses:
Type 2 DM
Hypertension
Thalassemia/Anemia
Venous insufficiency secondary to h/o DVT
Hypercholesterolemia
Discharge Condition:
stable; cellulitis improving
Discharge Instructions:
Please contact your primary contact doctor should you have any
fevers, chills, night seats, worsening leg pain or swelling, or
any other complaints.
Because you recently had a CT scan, DO NOT take your Metformin
until the evening of [**8-18**].
Followup Instructions:
Please make an appointment to follow up with Dr. [**Last Name (STitle) 58**] next
week.
| 20,088 | 128,823 | 0389,78552,6826,28249,99592,45981,25000,4019,28529,2720 |
Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-26**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old
male with a past medical history of diabetes, hypertension,
and deep venous thrombosis presenting with a fever and lower
extremity pain times one day.
In the Emergency Department, the patient was noted to have a
fever and hypotension. He received 6 liters of intravenous
fluids, Ancef, and Unasyn and was transferred to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Bilateral deep venous thrombosis.
4. High cholesterol.
5. Anal fissure.
6. Thalassemia.
MEDICATIONS ON ADMISSION: Actos, Glucophage, atenolol,
aspirin, and Lipitor.
ALLERGIES: ERYTHROMYCIN.
SOCIAL HISTORY: No alcohol. No tobacco. No drug use.
FAMILY HISTORY: Mother with diabetes.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient had a temperature of 103.5, his
heart rate was 112, his blood pressure was 109/50, his
respiratory rate was 20, and his oxygen saturation was 100%
on 2 liters. In general, he was alert and oriented times
three. In no acute distress. Head, eyes, ears, nose, and
throat examination revealed the sclerae were anicteric. The
oropharynx was clear. No neck stiffness. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. No murmurs. The lungs
were clear to auscultation bilaterally. The abdomen was
soft, nontender, and nondistended. Positive bowel sounds.
Extremities revealed right lower extremity venous changes.
Pain the medial thigh to the calf. No rash. Neurologic
examination revealed cranial nerves II through XII were
intact. Sensation and strength were [**6-10**]. Distal pulses were
2+ distally.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 12.8. His hematocrit was 37.1. Chemistries
were within normal limits. Urinalysis was normal. Lactate
was 3.3.
PERTINENT RADIOLOGY/IMAGING: A computed tomography angiogram
was negative for a pulmonary embolism.
A chest x-ray was normal.
A right lower extremity ultrasound revealed no deep venous
thrombosis.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient presented with
fevers, hypotension, right lower extremity pain, and septic
physiology responsive to intravenous fluids.
The patient had a negative ultrasound of his right lower
extremity for deep venous thrombosis and a negative computed
tomography angiogram for a pulmonary embolism. Urinalysis
was normal. No murmur was heard on cardiac examination, and
a transthoracic echocardiogram was negative for endocarditis.
It was thought that the source of his infection was a right
lower extremity cellulitis. He was initially started on
Unasyn, as the patient is a diabetic, and gentamicin was
added to cover Pseudomonas.
A right lower extremity magnetic resonance imaging was
performed which showed soft tissue edema. No focal fluid
collection, and no signs of fasciitis. General Surgery was
consulted, and vancomycin was added to the regimen for his
cellulitis.
The patient developed a headache without neck stiffness. A
lumbar puncture was attempted but was unsuccessful. The
patient's cellulitis continued to improve. Another line was
placed prior to discharge. He will be discharged on seven
days of Unasyn and then by mouth Augmentin for seven days.
He was instructed to use compression stockings to reduce the
swelling and improve circulation.
2. HEADACHE ISSUES: The patient's headache improved during
his hospital course. He did not have any associated
photophobia or neck stiffness. It was thought that this may
have been secondary to discontinuation of his beta blocker
because of his low blood pressures.
DISCHARGE STATUS: Discharge status was to home.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient to follow up
with Dr. [**Last Name (STitle) 58**] on Wednesday, [**11-27**].
MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: Mid line
placement on [**2176-11-25**].
MEDICATIONS ON DISCHARGE:
1. Unasyn 3 gram intravenously q.6h. (times seven days).
2. Augmentin 500/125 one tablet by mouth three times per day
(times seven days); starting in one week.
3. Normal saline flushes 10 cc before and after each Unasyn
dose.
3. Heparin flushes 2 cc after each Unasyn dose.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern1) 3476**]
MEDQUIST36
D: [**2177-3-19**] 12:03
T: [**2177-3-19**] 12:52
JOB#: [**Job Number 6061**]
| 20,088 | 137,881 | 6826,5990,28249,4019,25000,4589,7856,04100,7840 |