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"Admission Date: 2130-4-14 Discharge Date: 2130-4-17 | |
Date of Birth: 2082-12-11 Sex: M | |
Service: #58 | |
HISTORY OF PRESENT ILLNESS: Mr. Jefferson is a 47 year-old man | |
with extreme obesity with a body weight of 440 pounds who is | |
5'7"" tall and has a BMI of 69. He has had numerous weight | |
loss programs in the past without significant long term | |
effect and also has significant venostasis ulcers in his | |
lower extremities. He has no known drug allergies. | |
His only past medical history other then obesity is | |
osteoarthritis for which he takes Motrin and smoker's cough | |
secondary to smoking one pack per day for many years. He has | |
used other narcotics, cocaine and marijuana, but has been | |
clean for about fourteen years. | |
He was admitted to the General Surgery Service status post | |
gastric bypass surgery on 2130-4-14. The surgery was | |
uncomplicated, however, Mr. Jefferson was admitted to the Surgical | |
Intensive Care Unit after his gastric bypass secondary to | |
unable to extubate secondary to a respiratory acidosis. The | |
patient had decreased urine output, but it picked up with | |
intravenous fluid hydration. He was successfully extubated | |
on 4-15 in the evening and was transferred to the floor | |
on 2130-4-16 without difficulty. He continued to have | |
slightly labored breathing and was requiring a face tent mask | |
to keep his saturations in the high 90s. However, was | |
advanced according to schedule and tolerated a stage two diet | |
and was transferred to the appropriate pain management. He | |
was out of bed without difficulty and on postoperative day | |
three he was advanced to a stage three diet and then slowly | |
was discontinued. He continued to use a face tent overnight, | |
but this was discontinued during the day and he was advanced | |
to all of the usual changes for postoperative day three | |
gastric bypass patient. He will be discharged home today | |
postoperative day three in stable condition status post | |
gastric bypass. | |
DISCHARGE MEDICATIONS: Vitamin B-12 1 mg po q.d., times two | |
months, Zantac 150 mg po b.i.d. times two months, Actigall | |
300 mg po b.i.d. times six months and Roxicet elixir one to | |
two teaspoons q 4 hours prn and Albuterol Atrovent meter dose | |
inhaler one to two puffs q 4 to 6 hours prn. | |
He will follow up with Dr. Morrow in approximately two weeks as | |
well as with the Lowery Medical Center Clinic. | |
Kevin Gonzalez, M.D. R35052373 | |
Dictated By:Dotson | |
MEDQUIST36 | |
D: 2130-4-17 08:29 | |
T: 2130-4-18 08:31 | |
JOB#: Job Number 20340" | |
"Admission Date: 2107-11-13 Discharge Date: 2107-11-15 | |
Date of Birth: 2078-9-5 Sex: M | |
Service: EMERGENCY | |
Allergies: | |
No Known Allergies / Adverse Drug Reactions | |
Attending:Annetta | |
Chief Complaint: | |
DKA | |
Major Surgical or Invasive Procedure: | |
None | |
History of Present Illness: | |
Mr. Abel is a 29 year old man with h/o Type I DM, 10 prior | |
admissions for DKA since 1-4, who presents with SOB/chest | |
discomfort, found to be in DKA. | |
The patient was at work today when he started feeling dyspnea on | |
exertion and substernal chest discomfort. CP worsened with deep | |
breaths. No difference with change in position. FS at that time | |
was 491, so the patient gave himself Humalog 7units. Repeat FS | |
369. He drove himself to the ED for further evaluation. | |
Of note, the patient was just admitted to Sprague Clinic 4 days prior in DKA, symptoms of N/V, discharged the | |
following day without any changes to his prior regimen. He had | |
been on insulin pump in the past, but was discontinued in 1-4. | |
Just restarted on insulin pump 10 days prior to this admission - | |
basal rate 0.75units/hr with bolus dosing at mealtime. Follows | |
with Dr. Rothwell as an outpatient, last seen on 2107-11-4 and | |
started on insulin pump at that time. | |
In the ED, initial vs were: 98.4 100 112/72 15 100% RA. Chest | |
discomfort resolved on arrival to the ED. Initial FS was >500, | |
with anion gap of 22, urine ketones 150. Patient was given IVF - | |
2LNS, 1L IVF with K, and started on 1L D5NS; started on insulin | |
gtt. Repeat lytes showed improved gap from 22 -> 18. | |
On the floor, the patient is currently comfortable. Only | |
complaint is that he is hungry. No fevers, chills, cough, sore | |
throat, N/V, abdominal pain, dysuria. SOB and CP are still | |
resolved. | |
Past Medical History: | |
- Type I DM, diagnosed 2096, frequent hospitalizations with DKA | |
- Diabetic cataract left eye s/p phacoemulsification with | |
posterior chamber lens implant 2098. | |
- Senile cataract right eye s/p phacoemulsification with | |
posterior chamber lens implant 2099. | |
- R shoulder subluxation | |
Social History: | |
- Tobacco: 10 cigarettes/day x 3 years | |
- Alcohol: occasional | |
- Illicits: none | |
The patient works as a line cook at House of Blues. | |
Family History: | |
Diabetes mellitus Type II in his father, paternal grandfather, | |
paternal aunts and uncles and maternal aunt; maternal GF/GM both | |
died of heart failure | |
Physical Exam: | |
Vitals: T: 96.8 BP: 120/66 P: 82 R: 13 O2: 100%RA | |
General: Alert, oriented, no acute distress | |
HEENT: Sclera anicteric, MMM, oropharynx clear | |
Neck: supple, JVP not elevated, no LAD | |
Lungs: Clear to auscultation bilaterally, no wheezes, rales, | |
rhonchi | |
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, | |
gallops | |
Abdomen: soft, non-tender, non-distended, bowel sounds present, | |
no rebound tenderness or guarding, no organomegaly | |
GU: no foley | |
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or | |
edema | |
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly | |
intact in all extremities | |
Pertinent Results: | |
Admission labs: | |
2107-11-13 04:30PM WBC-6.0 RBC-4.58* HGB-14.4 HCT-40.9 MCV-89 | |
MCH-31.4 MCHC-35.1* RDW-11.7 | |
2107-11-13 04:30PM NEUTS-69.7 LYMPHS-26.3 MONOS-2.7 EOS-0.9 | |
BASOS-0.4 | |
2107-11-13 04:30PM PLT COUNT-271# | |
2107-11-13 04:30PM PT-10.6 PTT-22.1 INR(PT)-0.9 | |
2107-11-13 04:37PM PH-7.26* | |
2107-11-13 04:37PM GLUCOSE-GREATER TH LACTATE-1.8 NA+-130* | |
K+-4.9 CL--96 TCO2-12* | |
2107-11-13 04:37PM freeCa-1.19 | |
2107-11-13 04:30PM GLUCOSE-575* UREA N-23* CREAT-1.3* | |
2107-11-13 05:26PM URINE COLOR-Straw APPEAR-Clear SP Tucker-1.021 | |
2107-11-13 05:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG | |
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 | |
LEUK-NEG | |
EKG: NSR @ 80bpm, nl axis and intervals, diffuse STE, more | |
pronounced than prior in 9-4. | |
Discharge labs: | |
2107-11-15 05:54AM BLOOD WBC-7.2 RBC-4.72 Hgb-14.9 Hct-41.8 MCV-89 | |
MCH-31.5 MCHC-35.6* RDW-11.9 Plt Ct-276 | |
2107-11-15 05:54AM BLOOD Plt Ct-276 | |
2107-11-15 05:54AM BLOOD Glucose-67* UreaN-17 Creat-0.9 Na-143 | |
K-3.7 Cl-104 HCO3-26 AnGap-17 | |
2107-11-15 05:54AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8 | |
Brief Hospital Course: | |
Mr. Abel is a 29 year old man with h/o DM1, frequent | |
hospitalizations for DKA, recently restarted on insulin pump, | |
who was admitted in DKA. | |
. | |
#. DKA: Patient admitted for the 11th time this year with DKA. | |
Recently started on insulin pump, now with his second admission | |
in 10 days; insulin dosing did not appear to be adequate. No | |
signs or symptoms of infection as a trigger at this time, though | |
patient later had a persistent cough that was treated with | |
azithromycin. | |
On admission, patient was put on a regular insulin drip, and | |
started on D5 1/2NS when glucose came down <200. The next | |
morning, he was restarted on his insulin pump at a higher basal | |
dose. | |
The second day of admission, there was some confusion on two | |
levels. The patient misunderstood the calorie counts in the menu | |
and gave himself very low amounts of insulin based on his | |
calorie counting scale. His glucose meter was also poorly | |
calibrated and was giving finger stick readings about 150 lower | |
than actual. He was hyperglycemic to the 400s, but did not have | |
recurrent acidosis. His glucose levels subsequently improved. | |
The next day we spoke with his outpatient endocrinologist Dr. | |
Rothwell (114-594-2840), who said that he had only met the | |
patient once. He has few insulin pump patients, so the decision | |
was to have the patient return to Hughes for further follow-up. | |
He will see Dr. Ray the day after discharge to re-establish | |
care with him. | |
. | |
#. Cough: Patient had a productive cough. CXR negative. The | |
decision was made to treat him with azithromycin for a suspected | |
upper-respiratory tract infection. | |
. | |
#. ARF: Patient with Cr 1.3 on admission, baseline Cr 1.0. | |
Improved with fluid resuscitation. | |
Medications on Admission: | |
Insulin - on pump since 2107-11-4, basal rate 0.75units/hr, bolus | |
dosing for meals | |
Discharge Medications: | |
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY | |
(Daily) for 2 days. | |
Disp:*2 Tablet(s)* Refills:*0* | |
2. Burke Industries Insulin Pump Sig: One (1) once a day. | |
3. One Touch Ultra Test Strip Sig: One (1) strip | |
Miscellaneous four times a day. | |
4. Humalog 100 unit/mL Solution Sig: As directed units | |
Subcutaneous four times a day: Use with insulin pump per | |
directions. | |
Discharge insulin pump settings: | |
Basal Rates: | |
Midnight - midnight: 1.3 Units/Hr | |
Meal Bolus Rates: | |
Breakfast = 1:8 | |
Lunch = 1:8 | |
Dinner = 1:8 | |
Snacks = 1:8 | |
High Bolus: | |
Correction Factor = 1:50 | |
Correct To mg/dL | |
Discharge Disposition: | |
Home | |
Discharge Diagnosis: | |
Diabetic ketoacidosis | |
Type I diabetes | |
Discharge Condition: | |
Mental Status: Clear and coherent. | |
Level of Consciousness: Alert and interactive. | |
Activity Status: Ambulatory - Independent. | |
Discharge Instructions: | |
You were admitted with dangerously high blood sugar levels and | |
ketoacidosis. Your blood sugar levels improved with a continuous | |
insulin infusion and a lot of IV fluids. Your insulin pump was | |
restarted at a higher level, and you are now safe to go home. | |
You will need to follow your blood sugar very closely over the | |
next couple of days to make sure that your insulin pump is | |
properly titrated. | |
Your only medications are to continue using your insulin pump | |
and to take azithromycin for 2 more days. | |
Followup Instructions: | |
Please see Dr. Ray, at Hughes Diabetes Center, tomorrow, | |
11-15, at 3pm. You can call (250-886-7061 if you need | |
to make changes to that appointment. | |
Please follow-up with your primary care doctor, Dr Lareau, | |
within the next 2 weeks. You can call his office at | |
314-618-2706. | |
Completed by:2107-11-16" | |
"Admission Date: 2180-5-18 Discharge Date: 2180-5-25 | |
Date of Birth: 2118-11-28 Sex: F | |
Service: NEUROSURGERY | |
Allergies: | |
No Known Allergies / Adverse Drug Reactions | |
Attending:Joel | |
Chief Complaint: | |
confusion | |
Major Surgical or Invasive Procedure: | |
L Craniotomy for evacuation of L SDH | |
History of Present Illness: | |
This is a 61 year old woman without significant PMH who | |
presented to her PCP's office after becoming confused at work. | |
She remembers having a fall two weeks prior to presntation. An | |
MRI Brain was performed which revealed a large subacute left | |
SDH. She was sent to Reed Memorial Hospital ED and subsequently | |
transferred to Lorenzo Hospital. Neurosurgical consultation requested for | |
evaluation and treatment. | |
She states that she fell two weeks ago remembers hitting her | |
head | |
but does not recall which side. She does not think she is | |
confused but her co-workers believe that she is. She states that | |
her friends thought her walking was impaired. Otherwise she | |
reports no headache. She does say that she had trouble with her | |
right hand when writing. She denies seizure like | |
activity, LOC, fever, chills, Nausea, vomiting, chest pain or | |
pressure, sob, or weakness in other extremities. | |
Past Medical History: | |
rheumatoid arthritis, rectal bleeding, HTN, seasonal | |
allergies | |
Social History: | |
She works for the city of Lakeview, married, husband is currently | |
ill. Denies tobacco,etoh, drugs | |
Family History: | |
non-contributory | |
Physical Exam: | |
On Admission: | |
O: T: BP: 130/60 HR: 92 R 18 O2Sats 99% 3L | |
Gen: WD/WN, comfortable, NAD. | |
HEENT: Pupils: 4 to 2mm equal. EOMs Intact no nystagmus | |
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 with mild | |
inattentiveness. Orientation: Oriented to person, place, and | |
date. Language: Speech fluent with good comprehension and | |
repetition. | |
Naming intact. No dysarthria or paraphasic errors. | |
Cranial Nerves: | |
I: Not tested | |
II: Pupils equally round and reactive to light, 4mm to 2 | |
mm bilaterally. Visual fields perceived as full although | |
inattentive to task at times. | |
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. | |
Dr. Brown: Sternocleidomastoid and trapezius normal bilaterally. | |
XII: Tongue midline without fasciculations. | |
Motor: tone increased b/l lower extremities. No abnormal | |
movements, | |
tremors. no drift noted. Motor impersistence. Strength was full | |
with the following exceptions, has b/l tricep 4-25, IP's 5-/5 and | |
Hamstrigs 5-/5. The hands have significant pain and rheumatic | |
changes and finger extension and wrist extension were not tested | |
adequately. | |
Sensation: Intact to light touch bilaterally. | |
Reflexes: were grade 3 throughout. | |
Toes upgoing bilaterally | |
Gait: able to get up and out of bed with minimal assistance, | |
unsteady gait with swaying backward upon standing. | |
On Discharge: PERRLA, AAx O to person, hospital, Lakeview, time. | |
No word finding difficulties. Right pronator drift. LE's full | |
strength. RUE strength is 4- to 4-25 and LUE is 4 to 4+/5. | |
Pertinent Results: | |
CT HEAD W/O CONTRAST 2180-5-18 | |
Evolving large left vertex subdural hematoma with rightward | |
subfalcine herniation and moderate effacement of the left | |
lateral ventricle. Allowing for differences in technique, the | |
findings are little changed since the 14:11 MRI examination. | |
CT head 2180-5-19 | |
1. Status post left craniotomy with evacuation of large subdural | |
hematoma. Post-surgical changes with bilateral pneumocephalus, | |
left more than right with interval decrease of rightward shift | |
of normally midline structures. | |
2. No new focus of hemorrhage. Ventricles are stable in size. | |
CT head 2180-5-22 | |
1. Increased size of a left vertex subdural hematoma with | |
increased | |
neighboring sulcal effacement and slight increase in rightward | |
subfalcine | |
herniation. | |
2. Increased hyperdense material subjacent to the craniotomy | |
site indicative of interval bleeding since 2180-5-19. | |
3. New minimal effacement of the quadrigeminal and suprasellar | |
cisterns. | |
4. Increased soft tissue swelling and subgaleal hematoma at the | |
craniotomy | |
site. | |
5. Evolving focal left frontal infarct at the subfalcine | |
herniation site. | |
Brief Hospital Course: | |
This is a 61 y/o woman who had a fall 2 weeks prior to admision, | |
striking her head. She presents to the ED with confusion. Head | |
CT revealed L SDH with significant midline shift. She was taken | |
to OR emergently for a L side craniotomy for evacuation of SDH. | |
Post operatively patient was transferred to ICU for recovery. On | |
5-19, post op head CT showed minimal improvement of midline | |
shift and pneumocephalus. On examination, patient was a&ox3, R | |
triceps 4-25, otherwise she was intact. She was transferred to | |
step down unit and PT/OT consulted. | |
On 5-21 the patient was neurologically stable and dilantin level | |
was therapeutic. | |
On 5-22 a repeat head CT was performed which revealed an increase | |
in MLS. Fluid and air was aspirated from the crani site at the | |
bedside and she was placed on 100%O2 for pneumocephalus. Her | |
exam improved and word finding difficulties resolved. She was | |
sorking with PT and OT and was being screened for rehab. Her BUN | |
elevated to 21 on 5-23 and IVF were restarted at 50cc/hr. Her Bun | |
stabilized to 20 and she was discharged to rehab on 5-25. | |
Medications on Admission: | |
Amlodipine Besy-Benxapril 11-9, plaquenil 1 tab Self Memorial Hospital (250mg), | |
naprosyn 500mg Self Memorial Hospital, prednisone 5mg daily | |
Discharge Medications: | |
1. insulin regular human 100 unit/mL Solution Sig: Two (2) units | |
Injection ASDIR (AS DIRECTED). | |
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). | |
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). | |
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 | |
hours) as needed for pain or fever: max 4g/24 hrs. | |
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One | |
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). | |
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule | |
PO TID (3 times a day). | |
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a | |
day): hold for loose stools. | |
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) | |
as needed for pain. | |
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) | |
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for | |
constipation. | |
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID | |
(2 times a day): hold for loose stools. | |
11. heparin (porcine) 5,000 unit/mL Solution Sig: 14428 (14428) | |
units Injection TID (3 times a day). | |
12. benazepril 10 mg Tablet Sig: Two (2) Tablet PO Daily (): | |
Hold if SBP <105 or K> 4.5 | |
. | |
Discharge Disposition: | |
Extended Care | |
Facility: | |
Duncan Medical Center Martinez Memorial Hospital Rehabilitation and Nursing Center - Eerie | |
Discharge Diagnosis: | |
L SDH with midline shift | |
Discharge Condition: | |
Level of Consciousness: Alert and interactive. | |
Activity Status: Ambulatory - Independent. | |
Mental Status: Confused - always. | |
Discharge Instructions: | |
?????? Have a friend/family member check your incision daily for | |
signs of infection. | |
?????? Take your pain medicine as prescribed. | |
?????? Exercise should be limited to walking; no lifting, straining, | |
or excessive bending. | |
?????? You may wash your hair only after sutures and/or staples have | |
been removed. They should be removed on 5-27. | |
?????? 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. | |
?????? You may resume taking prednisone | |
?????? If you were on a medication such as Coumadin (Warfarin), or | |
Plavix (clopidogrel), or Aspirin, prior to your injury, you may | |
safely resume taking after post-op review | |
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure | |
medicine, take it as prescribed and follow up with laboratory | |
blood drawing in one week. This can be drawn at your PCP??????s | |
office, but please have the results faxed to 311-654-8171. | |
?????? Clearance to drive and return to work will be addressed at | |
your post-operative office visit. | |
?????? Make sure to continue to use your incentive spirometer while | |
at home, unless you have been instructed not to. | |
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE | |
FOLLOWING | |
?????? New onset of tremors or seizures. | |
?????? Any confusion or change in mental status. | |
?????? Any numbness, tingling, weakness in your extremities. | |
?????? Pain or headache that is continually increasing, or not | |
relieved by pain medication. | |
?????? Any signs of infection at the wound site: redness, swelling, | |
tenderness, or drainage. | |
?????? Fever greater than or equal to 101?????? F. | |
Followup Instructions: | |
Follow-Up Appointment Instructions | |
??????You may return to the office in 7-30 days(from your date of | |
surgery) for removal of your staples/sutures and/or a wound | |
check. This can alos be done at rehab by 5-27. | |
??????Please call (505-473-5282 to schedule an appointment with Dr. | |
Wise, to be seen in 4 weeks. | |
??????You will need a CT scan of the brain without contrast. | |
Ashley Jerald MD I17811034 | |
Completed by:2180-5-25" | |
"Admission Date: 2177-10-2 Discharge Date: 2177-10-30 | |
Date of Birth: 2120-8-4 Sex: M | |
Service: CARDIOTHORACIC | |
Allergies: | |
Patient recorded as having No Known Allergies to Drugs | |
Attending:Johnny | |
Chief Complaint: | |
Epigastric discomfort and lethargy | |
Major Surgical or Invasive Procedure: | |
2177-10-6 Five Vessel Coronary Artery Bypass Grafting(LIMA to | |
LAD, with vein grafts to first diagonal, second diagonal, obtuse | |
marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring), | |
with Insertion of an IABP. | |
History of Present Illness: | |
Mr. Gladys is a 57 year old male who presented to OSH in mid | |
September with shortness of breath, gastric discomfort and | |
fatigue. He ruled in for a ST elevation MI. Subsequent cardiac | |
catheterization revealed severe three vessel coronary artery | |
disease and an LVEF of 36%. Echocardiogram at that time was | |
notable for an LVEF of 40% with inferior wall akinesis and | |
moderate mitral regurgitation. Patient was declined for surgery | |
at Starr Clinic(secondary to poor distal targets) and | |
eventually transferred to the Wood Memorial Hospital for further evaluation and | |
treatment. | |
Past Medical History: | |
Ischemic Cardiomyopathy, Coronary Artery Disease with inferior | |
wall ST Elevation MI on 2177-9-30, Mitral Regurgitation, | |
Hypertension, Type II Diabetes Mellitus(poorly controlled), | |
Hyperlipidemia | |
Social History: | |
Denies tobacco and ETOH. He lives alone. He is a truck driver. | |
Family History: | |
Denies family history of premature coronary artery disease. | |
Physical Exam: | |
Admission | |
HR 74 SR BP 126/62 RR 20 Sat 96% on 4L | |
Neuro Arousable, follows commands with encouragement. MAE, | |
strength 5/5 t/o. PERRL. | |
CV RRR no M.R.G | |
Lungs wheezes, crackles | |
Abdomen soft/NT | |
Extrem 1+ edema, warm 2+ pulses t/o | |
no carotid bruits | |
Discharge | |
T 99.6 HR 76SR BP104/60 RR22 O2sat 96%RA | |
Neuro: Awake, moves rt side to command, left dense hemiparesis | |
CV: RRR, sternum stable | |
Pulm: course rhonchi | |
Abdm: soft, NT/+BS | |
Ext: left LE 3+ edema, Rt LE no edema | |
Pertinent Results: | |
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct | |
2177-10-30 02:29AM 8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0* | |
281 | |
Source: Line-CVL | |
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) | |
2177-10-30 02:29AM 281 | |
Source: Line-CVL | |
2177-10-30 02:29AM 20.5*1 65.6* 1.9* | |
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap | |
2177-10-30 02:29AM 150* 25* 1.2 137 3.8 99 30 12 | |
RADIOLOGY Final Report | |
CHEST (PORTABLE AP) 2177-10-29 1:30 PM | |
CHEST (PORTABLE AP) | |
Reason: dobhoff placement | |
Choudhury Medical Center MEDICAL CONDITION: | |
57 year old man with s/p CABG | |
REASON FOR THIS EXAMINATION: | |
dobhoff placement | |
CHEST, SINGLE AP FILM | |
History of CABG. | |
Status post CABG. Distal end of feeding tube overlies body of | |
stomach. There is cardiomegaly and a left pleural effusion with | |
associated atelectasis in the visualized left lower lung. No | |
pneumothorax. The left subclavian CV line has tip located over | |
the proximal SVC. | |
IMPRESSION: No definite pneumothorax. Left pleural effusion and | |
associated atelectasis in left lower lobe, overall appearances | |
being essentially unchanged since prior study of 2177-10-28. | |
DR. Herbert Castaneda | |
2177-10-2 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4 | |
MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273 | |
2177-10-2 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4* | |
2177-10-2 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133 | |
K-4.7 Cl-94* HCO3-27 AnGap-17 | |
2177-10-2 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531* | |
AlkPhos-325* Amylase-35 TotBili-0.6 | |
2177-10-2 10:30PM BLOOD Albumin-3.3* Mg-2.5 | |
2177-10-2 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49* | |
calTCO2-28 Base XS-4 | |
2177-10-2 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1 | |
Cl-94* | |
2177-10-5 08:58PM BLOOD %HbA1c-12.4* | |
2177-10-3 Non Contrast Head CT Scan: | |
There is no evidence of intracranial hemorrhage, mass effect, or | |
shift of normally midline structures. Dr. Butler-white matter | |
differentiation is preserved. The ventricles are normal in size | |
and symmetric. There is no evidence of acute major vascular | |
territorial infarction. There are moderate cavernous carotid | |
calcifications. There is complete opacification of the right | |
maxillary sinus. The remaining paranasal sinuses and mastoid air | |
cells are clear. | |
2177-10-6 Intraoperative TEE: | |
PRE-BYPASS: | |
Pt requiring dobutamine infusion at 7.5 | |
1. No atrial septal defect is seen by 2D or color Doppler. | |
2. There is mild to moderate global left ventricular hypokinesis | |
(LVEF = 35-40 %), with basal to mid inferior and | |
inferior-lateral akinesis. [Intrinsic left ventricular systolic | |
function is likely more depressed given the severity of valvular | |
regurgitation.]. | |
3. Right ventricular chamber size is normal. There is mild to | |
moderate global right ventricular free wall hypokinesis. | |
4. There are simple atheroma in the ascending aorta. The | |
descending thoracic aorta is mildly dilated. There are simple | |
atheroma in the descending thoracic aorta. | |
5. There are three aortic valve leaflets. The aortic valve | |
leaflets are mildly thickened. Trace aortic regurgitation is | |
seen. | |
6. The mitral valve leaflets are mildly thickened. Moderate to | |
severe (3+) mitral regurgitation is seen, with noted centrally | |
directed regurgitant jet. The mitral regurgitation vena | |
contracta is >=0.7cm. | |
7.The tricuspid valve leaflets are mildly thickened; there is | |
mild to moderate (12-17+) tricuspid regurgitation. | |
POST-BYPASS: | |
Pt removed from cardiopulmonary bypass on vasopression, | |
milrinone, epinephrine and norephinephrine infusions and | |
placement of intra-aortic balloon pump. | |
1. Pt s/p mitral valve annuloplasty. There is no mitral | |
regurgitation. | |
2. Biventricular function is improved. Right ventricular is | |
normal sized and function has improved from moderate to mild | |
dysfunction. Left ventricular function remains globally | |
depressed; basal to mid inferior walls remain akinetic; there is | |
improvement of anterior wall function. | |
3. Aortic contours are intact post-decannulation. There is an | |
intra-aortic balloon noted in the proper position. | |
2177-10-15 Transthoracic ECHO: | |
The left atrium is moderately dilated. There is mild symmetric | |
left ventricular hypertrophy with normal cavity size. There is | |
moderate regional left ventricular systolic dysfunction with | |
akinesis of the inferior and inferolateral walls. The remaining | |
segments contract normally (LVEF = 35-40 %). The aortic valve | |
leaflets (3) are mildly thickened but aortic stenosis is not | |
present. No aortic regurgitation is seen. The mitral valve | |
leaflets are mildly thickened. A mitral valve annuloplasty ring | |
is present. The mitral annular ring appears well seated and is | |
not obstructing flow. No mitral regurgitation is seen. There is | |
borderline pulmonary artery systolic hypertension. There is a | |
very small pericardial effusion most prominent around the right | |
atrium. | |
2177-10-16 Cardiac Catheterization: | |
1. Selective coronary angiography of this right dominant system | |
demonstrated native 3 vessel coronary artery disease. The LMCA | |
had | |
diffuse mild disease. The LAD was occluded in the mid vessel. | |
The LCX | |
was occluded proximally. The RCA was occluded proximally. The | |
SVG-PDA | |
was patent with slow flow into a small PDA. The SVG-D1 was | |
patent as was | |
SVG-D2, both with slow flow into small distal vessels. The | |
SVG-OM was | |
patent with slow flow as well. The LIMA-LAD was patent. The LAD | |
beyond | |
the LIMA was diffusely small with slow flow. | |
2. Limited resting hemodynamics were performed. The systemic | |
arterial pressures were borderline low measuring 86/63mmHg. | |
2177-10-20 Non contrast Head CT Scan: | |
There is no sign for the presence of an intracranial hemorrhage. | |
There is a question of a 1cm area of low density seen within the | |
region of the right uncus, which did not appear to be present on | |
the prior CT scan. If real, this finding could represent an area | |
of developing infarction. No other definite interval changes are | |
appreciated. There is no hydrocephalus or shift of normally | |
midline structures. | |
2177-10-21 MRA Brain: | |
Multiple areas of restricted diffusion bilaterally including | |
also the right cerebellar hemisphere as described above, areas | |
of subacute ischemic changes extending from the posterior limb | |
of the right internal capsule to the right, hippocampal area. | |
These December are suggestive of subacute infarcts likely from | |
an embolic source involving multiple vascular territories. | |
Brief Hospital Course: | |
Mr. Gladys was admitted to the cardiac surgical service. He | |
remained pain free on intravenous Heparin and Nitroglycerin. He | |
was initially evaluated by the Neurology service for an altered | |
mental status, experiencing periods of unresponiveness, | |
confusion and agitation/delirium. A head CT scan was | |
unremarkable and his altered mental status was attributed | |
metabolic encephalopathy. There was no evidence of stroke. Over | |
the next several days from a cardiac standpoint, he gradually | |
developed cardiogenic shock and required inotropic support. | |
Given his critical condition, he was urgently brought to the | |
operating room on 10-6 where Dr. Hess performed | |
coronary artery bypass grafting and mitral valve repair. Given | |
his low ejection fraction, an IABP was placed prior to weaning | |
from cardiopulmonary bypass. For additional surgical details, | |
please see seperate dictated operative note. Following the | |
operation, he was brought to the CVICU in critical condition. | |
His postoperative course will now be broken down into systems: | |
CARDIAC: Initially required multiple inotropes for poor | |
hemodynamics. Started on Amiodarone on postoperative day two for | |
atrial and ventricular arrhythmias. The IABP was slowly weaned | |
and eventually removed on postoperative day four without | |
complication. He remained pressor dependent at that time. | |
Cardioversion was performed on postoperative day six for | |
episodes of atrial fibrillation associated with a decrease in | |
SVO2. By postoperative seven, all inotropic support was weaned. | |
Despite Amiodarone, he continued to experience atrial and | |
ventricular arrhythmias. He went on to develop an episode of | |
sustained ventricular fibrillation/torsades on postoperative day | |
eight for which successfull defibrillation was performed. | |
Amiodarone was discontinued and switched to Lidocaine. A calcium | |
channel blocker was concomitantly initiated. The EP/cardiology | |
services were consulted and recommended EPS with potential VT | |
ablation. To rule out ischemia as the cause for ventricular | |
tachycardia, cardiac catheterization was performed on 10-16 which showed patent grafts. Given ventricular arrhythmias, | |
he was eventually started on Mexiletine. | |
PULMONARY: Given critical condition, required prolonged | |
mechanical ventilation. Eventually extubated on postoperative | |
day nine. He was electively re-intubated for cardiac | |
catheterization on 10-16, and re-extubated later that | |
night. Unfortunatly, he went on to develop acute respiratory | |
failure later that night and required reintubation. Bronchoscopy | |
was performed on 10-17 which found patent airways without | |
evidence of mucous plugs and only minimal scant secretions. A | |
left sided chest tube was placed for pleural effusion. The | |
effusion improved and the chest tube as removed. | |
NEURO: Given his critical condition, had a prolonged period of | |
sedation. Following his initial extubation, he awoke | |
neurologically intact. Following his second re-extubation on | |
postoperative day 14, he was noted to have new onset left | |
hemiparesis and left sided neglect. Neurology was consulted | |
while head CT scans and MR Donald Scrivens consistent with | |
embolic stroke(see result section). Heparin and coumadin were | |
started. | |
RENAL: Developed oliguric acute renal failure. Creatinine peaked | |
to 2.9 on postoperative day eight. The renal service was | |
consulted and attributed his renal insufficiency to pre-renal | |
etiology. Renal function gradually improved and he responded | |
nicely to diuretics. | |
ENDOCRINE: Initially maintained on Insulin drip. Transitioned to | |
lantus insulin. | |
HEME: Mild postoperative anemia and was intermittently | |
transfused to maintain hematocrit near 30%. | |
ID: Remained afebrile with no evidence of infection. | |
GI: Bedside swallow on 10-22 recommended continuing NPO/tube | |
feeding as he was not consistently awake enough to safely | |
attempt anything by mouth. Tolerating tube feedings. | |
Skin: A hematoma formed at an ex-chest tube site on his left | |
flank and began bleeding with anticoagulation. It was sutured on | |
10-26 and subsequently improved. | |
Medications on Admission: | |
Intravenous Nitroglycerin | |
Docusate Sodium 100 Showalter Medical Center | |
Metoprolol 75 Showalter Medical Center | |
Pantoprazole 40 qd | |
Aspirin 325 qd | |
Lisinopril 2.5 qd | |
Simvastatin 40 qd | |
Glargine 20 units qhs | |
RISS | |
Discharge Medications: | |
1. Simvastatin 40 mg Tablet Showalter Medical Center: One (1) Tablet PO DAILY | |
(Daily). | |
2. Aspirin 81 mg Tablet, Chewable Showalter Medical Center: One (1) Tablet, Chewable | |
PO DAILY (Daily). | |
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Showalter Medical Center: Two | |
(2) Puff Inhalation Q4H (every 4 hours). | |
4. Fluticasone 110 mcg/Actuation Aerosol Showalter Medical Center: Two (2) Puff | |
Inhalation Showalter Medical Center (2 times a day). | |
5. Docusate Sodium 50 mg/5 mL Liquid Showalter Medical Center: One (1) PO BID (2 | |
times a day). | |
6. Carvedilol 12.5 mg Tablet Showalter Medical Center: Two (2) Tablet PO BID (2 times | |
a day). Tablet(s) | |
7. Mexiletine 150 mg Capsule Showalter Medical Center: One (1) Capsule PO Q8H (every | |
8 hours). | |
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR Kenison: One (1) | |
Tablet,Rapid Dissolve, DR Kenison DAILY (Daily). | |
9. Bisacodyl 10 mg Suppository Kenison: One (1) Suppository Rectal | |
DAILY (Daily). | |
10. Sodium Chloride 0.65 % Aerosol, Spray Kenison: 12-17 Sprays Nasal | |
QID (4 times a day) as needed. | |
11. Ipratropium Bromide 0.02 % Solution November: One (1) Inhalation | |
Q6H (every 6 hours) as needed. | |
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1) | |
Inhalation Q4H (every 4 hours) as needed. | |
13. Artificial Tear with Lanolin 0.1-0.1 % Ointment November: One (1) | |
Appl Ophthalmic PRN (as needed). | |
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1) | |
Inhalation Q6H (every 6 hours) as needed. | |
15. Warfarin 1 mg Tablet November: as directed Tablet PO DAILY | |
(Daily): target INR 2-2.5 | |
Pt to receive 7.5mg on 10-30. | |
16. Lisinopril 5 mg Tablet April: One (1) Tablet PO DAILY (Daily). | |
17. Furosemide 80 mg Tablet April: One (1) Tablet PO BID (2 times | |
a day). | |
Discharge Disposition: | |
Extended Care | |
Facility: | |
Blackwater Senior Care - Thomas Memorial Hospital | |
Discharge Diagnosis: | |
- Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction, | |
Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock | |
- s/p Urgent CABG and Mitral Valve Repair on IABP | |
- Postoperative Stroke | |
- Postoperative Acute Respiratory Failure | |
- Postoperative Acute Renal Failure | |
- Postoperative Atrial Fibrillation/Flutter | |
- Postoperative Ventricular Tachycardia | |
- Postoperative Bradycardia | |
- Postoperative Anemia | |
- Postoperative Pleural Effusion | |
- Hypertension | |
- Hyperlipidemia | |
- Type II Diabetes Mellitus | |
Discharge Condition: | |
Stable. | |
Discharge Instructions: | |
1)Please shower daily. No baths. Pat dry incisions, do not rub. | |
2)Avoid creams and lotions to surgical incisions. | |
3)Call cardiac surgeon if there is concern for wound infection. | |
4)No lifting more than 10 lbs for at least 10 weeks from | |
surgical date. | |
Dineenp Instructions: | |
Dr. Smith 4-5 weeks, please call for appt | |
Cardiology clinic-Dr Kenison (EP) in 2-16 weeks, please call | |
for appt | |
Completed by:2177-10-30" | |
"Name: Kelli,Elizabeth Unit No: 66109 | |
Admission Date: 2183-7-12 Discharge Date: 2183-7-27 | |
Date of Birth: 2127-9-2 Sex: F | |
Service: MED | |
Allergies: | |
Percocet / Codeine / Robaxin / Lomotil / Vancomycin And | |
Derivatives | |
Attending:Courtney | |
Chief Complaint: | |
Fatique, fever | |
Major Surgical or Invasive Procedure: | |
surgical removal of port. | |
Brief Hospital Course: | |
See prior addenda | |
Discharge Medications: | |
additional d/c medication, insulin: | |
Lantus(Glargine) - 13 Units q evening, Loftus Memorial Hospital. | |
Discharge Disposition: | |
Extended Care | |
Facility: | |
Blackwater House Nursing Home - Thundera | |
Discharge Diagnosis: | |
Line sepsis from infected Lt. port; MRSA bacteremia | |
Discharge Condition: | |
Good | |
John Sorrell MD J60211121 | |
Completed by:2183-7-27" | |
"Admission Date: 2135-6-22 Discharge Date: 2135-7-2 | |
Date of Birth: 2076-4-4 Sex: M | |
Service: | |
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old | |
male with a history of metastatic melanoma to bowel and known | |
pulmonary and CNS metastases status post craniotomy with | |
resection of the brain metastases. The patient presented | |
with a three day history of intermittent worsening and crampy | |
abdominal pain in the lower quadrants, worse on the right | |
than on the left. The pain was described as severe. The | |
patient had a bowel movement until the day prior to | |
admission. KUB on arrival in the Emergency Department showed | |
dilated loops of small bowel with air fluid levels. A CT | |
scan obtained shortly thereafter showed two large mesenteric | |
masses with erosion into small bowel and free perforation of | |
the more proximal segment of small bowel, as well as | |
mechanical mid small bowel obstruction. | |
PAST MEDICAL HISTORY: | |
1. Metastatic melanoma with metastases to the lung, brain, | |
bowel, left flank | |
MEDICATIONS: | |
1. Nexium 40 mg po qd | |
2. Flomax | |
3. Flonase | |
4. Compazine | |
5. Ambien 10 mg | |
6. Quinine 260 mg | |
7. Prednisone 10 mg po | |
8. 50 mcg fentanyl patch | |
The patient had recently been on his first week to Taxol | |
dexamethasone therapy and had also been through four cycles | |
of IL-2/temozolomide for his metastatic melanoma. | |
ALLERGIES: The patient has no known drug allergies. | |
SOCIAL HISTORY: The patient had smoked one pack per day for | |
about 20 years, but quit 20 years ago. | |
PHYSICAL EXAM: | |
VITAL SIGNS: Temperature 98.8??????, blood pressure 120/70, pulse | |
117, respiratory rate 20, O2 saturation 96% on room air. | |
GENERAL: The patient was awake and comfortable and appeared | |
well nourished. | |
HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous | |
distention, no palpable nodes. Oropharynx was clear. | |
NECK: Supple. | |
HEART: S1, S2, tachycardic with no murmurs, rubs or gallops. | |
LUNGS: Clear to auscultation bilaterally. | |
ABDOMEN: Distended, nontender, no hepatosplenomegaly. There | |
were decreased bowel sounds. Abdomen was tense and was a 7 | |
cm subcutaneous mass on the left flank. | |
EXTREMITIES: There was no lower extremity edema, cyanosis or | |
clubbing. | |
LABS: White cell count 9.8, hematocrit 13.8, platelets 947. | |
PT 12.8, PTT 21.5, INR 1.1. Chem-7 - sodium 136, potassium | |
4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6, | |
glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2. | |
HOSPITAL COURSE: The patient arrived in the hospital on the | |
evening of 6-22 and evaluation was initiated. The patient | |
was taken to the Operating Room late in the night of 6-22 | |
where, per the Operating Room note, tumors were discovered in | |
the ileum and jejunum with free perforation of both lesions. | |
The patient was then transferred to the Intensive Care Unit. | |
The patient was started on ampicillin, levofloxacin and | |
Flagyl. | |
On postoperative day #2, which was 2135-6-25, the patient was | |
started on TPN. His antibiotics were continued. On | |
postoperative day #3, the patient was noted to have a | |
slightly increased temperature to 100.2??????. He was pan | |
cultured given the fact he had recently been on steroids. | |
His central line was also changed. During the course of the | |
day, the patient was agitated at one point and pulled his | |
A-line. Haldol was prescribed. | |
On postoperative day #4, the patient appeared to be less | |
confused. He was transferred to the floor with a sitter. By | |
postoperative day #5, while the patient was on the floor, he | |
was appearing much more lucid, communicating appropriately | |
and the sitter was discontinued. The patient was continued | |
on total parenteral nutrition. Because of continued increase | |
in white cell count from 14.3 on postoperative day #4 to 16.0 | |
on postoperative day #5, the patient was sent for an | |
abdominal CT. Although no abscess was identified that could | |
explain the patient's increase in white cell count, the | |
patient was noted to have developed mural thrombus in his | |
abdominal aorta and in the left iliac artery. The patient | |
was also noted to develop some new bilateral pleural | |
effusions with some barium in the left lung base. On being | |
notified of these findings, the surgical team immediately | |
consulted the patient's neuro-oncologist and oncologist team | |
for advice on the propriety of placing the patient on | |
anticoagulation. | |
The patient was seen by his neuro-oncologist on postoperative | |
day #6, which was the 4-29. The patient's | |
neuro-oncologist requested head CT be obtained to rule out | |
any new brain metastases with bleeding because this would | |
determine the patient's suitably for anticoagulation. The | |
head CTs were negative and per neuro-oncology, there was no | |
contraindication to anticoagulating the patient. The patient | |
was seen by his oncologist team also on postoperative day #6. | |
Oncology was of the opinion of the patient, was unsuitable | |
for anticoagulation with Coumadin or heparin but that aspirin | |
could be initiated. The patient was therefore started on | |
aspirin. | |
The patient's steroids were also tapered beginning on | |
postoperative day #7. His fluconazole was discontinued. At | |
the suggestion of the patient's oncology team, the surgery | |
team also transfused the patient with 1 unit packed red blood | |
cells on postoperative day #8 for borderline low hematocrit | |
of 26.1. On postoperative day #7, the patient's diet was | |
changed from NPO to sips. The patient tolerated this well | |
and so on postoperative day #8, the patient was advanced to a | |
clear liquid diet and his TPN was discontinued. By the | |
evening of postoperative day #8, the patient was able to | |
tolerate a regular diet and on the day of discharge, which | |
was 2135-7-2, the patient had a regular breakfast without any | |
problems. Lindsey is to be discharged home with visiting nurse | |
assistant for wound care. Mr. Jeannette continues to have an | |
open vertical incision in the midline of his abdomen that | |
would require wet to dry dressings twice a day. | |
DISCHARGE MEDICATIONS: | |
1. Flomax | |
2. Flonase | |
3. Compazine | |
4. Ambien | |
5. Quinine | |
6. Prednisone 10 mg po qd | |
7. Protonix 40 mg po bid | |
8. Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours | |
9. Levofloxacin 500 mg po qd x5 more days | |
FOLLOW UP: The patient is to follow up with oncology on 7-18. The patient is to call Dr.Ervin office for | |
follow up appointment this coming week. | |
Barbara Sundberg, M.D. W92784896 | |
Dictated By:George | |
MEDQUIST36 | |
D: 2135-7-2 10:51 | |
T: 2135-7-2 11:14 | |
JOB#: Job Number 18599 | |
" | |
"Admission Date: 2161-12-15 Discharge Date: 2161-12-22 | |
Date of Birth: 2118-1-10 Sex: F | |
Service: | |
DIAGNOSIS: | |
Tracheal bronchial malacia. | |
HISTORY OF PRESENT ILLNESS: The patient is a delightful 43 | |
year-old woman who was found to have tracheal bronchial | |
malacia and has suffered from years of dyspnea on exertion, | |
persistent tracheal bronchitis and recurrent infections. She | |
is therefore admitted to undergo a right thoracotomy and | |
tracheoplasty. | |
HOSPITAL COURSE: The patient is admitted to the hospital and | |
underwent minimally invasive muscle sparring oscillatory | |
triangle thoracotomy with tracheal bronchoplasty on the day | |
of admission. She did well and was discharged without | |
problems. | |
Diane Lewis, M.D. C45888251 | |
Dictated By:Vail | |
MEDQUIST36 | |
D: 2162-4-5 05:00 | |
T: 2162-4-7 09:38 | |
JOB#: Job Number 33135 | |
" | |
"Admission Date: 2163-11-21 Discharge Date: 2163-12-1 | |
Date of Birth: 2086-12-16 Sex: M | |
Service: MEDICINE | |
Allergies: | |
Patient recorded as having No Known Allergies to Drugs | |
Attending:Flossie | |
Chief Complaint: | |
CHF, ARF, Mediastinal lymphadenopathy | |
Major Surgical or Invasive Procedure: | |
Bronchoscopy x 2 | |
Mediastinoscopy with lymph node biopsy | |
History of Present Illness: | |
76M initially went to Davis Hospital hospital with L flank and sent | |
home with narcs. Represented with DOE, weight gain and L flank | |
pain. He reports that he has had intermittent DOE for year but | |
notice a sharp increase in his weight over a period of 10 days. | |
He gained 8-10lbs with associated LE swelling, but without | |
medication noncompliance, dietary changes, chest pain, | |
orthopnea, PND. This happened at the beginning of July and | |
his Lasix was increased from 40 to 60 daily. He also had a | |
holter revealing afib (rate 40-100), nuclear stress | |
(2163-11-1)without ischemia and normal ECHO on 2163-11-3 (mild AS, | |
mild MR). Upon arrival to the ED he was found to be hypotensive | |
with hyperkalemia and ARF (Cr ~4 from basline of 1.2) He was | |
sent to the floor, diuresed and then sent to the ICU after he | |
was hypotensive requiring dopamine and vasopressin. He had a | |
Swan-Ganz catheter placed on 11-19 and had renally dosed | |
dopamine. He was thought to be fluid overloaded and had a | |
transudative thoracentesis (amount removed unknown). He was | |
aggressively diuresed with Lasix and renally dosed Dopamine. His | |
renal function improved prior to transfer. | |
Swan numbers: | |
RA: 25 | |
RV: 55/20/10 | |
PA: 55/25 | |
PCW: 26 | |
His L flank pain was evaluated with a CT Abdomen and he was | |
found to have L nephrolithiasis and an exophytic cyst on the | |
lower pole of the L kidney. His pain has been controlled with | |
narcotics. | |
He had also been recieving Zyvox for presumed pneumonia and | |
solumedrol 60 mg q6h for presumed COPD. | |
He was transferred for evaluation of his mediatinal LAD. This | |
has been watched for seveal years and he has two non-FDG avid | |
PET CTs, most recently in 2163-6-26. He denies any B symptoms. | |
He does have decreased appetite, but has been active with | |
outside hobbies including golf and curling. The thoracics | |
service was contactTammy for this evaluation and it was suggested | |
that the patient be admitted to the MICU given his underlying | |
medical problems. | |
Past Medical History: | |
PAST MEDICAL HISTORY: | |
==================== | |
AF, on coumadin at home | |
CRI Cr:1.6 | |
Chronic Anemia | |
CHF EF | |
Bladder CIS s/p BCG washout in 10/2163 | |
Colonic dysplastic lesions on bx | |
OSA- unable to tolerate CPAP | |
low grade NHL with diffuse stable LAD | |
AS | |
R popliteal artery endarterectomy | |
uretral stent | |
Gout | |
PVD | |
L CEA 2159 | |
UGIB 2161 | |
LLL lobectomy in 2135 | |
Nephrolithiasis | |
Social History: | |
EtOH: 2 martinis daily | |
Tobacco: quit 1ppd 25 yrs ago | |
outside hobbies included golf and curling | |
Family History: | |
no history of malignancy | |
Physical Exam: | |
Tmax: 35.9 ??????C (96.6 ??????F) | |
Tcurrent: 35.9 ??????C (96.6 ??????F) | |
HR: 74 (67 - 75) bpm | |
BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg | |
RR: 20 (20 - 24) insp/min | |
SpO2: 96% | |
Heart rhythm: AF (Atrial Fibrillation) | |
Physical Examination | |
General Appearance: Well nourished, No acute distress | |
Eyes / Conjunctiva: PERRL | |
Head, Ears, Nose, Throat: Normocephalic, MMM | |
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) | |
Cervical adenopathy | |
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), | |
III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at | |
base | |
Peripheral Vascular: (Right radial pulse: Present), (Left radial | |
pulse: Present), (Right DP pulse: Present), (Left DP pulse: | |
Present) | |
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: | |
Crackles : bilateral bases) | |
Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present, | |
Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds | |
Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t) | |
Clubbing | |
Skin: Not assessed | |
Neurologic: Responds to: Not assessed, Movement: Not assessed, | |
Tone: Not assessed | |
Pertinent Results: | |
2163-11-22 Echo: The left atrium is elongated. The right atrium is | |
markedly dilated. The right atrial pressure is indeterminate. | |
There is moderate symmetric left ventricular hypertrophy. The | |
left ventricular cavity size is normal. Left ventricular | |
systolic function is hyperdynamic (EF>75%). Right ventricular | |
chamber size and free wall motion are normal. The aortic root is | |
mildly dilated at the sinus level. The ascending aorta is mildly | |
dilated. The aortic valve leaflets (3) are mildly thickened. | |
There is mild to moderate aortic valve stenosis (area 1.2 cm2). | |
No aortic regurgitation is seen. The mitral valve leaflets are | |
mildly thickened. Physiologic mitral regurgitation is seen | |
(within normal limits). [Due to acoustic shadowing, the severity | |
of mitral regurgitation may be significantly UNDERestimated.] | |
The tricuspid valve leaflets are mildly thickened. Moderate [2+] | |
tricuspid regurgitation is seen. There is moderate pulmonary | |
artery systolic hypertension. There is a small pericardial | |
effusion. There are no echocardiographic signs of tamponade. | |
2163-11-23 Pathology report | |
1. Lymph nodes, 4L, biopsy (A-C): | |
Metastatic neuroendocrine neoplasm, most consistent with | |
carcinoid tumor, in two of ten lymph nodes/lymph node fragments. | |
2. Lymph nodes, 7, biopsy (D): | |
Metastatic neuroendocrine neoplasm, most consistent with | |
carcinoid tumor, in three of four lymph nodes/lymph node | |
fragments. See note. | |
3. Lymph nodes, level 7, biopsy (E): | |
Metastatic neuroendocrine neoplasm, most consistent with | |
carcinoid tumor, in one of two lymph nodes/lymph node fragments. | |
Note: | |
Immunohistochemical stains show the tumor cells are diffusely | |
positive for synaptophysin and chromogranin and are negative for | |
CK 7 and TTF-1. Rare tumor cells are positive for CK20. | |
Despite the negative TTF-1, the tumor is compatible with a lung | |
primary. Clinical correlation recommended. | |
FLOW CYTOMETRY 11-23: | |
FLOW CYTOMETRY IMMUNOPHENOTYPING: | |
The following tests (antibodies) were performed: HLA-DR, FMC-7, | |
Kappa, Lambda and CD antigens: 2,3,5,7,19,20,23, and 45. | |
RESULTS: | |
Three color gating is performed (light scatter vs. CD45) to | |
optimize lymphocyte yield. B cells comprise 34% of | |
lymphoid-gated events, are polyclonal, and do not express | |
aberrant antigens. T cells comprise 50% of lymphoid gated | |
events, and express mature lineage antigens. | |
INTERPRETATION: | |
Non-specific T cell dominant lymphoid profile; diagnostic | |
immunophenotypic features of involvement by lymphoma are not | |
seen in specimen. Correlation with clinical findings and | |
morphology (see S08-85352) is recommended. Flow cytometry | |
immunophenotyping may not detect all lymphomas due to | |
topography, sampling or artifacts of sample preparation. | |
11-23 Bronchial Washings: | |
Bronchial washing, left upper lobe: | |
NEGATIVE FOR MALIGNANT CELLS. | |
Reactive bronchial epithelial cells and alveolar | |
macrophages. | |
ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL) | |
was | |
reviewed and shows alveolar macrophages. No evidence of | |
malignancy. | |
11-23 CXR: | |
FINDINGS: No pneumothorax. There is complete opacification of | |
the left lung, which is indicating collapse in the left upper | |
lung, likely due to mucus plug. There is overlapping | |
opacification, which was seen on the previous film, in the left | |
lower lung which might be postoperative, inflammatory, or | |
malignant and further evaluation is needed. | |
There is a small right pleural effusion, unchanged. There is no | |
consolidation in the right lung. The right jugular line was | |
removed. | |
2163-11-23 CXR Post-Bronch: | |
FINDINGS: As compared to the previous examination, the left lung | |
is slightly better aerated. There is no evidence of left-sided | |
pneumothorax. In the right lung, in the middle lobe, some subtle | |
areas of atelectasis are seen. No evidence of larger pleural | |
effusions. | |
2163-11-24 CXR: | |
PORTABLE CHEST RADIOGRAPH: Compared to recent studies of | |
2163-11-23, there is improved aeration of the left upper lung, | |
without evidence of new | |
pneumothorax. There persists opacification of the left perihilar | |
and left | |
lower lung, likely representing combination of pleural effusion | |
and | |
atelectasis, although underlying consolidation cannot be | |
excluded. There is also improved aeration of the right lung | |
although small right pleural effusion persists. | |
2163-11-25 CXR: | |
REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy. | |
Since yesterday, diffuse opacification of the left lung is | |
overall unchanged, mostly in the perihilar and left lower lung | |
region, likely a combination of left pleural effusion and | |
atelectasis, possibly consolidation. Small right pleural | |
effusion is unchanged. The right lung is otherwise normal. There | |
is no other change. | |
2163-11-25 CT Scan Chest: | |
IMPRESSIONS: | |
1. Subcutaneous gas consistent with recent mediastinoscopy. A | |
small left | |
lower paratracheal collection containing fluid and gas could | |
represent post- procedural changes. Correlation with recent | |
procedure and clinical symptoms recommended. Multiple | |
mediastinal lymph nodes are noted. Larger soft tissue density in | |
the subcarinal region could represent lymphadenopathy or in the | |
right clinical context could also represent a hematoma. | |
Comparison with prior study if available could help | |
differentiate between the two. | |
2. Status post left lower lobectomy with fibrotic changes and | |
atelectasis | |
noted in the left lung. Fluid collection with thick enhancing | |
rind in the | |
left posterior sulcus is chronic and organized. | |
3. Nodule in the anterior left lung could represent rounded | |
atelectasis, | |
though in atypical location. Recurrent tumor cannot be excluded. | |
4. Moderate right dependent pleural effusion with associated | |
dependent | |
atelectasis of the left lower lobe. | |
5. Left adrenal mass. Dedicated imaging of the adrenal glands | |
recommended | |
for further evaluation. There is also suggestion of | |
lymphadenopathy in the | |
retroperitoneum that is incompletely imaged. Small ascites noted | |
along the | |
dome of the liver. | |
EKG 2163-11-27: | |
Normal sinus rhythm. Poor R wave progression, possibly related | |
to lead | |
placement. No other abnormality. No previous tracing available | |
for | |
comparison. | |
Intervals Axes | |
Rate PR QRS QT/QTc P QRS T | |
72 0 88 912-120-18471 | |
OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of 2163-11-29 | |
Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE | |
NEOPLASM | |
Prelim findings c/w metastatic carcinoid, full report pending. | |
2163-11-21 07:32PM GLUCOSE-130* UREA N-119* CREAT-2.2* | |
SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 | |
2163-11-21 07:32PM estGFR-Using this | |
2163-11-21 07:32PM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4 | |
2163-11-21 07:32PM URINE HOURS-RANDOM UREA N-828 CREAT-45 | |
SODIUM-LESS THAN | |
2163-11-21 07:32PM URINE OSMOLAL-427 | |
2163-11-21 07:32PM WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4* | |
MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1 | |
2163-11-21 07:32PM NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0 | |
BASOS-0 | |
2163-11-21 07:32PM PLT COUNT-389 | |
2163-11-21 07:32PM PT-33.9* PTT-43.6* INR(PT)-3.6* | |
2163-11-21 07:32PM URINE COLOR-Yellow APPEAR-Clear SP Gruwell-1.013 | |
2163-11-21 07:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG | |
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR | |
Other labs: | |
Hematology | |
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct | |
2163-12-1 05:45AM 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6 | |
288 | |
2163-11-30 08:05AM 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7 | |
277 | |
2163-11-29 06:45AM 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1 | |
280 | |
2163-11-28 07:00AM 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4 | |
242 | |
2163-11-27 07:25AM 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5 | |
247 | |
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap | |
2163-12-1 05:45AM 96 18 1.0 147* 4.0 105 37* 9 | |
2163-11-30 08:05AM 81 20 0.9 145 4.0 108 34* 7* | |
2163-11-29 06:45AM 77 22* 0.9 1441 4.0 106 36* 6* | |
2163-11-28 07:00AM 79 27* 1.0 144 4.1 105 32 11 | |
2163-11-27 07:25AM 95 30* 1.0 143 4.0 106 33* 8 | |
2163-11-26 07:00AM 103 37* 0.9 143 4.2 107 33* 7* | |
2163-11-25 03:37PM 104 43* 1.0 147* 4.4 110* 33* 8 | |
2163-11-25 02:07AM 168* 60* 1.0 146* 4.3 110* 31 9 | |
2163-11-24 04:25AM 92 87* 1.2 150* 4.2 113* 31 10 | |
2163-11-23 07:05AM 97 115* 1.7* 147* 4.5 108 31 13 | |
2163-11-22 02:52PM 126* 2.0* | |
2163-11-22 05:34AM 122* 125* 2.1* 143 4.5 104 28 16 | |
DIG ADDED 9:08AM | |
2163-11-21 07:32PM 130* 119* 2.2* 141 3.8 100 29 16 | |
2163-11-27 07:25AM BNP 7554*1 | |
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron | |
2163-12-1 05:45AM 8.9 3.2 2.2 | |
2163-11-30 08:05AM 9.0 3.4 2.3 | |
2163-11-29 06:45AM 9.0 2.8 2.3 | |
2163-11-28 07:00AM 8.6 2.7 2.2 | |
HEMATOLOGIC calTIBC Ferritn TRF | |
2163-11-22 05:34AM 153* 270 118* | |
DIG ADDED 9:08AM | |
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE | |
2163-11-22 05:34AM NO SPECIFI1 1700-410-4771 NO MONOCLO2 | |
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone | |
Bilirub Urobiln pH Leuks | |
2163-11-22 01:50PM NEG NEG NEG NEG NEG NEG NEG 5.0 NEG | |
Source: Catheter | |
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE | |
RenalEp | |
2163-11-22 01:50PM 3* 2 FEW NONE <1 <1 | |
Source: Catheter | |
URINE CASTS CastHy | |
2163-11-22 01:50PM 9* | |
Source: Catheter | |
OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other | |
2163-11-24 08:13AM 01 01 71* 8* 6* 15* 02 | |
BRONCHIAL LAVAGE | |
2163-11-25 3:37 pm SPUTUM Source: Expectorated. | |
**FINAL REPORT 2163-11-27** | |
GRAM STAIN (Final 2163-11-27): | |
<10 PMNs and >10 epithelial cells/100X field. | |
Gram stain indicates extensive contamination with upper | |
respiratory | |
secretions. Bacterial culture results are invalid. | |
PLEASE SUBMIT ANOTHER SPECIMEN. | |
2163-11-24 8:13 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. | |
**FINAL REPORT 2163-11-26** | |
GRAM STAIN (Final 2163-11-24): | |
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. | |
NO MICROORGANISMS SEEN. | |
RESPIRATORY CULTURE (Final 2163-11-26): NO GROWTH, <1000 | |
CFU/ml. | |
2163-11-23 7:10 pm TISSUE Site: LYMPH NODE | |
GRAM STAIN (Final 2163-11-23): | |
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR | |
LEUKOCYTES. | |
NO MICROORGANISMS SEEN. | |
TISSUE (Final 2163-11-26): NO GROWTH. | |
ANAEROBIC CULTURE (Final 2163-11-29): NO GROWTH. | |
ACID FAST SMEAR (Final 2163-11-24): | |
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. | |
ACID FAST CULTURE (Preliminary): | |
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. | |
POTASSIUM HYDROXIDE PREPARATION (Final 2163-11-24): | |
NO FUNGAL ELEMENTS SEEN. | |
LEGIONELLA CULTURE (Final 2163-11-30): NO LEGIONELLA | |
ISOLATED. | |
Immunoflourescent test for Pneumocystis jirovecii (carinii) | |
(Final | |
2163-11-24): NEGATIVE for Pneumocystis jirovecii | |
(carinii).. | |
Brief Hospital Course: | |
76M initially admitted to Davis Hospital hospital for CHF | |
exacerbation, and then transferred ICU-to-ICU for workup of | |
chronic mediastinal LAD. Thoracic Surgery had been contactTammy | |
and was interested in seeing the patient and deemed that he | |
would be most appropriate for MICU given his ongoing ARF. While | |
in the ICU his renal function improved with gentle intravascular | |
hydration. Echo was performed which revealed severe diastolic | |
dysfunction with ejection fraction of >70%. His digoxin was | |
therefore discontinued. He was discharged to the floor after | |
~24 hours of observation. | |
While on the medical service, the patient was brought to the OR | |
on 2163-11-23 for Flexible bronchoscopy with bronchoalveolar | |
lavage of the left upper lobe, cervical mediastinoscopy and | |
bronchoscopy. On post-op CXR there was noticeable whiteout of | |
the left lung field and the patient was kept in the PACU for | |
observation. He was treated with Chest PT, IS and suctioning | |
for the thought of possible mucus plugging. As per | |
documentation, the patient was doing well until the morning when | |
he had increasing oxygen requirements and more labored | |
breathing. At 8am on 2163-11-24 the patient underwent | |
unremarkable bronchoscopy by IP. Patient continued to have a | |
significant oxygen requirement, satting 93% on 40% facemask, | |
thus was transferred to the ICU for monitoring. | |
In ICU on 11-25, patient underwent upper airway suctioning, | |
along with albuterol, ipratropium, and mucinex treatment. He | |
utilized incentive spirometry as well. Serial chest x-rays | |
showed eventual clearing of his left lung. His oxygen saturation | |
improved to 100% on 4L. He underwent a chest CT which showed a | |
large right pleural effusion and left airspace disease possibly | |
consistent with pneumonia. he continued to produce increasing | |
amounts of airway mucous. Though he did not spike a fever or | |
develop a leukocytosis, he was started on empiric coverage for | |
hospital acquired pneumonia with vancomycin and zosyn. This was | |
continued for a total of 4 days, and then discontinued. His | |
respiratory status continued to improve, and he was weaned down | |
to 2L NC O2, and often maintained O2 sats > 94% on room air at | |
rest. | |
He was transferred from the ICU to the medicine floor on 11-25, | |
where the below issues were addressed: | |
Hypoxia: Thought to be due to mucus plugging in setting of | |
procedure. Given the acuity of both the change and the reversal | |
it is likely that he experienced lung collapse and then | |
reaeration of expectorating mucus. Received 4 days of vanc/zosyn | |
for presumed HAP coverage in setting of hypoxia and increased | |
sputum production, this was d/c'd 11-28 with no additional fevers | |
and decreasing sputum. He was continued on ipratropium nebs, | |
mucomyst nebs, guaifenesin, incentive spirometry. During his | |
stay, his oxygen requirement was weaned, now requiring 2L NC | |
only intermittently. Will continue albuterol and ipratropium | |
nebs on a prn basis. | |
. | |
Hypernatremia: Na as high as 150, did decrease with IVF but | |
still mildly elevated on transfer to floor. Improved to 147 | |
with D5W. IV hydration stopped at this time and POs encouraged | |
given risk of CHF. Free water deficit estimated at 2.3L on | |
transfer to floor. Na remained stable in range of 143-147 when | |
taking more PO fluid. Recommend continued intermittent | |
monitoring. | |
LAD: s/p mediastinoscopy. | |
His mediastinal lymph node biopsy results were consistent with | |
carcinoid. The hematology/oncology service was consulted, and | |
they recommended getting an octreotide scan, the preliminary | |
read showed metastatic carcinoid. These results were discussed | |
with the patient and his outpatient oncologist. The patient | |
requested to be followed by his oncologist in Lewis Memorial Hospital. | |
. | |
diastolic Congestive Heart Failure: ECHO with EF of 75%, has | |
severe dCHF. Cards consulted while in ICU. Digoxin was | |
discontinued in setting of diastolic CHF. Cardiology | |
recommended using either BB or verapamil to control HR, goal to | |
have <80. HR was well controlled without meds on transfer from | |
ICU. Added Metoprolol 12.5 mg Meredith Medical Center on 11-26, though this was | |
d/c'd 11-27 for episodes of bradycardia to 30s. Added 12.5 | |
Metoprolol SR 11-28, which he has tolerated well. Also added | |
Candesartan at low-dose (4mg, home dose 16 mg) given h/o | |
diastolic CHF and goal of reducing afterload. This can be | |
titrated up as his blood pressure allows. He did have some | |
increased edema during his stay on the medical floor, and was | |
given TEDs stockings and encouraged to ambulate. He also | |
received 40 mg IV lasix x 1 2163-11-28, and an additional dose of | |
40 mg po on 11-30 and 40mg IV on 12-1. The long-term goal | |
remains to minimize diuretics, but use extreme caution with | |
fluids as pt is exquisitely volume sensitive due to severity of | |
dCHF. Discharged with instructions to continue home lasix (40 | |
mg) for 3 days with monitoring of daily weights and chemistries, | |
this may need to be reassessed and monitored. | |
. | |
RHYTHM: He has chronic afib. His heparin was held after | |
surgery. He was restarted on coumadin 1.25 mg daily on 11-26. | |
His INR rose to the therapeutic range, and was 2.5 on discharge. | |
Recommend intermittent monitoring to tritrate necessary dosing | |
regimen. | |
. | |
ARF: Improved with hydration. Renal signed off prior to transfer | |
to floor. Diuresis minimized on the floor, received 40 mg IV | |
lasix and 40mg PO lasix on two occasions with good diuresis, pt | |
maintained blood pressures. The goal continues to be to | |
minimize diuresis to prevent excessive preload reduction. | |
. | |
CAD: He was continued on his statin, held ASA due to h/o GI | |
bleed | |
Medications on Admission: | |
PPI | |
Lipitor 10 | |
Atacand 16 (confirmed with spouse) | |
Digoxin 0.125 mg qd | |
Aldactone 25 qd | |
Lasix 40 qd | |
Allopurinol 100 mg qd | |
Verapamil 180 qd | |
Coumadin 2.5 (MWF); 1.25 (TTSS) | |
Flomax 0.5 | |
Discharge Medications: | |
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr | |
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). | |
2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily). | |
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One | |
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). | |
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY | |
(Daily). | |
5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily (). | |
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) | |
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. | |
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a | |
day) as needed. | |
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 | |
times a day). | |
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for | |
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as | |
needed. | |
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb | |
Inhalation Q6H (every 6 hours) as needed. | |
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3 | |
days. | |
Discharge Disposition: | |
Extended Care | |
Facility: | |
Lianes Medical Center - Thundera | |
Discharge Diagnosis: | |
Primary: | |
Mediastinal Lymphadenopathy | |
Metastatic Carcinoid | |
Acute renal failure | |
Secondary: | |
chronic diastolic congestive heart failure | |
anemia | |
atrial fibrillation | |
chronic renal insufficiency | |
Discharge Condition: | |
fair, tolerating PO, afebrile, VS wnl, O2 95-100% on | |
supplemental O2 2L Tomblin Hospital transfer to chair with assist | |
Discharge Instructions: | |
You were admitted to the hospital with mediastinal | |
lymphadenopathy. You had a mediastinoscopy and bronchcoscopy. | |
The pathology reports showed this was consistent with carcinoid. | |
You were seen by the oncologists, who recommended an Octreotide | |
scan; you indicated you would like to follow up with your | |
outpatient oncologist. | |
You were also noted to have an exacerbation of your heart | |
failure. You were seen by the cardiologists, who recommended | |
you stop your digoxin. You were given diuretics to remove | |
fluid. You also had acute renal failure, which resolved during | |
your stay. | |
. | |
A CT scan showed a mass on your left adrenal gland, this should | |
be worked up as an outpatient, you should talk with your primary | |
care doctor about further evaluation. | |
. | |
The following changes were made to your medications: | |
Your digoxin, verapamil and aldactone were stopped | |
Your atacand dose was decreased to 4 mg | |
You were started on metoprolol | |
You were started on docusate, senna, and bisacodyl as needed for | |
constipation and albuterol and ipratropium nebs as needed for | |
SOB/wheezing | |
Your allopurinol and flomax were held, these can be restarted | |
during your rehab stay | |
Your coumadin was decreased to 1.25 mg daily, this can be | |
adjusted based on your INR | |
. | |
Please call your doctor or return to the ED for: | |
- fevers/chills | |
- shortness or breath or chest pain | |
- increasing sputum production | |
- weight gain > 3 lbs | |
- any other new or concerning symptoms | |
Followup Instructions: | |
Follow up with your primary care provider, Cooper. Audry Hall | |
(576-277-8956, within 1 week of leaving rehab. On a CT scan, | |
you were noted to have a mass on your left adrenal gland, and | |
they recommended dedicated CT or MRI for better | |
characterization. Dr. Mora should help you this setting this | |
up. | |
Follow up with your cardiologist Dr. Morales Carol 118-669-6208, | |
fax 186-417-7342 within the next 2-3 weeks for reevaluation and | |
adjustment of heart failure meds as needed. | |
Oncology Dr. Gean 989-690-8790. You have an appointment on | |
12-13 at 1:20 PM, call if you need to reschedule or be | |
seen sooner. | |
" | |
"Admission Date: 2139-2-27 Discharge Date: 2139-3-10 | |
Service: | |
ADMITTING DIAGNOSIS: Barrett's esophagus with high grade | |
dysplasia. | |
DISCHARGE DIAGNOSES: | |
1. Barrett's esophagus with high grade dysplasia. | |
2. Status post trans-hiatal esophagectomy. | |
3. Aspiration. | |
4. Myocardial infarction. | |
5. Cardiogenic shock. | |
6. Anoxic encephalopathy. | |
7. Death. | |
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old | |
male who had a long standing history of gastroesophageal | |
reflux disease and Barrett's esophagus and had high grade | |
dysplasia diagnosed on recent endoscopy. The patient elected | |
to have an esophagectomy performed. | |
PAST MEDICAL HISTORY: | |
1. Hypertension. | |
2. Question renal insufficiency. | |
3. Gastroesophageal reflux disease. | |
MEDICATIONS: | |
1. Norvasc. | |
2. Prilosec. | |
3. Carafate. | |
PHYSICAL EXAMINATION: On admission, the patient is an | |
elderly man in no acute distress. Vital signs are stable. | |
Afebrile. Chest is clear to auscultation bilaterally. | |
Cardiovascular is regular rate and rhythm without murmur, rub | |
or gallop. Abdomen is soft, nontender, nondistended without | |
masses or organomegaly. Extremities are warm, not cyanotic | |
and not edematous times four. Neurological is grossly | |
intact. | |
HOSPITAL COURSE: The patient was taken to the Operating | |
Room on 2139-2-27, where he underwent transhiatal | |
esophagectomy without significant complication. In the | |
postoperative course, he was initially admitted under the | |
Intensive Care Unit care and kept in the Post Anesthesia Care | |
Unit overnight. The patient was seen to have a low urine | |
output and both metabolic and respiratory acidosis and was | |
given approximately 8.5 liters of Crystalloid in the | |
perioperative period, including OR. | |
The patient was briefly agitated in the Post Anesthesia Care | |
Unit and discontinued his nasogastric tube. On postoperative | |
day number one, the patient was doing well with a fairly | |
normalized blood gas of 7.35/43/94/25/minus 1 and was | |
transferred to the floor. | |
On postoperative day two, the patient was seen to have a | |
baseline oxygen requirement of 70% face mask in the morning | |
but was saturating well and otherwise seemed to be doing | |
relatively well. | |
The patient had a white count of 22.1 which prompted a chest | |
x-ray showing bilateral pleural effusion and patchy bibasilar | |
atelectasis but no focal infiltrates. Over the course of the | |
day, the patient had deteriorating in his respiratory status | |
and became increasingly tachypneic with wheezing and coarse | |
breath sounds. | |
An EKG was performed which showed atrial fibrillation but no | |
ischemic changes. A baseline arterial blood gas was obtained | |
at that point which was 7.37/47/86/28/zero, again on 70% face | |
mask. | |
Intravenous fluids were then stopped and the patient was | |
begun on 20 mg of intravenous Lasix and albuterol nebulizers. | |
The patient was transferred to another floor for Telemetry | |
purposes and cycled for myocardial infarction. His | |
respiratory status during transfer seemed somewhat improved. | |
Upon arrival to the other floor, the patient stopped | |
respiring briefly and went bradycardic. Upon stimulation, he | |
was tachycardic to the 110s with a blood pressure 130/70. | |
Immediately subsequent to that the patient went pulseless and | |
into respiratory and cardiac arrest and was down for | |
approximately two to three minutes. CPR was begun and the | |
patient intubated and 15 to 20 cc. of brownish fluid was | |
suctioned from the endotracheal tube post intubation. | |
The patient regained pulse and cardiac activity and was | |
transferred to the Intensive Care Unit. | |
Cardiac consultation at that time recommended aspirin, | |
cycling enzymes and agreed with probable aspiration event. | |
They suggested a heparin drip but not is surgically | |
contraindicated. A heparin drip was not started. The | |
patient ruled in for myocardial infarction with a troponin of | |
26.5. | |
In the patient's Intensive Care Unit stay, he was supported | |
with a dopamine drip and diuresed for fluid overload. | |
Pressors were weaned off on postoperative day number eight. | |
Respiratory function was supported throughout his Intensive | |
Care Unit course appropriately with mechanical ventilation. | |
The patient was noted to be unresponsive after the aspiration | |
event, with some slow return of responsiveness over the next | |
several days, but no purposeful movement. To evaluate | |
possible neurologic injury, a CT scan was obtained after the | |
patient was felt to be stable enough to be transferred. | |
On postoperative day six, the CT scan showed no acute | |
intracranial event but was consistent with chronic | |
microvascular infarction. EEG was also obtained which | |
revealed diffuse widespread encephalopathy. There was a | |
question of possible seizure activity involving the left | |
upper extremity and phenytoin was begun empirically. | |
A repeat EEG was obtained on postoperative day number 10 and | |
again showed moderately severe diffuse encephalopathy with no | |
seizure focus. | |
A Neurology consultation was obtained and assessed the | |
patient to have minimal chance for a meaningful recovery. | |
In accordance with the patient's living will, the family's | |
wishes and discussion with the surgical attending, the | |
patient was made comfort measures only and expired on | |
postoperative day number 11. | |
Joshua Guttmann, M.D. P39287153 | |
Dictated By:Branch | |
MEDQUIST36 | |
D: 2139-3-24 10:08 | |
T: 2139-3-28 16:18 | |
JOB#: Job Number 48824 | |
" | |
"Admission Date: Discharge Date: | |
Date of Birth: Sex: M | |
Service: UROLOGY | |
HISTORY OF PRESENT ILLNESS: Mr. Stephen is a 53-year-old | |
gentleman who presented on 2121-6-28 for cystectomy and | |
neobladder diversion. He had grade 3 of 3 TCC. | |
PAST MEDICAL HISTORY: | |
2. Myocardial infarction in '09 | |
3. Hypertension | |
4. Left internal capsule cerebrovascular accident in '18 | |
5. Hypothyroidism | |
6. Gastroesophageal reflux disease | |
7. Hypercholesterolemia | |
8. Depression | |
PAST SURGICAL HISTORY: | |
1. TURBT's in '13 and '15 | |
ALLERGIES: He has no known drug allergies. | |
HOME MEDICATIONS: | |
1. Aspirin 250 mg q.d. which was held | |
2. Metoprolol 25 mg b.i.d. | |
3. Levoxyl 300 mcg once a day | |
4. Paxil 40 mg once a day | |
5. Lipitor 20 once a day | |
ADMISSION LABS: CBC of 9.3, 43.6, 252. Chem-7 of 135, 4.4, | |
97, 23, 16, 0.8, 252. PT 12.8, PTT 24.4, INR 1.1. Liver | |
enzymes: ALT 23, AST 18, alkaline phosphatase 101, albumin | |
3.8, total protein 7.4. | |
IMAGING: Preoperative electrocardiogram showed left atrial | |
abnormalities with Q-waves in 2, 4, AVF, V5, V6. Thallium | |
stress test done preoperatively showed normal heart rate, | |
normal blood pressure, normal respirations, no acute | |
electrocardiogram changes, some portal V-function from an old | |
infarction prior myocardial infarction, however it was clear | |
for the operation. His chest films revealed no acute | |
cardiopulmonary process. | |
The inital surgery resulted in creation of a neobladder from | |
ileum. Postoperatively, the patient remained intubated with a | |
septic picture that deteriorated, requiring pressor agents. | |
The patient returned to the Operating Room on | |
2121-7-8 for an exploratory laparotomy and excision of an | |
infarcted neobladder and resection of a nonviable segment of | |
small bowel x2, creation of a jejunal conduit. His postop | |
course was equally stormy with spiking fevers, renal failure, | |
and BP instability | |
A third surgical exploration was necessary on 7-26. At this time, | |
the patient | |
More ischemic bowel was removed where perforations had occurred | |
resulting in peritonitis. The jejunal loop was excised and the | |
right ureter ligated. A left cutaneous ureterostomy was created. | |
Postop he had bilateral nephrostomies inserted and continued to | |
have an extended stormy ICU course. A tracheostomy was | |
necessary because of hi need for prolonged ventilator support. | |
He also developed extensive DVT requiring anticoagulation. | |
Bowel function gradually returned allowing for tube feedings. | |
Multiple courses of antibiotic therapy were given during his | |
hospital stay. | |
NEUROLOGICALLY: By system, neurologically the patient is | |
status post a left internal capsule infarct with residual | |
right sided weakness. His history of depression leaves on | |
Paxil and he was started on such. Radiologically, the | |
patient had a CT done of the head done during his admission. | |
Showed a stable appearance, considering no definitive | |
evidence of any type of abscess. Neurologically, the patient | |
is being discharged home and is stable. He is alert, however | |
he is unable to move secondary to his wasting and being in | |
bed for so long without assistance. The patient is able to | |
get out of bed to chair. Neurologically, the patient has no | |
acute issues upon discharge. | |
CARDIOVASCULAR: The patient is status post myocardial | |
infarction in 2109 and he did not have a myocardial | |
infarction during the course of his stay in-house at the | |
hospital and he was ruled out by enzymes with no acute | |
electrocardiogram changes. The patient has no acute | |
cardiovascular issues. The patient is not on clonidine, nor | |
is he on Lopressor currently and his pressure is tolerating, | |
basically being on nothing. The patient had been on pressors | |
immediately because of sepsis which was weaned off slowly | |
during the course of his stay. He has not been on pressors | |
for the previous month. | |
RESPIRATORY: The patient had poor respiratory failure and | |
required full respiratory support. He is postoperative his | |
three operations and has been slowly weaned down to a | |
pressure support of 40 with a CPAP pressure support with 405 | |
FIO2 with a PEEP of 5 and a pressure support of 5 with tidal | |
volumes ranging from 550 to 650. The patient | |
was also bronched on 8-22 and mucous plugs were removed from | |
the patient. A CT done on this patient in the last two weeks | |
in the middle of January showed that he had no acute | |
pulmonary process with possible left lower lobe pneumonia. | |
At that point, he had also been on antibiotics with this | |
course. Upon discharge, the patient has no acute pulmonary | |
process and his lungs are sounding remarkably clearer. | |
GASTROINTESTINAL: The patient is not able to eat on his own | |
and has a left Dobbhoff tube and is suffering from short--gut | |
syndrome requiring B12 injections. The patient is currently | |
tolerating his tube feeds of Impact at goal rate of 90 cc an | |
hour and is having some stool output. Clostridium difficile | |
sent on the patient recently as of 9-15 came back negative. | |
The patient is receiving all his feeds through tube feeds and | |
is not a candidate for a PEG given his previous abdominal | |
surgery. The patient's other gastrointestinal issues are | |
obviously evolving around the reception as previously stated | |
of massive portions of his small bowel, as well as the large | |
bowel and appendix. Upon discharge, there are no acute | |
discharge issues for this patient. | |
GENITOURINARY: The pathology report from the original | |
surgery showed a high grade invasive TCC involving the | |
bladder neck, prostate, urethral margin and regional | |
nodes. His right ureter is tied off secondary to | |
the leak and he has a right nephrostomy tube which was | |
changed on 9-16 as well as his left nephrostomy tube. His | |
ureterostomy tube on the left side was changed on 9-18. All | |
this was done in response to his febrile episode he had which | |
will be outlined later which was felt to be urosepsis. On | |
discharge, it was found that his nephrostomies were positive | |
for yeast, most likely colonized. The patient was not on any | |
type of antimicrobial for that. The patient has been showing | |
yeast growing from the left side nephrostomy and | |
ureterostomies almost to his Intensive Care Unit stay, but no | |
evidence of acutely febrile as a result most likely due to | |
colonization. The patient has a left nephrostomy tube in | |
addition to the ureterostomy of the left side and does not | |
have a Foley inserted into his neobladder obviously because | |
of drainage from that point of view. Upon discharge from a | |
urological standpoint, the patient is stable. His tubes are | |
draining clear urine and there is no blood present. Some | |
blood may be noted in the urine with positional changes on | |
the patient and that is completely normal as long as it is | |
consistent with old blood and no massive bleeds. | |
EXTREMITIES: The patient was found to have a lower extremity | |
deep venous thrombosis on 8-3, as well as 8-8 which found | |
upper extremity bilateral deep venous thromboses. The | |
patient basically had deep venous thromboses x4 and was | |
started on a heparin drip continuously to resolve his deep | |
venous thromboses and heparin drip was continued until | |
Coumadin was started in the last two weeks of January prior | |
to his discharge. An ultrasound of the upper extremities | |
done on Mr. Stephen on 9-12, showed that he resolved his | |
upper extremity clots completely with the exception of some | |
small residual clot at the left and right IJ. The patient is | |
being discharged on Coumadin with the hope of achieving an | |
INR of approximately 2 to 2.5. The most recent INR was 1.3, | |
came back on 9-18 and the patient continued to receive | |
Coumadin until he reaches his goal without any heparin. In | |
addition, the patient's hematocrit has remained stable, | |
however. | |
HEME: The patient has been on Coumadin. His hematocrit has | |
remained stable as of late and his last blood transfusion was | |
on 7-12. Since then, his hematocrit has remained stable at | |
around 29 to 28 with no acute signs of bleeding. As far as | |
his renal function, the patient has been increasing sodium | |
and has been given free water to resolve that. His | |
hematocrit is stable and his white cell count on 9-18 was | |
8.0. | |
INFECTIOUS DISEASE: The patient was febrile postoperative | |
and several cultures were sent out. Regarding his blood | |
cultures, from 7-8 to the middle of January, he did not | |
grow anything out. He was on triple antibiotics which were | |
actually discontinued on 2121-8-29. He failed to grow | |
anything however fluconazole was continued until 9-2 to rule | |
out any other type of infection and to make sure that there | |
was no acute yeast systemic process going on even though he | |
had colonized his tubes. The patient became febrile again on | |
9-8 unfortunately with a T-max of 104.4??????. The patient was | |
started immediately on vancomycin, Zosyn and fluconazole | |
until cultures came back. Blood cultures and catheter | |
cultures came back revealing that the patient had been | |
infected and was handling what was later decided was probably | |
urosepsis for Klebsiella. Based on this, the patient resumed | |
a 10 day treatment cycle of Levaquin based on infectious | |
disease's recommendation and the other antibiotics were | |
stopped. This is actually day 8 of 10 of his levofloxacin | |
course and as of 2121-9-19 the patient will be receiving two | |
more days of Levaquin. | |
The patient upon discharge is afebrile and his surveillance | |
blood cultures have come back negative even though his | |
nephrostomy tubes which were changed showed some fungal | |
colonization growth. His blood has remained negative for any | |
type of infection. During his stay, other cultures sent off | |
included blood flowing through his catheter lines which were | |
negative except for that one change which was required on | |
9-8 after he became febrile. His left subclavian has | |
changed. Today, on 9-19, he has a right sided subclavian of | |
the left sided one which was considered a possible source of | |
infection. His lines are not likely the source of the | |
infection. It is hoped that he will get a PICC line before | |
he is discharged to rehabilitation today and his central line | |
will be taken out. | |
MICROBIOLOGY: A spinal tap was also done and no consequence | |
of that resulted. No significant findings. | |
Today, the patient is being discharged and he is on the | |
following medications: | |
1. Glutamine 5 mg p.o. tube feeds to prevent excessive | |
stool, secondary to short-gut. | |
2. NPH 8 units subcutaneous b.i.d. | |
3. Thyroxine 200 mcg p.o. q.d. | |
4. Vitamin C p.o. per the nasogastric tube every day. | |
5. Insulin sliding scale 2, 4, 6, 8 which is not being used | |
much. | |
6. Paxil 20 mg nasogastric tube q.d. | |
7. Levofloxacin 500 mg intravenous to be continued for | |
another two days hopefully. | |
8. Tincture of iodine 10 drops to every 500 cc of tube | |
feeds. | |
He received 2.5 mg of Coumadin last night. He has not | |
received any recent Dilaudid or albuterol nebulizer | |
treatment. He is receiving KCL 40 mg intravenous prn for low | |
potassium of less than 4, magnesium of 2 gm intravenous prn | |
for less than 2.0 magnesium levels, last dose on 9-18, as was the last dose of potassium. The patient has not | |
been requiring any Ativan or Dilaudid or sedation as of | |
recently. He was on Epogen for a hematocrit which has now | |
been stabilized, so it is no longer as issue. It was felt | |
that the patient was in early on acute renal failure which | |
turned out to be a leak and the patient is not on renal | |
failure, no requiring any Epogen. On this date, 9-19, Mr. | |
Stephen is basically receiving in addition to just the | |
glutamine 5 mg tube feeds, Synthroid which are outlined and | |
he is also getting Protonix 40 mg intravenous q.d. for | |
gastrointestinal prophylaxis, as well as Coumadin to keep an | |
INR of 2 to 2.4 for prophylaxis. | |
It is our hope that Mr. Schrack, despite his advanced | |
cancer and multiple surgeries, will be rehabilitated and able | |
to resume assemblance of his functional life. We hope that | |
he continues receiving chest PT, that he is respiratorily | |
stable with no acute issues at this time. We also hope that | |
he will eventually no longer require ventilatory support and | |
a collar could be used on him as well as eventually assume | |
breathing on room air. | |
Final Diagnoses: | |
1. Transitional Cell Ca of Bladder and Prostate, metstatic to | |
regional nodes | |
2. Multiple postoperative complications, including intestinal | |
perforation with peritonitis, neobladder infarction, sepsis, | |
vascular instability with hypotension, DVT, and renal | |
insufficiency. | |
3. Respiratory insufficiency | |
4. s/p tracheostomy | |
Michele Initial (NamePattern1) Beaufort, MD A79903668 | |
Dictated By:Leon | |
MEDQUIST36 | |
D: 2121-9-19 09:01 | |
T: 2121-9-19 09:11 | |
JOB#: Job Number 39316 | |
rp 2121-9-19 | |
" | |