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1
+ PARSED
2
+ "Admission Date: 2130-4-14 Discharge Date: 2130-4-17
3
+ Date of Birth: 2082-12-11 Sex: M
4
+ Service: #58
5
+ HISTORY OF PRESENT ILLNESS: Mr. Jefferson is a 47 year-old man
6
+ with extreme obesity with a body weight of 440 pounds who is
7
+ 5'7"" tall and has a BMI of 69. He has had numerous weight
8
+ loss programs in the past without significant long term
9
+ effect and also has significant venostasis ulcers in his
10
+ lower extremities. He has no known drug allergies.
11
+ His only past medical history other then obesity is
12
+ osteoarthritis for which he takes Motrin and smoker's cough
13
+ secondary to smoking one pack per day for many years. He has
14
+ used other narcotics, cocaine and marijuana, but has been
15
+ clean for about fourteen years.
16
+ He was admitted to the General Surgery Service status post
17
+ gastric bypass surgery on 2130-4-14. The surgery was
18
+ uncomplicated, however, Mr. Jefferson was admitted to the Surgical
19
+ Intensive Care Unit after his gastric bypass secondary to
20
+ unable to extubate secondary to a respiratory acidosis. The
21
+ patient had decreased urine output, but it picked up with
22
+ intravenous fluid hydration. He was successfully extubated
23
+ on 4-15 in the evening and was transferred to the floor
24
+ on 2130-4-16 without difficulty. He continued to have
25
+ slightly labored breathing and was requiring a face tent mask
26
+ to keep his saturations in the high 90s. However, was
27
+ advanced according to schedule and tolerated a stage two diet
28
+ and was transferred to the appropriate pain management. He
29
+ was out of bed without difficulty and on postoperative day
30
+ three he was advanced to a stage three diet and then slowly
31
+ was discontinued. He continued to use a face tent overnight,
32
+ but this was discontinued during the day and he was advanced
33
+ to all of the usual changes for postoperative day three
34
+ gastric bypass patient. He will be discharged home today
35
+ postoperative day three in stable condition status post
36
+ gastric bypass.
37
+ DISCHARGE MEDICATIONS: Vitamin B-12 1 mg po q.d., times two
38
+ months, Zantac 150 mg po b.i.d. times two months, Actigall
39
+ 300 mg po b.i.d. times six months and Roxicet elixir one to
40
+ two teaspoons q 4 hours prn and Albuterol Atrovent meter dose
41
+ inhaler one to two puffs q 4 to 6 hours prn.
42
+ He will follow up with Dr. Morrow in approximately two weeks as
43
+ well as with the Lowery Medical Center Clinic.
44
+ Kevin Gonzalez, M.D. R35052373
45
+ Dictated By:Dotson
46
+ MEDQUIST36
47
+ D: 2130-4-17 08:29
48
+ T: 2130-4-18 08:31
49
+ JOB#: Job Number 20340"
50
+ "Admission Date: 2107-11-13 Discharge Date: 2107-11-15
51
+
52
+ Date of Birth: 2078-9-5 Sex: M
53
+
54
+ Service: EMERGENCY
55
+
56
+ Allergies:
57
+ No Known Allergies / Adverse Drug Reactions
58
+
59
+ Attending:Annetta
60
+ Chief Complaint:
61
+ DKA
62
+
63
+ Major Surgical or Invasive Procedure:
64
+ None
65
+
66
+ History of Present Illness:
67
+ Mr. Abel is a 29 year old man with h/o Type I DM, 10 prior
68
+ admissions for DKA since 1-4, who presents with SOB/chest
69
+ discomfort, found to be in DKA.
70
+
71
+ The patient was at work today when he started feeling dyspnea on
72
+ exertion and substernal chest discomfort. CP worsened with deep
73
+ breaths. No difference with change in position. FS at that time
74
+ was 491, so the patient gave himself Humalog 7units. Repeat FS
75
+ 369. He drove himself to the ED for further evaluation.
76
+
77
+ Of note, the patient was just admitted to Sprague Clinic 4 days prior in DKA, symptoms of N/V, discharged the
78
+ following day without any changes to his prior regimen. He had
79
+ been on insulin pump in the past, but was discontinued in 1-4.
80
+ Just restarted on insulin pump 10 days prior to this admission -
81
+ basal rate 0.75units/hr with bolus dosing at mealtime. Follows
82
+ with Dr. Rothwell as an outpatient, last seen on 2107-11-4 and
83
+ started on insulin pump at that time.
84
+
85
+ In the ED, initial vs were: 98.4 100 112/72 15 100% RA. Chest
86
+ discomfort resolved on arrival to the ED. Initial FS was >500,
87
+ with anion gap of 22, urine ketones 150. Patient was given IVF -
88
+ 2LNS, 1L IVF with K, and started on 1L D5NS; started on insulin
89
+ gtt. Repeat lytes showed improved gap from 22 -> 18.
90
+
91
+ On the floor, the patient is currently comfortable. Only
92
+ complaint is that he is hungry. No fevers, chills, cough, sore
93
+ throat, N/V, abdominal pain, dysuria. SOB and CP are still
94
+ resolved.
95
+
96
+ Past Medical History:
97
+ - Type I DM, diagnosed 2096, frequent hospitalizations with DKA
98
+ - Diabetic cataract left eye s/p phacoemulsification with
99
+ posterior chamber lens implant 2098.
100
+ - Senile cataract right eye s/p phacoemulsification with
101
+ posterior chamber lens implant 2099.
102
+ - R shoulder subluxation
103
+
104
+ Social History:
105
+ - Tobacco: 10 cigarettes/day x 3 years
106
+ - Alcohol: occasional
107
+ - Illicits: none
108
+ The patient works as a line cook at House of Blues.
109
+
110
+
111
+ Family History:
112
+ Diabetes mellitus Type II in his father, paternal grandfather,
113
+ paternal aunts and uncles and maternal aunt; maternal GF/GM both
114
+ died of heart failure
115
+
116
+
117
+ Physical Exam:
118
+ Vitals: T: 96.8 BP: 120/66 P: 82 R: 13 O2: 100%RA
119
+ General: Alert, oriented, no acute distress
120
+ HEENT: Sclera anicteric, MMM, oropharynx clear
121
+ Neck: supple, JVP not elevated, no LAD
122
+ Lungs: Clear to auscultation bilaterally, no wheezes, rales,
123
+ rhonchi
124
+ CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
125
+ gallops
126
+ Abdomen: soft, non-tender, non-distended, bowel sounds present,
127
+ no rebound tenderness or guarding, no organomegaly
128
+ GU: no foley
129
+ Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
130
+ edema
131
+ Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
132
+ intact in all extremities
133
+
134
+
135
+ Pertinent Results:
136
+ Admission labs:
137
+ 2107-11-13 04:30PM WBC-6.0 RBC-4.58* HGB-14.4 HCT-40.9 MCV-89
138
+ MCH-31.4 MCHC-35.1* RDW-11.7
139
+ 2107-11-13 04:30PM NEUTS-69.7 LYMPHS-26.3 MONOS-2.7 EOS-0.9
140
+ BASOS-0.4
141
+ 2107-11-13 04:30PM PLT COUNT-271#
142
+ 2107-11-13 04:30PM PT-10.6 PTT-22.1 INR(PT)-0.9
143
+ 2107-11-13 04:37PM PH-7.26*
144
+ 2107-11-13 04:37PM GLUCOSE-GREATER TH LACTATE-1.8 NA+-130*
145
+ K+-4.9 CL--96 TCO2-12*
146
+ 2107-11-13 04:37PM freeCa-1.19
147
+ 2107-11-13 04:30PM GLUCOSE-575* UREA N-23* CREAT-1.3*
148
+ 2107-11-13 05:26PM URINE COLOR-Straw APPEAR-Clear SP Tucker-1.021
149
+ 2107-11-13 05:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
150
+ GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
151
+ LEUK-NEG
152
+
153
+ EKG: NSR @ 80bpm, nl axis and intervals, diffuse STE, more
154
+ pronounced than prior in 9-4.
155
+
156
+ Discharge labs:
157
+ 2107-11-15 05:54AM BLOOD WBC-7.2 RBC-4.72 Hgb-14.9 Hct-41.8 MCV-89
158
+ MCH-31.5 MCHC-35.6* RDW-11.9 Plt Ct-276
159
+ 2107-11-15 05:54AM BLOOD Plt Ct-276
160
+ 2107-11-15 05:54AM BLOOD Glucose-67* UreaN-17 Creat-0.9 Na-143
161
+ K-3.7 Cl-104 HCO3-26 AnGap-17
162
+ 2107-11-15 05:54AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8
163
+
164
+ Brief Hospital Course:
165
+ Mr. Abel is a 29 year old man with h/o DM1, frequent
166
+ hospitalizations for DKA, recently restarted on insulin pump,
167
+ who was admitted in DKA.
168
+ .
169
+ #. DKA: Patient admitted for the 11th time this year with DKA.
170
+ Recently started on insulin pump, now with his second admission
171
+ in 10 days; insulin dosing did not appear to be adequate. No
172
+ signs or symptoms of infection as a trigger at this time, though
173
+ patient later had a persistent cough that was treated with
174
+ azithromycin.
175
+ On admission, patient was put on a regular insulin drip, and
176
+ started on D5 1/2NS when glucose came down <200. The next
177
+ morning, he was restarted on his insulin pump at a higher basal
178
+ dose.
179
+ The second day of admission, there was some confusion on two
180
+ levels. The patient misunderstood the calorie counts in the menu
181
+ and gave himself very low amounts of insulin based on his
182
+ calorie counting scale. His glucose meter was also poorly
183
+ calibrated and was giving finger stick readings about 150 lower
184
+ than actual. He was hyperglycemic to the 400s, but did not have
185
+ recurrent acidosis. His glucose levels subsequently improved.
186
+ The next day we spoke with his outpatient endocrinologist Dr.
187
+ Rothwell (114-594-2840), who said that he had only met the
188
+ patient once. He has few insulin pump patients, so the decision
189
+ was to have the patient return to Hughes for further follow-up.
190
+ He will see Dr. Ray the day after discharge to re-establish
191
+ care with him.
192
+ .
193
+ #. Cough: Patient had a productive cough. CXR negative. The
194
+ decision was made to treat him with azithromycin for a suspected
195
+ upper-respiratory tract infection.
196
+ .
197
+ #. ARF: Patient with Cr 1.3 on admission, baseline Cr 1.0.
198
+ Improved with fluid resuscitation.
199
+
200
+ Medications on Admission:
201
+ Insulin - on pump since 2107-11-4, basal rate 0.75units/hr, bolus
202
+ dosing for meals
203
+
204
+ Discharge Medications:
205
+ 1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
206
+ (Daily) for 2 days.
207
+ Disp:*2 Tablet(s)* Refills:*0*
208
+ 2. Burke Industries Insulin Pump Sig: One (1) once a day.
209
+ 3. One Touch Ultra Test Strip Sig: One (1) strip
210
+ Miscellaneous four times a day.
211
+ 4. Humalog 100 unit/mL Solution Sig: As directed units
212
+ Subcutaneous four times a day: Use with insulin pump per
213
+ directions.
214
+ Discharge insulin pump settings:
215
+
216
+ Basal Rates:
217
+ Midnight - midnight: 1.3 Units/Hr
218
+ Meal Bolus Rates:
219
+ Breakfast = 1:8
220
+ Lunch = 1:8
221
+ Dinner = 1:8
222
+ Snacks = 1:8
223
+ High Bolus:
224
+ Correction Factor = 1:50
225
+ Correct To mg/dL
226
+
227
+ Discharge Disposition:
228
+ Home
229
+
230
+ Discharge Diagnosis:
231
+ Diabetic ketoacidosis
232
+ Type I diabetes
233
+
234
+ Discharge Condition:
235
+ Mental Status: Clear and coherent.
236
+ Level of Consciousness: Alert and interactive.
237
+ Activity Status: Ambulatory - Independent.
238
+
239
+ Discharge Instructions:
240
+ You were admitted with dangerously high blood sugar levels and
241
+ ketoacidosis. Your blood sugar levels improved with a continuous
242
+ insulin infusion and a lot of IV fluids. Your insulin pump was
243
+ restarted at a higher level, and you are now safe to go home.
244
+
245
+ You will need to follow your blood sugar very closely over the
246
+ next couple of days to make sure that your insulin pump is
247
+ properly titrated.
248
+
249
+ Your only medications are to continue using your insulin pump
250
+ and to take azithromycin for 2 more days.
251
+
252
+ Followup Instructions:
253
+ Please see Dr. Ray, at Hughes Diabetes Center, tomorrow,
254
+ 11-15, at 3pm. You can call (250-886-7061 if you need
255
+ to make changes to that appointment.
256
+
257
+ Please follow-up with your primary care doctor, Dr Lareau,
258
+ within the next 2 weeks. You can call his office at
259
+ 314-618-2706.
260
+
261
+
262
+ Completed by:2107-11-16"
263
+ "Admission Date: 2180-5-18 Discharge Date: 2180-5-25
264
+
265
+ Date of Birth: 2118-11-28 Sex: F
266
+
267
+ Service: NEUROSURGERY
268
+
269
+ Allergies:
270
+ No Known Allergies / Adverse Drug Reactions
271
+
272
+ Attending:Joel
273
+ Chief Complaint:
274
+ confusion
275
+
276
+
277
+ Major Surgical or Invasive Procedure:
278
+ L Craniotomy for evacuation of L SDH
279
+
280
+
281
+ History of Present Illness:
282
+ This is a 61 year old woman without significant PMH who
283
+ presented to her PCP's office after becoming confused at work.
284
+ She remembers having a fall two weeks prior to presntation. An
285
+ MRI Brain was performed which revealed a large subacute left
286
+ SDH. She was sent to Reed Memorial Hospital ED and subsequently
287
+ transferred to Lorenzo Hospital. Neurosurgical consultation requested for
288
+ evaluation and treatment.
289
+ She states that she fell two weeks ago remembers hitting her
290
+ head
291
+ but does not recall which side. She does not think she is
292
+ confused but her co-workers believe that she is. She states that
293
+ her friends thought her walking was impaired. Otherwise she
294
+ reports no headache. She does say that she had trouble with her
295
+ right hand when writing. She denies seizure like
296
+ activity, LOC, fever, chills, Nausea, vomiting, chest pain or
297
+ pressure, sob, or weakness in other extremities.
298
+
299
+
300
+ Past Medical History:
301
+ rheumatoid arthritis, rectal bleeding, HTN, seasonal
302
+ allergies
303
+
304
+
305
+ Social History:
306
+ She works for the city of Lakeview, married, husband is currently
307
+ ill. Denies tobacco,etoh, drugs
308
+
309
+
310
+ Family History:
311
+ non-contributory
312
+
313
+
314
+ Physical Exam:
315
+ On Admission:
316
+ O: T: BP: 130/60 HR: 92 R 18 O2Sats 99% 3L
317
+ Gen: WD/WN, comfortable, NAD.
318
+ HEENT: Pupils: 4 to 2mm equal. EOMs Intact no nystagmus
319
+ Neck: Supple.
320
+ Lungs: CTA bilaterally.
321
+ Cardiac: RRR. S1/S2.
322
+ Abd: Soft, NT, BS+
323
+ Extrem: Warm and well-perfused.
324
+
325
+ Neuro:
326
+ Mental status: Awake and alert, cooperative with exam with mild
327
+ inattentiveness. Orientation: Oriented to person, place, and
328
+ date. Language: Speech fluent with good comprehension and
329
+ repetition.
330
+ Naming intact. No dysarthria or paraphasic errors.
331
+
332
+ Cranial Nerves:
333
+ I: Not tested
334
+ II: Pupils equally round and reactive to light, 4mm to 2
335
+ mm bilaterally. Visual fields perceived as full although
336
+ inattentive to task at times.
337
+ III, IV, VI: Extraocular movements intact bilaterally without
338
+ nystagmus.
339
+ V, VII: Facial strength and sensation intact and symmetric.
340
+ VIII: Hearing intact to voice.
341
+ IX, X: Palatal elevation symmetrical.
342
+ Dr. Brown: Sternocleidomastoid and trapezius normal bilaterally.
343
+ XII: Tongue midline without fasciculations.
344
+ Motor: tone increased b/l lower extremities. No abnormal
345
+ movements,
346
+ tremors. no drift noted. Motor impersistence. Strength was full
347
+ with the following exceptions, has b/l tricep 4-25, IP's 5-/5 and
348
+ Hamstrigs 5-/5. The hands have significant pain and rheumatic
349
+ changes and finger extension and wrist extension were not tested
350
+ adequately.
351
+ Sensation: Intact to light touch bilaterally.
352
+ Reflexes: were grade 3 throughout.
353
+ Toes upgoing bilaterally
354
+
355
+ Gait: able to get up and out of bed with minimal assistance,
356
+ unsteady gait with swaying backward upon standing.
357
+
358
+ On Discharge: PERRLA, AAx O to person, hospital, Lakeview, time.
359
+ No word finding difficulties. Right pronator drift. LE's full
360
+ strength. RUE strength is 4- to 4-25 and LUE is 4 to 4+/5.
361
+
362
+ Pertinent Results:
363
+ CT HEAD W/O CONTRAST 2180-5-18
364
+ Evolving large left vertex subdural hematoma with rightward
365
+ subfalcine herniation and moderate effacement of the left
366
+ lateral ventricle. Allowing for differences in technique, the
367
+ findings are little changed since the 14:11 MRI examination.
368
+
369
+ CT head 2180-5-19
370
+ 1. Status post left craniotomy with evacuation of large subdural
371
+ hematoma. Post-surgical changes with bilateral pneumocephalus,
372
+ left more than right with interval decrease of rightward shift
373
+ of normally midline structures.
374
+ 2. No new focus of hemorrhage. Ventricles are stable in size.
375
+
376
+
377
+ CT head 2180-5-22
378
+ 1. Increased size of a left vertex subdural hematoma with
379
+ increased
380
+ neighboring sulcal effacement and slight increase in rightward
381
+ subfalcine
382
+ herniation.
383
+ 2. Increased hyperdense material subjacent to the craniotomy
384
+ site indicative of interval bleeding since 2180-5-19.
385
+ 3. New minimal effacement of the quadrigeminal and suprasellar
386
+ cisterns.
387
+ 4. Increased soft tissue swelling and subgaleal hematoma at the
388
+ craniotomy
389
+ site.
390
+ 5. Evolving focal left frontal infarct at the subfalcine
391
+ herniation site.
392
+
393
+
394
+
395
+
396
+ Brief Hospital Course:
397
+ This is a 61 y/o woman who had a fall 2 weeks prior to admision,
398
+ striking her head. She presents to the ED with confusion. Head
399
+ CT revealed L SDH with significant midline shift. She was taken
400
+ to OR emergently for a L side craniotomy for evacuation of SDH.
401
+ Post operatively patient was transferred to ICU for recovery. On
402
+ 5-19, post op head CT showed minimal improvement of midline
403
+ shift and pneumocephalus. On examination, patient was a&ox3, R
404
+ triceps 4-25, otherwise she was intact. She was transferred to
405
+ step down unit and PT/OT consulted.
406
+ On 5-21 the patient was neurologically stable and dilantin level
407
+ was therapeutic.
408
+ On 5-22 a repeat head CT was performed which revealed an increase
409
+ in MLS. Fluid and air was aspirated from the crani site at the
410
+ bedside and she was placed on 100%O2 for pneumocephalus. Her
411
+ exam improved and word finding difficulties resolved. She was
412
+ sorking with PT and OT and was being screened for rehab. Her BUN
413
+ elevated to 21 on 5-23 and IVF were restarted at 50cc/hr. Her Bun
414
+ stabilized to 20 and she was discharged to rehab on 5-25.
415
+
416
+
417
+ Medications on Admission:
418
+ Amlodipine Besy-Benxapril 11-9, plaquenil 1 tab Self Memorial Hospital (250mg),
419
+ naprosyn 500mg Self Memorial Hospital, prednisone 5mg daily
420
+
421
+
422
+ Discharge Medications:
423
+ 1. insulin regular human 100 unit/mL Solution Sig: Two (2) units
424
+ Injection ASDIR (AS DIRECTED).
425
+ 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
426
+
427
+ 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
428
+
429
+ 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
430
+ hours) as needed for pain or fever: max 4g/24 hrs.
431
+ 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
432
+ (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
433
+ 6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
434
+ PO TID (3 times a day).
435
+ 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
436
+ day): hold for loose stools.
437
+ 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
438
+ as needed for pain.
439
+ 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
440
+ Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
441
+ constipation.
442
+ 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
443
+ (2 times a day): hold for loose stools.
444
+ 11. heparin (porcine) 5,000 unit/mL Solution Sig: 14428 (14428)
445
+ units Injection TID (3 times a day).
446
+ 12. benazepril 10 mg Tablet Sig: Two (2) Tablet PO Daily ():
447
+ Hold if SBP <105 or K> 4.5
448
+ .
449
+
450
+
451
+ Discharge Disposition:
452
+ Extended Care
453
+
454
+ Facility:
455
+ Duncan Medical Center Martinez Memorial Hospital Rehabilitation and Nursing Center - Eerie
456
+
457
+ Discharge Diagnosis:
458
+ L SDH with midline shift
459
+
460
+
461
+ Discharge Condition:
462
+ Level of Consciousness: Alert and interactive.
463
+ Activity Status: Ambulatory - Independent.
464
+ Mental Status: Confused - always.
465
+
466
+
467
+ Discharge Instructions:
468
+ ?????? Have a friend/family member check your incision daily for
469
+ signs of infection.
470
+ ?????? Take your pain medicine as prescribed.
471
+ ?????? Exercise should be limited to walking; no lifting, straining,
472
+ or excessive bending.
473
+ ?????? You may wash your hair only after sutures and/or staples have
474
+ been removed. They should be removed on 5-27.
475
+ ?????? You may shower before this time using a shower cap to cover
476
+ your head.
477
+ ?????? Increase your intake of fluids and fiber, as narcotic pain
478
+ medicine can cause constipation. We generally recommend taking
479
+ an over the counter stool softener, such as Docusate (Colace)
480
+ while taking narcotic pain medication.
481
+ ?????? You may resume taking prednisone
482
+ ?????? If you were on a medication such as Coumadin (Warfarin), or
483
+ Plavix (clopidogrel), or Aspirin, prior to your injury, you may
484
+ safely resume taking after post-op review
485
+ ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
486
+ medicine, take it as prescribed and follow up with laboratory
487
+ blood drawing in one week. This can be drawn at your PCP??????s
488
+ office, but please have the results faxed to 311-654-8171.
489
+ ?????? Clearance to drive and return to work will be addressed at
490
+ your post-operative office visit.
491
+ ?????? Make sure to continue to use your incentive spirometer while
492
+ at home, unless you have been instructed not to.
493
+
494
+ CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
495
+ FOLLOWING
496
+
497
+ ?????? New onset of tremors or seizures.
498
+ ?????? Any confusion or change in mental status.
499
+ ?????? Any numbness, tingling, weakness in your extremities.
500
+ ?????? Pain or headache that is continually increasing, or not
501
+ relieved by pain medication.
502
+ ?????? Any signs of infection at the wound site: redness, swelling,
503
+ tenderness, or drainage.
504
+ ?????? Fever greater than or equal to 101?????? F.
505
+
506
+
507
+ Followup Instructions:
508
+ Follow-Up Appointment Instructions
509
+
510
+ ??????You may return to the office in 7-30 days(from your date of
511
+ surgery) for removal of your staples/sutures and/or a wound
512
+ check. This can alos be done at rehab by 5-27.
513
+ ??????Please call (505-473-5282 to schedule an appointment with Dr.
514
+ Wise, to be seen in 4 weeks.
515
+ ??????You will need a CT scan of the brain without contrast.
516
+
517
+
518
+ Ashley Jerald MD I17811034
519
+
520
+ Completed by:2180-5-25"
521
+ "Admission Date: 2177-10-2 Discharge Date: 2177-10-30
522
+
523
+ Date of Birth: 2120-8-4 Sex: M
524
+
525
+ Service: CARDIOTHORACIC
526
+
527
+ Allergies:
528
+ Patient recorded as having No Known Allergies to Drugs
529
+
530
+ Attending:Johnny
531
+ Chief Complaint:
532
+ Epigastric discomfort and lethargy
533
+
534
+ Major Surgical or Invasive Procedure:
535
+ 2177-10-6 Five Vessel Coronary Artery Bypass Grafting(LIMA to
536
+ LAD, with vein grafts to first diagonal, second diagonal, obtuse
537
+ marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring),
538
+ with Insertion of an IABP.
539
+
540
+
541
+ History of Present Illness:
542
+ Mr. Gladys is a 57 year old male who presented to OSH in mid
543
+ September with shortness of breath, gastric discomfort and
544
+ fatigue. He ruled in for a ST elevation MI. Subsequent cardiac
545
+ catheterization revealed severe three vessel coronary artery
546
+ disease and an LVEF of 36%. Echocardiogram at that time was
547
+ notable for an LVEF of 40% with inferior wall akinesis and
548
+ moderate mitral regurgitation. Patient was declined for surgery
549
+ at Starr Clinic(secondary to poor distal targets) and
550
+ eventually transferred to the Wood Memorial Hospital for further evaluation and
551
+ treatment.
552
+
553
+ Past Medical History:
554
+ Ischemic Cardiomyopathy, Coronary Artery Disease with inferior
555
+ wall ST Elevation MI on 2177-9-30, Mitral Regurgitation,
556
+ Hypertension, Type II Diabetes Mellitus(poorly controlled),
557
+ Hyperlipidemia
558
+
559
+ Social History:
560
+ Denies tobacco and ETOH. He lives alone. He is a truck driver.
561
+
562
+ Family History:
563
+ Denies family history of premature coronary artery disease.
564
+
565
+ Physical Exam:
566
+ Admission
567
+ HR 74 SR BP 126/62 RR 20 Sat 96% on 4L
568
+ Neuro Arousable, follows commands with encouragement. MAE,
569
+ strength 5/5 t/o. PERRL.
570
+ CV RRR no M.R.G
571
+ Lungs wheezes, crackles
572
+ Abdomen soft/NT
573
+ Extrem 1+ edema, warm 2+ pulses t/o
574
+ no carotid bruits
575
+ Discharge
576
+ T 99.6 HR 76SR BP104/60 RR22 O2sat 96%RA
577
+ Neuro: Awake, moves rt side to command, left dense hemiparesis
578
+ CV: RRR, sternum stable
579
+ Pulm: course rhonchi
580
+ Abdm: soft, NT/+BS
581
+ Ext: left LE 3+ edema, Rt LE no edema
582
+
583
+ Pertinent Results:
584
+ COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
585
+ 2177-10-30 02:29AM 8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0*
586
+ 281
587
+ Source: Line-CVL
588
+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
589
+ 2177-10-30 02:29AM 281
590
+ Source: Line-CVL
591
+ 2177-10-30 02:29AM 20.5*1 65.6* 1.9*
592
+ RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
593
+ 2177-10-30 02:29AM 150* 25* 1.2 137 3.8 99 30 12
594
+
595
+ RADIOLOGY Final Report
596
+ CHEST (PORTABLE AP) 2177-10-29 1:30 PM
597
+ CHEST (PORTABLE AP)
598
+ Reason: dobhoff placement
599
+ Choudhury Medical Center MEDICAL CONDITION:
600
+ 57 year old man with s/p CABG
601
+ REASON FOR THIS EXAMINATION:
602
+ dobhoff placement
603
+ CHEST, SINGLE AP FILM
604
+ History of CABG.
605
+ Status post CABG. Distal end of feeding tube overlies body of
606
+ stomach. There is cardiomegaly and a left pleural effusion with
607
+ associated atelectasis in the visualized left lower lung. No
608
+ pneumothorax. The left subclavian CV line has tip located over
609
+ the proximal SVC.
610
+ IMPRESSION: No definite pneumothorax. Left pleural effusion and
611
+ associated atelectasis in left lower lobe, overall appearances
612
+ being essentially unchanged since prior study of 2177-10-28.
613
+
614
+ DR. Herbert Castaneda
615
+
616
+ 2177-10-2 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4
617
+ MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273
618
+ 2177-10-2 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4*
619
+ 2177-10-2 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133
620
+ K-4.7 Cl-94* HCO3-27 AnGap-17
621
+ 2177-10-2 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531*
622
+ AlkPhos-325* Amylase-35 TotBili-0.6
623
+ 2177-10-2 10:30PM BLOOD Albumin-3.3* Mg-2.5
624
+ 2177-10-2 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49*
625
+ calTCO2-28 Base XS-4
626
+ 2177-10-2 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1
627
+ Cl-94*
628
+ 2177-10-5 08:58PM BLOOD %HbA1c-12.4*
629
+ 2177-10-3 Non Contrast Head CT Scan:
630
+ There is no evidence of intracranial hemorrhage, mass effect, or
631
+ shift of normally midline structures. Dr. Butler-white matter
632
+ differentiation is preserved. The ventricles are normal in size
633
+ and symmetric. There is no evidence of acute major vascular
634
+ territorial infarction. There are moderate cavernous carotid
635
+ calcifications. There is complete opacification of the right
636
+ maxillary sinus. The remaining paranasal sinuses and mastoid air
637
+ cells are clear.
638
+ 2177-10-6 Intraoperative TEE:
639
+ PRE-BYPASS:
640
+ Pt requiring dobutamine infusion at 7.5
641
+ 1. No atrial septal defect is seen by 2D or color Doppler.
642
+ 2. There is mild to moderate global left ventricular hypokinesis
643
+ (LVEF = 35-40 %), with basal to mid inferior and
644
+ inferior-lateral akinesis. [Intrinsic left ventricular systolic
645
+ function is likely more depressed given the severity of valvular
646
+ regurgitation.].
647
+ 3. Right ventricular chamber size is normal. There is mild to
648
+ moderate global right ventricular free wall hypokinesis.
649
+ 4. There are simple atheroma in the ascending aorta. The
650
+ descending thoracic aorta is mildly dilated. There are simple
651
+ atheroma in the descending thoracic aorta.
652
+ 5. There are three aortic valve leaflets. The aortic valve
653
+ leaflets are mildly thickened. Trace aortic regurgitation is
654
+ seen.
655
+ 6. The mitral valve leaflets are mildly thickened. Moderate to
656
+ severe (3+) mitral regurgitation is seen, with noted centrally
657
+ directed regurgitant jet. The mitral regurgitation vena
658
+ contracta is >=0.7cm.
659
+ 7.The tricuspid valve leaflets are mildly thickened; there is
660
+ mild to moderate (12-17+) tricuspid regurgitation.
661
+ POST-BYPASS:
662
+ Pt removed from cardiopulmonary bypass on vasopression,
663
+ milrinone, epinephrine and norephinephrine infusions and
664
+ placement of intra-aortic balloon pump.
665
+ 1. Pt s/p mitral valve annuloplasty. There is no mitral
666
+ regurgitation.
667
+ 2. Biventricular function is improved. Right ventricular is
668
+ normal sized and function has improved from moderate to mild
669
+ dysfunction. Left ventricular function remains globally
670
+ depressed; basal to mid inferior walls remain akinetic; there is
671
+ improvement of anterior wall function.
672
+ 3. Aortic contours are intact post-decannulation. There is an
673
+ intra-aortic balloon noted in the proper position.
674
+ 2177-10-15 Transthoracic ECHO:
675
+ The left atrium is moderately dilated. There is mild symmetric
676
+ left ventricular hypertrophy with normal cavity size. There is
677
+ moderate regional left ventricular systolic dysfunction with
678
+ akinesis of the inferior and inferolateral walls. The remaining
679
+ segments contract normally (LVEF = 35-40 %). The aortic valve
680
+ leaflets (3) are mildly thickened but aortic stenosis is not
681
+ present. No aortic regurgitation is seen. The mitral valve
682
+ leaflets are mildly thickened. A mitral valve annuloplasty ring
683
+ is present. The mitral annular ring appears well seated and is
684
+ not obstructing flow. No mitral regurgitation is seen. There is
685
+ borderline pulmonary artery systolic hypertension. There is a
686
+ very small pericardial effusion most prominent around the right
687
+ atrium.
688
+ 2177-10-16 Cardiac Catheterization:
689
+ 1. Selective coronary angiography of this right dominant system
690
+ demonstrated native 3 vessel coronary artery disease. The LMCA
691
+ had
692
+ diffuse mild disease. The LAD was occluded in the mid vessel.
693
+ The LCX
694
+ was occluded proximally. The RCA was occluded proximally. The
695
+ SVG-PDA
696
+ was patent with slow flow into a small PDA. The SVG-D1 was
697
+ patent as was
698
+ SVG-D2, both with slow flow into small distal vessels. The
699
+ SVG-OM was
700
+ patent with slow flow as well. The LIMA-LAD was patent. The LAD
701
+ beyond
702
+ the LIMA was diffusely small with slow flow.
703
+ 2. Limited resting hemodynamics were performed. The systemic
704
+ arterial pressures were borderline low measuring 86/63mmHg.
705
+ 2177-10-20 Non contrast Head CT Scan:
706
+ There is no sign for the presence of an intracranial hemorrhage.
707
+ There is a question of a 1cm area of low density seen within the
708
+ region of the right uncus, which did not appear to be present on
709
+ the prior CT scan. If real, this finding could represent an area
710
+ of developing infarction. No other definite interval changes are
711
+ appreciated. There is no hydrocephalus or shift of normally
712
+ midline structures.
713
+ 2177-10-21 MRA Brain:
714
+ Multiple areas of restricted diffusion bilaterally including
715
+ also the right cerebellar hemisphere as described above, areas
716
+ of subacute ischemic changes extending from the posterior limb
717
+ of the right internal capsule to the right, hippocampal area.
718
+ These December are suggestive of subacute infarcts likely from
719
+ an embolic source involving multiple vascular territories.
720
+
721
+
722
+
723
+
724
+ Brief Hospital Course:
725
+ Mr. Gladys was admitted to the cardiac surgical service. He
726
+ remained pain free on intravenous Heparin and Nitroglycerin. He
727
+ was initially evaluated by the Neurology service for an altered
728
+ mental status, experiencing periods of unresponiveness,
729
+ confusion and agitation/delirium. A head CT scan was
730
+ unremarkable and his altered mental status was attributed
731
+ metabolic encephalopathy. There was no evidence of stroke. Over
732
+ the next several days from a cardiac standpoint, he gradually
733
+ developed cardiogenic shock and required inotropic support.
734
+ Given his critical condition, he was urgently brought to the
735
+ operating room on 10-6 where Dr. Hess performed
736
+ coronary artery bypass grafting and mitral valve repair. Given
737
+ his low ejection fraction, an IABP was placed prior to weaning
738
+ from cardiopulmonary bypass. For additional surgical details,
739
+ please see seperate dictated operative note. Following the
740
+ operation, he was brought to the CVICU in critical condition.
741
+ His postoperative course will now be broken down into systems:
742
+
743
+ CARDIAC: Initially required multiple inotropes for poor
744
+ hemodynamics. Started on Amiodarone on postoperative day two for
745
+ atrial and ventricular arrhythmias. The IABP was slowly weaned
746
+ and eventually removed on postoperative day four without
747
+ complication. He remained pressor dependent at that time.
748
+ Cardioversion was performed on postoperative day six for
749
+ episodes of atrial fibrillation associated with a decrease in
750
+ SVO2. By postoperative seven, all inotropic support was weaned.
751
+ Despite Amiodarone, he continued to experience atrial and
752
+ ventricular arrhythmias. He went on to develop an episode of
753
+ sustained ventricular fibrillation/torsades on postoperative day
754
+ eight for which successfull defibrillation was performed.
755
+ Amiodarone was discontinued and switched to Lidocaine. A calcium
756
+ channel blocker was concomitantly initiated. The EP/cardiology
757
+ services were consulted and recommended EPS with potential VT
758
+ ablation. To rule out ischemia as the cause for ventricular
759
+ tachycardia, cardiac catheterization was performed on 10-16 which showed patent grafts. Given ventricular arrhythmias,
760
+ he was eventually started on Mexiletine.
761
+
762
+ PULMONARY: Given critical condition, required prolonged
763
+ mechanical ventilation. Eventually extubated on postoperative
764
+ day nine. He was electively re-intubated for cardiac
765
+ catheterization on 10-16, and re-extubated later that
766
+ night. Unfortunatly, he went on to develop acute respiratory
767
+ failure later that night and required reintubation. Bronchoscopy
768
+ was performed on 10-17 which found patent airways without
769
+ evidence of mucous plugs and only minimal scant secretions. A
770
+ left sided chest tube was placed for pleural effusion. The
771
+ effusion improved and the chest tube as removed.
772
+
773
+ NEURO: Given his critical condition, had a prolonged period of
774
+ sedation. Following his initial extubation, he awoke
775
+ neurologically intact. Following his second re-extubation on
776
+ postoperative day 14, he was noted to have new onset left
777
+ hemiparesis and left sided neglect. Neurology was consulted
778
+ while head CT scans and MR Donald Scrivens consistent with
779
+ embolic stroke(see result section). Heparin and coumadin were
780
+ started.
781
+
782
+ RENAL: Developed oliguric acute renal failure. Creatinine peaked
783
+ to 2.9 on postoperative day eight. The renal service was
784
+ consulted and attributed his renal insufficiency to pre-renal
785
+ etiology. Renal function gradually improved and he responded
786
+ nicely to diuretics.
787
+
788
+ ENDOCRINE: Initially maintained on Insulin drip. Transitioned to
789
+ lantus insulin.
790
+
791
+ HEME: Mild postoperative anemia and was intermittently
792
+ transfused to maintain hematocrit near 30%.
793
+
794
+ ID: Remained afebrile with no evidence of infection.
795
+
796
+ GI: Bedside swallow on 10-22 recommended continuing NPO/tube
797
+ feeding as he was not consistently awake enough to safely
798
+ attempt anything by mouth. Tolerating tube feedings.
799
+
800
+ Skin: A hematoma formed at an ex-chest tube site on his left
801
+ flank and began bleeding with anticoagulation. It was sutured on
802
+ 10-26 and subsequently improved.
803
+
804
+
805
+ Medications on Admission:
806
+ Intravenous Nitroglycerin
807
+ Docusate Sodium 100 Showalter Medical Center
808
+ Metoprolol 75 Showalter Medical Center
809
+ Pantoprazole 40 qd
810
+ Aspirin 325 qd
811
+ Lisinopril 2.5 qd
812
+ Simvastatin 40 qd
813
+ Glargine 20 units qhs
814
+ RISS
815
+
816
+ Discharge Medications:
817
+ 1. Simvastatin 40 mg Tablet Showalter Medical Center: One (1) Tablet PO DAILY
818
+ (Daily).
819
+ 2. Aspirin 81 mg Tablet, Chewable Showalter Medical Center: One (1) Tablet, Chewable
820
+ PO DAILY (Daily).
821
+ 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Showalter Medical Center: Two
822
+ (2) Puff Inhalation Q4H (every 4 hours).
823
+ 4. Fluticasone 110 mcg/Actuation Aerosol Showalter Medical Center: Two (2) Puff
824
+ Inhalation Showalter Medical Center (2 times a day).
825
+ 5. Docusate Sodium 50 mg/5 mL Liquid Showalter Medical Center: One (1) PO BID (2
826
+ times a day).
827
+ 6. Carvedilol 12.5 mg Tablet Showalter Medical Center: Two (2) Tablet PO BID (2 times
828
+ a day). Tablet(s)
829
+ 7. Mexiletine 150 mg Capsule Showalter Medical Center: One (1) Capsule PO Q8H (every
830
+ 8 hours).
831
+ 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR Kenison: One (1)
832
+ Tablet,Rapid Dissolve, DR Kenison DAILY (Daily).
833
+ 9. Bisacodyl 10 mg Suppository Kenison: One (1) Suppository Rectal
834
+ DAILY (Daily).
835
+ 10. Sodium Chloride 0.65 % Aerosol, Spray Kenison: 12-17 Sprays Nasal
836
+ QID (4 times a day) as needed.
837
+ 11. Ipratropium Bromide 0.02 % Solution November: One (1) Inhalation
838
+ Q6H (every 6 hours) as needed.
839
+ 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
840
+ Inhalation Q4H (every 4 hours) as needed.
841
+ 13. Artificial Tear with Lanolin 0.1-0.1 % Ointment November: One (1)
842
+ Appl Ophthalmic PRN (as needed).
843
+ 14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
844
+ Inhalation Q6H (every 6 hours) as needed.
845
+ 15. Warfarin 1 mg Tablet November: as directed Tablet PO DAILY
846
+ (Daily): target INR 2-2.5
847
+ Pt to receive 7.5mg on 10-30.
848
+ 16. Lisinopril 5 mg Tablet April: One (1) Tablet PO DAILY (Daily).
849
+
850
+ 17. Furosemide 80 mg Tablet April: One (1) Tablet PO BID (2 times
851
+ a day).
852
+
853
+
854
+ Discharge Disposition:
855
+ Extended Care
856
+
857
+ Facility:
858
+ Blackwater Senior Care - Thomas Memorial Hospital
859
+
860
+ Discharge Diagnosis:
861
+ - Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction,
862
+ Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock
863
+ - s/p Urgent CABG and Mitral Valve Repair on IABP
864
+ - Postoperative Stroke
865
+ - Postoperative Acute Respiratory Failure
866
+ - Postoperative Acute Renal Failure
867
+ - Postoperative Atrial Fibrillation/Flutter
868
+ - Postoperative Ventricular Tachycardia
869
+ - Postoperative Bradycardia
870
+ - Postoperative Anemia
871
+ - Postoperative Pleural Effusion
872
+ - Hypertension
873
+ - Hyperlipidemia
874
+ - Type II Diabetes Mellitus
875
+
876
+
877
+ Discharge Condition:
878
+ Stable.
879
+
880
+
881
+ Discharge Instructions:
882
+ 1)Please shower daily. No baths. Pat dry incisions, do not rub.
883
+ 2)Avoid creams and lotions to surgical incisions.
884
+ 3)Call cardiac surgeon if there is concern for wound infection.
885
+ 4)No lifting more than 10 lbs for at least 10 weeks from
886
+ surgical date.
887
+
888
+ Dineenp Instructions:
889
+ Dr. Smith 4-5 weeks, please call for appt
890
+ Cardiology clinic-Dr Kenison (EP) in 2-16 weeks, please call
891
+ for appt
892
+
893
+
894
+
895
+ Completed by:2177-10-30"
896
+ "Name: Kelli,Elizabeth Unit No: 66109
897
+
898
+ Admission Date: 2183-7-12 Discharge Date: 2183-7-27
899
+
900
+ Date of Birth: 2127-9-2 Sex: F
901
+
902
+ Service: MED
903
+
904
+ Allergies:
905
+ Percocet / Codeine / Robaxin / Lomotil / Vancomycin And
906
+ Derivatives
907
+
908
+ Attending:Courtney
909
+ Chief Complaint:
910
+ Fatique, fever
911
+
912
+ Major Surgical or Invasive Procedure:
913
+ surgical removal of port.
914
+
915
+
916
+ Brief Hospital Course:
917
+ See prior addenda
918
+
919
+ Discharge Medications:
920
+ additional d/c medication, insulin:
921
+
922
+ Lantus(Glargine) - 13 Units q evening, Loftus Memorial Hospital.
923
+
924
+ Discharge Disposition:
925
+ Extended Care
926
+
927
+ Facility:
928
+ Blackwater House Nursing Home - Thundera
929
+
930
+ Discharge Diagnosis:
931
+ Line sepsis from infected Lt. port; MRSA bacteremia
932
+
933
+
934
+ Discharge Condition:
935
+ Good
936
+
937
+ John Sorrell MD J60211121
938
+
939
+ Completed by:2183-7-27"
940
+ "Admission Date: 2135-6-22 Discharge Date: 2135-7-2
941
+
942
+ Date of Birth: 2076-4-4 Sex: M
943
+
944
+ Service:
945
+
946
+ HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
947
+ male with a history of metastatic melanoma to bowel and known
948
+ pulmonary and CNS metastases status post craniotomy with
949
+ resection of the brain metastases. The patient presented
950
+ with a three day history of intermittent worsening and crampy
951
+ abdominal pain in the lower quadrants, worse on the right
952
+ than on the left. The pain was described as severe. The
953
+ patient had a bowel movement until the day prior to
954
+ admission. KUB on arrival in the Emergency Department showed
955
+ dilated loops of small bowel with air fluid levels. A CT
956
+ scan obtained shortly thereafter showed two large mesenteric
957
+ masses with erosion into small bowel and free perforation of
958
+ the more proximal segment of small bowel, as well as
959
+ mechanical mid small bowel obstruction.
960
+
961
+ PAST MEDICAL HISTORY:
962
+ 1. Metastatic melanoma with metastases to the lung, brain,
963
+ bowel, left flank
964
+
965
+ MEDICATIONS:
966
+ 1. Nexium 40 mg po qd
967
+ 2. Flomax
968
+ 3. Flonase
969
+ 4. Compazine
970
+ 5. Ambien 10 mg
971
+ 6. Quinine 260 mg
972
+ 7. Prednisone 10 mg po
973
+ 8. 50 mcg fentanyl patch
974
+
975
+ The patient had recently been on his first week to Taxol
976
+ dexamethasone therapy and had also been through four cycles
977
+ of IL-2/temozolomide for his metastatic melanoma.
978
+
979
+ ALLERGIES: The patient has no known drug allergies.
980
+
981
+ SOCIAL HISTORY: The patient had smoked one pack per day for
982
+ about 20 years, but quit 20 years ago.
983
+
984
+ PHYSICAL EXAM:
985
+ VITAL SIGNS: Temperature 98.8??????, blood pressure 120/70, pulse
986
+ 117, respiratory rate 20, O2 saturation 96% on room air.
987
+ GENERAL: The patient was awake and comfortable and appeared
988
+ well nourished.
989
+ HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous
990
+ distention, no palpable nodes. Oropharynx was clear.
991
+ NECK: Supple.
992
+ HEART: S1, S2, tachycardic with no murmurs, rubs or gallops.
993
+ LUNGS: Clear to auscultation bilaterally.
994
+ ABDOMEN: Distended, nontender, no hepatosplenomegaly. There
995
+ were decreased bowel sounds. Abdomen was tense and was a 7
996
+ cm subcutaneous mass on the left flank.
997
+ EXTREMITIES: There was no lower extremity edema, cyanosis or
998
+ clubbing.
999
+
1000
+ LABS: White cell count 9.8, hematocrit 13.8, platelets 947.
1001
+ PT 12.8, PTT 21.5, INR 1.1. Chem-7 - sodium 136, potassium
1002
+ 4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6,
1003
+ glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2.
1004
+
1005
+ HOSPITAL COURSE: The patient arrived in the hospital on the
1006
+ evening of 6-22 and evaluation was initiated. The patient
1007
+ was taken to the Operating Room late in the night of 6-22
1008
+ where, per the Operating Room note, tumors were discovered in
1009
+ the ileum and jejunum with free perforation of both lesions.
1010
+ The patient was then transferred to the Intensive Care Unit.
1011
+ The patient was started on ampicillin, levofloxacin and
1012
+ Flagyl.
1013
+
1014
+ On postoperative day #2, which was 2135-6-25, the patient was
1015
+ started on TPN. His antibiotics were continued. On
1016
+ postoperative day #3, the patient was noted to have a
1017
+ slightly increased temperature to 100.2??????. He was pan
1018
+ cultured given the fact he had recently been on steroids.
1019
+ His central line was also changed. During the course of the
1020
+ day, the patient was agitated at one point and pulled his
1021
+ A-line. Haldol was prescribed.
1022
+
1023
+ On postoperative day #4, the patient appeared to be less
1024
+ confused. He was transferred to the floor with a sitter. By
1025
+ postoperative day #5, while the patient was on the floor, he
1026
+ was appearing much more lucid, communicating appropriately
1027
+ and the sitter was discontinued. The patient was continued
1028
+ on total parenteral nutrition. Because of continued increase
1029
+ in white cell count from 14.3 on postoperative day #4 to 16.0
1030
+ on postoperative day #5, the patient was sent for an
1031
+ abdominal CT. Although no abscess was identified that could
1032
+ explain the patient's increase in white cell count, the
1033
+ patient was noted to have developed mural thrombus in his
1034
+ abdominal aorta and in the left iliac artery. The patient
1035
+ was also noted to develop some new bilateral pleural
1036
+ effusions with some barium in the left lung base. On being
1037
+ notified of these findings, the surgical team immediately
1038
+ consulted the patient's neuro-oncologist and oncologist team
1039
+ for advice on the propriety of placing the patient on
1040
+ anticoagulation.
1041
+
1042
+ The patient was seen by his neuro-oncologist on postoperative
1043
+ day #6, which was the 4-29. The patient's
1044
+ neuro-oncologist requested head CT be obtained to rule out
1045
+ any new brain metastases with bleeding because this would
1046
+ determine the patient's suitably for anticoagulation. The
1047
+ head CTs were negative and per neuro-oncology, there was no
1048
+ contraindication to anticoagulating the patient. The patient
1049
+ was seen by his oncologist team also on postoperative day #6.
1050
+ Oncology was of the opinion of the patient, was unsuitable
1051
+ for anticoagulation with Coumadin or heparin but that aspirin
1052
+ could be initiated. The patient was therefore started on
1053
+ aspirin.
1054
+
1055
+ The patient's steroids were also tapered beginning on
1056
+ postoperative day #7. His fluconazole was discontinued. At
1057
+ the suggestion of the patient's oncology team, the surgery
1058
+ team also transfused the patient with 1 unit packed red blood
1059
+ cells on postoperative day #8 for borderline low hematocrit
1060
+ of 26.1. On postoperative day #7, the patient's diet was
1061
+ changed from NPO to sips. The patient tolerated this well
1062
+ and so on postoperative day #8, the patient was advanced to a
1063
+ clear liquid diet and his TPN was discontinued. By the
1064
+ evening of postoperative day #8, the patient was able to
1065
+ tolerate a regular diet and on the day of discharge, which
1066
+ was 2135-7-2, the patient had a regular breakfast without any
1067
+ problems. Lindsey is to be discharged home with visiting nurse
1068
+ assistant for wound care. Mr. Jeannette continues to have an
1069
+ open vertical incision in the midline of his abdomen that
1070
+ would require wet to dry dressings twice a day.
1071
+
1072
+ DISCHARGE MEDICATIONS:
1073
+ 1. Flomax
1074
+ 2. Flonase
1075
+ 3. Compazine
1076
+ 4. Ambien
1077
+ 5. Quinine
1078
+ 6. Prednisone 10 mg po qd
1079
+ 7. Protonix 40 mg po bid
1080
+ 8. Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours
1081
+ 9. Levofloxacin 500 mg po qd x5 more days
1082
+
1083
+ FOLLOW UP: The patient is to follow up with oncology on 7-18. The patient is to call Dr.Ervin office for
1084
+ follow up appointment this coming week.
1085
+
1086
+
1087
+
1088
+
1089
+ Barbara Sundberg, M.D. W92784896
1090
+
1091
+
1092
+ Dictated By:George
1093
+ MEDQUIST36
1094
+
1095
+ D: 2135-7-2 10:51
1096
+ T: 2135-7-2 11:14
1097
+ JOB#: Job Number 18599
1098
+ "
1099
+ "Admission Date: 2161-12-15 Discharge Date: 2161-12-22
1100
+
1101
+ Date of Birth: 2118-1-10 Sex: F
1102
+
1103
+ Service:
1104
+
1105
+ DIAGNOSIS:
1106
+ Tracheal bronchial malacia.
1107
+
1108
+ HISTORY OF PRESENT ILLNESS: The patient is a delightful 43
1109
+ year-old woman who was found to have tracheal bronchial
1110
+ malacia and has suffered from years of dyspnea on exertion,
1111
+ persistent tracheal bronchitis and recurrent infections. She
1112
+ is therefore admitted to undergo a right thoracotomy and
1113
+ tracheoplasty.
1114
+
1115
+ HOSPITAL COURSE: The patient is admitted to the hospital and
1116
+ underwent minimally invasive muscle sparring oscillatory
1117
+ triangle thoracotomy with tracheal bronchoplasty on the day
1118
+ of admission. She did well and was discharged without
1119
+ problems.
1120
+
1121
+
1122
+
1123
+
1124
+
1125
+
1126
+ Diane Lewis, M.D. C45888251
1127
+
1128
+ Dictated By:Vail
1129
+
1130
+ MEDQUIST36
1131
+
1132
+ D: 2162-4-5 05:00
1133
+ T: 2162-4-7 09:38
1134
+ JOB#: Job Number 33135
1135
+ "
1136
+ "Admission Date: 2163-11-21 Discharge Date: 2163-12-1
1137
+
1138
+ Date of Birth: 2086-12-16 Sex: M
1139
+
1140
+ Service: MEDICINE
1141
+
1142
+ Allergies:
1143
+ Patient recorded as having No Known Allergies to Drugs
1144
+
1145
+ Attending:Flossie
1146
+ Chief Complaint:
1147
+ CHF, ARF, Mediastinal lymphadenopathy
1148
+
1149
+ Major Surgical or Invasive Procedure:
1150
+ Bronchoscopy x 2
1151
+ Mediastinoscopy with lymph node biopsy
1152
+
1153
+ History of Present Illness:
1154
+ 76M initially went to Davis Hospital hospital with L flank and sent
1155
+ home with narcs. Represented with DOE, weight gain and L flank
1156
+ pain. He reports that he has had intermittent DOE for year but
1157
+ notice a sharp increase in his weight over a period of 10 days.
1158
+ He gained 8-10lbs with associated LE swelling, but without
1159
+ medication noncompliance, dietary changes, chest pain,
1160
+ orthopnea, PND. This happened at the beginning of July and
1161
+ his Lasix was increased from 40 to 60 daily. He also had a
1162
+ holter revealing afib (rate 40-100), nuclear stress
1163
+ (2163-11-1)without ischemia and normal ECHO on 2163-11-3 (mild AS,
1164
+ mild MR). Upon arrival to the ED he was found to be hypotensive
1165
+ with hyperkalemia and ARF (Cr ~4 from basline of 1.2) He was
1166
+ sent to the floor, diuresed and then sent to the ICU after he
1167
+ was hypotensive requiring dopamine and vasopressin. He had a
1168
+ Swan-Ganz catheter placed on 11-19 and had renally dosed
1169
+ dopamine. He was thought to be fluid overloaded and had a
1170
+ transudative thoracentesis (amount removed unknown). He was
1171
+ aggressively diuresed with Lasix and renally dosed Dopamine. His
1172
+ renal function improved prior to transfer.
1173
+ Swan numbers:
1174
+ RA: 25
1175
+ RV: 55/20/10
1176
+ PA: 55/25
1177
+ PCW: 26
1178
+ His L flank pain was evaluated with a CT Abdomen and he was
1179
+ found to have L nephrolithiasis and an exophytic cyst on the
1180
+ lower pole of the L kidney. His pain has been controlled with
1181
+ narcotics.
1182
+ He had also been recieving Zyvox for presumed pneumonia and
1183
+ solumedrol 60 mg q6h for presumed COPD.
1184
+ He was transferred for evaluation of his mediatinal LAD. This
1185
+ has been watched for seveal years and he has two non-FDG avid
1186
+ PET CTs, most recently in 2163-6-26. He denies any B symptoms.
1187
+ He does have decreased appetite, but has been active with
1188
+ outside hobbies including golf and curling. The thoracics
1189
+ service was contactTammy for this evaluation and it was suggested
1190
+ that the patient be admitted to the MICU given his underlying
1191
+ medical problems.
1192
+
1193
+
1194
+ Past Medical History:
1195
+ PAST MEDICAL HISTORY:
1196
+ ====================
1197
+ AF, on coumadin at home
1198
+ CRI Cr:1.6
1199
+ Chronic Anemia
1200
+ CHF EF
1201
+ Bladder CIS s/p BCG washout in 10/2163
1202
+ Colonic dysplastic lesions on bx
1203
+ OSA- unable to tolerate CPAP
1204
+ low grade NHL with diffuse stable LAD
1205
+ AS
1206
+ R popliteal artery endarterectomy
1207
+ uretral stent
1208
+ Gout
1209
+ PVD
1210
+ L CEA 2159
1211
+ UGIB 2161
1212
+ LLL lobectomy in 2135
1213
+ Nephrolithiasis
1214
+
1215
+
1216
+ Social History:
1217
+ EtOH: 2 martinis daily
1218
+ Tobacco: quit 1ppd 25 yrs ago
1219
+ outside hobbies included golf and curling
1220
+
1221
+
1222
+ Family History:
1223
+ no history of malignancy
1224
+
1225
+ Physical Exam:
1226
+ Tmax: 35.9 ??????C (96.6 ??????F)
1227
+
1228
+ Tcurrent: 35.9 ??????C (96.6 ??????F)
1229
+
1230
+ HR: 74 (67 - 75) bpm
1231
+
1232
+ BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg
1233
+
1234
+ RR: 20 (20 - 24) insp/min
1235
+
1236
+ SpO2: 96%
1237
+
1238
+ Heart rhythm: AF (Atrial Fibrillation)
1239
+ Physical Examination
1240
+
1241
+ General Appearance: Well nourished, No acute distress
1242
+
1243
+ Eyes / Conjunctiva: PERRL
1244
+
1245
+ Head, Ears, Nose, Throat: Normocephalic, MMM
1246
+
1247
+ Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
1248
+ Cervical adenopathy
1249
+
1250
+ Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
1251
+ III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at
1252
+ base
1253
+
1254
+ Peripheral Vascular: (Right radial pulse: Present), (Left radial
1255
+ pulse: Present), (Right DP pulse: Present), (Left DP pulse:
1256
+ Present)
1257
+
1258
+ Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
1259
+ Crackles : bilateral bases)
1260
+
1261
+ Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present,
1262
+ Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds
1263
+
1264
+ Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t)
1265
+ Clubbing
1266
+
1267
+ Skin: Not assessed
1268
+
1269
+ Neurologic: Responds to: Not assessed, Movement: Not assessed,
1270
+ Tone: Not assessed
1271
+
1272
+
1273
+ Pertinent Results:
1274
+ 2163-11-22 Echo: The left atrium is elongated. The right atrium is
1275
+ markedly dilated. The right atrial pressure is indeterminate.
1276
+ There is moderate symmetric left ventricular hypertrophy. The
1277
+ left ventricular cavity size is normal. Left ventricular
1278
+ systolic function is hyperdynamic (EF>75%). Right ventricular
1279
+ chamber size and free wall motion are normal. The aortic root is
1280
+ mildly dilated at the sinus level. The ascending aorta is mildly
1281
+ dilated. The aortic valve leaflets (3) are mildly thickened.
1282
+ There is mild to moderate aortic valve stenosis (area 1.2 cm2).
1283
+ No aortic regurgitation is seen. The mitral valve leaflets are
1284
+ mildly thickened. Physiologic mitral regurgitation is seen
1285
+ (within normal limits). [Due to acoustic shadowing, the severity
1286
+ of mitral regurgitation may be significantly UNDERestimated.]
1287
+ The tricuspid valve leaflets are mildly thickened. Moderate [2+]
1288
+ tricuspid regurgitation is seen. There is moderate pulmonary
1289
+ artery systolic hypertension. There is a small pericardial
1290
+ effusion. There are no echocardiographic signs of tamponade.
1291
+
1292
+ 2163-11-23 Pathology report
1293
+ 1. Lymph nodes, 4L, biopsy (A-C):
1294
+ Metastatic neuroendocrine neoplasm, most consistent with
1295
+ carcinoid tumor, in two of ten lymph nodes/lymph node fragments.
1296
+ 2. Lymph nodes, 7, biopsy (D):
1297
+ Metastatic neuroendocrine neoplasm, most consistent with
1298
+ carcinoid tumor, in three of four lymph nodes/lymph node
1299
+ fragments. See note.
1300
+ 3. Lymph nodes, level 7, biopsy (E):
1301
+ Metastatic neuroendocrine neoplasm, most consistent with
1302
+ carcinoid tumor, in one of two lymph nodes/lymph node fragments.
1303
+ Note:
1304
+ Immunohistochemical stains show the tumor cells are diffusely
1305
+ positive for synaptophysin and chromogranin and are negative for
1306
+ CK 7 and TTF-1. Rare tumor cells are positive for CK20.
1307
+ Despite the negative TTF-1, the tumor is compatible with a lung
1308
+ primary. Clinical correlation recommended.
1309
+
1310
+ FLOW CYTOMETRY 11-23:
1311
+ FLOW CYTOMETRY IMMUNOPHENOTYPING:
1312
+
1313
+ The following tests (antibodies) were performed: HLA-DR, FMC-7,
1314
+ Kappa, Lambda and CD antigens: 2,3,5,7,19,20,23, and 45.
1315
+
1316
+
1317
+
1318
+ RESULTS:
1319
+
1320
+ Three color gating is performed (light scatter vs. CD45) to
1321
+ optimize lymphocyte yield. B cells comprise 34% of
1322
+ lymphoid-gated events, are polyclonal, and do not express
1323
+ aberrant antigens. T cells comprise 50% of lymphoid gated
1324
+ events, and express mature lineage antigens.
1325
+
1326
+ INTERPRETATION:
1327
+ Non-specific T cell dominant lymphoid profile; diagnostic
1328
+ immunophenotypic features of involvement by lymphoma are not
1329
+ seen in specimen. Correlation with clinical findings and
1330
+ morphology (see S08-85352) is recommended. Flow cytometry
1331
+ immunophenotyping may not detect all lymphomas due to
1332
+ topography, sampling or artifacts of sample preparation.
1333
+
1334
+ 11-23 Bronchial Washings:
1335
+ Bronchial washing, left upper lobe:
1336
+
1337
+ NEGATIVE FOR MALIGNANT CELLS.
1338
+
1339
+ Reactive bronchial epithelial cells and alveolar
1340
+ macrophages.
1341
+
1342
+ ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL)
1343
+ was
1344
+ reviewed and shows alveolar macrophages. No evidence of
1345
+ malignancy.
1346
+
1347
+ 11-23 CXR:
1348
+ FINDINGS: No pneumothorax. There is complete opacification of
1349
+ the left lung, which is indicating collapse in the left upper
1350
+ lung, likely due to mucus plug. There is overlapping
1351
+ opacification, which was seen on the previous film, in the left
1352
+ lower lung which might be postoperative, inflammatory, or
1353
+ malignant and further evaluation is needed.
1354
+
1355
+ There is a small right pleural effusion, unchanged. There is no
1356
+ consolidation in the right lung. The right jugular line was
1357
+ removed.
1358
+
1359
+ 2163-11-23 CXR Post-Bronch:
1360
+
1361
+ FINDINGS: As compared to the previous examination, the left lung
1362
+ is slightly better aerated. There is no evidence of left-sided
1363
+ pneumothorax. In the right lung, in the middle lobe, some subtle
1364
+ areas of atelectasis are seen. No evidence of larger pleural
1365
+ effusions.
1366
+
1367
+ 2163-11-24 CXR:
1368
+ PORTABLE CHEST RADIOGRAPH: Compared to recent studies of
1369
+ 2163-11-23, there is improved aeration of the left upper lung,
1370
+ without evidence of new
1371
+ pneumothorax. There persists opacification of the left perihilar
1372
+ and left
1373
+ lower lung, likely representing combination of pleural effusion
1374
+ and
1375
+ atelectasis, although underlying consolidation cannot be
1376
+ excluded. There is also improved aeration of the right lung
1377
+ although small right pleural effusion persists.
1378
+
1379
+ 2163-11-25 CXR:
1380
+ REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy.
1381
+
1382
+ Since yesterday, diffuse opacification of the left lung is
1383
+ overall unchanged, mostly in the perihilar and left lower lung
1384
+ region, likely a combination of left pleural effusion and
1385
+ atelectasis, possibly consolidation. Small right pleural
1386
+ effusion is unchanged. The right lung is otherwise normal. There
1387
+ is no other change.
1388
+
1389
+ 2163-11-25 CT Scan Chest:
1390
+
1391
+ IMPRESSIONS:
1392
+ 1. Subcutaneous gas consistent with recent mediastinoscopy. A
1393
+ small left
1394
+ lower paratracheal collection containing fluid and gas could
1395
+ represent post- procedural changes. Correlation with recent
1396
+ procedure and clinical symptoms recommended. Multiple
1397
+ mediastinal lymph nodes are noted. Larger soft tissue density in
1398
+ the subcarinal region could represent lymphadenopathy or in the
1399
+ right clinical context could also represent a hematoma.
1400
+ Comparison with prior study if available could help
1401
+ differentiate between the two.
1402
+
1403
+ 2. Status post left lower lobectomy with fibrotic changes and
1404
+ atelectasis
1405
+ noted in the left lung. Fluid collection with thick enhancing
1406
+ rind in the
1407
+ left posterior sulcus is chronic and organized.
1408
+
1409
+ 3. Nodule in the anterior left lung could represent rounded
1410
+ atelectasis,
1411
+ though in atypical location. Recurrent tumor cannot be excluded.
1412
+
1413
+
1414
+ 4. Moderate right dependent pleural effusion with associated
1415
+ dependent
1416
+ atelectasis of the left lower lobe.
1417
+
1418
+ 5. Left adrenal mass. Dedicated imaging of the adrenal glands
1419
+ recommended
1420
+ for further evaluation. There is also suggestion of
1421
+ lymphadenopathy in the
1422
+ retroperitoneum that is incompletely imaged. Small ascites noted
1423
+ along the
1424
+ dome of the liver.
1425
+
1426
+ EKG 2163-11-27:
1427
+ Normal sinus rhythm. Poor R wave progression, possibly related
1428
+ to lead
1429
+ placement. No other abnormality. No previous tracing available
1430
+ for
1431
+ comparison.
1432
+ Intervals Axes
1433
+ Rate PR QRS QT/QTc P QRS T
1434
+ 72 0 88 912-120-18471
1435
+
1436
+ OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of 2163-11-29
1437
+ Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE
1438
+ NEOPLASM
1439
+ Prelim findings c/w metastatic carcinoid, full report pending.
1440
+
1441
+ 2163-11-21 07:32PM GLUCOSE-130* UREA N-119* CREAT-2.2*
1442
+ SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
1443
+ 2163-11-21 07:32PM estGFR-Using this
1444
+ 2163-11-21 07:32PM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4
1445
+ 2163-11-21 07:32PM URINE HOURS-RANDOM UREA N-828 CREAT-45
1446
+ SODIUM-LESS THAN
1447
+ 2163-11-21 07:32PM URINE OSMOLAL-427
1448
+ 2163-11-21 07:32PM WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4*
1449
+ MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1
1450
+ 2163-11-21 07:32PM NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0
1451
+ BASOS-0
1452
+ 2163-11-21 07:32PM PLT COUNT-389
1453
+ 2163-11-21 07:32PM PT-33.9* PTT-43.6* INR(PT)-3.6*
1454
+ 2163-11-21 07:32PM URINE COLOR-Yellow APPEAR-Clear SP Gruwell-1.013
1455
+ 2163-11-21 07:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
1456
+ GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
1457
+
1458
+ Other labs:
1459
+ Hematology
1460
+ COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
1461
+ 2163-12-1 05:45AM 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6
1462
+ 288
1463
+ 2163-11-30 08:05AM 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7
1464
+ 277
1465
+ 2163-11-29 06:45AM 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1
1466
+ 280
1467
+ 2163-11-28 07:00AM 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4
1468
+ 242
1469
+ 2163-11-27 07:25AM 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5
1470
+ 247
1471
+
1472
+ RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
1473
+ 2163-12-1 05:45AM 96 18 1.0 147* 4.0 105 37* 9
1474
+ 2163-11-30 08:05AM 81 20 0.9 145 4.0 108 34* 7*
1475
+ 2163-11-29 06:45AM 77 22* 0.9 1441 4.0 106 36* 6*
1476
+ 2163-11-28 07:00AM 79 27* 1.0 144 4.1 105 32 11
1477
+ 2163-11-27 07:25AM 95 30* 1.0 143 4.0 106 33* 8
1478
+ 2163-11-26 07:00AM 103 37* 0.9 143 4.2 107 33* 7*
1479
+ 2163-11-25 03:37PM 104 43* 1.0 147* 4.4 110* 33* 8
1480
+ 2163-11-25 02:07AM 168* 60* 1.0 146* 4.3 110* 31 9
1481
+ 2163-11-24 04:25AM 92 87* 1.2 150* 4.2 113* 31 10
1482
+ 2163-11-23 07:05AM 97 115* 1.7* 147* 4.5 108 31 13
1483
+ 2163-11-22 02:52PM 126* 2.0*
1484
+ 2163-11-22 05:34AM 122* 125* 2.1* 143 4.5 104 28 16
1485
+ DIG ADDED 9:08AM
1486
+ 2163-11-21 07:32PM 130* 119* 2.2* 141 3.8 100 29 16
1487
+
1488
+ 2163-11-27 07:25AM BNP 7554*1
1489
+
1490
+
1491
+ CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
1492
+
1493
+ 2163-12-1 05:45AM 8.9 3.2 2.2
1494
+ 2163-11-30 08:05AM 9.0 3.4 2.3
1495
+ 2163-11-29 06:45AM 9.0 2.8 2.3
1496
+ 2163-11-28 07:00AM 8.6 2.7 2.2
1497
+
1498
+ HEMATOLOGIC calTIBC Ferritn TRF
1499
+ 2163-11-22 05:34AM 153* 270 118*
1500
+ DIG ADDED 9:08AM
1501
+ PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
1502
+ 2163-11-22 05:34AM NO SPECIFI1 1700-410-4771 NO MONOCLO2
1503
+
1504
+ DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
1505
+ Bilirub Urobiln pH Leuks
1506
+ 2163-11-22 01:50PM NEG NEG NEG NEG NEG NEG NEG 5.0 NEG
1507
+ Source: Catheter
1508
+ MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
1509
+ RenalEp
1510
+ 2163-11-22 01:50PM 3* 2 FEW NONE <1 <1
1511
+ Source: Catheter
1512
+ URINE CASTS CastHy
1513
+ 2163-11-22 01:50PM 9*
1514
+ Source: Catheter
1515
+
1516
+ OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other
1517
+
1518
+ 2163-11-24 08:13AM 01 01 71* 8* 6* 15* 02
1519
+ BRONCHIAL LAVAGE
1520
+
1521
+
1522
+ 2163-11-25 3:37 pm SPUTUM Source: Expectorated.
1523
+
1524
+ **FINAL REPORT 2163-11-27**
1525
+
1526
+ GRAM STAIN (Final 2163-11-27):
1527
+ <10 PMNs and >10 epithelial cells/100X field.
1528
+ Gram stain indicates extensive contamination with upper
1529
+ respiratory
1530
+ secretions. Bacterial culture results are invalid.
1531
+ PLEASE SUBMIT ANOTHER SPECIMEN.
1532
+
1533
+ 2163-11-24 8:13 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
1534
+
1535
+ **FINAL REPORT 2163-11-26**
1536
+
1537
+ GRAM STAIN (Final 2163-11-24):
1538
+ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1539
+ NO MICROORGANISMS SEEN.
1540
+
1541
+ RESPIRATORY CULTURE (Final 2163-11-26): NO GROWTH, <1000
1542
+ CFU/ml.
1543
+
1544
+ 2163-11-23 7:10 pm TISSUE Site: LYMPH NODE
1545
+
1546
+ GRAM STAIN (Final 2163-11-23):
1547
+ 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
1548
+ LEUKOCYTES.
1549
+ NO MICROORGANISMS SEEN.
1550
+
1551
+ TISSUE (Final 2163-11-26): NO GROWTH.
1552
+
1553
+ ANAEROBIC CULTURE (Final 2163-11-29): NO GROWTH.
1554
+
1555
+ ACID FAST SMEAR (Final 2163-11-24):
1556
+ NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
1557
+
1558
+ ACID FAST CULTURE (Preliminary):
1559
+
1560
+ FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
1561
+
1562
+ POTASSIUM HYDROXIDE PREPARATION (Final 2163-11-24):
1563
+ NO FUNGAL ELEMENTS SEEN.
1564
+
1565
+ LEGIONELLA CULTURE (Final 2163-11-30): NO LEGIONELLA
1566
+ ISOLATED.
1567
+
1568
+ Immunoflourescent test for Pneumocystis jirovecii (carinii)
1569
+ (Final
1570
+ 2163-11-24): NEGATIVE for Pneumocystis jirovecii
1571
+ (carinii)..
1572
+
1573
+
1574
+ Brief Hospital Course:
1575
+ 76M initially admitted to Davis Hospital hospital for CHF
1576
+ exacerbation, and then transferred ICU-to-ICU for workup of
1577
+ chronic mediastinal LAD. Thoracic Surgery had been contactTammy
1578
+ and was interested in seeing the patient and deemed that he
1579
+ would be most appropriate for MICU given his ongoing ARF. While
1580
+ in the ICU his renal function improved with gentle intravascular
1581
+ hydration. Echo was performed which revealed severe diastolic
1582
+ dysfunction with ejection fraction of >70%. His digoxin was
1583
+ therefore discontinued. He was discharged to the floor after
1584
+ ~24 hours of observation.
1585
+
1586
+ While on the medical service, the patient was brought to the OR
1587
+ on 2163-11-23 for Flexible bronchoscopy with bronchoalveolar
1588
+ lavage of the left upper lobe, cervical mediastinoscopy and
1589
+ bronchoscopy. On post-op CXR there was noticeable whiteout of
1590
+ the left lung field and the patient was kept in the PACU for
1591
+ observation. He was treated with Chest PT, IS and suctioning
1592
+ for the thought of possible mucus plugging. As per
1593
+ documentation, the patient was doing well until the morning when
1594
+ he had increasing oxygen requirements and more labored
1595
+ breathing. At 8am on 2163-11-24 the patient underwent
1596
+ unremarkable bronchoscopy by IP. Patient continued to have a
1597
+ significant oxygen requirement, satting 93% on 40% facemask,
1598
+ thus was transferred to the ICU for monitoring.
1599
+
1600
+ In ICU on 11-25, patient underwent upper airway suctioning,
1601
+ along with albuterol, ipratropium, and mucinex treatment. He
1602
+ utilized incentive spirometry as well. Serial chest x-rays
1603
+ showed eventual clearing of his left lung. His oxygen saturation
1604
+ improved to 100% on 4L. He underwent a chest CT which showed a
1605
+ large right pleural effusion and left airspace disease possibly
1606
+ consistent with pneumonia. he continued to produce increasing
1607
+ amounts of airway mucous. Though he did not spike a fever or
1608
+ develop a leukocytosis, he was started on empiric coverage for
1609
+ hospital acquired pneumonia with vancomycin and zosyn. This was
1610
+ continued for a total of 4 days, and then discontinued. His
1611
+ respiratory status continued to improve, and he was weaned down
1612
+ to 2L NC O2, and often maintained O2 sats > 94% on room air at
1613
+ rest.
1614
+
1615
+ He was transferred from the ICU to the medicine floor on 11-25,
1616
+ where the below issues were addressed:
1617
+
1618
+ Hypoxia: Thought to be due to mucus plugging in setting of
1619
+ procedure. Given the acuity of both the change and the reversal
1620
+ it is likely that he experienced lung collapse and then
1621
+ reaeration of expectorating mucus. Received 4 days of vanc/zosyn
1622
+ for presumed HAP coverage in setting of hypoxia and increased
1623
+ sputum production, this was d/c'd 11-28 with no additional fevers
1624
+ and decreasing sputum. He was continued on ipratropium nebs,
1625
+ mucomyst nebs, guaifenesin, incentive spirometry. During his
1626
+ stay, his oxygen requirement was weaned, now requiring 2L NC
1627
+ only intermittently. Will continue albuterol and ipratropium
1628
+ nebs on a prn basis.
1629
+ .
1630
+ Hypernatremia: Na as high as 150, did decrease with IVF but
1631
+ still mildly elevated on transfer to floor. Improved to 147
1632
+ with D5W. IV hydration stopped at this time and POs encouraged
1633
+ given risk of CHF. Free water deficit estimated at 2.3L on
1634
+ transfer to floor. Na remained stable in range of 143-147 when
1635
+ taking more PO fluid. Recommend continued intermittent
1636
+ monitoring.
1637
+
1638
+ LAD: s/p mediastinoscopy.
1639
+ His mediastinal lymph node biopsy results were consistent with
1640
+ carcinoid. The hematology/oncology service was consulted, and
1641
+ they recommended getting an octreotide scan, the preliminary
1642
+ read showed metastatic carcinoid. These results were discussed
1643
+ with the patient and his outpatient oncologist. The patient
1644
+ requested to be followed by his oncologist in Lewis Memorial Hospital.
1645
+ .
1646
+ diastolic Congestive Heart Failure: ECHO with EF of 75%, has
1647
+ severe dCHF. Cards consulted while in ICU. Digoxin was
1648
+ discontinued in setting of diastolic CHF. Cardiology
1649
+ recommended using either BB or verapamil to control HR, goal to
1650
+ have <80. HR was well controlled without meds on transfer from
1651
+ ICU. Added Metoprolol 12.5 mg Meredith Medical Center on 11-26, though this was
1652
+ d/c'd 11-27 for episodes of bradycardia to 30s. Added 12.5
1653
+ Metoprolol SR 11-28, which he has tolerated well. Also added
1654
+ Candesartan at low-dose (4mg, home dose 16 mg) given h/o
1655
+ diastolic CHF and goal of reducing afterload. This can be
1656
+ titrated up as his blood pressure allows. He did have some
1657
+ increased edema during his stay on the medical floor, and was
1658
+ given TEDs stockings and encouraged to ambulate. He also
1659
+ received 40 mg IV lasix x 1 2163-11-28, and an additional dose of
1660
+ 40 mg po on 11-30 and 40mg IV on 12-1. The long-term goal
1661
+ remains to minimize diuretics, but use extreme caution with
1662
+ fluids as pt is exquisitely volume sensitive due to severity of
1663
+ dCHF. Discharged with instructions to continue home lasix (40
1664
+ mg) for 3 days with monitoring of daily weights and chemistries,
1665
+ this may need to be reassessed and monitored.
1666
+ .
1667
+ RHYTHM: He has chronic afib. His heparin was held after
1668
+ surgery. He was restarted on coumadin 1.25 mg daily on 11-26.
1669
+ His INR rose to the therapeutic range, and was 2.5 on discharge.
1670
+ Recommend intermittent monitoring to tritrate necessary dosing
1671
+ regimen.
1672
+ .
1673
+ ARF: Improved with hydration. Renal signed off prior to transfer
1674
+ to floor. Diuresis minimized on the floor, received 40 mg IV
1675
+ lasix and 40mg PO lasix on two occasions with good diuresis, pt
1676
+ maintained blood pressures. The goal continues to be to
1677
+ minimize diuresis to prevent excessive preload reduction.
1678
+ .
1679
+ CAD: He was continued on his statin, held ASA due to h/o GI
1680
+ bleed
1681
+
1682
+
1683
+
1684
+
1685
+
1686
+ Medications on Admission:
1687
+ PPI
1688
+ Lipitor 10
1689
+ Atacand 16 (confirmed with spouse)
1690
+ Digoxin 0.125 mg qd
1691
+ Aldactone 25 qd
1692
+ Lasix 40 qd
1693
+ Allopurinol 100 mg qd
1694
+ Verapamil 180 qd
1695
+ Coumadin 2.5 (MWF); 1.25 (TTSS)
1696
+ Flomax 0.5
1697
+
1698
+
1699
+ Discharge Medications:
1700
+ 1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
1701
+ Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
1702
+ 2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily).
1703
+ 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
1704
+ (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
1705
+ 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
1706
+ (Daily).
1707
+ 5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily ().
1708
+ 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
1709
+ Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
1710
+ 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
1711
+ day) as needed.
1712
+ 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
1713
+ times a day).
1714
+ 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
1715
+ Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
1716
+ needed.
1717
+ 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
1718
+ Inhalation Q6H (every 6 hours) as needed.
1719
+ 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
1720
+ days.
1721
+
1722
+
1723
+ Discharge Disposition:
1724
+ Extended Care
1725
+
1726
+ Facility:
1727
+ Lianes Medical Center - Thundera
1728
+
1729
+ Discharge Diagnosis:
1730
+ Primary:
1731
+ Mediastinal Lymphadenopathy
1732
+ Metastatic Carcinoid
1733
+ Acute renal failure
1734
+
1735
+ Secondary:
1736
+ chronic diastolic congestive heart failure
1737
+ anemia
1738
+ atrial fibrillation
1739
+ chronic renal insufficiency
1740
+
1741
+
1742
+ Discharge Condition:
1743
+ fair, tolerating PO, afebrile, VS wnl, O2 95-100% on
1744
+ supplemental O2 2L Tomblin Hospital transfer to chair with assist
1745
+
1746
+
1747
+ Discharge Instructions:
1748
+ You were admitted to the hospital with mediastinal
1749
+ lymphadenopathy. You had a mediastinoscopy and bronchcoscopy.
1750
+ The pathology reports showed this was consistent with carcinoid.
1751
+ You were seen by the oncologists, who recommended an Octreotide
1752
+ scan; you indicated you would like to follow up with your
1753
+ outpatient oncologist.
1754
+
1755
+ You were also noted to have an exacerbation of your heart
1756
+ failure. You were seen by the cardiologists, who recommended
1757
+ you stop your digoxin. You were given diuretics to remove
1758
+ fluid. You also had acute renal failure, which resolved during
1759
+ your stay.
1760
+ .
1761
+ A CT scan showed a mass on your left adrenal gland, this should
1762
+ be worked up as an outpatient, you should talk with your primary
1763
+ care doctor about further evaluation.
1764
+ .
1765
+ The following changes were made to your medications:
1766
+ Your digoxin, verapamil and aldactone were stopped
1767
+ Your atacand dose was decreased to 4 mg
1768
+ You were started on metoprolol
1769
+ You were started on docusate, senna, and bisacodyl as needed for
1770
+ constipation and albuterol and ipratropium nebs as needed for
1771
+ SOB/wheezing
1772
+ Your allopurinol and flomax were held, these can be restarted
1773
+ during your rehab stay
1774
+ Your coumadin was decreased to 1.25 mg daily, this can be
1775
+ adjusted based on your INR
1776
+ .
1777
+ Please call your doctor or return to the ED for:
1778
+ - fevers/chills
1779
+ - shortness or breath or chest pain
1780
+ - increasing sputum production
1781
+ - weight gain > 3 lbs
1782
+ - any other new or concerning symptoms
1783
+
1784
+ Followup Instructions:
1785
+ Follow up with your primary care provider, Cooper. Audry Hall
1786
+ (576-277-8956, within 1 week of leaving rehab. On a CT scan,
1787
+ you were noted to have a mass on your left adrenal gland, and
1788
+ they recommended dedicated CT or MRI for better
1789
+ characterization. Dr. Mora should help you this setting this
1790
+ up.
1791
+
1792
+ Follow up with your cardiologist Dr. Morales Carol 118-669-6208,
1793
+ fax 186-417-7342 within the next 2-3 weeks for reevaluation and
1794
+ adjustment of heart failure meds as needed.
1795
+
1796
+ Oncology Dr. Gean 989-690-8790. You have an appointment on
1797
+ 12-13 at 1:20 PM, call if you need to reschedule or be
1798
+ seen sooner.
1799
+
1800
+
1801
+
1802
+ "
1803
+ "Admission Date: 2139-2-27 Discharge Date: 2139-3-10
1804
+
1805
+
1806
+ Service:
1807
+
1808
+ ADMITTING DIAGNOSIS: Barrett's esophagus with high grade
1809
+ dysplasia.
1810
+
1811
+ DISCHARGE DIAGNOSES:
1812
+ 1. Barrett's esophagus with high grade dysplasia.
1813
+ 2. Status post trans-hiatal esophagectomy.
1814
+ 3. Aspiration.
1815
+ 4. Myocardial infarction.
1816
+ 5. Cardiogenic shock.
1817
+ 6. Anoxic encephalopathy.
1818
+ 7. Death.
1819
+
1820
+ HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
1821
+ male who had a long standing history of gastroesophageal
1822
+ reflux disease and Barrett's esophagus and had high grade
1823
+ dysplasia diagnosed on recent endoscopy. The patient elected
1824
+ to have an esophagectomy performed.
1825
+
1826
+ PAST MEDICAL HISTORY:
1827
+ 1. Hypertension.
1828
+ 2. Question renal insufficiency.
1829
+ 3. Gastroesophageal reflux disease.
1830
+
1831
+ MEDICATIONS:
1832
+ 1. Norvasc.
1833
+ 2. Prilosec.
1834
+ 3. Carafate.
1835
+
1836
+ PHYSICAL EXAMINATION: On admission, the patient is an
1837
+ elderly man in no acute distress. Vital signs are stable.
1838
+ Afebrile. Chest is clear to auscultation bilaterally.
1839
+ Cardiovascular is regular rate and rhythm without murmur, rub
1840
+ or gallop. Abdomen is soft, nontender, nondistended without
1841
+ masses or organomegaly. Extremities are warm, not cyanotic
1842
+ and not edematous times four. Neurological is grossly
1843
+ intact.
1844
+
1845
+ HOSPITAL COURSE: The patient was taken to the Operating
1846
+ Room on 2139-2-27, where he underwent transhiatal
1847
+ esophagectomy without significant complication. In the
1848
+ postoperative course, he was initially admitted under the
1849
+ Intensive Care Unit care and kept in the Post Anesthesia Care
1850
+ Unit overnight. The patient was seen to have a low urine
1851
+ output and both metabolic and respiratory acidosis and was
1852
+ given approximately 8.5 liters of Crystalloid in the
1853
+ perioperative period, including OR.
1854
+
1855
+ The patient was briefly agitated in the Post Anesthesia Care
1856
+ Unit and discontinued his nasogastric tube. On postoperative
1857
+ day number one, the patient was doing well with a fairly
1858
+ normalized blood gas of 7.35/43/94/25/minus 1 and was
1859
+ transferred to the floor.
1860
+
1861
+ On postoperative day two, the patient was seen to have a
1862
+ baseline oxygen requirement of 70% face mask in the morning
1863
+ but was saturating well and otherwise seemed to be doing
1864
+ relatively well.
1865
+
1866
+ The patient had a white count of 22.1 which prompted a chest
1867
+ x-ray showing bilateral pleural effusion and patchy bibasilar
1868
+ atelectasis but no focal infiltrates. Over the course of the
1869
+ day, the patient had deteriorating in his respiratory status
1870
+ and became increasingly tachypneic with wheezing and coarse
1871
+ breath sounds.
1872
+
1873
+ An EKG was performed which showed atrial fibrillation but no
1874
+ ischemic changes. A baseline arterial blood gas was obtained
1875
+ at that point which was 7.37/47/86/28/zero, again on 70% face
1876
+ mask.
1877
+
1878
+ Intravenous fluids were then stopped and the patient was
1879
+ begun on 20 mg of intravenous Lasix and albuterol nebulizers.
1880
+ The patient was transferred to another floor for Telemetry
1881
+ purposes and cycled for myocardial infarction. His
1882
+ respiratory status during transfer seemed somewhat improved.
1883
+ Upon arrival to the other floor, the patient stopped
1884
+ respiring briefly and went bradycardic. Upon stimulation, he
1885
+ was tachycardic to the 110s with a blood pressure 130/70.
1886
+
1887
+ Immediately subsequent to that the patient went pulseless and
1888
+ into respiratory and cardiac arrest and was down for
1889
+ approximately two to three minutes. CPR was begun and the
1890
+ patient intubated and 15 to 20 cc. of brownish fluid was
1891
+ suctioned from the endotracheal tube post intubation.
1892
+
1893
+ The patient regained pulse and cardiac activity and was
1894
+ transferred to the Intensive Care Unit.
1895
+
1896
+ Cardiac consultation at that time recommended aspirin,
1897
+ cycling enzymes and agreed with probable aspiration event.
1898
+ They suggested a heparin drip but not is surgically
1899
+ contraindicated. A heparin drip was not started. The
1900
+ patient ruled in for myocardial infarction with a troponin of
1901
+ 26.5.
1902
+
1903
+ In the patient's Intensive Care Unit stay, he was supported
1904
+ with a dopamine drip and diuresed for fluid overload.
1905
+ Pressors were weaned off on postoperative day number eight.
1906
+ Respiratory function was supported throughout his Intensive
1907
+ Care Unit course appropriately with mechanical ventilation.
1908
+
1909
+ The patient was noted to be unresponsive after the aspiration
1910
+ event, with some slow return of responsiveness over the next
1911
+ several days, but no purposeful movement. To evaluate
1912
+ possible neurologic injury, a CT scan was obtained after the
1913
+ patient was felt to be stable enough to be transferred.
1914
+
1915
+ On postoperative day six, the CT scan showed no acute
1916
+ intracranial event but was consistent with chronic
1917
+ microvascular infarction. EEG was also obtained which
1918
+ revealed diffuse widespread encephalopathy. There was a
1919
+ question of possible seizure activity involving the left
1920
+ upper extremity and phenytoin was begun empirically.
1921
+
1922
+ A repeat EEG was obtained on postoperative day number 10 and
1923
+ again showed moderately severe diffuse encephalopathy with no
1924
+ seizure focus.
1925
+
1926
+ A Neurology consultation was obtained and assessed the
1927
+ patient to have minimal chance for a meaningful recovery.
1928
+
1929
+ In accordance with the patient's living will, the family's
1930
+ wishes and discussion with the surgical attending, the
1931
+ patient was made comfort measures only and expired on
1932
+ postoperative day number 11.
1933
+
1934
+
1935
+ Joshua Guttmann, M.D. P39287153
1936
+
1937
+ Dictated By:Branch
1938
+
1939
+ MEDQUIST36
1940
+
1941
+ D: 2139-3-24 10:08
1942
+ T: 2139-3-28 16:18
1943
+ JOB#: Job Number 48824
1944
+ "
1945
+ "Admission Date: Discharge Date:
1946
+
1947
+ Date of Birth: Sex: M
1948
+
1949
+ Service: UROLOGY
1950
+ HISTORY OF PRESENT ILLNESS: Mr. Stephen is a 53-year-old
1951
+ gentleman who presented on 2121-6-28 for cystectomy and
1952
+ neobladder diversion. He had grade 3 of 3 TCC.
1953
+
1954
+ PAST MEDICAL HISTORY:
1955
+ 2. Myocardial infarction in '09
1956
+ 3. Hypertension
1957
+ 4. Left internal capsule cerebrovascular accident in '18
1958
+ 5. Hypothyroidism
1959
+ 6. Gastroesophageal reflux disease
1960
+ 7. Hypercholesterolemia
1961
+ 8. Depression
1962
+ PAST SURGICAL HISTORY:
1963
+ 1. TURBT's in '13 and '15
1964
+
1965
+ ALLERGIES: He has no known drug allergies.
1966
+
1967
+ HOME MEDICATIONS:
1968
+ 1. Aspirin 250 mg q.d. which was held
1969
+ 2. Metoprolol 25 mg b.i.d.
1970
+ 3. Levoxyl 300 mcg once a day
1971
+ 4. Paxil 40 mg once a day
1972
+ 5. Lipitor 20 once a day
1973
+
1974
+ ADMISSION LABS: CBC of 9.3, 43.6, 252. Chem-7 of 135, 4.4,
1975
+ 97, 23, 16, 0.8, 252. PT 12.8, PTT 24.4, INR 1.1. Liver
1976
+ enzymes: ALT 23, AST 18, alkaline phosphatase 101, albumin
1977
+ 3.8, total protein 7.4.
1978
+
1979
+ IMAGING: Preoperative electrocardiogram showed left atrial
1980
+ abnormalities with Q-waves in 2, 4, AVF, V5, V6. Thallium
1981
+ stress test done preoperatively showed normal heart rate,
1982
+ normal blood pressure, normal respirations, no acute
1983
+ electrocardiogram changes, some portal V-function from an old
1984
+ infarction prior myocardial infarction, however it was clear
1985
+ for the operation. His chest films revealed no acute
1986
+ cardiopulmonary process.
1987
+
1988
+ The inital surgery resulted in creation of a neobladder from
1989
+ ileum. Postoperatively, the patient remained intubated with a
1990
+ septic picture that deteriorated, requiring pressor agents.
1991
+ The patient returned to the Operating Room on
1992
+ 2121-7-8 for an exploratory laparotomy and excision of an
1993
+ infarcted neobladder and resection of a nonviable segment of
1994
+ small bowel x2, creation of a jejunal conduit. His postop
1995
+ course was equally stormy with spiking fevers, renal failure,
1996
+ and BP instability
1997
+ A third surgical exploration was necessary on 7-26. At this time,
1998
+ the patient
1999
+ More ischemic bowel was removed where perforations had occurred
2000
+ resulting in peritonitis. The jejunal loop was excised and the
2001
+ right ureter ligated. A left cutaneous ureterostomy was created.
2002
+ Postop he had bilateral nephrostomies inserted and continued to
2003
+ have an extended stormy ICU course. A tracheostomy was
2004
+ necessary because of hi need for prolonged ventilator support.
2005
+ He also developed extensive DVT requiring anticoagulation.
2006
+ Bowel function gradually returned allowing for tube feedings.
2007
+ Multiple courses of antibiotic therapy were given during his
2008
+ hospital stay.
2009
+
2010
+ NEUROLOGICALLY: By system, neurologically the patient is
2011
+ status post a left internal capsule infarct with residual
2012
+ right sided weakness. His history of depression leaves on
2013
+ Paxil and he was started on such. Radiologically, the
2014
+ patient had a CT done of the head done during his admission.
2015
+ Showed a stable appearance, considering no definitive
2016
+ evidence of any type of abscess. Neurologically, the patient
2017
+ is being discharged home and is stable. He is alert, however
2018
+ he is unable to move secondary to his wasting and being in
2019
+ bed for so long without assistance. The patient is able to
2020
+ get out of bed to chair. Neurologically, the patient has no
2021
+ acute issues upon discharge.
2022
+
2023
+ CARDIOVASCULAR: The patient is status post myocardial
2024
+ infarction in 2109 and he did not have a myocardial
2025
+ infarction during the course of his stay in-house at the
2026
+ hospital and he was ruled out by enzymes with no acute
2027
+ electrocardiogram changes. The patient has no acute
2028
+ cardiovascular issues. The patient is not on clonidine, nor
2029
+ is he on Lopressor currently and his pressure is tolerating,
2030
+ basically being on nothing. The patient had been on pressors
2031
+ immediately because of sepsis which was weaned off slowly
2032
+ during the course of his stay. He has not been on pressors
2033
+ for the previous month.
2034
+
2035
+ RESPIRATORY: The patient had poor respiratory failure and
2036
+ required full respiratory support. He is postoperative his
2037
+ three operations and has been slowly weaned down to a
2038
+ pressure support of 40 with a CPAP pressure support with 405
2039
+ FIO2 with a PEEP of 5 and a pressure support of 5 with tidal
2040
+ volumes ranging from 550 to 650. The patient
2041
+ was also bronched on 8-22 and mucous plugs were removed from
2042
+ the patient. A CT done on this patient in the last two weeks
2043
+ in the middle of January showed that he had no acute
2044
+ pulmonary process with possible left lower lobe pneumonia.
2045
+ At that point, he had also been on antibiotics with this
2046
+ course. Upon discharge, the patient has no acute pulmonary
2047
+ process and his lungs are sounding remarkably clearer.
2048
+
2049
+ GASTROINTESTINAL: The patient is not able to eat on his own
2050
+ and has a left Dobbhoff tube and is suffering from short--gut
2051
+ syndrome requiring B12 injections. The patient is currently
2052
+ tolerating his tube feeds of Impact at goal rate of 90 cc an
2053
+ hour and is having some stool output. Clostridium difficile
2054
+ sent on the patient recently as of 9-15 came back negative.
2055
+ The patient is receiving all his feeds through tube feeds and
2056
+ is not a candidate for a PEG given his previous abdominal
2057
+ surgery. The patient's other gastrointestinal issues are
2058
+ obviously evolving around the reception as previously stated
2059
+ of massive portions of his small bowel, as well as the large
2060
+ bowel and appendix. Upon discharge, there are no acute
2061
+ discharge issues for this patient.
2062
+
2063
+ GENITOURINARY: The pathology report from the original
2064
+ surgery showed a high grade invasive TCC involving the
2065
+ bladder neck, prostate, urethral margin and regional
2066
+ nodes. His right ureter is tied off secondary to
2067
+ the leak and he has a right nephrostomy tube which was
2068
+ changed on 9-16 as well as his left nephrostomy tube. His
2069
+ ureterostomy tube on the left side was changed on 9-18. All
2070
+ this was done in response to his febrile episode he had which
2071
+ will be outlined later which was felt to be urosepsis. On
2072
+ discharge, it was found that his nephrostomies were positive
2073
+ for yeast, most likely colonized. The patient was not on any
2074
+ type of antimicrobial for that. The patient has been showing
2075
+ yeast growing from the left side nephrostomy and
2076
+ ureterostomies almost to his Intensive Care Unit stay, but no
2077
+ evidence of acutely febrile as a result most likely due to
2078
+ colonization. The patient has a left nephrostomy tube in
2079
+ addition to the ureterostomy of the left side and does not
2080
+ have a Foley inserted into his neobladder obviously because
2081
+ of drainage from that point of view. Upon discharge from a
2082
+ urological standpoint, the patient is stable. His tubes are
2083
+ draining clear urine and there is no blood present. Some
2084
+ blood may be noted in the urine with positional changes on
2085
+ the patient and that is completely normal as long as it is
2086
+ consistent with old blood and no massive bleeds.
2087
+
2088
+ EXTREMITIES: The patient was found to have a lower extremity
2089
+ deep venous thrombosis on 8-3, as well as 8-8 which found
2090
+ upper extremity bilateral deep venous thromboses. The
2091
+ patient basically had deep venous thromboses x4 and was
2092
+ started on a heparin drip continuously to resolve his deep
2093
+ venous thromboses and heparin drip was continued until
2094
+ Coumadin was started in the last two weeks of January prior
2095
+ to his discharge. An ultrasound of the upper extremities
2096
+ done on Mr. Stephen on 9-12, showed that he resolved his
2097
+ upper extremity clots completely with the exception of some
2098
+ small residual clot at the left and right IJ. The patient is
2099
+ being discharged on Coumadin with the hope of achieving an
2100
+ INR of approximately 2 to 2.5. The most recent INR was 1.3,
2101
+ came back on 9-18 and the patient continued to receive
2102
+ Coumadin until he reaches his goal without any heparin. In
2103
+ addition, the patient's hematocrit has remained stable,
2104
+ however.
2105
+
2106
+ HEME: The patient has been on Coumadin. His hematocrit has
2107
+ remained stable as of late and his last blood transfusion was
2108
+ on 7-12. Since then, his hematocrit has remained stable at
2109
+ around 29 to 28 with no acute signs of bleeding. As far as
2110
+ his renal function, the patient has been increasing sodium
2111
+ and has been given free water to resolve that. His
2112
+ hematocrit is stable and his white cell count on 9-18 was
2113
+ 8.0.
2114
+
2115
+ INFECTIOUS DISEASE: The patient was febrile postoperative
2116
+ and several cultures were sent out. Regarding his blood
2117
+ cultures, from 7-8 to the middle of January, he did not
2118
+ grow anything out. He was on triple antibiotics which were
2119
+ actually discontinued on 2121-8-29. He failed to grow
2120
+ anything however fluconazole was continued until 9-2 to rule
2121
+ out any other type of infection and to make sure that there
2122
+ was no acute yeast systemic process going on even though he
2123
+ had colonized his tubes. The patient became febrile again on
2124
+ 9-8 unfortunately with a T-max of 104.4??????. The patient was
2125
+ started immediately on vancomycin, Zosyn and fluconazole
2126
+ until cultures came back. Blood cultures and catheter
2127
+ cultures came back revealing that the patient had been
2128
+ infected and was handling what was later decided was probably
2129
+ urosepsis for Klebsiella. Based on this, the patient resumed
2130
+ a 10 day treatment cycle of Levaquin based on infectious
2131
+ disease's recommendation and the other antibiotics were
2132
+ stopped. This is actually day 8 of 10 of his levofloxacin
2133
+ course and as of 2121-9-19 the patient will be receiving two
2134
+ more days of Levaquin.
2135
+
2136
+ The patient upon discharge is afebrile and his surveillance
2137
+ blood cultures have come back negative even though his
2138
+ nephrostomy tubes which were changed showed some fungal
2139
+ colonization growth. His blood has remained negative for any
2140
+ type of infection. During his stay, other cultures sent off
2141
+ included blood flowing through his catheter lines which were
2142
+ negative except for that one change which was required on
2143
+ 9-8 after he became febrile. His left subclavian has
2144
+ changed. Today, on 9-19, he has a right sided subclavian of
2145
+ the left sided one which was considered a possible source of
2146
+ infection. His lines are not likely the source of the
2147
+ infection. It is hoped that he will get a PICC line before
2148
+ he is discharged to rehabilitation today and his central line
2149
+ will be taken out.
2150
+
2151
+ MICROBIOLOGY: A spinal tap was also done and no consequence
2152
+ of that resulted. No significant findings.
2153
+
2154
+ Today, the patient is being discharged and he is on the
2155
+ following medications:
2156
+ 1. Glutamine 5 mg p.o. tube feeds to prevent excessive
2157
+ stool, secondary to short-gut.
2158
+ 2. NPH 8 units subcutaneous b.i.d.
2159
+ 3. Thyroxine 200 mcg p.o. q.d.
2160
+ 4. Vitamin C p.o. per the nasogastric tube every day.
2161
+ 5. Insulin sliding scale 2, 4, 6, 8 which is not being used
2162
+ much.
2163
+ 6. Paxil 20 mg nasogastric tube q.d.
2164
+ 7. Levofloxacin 500 mg intravenous to be continued for
2165
+ another two days hopefully.
2166
+ 8. Tincture of iodine 10 drops to every 500 cc of tube
2167
+ feeds.
2168
+
2169
+ He received 2.5 mg of Coumadin last night. He has not
2170
+ received any recent Dilaudid or albuterol nebulizer
2171
+ treatment. He is receiving KCL 40 mg intravenous prn for low
2172
+ potassium of less than 4, magnesium of 2 gm intravenous prn
2173
+ for less than 2.0 magnesium levels, last dose on 9-18, as was the last dose of potassium. The patient has not
2174
+ been requiring any Ativan or Dilaudid or sedation as of
2175
+ recently. He was on Epogen for a hematocrit which has now
2176
+ been stabilized, so it is no longer as issue. It was felt
2177
+ that the patient was in early on acute renal failure which
2178
+ turned out to be a leak and the patient is not on renal
2179
+ failure, no requiring any Epogen. On this date, 9-19, Mr.
2180
+ Stephen is basically receiving in addition to just the
2181
+ glutamine 5 mg tube feeds, Synthroid which are outlined and
2182
+ he is also getting Protonix 40 mg intravenous q.d. for
2183
+ gastrointestinal prophylaxis, as well as Coumadin to keep an
2184
+ INR of 2 to 2.4 for prophylaxis.
2185
+
2186
+ It is our hope that Mr. Schrack, despite his advanced
2187
+ cancer and multiple surgeries, will be rehabilitated and able
2188
+ to resume assemblance of his functional life. We hope that
2189
+ he continues receiving chest PT, that he is respiratorily
2190
+ stable with no acute issues at this time. We also hope that
2191
+ he will eventually no longer require ventilatory support and
2192
+ a collar could be used on him as well as eventually assume
2193
+ breathing on room air.
2194
+
2195
+ Final Diagnoses:
2196
+ 1. Transitional Cell Ca of Bladder and Prostate, metstatic to
2197
+ regional nodes
2198
+ 2. Multiple postoperative complications, including intestinal
2199
+ perforation with peritonitis, neobladder infarction, sepsis,
2200
+ vascular instability with hypotension, DVT, and renal
2201
+ insufficiency.
2202
+ 3. Respiratory insufficiency
2203
+ 4. s/p tracheostomy
2204
+
2205
+
2206
+
2207
+ Michele Initial (NamePattern1) Beaufort, MD A79903668
2208
+
2209
+ Dictated By:Leon
2210
+ MEDQUIST36
2211
+
2212
+ D: 2121-9-19 09:01
2213
+ T: 2121-9-19 09:11
2214
+ JOB#: Job Number 39316
2215
+
2216
+ rp 2121-9-19
2217
+ "